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Conversion hysteria: towards a neuropsychological account
  1. Michael Trimble

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It probably would not have pleased Aubrey Lewis to know that one of his lasting legacies to psychiatry is his now often quoted words from his paper The survival of hysteria to the effect that hysteria will outlive its obituarists. It seems that in the past decade, almost in defiant opposition to the mighty DSM goliath, humble hysteria is not only once again a popular topic for investigation, but its very name lives on. In this book, the term hysteria is unashamedly used, even in the title, and it is not cloaked by its suit of new invisible clothes dressing up as somatoform disorders or one of their variants.

This small but very readable book is a collection of papers published as a special edition by the Journal of Cognitive Neuropsychiatry. The aim was to bring modern neurocognitive theory to the field, to balance the “traditional overreliance on psychodynamic accounts”. However, it also embraces the paradigm, enunciated over a century ago by Charcot, that hysteria should be open to investigation as other conditions in medicine, using the same methods and observation techniques.

Thus, in the text, several of the chapters touch on the more recent neuroimaging and evoked potential studies. These seem fairly consistent, noting the important association of the frontal and cingulate cortex to symptom presentation, and, with a paretic limb, the failure of the appropriate parietal activation with effort to movement. Other chapters take a somewhat more traditional role, outlining the historical trends, discussing the Freudian and post-Freudian contributions, and linking in neuroanatomical and neurophysiological data with speculations on limbic and especially right hemisphere dysfunction in association with hysteria.

The most interesting contributions, however, are the newer cognitive neuropsychological approaches to the subject. For, and here Lewis was surely right, hysteria lingers on in clinical practice, as seen in patients galore, in different guises, especially in the neurology clinic and in settings such as medicolegal practice. Yet the mechanisms leading to the florid manifestations of hysteria in these patients may be part of a psychological tendency available to a much wider community, and to this extent perhaps should not be even regarded as pathological. The main thrust of the book, and the most relevant for those engaged with such patients, reflects on this theme. The wider patient social construct is emphasised, the relevance of the concept of the Will is debated (another famous quote, from Paget, repeated here: “The patient says he cannot, it looks like he will not, but the truth is that the patient cannot will”), and the role of consciousness re-examined. For sure, one of the most tedious yet well intentioned questions that doctors are asked when discussing such patients is “well, is it conscious, or unconscious?”.

The text provides elegant ways of resolving this dilemma, in themes in keeping with modern cognitive psychology. Like a good book reviewer, I will not give the game away, but encourage the interested to read the texts herein published. One quote will help the temptation: “In an attempt to encapsulate the self-deceptive view of hypnotised subjects, they have been labelled as “honest liars”. By the same token, hysterics should perhaps be seen as “genuine malingerers”” (Oakley).

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