Cognitive Performance Conversion Hysteria Fernando
Bendefeldt, MD;
Loren L.
Miller, PhD; Arnold M. Ludwig, MD
. In order to test some neurobiologically based assumptions pertaining to attention and memory dysfunction in conversion hysteria, a series of tasks was given to 17 hospitalized patients with hysterical conversion reaction and to a control group of nonpsychotic patients under conditions of nonstress and stress. The results indicated significant differences in performance between hysteria and control subjects. The former group, in comparison to controls, had heightened suggestibility, greater field dependency, and greater impairment of recent memory and vigilance-attention. A discriminant analysis indicated the feasibility of using such tests as objective diagnostic criteria for hysteria. (Arch Gen Psychiatry 33:1250-1254, 1976)
A lthough there is an enormous literature on the historiXI cal, descriptive, and psychodynamic aspects of
conversion hysteria, virtually no research has been conducted on the possible biological or cognitive determi¬ nants of this disorder. Recently, however, Ludwig' has advanced a neurobiological theory of conversion hysteria that permits the scientific testing of specific hypotheses. This theory, based on the assumption of an underlying cortical inhibitory state (ie, excessive corticofugal inhibi¬ tion of afferent stimulation), postulates the presence of "a subtle but particular type of memory disorder," as well as a distinctive kind of attention dysfunction. Presumably, all
of the classical features of conversion hysteria, including la belle indifférence and nonanatomically or nonphysiologically based symptoms, can be attributed to these memoryattentional characteristics.
Accepted publication July 28, 1975. From the Department of Psychiatry, University of Kentucky College of Medicine, Lexington. Reprint requests to Department of Psychiatry, Room M-N368, University of Kentucky, Lexington, KY 40506 (Dr Ludwig). for
in
a neurobiological not preclude or does hysteria approach exclude the symbolic interpretation of symptoms or the possible, interpersonal manipulative and communicative
At the outset, it must be stated that to conversion
aspects of this disorder. Since all behavior
must be repre¬
by specific brain activity, the neurobiological approach seeks to unravel and elucidate the particular kind of brain processes that can sustain and permit the bizarre, dramatic, and often puzzling symptoms characteristic of hysteria. Unless these processes can become better under¬ stood, it is unlikely that scientific, objective knowledge of this age-old disorder will advance. More specifically, this neurobiological theory hypothe¬
sented
sizes that the memory disorder will (1) be more marked during the presence of symptoms than during symptomfree periods; (2) be more prominent during anxiety or arousal testing conditions than during relaxed supportive testing conditions: (3) pertain primarily to recent memory, especially for tasks that require concentration, sustained attention, and the shifting of mental sets; and (4) pertain more to defects in retention and recall functions rather than perception and registration of information. Aside from certain predictions pertaining to stimulus intensity control and scanning control, the assessment of which require a variety of physiological and electrocortical proce¬ dures, the theory also predicts the presence of a fielddependent cognitive style that, in turn, should contribute to
heightened suggestibility.
Jhe present study, though
not
designed
to
provide
a
assessment of this theory, attempts to disconfirm most of the specific hypotheses
comprehensive
confirm or relevant to the cognitive functioning of patients with conversion hysteria. To our knowledge, this is the first such controlled study reporting objective performance data for patients with conversion hysteria.
