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At the end of the 19th century, several authors became interested in the physical and psychological symptoms resulting from traumatic life events. Oppenheim presented 42 detailed clinical observations. He suggested the term "traumatic neurosis." Charcot, who was interested in male hysteria, published over 20 cases of traumatic hysteria between 1878 and 1893. The symptoms were considered to have a dynamic or functional origin. The role of horror and terror during the trauma was emphasized. However, Charcot opposed the idea of traumatic neuroses as specific syndromes as he considered them to be only an etiological form of hystero-neurasthenia. In The Tuesday Lessons (Les Leçons du Mardi), he presents several observations. They are surprising when compared with the current criteria for posttraumatic stress disorder (PTSD). Although he had rejected this new entity, a hundred years before the appearance of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, Charcot described most of the symptoms mentioned for a diagnosis of PTSD such as intrusion (reliving the trauma, nightmares, and severe emotional distress), avoidance, negative changes in thinking and mood (negative thoughts, lack of interest, etc.), arousal, and reactivity (trouble sleeping, trouble concentrating, being easily startled or frightened, irritability, etc.).

Background: In the late 19th century, a man with a psychogenic movement disorder was evaluated by many of the Philadelphia neurologists associated with Silas Weir Mitchell. In 1885, prior to the development of movie cameras or projectors, the patient was photographed by pioneering photographer Eadweard Muybridge, in collaboration with neurologist Francis Dercum, using arrays of sequentially triggered single-image cameras. The photographic sequences are among the first motion picture sequences of patients with neurologic disorders., Methods: Examination of extant primary source documents concerning this patient, including published writings and photographic sequences by Muybridge and Dercum, the original clinical descriptions, Mitchell's documentation of the patient's later clinical course, and results of the autopsy., Results: Mitchell and his colleagues concluded that this was a "case of undoubted hysteria" in a man. Support for this contention includes the following: protracted course, spanning decades with temporary remissions; inconsistent character of the movement and features incongruous with typical "organic" tremors; complex, bizarre movements that are difficult to classify; increase in movements with attention; alteration in frequency of the movements with movement of the opposite arm; ability to trigger or temporarily stop the movements with unusual or nonphysiologic interventions; involvement of the opposite arm in a synchronous abnormal movement later in the course; remission with hypnotic suggestion; absence of other neurologic signs; and normal brain autopsy., Conclusion: The clinical history, serial examinations, photographic documentation, and autopsy results support Mitchell's contention that this was a case of male hysteria, or, in modern terminology, a psychogenic movement disorder., (© 2015 American Academy of Neurology.)

Four patients with the diagnosis of hysterical hemiparesis and normal magnetic resonance imagings were referred to us for further evaluation. All were being treated with antidepressant or antianxiety drugs or both, with no benefit. In all 4 cases single photon emission computed tomography revealed decreased regional cerebral blood flow in frontal regions in cortical areas corresponding to their neurologic deficits. In all 4 cases improvement followed neurologic treatment. We suspect that reduced blood flow in frontal regions may have produced the neurologic deficits. We call these conditions "pseudohysterical hemiparesis."

A bilateral sixth nerve palsy portends serious disease of the central nervous system and precipitates extensive patient studies. Spasm of the near reflex, characterized by intermittent convergence, accommodation, and miosis, is a functional disturbance. Five patients with hysterical spasm of the near reflex erroneously diagnosed as a bilateral sixth nerve palsy are reported. The pupillary sign, intense miosis on attempted lateral gaze, is emphasized as an important clue to the correct diagnosis. Despite extensive investigation, no disease of the central nervous system was found. Neurotic or hysterical features were evident in every patient.

In an attempt to validate recent assertions that the strongest indicators of hysteria are the "positive" findings in the neurological examination, seven of the most accepted features (history of hypochondriasis, secondary gain, la belle indifference, nonanatomical sensory loss, split of midline by pain or vibratory stimulation, changing boundaries of hypalgesia, giveaway weakness) were sought in 30 consecutive neurology service admissions with acute structural nervous system damage. All subjects showed at least one of these findings; most presented three or four. The presence of these "positive" findings of hysteria in patients with acute structural brain disease invalidates their use as pathognomonic evidence of hysteria. A second, retrospective study on the misdiagnosis of hysteria demonstrated that women, homosexual men, the psychiatrically ill, and patients presenting plausible psychogenic explanations for their illness are most liable to be misdiagnosed. Certain disorders, particularly movement disorders and paralysis, are most often mislabeled as hysteria. A diagnosis of hysteria must be made with great caution as it so often proves incorrect.

Simulated gait abnormalities involve weakness of 1 or both legs or ataxia and trembling. The patterns rarely duplicate those of neurologic disability and are usually promptly suspected of being functional by the experienced clinician. As with other pseudoneurologic signs, normal underlying neurologic function must be demonstrated. A dramatic cure is the best diagnostic evidence, and a bias toward organic etiology is warranted by a relatively greater risk in delayed diagnosis. Dystonia and chorea are the signs most likely to be mistaken for functional conditions. While CT and MRI now provide a welcome diagnostic safety net, the variety of hysterical gaits, and probably the effectiveness of "moral" treatment, does not appear to have changed appreciably in the past century.