Hysteria Diagnosis is Now Called a Conversion Disorder
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In understanding the stain that the hysteria diagnosis has left on our medical science, it is important to distinguish “hysteria” from PTSD. The modern term for the hysteria diagnosis (if there should even be a modern term for it) is “Conversion Disorder”. See DSM-IV 300.11. PTSD is an entirely different matter as it relates to the development of specific emotional problems, as a result of emotional trauma. In Conversion Disorder, the emotional issues of the patient (not traumatically induced symptoms) are converted into physical problems. In Myers’ case studies, he attributed the neurological symptoms of his soldiers to this type of “hysterical” conversion of emotional problems.
The DSM-IV criteria for Conversion Disorder, which replaces the classic Hysteria Diagnosis, stresses the likelihood that the patient have a prior history of psychosis.
“A history of other unexplained somatic (especially conversion) or dissociative symptoms signifies a greater likelihood that an apparent conversion symptom is not due to a general medical condition, especially if criteria for Somatization Disorder have been met in the past.”
While such criteria were not formally laid out in his time, Myers seemed to sense the need to show that his soldiers were psychologically weak before labeling them as having a hysteria diagnosis. With respect to Soldier #1, he said:
“Prior history. –He had been for two months in the Aisne district on the lines of communication, sleeping badly all that time owing to lumbar pains (and toothache during the first three weeks.) He had failed to pass a medical examination some time previously because of renal trouble (abnormal amount of albumin in water) until after a long period of treatment. He had had lumbar pains a few nights before coming to France.”
The significance of the reference to the lumbar pains, seems to be the implication that the emotional stress of coming combat had brought them on.
With respect to Soldier #2:
“As to his past history, he came out to the war on August 13th, and was in the last two days’ retreat at Mons and after at La Bassee. Has slept very badly since the start, often when billeted taking large doses of whisky to procure sleep. Has led a ‘fast’ life and has had recent domestic worry.”
While he has no comment on the prior history of Soldier #3, he stresses the nervousness of the soldier in his narrative.
“A healthy looking man, well-nourished, but obviously in an extremely nervous condition. He complains that the slightest noise makes him start…. His hands became very tremulous and his forehead sweated profusely. He appeared as if about to faint, and says that he felt cold and dizzy, and experienced “round and round movements of the stomach…. He complains that he gets very excited when anyone addresses him.”
The use of these implicit (without direct comment on their relevancy) comments by Myers is strongly reminiscent of the character assassination found in Defense neurological and neuropsychological opinions. No where does Myers say these symptoms are related to these character issues, just the “no comment seems necessary.”
While Myers wasn’t working with a formal diagnostic criteria for a Hysteria Diagnosis, the modern definition of Conversion Disorder does at a minimum require ruling out all medical explanations for the neurological symptoms.
“A diagnosis of Conversion Disorder should be made only after a thorough medical investigation has been performed to rule out an etiological neurological or general medical condition. Because a general medical etiology for many cases of apparent Conversion Disorder can take years to become evident, the diagnosis should be evaluated periodically.” DSM-IV, page 493.
Myers failed to Rule Out Other Medical Explanations
Did Myers rule out all medical conditions for the neurological symptoms? Of course not. As discussed in the previous parts, there are clear neurological, biomechanical and pathological explanations for the amnesia and the anosmia. Much is made by Myers of the partial visual complaints of these three soldiers. Yet other Cranial Nerve damage can account for many of these phenomenon, even without any damage to the eye, or the Optic Nerve. There are references to Soldier #3’s stomach complaints, but anyone acquainted with the vestibular system should recognize these symptoms as being explained by vertigo: “He appeared as if about to faint, and says that he felt cold and dizzy, and experienced “round and round movements of the stomach.” See http://vestibulardisorder.com
Further, the reports of sweating and feeling like he is about to faint, is clearly explained by a condition called POTS (postural orthostatic tachycardia syndrome), which would also cause the vertigo. POTS, vertigo, cranial nerve damage – are all clear markers of traumatic brain injury.
The Character Assassination Implicit in Hysteria Diagnosis
Soldier #1 back pains prior to deployment; Soldier #2, heavy drinker with domestic problems. While there might be emotional explanations for increasing back pain under extreme stress, that isn’t the type of deep psychosis which would explain an extremely rare Hysteria Diagnosis. As for his attacks on Soldier #2’s character, one must ask: How many soldiers are heavy drinkers? What soldier doesn’t have some worry about his marriage, his family while deployed in a combat zone?
Sleep Common Symptom of Brain Injury
Myers discusses sleep with each of his soldiers. But a hysteria diagnosis versus organic injury to the brain and neurological system because of pre-morbid problems with sleep, makes as much sense as stating that these soldiers were carrying a gun at the time they were shelled. The soldier who sleeps well, like a soldier who doesn’t carry a gun, is not a soldier to fare well in combat.
Combat requires hypervigilance. The soldier who sleeps soundly, especially in World War I, is the soldier who is in peril. One of the most cogent theories of PTSD is that it is a result not of the specific instances of emotional shock, but as a result of the constant need to be hyper-aware. It is the never sleeping well, the need to be always ready to reach for the gun, to leap for cover, that may be the hardest thing for the combat veteran to wind down from. It may be the inability to shut off the mechanism to never truly sleep, to dream, that causes the surrealistic elements of post combat stress.
We will next discuss the elements of PTSD, its roots in combat, and its questionable applicability to more routine civilian stressors. But before this commentary leaves Myers behind, I do want to stress one important point:
Myers was not wrong to factor in the terror at the time of the injury and the precedent emotional vulnerability of the patient. His mistake was to miss the clear organic evidence of brain trauma, brain damage. It may be the terror or the emotional makeup of these specific soldiers, made them more likely to be disabled by the blast injury that might not have disabled a stronger individual. But the diagnosis must begin with a full differential consideration of brain or neurological damage. Once brain damage has been identified, it is fully appropriate to incorporate the synergistic interplay of the vulnerability of each individual, the additive factors of the combat stress such individual was under, and the emotional impact of such injury, on that particular brain.
Myers may not have had all the tools of modern medicine available to him, but he did have the most important: history and examination. He took the history, seemingly quite accurately. He did the examination better than most modern doctor s (especially with respect to the Olfactory Nerve). Where he failed, and perhaps because of British unwillingness to believe the brain could be so easily damaged, was in not believing the realness of his own findings. His soldiers couldn’t smell. They couldn’t remember. They had neurological explanations for the vast majority of their symptoms. Combat emotional stress could certainly explain the rest. Brain injury, by any other name, will still disable.