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Table 1—Symptoms Present ¡ Hysterical Conversion Patients Patient
Perception Triplopia
1
Consciousness Pass-out spells Pass-out spells Pass-out spells
Eidetic hallucinations
Unilateral blindness
Senso rium
Motor Function
Tingling extremities Tingling, hypalgesia
Dysarthna, staggering Weakness, right side
Multiple personality
Tingling, hypalgesia Hypesthesias
Incontinence
Numbness
Weakness, left leg
Purple spots Black-out spells Dizziness
Tubular vision 10
Black-out spells Black-out spells, dizziness Black-out spells Pass-out spells Pass-out spells Pass-out spells
Hypacusia, blindness 12
13 14
15 16 17
Tubular vision, dimness
SUBJECTS AND METHODS
pertaining
to perception, consciousness, sensation, or voluntary motor functions in the absence of demonstrable organic basis; (2) symptoms and signs that do not reflect anatomical functions, do not correspond to known neurological segmental distribution, and do not follow known principles of neurophysiologic response
patterns; (3) the magnitude or extent of the disability tends not to
directly severely with the preservation of survival functions; (4) presence of increased susceptibility to external suggestion; or (5) la belle indifference. Patients with a past or present history of major psychosis, organic brain syndrome, or any kind of drug dependence were excluded. The specific symptoms of these patients are summarized in Table 1. A control group of 17 hospitalized psychiatric patients (eight men and nine women), excluding those with psychotic reactions, alcoholism, and organic brain syndromes, were selected from the same wards. The specific diagnostic composition of this group included six patients with neurotic depression, four with obses¬ sive-compulsive personality disorders, five with passive-aggres¬ sive personality disorders, and two schizoid personalities. No patients in the experimental or control groups were taking psychotropic médication at the time of testing. Mean ages for the experimental control subjects were 32.8 and 27.8, respectively, and mean educational levels were 11.1 and 11.9 years, respectively. There were no significant differences between these groups for age, marital status, or level of education. A higher proportion of controls, however, came from urban settings ( 2 4.09; < .05). or
=
Procedure All subjects were told that the purpose of the study was "to learn about memory and concentration during psychiatric hospi¬ talization," and that participation was entirely voluntary. After a standardized interview for demographic and medical-psychiatric symptom information, subjects were scheduled for two separate testing sessions, one representing a "stress" and the other a "nonstress" condition. The order of administration of these condi¬ tions was random and they were spaced about one week apart. In the nonstress condition, the experimenter made numerous more
Partial mutism
Blepharospasm Trembling, weakness
Generalized numbness Numbness of body Numbness of body
Tingling
Astasia-abasia Poor sphincter control
Numbness
Seventeen hospitalized psychiatric patients (seven men and ten women), with the primary diagnosis of "hysterical conversion reaction" as established by at least two attending psychiatrists (who were unaware of the perceptual task results of this study), constituted the experimental group. All patients met at least four of the five following classical diagnostic criteria: (1) disorders
interfere
Numbness, hypesthesia Tingling of eyelids
empathie, supportive, lenient, and encouraging statements to subjects throughout the session, such as "you are doing fine," and "very good." In the stress condition, subjects were tested in the room used for electroconvulsive shock treatment and coldly told by the experimenter to complete the test to the best of their abilities. Paradoxical injunctions, such as "don't be nervous," were frequently made. A timer was also placed on the desk in front of the subject.
Testing
Instruments
The following six tests were administered to each conditions of nonstress and stress:
subject under
Recent Memory.-Guessing Technique (GT).-The method of Hinrichs,2 called the Guessing Technique, was employed as an
indirect measure for retention/recall functions of recent memory. In brief, this method consists of the random presentation of all the letters of the alphabet, each individually flashed by means of a slide projector. On presentation of a letter, the subject is to make a guess as to the next letter that will appear and repeat this for each letter presented. As a subject's recent memory fails, he begins to guess items that have already been presented. The occurrence of these incorrect guesses is the basic measure of memory loss. There are two restrictions to the guessing: the subject is not to ), and the guess the same letter until it appears (eg, A, A, A subject is not to alternate between two letters until one or the other appears (eg, , , A, ). The most important rule is to avoid guessing letters already presented. After one practice trial (a complete alphabet), the procedure is initiated for each subject individually. Each letter is flashed for eight seconds on the screen, during which time the subject is to guess the next letter. A full trial lasts about 3.5 minutes, and it requires 40 minutes to run ten trials. The scores obtained were the total number of errors. Paired Associates Test (PAT).-As another measure of memory, requiring somewhat longer retention of material than the Guess¬ ing Technique above and presumably independent of general intellectual functioning,1 a series of paired words with two levels of association strength were used. List A contained ten familiar associations-eg, blue-sky: List contained ten remote associations-eg, book-chalk. After explaining the task to the subject, the experimenter reads aloud all the paired words from list A. An interval of about five seconds is allowed between each pair of words. Then the experi¬ menter tests the subject by providing, in random order, the first member of each word pair (stimulus word), after which the subject ...
...
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Table 2.—Means for Multivariate Analysis of Variance (MANOVA) Suggestibility
Diagnosis Control
Hysteria Condition Nonstress
Stress_
Diagnosis
X condition Control Nonstress
Stress Hysteria Nonstress
Stress
Arm
Arm
Lowering
Lévitation
?:a2.}-
Bendefeldt, MD;
Loren L.
