Hysteria
Hysteria
Phenomenology and explanations of hysteria
Psychoanalytic theory of hysteria
In contemporary usage, the name hysteria is given to a form of mental illness characterized by the exhibition of bodily signs such as paralysis or spasmodic movements and by complaints about the body, such as anesthesia or pain. The terms conversion hysteria and dissociative reaction are other names given to these phenomena. Bodily communications indistinguishable from those typical of hysteria may also be present in individuals diagnosed as hypochondriacal, neurasthenic, or schizophrenic, and sometimes in so-called normal persons as well.
Historical overview of the problem. The group of phenomena we now call hysteria and regard as a type of mental disease has been known since antiquity. Its many interpretations, during different historical periods, reflect the varied cultural concepts for explaining bodily illness and social deviance.
The term hysteria comes from the Greek word hystera, which means the womb or uterus. Hippocrates thought that the uterus was a free, peregrinating organ and that its wandering about the woman’s body caused hysteria. Although he considered it a distinct, organic disease, he may have sensed its relation to the sexual passions, for he recommended marriage as the best remedy. The notion that hysteria was a condition limited to women was thus firmly established and was not seriously challenged until the latter half of the nineteenth century by Charcot (Zilboorg 1941).
During the first ten centuries of Christianity, with medical thought stagnating under the authoritarian influence of Galenic concepts, most cases of hysteria were probably mistaken for various bodily diseases. During the Middle Ages, as the attitude toward sickness changed from naturalistic to demonotheologic, many cases of hysteria, and undoubtedly of organic disease too, were interpreted as manifestations of witchcraft.
With the flowering of empiricism and science during the Renaissance, hysteria was again rediscovered as a disease. It is interesting that in the eighteenth century its main cause was attributed to emotions, passions, and human suggestibility, and in the early nineteenth, to organic dysfunction. It fell to Charcot, Janet, and Freud to clarify the distinction between neurological illness and hysteria. They showed that hysteria is a condition resembling physical disease that occurs in persons with healthy bodies. If this was hysteria, it is evident why it had to be distinguished from malingering. In theory, this was accomplished by defining hysteria as the unconscious imitation of illness, and malingering as the conscious imitation of it. In practice, the distinction was less easy to make.
It is only a small step from the psychoanalytic view of hysteria, which regards it as a form of illness, albeit without physical causation, to the communicational view of hysteria, which regards it as a form of communication—specifically, as the language of illness. The implications of the various concepts of hysteria for its epidemiology and therapy will be discussed later.
Phenomenology and explanations of hysteria
What is hysteria? What kind of “thing” is it? The most popular view today is that hysteria is a disease. Some consider it an organic disease; others, a mental disease.
Organic theory. The idea that hysteria is an organic disease has the merit of being logical. After all, the hysteric acts sick and looks sick; he is manifestly disabled; and he says he is ill. Supporters of this view argue that people have been disabled by many conditions—for example, diabetes and neurosyphilis—that were not understood as diseases with specifiable physicochemical causes and disturbances until recent times. They claim that hysteria is another such disease: we understand only its “mental symptoms,” but in time will discover its physicochemical cause (Szasz 1961, pp. 91-93).
Thus, according to the organic theory of hysteria, the condition is basically similar to diseases of the central nervous system, such as multiple sclerosis. In this frame of reference, hysteria is a disease that happens to a person: he suffers from it and may be cured of it. Logically, this is a sound position. Factually, I consider it false.
Psychopathological theory. Few behavioral scientists accept the theory of the organic causation of hysteria. Those who consider hysteria an illness usually qualify it as a mental illness. Its pathology, therefore, is sought not in the patient’s brain or body but in his psyche; hence we have various hypotheses about the so-called psychopathology of hysteria. The specific content of these hypotheses varies with the theories of particular schools of psychodynamics. There is general agreement, however, that hysterical bodily signs represent an unconscious conversion of repressed ideas, feelings, or conflicts into symptoms.
Thus, the psychopathological theory of hysteria also regards this condition as a disease, but with psychological causes rather than physiological. This explanation is weak logically (Ryle 1949) and is not adequately testable.
