The Psychology of Hysteria - A Selection of Classic Articles on the Analysis and Symptoms of Hysteria

HYSTERIA

THE nature of this disorder has already been discussed. No definition will be attempted here, as it depends upon what view is supported—for example, the suggestionist or the repression theories—as to the origin of the symptoms.

§ 1. Etiology.

As regards the psychological basis of the condition, the following points may be noted. Factors of suggestion and imitation play a considerable part in the symptomatology. Hysterical manifestations may affect large numbers of individuals—for example, at ‘revival’ meetings—and may even be epidemic in character, as in the Latah and Amok of certain coloured races. Hysteria may run, like an infection, through a community such as a girls’ school. In general, the condition occurs most commonly in young adults, rarely before puberty, though it is not unknown in quite young children. Under civilian conditions hysterical manifestations are more common in women, although the male sex contributes a fair quota to the number of industrial and compensation neuroses of hysterical type. Hysteria was also a common neurosis amongst the forces during the Great War. The Jews and the Latin races are more liable to hysteria than the more stable northern peoples. A neuropathic heredity is common, and many hysterics are children of neurotic, tuberculous, or alcoholic parents. The symptoms appear first commonly after physical or emotional shock.

§ 2. Symptoms.

These may be classified under the various systems affected.

Central Nervous System.

Motor phenomena:

(a) Minor: Attacks of giggling; laughing and crying; crises of agitation; ‘nerve-storms’; sense of choking (globus hystericus), with the appropriate movements

(b) Major: Grande hystérie; hystero-epilepsy. Hysterical fits may assume many forms, some of which are not easily distinguished from true epilepsy; the two conditions may coexist. An epileptic convulsion may be preceded or followed by phenomena which are undoubtedly ‘functional’ in character. Some authorities make no clear distinction between hysteria and epilepsy, but regard both as psychogenic in origin. The following are some points of difference:

The hysterical fit can often be controlled by suggestion or by such stimuli as cold water or the faradic current.

Paralysis in hysteria may simulate any form of organic lesion, but certain points of difference will usually be apparent. Hence the need for the most careful examination. The diagnosis between ‘organic’ and ‘functional’ may present the greatest difficulties. Mixed cases occur. Disseminated sclerosis in the early stages has been mistaken for hysteria, as have also some forms of cerebral tumour. In general, hysterical paralysis—

Often follows some emotional shock.

Affects functional groups of muscles and movements, whereas in organic lesions single muscles may be paralysed or groups supplied by a single nerve, nerve-trunk, spinal segment, or other anatomical system. Active or passive movement in hysteria is usually accompanied by activity of the antagonising muscles.

Never shows the electrical reaction of degeneration.

Deep reflexes are never quite abolished, even in the flaccid type of paresis. Pseudo-clonus may occur, especially in the ankle. The thrust of the foot against the hand is quite unmistakable in pseudo-clonus, and the movements are never sustained as in organic clonus.

Plantar response is flexor.

Babinski’s Test for Organic Hemiplegia (combined flexion of hip and trunk).—When the subject of organic paralysis attempts to sit up from the supine position without using the arms, the heel of the paralysed leg is raised up into the air, the toes are spread out fanwise, and the healthy shoulder is carried forwards. This does not occur in hysterical hemiplegia. Spastic paraplegia may be differentiated from hysterical paralysis of the legs by the fact that in organic paralysis, when one leg is passively lifted up, the other is raised into the air also.

Contractures may develop suddenly in hysteria. In organic disease contractures develop as the result of the predominating action of more powerful muscle groups; the contracture in hysteria is rather the maintaining of a certain posture. The deep reflexes are not lost, and reaction of degeneration does not occur, but there may be muscular wasting from disuse. The contractures occur more commonly in the arm. The face may be affected together with the tongue, as in glosso-labial hemispasm. The tongue is deviated to an extreme degree towards the ‘paralysed’ side of the face, in which the naso-labial fold is strongly marked. Such a fold would be slight or absent in organic disease.

