Cerebral Disease and Hysteria Alec Roy
A
N ASSOCIATION between hysteria and cerebral disease is well recognized.‘-J Slate? reported that at follow-up of 85 patients originally diagnosed as hysteria, in only “approximately 40% . no evidence for organic disease has yet been found.” Slater and Roth” considered that this association “may occur in either of two ways. Organic damage to the brain . . . may create or greatly increase a natural disposition to hysterical manifestations,” or secondly “. . by providing a focus for the development of a constellation of ideas.” Recently, Merskey and Buhrich: reported that 48% of 89 patients with conversion symptoms had cerebral disorder or systemic illness affecting the brain. They too concluded that this indicated “a relationship between organic cerebral disease and hysterical conversion symptoms.” They also considered that this was due to both an organic factor as well as to psychological factors. The difficulty in attempting to separate and evaluate the relative contribution of organic and psychological factors is that cerebral disease often causes symptoms with which both can be identified. Thus, both factors may be present in the same patient with an hysterical neurosis. To examine this question it was decided to study patients with hysterical convulsions. The hypothesis tested here was that there is an association between hysteria and brain disease and that it is due mainly to psychological factors. MATERIALS
AND METHODS
The experimental group consisted of a consecutive series of 34 patients seen by the author with convulsions admitted to hospital between May 1974 and December 1976 for investigation and treatment of epilepsy and whose discharge diagnosis was hysterical neurosis.” Twelve were investigated by the Maudsley-King’s Neurology Unit, 14 by the Maudsley Epilepsy Unit, and 8 by general psychiatric units. Each was matched for age and sex (within five years) with the next patient seen by the author admitted to one of two Maudsley general psychiatric units whose discharge diagnosis was depressive neurosis.” Each patient was given a medical and psychiatric interview by the author and their case notes and results of physical examination, routine and special investigations examined. All were discussed with their doctors and the absence or presence of any brain disease recorded. Both groups consisted of 29 women and 5 men. The mean age of the control group was 3 I .5 years and of the experimental
years.
In the statistical
group 31.6 years, and they had had their convulsions for an average of 2.X
analysis
Fischer’s
exact test was used.
RESULTS
Thirteen of the 34 patients in the hysterical neurosis group had organic brain disease compared with one of the 34 patients in the depressive neurosis group. This difference between the groups is statistically significant ( p < 0.001).
From Maudslqv Hospital, London, England. Alec Roy. Senior Registrar, Maudsley Hospital, London S.E. 5. England. Address reprint requests to Dr. Alec Rqv. Maudsley Hospital, Denmark Hill, London SE5 RAZ. England. SC> 1977 by Grune & Stratton, Inc. ISSNOOIO 440X. Comprehensive Psychiatry. Vol. 18, No. 6 (November/December).
1977
607
608
ALEC ROY
Eleven of the 34 patients in the hysterical neurosis group were well-controlled epileptics in whom over 80% of their current convulsions were hysterical convulsions (hysteroepileptic group). In all 11 their epileptic attacks were convulsions. Five had idiopathic epilepsy, four temporal lobe epilepsy, and two secondary major epilepsy. The remaining 23 patients were nonepileptics with hysterical convulsions (hysterical convulsions only group). Only two of these had organic brain disease (one due to kernicterus and the other to birth injury) compared with one of their matched 23 control patients (due to past encephalitis). Statistical analysis failed to show any significant difference between these two groups.
