Paris/Beaune (France) : 8-12 juin 1998
Paris/Beaune (France) : June 8-12, 1998

What happened
to hysteria ?

P.R. McHug, Baltimore, Etats-Unis

  • Hysteria is one of the great words of psychiatry - right up there with mania, delirium, and dementia. But, that may be its biggest problem. The noun, hysteria, suggests something a patient has - an illness or disease. But, hysteria is not something a patient has, it is something the patient does - i.e. it is a behavior. The patient with hysteria is acting in such a way as to imitate the symptoms or signs of a medical or psychiatric disorder. This behavior has changed over time but has not disappeared.

    Consider this more comprehensive definition : hysteria is a behavior - engaged in more or less unwittingly - that imitates a medical, surgical, or psychiatric disorder through such actions as complaining of " symptoms " or producing " signs " of affliction all with the goal of achieving the social status of a " sick person " where certain privileges, considerations, and attitudes from others can be expected. Even this definition needs some elaboration to resolve the remaining ambiguities tied to the behavior.

    The " more or less unwittingly " phrase bracketed within our definition broaches the idea that these people are not frauds or malingerers. The human power of self-deception can bring many people to believe in the validity of " symptoms " that offer them advantages. They are not so much trying to deceive the doctors as they are deceiving themselves and everyone else with the idea that they are sick.

    Indeed, the goal of appearing sick is not calculatedly chosen so much as it is gradually assumed as advantages emerge, implications are felt, and encouragement is received. The patients learn the behavior. This explains why many manifestations develop and change over time ­ shaped by the responses of observers ­ and why many patients, on recovery, report that they had to struggle to retain their own belief in their " sickness ".

    An acute hysteria is usefully differentiated from a chronic form. Acute hysteria ­ subsumed in DSM IV as conversion and dissociative disorders

    ­ is the relatively abrupt appearance of an artifactual set of signs and symptoms that call attention to themselves. Patients with chronic hysteria

    ­ the form subsumed in DSM IV as somatization disorder or briquet's syndrome ­ are characterized by habitual complaints of symptoms such as pains, faintness, abdominal cramping, nausea, coughing, shortness of breath that turn out to be groundless and artifactual.

    The belief that hysteria is disappearing is incorrect. At Johns Hopkins Hospital about 2.5% of the patients seen in psychiatric consultation have some form of hysteria. The chronic variety is more commonly seen on the medical services while the acute form shows up on the neurological and psychiatric wards.

    Hysteria is not disappearing but has taken on less conspicuous guises as people learn what can pass as disease today. The previously common expressions of motor-sensory dysfunctions as in convulsions and choreo-athetotic writhings have been replaced with subtle disorders of psychological functions such as amnesia or alterations in consciousness. Multiple Personality Disorder is the best contemporary example of the trend. The natural hosts of hysterical behaviors are the immature, the dependant, the burdened, the emotionally unstable - those predisposed to fears and conflicts who may lack the capacity to find efficient ways to solve their problems. They may be embittered and inclined to imagine mistreatment. Some may be especially prone to influence and suggestion - a personality disposition correlated with being highly hypnotizable.

    Karl Jaspers noted a zeal for exaggeration and drama amongst these patients and characterized them as " craving to appear, both to themselves and others, as more than they are and to experience more than they are ever capable of ". Fascination with one's self and its corollary preoccupation with how one is viewed by others are embedded in this temperament. Such people -- often but not always youthful ­ are prone to opinions and behaviors that, they believe, mark them as having some special social standing - in particular giving them the glamour of intellectual complexity, spiritual depth, or dramatic and unsuspected suffering. The conjunction of this disposition with life circumstances where the individual feels neglected or senses disinterest from others can promote hysterical demeanors crying out for attention.

    Several social agents can provoke hysteria. All act to teach ­ indeed to seduce ­ patients into self-deceptions about their health. These agents may provide models of disease, act as transmitting vectors amplifying social concerns about danger and disorder, or shape pre-existing concerns of patients into dramatic manifestations. As an example, one person with hysteria can act so dramatically as to " infect " others with the idea that they also are sick producing astonishing but usually short-lived epidemics of acute hysteria in a school, an office, or a convent. Unsuspecting physicians may suggest symptoms in the course of examining troubled patients - as did Jean-Martin Charcot who, when directing the Parisian mental hospital, the Salpetriere, in the 1880s, evoked the behavior of " hystero-epilepsy " in many of the patients as he studied them.

    An amplifying and sustaining role for learning must be added to these provocative circumstances in order to understand hysteria. That is, the social context not only provides the goal ­ the sick role ­ but also can provide directions to it. These directives can come with : 1) models : as might come from witnessing illness in others or from reading books such as the three faces of Eve; 2) rewards : as by repetitive demonstration of professional interest in certain " symptoms " ; 3) explicit instructions : as in books describing how to review one's feelings and sensations when worrying about such poorly defined conditions as chronic fatigue syndrome, lyme disease or " repressed memories ".

    The role of learning behind an hysterical presentation is often evident when a careful history of its progression is taken. Such a history will reveal how the " symptoms " first appeared in as a slight almost insignificant way - perhaps a little unsteadiness afoot, a tic-like twitch, a vague " memory " - only to progress over time as it draws the attention of examining doctors into paralysis, choreoathetotic movement, memories of sexual abuse in satanic rituals or spacecraft abductions.

    Hysterical behaviors - regardless of their provocations and predispositions - are sustained by the effects these behaviors have on everyone including the self-deceived patients themselves. They certainly do receive support and even more instruction from the interested observers around them. Doctors and therapists especially may have played a critical role in suggesting a disorder. But, the crucial sustaining ingredient - the one that produces fury against skeptics - is the patient's own wish (or sensed need) to remain consistent to the guises of illness assumed. For consistency's sake many will continue an hysterical behavior long after the predisposing depressions, life crises, or demoralizations have disappeared. Compliance to a suggestion, followed by consistency to its consequences, is the formula for sustaining abnormal illness behavior.

    Hysteria is a formidable term in medicine not only because of its antiquity but also because of the many explanatory misdirections that it has prompted. What is most intriguing is the virtual identity of the error. It rests upon assuming that the manifestations of hysteria reveal the actions of some inner process, just as symptoms of a disease reveal its pathologic physiology or emotional states such as grief relate to specific provocations. Indeed, the classical explanations of hysteria follow an historic line of descent from the wandering uterus, to possession by demons, to evil spells of witches, to " animal magnetism " of Franz Mesmer, to the physiological propositions of Charcot, to Freud's opinion that the features are symbolic " conversions " of sexual conflicts, out to the present fashion that would hold that multiple personality disorder hides forgotten early life sexual abuse by compartmentalizing the memories into " alter personalities " through " robust repression " or " dissociation ".

    This methodologic analysis has several practical implications. If the problem is not primarily the expression of some inner pathology or psychologic process but a behavioral act prompted by suggestion, enhanced by learning, and seeking a solution to a crisis, then the treatments must follow this aim. The emphasis should not be on attempts to cure a pathology, resolve an unconscious conflict, or bring some special events to mind as though these were fundamental to the issue. Rather, efforts at interrupting the misdirected appeal of the " sick role " (by some form of counter-suggestion or re-learning) should be the first steps, followed by guiding the patient towards more effective ways of managing all his troubles.