Catalepsy.—The rigidity is general. The condition must be distinguished from the katatonia of dementia præcox, q.v. Other spasms which may occur are hysterical trismus, simulating the jaw spasm of tetanus, phantom tumours of the abdomen (pseudocyesis), and in the pectoral region, due to local muscular contraction. Hysterical contractures usually disappear during sleep and under deep anæsthesia, but if of long duration may persist owing to the formation of adhesions in the joints. Hysterical pseudo-myopia, due to spasm of the ciliary muscle, may be recognised and treated by the instillation of atropine. Hysterical blepharospasm may follow exposure to sudden bright light or some horrible spectacle, and was common as a war neurosis.

Anæsthesia.—In severe cases this may be universal, affecting even the mucous membranes. More commonly there is anæsthesia of one-half of the body or of the whole or part of a limb. The anæsthesia may be total or for one or more forms of sensation. The affected area corresponds to no definite nerve distribution or root or segmental supply, but rather to the patient’s idea of ‘finger,’ ‘hand,’ ‘arm,’ etc. There may be no loss even of fine movements in the anæsthetic limb. In fact, the limb is anæsthetic to the observer, but not to the patient. Babinski held that hysterical anæsthesia is always the result of suggestion on the part of the physician.

Janet’s Test.—The patient is instructed to answer ‘yes’ when he feels, and ‘no’ when he does not feel. The hysteric will answer ‘no’ when the anæsthetic area is being explored.

In the ‘glove’ and ‘stocking’ types of anæsthesia the line of demarcation between the normal and anæsthetic areas may vary when the test is repeated in the reverse direction.

The special senses are affected on the same side as the skin; this does not occur with organic lesions.

Vision.—There may be concentric contraction of the visual fields with additional diminution as the test is prolonged.

Tests for hysterical amaurosis:

1. Production of diplopia by use of prisms.

2. Patient may read distant type when the ‘blind’ eye is covered with plain lens and sound eye with high + or − lens.

Deafness.—This commonly follows some sudden shock, as was the case with the war neuroses. The deafness is usually bilateral and complete, but without disturbance of the vestibular function. Organic lesions severe enough to cause total deafness are, as a rule, associated with labyrinthine disturbances. In the healthy subject nystagmus is produced when the ear is syringed with water which is well above or below the normal temperature of the body.

Hysterical loss of taste and smell also occur.

Hyperæsthesia is a frequent complaint on the part of hysterics. Certain regions of the body may be affected. There may be hemihyperæsthesia, painful joints, coccygodynia, rachialgia (painful vertebral spines, railway spine), clavus hystericus (boring sensation on the vertex of the head), mastodynia (painful breasts), appendicular or ovarian tenderness. Such areas have been termed hysterogenic or hysterofrenic, since hysterical outbursts such as fits may be provoked or checked by pressure or faradism applied to these sites.

Paræsthesia.—The following forms of perverted sensation are met with in hysteria:

Haphalgesia—complaint of severe pain when certain objects—e.g., particular metals—are applied to the skin.

Allocheiria—the stimulus is felt at the corresponding point on the other side of the body.

Micropsia and macropsia; this is a condition in which objects appear unduly small or large. It may be due to organic causes. Monocular diplopia is usually hysterical.

Gait may be affected in various ways, and it may be difficult to exclude organic disease. The patient may hold the ‘paralysed’ leg stiff and push it forwards as he walks, or simply trail it limply after him. The legs may be flourished in the air in an exaggerated fashion in the process of walking or toeing a given line. In astasia-abasia the patient can use his limbs perfectly when lying down, but can neither stand nor walk.

Speech.—Articulation in hysterics is often affected The enunciation may be peculiar or there may be interpolation of strange grunts and snorts. The barking cough of puberty, cynobex hebetica, is not uncommon.

