This article was downloaded by: [University of New Hampshire] On: 15 February 2015, At: 22:11 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The Journal of Genetic Psychology: Research and Theory on Human Development Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vgnt20
Hysteria in India: Clinical Aspects a
B. B. Sethi & Narottam Lal
a
a
Department of Psychiatry , King George's Medical College , Lucknow , India Published online: 04 Sep 2012.
To cite this article: B. B. Sethi & Narottam Lal (1976) Hysteria in India: Clinical Aspects, The Journal of Genetic Psychology: Research and Theory on Human Development, 129:2, 291-300, DOI: 10.1080/00221325.1976.10534040 To link to this article: http://dx.doi.org/10.1080/00221325.1976.10534040
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
The Journal of Genetic Psychology, 1976, 129, 291-300.
HYSTERIA IN INDIA: CLINICAL ASPECTS* Department of Psychiat'Y?" King George's Medical College, Lucknow, India
B. B. SETHI AND NAROTTAM LAL
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
SUMMARY
Two hundred fifteen cases (38 males, 177 females) of hysteria were studied, while the investigators kept in view the cultural factors affecting clinical presentations and influencing etiological aspects of emotional disorders. Indian hysterics of either sex presented with multiple symptoms, usually combinations of physical and psychogenic manifestations. There was no significant difference between clinical presentations as observed in the two sexes. Sensory disturbances, paraplegias, monoplegias were in low frequency. Although a wide range of premorbid personality patterns could be identified in the present study, the most frequently occurring personality in females was hysterical and in males antisocial. Family history and parental deprivation did not appear to offer any relationship towards the occurrence of hysteria. A.
INTRODUCTION
The understanding of hysteria in terms of etiology has undergone gradual change since the days of the Greeks, when it was recognized as a disorder related to sexual dysfunction (1). The clinician of today does not rely mainly on the psychodynamic model for its understanding. A search for the etiological factors include an evaluation of personality, early emotional trauma, environmental trigger factors, and genetic predisposition. There is convincing evidence that cultural factors affect the presentation and causation of emotional disorders (32). A large number of studies in support of the cultural hypothesis have made their appearance in the literature in the recent past (3, 4, 17, 20, 22, 24, 25, 30). Descriptions as given by clinicians indicate that hysteria may manifest itself in different systems of the body, depending on whether the patient is being observed in India, Africa, or the United States.
* Received in the Editorial Office, Provincetown, Massachusetts, on March 5, 1975. Copyright, 1976, by The Journal Press. 291
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
292
JOURNAL OF GENETIC PSYCHOLOGY
Laughlin (16) felt that longstanding somatic conversions are prevalent in the Far East and Middle East. With the increase of sophistication, the conversion symptoms are becoming more subtle so as to be acceptable to society. The lesser the sophistication, the grosser the symptoms. Although studies on hysteria are available for Indian S s (20, 24), these studies only relate to sociodemographic variables in general, and only a passing comment is made about etiology. A comprehensive study for Indian Ss related to etiopathological and clinical aspects is lacking. Attempts have been made to study the disease in the two sexes separately, but results have not been conclusive (20). In the present study, therefore, the investigators have attempted to study (a) Personality, (b) Parental deprivation, (c) Environmental triggering factors, (d) Family history of hysterical illness, (e) Past episodes of emotional illnesses in the subjects, if) Number of hysterical episodes, (g) Duration of present phase of illness, and (h) Clinical symptomatology in cases diagnosed as hysteria (conversion type). The data were analyzed for the two sexes separately. B.
METHOD
The sample for the present study consisted of 215 patients of hysteria, who attended the adult psychiatric outpatients' department of King George's Medical College, Lucknow, during the years 1970-1973. The diagnostic work-up is based on diagnostic and statistical manual-Il of the American Psychiatric Association (2) and interrater reliability of the attending consultants had a high correlation as reported earlier (15).
C.
OBSERVATION AND RESULTS
1. Parental Deprivation Loss of one or both parents before the 16th birthday of the patient has been utilized as a criterion for parental deprivation in a number of studies (6, 21, 23, 26). The same has been employed in the present study as well. Only 27 cases (12.6%) reported loss of either one or both parents before the age of 16.
2.
Family History of Psychiatric Illness
The cases were grouped on the basis of presence or absence of a family history of psychiatric disorder. It was revealed that only 32 cases (14.9%) had a positive history of psychiatric disorder in the family. These cases were evaluated for type of illness in the family members on the basis of history, and it was seen that families of 21 (11. 8%) females had a history suggestive
B. B. SETHI AND NAROTTAM LAL
293
of hysterical symptoms. In 13 cases it was the mother who was affected, and in the rest one or more siblings were affected at one time or another.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
3. Precipitating Events The cases were analyzed for recent and remote events which could have had a bearing on the present illness. An event occurring within a year of the evaluation of the patient was considered as a recent event. Those occurring earlier than one year were categorized as remote. The results revealed that 71 cases (33.0%) reported the occurrence of precipitating events. Further, 26 males (68.4%) and 31 females (17.5%) reported only recent precipitating events, whereas in the rest of the cases, events were remote and were present only in the females (7.9%). Detailed analysis of such events is presented in Table I(D). The personality of the S s, as evaluated by an assessment ofthe patient and information obtained from close relatives, is listed in Table I(E). The most commonly reported premorbid personality in females is hysterical, whereas in males it is antisocial.
4. Duration of Illness One hundred three cases (47.9%) had a duration of one month or less. The shortest period of illness was only a few hours before the patients were brought in for treatment. Fifty percent of these 103 had a history lasting for only one day. Maximum duration of illness was four years in one female. Seventy-five percent of cases of less than one month duration presented with either fits or fits with one or more bodily symptoms. The rest of the cases were of paraplegia and hyperventilation. Cases reporting rather late for treatment were those with a mild or moderate degree of somatic symptoms.
