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Functional neurological disorders—classically labeled as “hysteria”—are among the most common conditions leading to admissions to neurological services. This term has been abundantly criticized for both methodological and ethical reasons. More recently, a clinical commentary that appeared in January 2019 (Madva et al., 2019) emphasized a specific aspect of this criticisms: The authors appeal to drop the term “hysteria” because evidence from functional neuroimaging shows that these symptoms have a clear neurobiological basis and are therefore not “faked.” They first cite functional neuroimaging studies that show distinctive brain activations in patients diagnosed with “conversion weakness” 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 their symptoms” (p. e3). Second, the authors report further functional neuroimaging studies showing that patients with conversion symptoms have relatively less activity in the right temporoparietal junction (TPJ). This, the authors conclude, “may reflect a deficit in the pathway responsible for individuals' having a sense of agency over their motor function” (p. e4). In summary, patients with conversion disorders are not faking their symptoms but rather may have no sense of agency over them, which is why we should drop the term “hysteria.” We do value the authors' conclusion that we should no longer use the semantically incorrect and discriminating term “hysteria” and speak 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 in clinical training in psychosomatics, psychiatry, psychotherapy, and adjacent disciplines. However, we would like to take this opportunity to address a more fundamental point: The authors in this 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 dichotomy is abundantly used in both scientific research and clinical practice, but, in our opinion, is highly questionable for anthropological, clinical, and ethical reasons.

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