Mutism sometimes occurs together with hysterical deafness, and usually follows some shock. No sign of organic lesion can be detected, either in the form of nerve paralysis or of interference with the functions of word-seeing, writing, gesture language, etc., which are usually affected in true aphasia.

Aphonia.—The ability to cough is retained, and laryngoscopic examination reveals adductor paralysis of the cords. Hysterical mutism and aphonia usually disappear during anæsthetisation.

Tremors in hysteria have their origin in the normal trembling of fear, but become coarser and more generalised as time goes on. The muscles of the affected part are usually held rigid.

§ 3. Visceral Phenomena in Hysteria.

Cardio-Vascular.—Attacks of tachycardia and pseudo-anginal crises are not uncommon. Cutaneous vaso-motor instability may be extreme so that extensive wheals are produced (dermographism). The various hysterical ‘stigmata,’ such as rashes and hyperæmic areas, are usually self-induced.

Respiratory.—Tachypnœa may occur together with a great display of emotion. The pulse-rate is but slightly increased, and there is no cyanosis or apparent organic cause.

Gastro-Intestinal.—Globus-hystericus has already been mentioned. Dysphagia from localised spasm may raise the suspicion of malignant growth, but an X-ray examination will show the true nature of the condition.

Aerophagy may cause enormous distension of the abdomen.

Hysterical vomiting is frequently a source of anxiety. It may succeed the physiological vomiting of the early months of pregnancy and persist by a process of auto-suggestion. It is rarely so severe as to cause serious loss of weight, but in anorexia nervosa, the pining disorder of the slighted young heroine in the novels, emaciation may reach an extreme degree. Pseudo-hæmoptysis and pseudo-hæmatemesis are produced by extracting blood from the lips, gums, or pharynx.

§ 4. Dissociation.

The above-mentioned conditions may be considered as incomplete forms of dissociation. The dissociation is more complete in:

Somnambulism and Automatism.—The patient carries out a more or less complicated train of action of which he may or may not afterwards remain aware. The changes between the normal and dissociated states are usually sudden. Ordinary sleep-walking may occur under conditions of great fatigue, gastrointestinal irritation, etc., and the subject, as it were, acts his dream. The somnambulism of hysteria may occur apart from sleep, and the patient can afterwards give no account of any dream. It is important to exclude the automatism of epilepsy, q.v.

Fugues are somnambulisms or automatisms during which the patient wanders or undertakes a journey.

Double personality is a more complete form of dissociation than is the case in somnambulism. There may be two or more personalities in the same individual, which may be totally different and quite independent of each other (Jekyll and Hyde). These states may be revived and their mental content explored by means of hypnotism.

Narcolepsy.—This is characterised by paroxysms of diurnal sleep which may occur in the midst of any occupation. There may be prodromal headache, but premonitory signs are often absent. A transient feeling of drowsiness is followed by deep sleep, during which the patient may sink to the ground and even expose himself to danger by lying in the roadway. Sometimes the patient may be roused only with great difficulty, while in other cases the sleep is lighter and disturbed by dreams. The condition has been described by C. Worster-Drought, who finds that the sleep rarely lasts more than twenty minutes. The frequency of the attacks varies from several a day to one or two a year. The condition may or may not be associated with organic disease. Narcolepsy occurring in the absence of organic disease may be of several varieties (Worster-Drought):

1. Apparent sleep, but with memory of contemporaneous events. The patient merely feels incapable of response.

2. Apparent sleep with amnesia for the attack. In this form the respiration is mainly diaphragmatic, and it may be difficult to rouse the patient.

3. Attack is preceded by irresistible impulse to sleep, and the patient may make active attempts, without success, to keep awake. Stimulation by faradism may provoke defensive movements.

4. Narcolepsy may be provoked by a purely psychological situation. Sleep is profound, and there may be great similarity to death. Many cases of catalepsy are of this variety (hysterical suspended animation). Superficial reflexes may be abolished, but deep reflexes are retained.