5. Past Episodes of Hysteria Hysteria in the literature has been reported as a repetitive illness (19,28), but in the present series only 43 females (24.3%) had a history of a past hysterical episode. None of males had any previous history of an hysterical illness. 6. Number of Presenting Symptoms A maximum of nine symptoms were presented by two cases (.9%) only, both being female. Maximum cases (21.4%) presented with one and two symptoms. The cases presenting with single symptom were of fits or unconsciousness. Patients with multiple symptoms presented with somatic manifestations predominantly.
294
JOURNAL OF GENETIC PSYCHOLOGY TABLE 1 ETIOLOGICAL VARIABLE PERSONALITY AND SYMPTOMATOLOGY IN HYSTERIA Male = 38)
Variables A.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
B.
C.
D.
E.
F.
G.
Parental Deprivation Father Mother Both None
(N N
%
6
15.8
32
84.2
Family History of Psychiatric lllness Hysteria Neurotic disorders other than hysteria 1 Affective disorders 3 Schizophrenia Addiction Nature of Precipitating Events Remote Recent Nil Type of Events Difficulty in studies/maladj ustment in school life/ failure in examination Family mal-adjustment/tense relations with parents Marital disharmony Disappointment in a love affair Other Personality in Hysteria Hysterical Schizoid Cyclothymic Paranoid Obsessive compulsive Passive-aggressive Antisocial Duration of lllness Up to 1 month 1-3 months 3-6 months 6-9 months 9-12 months More than 12 months Past Episode of Hysteria Present Absent
2.6 7.9
Female = 177)
Total = 215)
(N N
%
(N N
7 12 2 156
4.0 6.8 1.1 88.1
7 18 2 188
3.3 8.4 0.9 87.4
21
11.8
21
9.7
2 3 1 1
1.1
1.7 0.6 0.6
3' 6 1 1
1.4 2.8 0.5 0.5
%
28 12
68.4 31.6
14 31 132
7.2 17.5 74.6
14 57 144
6.5 26.5 67.0
19
50.0
13
7.3
32
14.3
6
15.8
19 7 2 4
10.7 4.0
25 7 2 5
11.6 3.3 0.9 2.3
2.6
1.1
2.3
4 9 2 5 1 3 14
10.5 23.7 5.3 13.2 2.6 7.9 36.8
115 7 4 8 36 7
64.9 4.0 2.3 4.5 20.3 4.0
119 16 6 13 37 10 14
55.4 7.4 2.8 6.0 17.2 4.7 6.5
22 7 3 5 1
57.9 18.4 7.9 13.2 2.6
81 32 16 16 10
45.8 18.1 12.4 9.0 8.0 5.7
113 39 25 21 17 10
47.9 18.1 11.6 9.8 7.9 4.7
38
100.0
43 134
24.3 75.7
43 172
20.0 80.0
22
295
B. B. SETHI AND NAROTTAM LAL TABLE 1 (Continued) Male (N = 38) N %
Variables
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
H.
I.
Number of Presenting Symptoms One Two Three Four Five Six Seven Eight Nine Presenting Symptomatology Psychogenic symptoms Motor system Sensory system Respiratory system Gastro-intestinal system Thoracic and cardiac system Head and neck region Genito-urinary and endocrinal system Unconsciousness Miscellaneous
7.
4 18 9 2 3 2
10.5 47.3 23.7 5.3 7.9 5.3
Female (N = 177) N %
Total (N = 215) N %
42 28 27 29 21 17 8 3 2
23.7 15.8 15.3 16.4 11.9 9.6 4.5 1.7
46 46 36 31 24 19 8 3 2
21.4 21.4 16.8 14.4 11.2 8.8 3.7 1.4 0.9
71.2 55.4 2.8 11.9 57.6 22.0
67 108 5 24 88 117 49
31.2 50.2 2.3 11.2 40.9 54.4 22.8
9.6 51.4 20.3
18 104 45
8.4 48.4 20.9
18 10
47.4 26.3
3 15 15 10
7.9 39.5 39.5 26.3
126 98 5 21 73 102 39
1 13 9
2.6 34.2 23.7
17 91 36
1.1
41.~
Symptomatology
The presenting symptoms in cases of hysteria have been grouped according to system involved in two sexes. The detailed analysis revealed that the motor disturbances included generalized body convulsions (M = 6, F = 89), localized convulsions of upper limbs (M = 3, F = 4) and lower limbs (F = 3), paraplegia (F = 2) and monoplegia (M = 1). The involvement of sensory system included blurring of vision (F = 1), complete blindness of both eyes (F = 3) and abnormal sensation over right hand (F = 1). The involvement of respiratory system was in the form of increased episodic breathing lasting for few minutes and could be categorized as hyperventilation syndrome in three males and 21 females. A large number of gastrointestinal complaints were reported by these patients which were in the form of nausea and vomiting (M = 2, F = 6), vague pain and burning sensation in abdomen (M = 4, F = 40), air and moving lump in abdomen (F = 11), and decreased or loss of appetite (M = 9, F
= 16).
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
296
JOURNAL OF GENETIC PSYCHOLOGY
The thoracic and cardiac system involvement included burning sensation and vague pain in chest (M = 6, F = 23) and palpitation (M = 9, F = 79). Symptoms confined to head and back region were in the form of headache and burning (M = 7, F = 26), and giddiness (M = 3, F = 13). The manifestations of genito-urinary and endocrinal system involvement were in the form of difficulty in micturition in one male. Seventeen females reported menstrual disturbances in the form of amenorrhoea and leucorrhoea. The psychogenic symptoms were sleep disturbances (M = 6, F = 9), irritability (M = 4, F = 7), nervousness (M = 1, F = 29), lack of interest in work (M = 7, F = 19), weeping and crying (F = 12), anxiety (F = 11), depression (F = 5), fatiguability (F = 14), and general weakness (F = 20). The miscellaneous group included hiccough (F = 2), purposeless laughter (F = 3), irrelevent talking and aggressive behavior (F = 2). The symptoms of purposeless laughter, irrelevent talking, and aggressive behavior were parts of what the attendants called a fit, usually lasting for a short time and the patient was completely clear afterwards. The rest of the patients in this group had vague generalized or localized pains. A large number of patients presented with what they called attacks of unconsciousness (M = 13, F = 91). Of these, 79 patients (M = 6, F = 73) had generalized body convulsions along with episodes of unconsciousness, and the remaining patients (M = 7, F = 18) had a history of falling unconscious during which their bodies became motionless and rigid. Most of these patients denied awareness of the surroundings during the attacks. It should be noted that more than 60% of the cases presented with a combination of psychogenic and physical manifestations. Only small numbers of cases (5%) presented with pure psychogenic symptoms, and the rest had only physical complaints. D.
