Hysteria

   In 1802, Paris psychiatrist Jean-Baptiste Louyer-Villermay (1775–1837), in an essay differentiating hypochondria from hysteria, described a young female patient, uncertain about romance, who, "at the sight of her loved one fainted, uttering plaintive cries and sobbing involuntarily as she drifted in and out of somnolence. As she slipped into total unconsciousness, uncoordinated contractions of her upper limbs began, a convulsive twitching of her chest, violent palpitations and spasmodic contractions at the throat, with a feeling of strangulation and ‘globe hystérique [lump in the throat],’ also a tetanic contraction of her lower jaw and occasional convulsions of its muscles" (pp. 40–41). Louyer-Villermay made the diagnosis of hysteria. Although the view is commonly heard that the term "hysteria" goes back to the Ancient Greeks, in fact it does not: the diagnosis filters into medicine only in the seventeenth century.

   In the great gamut of "psychophysiological disorders," or breakdowns of the mind–body relationship, hysteria has always occupied a particular niche, defined as (a) a stigmatizing term that male physicians have always used for behavior in women that they do not understand; (b) a synonym for functional convulsive disorders, or "pseudoepilepsy"; (c) a synonym for psychosomatic illness, or "functional" illness, sometimes called "conversion symptoms," or "conversion disorder"; (d) latterly, as a kind of personality disorder, again, primarily in women. There follow some of the landmarks from the seventeenth century, when the term "hysteria" first started to be used, to 1980, when it officially was dropped from psychiatric terminology. The vicissitudes of the term "hypochondriasis," meaning abnormal fear of illness or concern with bodily symptoms, have been so numerous that they will not be considered in this Dictionary. (See, however, DEPRESSION: EMERGENCE: hypochondria as a subform of depression [1860].)

   Hysteria as a convulsive phenomenon, or fits (1667). In an Essay of the Pathology of Brain and Nervous Stock, the Oxford physician and lecturer Thomas Willis (1621–1675), the founder of neurology, equated hysteria with convulsive phenomena (including doubtless a good deal of epilepsy): "The hysterical passion is of so ill fame, among the diseases belonging to women, that like one half damned, it bears the faults of many other diseases. . . . a choaking in the throat, a vertigo, an inversio, or rolling about of the eyes, oftentimes, laughing, or weeping . . . sometimes convulsive motions in the face and limbs, and sometimes in the whole body, are excited" (quoted in Hunter-Macalpine, 300 Years, p. 189). Willis thus founded the doctrine of hysteria that would run through neurology for the next 300 years.

   Hysteria as a synonym for medically unexplained symptoms (1682). For Thomas Sydenham (1624–1689), the great London physician who is considered the father of medicine based on observation, "hysteric disorders" were the counterfeiters of illness. As he wrote in 1681, "The frequency of hysteria is no less remarkable than the multiformity of the shapes which it puts on. Few of the maladies of miserable mortality are not imitated by it. Whatever part of the body it attacks, it will create the proper symptom of that part" (Works, II, p. 85). Further: "Almost all the hysterical women that I have ever seen complain of a dejection (a sinking as they call it) of the spirits; and, when they wish to show where this contraction (or sinking) exists, they point to the chest. . . . That hysterical women break out into immoderate fits, sometimes of laughing, sometimes of crying, and that without any manifest cause, is known all the world over" (p. 88). In his note on hysteria, Sydenham thus originated the concept that would inform much of psychiatry, and all of internal medicine, for the next 300 years.

   In the interests of brevity, this Dictionary will skip over the numerous contributions to hysteria between the seventeenth century, when the above authors founded the doctrine, to the mid-nineteenth century, when the outlines of contemporary interpretations become discernible. It would also be unmanageable to mention the great medical literature of the nineteenth century on mind–body relations, details of which may be found in my book From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era (1992).

