In Defense of Hysteria

It now is fashionable to dismiss early psychologists like Jean-Martin Charcot, director of the Salpêtrière Hospital in the late 19th century and the modern inventor of hysteria.  Charcot had plenty of raw materials to work with; Salpêtrière housed over 5,000 female patients, many of who were insane, demented, destitute or deemed “incurable” (Makari, p. 14).

Diagnostically, “hysteria” comprised congeries of symptoms such as abnormal muscular spasms or variations of reflexes and sensory functions (Ehrenwald, p. 255).  It was applied predominantly to women and thought to be caused by disturbances of the uterus.  Charcot believed hysteria resulted from an organic neurological disorder (Hunt, p. 191).  This is significant because (according to Charcot) it means it could not have been brought about by mental factors alone.

Then something unusual happened.  Charcot began using hypnosis to induce states of hysteria, which implies pathological ideations had at least some role in its etiology.  This created a paradox, however, because if mental factors also were involved, then one pathogenic idea (the hysterical one) simply was being counteracted by another (the one induced by hypnosis).  Both ideas controlled the patient’s experience and behavior, even though the patient was aware of neither (Mitchell & Black, p. 3).

Josef Breuer exploited this anomaly in his treatment of Anna O.  Under hypnosis, she free-associated back to the point in time when her symptoms started.  Once she remembered this event (which was disturbing and stressful), then her symptoms disappeared.  This lead Breuer to conclude hysteria was caused by trapped memories and the feelings associated with them.  Once hysterical symptoms were traced to their origin, their meaning became apparent and then they resolved.  Sigmund Freud became intrigued with Breuer’s work and in 1895 they published Studies in Hysteria, which remains the defining work in the field (although now of historical interest only).  Based on the Anna O. case, Breuer and Freud hypothesized the etiology of hysteria was predominantly (if not purely) psychological, eliminating Charcot’s theory of neurological origins.

There came a time when hysteria became an unpopular diagnosis.  The Mental Disorders Diagnostic Manual (precursor of the DSM) deleted hysteria, institutionalizing its disappearance.  Hysteria also has gone almost completely missing from current psychiatric literature.  Diagnoses (such as hysteria) “disappear as time elapses or even cease existence under the influence of certain social developments, while other, new entities take their place” (Libbrecht, p. 170).

Various explanations for this have been offered.  The most popular one is that, from a post-modern standpoint, gender relations became absorbed in medical discourse; when women are the doctors and the theorizers, rather than the patients, the narratives of hysteria change (Showalter et al., 1993).  Hysteria carries a “resonance” for commentators because of its “textual tradition.”  It is a “powerful, descriptive trope” even in non-medical domains, including poetry, fiction, theater, social thought, political criticism and the arts.  In this way it sheds light on the history of disease in general (Micale, 1994).

Another explanation is the “argument from psychological literacy.”  According to this interpretation people were “relatively primitive in their psychological processes” before the 20th century and found it easier to express “acute emotional symptoms” through the formation of psychogenic physical symptoms.  However, with the coming of age of our “psychological society” and the popularization of concepts such as “unconscious motivation,” the psychodynamics of hysterical conversion systems changed.  They “failed to elicit the desired social response and subjective gratification” (Micale, 1993).

Hysteria now has been relegated to an obscure corner of DSM-IV under the headings somatoform disorder (DSM-IV 300.81) and dissociative disorders (DSM-IV 300.6, depersonalization disorder).  There is some recent work (using fMRI) attempting to restore its neurological underpinnings (Halligan et al., 2001).  This research suggests the inhibitory mechanisms originally associated with hysteria operate at a high, cognitive level of sensory-motor processing.  They originate in the right inferior parietal cortex and restrict awareness of information as to the ongoing status of sensory and motor functions.  The right inferior parietal cortex is a crucial structure in the mediation of awareness and the brain’s attentional system.  Unlike other primary sensory cortices it is independent from topological constrains and laterializes to the left side regardless of hand dominance.  This may explain the peculiar anatomical features of conversion symptoms (Sierra & Berrios, 1999).  It also supports a hypothesis that residual unconscious cognitive processing occurs even in the absence of awareness – an ironic return back to Charcot’s original theory.

In my opinion the current disapproved state of hysteria results from historical revisionism and medico-cultural imperialism.  Women around the turn of the last century who were thought to be suffering from hysteria actually were suffering from hysteria.  Even though this diagnosis now may be incomprehensible to us it defined and structured the then-prevailing symptomatology.  In this respect hysteria is like many of the other culturally-deficient aspects of the DSM (Regier et al., 2009).  In this respect I am in substantial sympathy with the views of Paul Feyerabend (1975) regarding the incommensurability of scientific theories.

To be fair, DSM-IV suggests several intriguing directions.  The main one is dissociative trance disorder, a “criteria set and axis provided for further study.”  Its primary symptom is “an involuntary state of trance that is not accepted by the person’s culture as a normal part of a collective cultural or religious practice.”  In other words, the patient is possessed, most likely by the devil, and exorcism is the only effective means of relief.

Similarly, at Appendix I, DSM-IV sets forth a list of 25 culture-bound syndromes.  These are more than just pathologies of belief.  Rather, their victims actually think they are victims of the disorder, and actually are cured by appropriate culturally-specific interventions; such as, perhaps, a voodoo spell or the services of a witch doctor.  The epidemiology, etiology, neurochemistry and treatment of these conditions can be addressed empirically, through research.  An interesting project would be to define the parameters of such studies, eliminating confounding variables to the fullest extent possible.

References

American Psychiatric Ass’n. (4th ed. 2000).  Diagnostic and Statistical Manual of Mental Disorders.  Arlington, VA: American Psychiatric Ass’n.

Breuer, J. & Freud, S. (1895).  Studies in Hysteria.

Ehrenwald, J. (1991).  The History of Psychotherapy (1991).  New York, NY: Aronson.

Feyerabend, P. (1975).  Against Method.  London, UK: Verso.

Halligan, P., Bass, C. & Marshall, J. (2001).  Contemporary Approaches to the Study of Hysteria: Clinical and Theoretical Perspectives.  New York, NY: Oxford U. Press.

Hunt, M. (2nd ed. 2007).  The Story of Psychology.  New York, NY: Anchor.

Libbrecht, K. (1995).  Hysterical Psychosis – a Historical Survey.  New Brunswick, NJ: Transaction Publishers.

Makari, G. (2008).  Revolution in Mind – the Creation of Psychoanalysis.  New York, NY: Harper.

Micale, M. (1993).  “On the ‘Disappearance’ of Hysteria: A Study in the Clinical Deconstruction of a Diagnosis.”  Isis, 84 (3), pp. 496 – 526.

Micale, M. (1994).  Approaching Hysteria.  Princeton, NJ: Princeton U. Press.

Mitchell, S. & Black, M. (1995).  Freud and Beyond – a History of Modern Psychoanalytic Thought.  New York, NY: Basic Books.

Regier, D., Narrow, W., Kuhl, E. & Kupfer, D. (2009).  “The Conceptual Development of DSM-IV.”  Am. J. Psychiatry, 166 (6), 645 – 650.

Showalter, E., Gilman, S., King, H., Porter, R. & Rousseau, G. (1993).  Hysteria Beyond Freud.  Berkeley, California: University of California Press.

Sierra, M. & Berrios, G. (1999).  “Towards a Neuropsychiatry of Conversive Hysteria.”  Cognitive Neuropsychiatry, 4 (3), 267 – 287.