DISCUSSION
The history of psychiatry unfolds an interesting progress of hysteria over the ages. In the 19th century, Charcot and his colleagues (19) attributed the symptoms of hysteria to an hereditary degenerative process of the nervous system. The degenerative concept was later contradicted by Bernheim (7). Bernheim (7) and Janet (12) talked about an unconscious mental mechanism responsible for the disorder. In Freud's earliest papers (11) one finds reference to the etiology of hysterical symptoms which became the basis of a whole theoretical structure now known as psychoanalysis. Although the role of emotional trauma in early childhood has been clearly delineated in the
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
B. B. SETHI AND NAROTTAM LAL
297
literature there are not many reports dealing with precipitating factors. It has been pointed out by Slater and Roth (28) that "there is little that is specific about the precipitating causes of hysterical illness, the sudden break down in a previously normal personality may occur under almost any sort of sharply imposed emotional strain." Studies have been conducted in the past on the genetical aspects of hysteria (8, 13, 18, 27), but findings have been inconsistent and the contemporary view holds the disease to be not a genetically determined one. Premorbid personality as a precursor for developing hysteria is described as one being dramatic, exhibitionistic, narcissistic, seductive, manipulative, and dependent. When hysteria occurs in males it is usually associated with passive, feminine, homosexual traits. Earlier opinion was that patients with conversion symptoms always invariably showed hysterical personality traits, but more recent observations are not in favor of such a broad generalization (19). Conversion reactions, especially in men, may occur in patients exhibiting a wide variety of personality patterns: i.e., passive-aggressive, schizoid, and paranoid (19). More recent studies of hysterical personality developing into a neurosis have failed to demonstrate any specific genetic attributes. Further Chodoff and Lyon (9) have demonstrated varieties of personalities, such as passive-aggressive, emotionally unstable, inadequate, schizoid, paranoid, etc., in patients who develop an hysterical neurosis. Similarly Ziegler et al. (33) and Stephens and Kamp (29) did not find predominance of hysterical personality in patients manifesting hysterical symptoms. The present study has revealed that parental deprivation was present to an extent of 12.8%. Deprivation thus seen is of a much lesser frequency in hysteria as compared to depression (6, 21, 23), schizophrenia (4, 23), other neurotic disorders (23), and such other illnesses as sexual disorders (3), manic depressive psychoses (23), criminal behavior (26), alcoholism in prisoners (26), and attempted suicide (5). Similarly when an evaluation was made (23), for personality disorders and for a general psychiatric hospital sample, the frequency of deprivation was higher than in hysteria. In terms of family history of psychiatric illness, it was revealed that a positive family history of hysteria was present in only 9.7% of cases. A total of 15.2% cases had family with history of one or other mental illness including hysteria. No major difference was observed in incidence of mental illness in the families of male and female hysterics; 12.0% ofthe females had positive history of hysteria in the family, while none of the male hysterics had a family history of hysterical illness. Another available Indian study (31) showed that 22.6% of the cases had a significant family history.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
298
JOURNAL OF GENETIC PSYCHOLOGY
A much larger percentage (33.6%) was observed for precipitating events. It appears that hysteria is likely to be provoked by emotionally loaded experience. Similar high percentages of precipitating factors have also been reported in depression (10, 14). Venkatarmaih and Embar (31) listed large numbers of environmental contributory factors towards the precipitation of hysteria and concluded that quarrels and pampering appear to play an important role. However, an interesting finding relates to the type of personality, as assessed clinically, which is most prone to develop manifestations of hysteria. A total of 55.5% of our 5s were assessed as having a premorbid personality of hysterical type with a greater contribution (64.5%) from the female Ss, Another important observation suggests that the illness presents more frequently with multiple symptomatology: 76.6% cases presented with two or more symptoms. The major systems involved were motor system (50.2%), cardiac system (54.4%), gastrointestinal system (40.9%). In another study from the same center, Sethi and Nathawat (24) analyzed the symptomatology of hysteria and found a fairly high frequency of somatic symptoms. The involvement of viscera and body in hysteria is a well known phenomenon, but its occurrence in a massive way in this culture is of a significance. The majority of the Indian population has a low education and belongs to the lower socioeconomic strata. They have a firm belief that it is the body which is affected irrespective of type of illness. It is a widely held belief that the sickness is a result of one's misdeeds. They feel guilty but express this guilt only through somatic disturbances. It is common experience in this country that physical symptoms draw more attention. The high occurrence of gastrointestinal and cardiac symptoms may be related to a high degree of preoccupation by these patients for these symptoms. Any episodic shortlasting phenomenon is considered as a fit by our population. These may include hyperventilation, unconsciousness, and generalized and localized convulsions. In our earlier study 100% of the cases presented with fits (24). Only a small number of cases reported psychogenic symptoms alone, whereas in the majority of them psychogenic symptoms were associated with somatic symptoms. Thus somatization is a very characteristic phenomenon in our patients not only in depression as reported by many authors but also in hysteria. Surprisingly, paraplegia, monoplegia, sensory disturbances have been reported by a negligible number of patients, which is much contrary to the Western reports.
B. B. SETHI AND NAROTTAM LAL
299
We are not able to support the motion of Western authors (19, 28) that hysteria is a repetitive illness. Only 20% cases of our series had past history of hysterical illness. This may be because of a strong culturally held view that hysteria gets automatically cured after marriage and with advancing age in females. REFERENCES 1.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
2. 3. 4.