   Charcot’s doctrine of hysteria (from 1870). Jean-Martin Charcot’s involvement with hysteria at the Salpêtrière hospice began in 1870 when, as the senior physician at the infirmary of the hospice, he asked that a special ward be created for non-insane female patients from another service who had "hystero-epilepsy." As he began to study these patients systematically, he differentiated two forms of hysteria: one was "minor hysteria" (la pétite hystérie), represented by more or less permanent stigmata such as constricted visual fields, cutaneous anesthesia, or hypnotizability; the other was "major hysteria" (la grande hystérie), dramatic outbursts of passion and posturing as the patients supposedly evolved through the various stages of a major attack. For Charcot, hysteria was an inborn, constitutional illness of which men as well were at risk. His theory of hysteria, resting on the basis of artifactual phenomena, collapsed rapidly after his death in 1893. But his celebrity as a physician gave "hysteria," as a supposedly neurological, brain-based phenomenon, great international attention. His ideas were laid out systematically in his Tuesday Lectures at the Salpêtrière, Outpatient Department, 1887-1888 (Leçons du mardi à la Salpêtrière, Policliniques, 1887-1888).

   Briquet: hysteria as a constitutional illness (1881). In 1859, Pierre Briquet (1796–1881), an internist at the Charité Hospital in Paris, wrote a big book on hysteria, Clinical and Therapeutic Treatise on Hysteria (Traité clinique et thérapeutique de l’hystérie), based on a quantitative analysis of more than 400 of his female patients. The book helped destroy some customary myths about the disorder, such as its imputed cause from sexual frustration ; the book also cast light on the role of emotions and stress in the genesis of physical symptoms. Yet, it was only in a paper that Briquet gave to the Academy of Medicine in 1881, the year of his death, that he highlighted the role of family "predisposition" in hysteria. Looking at symptoms such as migraine, chronic pain, poor digestion, cutaneous anesthesia and pseudoepilepsy, he determined that "predisposed" women, including those with more laden histories on the female side of the family tree, had an earlier onset and longer duration of hospitalization than did the non-predisposed, and that they tended to have more frequently such challenging symptoms as anesthesias and convulsions. Although most patients recovered from their current illness, many relapsed. He referred to hysteria as "the insanity of sensibility" (la folie de la sensibilité). (The paper "On the Predisposition to Hysteria" ["De la prédisposition à l’hystérie"] was published in the Bulletin de l’Académie de médecine, Paris, 1881.)

   Silas Weir Mitchell identifies "hysterical motor ataxia" as a subform of hysteria (1881). Mitchell, who specialized in the functional affections of wealthy women, called attention in his Lectures on Diseases of the Nervous System, Especially in Women (1881) to "hysterical motor ataxia": "The real and singular want of power . . . seems to set this apart from cases of mere neurasthenia. . . . The disorder is one of those which adds many recruits to that large class which some one has called ‘bed cases,’ and which are above all things distinguished by their desire to remain at rest" (p. 48). This special form of hysteria remained common in this class of patient, called "sofa cases" as well, until around the time of the First World War.

   Astasia-abasia (Blocq syndrome) (1888). Paul-Oscar Blocq (1860–1896), at the time a hospital intern in Paris, described in the Archives de neurologie in 1888 "a disorder characterized by astasia and abasia" (the inability to stand up or walk). He said that Jean-Martin Charcot and Paul-Marie-Louis-Pierre Richer (1849–1933) had already characterized it in 1883 under the term "loss of motor power in the lower limbs because of lack of coordination in standing and walking" (p. 24). Yet, it was Blocq’s term that caught on, and not Charcot’s. (See also Akathisia.) Freud’s concept of hysteria (1892 and after). See Freudian Doctrine of Hysteria.

   Babinski’s definition of "hysteria" (1901). For Joseph-François-Félix Babinski (1857–1932), a Parisian neurologist who had trained under Charcot but by 1901 was head of the neurology service at La Pitié Hospital, hysteria was any disorder that could be induced by suggestion and abolished by persuasion. By "suggestion" he meant mainly medical suggestion, such as encouraging the patients to think they had a certain form of hysteria; by persuasion he meant hypnotism or some other form of psychotherapy. As he wrote in 1901 in the Neurological Review (Revue neurologique),

   "Hysteria is a psychological state that renders patients capable of self-suggestion" (p. 1077). No subsequent formulation has improved upon this.