5. Form which may occur as epileptic ‘equivalent.’

The organic conditions in which narcoleptic attacks may occur are:

Anæmia of various kinds.

Cerebral tumour, especially of frontal lobe and mid-brain. The attacks may occur before there is definite sign of organic disease.

Cerebral Arteriopathy.—Abnormal somnolence is not uncommon in all degrees of severity up to true coma.

Diabetes.—Coma may be preceded by attacks of diurnal sleep.

Encephalitis Lethargica.—Drowsiness and attacks of diurnal sleep are common in the early stages.

General paralysis in the early stages.

Hypothyroidism.

Obesity associated with endocrine disorders

Pituitary disorders, especially tumours which cause pressure in the region of the third ventricle.

Renal disease, especially chronic interstitial nephritis.

Trypanosomiasis in the later stages, when the central nervous system is involved.

Narcolepsy of non-organic origin may be treated by analysis with or without hypnosis, and the unpleasant psychological situation discovered.

§ 5. Varieties of Hysteria.

The Freudian classification is as follows:

Conversion Hysteria.—The patient attempts to solve his conflicts by means of a compromise composed of physical signs. The war neuroses were mostly of this type. For example, a hysterical paralysis enabled the patient to be removed from the seat of danger.

Anxiety Hysteria.—Fears and anxiety play a large part in the symptomatology. The condition is closely allied to the anxiety neurosis.

Fixation Hysteria.—The affected organ or limb has previously been the especial object of the patient’s attention through disease, injury, or for some other reason. A functional paralysis occurs commonly in a limb that has once been injured. There may be an hysterical persistence of pain after operations.

§ 6. Treatment of Hysteria.

In most cases removal from home and complete isolation are desirable, since medical advice is apt to be sought after the hysteric has gained complete control over her family. It should be remembered that hysteria flourishes in an atmosphere of excessive sympathy and attention. The paralyses and anæsthesias of conversion hysteria should be treated by persuasion and suggestion, which may be reinforced by various physiotherapeutic methods such as hydro- and electro-therapy and massage. The electric battery still proves of use. Suggestion may be applied to the patient in the hypnotic state, or during recovery from light anaesthesia. The causes which lead up to the hysterical signs and symptoms may be expounded to the patient by some form of psychological analysis; recovery will often follow. Where these methods have failed, it may be necessary to resort to the slower and more difficult procedure of mental analysis. The natural suggestibility and tendency to undue dependence of these patients usually renders the Freudian method unsuitable, and the older régime of encouragement and assistance towards cultivating more healthy interests should not be forgotten.

Anorexia nervosa has received some notice in recent years, and seems likely to become a fashionable neurosis. This condition usually proves refractory until the patient is moved to hospital, where Weir-Mitchell principles rarely fail.

§ 7. War Neurosis (Shell-Shock).

The mental disorders occurring in warfare are not fundamentally different from those occurring under peace conditions. War neurosis mostly takes the form of conversion and anxiety hysteria in which a physical sign or mental symptom achieves the same end as a wound—i.e., removal from the seat of war. Most of those who were actually in the fighting zone suffered a conflict between the self-preservation instinct (desire to run away) and the herd instinct (desire to ‘play the game’). When the conflict could not be settled in a normal manner a compromise was reached by means of the neurosis and both instincts were satisfied, just as if the patient had had to give up ‘playing the game’ owing to a wound. As regards the other neuroses (neurasthenia, obsessional neurosis, etc.) and the psychoses, the strain and stress of war conditions merely precipitate the onset in individuals who would have been liable to the same disorders in peace-time.

HYSTERIA

"This is hysteria; to dramatise the conflicts, if possible directly in the appropriate bodily organ, or as a next best thing in some portion of the body which takes on the symbolical significance of this organ. That is why the Greeks named it ‘Hysteria’ literally ‘a wandering womb’."