Miller, PhD; Arnold M. Ludwig, MD
. In order to test some neurobiologically based assumptions pertaining to attention and memory dysfunction in conversion hysteria, a series of tasks was given to 17 hospitalized patients with hysterical conversion reaction and to a control group of nonpsychotic patients under conditions of nonstress and stress. The results indicated significant differences in performance between hysteria and control subjects. The former group, in comparison to controls, had heightened suggestibility, greater field dependency, and greater impairment of recent memory and vigilance-attention. A discriminant analysis indicated the feasibility of using such tests as objective diagnostic criteria for hysteria. (Arch Gen Psychiatry 33:1250-1254, 1976)
A lthough there is an enormous literature on the historiXI cal, descriptive, and psychodynamic aspects of
conversion hysteria, virtually no research has been conducted on the possible biological or cognitive determi¬ nants of this disorder. Recently, however, Ludwig' has advanced a neurobiological theory of conversion hysteria that permits the scientific testing of specific hypotheses. This theory, based on the assumption of an underlying cortical inhibitory state (ie, excessive corticofugal inhibi¬ tion of afferent stimulation), postulates the presence of "a subtle but particular type of memory disorder," as well as a distinctive kind of attention dysfunction. Presumably, all
of the classical features of conversion hysteria, including la belle indifférence and nonanatomically or nonphysiologically based symptoms, can be attributed to these memoryattentional characteristics.
Accepted publication July 28, 1975. From the Department of Psychiatry, University of Kentucky College of Medicine, Lexington. Reprint requests to Department of Psychiatry, Room M-N368, University of Kentucky, Lexington, KY 40506 (Dr Ludwig). for
in
a neurobiological not preclude or does hysteria approach exclude the symbolic interpretation of symptoms or the possible, interpersonal manipulative and communicative
At the outset, it must be stated that to conversion
aspects of this disorder. Since all behavior
must be repre¬
by specific brain activity, the neurobiological approach seeks to unravel and elucidate the particular kind of brain processes that can sustain and permit the bizarre, dramatic, and often puzzling symptoms characteristic of hysteria. Unless these processes can become better under¬ stood, it is unlikely that scientific, objective knowledge of this age-old disorder will advance. More specifically, this neurobiological theory hypothe¬
sented
sizes that the memory disorder will (1) be more marked during the presence of symptoms than during symptomfree periods; (2) be more prominent during anxiety or arousal testing conditions than during relaxed supportive testing conditions: (3) pertain primarily to recent memory, especially for tasks that require concentration, sustained attention, and the shifting of mental sets; and (4) pertain more to defects in retention and recall functions rather than perception and registration of information. Aside from certain predictions pertaining to stimulus intensity control and scanning control, the assessment of which require a variety of physiological and electrocortical proce¬ dures, the theory also predicts the presence of a fielddependent cognitive style that, in turn, should contribute to
heightened suggestibility.
Jhe present study, though
not
designed
to
provide
a
assessment of this theory, attempts to disconfirm most of the specific hypotheses
comprehensive
confirm or relevant to the cognitive functioning of patients with conversion hysteria. To our knowledge, this is the first such controlled study reporting objective performance data for patients with conversion hysteria.