Communicational theory. Finally, there is the communicational theory of hysteria. It is based on the proposition that not all types of disability should be classified as illness; and, further, that so-called hysterical symptoms are a form of communication and game playing. Hysteria is a game with a theme of helplessness and helpfulness. The hysteric acts disabled and sick: however, his illness is not real, but is merely an imitation of a bodily illness. Because the hysteric impersonates the sick role, the result is genuine disability. But if we call this condition an illness, we use this term metaphorically, whether or not we realize it (Szasz 1961, pp. 259-279).
Thus, according to the communicational approach to hysteria, the phenomena that the patient presents are examined and interpreted not only in the context of his past, but in the context of his total human situation. Through body language, the hysteric communicates with himself and others —but especially with those who are willing, and often eager, to assume the role of being protective and controlling. This explanation is logically sound and testable. To date, I consider it our most adequate theory of hysteria.
Incidence
It is appropriate to raise certain questions now, such as: Is hysteria the same as it has always been or has it changed during the past fifty to eighty years? Is it more, or less, common today than it was in the past? Our answers will depend, in part, on our concept of hysteria.
It has been widely suggested (for example, by Chodoff 1954; Wheelis 1958; and others) that hysteria was more common in Austria toward the end of the last century than it is in America today. The evidence for this view is unconvincing. What has changed, without any doubt, is the sociology of medical practice. Thus, in the Paris or Vienna of the 1880s, persons with bodily complaints were seen by general practitioners or neurologists. The doctor’s main task was to make a differential diagnosis between organic disease and conversion hysteria (and malingering). Today, such patients still seek the help of the general practitioner and the medical specialist. In the meantime, however, there developed a new medical specialty: psychiatry. Because hysterical patients consider themselves medically, not mentally, ill, they do not usually consult psychiatrists.
As psychiatry became a separate discipline, hysteria (and other mental disorders) became a specifically psychiatric diagnosis (much as, for example, myelogenous leukemia is a specifically hematologic diagnosis). It is expected, therefore, that this diagnosis will be attached to so-called psychiatric patients. However, persons who consult psychiatrists voluntarily or who are committed to their care involuntarily rarely suffer from what appears to be bodily illness; more often, they feel anguished or they annoy others. Thus, it is true that among the contemporary psychiatrist’s patients hysteria is not a conspicuous complaint. But this does not mean that the incidence of hysteria in the population at large has decreased. I believe it has not.
The evidence suggests that hysteria is as common as ever, and perhaps more so. To be sure, as we have noted, persons who imitate illness, or who communicate with others in the language of illness, do not crowd the psychoanalyst’s private office. Instead they go where—to paraphrase the signs that announce Aqul se habla espanol or lei on parle frangais—the sign proclaims, We speak the language of illness. Where are such signs displayed? In the offices of general practitioners, internists, dermatologists, neurologists, and so forth; in medical clinics, and especially in famous diagnostic centers; in clinics where compensation for illness is awarded, such as those operated by the Veterans Administration; and in the offices of lawyers and in courts, where money damages may be sought and obtained for illness, both organic and mental, real and counterfeit.
Because of these radical changes during the past half century in the sociology of medical and psychiatric practice, I consider it misleading to speak simply of the incidence of hysteria. We must specify the particular situation, with respect to the social identity of both the observer and the observed, in which the incidence of the disorder is to be established.
Psychoanalytic theory of hysteria
Working as a physician, Freud developed his theory of hysteria to account for, and to help him cope with, some of the practical problems that faced him. What were these problems? Here is a typical example of one from Breuer and Freud’s classic work, Studies on Hysteria:
In the autumn of 1892, I was asked by a doctor I knew to examine a young lady who had been suffering for more than two years from pains in her legs and who had difficulties in walking…. All that was apparent was that she complained of great pain in walking and of being quickly overcome by fatigue both in walking and… standing, and that after a short time she had to rest, which lessened the pains but did not do away with them altogether…. I did not find it easy to arrive at a diagnosis, but I decided for two reasons to assent to the one proposed by my colleague, viz. that it was a case of hysteria. (Breuer & Freud [1893-1895] 1955, pp. 135-136)
What was wrong with this young woman? Because of the absence of neurological and other medical illness, and for certain other reasons as well, Freud concluded that she suffered from the disease called hysteria. How is this disease brought into being? This was Freud’s explanation:
According to the view suggested by the conversion theory what happened may be described as follows: She repressed her erotic idea from consciousness and transformed the amount of its affect into physical sensations of pain.—We may ask: What is it that turns into physical pain here? A cautious reply would be: Something that might have become, and should have become, mental pain. If we venture a little further and try to represent the ideational mechanism into a kind of algebraical picture, we may attribute a certain quota of affect to the ideational complex of these erotic feelings which remained unconscious, and say that this quantity (the quota of affect) is what was converted. (Breuer & Freud [1893-1895] 1955, p. 166)
Etiology. The mechanism of the pathogenesis of hysteria was subsequently elaborated and refined by Freud and other psychoanalysts and came to include certain other features. According to Glover (1939, pp. 140-149), the following etio-logical factors are responsible for the occurrence and specific content of conversion symptoms:
(1)Somatic compliance. Symptoms are localized in accordance with the distribution and fixation of body libido; body parts or organs, overli-bidinized by previous organic disease or continuous hyperfunction, become the media of expression.
