Descriptive Psychopathology: The Signs and Symptoms of ...

182 Section 3: Examination domainspinprick ...over the left body and extremities ...sensory loss was patchy withinconsistent borders; she expressed no concern.” Her symptoms were eventuallyunderstood as arising from a recent infarction of the right parietal andtemporal lobes. 118Gould and colleagues reported that persons most likely to be misdiagnosed as“hysterical” were women, homosexual men, patients with previous psychiatricdiagnoses, and those with a plausible psychological explanation for their condition.The biases in the application of the hysteria label are patent.Devinsky et al. (2001) described 79 patients previously diagnosed withconversion disorder who were then found to have defined brain disease. Sixtypatients (76%) had unilateral cerebral abnormalities, of which 85% were structural.Ictal or inter-ictal EEG abnormalities were found in 78% of these patients.A right hemisphere lesion was found in 78% of the patients with a definedabnormality.A four-year follow-up of children and adolescents with the diagnosis of conversionfound the conversion features had fully resolved in 85%, but 35% sufferedfrom mood or anxiety disorder. 119 Among 103 patients with dystonia consideredpsychogenic or a feature of somatization disorder, most were explained by previousperipheral injury or the presence of other psychiatric conditions. For some patients,no cause, including psychiatric, could be identified. 120Motor conversion and pseudoseizure diagnoses are most likely to presage adefinitive neurologic diagnosis, and dystonia and chorea are features of diseasemost often misunderstood and labeled “psychogenic”. 121 Among patients said tohave psychogenic non-epileptic seizures based on video-EEG monitoring, commonfeatures are clonic and exaggerated movements of the extremities, pelvic thrusting,head movements, and tonic posturing of the head, a “trembling” syndrome of allextremities, and an “atonic” condition, the patient falling to the floor as the onlyfeature. 122 As illustrated by Patient 7.9 and other reports, 123 such patients, althoughreported as having a “psychogenic” condition, often have a seizure disorder.Patient 7.9A 22-year-old active-duty military service woman was hospitalized for possiblemalingering to avoid work responsibilities. Her difficulties were described as“nightmares” during which she was observed by her roommates to get out ofbed, scream for several minutes, and then return to sleep. She had similarepisodes during the day and these continued in the hospital. She was noted tosuddenly stop the activity in which she was engaged, flex both her arms withclenched fists, start screaming and then repeat the phrase “It’s okay, it’s okay ...”.Her arms moved up and down symmetrically as if she were pounding a table.