Downloaded From: http://archpsyc.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/31/2015
Table 1—Symptoms Present ¡ Hysterical Conversion Patients Patient
Perception Triplopia
1
Consciousness Pass-out spells Pass-out spells Pass-out spells
Eidetic hallucinations
Unilateral blindness
Senso rium
Motor Function
Tingling extremities Tingling, hypalgesia
Dysarthna, staggering Weakness, right side
Multiple personality
Tingling, hypalgesia Hypesthesias
Incontinence
Numbness
Weakness, left leg
Purple spots Black-out spells Dizziness
Tubular vision 10
Black-out spells Black-out spells, dizziness Black-out spells Pass-out spells Pass-out spells Pass-out spells
Hypacusia, blindness 12
13 14
15 16 17
Tubular vision, dimness
SUBJECTS AND METHODS
pertaining
to perception, consciousness, sensation, or voluntary motor functions in the absence of demonstrable organic basis; (2) symptoms and signs that do not reflect anatomical functions, do not correspond to known neurological segmental distribution, and do not follow known principles of neurophysiologic response
patterns; (3) the magnitude or extent of the disability tends not to
directly severely with the preservation of survival functions; (4) presence of increased susceptibility to external suggestion; or (5) la belle indifference. Patients with a past or present history of major psychosis, organic brain syndrome, or any kind of drug dependence were excluded. The specific symptoms of these patients are summarized in Table 1. A control group of 17 hospitalized psychiatric patients (eight men and nine women), excluding those with psychotic reactions, alcoholism, and organic brain syndromes, were selected from the same wards. The specific diagnostic composition of this group included six patients with neurotic depression, four with obses¬ sive-compulsive personality disorders, five with passive-aggres¬ sive personality disorders, and two schizoid personalities. No patients in the experimental or control groups were taking psychotropic médication at the time of testing. Mean ages for the experimental control subjects were 32.8 and 27.8, respectively, and mean educational levels were 11.1 and 11.9 years, respectively. There were no significant differences between these groups for age, marital status, or level of education. A higher proportion of controls, however, came from urban settings ( 2 4.09; < .05). or
=
Procedure All subjects were told that the purpose of the study was "to learn about memory and concentration during psychiatric hospi¬ talization," and that participation was entirely voluntary. After a standardized interview for demographic and medical-psychiatric symptom information, subjects were scheduled for two separate testing sessions, one representing a "stress" and the other a "nonstress" condition. The order of administration of these condi¬ tions was random and they were spaced about one week apart. In the nonstress condition, the experimenter made numerous more
Partial mutism
Blepharospasm Trembling, weakness
Generalized numbness Numbness of body Numbness of body
Tingling
Astasia-abasia Poor sphincter control
Numbness
Seventeen hospitalized psychiatric patients (seven men and ten women), with the primary diagnosis of "hysterical conversion reaction" as established by at least two attending psychiatrists (who were unaware of the perceptual task results of this study), constituted the experimental group. All patients met at least four of the five following classical diagnostic criteria: (1) disorders
interfere
Numbness, hypesthesia Tingling of eyelids
empathie, supportive, lenient, and encouraging statements to subjects throughout the session, such as "you are doing fine," and "very good." In the stress condition, subjects were tested in the room used for electroconvulsive shock treatment and coldly told by the experimenter to complete the test to the best of their abilities. Paradoxical injunctions, such as "don't be nervous," were frequently made. A timer was also placed on the desk in front of the subject.
Testing
Instruments
The following six tests were administered to each conditions of nonstress and stress:
subject under
Recent Memory.-Guessing Technique (GT).-The method of Hinrichs,2 called the Guessing Technique, was employed as an
indirect measure for retention/recall functions of recent memory. In brief, this method consists of the random presentation of all the letters of the alphabet, each individually flashed by means of a slide projector. On presentation of a letter, the subject is to make a guess as to the next letter that will appear and repeat this for each letter presented. As a subject's recent memory fails, he begins to guess items that have already been presented. The occurrence of these incorrect guesses is the basic measure of memory loss. There are two restrictions to the guessing: the subject is not to ), and the guess the same letter until it appears (eg, A, A, A subject is not to alternate between two letters until one or the other appears (eg, , , A, ). The most important rule is to avoid guessing letters already presented. After one practice trial (a complete alphabet), the procedure is initiated for each subject individually. Each letter is flashed for eight seconds on the screen, during which time the subject is to guess the next letter. A full trial lasts about 3.5 minutes, and it requires 40 minutes to run ten trials. The scores obtained were the total number of errors. Paired Associates Test (PAT).-As another measure of memory, requiring somewhat longer retention of material than the Guess¬ ing Technique above and presumably independent of general intellectual functioning,1 a series of paired words with two levels of association strength were used. List A contained ten familiar associations-eg, blue-sky: List contained ten remote associations-eg, book-chalk. After explaining the task to the subject, the experimenter reads aloud all the paired words from list A. An interval of about five seconds is allowed between each pair of words. Then the experi¬ menter tests the subject by providing, in random order, the first member of each word pair (stimulus word), after which the subject ...
...
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Table 2.—Means for Multivariate Analysis of Variance (MANOVA) Suggestibility
Diagnosis Control
Hysteria Condition Nonstress
Stress_
Diagnosis
X condition Control Nonstress
Stress Hysteria Nonstress
Stress
Arm
Arm
Lowering
Lévitation
?:a2.}-
