Subjective Aspects of Diagnosis

If there is nothing at all consistent in the medical condition of the patients who get diagnosed as "hysterics," are there other non-medical characteristics which get taken into account? What are the qualities in the patient which make the doctor call him a "hysteric"? It was possible to get some idea of this from the medical records; and these characteristics could then be listed in order of frequency, and seen in relation to the presence or absence of organic disorder on follow-up.

    Absence of relevant physical findings is, of course, one of the commonest. Nevertheless, as we have seen, the presence of some physical findings does not deter the doctor from diagnosing "hysteria" if he thinks they are non-relevant. This characteristic stands low in reliability. Physical findings which appear non-relevant at first may show their relevance later on, when the case is looked at with fresh eyes; and absence of physical findings applies universally to a stage in the development of all diseases.

    The motivating factor which comes second in frequency is the presence of a multitude of symptoms. Since it is unlikely that all the complaints of the polysymptomatic patient can be accounted for by any organic condition, it follows that some of them must be non-organic. But if some of them are nonorganic, why not all of them ? This, of course, is a very dangerous presumption; and one that ignores the effect of disturbances of bodily function on the emotional state.

    Next in frequency in the material studied was the existence of some evidence of psychogenesis. This was found about twice as commonly in the non-organic patients as in the organic ones, but in the latter it was far from infrequent. Unfortunately we have to recognize that trouble, discord, anxiety, and frustration are so prevalent at all stages of life that their mere occurrence near to the time of onset of an illness does not mean very much.

    Next in frequency is what might be called the suspect symptom, such as a history of aphonia or amnesia. Oddly enough these symptoms were about as frequent in the organic as in the non-organic patients. We need not be unduly surprised. As Guze and others have shown, conversion symptoms not infrequently arise on an organic basis. The difficulty for the clinician comes from the fact that these symptoms are very striking, and can often be removed by simple psychotherapeutic measures. Unfortunately, as it seems, the symptom may go, while the disordered state of the nervous system which made it possible persists unrecognized.

    Strong motivations for the diagnosis of "hysteria" are provided by the signs of certain personality traits. These may be shown in any tendency on the part of the patient to seek more attention than he is thought to deserve; any tendency to play up or to exaggerate symptoms; extraverted manners and lively phraseology; self-pity and self-concern; dependence and immaturity; any tendency either to over-react emotionally or to show what is thought to be belle indifference. All these phenomena seem to be entirely irrelevant to the formulation of a trustworthy diagnosis. People with, say, a histrionic temperament naturally lend the stamp of their personality to their symptoms, whether they are suffering from an organic or a neurotic disorder. All that one can say is that these modes of behaviour seem to constitute part of a stimulus-response system between patient and doctor. Unwittingly, inevitably, from his very nature, the patient applies the hystero-diagnostic stimulus; unwittingly, inevitably, from the long process of conditioned training through which he has gone the doctor reacts with the hystero-diagnostic response.