The essential features of hysteria are: (a) physical symptoms, (b) absence of organic pathology, and (c) psychological conflict.
Classification and clinical features
There are three main patterns of hysteria: monosymptomatic, polysymptomatic and epidemic.
Monosymptomatic hysteria (conversion disorder)Typically there is gross loss of neurological function. Thismay involve:
• the limbs, e.g. paralysis, anaesthesia or dystonia the higher functions, e.g. hysterical fits, hysterical blindness,fugue states(in which the patient has complete memory loss), or evenhysterical psychosis(where the patient develops a short-lived and dramatic psychosis in response to external stress). The pattern of dysfunction follows the patient's 'idea' of how the body works, rather than anatomy. Similarly, in hysterical psychosis the patient behaves in the way he thinks a madman ought to behave, rather than demonstrating the specific symptoms of schizophrenia. A neurologist can usually determine the integrity of the nervous system, either by subtle physical examination (extensor activity in apparently paralysed limbs) or by investigation (intact visual evoked potentials in hysterical blindness). The patient may also exhibit thebelle indifferencedescribed by Janet, i.e. an apparent lack of anxiety in the face of a crippling disorder. Psychophysiological measures of arousal show that hysterical patients are in fact often highly aroused, despite the absence of manifest anxiety.
Polysymptomatic hysteria (Briquet's syndrome, somatizotion disorder)
Patients suffering from polysymptomatic hysteria (usually women in their 30s) develop a wide variety of physical complaints with no organic basis over a number of years. These often involve pain in the abdomen, back and pelvis. Such patients have often been extensively investigated by physicians and frequently admitted to hospital. Their medical notes are thick but inconclusive. Unlike patients with monosymptomatic hysteria, their prognosis is poor and is related to general personality difficulties rather than a specific conflict.
Epidemic hysteria
This rare and self-limiting condition occurs in schools and other situations where young people are in close proximity. Fainting, nausea and paraesthesia brought on by overbreathing are common presentations. The condition is sometimes wrongly assumed to have an infective cause.
Diagnosis
Hysteria is not an easy diagnosis to make. A proportion of patients diagnosed as hysterical turn out to have genuine organic disease: multiple sclerosis or occult cancer, for example. Others may develop another psychiatric condition, such as a depressive illness or even schizophrenia. However, it is important to recognize and diagnose hysteria when it does occur, so as to spare the patient unnecessary investigation. Hysteria and organic illness can also, and often do, coexist; establishing one diagnosis should not prevent the search for another.
Meaning and aetiology
The manifestations of hysteria are often dramatic, and therein lies a clue to its nature. Most people, especially as children, have the capacity to act a role. This involves an internalsplitting,ordissociation,between the actor and his part. The actor is not really Hamlet, yet becomes Hamlet as he acts the role. The hysteric is not paralysed and yet, psychologically, can become so. According to Freud, the symptoms in hysteria have ameaningwhich can be understood in terms of the patient's life. Psychological theories of hysteria also highlight several other important aspects of the illness:
•Defence.Hysteria is a defence against the anxiety created by conflict. A young man from an academically minded family was facing exams which he feared he would fail; he became paralysed.
•Unconscious behaviour.Although a conflict is often obvious to others, the patient isunconsciousof it.
•Personal gain.There are two kinds of gain for patients in being ill. Theprimary gainis the fact that they are unaware of their conflict and thus do not experience anxiety. Thesecondary gainis the care and attention they get from family, friends and relatives. This is only possible if the family to some extent go along with it, or allow the patient tomanipulatethem. Here they may be meeting their own needs, e.g. the husband who only feels potent when he has a sick wife to look after. 'Manipulation' is a normal process in childhood, and hysteria always has childlike aspects. The child who does not want to go to school develops a tummy-ache; his mother lets him stay at home with her. A similar process is at work in hysteria. The child is not consciously making himself ill ormalingering(as, for example, is the soldier who deliberately shoots himself in the foot to avoid going to battle): there really is a pain, even if it clears up quickly once the danger of having to go to school has passed.
•Identification.A common finding in the histories of hysterical patients is that there has been a close relative who has suffered illness, often serious. The young man who became paralysed because he feared his exams had had a younger brother who had died with cerebral palsy, and on whom his parents had lavished all their care and attention. The patient often has such a model of illness and its accompanying behaviour which influences him.
Sociologists speak of'illness behaviour'to describe the socially sanctioned behaviour that accompanies illness and which is not strictly related to the pathophysiology of the disease. Sick people are allowed to retire tem-
Management in hysteria
• 'Psychosomatic' attitude on part of doctor
• Exploration of conflict
• Behavioural approaches
• (Antidepressants)
• Abreaction
• Long-term psychotherapy
porarily from work and spend time in bed; they receive flowers, cards and gifts from relatives and are treated with special consideration; they are allowed to be childish and demanding. Their medical attendants also adopt a particular role, usually one of reassurance, benevolence and quasi-omniscience. One of the rules of illness behaviour, however, seems to be that the patient should recover, or at least attempt to recover. When this does not happen there may be a sudden switch: the previously privileged patient may be seen as manipulative, attention- seeking and deviant, and be shunned or covertly punished by irate relatives and medical attendants. In hysteria this often results in a worsening of the symptoms.
Management
It is tempting to try to argue a hysterical patient out of his illness. Occasionally this can be helpful, but more often it entrenches the patient more deeply in his symptoms and an escalating battle between doctor and patient may then ensue. There is, moreover, a sense in which the patient is right: he is ill, but psychologically, not physically. There is something wrong, namely a psychological conflict, albeit one of which the patient is unconscious. A more helpful approach is therefore to adopt apsychosomaticattitude.This involves explaining to the patient that stress can cause illness, that he may have a psychological conflict, and that there may be a connection between this and the physical problem, both of which are real. The patient who has committed himself to a physical illness should be offered appropriate physical treatments (e.g. physiotherapy, massage) and should not be deprived of it out of spite. When recovery does take place the temptation to say T told you so' should be resisted. Instead, the patient needs a face-saving formula: the paralysed person must be allowed to put his crutch down gradually, inadvertently even, not have it knocked from under him.The psychological principles of treatment are:
•Exploration of conflict.With allowance for face-saving, this is perhaps the most helpful strategy. If the conflict is removed (e.g. the time for exams past) the symptoms will usually remit.
•Cognitive-behavioural approaches.These are often useful. They (a) aim to avoid reinforcement of the symp-toms, e.g. by suggesting to ward staff or relatives that they respond positively to any signs of movement in the paralysed patient, but as far as possible ignore (nonpunitively) helpless behaviour; (b) are directed towards helping the patient overcome his cognitive responses (e.g. of panic and catastrophe) towards the imagined illness. The latter is sometimes known as 'reattribution therapy' - the patient learns how he wrongly attributes normal bodily sensations to illness, and that this may be influenced by emotion, especially anxiety.Drugs.Where hysteria is secondary to a depressive illness antidepressants should be prescribed. In general, however, drug treatment should be avoided in hysteria, as the patient is often very suggestible and tends to develop dramatic reactions and side-effects. Hysterical amnesia can sometimes be approached byabreaction,in which painful experiences are 'relived' with the help of an intravenous injection of a sedative drug such as diazepam.
Psychotherapy.Some patients will benefit from longterm psychotherapy