5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
ABSE, D. W. Hysteria. In American Handbook ofPsychiatry (Vol. I), Arieti, S., Ed. New York: Basic Books, 1967. pp. 272-292. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.: Amer. Psychiat. Assoc., 1968. BAGADIA, V. N., DAVE, K. P., PRADHAN, P. V., & SHAH, L. P. A study of 258 male patients with sexual problems. Indian J. Psychiat., 1972, 14, 143-151. BAGADIA, V. N., SHASTRI, P. C., CHAWLA, R, DAVE, K. P., & SHAH, L. P. A prospective epidemiological study of 495 cases of schizophrenia. Paper read at 22nd Annual Conference of Indian Psychiatric Society, Hyderabad, 1970. BAGADIA, V. N., SHROFF, P., MEHTA, P., DOSHI, J. M., CHAWLA, R, DOSHI, S. V., SHAH, L. P., & SARAF, K. R Attempted suicide-A prospective psycho-social study of 512 consecutive cases during one year. Paper read at the Annual Conference of Indian Psychiatric Society, Ahmedabad, 1969. BECK, A. T., SETHI, B. B., & TUTHILL, R W. Childhood bereavement and adult depression. Arch. Gen. Psychiat., 1963, 9, 295-302. BERNHEIM, H. Suggestive Therapeutics. New York: Putnam's, 1897. (Quoted from reference No. 19 below, p. 873.) BROWN, F. W. Heredity in the psychoneurosis. Proc. Roy Soc. Med., 1942,35,785-790. CHODOFF, P., & LYONS, H. Hysteria, the hysterical personality and hysterical conversion. Amer. J. Psychiat., 1958, 114, 734-740. FORREST, A. D., FRASER, R H., & PRIEST, R G. Environmental factors in depressive illness. Brit. J. Psychiat., 1965, 111,243-253. FREUD, S. The Complete Psychological Works of Sigmund Freud. Vol. II. Hysterical Conversion. London: Hogarth Press, 1955. Pp, 203-214. JANET, P. The Major Symptoms of Hysteria. New York: Macmillan, 1907. (Quoted from reference No. 19 below, p. 873.) KRAULIS, W. Heredity of hysterical reactions. Z. ges. Neural. Psychiat., 1931, 136,174. (Quoted from reference No. 29 below, p. 103.) LAL, N. Pattern and distribution of depressive disorders: Thesis for M.D. (Psychiatry), Lucknow University, Lucknow, India, 1971. LAL, N., SETHI, B. B., GUPTA, S. C., & 'SINHA,.P. K. Diagnosis of Depression for purposes ofResearch (A Methodological Study). Indion J, Psychiat., 1974, 16,287-293. LAUGHLIN, H. P. The Neurosis in Clinical Practice: Philadelphia: Saunders, 1956; Chap. VII-Conversion Reaction, Pp, 253-263. LINTON, R. Culture and mental disorders. In The Solomon Lectures of the New York Academy of Medicine. Springfield, TIl.: Thomas, 1956. Pp, 101-112. McINNES, R G. Observations on heredity in neuroses. Proc. Roy. Soc. Med.,·1937, 30, 895-904. NEMIAH, J. C.: Conversion Reaction: In Comprehensive Text Book ofPsychiatry, Freed-
300
JOURNAL OF GENETIC PSYCHOLOGY man A. M. & Kaplan H. 1. (Eds.) Calcutta, India: Scientific Book Agency, 1967, Pp. 870-885.
20. 21.
RAY, S. D., & MATHUR, S. B. Pattern of hysteria observed at Psychiatric Clinic, Irwin Hospital, New Delhi. Indian J. Psychiat., 1966, 8, 32-36. SETHI, B. B. Relationship of separation to depression. Arch. Gen. Psychiat., 1964, 10, 486-496.
22. 23.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
24. 25.
SETHI, B. B., & GUPTA, S. C.: An epidemiological and cultural study of depression. Indian 1. Psychiat., 1970, 12, 13-22. - - - . An analysis of 2,000 private and hospital psychiatric patients. Indian 1. Psychiat., 1972, 14, 197-206. SETHI, B. B., & NATHAWAT, S. S. Hysteria in India. Paper delivered before the International Congress of Social Psychiatry in Zagreb, Yugoslavia, 1970. SETHI, B. B., NATHAWAT, S. S., & GUPTA, S. C. Depression in IndiaJ. Soc. Psychol., 1973, 91, 3-13.
26. 27. 28.
SETHI, B. B., GUPTA, S. c., SINHA, P. K., & GUPTA, O. P. Pattern of crime, alcoholism and parental deprivation. India 1. Psychiat., 1971, 13, 275-281. SLATER, E. The diagnosis of hysteria. Brit. Med. J., 1965, 1, 1395-1399. SLATER, E., & ROTH, M. Clinical Psychiatry. London: Bailliere, Tindall & Cassell, 1969.
pp. 103-119. 29. 30. 31. 32. 33.
STEPHENS, J. H .. & KAMP. M. On some aspects of hysteria: A clinical study. 1. Nero. Ment. Dis., 1962, 134,305 (quoted from reference No. 28 above, p. 104). TE]A, J., NARANG, R., & AGRAWAL, A. K. Depression across culture. Brit. 1. Psychiat., 1971, 119, 253-260. VENKATARMAIAH, V.. & EMBAR. P. A review of 50 cases of hysteria. Proceedings of the Second Regional Conference of Indian Psychiatric Society, Madras, 1969, pp. 1-6. WITTKOWER, E. D. Perspective of transcultural psychiatry. Internal. J. Psychiat., 1969, 8, 811-824. ZIEGLER, F. J., IMBODEN, J. B., & MEYER, E. Contemporary conversion reaction-A clinical study. Amer. 1. Psychiat., 1960, 116, 901-909.
