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Regarding the diagnosis of "hysteria" and the problem of "medically unexplained symptoms", I think we need to tread very carefully. While it is true that some physicians act as if "...all medically unexplained symptoms [are] really just undiagnosed medical illness. .." and thereby deprive patients of needed psychological understanding and treatment, it is also true that some patients presenting with medically unexplained symptoms are summarily dismissed as "crocks"; or are told that the problem is

"all in their heads."

As I indicated in Dr. Awais's posting on "epistemic injustice," one of my mentors in consultation-liaison psychiatry--the late Ellen Cook Jacobsen MD[1]--used to say that "hysteria" is the last diagnosis a patient will ever receive. Why? Because every subsequent somatic complaint will be shrugged off by physicians as just another symptom of the patient's (typically, the woman's) "hysteria."

There is, of course, the risk of excessive and unnecessary laboratory and imaging "work up" that can be detrimental to good patient care--the so-called "check the serum porcelain level" approach to undiagnosed medical symptoms. But the flip-side is the risk of attributing so-called "psychiatric" symptoms, such as delusions or hallucinations, to purely psychological mechanisms when, in fact, an underlying neurological or "medical" problem is the culprit. I am quite sure Dr. Santhouse has encountered this problem in the course of his career.

One recent example is the misdiagnosis of schizophrenia (or a "functional" psychosis) in patients who have anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis. Though rare, some patients with NMDAR encephalitis may demonstrate only psychiatric symptoms without any neurological involvement during the first disease episode or in a relapse episode [2].

In short, the art and science of psychiatry is such that we must perform a careful balancing act in diagnosing and evaluating medically unexplained symptoms--lest "hysteria" become the last diagnosis the patient will ever receive.

Ronald W. Pies, MD

Professor Emeritus of Psychiatry

SUNY Upstate Medical University


2. Kayser, M.S., Titulaer, M.J., Gresa-Arribas, N., et al.., 2013. Frequency and characteristics of isolated psychiatric episodes in anti-N-methyl-d-aspartate receptor encephalitis. JAMA Neurol. 70, 1133–1139. DOI: http://dx.doi.org/10.1001/jamaneurol.2013.3216. Crossref, Google Scholar

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