Editorial Hysteria

Editorial doi:10.1038/sj.sc.3101327

Hysteria

Hysteria has a long and complicated record. A contradictions, and realised improbabilities with a narrative which is unlikely to have a basis in a mysterious versatility. . . .' Freud also used the term pathological entity unchanging throughout its history. conversion hysteria: `In hysteria, the incompatible idea The earliest record is probably an Egyptian medical is rendered innocuous by its sum of excitation being papyrus dating from around 1990 BC recording transformed in to something somatic. For this I peculiar abnormalities produced by movement of the would like to propose the name of conversion'. Freud uterus, moving upwards from the pelvis, applying invoked, at ®rst, sexual trauma, and then sexual pressure on the diaphragm and giving rise to bizarre fantasy as the key pathogenic factor with the physical and mental symptoms. Plato (c. 429 ± 347 BC) emphasis, therefore, on psychological mechanisms, ie continued the descriptive language to evoke what men the repression of remote traumatic memories invari- found particularly irritating or incomprehensible about ably sexual in content. women `The animal within them is desirous of Over the last century or so there has been a decline procreating children, and when remaining unfruit- in the recorded incidence of hysteria, partly perhaps ful . . .gets discontented and angry, and wandering in due to a sexual liberalisation but also to the fact that every direction through the body . . .drives them to many previously described symptoms and syndromes extremity, causing all varieties of disease . . .'. Hippo- are now reassigned to organic disorders and the crates (c. 460 ± 377 BC) described how the female psychoses and psychoneuroses. In the past hysteria reproductive parts, moving, convulsing or prolapsing has not only produced brilliant clinical observation caused dizziness, motor paralysis and sensory dis- and neuropathological and psychological research, it turbance. Galen (AD 129 ± 216?) regarded the cause as has also been the vehicle for sensationalism and being due to the retention of excessive menstrual misogyny. blood. The obvious problem when confronted with a The onset and expansion of Christian civilisation patient with unexplained neurological or other com- produced a change towards the supernatural and plaints is making an accurate diagnosis and, in this hysteria was regarded as a sign of possession by the particular case, to rule out other physical and devil. Advances in the understanding of the human psychiatric disorders which require treatment. There nervous system produced a shift from gynaecological are modern diagnostic criteria but there remains and demonological theories. Thomas Willis (1621 ± confusion. The Diagnostic and Statistical Manual of 1675) thought that an excess of animal spirits was Mental Disorders (American Psychiatric Association, released from the brain and carried by the nerves to 1994, 4th Edition) does not show full agreement with eventually enter the blood stream and circulate the ICD-10 classi®cation (World Health Organisation, throughout the body. Robert Whytt (1714 ± 1766), The ICD-10 Classi®cation of Mental and Behavioural who ®rst described the phenomena of spinal shock, Disorders, Clinical Descriptions and Diagnostic thought that the disorder was caused by a disturbance Guidelines, 1992). In the DSM-IV, conversion disorder or weakness of the nerve ®bres. Charcot (1825 ± 1893) is classi®ed with the somatoform disorders, whereas felt that hysteria was a dysfunction of the central dissociative symptoms such as hysterical fugue states nervous system. Briquet, a nineteenth century French are classi®ed under dissociative disorders. The ICD-10 neurologist, has, somewhat dubiously, been credited classi®cation groups them altogether under neurotic, with the ®rst description of the syndrome of hysteria, stress-related, and somatoform disorders. The term and always insisted that it was a neurological disorder. hysteria has been dropped from both classi®cations Briquet's Syndrome is now known as somatisation although it is still widely used in practice. DSM-IV disorder, although the symptoms that Briquet actually criteria for somatisation disorder (Briquet's Syndrome) described show a greater resemblance to conversion includes: disorder. The term historical conversion was introduced by . Four or more unexplained bodily pains John Ferriar: `In hysterical conversion the body . Two or more unexplained gastrointestinal possesses a power of representing the most hazardous symptoms disorders . . . of counterfeiting the greatest derange- . One or more pseudo-neurological symptom ment . . .has in this class of diseases, reconciled . One or more sexual or menstrual symptom Hysteria LS Illis 312

Conversion disorder includes one or more symp- theory, and feel that the term conversion if used at all toms or de®cits aecting the motor or sensory function should refer to symptoms which mimic neurological which are not fully explained by general or medical disease (such as amnesia, paralysis, blindness . . .). conditions. Wessely (in Contemporary Approaches to The usual presentation in clinical neurology is either the Study of Hysteria, Ed. Halligan, Bass and of a chronic illness with many symptoms, often Marshall, OUP, 2001) points out that the formal dramatically or histrionically presented, with no diagnostic criteria for hysteria are unsatisfactory and evident cause and this is mainly found in girls and includes, amongst others, the following reasons: `We women, or an illness which is mostly found in men, keep changing them, they were invented by psychia- but occasionally in women, where there are physical trists but are used by neurologists, they have too many symptoms or disability with no obvious neurological categories. . . .' He suggests that the classic psycho- cause and usually, if not always, associated with analytic derived criteria for conversion disorder should compensation or litigation or avoiding military duty. be dropped, and that we should classify in clinically The study (perhaps meditation is a better word) of relevant ways `the suggested distinctions that appear hysteria goes far beyond conventional medicine. For to have some empirical and practical validation would example, Descartes felt that mind and matter were not be a diagnosis that continues to insist that either comparable, and the history of hysteria may be seen as symptoms and/or loss of function be inexplicable in an ongoing attempt to solve, or at least theorise, about conventional biomedical terms, and then distinguish his dualistic philosophy. between symptoms and loss of function, and between For something like 4000 years the subject of acute and chronic onset of either'. hysteria has re¯ected attitudes about health, about Many neurologists see no merit in the separation of religion and about relationships between the sexes and dissasociative type of hysteria and a conversion type, the interest raised by this extraordinary condition is based on dubious or unsubstantiated psychodynamic likely to continue. LS Illis

Spinal Cord