(2)Frustration, introversion, and regression. If there is frustration of instinctual drives in adult life, the libido tends to turn from reality to fantasy. Fantasy is subject to the laws of regression.
(3)Reactivation of the Oedipus situation. Infantile fantasies, especially those associated with the Oedipus complex, are reactivated through regression.
(4)Breakdown of repression. Repression, faulty to begin with, cannot cope with the additional charge of the reactivated infantile fantasies. The defense crumbles and the repressed content breaks through: the return of the repressed.
(5)Symptom formation through displacement and symbolization. The specific form of conversion symptoms is determined partly by the degree of genital symbolization of various parts (that is, to what extent, for any particular person, parts of his body resemble the genital organs); and partly by the extent of the person’s unconscious identification with his incestuous objects (that is, parents or siblings).
The result is an inhibition or exaggeration of bodily functions, giving rise to crippling or painful symptoms. These constitute a somatic dramatization of unconscious fantasies.
Hysteria as communication
The psychoanalytic theory of hysteria contains rudimentary suggestions for a communicational approach to this phenomenon. However, a systematic account of hysteria as language or communication was not developed until recently (Szasz 1961, pp. 115-163). To understand this view requires acquaintance with certain technical concepts, which I shall summarize here.
Anything in nature may or may not be a sign, depending on a person’s attitude toward it. A physical thing—a chalk mark, a dark cloud, a paralyzed arm—is a sign when it appears as a substitute for the object for which it stands, with respect to the sign user. The three-part relation of sign, object, and sign user is called the relation of denotation.
Classes of signs. Three classes of signs may be distinguished: indexical, iconic, and symbolic, or conventional, signs.
In the indexical class belong signs that acquire their sign function through a causal connection. For example, smoke is a sign of fire and fever a sign of infectious disease.
In the iconic class belong signs that acquire their sign function through similarity. For example, a photograph is a sign of the person in the picture; a map is a sign of the territory it represents.
In the third class, symbolic, or conventional, signs, belong signs that acquire their sign function through arbitrary convention and common agreement—for example, words and mathematical symbols. Symbols do not usually exist in isolation, but are coordinated with each other by a set of rules called the rules of language. The entire package, consisting of symbols, language rules, and social customs of language use, is sometimes referred to as the language game. [See Semantics and semiotics].
Hysteria and the language of illness. Communicational situations may comprise one, two, three, or a multitude of people. A semiotic and game-playing view of hysteria (Szasz 1961, pp. 115-293) does not imply a purely social approach and hence a neglect of the intrapersonal dimension of the problem.
For example, hysteria (and other so-called mental illnesses) may occur in a one-person situation. An individual who feels pain in his abdomen and concludes, falsely, that he suffers from acute appendicitis illustrates this phenomenon. Such a person fools himself, not others. He plays a game by disguising his personal problem as a medical disease. The advantage derived from such a one-person game corresponds closely to the psychoanalytic idea of primary gain.
However, since people generally do not live in isolation, the interpersonal and social aspects of hysterical (hypochondriacal, neurasthenic, etc.) communications are of great importance. Indeed, it is the complexity of communications among people that accounts for much of the complexity of hysteria as a so-called clinical syndrome (Szasz 1957).