   The term "somatization" is introduced to psychiatry (1924). It was Freud’s excollaborator Wilhelm Stekel (1868–1940), a Viennese family doctor and psychoanalyst, who introduced "somatization" to psychiatry. As early as 1924 he wrote, "As a result of the somatization of this lack of feeling [Gefühllosigkeit] the patient develops a complete anesthesia in both arms." This note appeared in the first volume of his own journal, New Research in Sexuality (Fortschritte der Sexualwissenschaft). In 1932, he described "An Interesting Case of Somatization" ("Eine interessante Somatisation") in Psychoanalytic Practice (Psychoanalytische Praxis).

   The "patient as a person" movement (from 1924). Within American internal medicine, in the 1920s the view arose that patients’ somatic symptoms could be as much a result of stress and nervousness as of organic disease. Some internists advocated viewing the "patient as a person" in order to treat comprehensively the disorders both of body and mind. The firing gun in this movement was probably Francis Weld Peabody’s (1881–1927) The Care of the Patient (1924). Peabody, professor of medicine at Harvard, said that the ultimate cause of these "symptoms for which an adequate organic cause could not be discovered . . . [was] to be found not in any gross structural change of the organs involved, but rather in nervous influences emanating from the emotional or intellectual life, which, directly or indirectly, affect . . . organs that are under either voluntary or involuntary control" (pp. 24–25). The apogee of the movement, just before the great marriage between biochemistry and internal medicine that occurred after the Second World War, was doubtless George Canby Robinson’s (1878–1960) The Patient as a Person: A Study of the Social Aspects of Illness, which appeared in 1939. Robinson, lecturer in medicine at Johns Hopkins University and a specialist in gastroenterology, noted, "Man is a unity of mind and body, and medicine must consider this unity. Physiology, chemistry, and biology cannot alone or together explain all the intricacies of illness. The disturbances of mind and body cannot be dealt with separately; they form two phases of a single problem" (p. 10).

   Alexander’s doctrine of "psychosomatic specificity" (1934 and after). In 1932, the emigé Hungarian psychoanalyst Franz Alexander (1891–1964) founded the Chicago Institute for Psychoanalysis and also received a professorship for psychoanalysis at the University of Chicago. At the institute, he occupied himself intensely with problems of the mind–body relationship. In an article in the Psychoanalytic Quarterly in 1934, he identified functional gastric disturbances with "the wish to receive or take," colitis-type illnesses with "the wish to give or eliminate," and constipation with "the wish to retain" (p. 508). Alexander did not at this point use the term "psychosomatic" but talked rather of "predominant conflict-situations and their solutions in each group [gastric, diarrhoea, constipation types]" (p. 533). In his later book Psychosomatic Medicine (1950), Alexander developed a doctrine whereby certain kinds of intrapsychic conflicts expressed themselves on the sympathetic side of the autonomic nervous system (ANS), others on the parasympathetic side. He claimed that the sympathetic, or "fight" side of the ANS responded to conflicts with such "psychosomatic" illnesses as hypertension, diabetes, and rheumatoid arthritis; the parasympathetic, or "flight" side with ulcerative colitis and asthma. These doctrines were highly influential in American psychosomatic medicine for a number of years. For example, the Rochester internist George Engel, later responsible for the "biopsychosocial" model of medicine, had studied with Alexander.

   Karl Menninger describes "polysurgical addiction" (1934). "We all know the facility with which the hysterical patient can produce symptoms which gratify his unconscious needs," Menninger wrote in the Psychoanalytic Quarterly. "And if that need can be further gratified through a surgical manipulation, the means will not fail him to bring about a condition which even the most conscientious surgeon will be inclined to regard as indicative, if not imperative, of surgical interference" (p. 176). Menninger found that this "compulsion to submit to surgical operations" represented an unconscious form of "self-destruction."

