|Year : 1972 | Volume
| Issue : 4 | Page : 173-178
Hysterical blindness versus malingering
Safdarjung Hospital, New Delhi, India
N C Singhal
Safdarjung Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singhal N C. Hysterical blindness versus malingering. Indian J Ophthalmol 1972;20:173-8
Emotions play a varying role in the body and mind. In ophthalmology, there are many eye conditions which have Arisen, wholly or partly as a result of emotional factors and labelled as psychosomatic. The term "psychosomatic" comes from "psyche" and "soma", meaning "mind" and "body".
Vision is of prime importance in every day's life because most occupations are essentially visual or visuocerebral in nature. Hence it is not surprising that funtional disturbances of psychosomatic origon, on account of some mental conflict, are probably more common in the eyes than in any other organ of the body.
One of the commonest functional disorder in ophthalmology is the hysterical reaction in which a subconcious wish is achieved by the production of a symptom. The commonest symptom presented is essentially a total or partial loss of vision.
A malingerer usually has the same complaint as a hysterical patient. It is due to an emotional drive-purposeful in nature i.e. to avoid something unpleasant such as military duty or to make a capital on an injury. It is therefore important to differentiate between the two because management in each case is diametrically opposite.
| Hysterical Blindness|| |
The commonest presentation of of hysterical reaction is defective visual acuity which is often the only symptom. It is usually bilateral and partial and labelled as hysterical amblyopia and rarely complete called amaurosis. Frequently the visual acuity is 6/60 or 6/36 in each eye. Examination of pupils, media and fundi including refractive errors is normal. The patient's demeanour is typically detached and indifferent and there appears a lack of appreciation of the apparent gravity of the defect. Having stated his symptom he does not attempt to enlarge upon it or exaggerate it.
When no abnormality is detected to account for the complaint, charting of the visual fields is the next important test. Hysterical amblyopia is diagnosed by the presence of tubular fields because nothing but hysteria will produce tubular fields except retinitis pigmentosa. The characters of tubular fields are:
(i) They are of the same size no matter at what distance they are charted. Usually the charting is done at distances from 2 to 4 meters and the size will remain essentially constant; any increase or decrease in size will be within a narrow range.
(ii) The fields have sharp margins so that different test objects will give the same isopters.
(iii) The fields are typically circular in shape, as though drawn by a compass, and do not show the normal widening to the temporal side.
There are other types of field defects occasionally met with in hysterical amblyopia such as spiral fields, ring scotoma and hemianopia but all have two distinct featues i.e. sharp margins and no change in size with distance.
| Hysterical Amaurosis|| |
The diagnosis of hysterical blindness is more difficult than that of amblyopia. The two important features are (1) suddenness of onset (2) normal ophthalmoscopic findings. Organic bilateral amaurosis is rare with clinically normal eyes but may be due to: (1) bilateral retrobulbar lesions (2) chiasmal lesions (3) bilateral lesions of tracts or radiations (4) bilateral cortical lesions. Since it is rare for organic lesions of a bilateral and severe nature to occur suddenly, the above two features are of great value in the diagnosis.
Patients with hysteria are typically amenable to suggestive therapy. Attempt has to be made to gain the confidence of the patient. Changing of plane lenses back and forth, or adding plus and minus lenses of equal power in order to exhort the patient, will make him read lower and lower on the chart. A hysteric patient will read everything in a hesitating manner. Such successful treatment, however, is seen in cases of recent onset. Longer the duration of the disease, more difficult the treatment because in these cases frequent unsuccessful visits to a doctor and growing sympathy of the well wishers of the patient will encourage the state of mind which tends to perpetuate the hysterical reaction. Examination with larger and more mysterious instruments, pretended operations, injections of distilled water, ether anesthesia, carbon dioxide therapy, perscription of glasses and psychotherapy are the various measures which one can undertake. Inspite of all these the prognosis may be poor.
Following two cases demonstrate the result of treatment in hysterical amblyopia of different durations.
CASE 1: A gecko fell on the left eyebrow of a gril of 14 years. This was followed by lot of crying and horror by the patient and the sympathy of the others in the house. After settling down and a few hours later she reported to her mother that she could not see anything by the left eye. Next day when brought to the hospital, it was found that she had vision of 6/6 in the right eye and only perception of light in the left eye. Examination revealed nothing. She was assured that vision will come. A drop of argyrol was put in the eye and a dose or carminature mixture with Tr. cardemum as a colouring agent was given. Then as testing with plane lenses continued, she began to read on the vision chart and in about 10 minutes she read 6/9 line. But reading was all the time in a hesitating manner. She was advised to continue the same drop and mixture as placebo and return after 48 hours. On the next visit her vision was 6/6 unhesitatingly. She was also prescribed Eskazine ½ mgm b.d. with a view to distract her mind from the incidence.