Department of Psychiatry King George's Medical College Lucknow, India
The Journal of Genetic Psychology: Research and Theory on Human Development Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vgnt20
Hysteria in India: Clinical Aspects a
B. B. Sethi & Narottam Lal
a
a
Department of Psychiatry , King George's Medical College , Lucknow , India Published online: 04 Sep 2012.
To cite this article: B. B. Sethi & Narottam Lal (1976) Hysteria in India: Clinical Aspects, The Journal of Genetic Psychology: Research and Theory on Human Development, 129:2, 291-300, DOI: 10.1080/00221325.1976.10534040 To link to this article: http://dx.doi.org/10.1080/00221325.1976.10534040
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
The Journal of Genetic Psychology, 1976, 129, 291-300.
HYSTERIA IN INDIA: CLINICAL ASPECTS* Department of Psychiat'Y?" King George's Medical College, Lucknow, India
B. B. SETHI AND NAROTTAM LAL
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
SUMMARY
Two hundred fifteen cases (38 males, 177 females) of hysteria were studied, while the investigators kept in view the cultural factors affecting clinical presentations and influencing etiological aspects of emotional disorders. Indian hysterics of either sex presented with multiple symptoms, usually combinations of physical and psychogenic manifestations. There was no significant difference between clinical presentations as observed in the two sexes. Sensory disturbances, paraplegias, monoplegias were in low frequency. Although a wide range of premorbid personality patterns could be identified in the present study, the most frequently occurring personality in females was hysterical and in males antisocial. Family history and parental deprivation did not appear to offer any relationship towards the occurrence of hysteria. A.
INTRODUCTION
The understanding of hysteria in terms of etiology has undergone gradual change since the days of the Greeks, when it was recognized as a disorder related to sexual dysfunction (1). The clinician of today does not rely mainly on the psychodynamic model for its understanding. A search for the etiological factors include an evaluation of personality, early emotional trauma, environmental trigger factors, and genetic predisposition. There is convincing evidence that cultural factors affect the presentation and causation of emotional disorders (32). A large number of studies in support of the cultural hypothesis have made their appearance in the literature in the recent past (3, 4, 17, 20, 22, 24, 25, 30). Descriptions as given by clinicians indicate that hysteria may manifest itself in different systems of the body, depending on whether the patient is being observed in India, Africa, or the United States.
* Received in the Editorial Office, Provincetown, Massachusetts, on March 5, 1975. Copyright, 1976, by The Journal Press. 291
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
292
JOURNAL OF GENETIC PSYCHOLOGY
Laughlin (16) felt that longstanding somatic conversions are prevalent in the Far East and Middle East. With the increase of sophistication, the conversion symptoms are becoming more subtle so as to be acceptable to society. The lesser the sophistication, the grosser the symptoms. Although studies on hysteria are available for Indian S s (20, 24), these studies only relate to sociodemographic variables in general, and only a passing comment is made about etiology. A comprehensive study for Indian Ss related to etiopathological and clinical aspects is lacking. Attempts have been made to study the disease in the two sexes separately, but results have not been conclusive (20). In the present study, therefore, the investigators have attempted to study (a) Personality, (b) Parental deprivation, (c) Environmental triggering factors, (d) Family history of hysterical illness, (e) Past episodes of emotional illnesses in the subjects, if) Number of hysterical episodes, (g) Duration of present phase of illness, and (h) Clinical symptomatology in cases diagnosed as hysteria (conversion type). The data were analyzed for the two sexes separately. B.
METHOD
The sample for the present study consisted of 215 patients of hysteria, who attended the adult psychiatric outpatients' department of King George's Medical College, Lucknow, during the years 1970-1973. The diagnostic work-up is based on diagnostic and statistical manual-Il of the American Psychiatric Association (2) and interrater reliability of the attending consultants had a high correlation as reported earlier (15).
C.
OBSERVATION AND RESULTS
1. Parental Deprivation Loss of one or both parents before the 16th birthday of the patient has been utilized as a criterion for parental deprivation in a number of studies (6, 21, 23, 26). The same has been employed in the present study as well. Only 27 cases (12.6%) reported loss of either one or both parents before the age of 16.
2.
Family History of Psychiatric Illness
The cases were grouped on the basis of presence or absence of a family history of psychiatric disorder. It was revealed that only 32 cases (14.9%) had a positive history of psychiatric disorder in the family. These cases were evaluated for type of illness in the family members on the basis of history, and it was seen that families of 21 (11. 8%) females had a history suggestive
B. B. SETHI AND NAROTTAM LAL
293
of hysterical symptoms. In 13 cases it was the mother who was affected, and in the rest one or more siblings were affected at one time or another.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
3. Precipitating Events The cases were analyzed for recent and remote events which could have had a bearing on the present illness. An event occurring within a year of the evaluation of the patient was considered as a recent event. Those occurring earlier than one year were categorized as remote. The results revealed that 71 cases (33.0%) reported the occurrence of precipitating events. Further, 26 males (68.4%) and 31 females (17.5%) reported only recent precipitating events, whereas in the rest of the cases, events were remote and were present only in the females (7.9%). Detailed analysis of such events is presented in Table I(D). The personality of the S s, as evaluated by an assessment ofthe patient and information obtained from close relatives, is listed in Table I(E). The most commonly reported premorbid personality in females is hysterical, whereas in males it is antisocial.
4. Duration of Illness One hundred three cases (47.9%) had a duration of one month or less. The shortest period of illness was only a few hours before the patients were brought in for treatment. Fifty percent of these 103 had a history lasting for only one day. Maximum duration of illness was four years in one female. Seventy-five percent of cases of less than one month duration presented with either fits or fits with one or more bodily symptoms. The rest of the cases were of paraplegia and hyperventilation. Cases reporting rather late for treatment were those with a mild or moderate degree of somatic symptoms.