   "Vegetative dystonia" (1934). Berthold Wichmann, a young assistant in the university psychiatric clinic in Münster, Germany, who had qualified in 1930, maintained in the Deutsche Medizinische Wochenschrift in 1934 that many functional internal disorders were owing to sympathetic and parasympathetic hyperarousal. He suggested the term "vegetative dystonia" (autonomic dystonia) for the varying headaches, feelings of dizziness, gastrointestinal upsets, hyperhidrosis (excessive sweating), heightened muscle excitability, changing pulse rhythm, and functional tremors that are common in primary care. Wichmann said the disorder was primarily constitutional, or organic, and not psychogenic, but that it could have secondary psychiatric effects as well. Although the diagnosis never caught on in the Anglo-Saxon world, it became popular on the Continent after the Second World War. For years, several Swiss drug companies marketed drugs specific for "vegetative dystonia," such as Sandoz’s Bellergal (a mixture of ergotamine, belladonna alkaloids, and phenobarbital). In 1961, Geigy launched the tricyclic antidepressant opipramol (Insidon), a sigma-receptor ligand that they bought from the discoverer company Rhône-Poulenc; from the first they marketed it for vegetative dystonia ("a psycho-vegetative harmonizer"). In the Anglo-Saxon world, vegetative dystonia is understood as somatic manifestations of mixed anxiety–depression.

   The term "psychosomatic" becomes accepted (1935). Helen Flanders Dunbar (1902–1959), who was cross-appointed in the departments of medicine and psychiatry at Columbia University, wrote a book in 1935 entitled Emotions and Bodily Changes: A Survey of Literature on Psychosomatic Interrelationships, 1910-1933. She had wanted to bring together the literature on what the Index Medicus was still calling "physicalmental relationships." The book encountered such an enthusiastic reception that in the preface of the second edition, published in 1938, she explained how she had coined the term (or she believed she had coined it, but its use goes back to the early nineteenth century): She said it was not that the body was split between a psyche and a soma. "The term ‘psychosomatic’ is descriptive rather of the observer in his endeavor to apprehend rather than of the organism observed. Psychic and somatic represent merely two angles of observation. Our understanding of disease rests on pictures taken from these two angles viewed simultaneously, united stereoscopically" (p. xix).

   The term "psychosomatic illness" is popularized (1938). James Lorimer Halliday (1897–1983), regional medical officer of the department of health for Scotland and confronting the problem of rising rates of chronic invalidism among the insured, suggested in the British Medical Journal in 1938 the term "psychosomatic illness" to designate the way in which psychological changes, acting via the brain, the autonomic nervous system, and the endocrine system (the "bodily mechanism of emotion" as others had termed it) might bring about "changes in chemistry, rhythm, secretion, and even structure in one or more parts of the body." Psychosomatic illness was thus for Halliday not co-terminous with "functional" illness, meaning symptoms in which there were no organic changes. Halliday’s book Psychosocial Medicine: A Study of the Sick Society (1948) made the concept of "psychosomatic affections" widely known.

   "Hysteria" as a distinct syndrome, not just individual conversion disorders (1951). James J. Purtell (?–1949), a psychiatrist at Tufts College Medical School, Eli Robins at St. Louis (see St. Louis school), and Mandel Cohen (1907–2000) at Harvard concluded in a study of chronic functional illness published in the New England Journal of Medicine that hysteria was a distinct syndrome seen mainly in female patients with long histories of multiple body symptoms, an onset early in life, and a certain personality style. "No patient had fewer than 11 symptoms," they wrote.

   "Psychophysiologic autonomic and visceral disorders" in DSM "One" (1952). This first edition of the Diagnostic and Statistical Manual of the American Psychiatric Association did not use the term "hysteria," avoided explicitly the term "psychosomatic disorders"—which expression they considered a "point of view" in medicine rather than certain specified illnesses—and chose the above rather complicated expression to identify "the visceral expression of affect" (p. 29). The Manual also admitted the classic psychoanalytic "conversion reaction," with the explanation that "the impulse causing the anxiety is ‘converted’ into functional symptoms in organs or parts of the body, usually those that are mainly under voluntary control" (pp. 32–33). Finally, it included the category of "dissociative reaction," grouped under "psychoneurotic disorders," for fugue states and the like.