DISCUSSION
The diagnosis of hysterical convulsions in each patient in the experimental group, and the absence or presence of any epilepsy, was made independent of this study, after careful inpatient assessment and investigation by Consultants with a special interest and knowledge of epilepsy. As well as routine physical and medical investigations, medications were serially withdrawn, and serial EEGs performed. Some patients had sphenoidal EEGs and specialized neuroradiologic investigations and psychometric tests. Convulsions were often witnessed on the ward and the patient examined by nursing and medical staff. A few patients had convulsions during EEG recordings. In no patient were the hysterical convulsions thought to be epileptic equivalents. The psychiatric diagnosis of hysteria was made initially by the psychiatrists and neurologists concerned with each patient. In each patient reported here the author agreed with their diagnosis using the definition of hysterical neurosis, 300.1, of the Glossary of Mental Disorders.8 In this study 26% of the total group of patients with conversion symptoms had cerebral disorder. This is less than reported in the studies of Slater et al.” There is an important institutional difference. Both their series came from the same neurological hospital, The National Hospital, London. Merskey and Buhrich’ state: “the purpose of the psychiatric departments of the National Hospitals is to provide a psychiatric service to patients with neurological illness.“’ In fact, 58% of their psychiatric control group also had cerebral disease. In contrast, the patients in this study were drawn from a psychiatric and a general hospital. In the hysteroepileptic group both organic and psychological factors are present in each patient. They all have cerebral disorder (epilepsy) and the same symptom (epileptic convulsions) on which to identify or model their hysterical convulsions. The patients in the hysterical convulsions-only group have no epilepsy and thus no personal symptom to model or identify with. Therefore, in this group any association with cerebral disorder can be attributed mainly to an organic factor. However, in this group no association with cerebral disease was found. Therefore, for this group presumably psychological factors are important. This finding suggests the possibility that in the hysteroepileptic group the associated cerebral disorder found may predispose to hysterical convulsions mainly because of psychological factors, like identification with the epileptic convulsions, rather than because of an organic factor.
CEREBRAL
DISEASE
AND
609
HYSTERIA
REFERENCES I.
Anderson
(ed 2). London,
EW, Trethowan
WH:
Bailliere,
& Cassell,
Tindall
Psychiatry 1967
5. Slater J l:l395-
E: Diagnosis
6. Mayer-Gross 2. Fish Bristol,
F: An
John Wright,
3. Linford chiatry
Outline
of Psychiatry
(ed 2).
1968
Rees WL:
(ed 2). London,
Clinical
Textbook
Hodder
of Psy-
and Stoughton.
I976
7. Merskey
LC:
8). Philadelphia,
Modern Saunders,
Clinical 1973
Psychiatry
(ed
brain
48:359
366. 1975
tionery
disease. of
Office, Office,
E, Roth
(ed 3). Baltimore,
H, Buhrich
ganic
Register
Br Med R (eds): Williams
1969
8. Glossary 4. Kolb
W, Slater
Psychiatry
and Wilkins,
Short
of “Hysteria.”
1399. 1965
Mental London,
1968
NA: Br
Hysteria J
Med
Disorders. Her
and orPsycho1 General
Majesty’s
Stn-
A
N ASSOCIATION between hysteria and cerebral disease is well recognized.‘-J Slate? reported that at follow-up of 85 patients originally diagnosed as hysteria, in only “approximately 40% . no evidence for organic disease has yet been found.” Slater and Roth” considered that this association “may occur in either of two ways. Organic damage to the brain . . . may create or greatly increase a natural disposition to hysterical manifestations,” or secondly “. . by providing a focus for the development of a constellation of ideas.” Recently, Merskey and Buhrich: reported that 48% of 89 patients with conversion symptoms had cerebral disorder or systemic illness affecting the brain. They too concluded that this indicated “a relationship between organic cerebral disease and hysterical conversion symptoms.” They also considered that this was due to both an organic factor as well as to psychological factors. The difficulty in attempting to separate and evaluate the relative contribution of organic and psychological factors is that cerebral disease often causes symptoms with which both can be identified. Thus, both factors may be present in the same patient with an hysterical neurosis. To examine this question it was decided to study patients with hysterical convulsions. The hypothesis tested here was that there is an association between hysteria and brain disease and that it is due mainly to psychological factors. MATERIALS
AND METHODS
The experimental group consisted of a consecutive series of 34 patients seen by the author with convulsions admitted to hospital between May 1974 and December 1976 for investigation and treatment of epilepsy and whose discharge diagnosis was hysterical neurosis.” Twelve were investigated by the Maudsley-King’s Neurology Unit, 14 by the Maudsley Epilepsy Unit, and 8 by general psychiatric units. Each was matched for age and sex (within five years) with the next patient seen by the author admitted to one of two Maudsley general psychiatric units whose discharge diagnosis was depressive neurosis.” Each patient was given a medical and psychiatric interview by the author and their case notes and results of physical examination, routine and special investigations examined. All were discussed with their doctors and the absence or presence of any brain disease recorded. Both groups consisted of 29 women and 5 men. The mean age of the control group was 3 I .5 years and of the experimental
years.
In the statistical
group 31.6 years, and they had had their convulsions for an average of 2.X
analysis
Fischer’s
exact test was used.