5. Past Episodes of Hysteria Hysteria in the literature has been reported as a repetitive illness (19,28), but in the present series only 43 females (24.3%) had a history of a past hysterical episode. None of males had any previous history of an hysterical illness. 6. Number of Presenting Symptoms A maximum of nine symptoms were presented by two cases (.9%) only, both being female. Maximum cases (21.4%) presented with one and two symptoms. The cases presenting with single symptom were of fits or unconsciousness. Patients with multiple symptoms presented with somatic manifestations predominantly.
294
JOURNAL OF GENETIC PSYCHOLOGY TABLE 1 ETIOLOGICAL VARIABLE PERSONALITY AND SYMPTOMATOLOGY IN HYSTERIA Male = 38)
Variables A.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
B.
C.
D.
E.
F.
G.
Parental Deprivation Father Mother Both None
(N N
%
6
15.8
32
84.2
Family History of Psychiatric lllness Hysteria Neurotic disorders other than hysteria 1 Affective disorders 3 Schizophrenia Addiction Nature of Precipitating Events Remote Recent Nil Type of Events Difficulty in studies/maladj ustment in school life/ failure in examination Family mal-adjustment/tense relations with parents Marital disharmony Disappointment in a love affair Other Personality in Hysteria Hysterical Schizoid Cyclothymic Paranoid Obsessive compulsive Passive-aggressive Antisocial Duration of lllness Up to 1 month 1-3 months 3-6 months 6-9 months 9-12 months More than 12 months Past Episode of Hysteria Present Absent
2.6 7.9
Female = 177)
Total = 215)
(N N
%
(N N
7 12 2 156
4.0 6.8 1.1 88.1
7 18 2 188
3.3 8.4 0.9 87.4
21
11.8
21
9.7
2 3 1 1
1.1
1.7 0.6 0.6
3' 6 1 1
1.4 2.8 0.5 0.5
%
28 12
68.4 31.6
14 31 132
7.2 17.5 74.6
14 57 144
6.5 26.5 67.0
19
50.0
13
7.3
32
14.3
6
15.8
19 7 2 4
10.7 4.0
25 7 2 5
11.6 3.3 0.9 2.3
2.6
1.1
2.3
4 9 2 5 1 3 14
10.5 23.7 5.3 13.2 2.6 7.9 36.8
115 7 4 8 36 7
64.9 4.0 2.3 4.5 20.3 4.0
119 16 6 13 37 10 14
55.4 7.4 2.8 6.0 17.2 4.7 6.5
22 7 3 5 1
57.9 18.4 7.9 13.2 2.6
81 32 16 16 10
45.8 18.1 12.4 9.0 8.0 5.7
113 39 25 21 17 10
47.9 18.1 11.6 9.8 7.9 4.7
38
100.0
43 134
24.3 75.7
43 172
20.0 80.0
22
295
B. B. SETHI AND NAROTTAM LAL TABLE 1 (Continued) Male (N = 38) N %
Variables
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
H.
I.
Number of Presenting Symptoms One Two Three Four Five Six Seven Eight Nine Presenting Symptomatology Psychogenic symptoms Motor system Sensory system Respiratory system Gastro-intestinal system Thoracic and cardiac system Head and neck region Genito-urinary and endocrinal system Unconsciousness Miscellaneous
7.
4 18 9 2 3 2
10.5 47.3 23.7 5.3 7.9 5.3
Female (N = 177) N %
Total (N = 215) N %
42 28 27 29 21 17 8 3 2
23.7 15.8 15.3 16.4 11.9 9.6 4.5 1.7
46 46 36 31 24 19 8 3 2
21.4 21.4 16.8 14.4 11.2 8.8 3.7 1.4 0.9
71.2 55.4 2.8 11.9 57.6 22.0
67 108 5 24 88 117 49
31.2 50.2 2.3 11.2 40.9 54.4 22.8
9.6 51.4 20.3
18 104 45
8.4 48.4 20.9
18 10
47.4 26.3
3 15 15 10
7.9 39.5 39.5 26.3
126 98 5 21 73 102 39
1 13 9
2.6 34.2 23.7
17 91 36
1.1
41.~
Symptomatology
The presenting symptoms in cases of hysteria have been grouped according to system involved in two sexes. The detailed analysis revealed that the motor disturbances included generalized body convulsions (M = 6, F = 89), localized convulsions of upper limbs (M = 3, F = 4) and lower limbs (F = 3), paraplegia (F = 2) and monoplegia (M = 1). The involvement of sensory system included blurring of vision (F = 1), complete blindness of both eyes (F = 3) and abnormal sensation over right hand (F = 1). The involvement of respiratory system was in the form of increased episodic breathing lasting for few minutes and could be categorized as hyperventilation syndrome in three males and 21 females. A large number of gastrointestinal complaints were reported by these patients which were in the form of nausea and vomiting (M = 2, F = 6), vague pain and burning sensation in abdomen (M = 4, F = 40), air and moving lump in abdomen (F = 11), and decreased or loss of appetite (M = 9, F
= 16).
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
296
JOURNAL OF GENETIC PSYCHOLOGY
The thoracic and cardiac system involvement included burning sensation and vague pain in chest (M = 6, F = 23) and palpitation (M = 9, F = 79). Symptoms confined to head and back region were in the form of headache and burning (M = 7, F = 26), and giddiness (M = 3, F = 13). The manifestations of genito-urinary and endocrinal system involvement were in the form of difficulty in micturition in one male. Seventeen females reported menstrual disturbances in the form of amenorrhoea and leucorrhoea. The psychogenic symptoms were sleep disturbances (M = 6, F = 9), irritability (M = 4, F = 7), nervousness (M = 1, F = 29), lack of interest in work (M = 7, F = 19), weeping and crying (F = 12), anxiety (F = 11), depression (F = 5), fatiguability (F = 14), and general weakness (F = 20). The miscellaneous group included hiccough (F = 2), purposeless laughter (F = 3), irrelevent talking and aggressive behavior (F = 2). The symptoms of purposeless laughter, irrelevent talking, and aggressive behavior were parts of what the attendants called a fit, usually lasting for a short time and the patient was completely clear afterwards. The rest of the patients in this group had vague generalized or localized pains. A large number of patients presented with what they called attacks of unconsciousness (M = 13, F = 91). Of these, 79 patients (M = 6, F = 73) had generalized body convulsions along with episodes of unconsciousness, and the remaining patients (M = 7, F = 18) had a history of falling unconscious during which their bodies became motionless and rigid. Most of these patients denied awareness of the surroundings during the attacks. It should be noted that more than 60% of the cases presented with a combination of psychogenic and physical manifestations. Only small numbers of cases (5%) presented with pure psychogenic symptoms, and the rest had only physical complaints. D.
