Descriptive Psychopathology: The Signs and Symptoms of ...

181 Chapter 7: Disturbances of motor functionPatient 7.6A 28-year-old man came to an emergency room because of left-sided numbnessand “loss of feeling” that had progressed over several hours. The manappeared anxious and said he was under substantial work-related stress.Examination revealed the numbness ending at the midline contrary to theanatomic distribution of dermatomes. The findings of the remainder of thebasic neurologic and general medical examination were reported as “normal”.A “psychogenic” disorder was considered, and the patient sent home withseveral doses of an anxiolytic and the recommendation to follow-up with hisprimary care physician in the next few days. The patient died that night and anautopsy revealing a ruptured aneurysm that had bled into his right thalamus.The emergency room physician may also have been swayed by the patient’s symptombeing left-sided, because of the long-held notion that unilateral psychogenic movementand somatosensory disorders will be more common on the left because ofinfluences of the right cerebral hemisphere, the putative site of unconscious processes.This left bias has been questioned, and a review of 121 studies totaling 1139 patientsconsidered to have conversion disorder could find no left–right difference. 116Many studies reinforce the need for careful consideration of alternative explanationsto conversion and psychogenic disorders. 117 Gould et al. (1986) reported30 patients with documented structural nervous system damage who were mistakenlysaid to have symptoms that were not understood by their treatingclinicians and therefore considered signs of hysteria. La belle indifference (a calmunconcern for the disabling features), introduced by Janet as a pathognomonicsign of conversion hysteria, was found to be an unreliable feature. Extracts fromthe case presentations are instructive.Patient 7.7“A 56-year-old woman” experienced “double vision and facial numbness ...diminished sensation on the right side of her face ...with exact midline splitof the forehead and jaw but the sensory loss spared the nose ...less sensationof vibration (to a tuning fork) on the right side” and “apparent giveawayweakness at the left biceps and deltoid.” The patient’s symptoms were eventuallyunderstood as arising from a nasopharyngeal epidermoid carcinoma.Patient 7.8A 59-year-old woman with a “history of complaints involving many organsystems but no medical diagnosis except hypertension” had recent “left-sidedweakness ... She was euphoric ... denying any weakness or numbness.Examination did not reveal any motor deficit but decreased appreciation of