ANSWER 70
This patient has hysteria, now renamed as dissociative disorder. The clues to this are the
cluster of:
- the bizarre complex of neurological symptoms and signs which do not fit neuroanatom-
ical principles, e.g. the reflex responses and withdrawal to stimuli despite the paralysis - the patient’s lack of concern, known by the French term of ‘la belle indifference’
- the onset in relation to stress, i.e. the loss of her partner
- secondary gain: removing herself from the parental home which is a painful reminder
of her splitting from her partner.
None of these on its own is specific for the diagnosis but put together they are typical. In
any case of dissociative disorder the diagnosis is one of exclusion; in this case the neuro-
logical examination excludes organic lesions. It is important to realize that this disorder is
distinct from malingering and factitious disease. The condition is real to patients and they
must not be told that they are faking illness or wasting the time of staff.
The management is to explain the dissociation – in this case it is between her will to move
her leg and its failure to respond – as being due to stress, and that there is no underlying
serious disease such as multiple sclerosis. A very positive attitude that she will recover is
essential, and it is important to reinforce this with appropriate physical treatment, in this
case physiotherapy.
The prognosis in cases of recent onset is good, and this patient made a complete recovery
in 8 days.
Dissociative disorder frequently presents with neurological symptoms, and the commonest
of these are convulsions, blindness, pain and amnesia. Clearly some of these will require
full neurological investigation to exclude organic disease.
- Dissociative disorder frequently presents as a neurological illness.
- The diagnosis of dissociative disorder must be one of exclusion.