Neuroscience Of Hysteria

A neuroscience of hysteria?
Matthew R. Broome
Purpose of review This paper reviews data from functional neuroimaging studies that have sought to determine the pathophysiology of motor conversion and sets it into a more conceptual framework of discussing the possibility of a scientific psychopathology. Recent findings Medically unexplained symptoms are real and not missed neurological morbidity;further, they are chronic and disabling. Imaging findings have suggested volition may or may not be impaired in motor conversion, and areas such as the anterior cingulate and dorsolateral prefrontal cortex have been implicated. Summary Hysteria is conceptually a difficult area to study scientifically, given the diagnosis being contingent upon unconscious mechanisms being posited. Given thisdifficulty, there have been some meaningful and elegant findings generated through the use of cognitive neuroscience. Keywords hysteria, conversion, dissociation, psychopathology, neuroscience
Curr Opin Psychiatry 17:465–469.
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Introduction
This paper sets out to explore from a conceptual and evidence-based perspective whether the methods of cognitive neuroscience, which have led to significantadvances in the scientific psychopathology of other psychiatric disorders, can be applied to and improve our understanding of hysteria. In this review, the diagnostic criteria for dissociative and conversion disorders will be discussed, a review of recent functional neuroimaging findings in hysteria will be outlined, and methodological concerns in the functional imaging of psychopathology generally,and medically unexplained neurological symptoms specifically, will then be addressed. Finally, possible means of refining future research in this area will be proposed.

Cognitive neuroscience and hysteria
The cognitive neuroscientific approach to the study of psychopathology has yielded impressive findings [1,2]. In the clinical practice of neuropsychiatry, three broad areas of work can bediscerned: neurological disease with psychiatric comorbidity, neurological disease that presents psychiatrically, and lastly, psychiatric illness that presents neurologically [3]. This last group includes all ‘medically unexplained’ symptoms and signs that present as a neurological problem; for example, paralysis, sensory abnormality or seizures. Patients with medically unexplained neurological symptomscan make up to onethird of new attendees at a neurology clinic [4] and tend to remain symptomatic [5 .,6 .]. Such symptoms are rarely explained subsequently by either a missed neurological disorder or subsequent development of such a disorder [5 .,7]. The notion of hysteria has changed over the years [8,9], but the concepts of dissociation and conversion remain enshrined in internationalclassifications [10,11]. Thus, the diagnosis of such disorders requires the clinician to posit a psychological aetiology. For a World Health Organization diagnosis [10], the clinician must be satisfied by ‘evidence for psychological causation, in the form of clear association in time with stressful events and problems or disturbed relationships (even if denied by the individual)’ (p. 153), while for theAmerican Psychiatric Association classification [11], ‘psychological factors are judged to be associated with the symptom or deficit, a judgement based upon the observation that the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors’ (p. 452). The explicit incorporation of unconscious, nonintentional mechanisms serves to differentiate such diagnoses from thewilled and conscious production of symptoms.
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2004 Lippincott Williams & Wilkins.

Section of Neuroimaging, Division of Psychological Medicine, Institute of Psychiatry, London, UK Correspondence to Matthew R. Broome, Lecturer, Section of Neuroimaging, Division of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK Tel: +44 20 7848 0355; fax: +44 20 7848...