RESULTS
Thirteen of the 34 patients in the hysterical neurosis group had organic brain disease compared with one of the 34 patients in the depressive neurosis group. This difference between the groups is statistically significant ( p < 0.001).
From Maudslqv Hospital, London, England. Alec Roy. Senior Registrar, Maudsley Hospital, London S.E. 5. England. Address reprint requests to Dr. Alec Rqv. Maudsley Hospital, Denmark Hill, London SE5 RAZ. England. SC> 1977 by Grune & Stratton, Inc. ISSNOOIO 440X. Comprehensive Psychiatry. Vol. 18, No. 6 (November/December).
1977
607
608
ALEC ROY
Eleven of the 34 patients in the hysterical neurosis group were well-controlled epileptics in whom over 80% of their current convulsions were hysterical convulsions (hysteroepileptic group). In all 11 their epileptic attacks were convulsions. Five had idiopathic epilepsy, four temporal lobe epilepsy, and two secondary major epilepsy. The remaining 23 patients were nonepileptics with hysterical convulsions (hysterical convulsions only group). Only two of these had organic brain disease (one due to kernicterus and the other to birth injury) compared with one of their matched 23 control patients (due to past encephalitis). Statistical analysis failed to show any significant difference between these two groups.
DISCUSSION
The diagnosis of hysterical convulsions in each patient in the experimental group, and the absence or presence of any epilepsy, was made independent of this study, after careful inpatient assessment and investigation by Consultants with a special interest and knowledge of epilepsy. As well as routine physical and medical investigations, medications were serially withdrawn, and serial EEGs performed. Some patients had sphenoidal EEGs and specialized neuroradiologic investigations and psychometric tests. Convulsions were often witnessed on the ward and the patient examined by nursing and medical staff. A few patients had convulsions during EEG recordings. In no patient were the hysterical convulsions thought to be epileptic equivalents. The psychiatric diagnosis of hysteria was made initially by the psychiatrists and neurologists concerned with each patient. In each patient reported here the author agreed with their diagnosis using the definition of hysterical neurosis, 300.1, of the Glossary of Mental Disorders.8 In this study 26% of the total group of patients with conversion symptoms had cerebral disorder. This is less than reported in the studies of Slater et al.” There is an important institutional difference. Both their series came from the same neurological hospital, The National Hospital, London. Merskey and Buhrich’ state: “the purpose of the psychiatric departments of the National Hospitals is to provide a psychiatric service to patients with neurological illness.“’ In fact, 58% of their psychiatric control group also had cerebral disease. In contrast, the patients in this study were drawn from a psychiatric and a general hospital. In the hysteroepileptic group both organic and psychological factors are present in each patient. They all have cerebral disorder (epilepsy) and the same symptom (epileptic convulsions) on which to identify or model their hysterical convulsions. The patients in the hysterical convulsions-only group have no epilepsy and thus no personal symptom to model or identify with. Therefore, in this group any association with cerebral disorder can be attributed mainly to an organic factor. However, in this group no association with cerebral disease was found. Therefore, for this group presumably psychological factors are important. This finding suggests the possibility that in the hysteroepileptic group the associated cerebral disorder found may predispose to hysterical convulsions mainly because of psychological factors, like identification with the epileptic convulsions, rather than because of an organic factor.
CEREBRAL
DISEASE
AND
609
HYSTERIA
REFERENCES I.
Anderson
(ed 2). London,
EW, Trethowan
WH:
Bailliere,
& Cassell,
Tindall
Psychiatry 1967
5. Slater J l:l395-
E: Diagnosis
6. Mayer-Gross 2. Fish Bristol,
F: An
John Wright,
3. Linford chiatry
Outline
of Psychiatry
(ed 2).
1968
Rees WL:
(ed 2). London,
Clinical
Textbook
Hodder
of Psy-
and Stoughton.
I976
7. Merskey
LC:
8). Philadelphia,
Modern Saunders,
Clinical 1973
Psychiatry
(ed
brain
48:359
366. 1975
tionery
disease. of
Office, Office,
E, Roth
(ed 3). Baltimore,
H, Buhrich
ganic
Register
Br Med R (eds): Williams
1969
8. Glossary 4. Kolb
W, Slater
Psychiatry
and Wilkins,
Short
of “Hysteria.”
1399. 1965
Mental London,
1968
NA: Br
Hysteria J
Med
Disorders. Her
and orPsycho1 General
Majesty’s
Stn-