CASE 2: A girl aged twenty had her tonsils removed in April 1969. This was followed after a few days by secondary haemorrhage which was controlled in time. The patient had heard from some one that bleeding from the operation and removal of a tooth often leads to defect in the vision. A fortnight after the heamorrhage she started complaining of defective vision in the right eye. The parents consulted a doctor in the hospital after a month. As usual in a busy public hospital, she was given a date for refraction under mydriasis. This resulted in further delay and frequent visits to the hospital. In the meantime she developed similar defect in the other eye. In order to determine the cause of defect the patient was subjected to various tests including lumber puncture, several x-rays of skull and orbit, blood tests and even encephalograms and carotid angiography but all were normal. By Jan. 1970 her vision was reduced to perception of light in the right eye and finger counting at one metre by the left eye. It was at that stage that we saw her first. She was always wearing dark glasses even at night and had her younger brother as an attendent. Lot of sympathy was shown by the parents because she was of marriageable age. She was admitted in the ward to watch her actions. It was seen that when her brother was not present she did not find difficulty in her movements and having developed an intimacy with a child patient, she used to play with him. Whenever a medicine was given, she would insist in knowing its name and would first feel in her hand. She resented the glasses to be taken off. By some assurance and by putting + 10 D lens in front of the left eye, she could count fingers at two feet by the right-eye without knowing which eye was being tested. When I revealed the diagnosis of hysteria to the parents, confidence was lost in me and they removed the patient. Some one had created the idea of brain tumour and they were interested to make a trip to the Vellore hospital at government expenses, being a government servant.
| Malingering|| |
Malingering is to mislead wilfully in regard to the existence of a disease in order to gain a desired end. Duke Elder describes several types of malingering.
1. Simulation: feigning of a nonexistent disease.
2. Exaggeration: the pretence that a certain condition is worse than it actually is..
3. False attribution: assignment to a disease or injury of an origin other than the real one.
4. Dissimulation: the pretence that a disease does not exist or that its effects are less than they actually are. It is thus a form of reverse malingering and is found in candidates for insurance or entry into service.
A malingerer usually complains of defective vision which may be divided into three classes: (1) total blindness in one eye, (2) partial blindness in one eye, (3) total or partial blindness in both eyes.
It is far simpler to suspect the malingerer than it is the psychosomatic patient although both have the same complaint. The similarities between hysteria and malingering are due to the fact that the patient with hysteria is malingering on a subconscious level, whereas a maligngerer is malingering on a conscious level. There are two basic approaches to the diagnosis of malingering: (1) a psychological assessment of the patient, (2) trapping the patient with various tests.
Psychological approach: This is based on a knowledge of the individual and upon his behaviour. The reaction of the patient during examination such as disgruntled and aggressive behaviour, the desire of uncooperating or overplaying his part should be noted.
Test Approach: A large number of tests are devised but the most important feature in the successful use of these is that the examiner should be well versed and carry them out rapidly and easily.
Tests for Total Blindness in one eye
(1) Binocular alignment : Upon testing the eyes for extraocular movements, both eyes move equally in all directions and keep their fixation on the target. An eye that is severely limited in vision will fail to follow the parallel movement.
(2) Objective prism test: If a high prism is placed base out in front of an eye, it will normally move inward involuntarily, to fuse the two images. A blind eye will not make any movement.
(3) Prism stairs test: Place a high base up prism before the blind eye and have the patient rapidly ascend and descend a stairway. If the eye is not blind he will be bothered by the diplopia.
(4) Bar reading test: When a patient is reading small type, a pencil is held by the examiner in front of the card. If one is blind, he will have to move his head to continue reading when the pencil gets in the way. If both eyes have good vision, he reads uninterruptedly.
(5) Duane's method: When a patient is reading aloud rapidly, place quickly a high prism base down before the allegedly blind eye. If the eye is blind, there will be no effect on reading. If there is vision in the eye, patient will stumble in his reading.
(6) Double prism test: A base tobase double prism is properly aligned in front of the good eye and an opaque disc is put before the "blind" eye. A card with a horizontal line is shown to him. He should see two lines but to prove his blindness in one eye he will pretend to see one line.
(7) Pinhole test: A pinhole disc is placed in front of the good eye while the "blind" eye is left uncovered. While he is reading, the trial frame is tilted slightly so that the hole gets out of the visual axis. If he continues to read he is doing so with the "blind"' eye.
(8) Plus 10 reading test: A plus 10 D lens is placed in front of the good eye. Such a lens has a focus at 4 inches. A reading card with fine print is held at that distance and gradually moved away while the patient is engrossed in his reading. If he continues to read he is doing so with the "blind" eye.
(9) Friend test: The patient wearing red and green goggles is asked to read the coloured word "Friend". The red and green glasses and the red and green letters should be of complimentary colours. If he reads all the letters of the word, he is using both the eyes.
(10) Synoptophore test: Show the patient a pair of fusion pictures in the synoptophore i.e. rabbits. If he sees both the controls, he clearly has good vision in each eye.
(11) Bishop-Harmn diaphragm test: Show the patient letters on this instrument. He does not know that he sees the left hand letters with the right eye and vice versa, and may well read only the letters seen by the pretended blind eye.