   Hysteria as a distinct "disease entity" (1962). Continuing the work at St. Louis that Eli Robins had begun with Purtell, in 1962 Michael Perley (1936–), a medical intern from the University of Minnesota who had a Public Health Service studentship at Washington University in St. Louis, and Samuel B. Guze published in the New England Journal of Medicine the results of a long-term follow-up study of 39 patients with hysteria according to the Purtell–Robins–Cohen criteria. They found that hysteria was a clinical syndrome, or "disease," involving "a dramatic, complicated medical history beginning before the age of thirty-five, with multiple symptoms involving many organ systems" (p. 423). The presentation was stable over time. Previous authorities, such as Jean-Martin Charcot, had also believed hysteria to be a definite disease. Yet, that thread was lost and the nosological view resumes with the St. Louis school. Hysteria in DSM-II (1968). In this second and more psychoanalytically oriented edition of the American Psychiatric Association’s Manual, hysteria returned under the "neuroses" as "hysterical neurosis": "an involuntary psychogenic loss or disorder of function." It was subdivided into "conversion type," and "dissociative type," thus encompassing the "dissociative reaction" of DSM-I. Unlike DSM-I, this second edition also admitted hysteria as a personality disorder, called "hysterical personality (histrionic personality disorder)": it was characterized by "seductive" and "attentionseeking" self-dramatization (p. 43). DSM-II retained the "psychophysiologic disorders" of DSM-I.

   "Somatization" is reintroduced to psychiatry in a nonpsychoanalytic sense (1968). After Stekel, somatization continued to be used within the psychoanalytic literature in a specialized way. Then in 1968, Zbigniew ("Bish") J. Lipowski (1924–1997), at the time a member of the psychiatric consultation service of the Royal Victoria Hospital and of the Allan Memorial Insitute of McGill University in Montreal, suggested in an article in Psychosomatic Medicine that somatization be redefined as "the tendency to experience . . . psychological states . . . as bodily sensations, functional changes, or somatic metaphors" (p. 413).

   "Briquet’s Syndrome" (1971). In 1881, Briquet (see above) identified a pattern of chronic psychosomatic illness in women, having a partially genetic nature and beginning early in life. A century later, writing in the American Journal of Psychiatry in 1971, Samuel Guze of the St. Louis school, together with collaborators Robert A. Woodruff, Jr. (1934–) and Paula Clayton (see WOMEN IN PSYCHIATRY) named the syndrome after Briquet. The authors noted that hysteria, or Briquet’s syndrome, is a "polysymptomatic disorder that is seen nearly always in females, begins early in life . . . and is characterized by recurrent or chronic ill health, the complicated history of which is frequently described dramatically" (p. 134). Hysteria in women and antisocial behavior in men tend to crop up in the same families, the authors noted. Four years later, in the American Journal of Psychiatry, Guze observed that hysteria and sociopathy tended to occur in the first-degree relatives of these patients, hence, it evidently had a partially genetic basis.

   Hysteria disappears from psychiatry in DSM-III (1980). Under the pressure of enlightened public opinion, which tended to see the word "hysteria" when applied to women as stigmatizing, the task force that designed DSM-III smashed hysteria into a number of fragments.

   This edition banished psychosomatic symptoms—historically the core of hysteria— to a group of diagnoses called "somatoform disorders," or "physical symptoms suggesting physical disorder." Among the somatoform disorders were "somatization disorder" (what Guze had called "Briquet’s syndrome") and "conversion disorder," a physical symptom that "is apparently an expression of a psychological conflict" (p. 244). It was the psychoanalysts who had given "hysterical personality" its currency, and in DSM-III this became "histrionic personality disorder": "Individuals with this disorder are lively and dramatic and are always drawing attention to themselves. They are prone to exaggeration and often act out a role, such as the ‘victim’ or the ‘princess,’ without being aware of it" (p. 313). Dissocation remained essentially unchanged. Those forms of hysteria once thought partly under the voluntary control of the patient were classified as "factitious disorders." The psychiatric tradition of seeing some brief psychoses as "hysterical" was acknowledged in a diagnosis called "brief reactive psychosis." (The index of DSM-III listed it under the adjective "hysterical.") Thus, DSM-III abolished hysteria from psychiatry.