Thus, if a person complains to his physician of abdominal pain and insists that it is due to an inflamed appendix, even though there is no other evidence to support this view, first his interpretation will be discredited, and then he himself will be discredited. The more he enlarges the social situation where he makes this claim, the more he risks being seriously discredited (for example, by being labeled schizophrenic and committed to a mental hospital). In a sense, such a person plays a game of fooling others. To the extent that he succeeds and is accepted as sick, he derives an advantage from his strategy. This advantage corresponds closely to the psychoanalytic idea of secondary gain.
From a communicational point of view, the traditional problem of differentiating hysteria from organic disease becomes one of distinguishing iconic signs from indexical ones. The physician and psychotherapist observe signs, not diseases—the latter being inferences drawn from the former. Thus, an analysis based on sign discrimination is likely to be more testable, as well as more serviceable, than one based on disease differentiation.
How, then, do we distinguish indexical signs from iconic signs? This is done by ascertaining whether the sign is “given” by a person or “given off” by him. Iconic signs resemble conventional ones because both are manufactured, more or less deliberately, by a person; indexical signs are passively given off, rather than actively emitted, by the signaling organism.
Thus, if a person complains of abdominal pain, our question is not, Is he suffering from acute appendicitis or from hysteria? but rather, Is the pain an indexical sign of an inflamed appendix or an iconic sign of it? Obviously, it could be both at once. It is therefore never possible to make a “diagnosis” of hysteria by ruling out organic illness, nor a diagnosis of organic illness by ruling out hysteria. Instead, in doubtful cases, both patient and physician must decide whether to approach the sign as though it were indexical, signaling a disease of the body, or as though it were iconic, signaling a complaint about the self and others. The former approach requires adequate medical investigation, the latter, meaningful communication.
Implications of a communicative view. I shall now list the major implications of a communicative view of hysteria:
First, hysteria is a particular type of forgery—namely, impersonation of the sick role.
Second, hysteria is a particular dialect of the language of sickness and health. It is a form of communication especially appropriate to the medical, or related, situation in which a person defines himself and is accepted as sick or disabled; those about him are then defined complementarily as physicians or healers.
Third, the language of hysteria is composed of iconic signs, is nondiscursive (Langer 1942), and hence ambiguous. The meaning the sender intends to convey is easily misunderstood or misinterpreted by the receiver. This may be useful to the sender, the receiver, or both.
Fourth, the language of hysteria cannot convey information accurately, but can induce feeling and promote action in others. It is thus a type of rhetoric, that is, a method of persuasion or coercion.
Rhetoric of hysteria. It is useful to distinguish between two types of communication—dialectical and rhetorical. The former term refers to attempts to explain something; the latter refers to efforts to convince someone.
I have suggested that hysteria is a form of rhetoric. I now wish to substantiate this view.
What does the hysteric do? Why is he called by this name? He complains of pain and suffering; he exhibits bodily signs suggesting that he is sick; and, finally, he adopts a general style of communication that enables him to arouse and alarm those about him. He does this by confronting them with desperate situations that seem to require immediate intervention.
Why does the hysteric do this? Freud and other psychoanalysts have suggested the main answers. However, I think there are two additional reasons. One is that the subject knows that he has no legitimate ground for making demands on others: he therefore resorts to the language of illness. The other is that he knows that the language of hysteria is more effective as a rhetorical device than everyday speech. The reason for this is simple.
To identify a person, we use his photograph or fingerprint, not a verbal description of his appearance. The hysteric uses an analogous principle. If one person seeks the attention, interest, or help of another individual, he can achieve these aims best by a dramatic display of messages that say, in effect, “I am sick! I am helpless! You must help me!” This can be accomplished more effectively by displaying the image or the icon of illness—an apparently sick body—than by asserting, calmly and in everyday language, the suspicion that one feels ill and perhaps ought to see a doctor. If one picture is worth a thousand words, one hysterical symptom is worth two thousand. Herein lies the rhetoric of hysteria.
Therapy of hysteria
Only in organic medicine can we speak meaningfully of treatment: a disease can be cured; a person can only be changed.
Does the hysteric want to be changed? Often he does not. Instead, he wants to change others, so that they will comply with his wishes more readily. This insight, poorly understood and even more poorly articulated, led many physicians to conclude that such patients were “social parasites” who “would … steal anything conveniently within reach, lie, cheat, make work and trouble for others …” (Rogues de Fursac 1903, p. 317 in 1920 edition.).