DISCUSSION
The history of psychiatry unfolds an interesting progress of hysteria over the ages. In the 19th century, Charcot and his colleagues (19) attributed the symptoms of hysteria to an hereditary degenerative process of the nervous system. The degenerative concept was later contradicted by Bernheim (7). Bernheim (7) and Janet (12) talked about an unconscious mental mechanism responsible for the disorder. In Freud's earliest papers (11) one finds reference to the etiology of hysterical symptoms which became the basis of a whole theoretical structure now known as psychoanalysis. Although the role of emotional trauma in early childhood has been clearly delineated in the
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
B. B. SETHI AND NAROTTAM LAL
297
literature there are not many reports dealing with precipitating factors. It has been pointed out by Slater and Roth (28) that "there is little that is specific about the precipitating causes of hysterical illness, the sudden break down in a previously normal personality may occur under almost any sort of sharply imposed emotional strain." Studies have been conducted in the past on the genetical aspects of hysteria (8, 13, 18, 27), but findings have been inconsistent and the contemporary view holds the disease to be not a genetically determined one. Premorbid personality as a precursor for developing hysteria is described as one being dramatic, exhibitionistic, narcissistic, seductive, manipulative, and dependent. When hysteria occurs in males it is usually associated with passive, feminine, homosexual traits. Earlier opinion was that patients with conversion symptoms always invariably showed hysterical personality traits, but more recent observations are not in favor of such a broad generalization (19). Conversion reactions, especially in men, may occur in patients exhibiting a wide variety of personality patterns: i.e., passive-aggressive, schizoid, and paranoid (19). More recent studies of hysterical personality developing into a neurosis have failed to demonstrate any specific genetic attributes. Further Chodoff and Lyon (9) have demonstrated varieties of personalities, such as passive-aggressive, emotionally unstable, inadequate, schizoid, paranoid, etc., in patients who develop an hysterical neurosis. Similarly Ziegler et al. (33) and Stephens and Kamp (29) did not find predominance of hysterical personality in patients manifesting hysterical symptoms. The present study has revealed that parental deprivation was present to an extent of 12.8%. Deprivation thus seen is of a much lesser frequency in hysteria as compared to depression (6, 21, 23), schizophrenia (4, 23), other neurotic disorders (23), and such other illnesses as sexual disorders (3), manic depressive psychoses (23), criminal behavior (26), alcoholism in prisoners (26), and attempted suicide (5). Similarly when an evaluation was made (23), for personality disorders and for a general psychiatric hospital sample, the frequency of deprivation was higher than in hysteria. In terms of family history of psychiatric illness, it was revealed that a positive family history of hysteria was present in only 9.7% of cases. A total of 15.2% cases had family with history of one or other mental illness including hysteria. No major difference was observed in incidence of mental illness in the families of male and female hysterics; 12.0% ofthe females had positive history of hysteria in the family, while none of the male hysterics had a family history of hysterical illness. Another available Indian study (31) showed that 22.6% of the cases had a significant family history.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
298
JOURNAL OF GENETIC PSYCHOLOGY
A much larger percentage (33.6%) was observed for precipitating events. It appears that hysteria is likely to be provoked by emotionally loaded experience. Similar high percentages of precipitating factors have also been reported in depression (10, 14). Venkatarmaih and Embar (31) listed large numbers of environmental contributory factors towards the precipitation of hysteria and concluded that quarrels and pampering appear to play an important role. However, an interesting finding relates to the type of personality, as assessed clinically, which is most prone to develop manifestations of hysteria. A total of 55.5% of our 5s were assessed as having a premorbid personality of hysterical type with a greater contribution (64.5%) from the female Ss, Another important observation suggests that the illness presents more frequently with multiple symptomatology: 76.6% cases presented with two or more symptoms. The major systems involved were motor system (50.2%), cardiac system (54.4%), gastrointestinal system (40.9%). In another study from the same center, Sethi and Nathawat (24) analyzed the symptomatology of hysteria and found a fairly high frequency of somatic symptoms. The involvement of viscera and body in hysteria is a well known phenomenon, but its occurrence in a massive way in this culture is of a significance. The majority of the Indian population has a low education and belongs to the lower socioeconomic strata. They have a firm belief that it is the body which is affected irrespective of type of illness. It is a widely held belief that the sickness is a result of one's misdeeds. They feel guilty but express this guilt only through somatic disturbances. It is common experience in this country that physical symptoms draw more attention. The high occurrence of gastrointestinal and cardiac symptoms may be related to a high degree of preoccupation by these patients for these symptoms. Any episodic shortlasting phenomenon is considered as a fit by our population. These may include hyperventilation, unconsciousness, and generalized and localized convulsions. In our earlier study 100% of the cases presented with fits (24). Only a small number of cases reported psychogenic symptoms alone, whereas in the majority of them psychogenic symptoms were associated with somatic symptoms. Thus somatization is a very characteristic phenomenon in our patients not only in depression as reported by many authors but also in hysteria. Surprisingly, paraplegia, monoplegia, sensory disturbances have been reported by a negligible number of patients, which is much contrary to the Western reports.
B. B. SETHI AND NAROTTAM LAL
299
We are not able to support the motion of Western authors (19, 28) that hysteria is a repetitive illness. Only 20% cases of our series had past history of hysterical illness. This may be because of a strong culturally held view that hysteria gets automatically cured after marriage and with advancing age in females. REFERENCES 1.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
2. 3. 4.