Major Hysteria: The well-known woman Parliamentarian and social reformer lay unconscious in the pathway outside her hotel. She had been ailing for several weeks and had come to this place to regain her health and, secretly, to obtain some peace from the intrusions of various turbulent members of her family.

Her hope had been in vain, for they had all individually and collectively followed her down there. The rows and quarrels from which she fled had also followed her. Her last memory before the collapse was that of her younger son having a shouting quarrel with the young woman whom she had befriended and taken with her as companion. She was trying to rest in the room upstairs while their raised voices assailed her.

Her husband had arrived and joined in the quarrel. Now he and her son had gone to the station. She had come as far as the front door to see them off. The son, still in a temper, had left her with an angry remark.

They disappeared round the bend. That was all she knew. Now she could remember she had had a strange sensation of losing the power of her legs . . . and then . . . nothing.

She awoke in a nursing home with no less than three doctors leaning over her bedside. She was conscious merely of agonising pains, pains that twisted her abdomen into knots and ran down both her legs—colicky feelings, twitchings and achings. Moreover these did not improve. Other doctors were consulted. A specialist from London was sent for.

By this time an idea had arisen in the mind of at least one of her medical attendants that this patient’s symptoms fitted into no orthodox medical category. He suspected functional disturbance, but the problem was how to convey this suspicion to such an important and intellectually dominating woman, or to find a way of shaking her out of it.

This doctor figured it out that it required some eminent member of the profession who would be in a sufficiently strong position to come and practise the traditional face-slapping or jug-of-cold-water type of treatment, and by the virtue of his eminence get away with it. Accordingly, he sent for his selected neurologist.

The lady told me subsequently: "When this man arrived I took an instant dislike to him. He was too well-dressed. His tie, handkerchief and socks matched too well. I hated his monocle, his collar, his tie, his face and everything that was his. And I think he hated me too.

"Anyhow he took a book from the shelf and hit me on the back of the neck with it. I screamed and got much worse. Now I come to think of it, it makes my blood boil. I fancy a little more, and I might have forgotten my paralysed legs and got up and torn him to pieces. It was either that or getting much worse, and I chose the latter.

"My husband came down and fussed around the nursing home and played the rôle of the devoted husband, but I could see that he was more devoted to the nurses than to me. He thoroughly enjoyed himself. I could have told them some things—but I was too near dying, or crazy, or both. Anyhow, it was finally decided that I would die if I remained in the nursing home, and so I was removed to a large flat at a seaside resort which a friend placed at my disposal.

"There I had a fiery Ulsterman for a doctor. The agonising pains were still in my legs, and I was still raving instead of sleeping. He told my housekeeper that he had the very thing. I was given an injection. He was called that same night because they thought I was dying.

"In the flat above a party was going on. The radiogram was blaring away. They had a number of guests including sailors. There was dancing. The doctor looked at me, his dying patient, and said, ‘That noise must stop.’ He dashed upstairs to stop it himself. They refused. I heard the raised voices and then the noise of a scuffle or fight.

It was like old times. They all thought I was unconscious, but I heard everything and struggled with the idea that I should get out of bed and take the doctor’s part.

Here I could not resist the interjection: "Oh no, you were already playing your own part very well indeed!"

"Presently the doctor was back in the room spluttering with rage. He telephoned the police station. But the radiogram did not stop until the police arrived and turned it off themselves. They placed the entire household and visitors, twenty-five people in all, under arrest. The doctor went off still spluttering, and two policemen stayed all night in the passage outside my room.

"In the morning there was more excitement, for a group of the guests tried to make a get-away. They started up a car at the back and nearly did the trick, only two police jumped on the running-board. I could not resist sticking my head out of the window at this, but it did not matter for at the moment everybody’s attention was distracted.

"They were all lined up at the police station and all fined. There was a great deal of hysteria. Several of the girls cried and said they were sorry, while