Because hysteria is a form of rhetoric, it often evokes counter-rhetoric in response. The patient tries to coerce through symptoms; the physician tries to coerce through hypnosis. The result is often a mutually antagonistic, coercive relationship; sometimes the patient dominates, sometimes the doctor, and often the contest ends in a draw.
It is also possible for the physician, knowingly or unwittingly, to treat the hysteric as if he (or she) were ill. Such a physician accepts the patient’s communications couched in the language of illness and replies in the same idiom. In the past, this took the form of mythical diagnoses, like uterine retroflexion or focal infection, and of surgical treatments whose value lay not in correcting abnormal bodily function but in symbolically legitimating the patient’s sick role.
Today, this type of conversation between patient and doctor, employing the language of illness, can be carried on with greater ease than ever, since modern tranquilizing drugs constitute a socially accepted form of medical treatment for nonexistent medical illnesses. By prescribing such drugs, the physician acts as if he accepts the hysteric as genuinely sick; at the same time, he tries to repress (alter) the symptoms. This may be expedient for the therapist and acceptable to the patient.
Why, then, should we not rejoice in this modern approach to the “treatment” of hysteria (and other mental disorders)? Because we must remember that every “mental” symptom is a veiled outcry of anguish. Against what? Against oppression, or what the patient experiences as oppression. The oppressed speak in a million tongues—the myriad symptoms of hysteria (and mental illness). They make use of all the well-tried languages of illness and suffering and constantly add tongues newly created for special occasions. They need these mar-velously complicated linguistic devices, for, at a single stroke, they must reveal and conceal themselves.
What of the psychiatrist or of others who wish to help such a person? Should they amplify the dissent and help the oppressed shout it aloud? Or should they strangle the cry and reoppress the fugitive slave? This is the psychiatric therapist’s moral dilemma (Szasz 1964).
It is such considerations that led Freud to develop the psychoanalytic method and others to refine it. The psychoanalytic therapy of hysteria was thus a moral, rather than a purely medical, breakthrough in psychiatry.
Because hysteria is a form of rhetoric, it tends to evoke one of two responses: acceptance or rejection of the idea (and action) that the patient seeks to impose on the doctor. Either course leads to subsequent difficulties: the first to the doctor’s inability to treat the patient, the second to an antagonistic relationship between patient and physician. Psychoanalysis seeks to avoid this interpersonal impasse by offering the patient another level of discourse. It substitutes dialectic for rhetoric and discursive language for nondiscursive.
Thomas S. Szasz
[See alsoPsychosomatic illness. Other relevant material may be found inPsychoanalysis; and the biographies ofCharcot; janet].
BIBLIOGRAPHY
Abse, D. Wilfred 1959 Hysteria. Volume 1, pages 272-292 in American Handbook of Psychiatry. Edited by Silvano Arieti. New York: Basic Books. ? A useful general work on hysteria.
Breuer, Josef; and Freud, Sigmund (1893-1895) 1955 The Standard Edition of the Complete Psychological Works of Sigmund Freud. Volume 2: Studies on Hysteria. London: Hogarth; New York: Macmillan. ? First published in German.
Chodoff, Paul 1954 A Re-examination of Some Aspects of Conversion Hysteria. Psychiatry 17:75-81.
Glover, Edward (1939) 1949 Psycho-analysis: A Handbook for Medical Practitioners and Students of Comparative Psychology. London: Staples.
Langer, Susanne K. (1942) 1961 Philosophy in a New Keg: A Study in the Symbolism of Reason, Rite, and Art. New York: New American Library.
Rogues de Fursac, Joseph (1903) 1938 Manual of Psychiatry and Mental Hygiene. 7th ed., rev. & enl. New York: Wiley. ? First published as Manuel de psy-chiatrie.
Ryle, Gilbert (1949) 1962 The Concept of Mind. London: Hutchinson’s University Library.
Szasz, Thomas S. 1957 Pain and Pleasure: A Study of Bodily Feelings. New York: Basic Books.
Szasz, Thomas S. 1961 The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Harper.
Szasz, Thomas S. 1964 The Moral Dilemma of Psychiatry: Autonomy or Heteronomy? American Journal of Psychiatry 121:521-528.
Wheelis, Allen 1958 The Quest for Identity. New York: Norton.
Zilboorg, Gregory 1941 A History of Medical Psychology. New York: Norton.