On the Purported Dichotomy Between Fake and Real Symptoms: The Case of Conversion Disorders

摘要

Functional neurological disorders—classically labeled as “hysteria”—are among the most commonconditions leading to admissions to neurological services. This term has been abundantly criticizedfor both methodological and ethical reasons. More recently, a clinical commentary that appearedin January 2019 (Madva et al., 2019) emphasized a specific aspect of this criticisms: The authorsappeal to drop the term “hysteria” because evidence from functional neuroimaging shows that thesesymptoms have a clear neurobiological basis and are therefore not “faked.” They first cite functionalneuroimaging studies that show distinctive brain activations in patients diagnosed with “conversionweakness” as compared to healthy subjects instructed to mimic a motor deficit. They conclude that“[. . . ] these findings suggest that patients with conversion weakness are not simply faking theirsymptoms” (p. e3). Second, the authors report further functional neuroimaging studies showingthat patients with conversion symptoms have relatively less activity in the right temporoparietaljunction (TPJ). This, the authors conclude, “may reflect a deficit in the pathway responsible forindividuals’ having a sense of agency over their motor function” (p. e4). In summary, patientswith conversion disorders are not faking their symptoms but rather may have no sense of agencyover them, which is why we should drop the term “hysteria.” We do value the authors’ conclusionthat we should no longer use the semantically incorrect and discriminating term “hysteria” andspeak of “functional disorders” instead. This transition, though, has been made many years ago(before functional neuroimaging provided the above cited evidence), and is already incorporated inclinical training in psychosomatics, psychiatry, psychotherapy, and adjacent disciplines. However,we would like to take this opportunity to address a more fundamental point: The authors inthis opinion article implicitly assume a basic dichotomy between “fake” and “real” symptoms,between “sense of agency” and “no sense of agency” in a rather categorical way. This dichotomyis abundantly used in both scientific research and clinical practice, but, in our opinion, is highlyquestionable for anthropological, clinical, and ethical reasons.