Defining hysterical symptoms

The conventional view would appear to define hysterical symptoms (whether so-called conversion symptoms or hysterical dissociation) in terms of a number of features. The first is the occurrence of a symptom which, if taken at face value, would be an indication of some underlying pathological process; yet no pathology of a conventional kind can be elicited, and the presence of such pathology (whether physical or in the form of a formal psychiatric disorder) seems highly unlikely. An example of something meeting this criterion is a sensory impairment that does not match any recognized anatomical distribution and/or, where evidence can be obtained that the sensory system must be functioning very much better than the patient's claimed symptomatology would suggest (as in the cases reported by Grosz & Zimmerman, 1965; Miller, 1986). This seems to be the central and essential criterion and it is widely accepted that patients meeting this criterion are encountered from time to time. There are three other common criteria and all raise problems. It is usually assumed that there must be some secondary gain from the symptom. The difficulty here is that all disorders or illnesses can give rise to some secondary gain (e.g. people feel under an obligation to be especially considerate to those who are ill). Secondary gain therefore raises problems as one of the defining criteria of hysteria since it does not readily distinguish hysteria from true illnesses. A second, classical feature is the alleged presence of' la belle indifference' although again this must be regarded as a rather unreliable sign. What evidence there is about anxiety in hysterical patients tends to indicate that levels of general anxiety are, if anything, raised in those with so-called 'conversion hysteria' (Lader & Sartorius, 1968). Many authorities on hysteria would probably accept that secondary gain and '/a belle indifference' are unreliable as signs of hysteria. The final criterion is more central to most views of hysteria. It is that the patient is regarded as experiencing the symptom as ' real' and is not consciously aware that the symptom is being produced and maintained by means other than those of conventional pathological mechanisms. Thus, the hysterical patient with paralysis really is unable to move his paralyzed limbs. It is this latter criterion which distinguishes the hysteric from the malingerer who consciously simulates symptoms. (There can also be a problem in distinguishing hysterical symptoms from hypochondriacal complaints but this is not an issue of such great relevance to present concerns.) This discussion is principally concerned with the last of the above criteria for hysterical symptoms; that of the subjective reality of the symptom from the point of view of the patient. The use of this criterion raises a number of difficulties. It entails a judgment about whether or not the patient is aware of the status of the symptom. This is necessarily an unreliable and unsatisfactory judgment because no examiner has access to the content of any patient's consciousness. To maintain this criterion also biases explanations of hysteria towards those that involve unconscious mental mechanisms (as in the psychoanalytic tradition) or which, following Janet (1907), use the concept of dissociation. A model of the mind has to be postulated which involves some mental structure operating outside the realms of normal consciousness which can be used to create the symptom (or the processes underlying it). Not only are such structural models of the mind open to dispute on philosophical grounds (e.g. Ryle, 1949; White, 1967), but they are not amenable to empirical test in any critical way. Of course, verifiable predictions can be derived from such models but not of a kind that would challenge the fundamental basis of the model itself.