Tests for partial blindness in one eye
1) Jackson's convex and concave cylinder test: A plus 6.00 cylinder and a minus 6.00 cylinder are placed with their axes superimposed in front of the good eye so that one lens neutralizes the other. While the patient is reading the distant chart, the front cylinder is gradually rotated until its axis is perpendicular to that of the other, so that if the patient is still able to read he is doing so with the poor eye.
(2). Special test cards: Malingeres frequently read only the first line on the chart i.e. a vision of 6/60. If the top letter is made of the size for 6/24 line, and if he reads this he has a vision of 6/24 line, and if he reads this he has a vision of 6/24.
(3) Mirror test: A mirror is placed on the wall alongside of the test chart and a similar chart, with letters reversed is placed above the head of the patient. The patient first reads the regular chart and then the same line on the mirror. Since the distance is twice as great in the mirror the vision is twice that of the chart on the wall.
(4) Amblyoscopic test: The tubes of the instrument are so arranged that the images are crossed when looking through them. If the patient claims his right eye to be blind, he will see the picture only on the left side thinking that he is seeing with his left eye. The examiner has to be careful that the patient does not wink his eye to know the secret of the test. This test is a proof of deception, either conscious or subconscious and can be demonstrated to any one.
(5) Cycloplegia test: Some cycloplegia is used in the normal eye and normal saline in the other eye. The patient is asked to read. Since the normal eye cannot read because of paralysed accommodation, ability to read gives a proof of malingering.
Tests given for complete blindness in one eye above may also be used for partial blindness.
Total or partial blindness in both eyes
It is rare for a malingerer to claim loss of sight in both eyes. Hysterical patients usually come with bilateral defective vision. The following tests are used for feigned total or partial blindness in both eyes:
Menace reflex: A sudden surprise movement of the examiner's hand towards the face of the patient often causes the patient to blink. Even if he learns to suppress a blink, such a patient will have an increase in the pulse rate.
Prism test: A base-in-prism is placed in front of one eye. If the vision is present, the eye will move outward and then inward when the prism is removed.
(3) Opticokinetic nystagmus test: When a patient is asked to look at a rotating drum marked with vertical stripes, he will develop nystagmus with fast and slow components if he has enough vision to see the drum.
The above tests are useful for total blindness in both eyes. Detection of a malingerer with bilateral partial blindness is rather a difficult task. Examination of one eye at a time by various tests given previously will be helpful.
After a thorough examination of the eyes the field is narrowed down to hysteria or malingering. Hysteria may also give positive results on the many different malingering tests so that the examiner has to be careful in diagnosing the case. The appraisement of the patient as a whole with a knowledge of the background has to be done. Hysterical amblyopia is usually bilateral whereas the malingerer usually feigns blindness in one eye. The hysteric typically enjoys the examination, whereas the malingerer is sulky and resentful of any tests. The most important test is the charting of visual fields at different distances. A tubular field typically belongs to a hysteric while in a malingerer it can be of any shape other than tubular.
In this connection the approach to the patient is very important. A hostile or rough attitude towards the subject is responded by an increasingly hostile attitude from the patient. To tell him that he is hysterical or is a malingerer from the start would be fatal. The approach should be friendly so that the subject is made to feel that the doctor believes in his "blindness". Placeboes play a great part in converting the patient to his own real state. Forthrite accusal of a hysterical state is resented not only by the subject but his near relations.
Secondly, it is as important to consider the accompanying relations as the subject himself. Case No. 2 amply illustrates this point where the parents could not be convinced in spite of definite proof. Successful treatment therefore needs a careful and a sympathetic approach.
As far as malingering is concerned there is a battle of wits between the subject and his doctor, a struggle in which a clever and well-informed malingerer may come out on the top. He wants to outwit the doctor. Let the doctor be on his guard and he must enter and face this battle of wits with equanimity, dignity and resource.
| Conclusion|| |
Life is complex and full of stress. Emotional conflicts keep on occurring in the day to day life of an individual but they are successfully faced with a balanced mind. At times the emotional conflicts result into an "anxiety" which in turn may create symptoms. Man will not tolerate anxiety for long and uses various defensive mechanisms to overcome it either subconsciously or at conscious level. If our objective examinations do not explain the cause of the symptoms or the symptoms do not correlate with the clinical findings, we must explore the mind of the patient. Blindness may be not only the inability to see but may be the desire not to see. We ophthalmologists should realise that a thorough understanding of the human eye is not enough. We must understand the human being of which the eye is but a small part.
| References|| |
Adler, F. H.: Textbook of Ophthalmology (1962), 7th Ed., W. B. Saunders Co., London.
Duke-Elder: Text Book of ophthalmology (1949) Vol. 4, Henry Kimpton, London.
May and Worth: Manual of Diseases of the Eye (1954) Bailliere, Tindall and Cox, London.
Walsh, F. B., Clinical Neuro-ophthalmology (1957). William and Wilkins Co. Baltimore.