5.
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
ABSE, D. W. Hysteria. In American Handbook ofPsychiatry (Vol. I), Arieti, S., Ed. New York: Basic Books, 1967. pp. 272-292. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.: Amer. Psychiat. Assoc., 1968. BAGADIA, V. N., DAVE, K. P., PRADHAN, P. V., & SHAH, L. P. A study of 258 male patients with sexual problems. Indian J. Psychiat., 1972, 14, 143-151. BAGADIA, V. N., SHASTRI, P. C., CHAWLA, R, DAVE, K. P., & SHAH, L. P. A prospective epidemiological study of 495 cases of schizophrenia. Paper read at 22nd Annual Conference of Indian Psychiatric Society, Hyderabad, 1970. BAGADIA, V. N., SHROFF, P., MEHTA, P., DOSHI, J. M., CHAWLA, R, DOSHI, S. V., SHAH, L. P., & SARAF, K. R Attempted suicide-A prospective psycho-social study of 512 consecutive cases during one year. Paper read at the Annual Conference of Indian Psychiatric Society, Ahmedabad, 1969. BECK, A. T., SETHI, B. B., & TUTHILL, R W. Childhood bereavement and adult depression. Arch. Gen. Psychiat., 1963, 9, 295-302. BERNHEIM, H. Suggestive Therapeutics. New York: Putnam's, 1897. (Quoted from reference No. 19 below, p. 873.) BROWN, F. W. Heredity in the psychoneurosis. Proc. Roy Soc. Med., 1942,35,785-790. CHODOFF, P., & LYONS, H. Hysteria, the hysterical personality and hysterical conversion. Amer. J. Psychiat., 1958, 114, 734-740. FORREST, A. D., FRASER, R H., & PRIEST, R G. Environmental factors in depressive illness. Brit. J. Psychiat., 1965, 111,243-253. FREUD, S. The Complete Psychological Works of Sigmund Freud. Vol. II. Hysterical Conversion. London: Hogarth Press, 1955. Pp, 203-214. JANET, P. The Major Symptoms of Hysteria. New York: Macmillan, 1907. (Quoted from reference No. 19 below, p. 873.) KRAULIS, W. Heredity of hysterical reactions. Z. ges. Neural. Psychiat., 1931, 136,174. (Quoted from reference No. 29 below, p. 103.) LAL, N. Pattern and distribution of depressive disorders: Thesis for M.D. (Psychiatry), Lucknow University, Lucknow, India, 1971. LAL, N., SETHI, B. B., GUPTA, S. C., & 'SINHA,.P. K. Diagnosis of Depression for purposes ofResearch (A Methodological Study). Indion J, Psychiat., 1974, 16,287-293. LAUGHLIN, H. P. The Neurosis in Clinical Practice: Philadelphia: Saunders, 1956; Chap. VII-Conversion Reaction, Pp, 253-263. LINTON, R. Culture and mental disorders. In The Solomon Lectures of the New York Academy of Medicine. Springfield, TIl.: Thomas, 1956. Pp, 101-112. McINNES, R G. Observations on heredity in neuroses. Proc. Roy. Soc. Med.,·1937, 30, 895-904. NEMIAH, J. C.: Conversion Reaction: In Comprehensive Text Book ofPsychiatry, Freed-
300
JOURNAL OF GENETIC PSYCHOLOGY man A. M. & Kaplan H. 1. (Eds.) Calcutta, India: Scientific Book Agency, 1967, Pp. 870-885.
20. 21.
RAY, S. D., & MATHUR, S. B. Pattern of hysteria observed at Psychiatric Clinic, Irwin Hospital, New Delhi. Indian J. Psychiat., 1966, 8, 32-36. SETHI, B. B. Relationship of separation to depression. Arch. Gen. Psychiat., 1964, 10, 486-496.
22. 23.
Downloaded by [University of New Hampshire] at 22:11 15 February 2015
24. 25.
SETHI, B. B., & GUPTA, S. C.: An epidemiological and cultural study of depression. Indian 1. Psychiat., 1970, 12, 13-22. - - - . An analysis of 2,000 private and hospital psychiatric patients. Indian 1. Psychiat., 1972, 14, 197-206. SETHI, B. B., & NATHAWAT, S. S. Hysteria in India. Paper delivered before the International Congress of Social Psychiatry in Zagreb, Yugoslavia, 1970. SETHI, B. B., NATHAWAT, S. S., & GUPTA, S. C. Depression in IndiaJ. Soc. Psychol., 1973, 91, 3-13.
26. 27. 28.
SETHI, B. B., GUPTA, S. c., SINHA, P. K., & GUPTA, O. P. Pattern of crime, alcoholism and parental deprivation. India 1. Psychiat., 1971, 13, 275-281. SLATER, E. The diagnosis of hysteria. Brit. Med. J., 1965, 1, 1395-1399. SLATER, E., & ROTH, M. Clinical Psychiatry. London: Bailliere, Tindall & Cassell, 1969.
pp. 103-119. 29. 30. 31. 32. 33.
STEPHENS, J. H .. & KAMP. M. On some aspects of hysteria: A clinical study. 1. Nero. Ment. Dis., 1962, 134,305 (quoted from reference No. 28 above, p. 104). TE]A, J., NARANG, R., & AGRAWAL, A. K. Depression across culture. Brit. 1. Psychiat., 1971, 119, 253-260. VENKATARMAIAH, V.. & EMBAR. P. A review of 50 cases of hysteria. Proceedings of the Second Regional Conference of Indian Psychiatric Society, Madras, 1969, pp. 1-6. WITTKOWER, E. D. Perspective of transcultural psychiatry. Internal. J. Psychiat., 1969, 8, 811-824. ZIEGLER, F. J., IMBODEN, J. B., & MEYER, E. Contemporary conversion reaction-A clinical study. Amer. 1. Psychiat., 1960, 116, 901-909.
Department of Psychiatry King George's Medical College Lucknow, India
