Psychological Medicine, 1975, 5, 13-17
The diagnosis of'hysteria' JOHN L. REED From the Department of Psychological Medicine, St. Bartholomew's Hospital, London SYNOPSIS A study of 120 inpatients diagnosed as suffering from hysteria is presented and the validity of the diagnosis questioned. Clinical study showed that 13% showed only hysterical symptoms, 33% showed hysterical symptoms occurring with affective symptoms, 28% showed affective symptomatology only, and the remainder were either of other or uncertain diagnostic grouping. It is concluded that the 13% are suffering from a condition that can only be diagnosed as hysteria. Hysteria, together with paranoia, has been mentioned by Lewis (1975) as one of the forms of psychiatric illness 'with a name going back two and a half millenia, which have had sentence of death passed upon them more than once, yet they survive'. In reviewing the literature of the last 100 years he has considered the many writers who have proposed that hysteria is not a disease, nor even a syndrome, and the few who have pleaded the cause of its retention. One may perhaps add to the list of those who have argued for the retention of the term Guze and his coworkers who have shown in their patients the uniformity of clinical picture and consistency of course that other studies of groups of patients with the diagnosis of hysteria have failed to find. Guze's group of cases, which he designates 'hysteria (Briquet's syndrome)' show a syndrome with early onset, occurring in females, and characterized by chronic ill-health, multiple somatic symptoms, anxiety, and depression and, at times, conversion symptoms which does not correspond with what most writers about hysteria are considering, whether they support the retention of the term or not.
position has almost been reached where to make a diagnosis of hysteria alone is a sign of bad psychiatric practice. Slater (1961), in an influential address, has said 'If in our patients we find the signs of hysteria and no more, then these are signs that we have not yet looked deeply enough'. The present paper is an attempt to examine the validity of the objections to the use of the terms hysteria and hysterical reaction. By studying the notes of a group of patients admitted to hospital with a diagnosis of 'hysteria' and by following up these patients an attempt is made to determine what factors, if any, the group of patients have in common, which might have influenced physicians in making the diagnosis of hysteria. An attempt is made to answer the two essential questions raised by Lewis: 'Is the clinical picture uniform, and does the course of the disorder show that its pattern remains consistent?'
The influence of the arguments of the impressive list of the opponents of the use of the term 'hysteria' diagnostically has been considerable. In the 1957 version of the International Classification of Diseases hysteria was accorded nine subcategories—Hysteria Not Otherwise Specified and eight varieties of conversion or dissociative state. The 1967-69 revision limits diagnosis to 'Hysterical Neurosis' comprising dissociative states and conversion phenomena only. The
CASE MATERIAL
METHOD
All patients who were admitted as inpatients to the Professorial Unit of the Maudsley Hospital between 1 January 1949 and 31 December 1964 and on whom a diagnosis of hysteria either as a primary illness or secondary condition had been made by the physician responsible for their care, formed the case material. The LCD. diagnostic codes 311.0-311.8 (excluding 311.1 anorexia nervosa) were included. Only those patients whose education and upbringing had been exclusively in Great Britain were included. 13
14
John L. Reed
RECORDING OF DATA
Data regarding antecedent history, clinical state, treatment, and immediate outcome were recorded on a special data sheet from all sources of information in the notes. Where patients had been previously under hospital care information about this was obtained from the hospital concerned. A sample data sheet is published elsewhere. TECHNIQUE OF FOLLOW-UP
Follow-up was almost exclusively postal. Letters were sent to the patients' general practitioners and to their nearest relative (or, if no near relative was known, to the patients themselves). When patients had been subsequently admitted to hospital, information was obtained from the hospital notes. Only those patients about whom information over a minimum of three years from index discharge or until death were included in the follow-up study.
was specified in the notes. Similar stringency was employed in marking symptoms as present. DEFINITIONS
Since subsequent discussion involves the use of the terms dissociation and conversion, the author is using them in the following sense. By dissociation is meant a condition where, in the absence of organic brain disease there is a degree of loss of personal awareness. This may be extensive, as in fugue states or some alternate personalities, or limited, as in the amnesia of an affect-laden single event. By conversion symptom is meant psychogenic disturbance of the function of an organ or organs of the body, for example, convulsions or paralysis that differs from the common disturbances of function— that is, tachycardia in anxiety—in that the conversion symptoms are never seen as concomitants of normal anxiety.
ANALYSIS OF RESULTS
RESULTS
Statistical The data were subjected to various statistical analytic procedures including direct comparisons of groups by chi-square and Student's t test, principal components analysis, and discriminant function analysis.
It is not proposed to include all the findings of the study in this paper, only those relating to the validity of the diagnosis of hysteria. Therefore, only outlines of information on some aspects of the case material will be presented.
Clinical analysis The case notes were re-examined, each case being considered in detail with a view to determining clinical groups, if such existed. By the original coding the material divided into those who showed conversion/dissociative symptoms (coded 311.2-311.8) and those hysteria N.O.S. (coded 311.0) who did not. In view of Slater's views and those of Kraepelin, it was decided to see if there were cases where symptoms of conversion/dissociative occurred in the absence of symptoms of other syndromes. The cases of hysteria N.O.S. were also examined to see if they formed a clinically homogeneous group or whether other diagnoses were tenable. The case notes of all 120 patients were re-examined to determine the presence or absence of the following six items: conversion/dissociative phenomena, belle indifference, gain, depression, anxiety, and other psychiatric symptoms—for example, of schizophrenia or organic mental states. During this re-examination 31 symptoms relating to other psychiatric syndromes were assessed as present or absent. This re-examination was made before any treatment had begun. Criteria were rigorous and, for example, depression and anxiety were marked as absent only when this
FOLLOW-UP
One hundred and thirteen patients (94-2%) were followed-up for three years or to death. The length of the follow-up was between three and 19 years with a mean of 11-3 years. Of the patients with whom contact was established, in TABLE 1 AGE AND SEX (WHOLE SAMPLE) Age (mean) (yr) range Sex (%) Male Female
35-2 15-69 27-5 72-5
63-2% of cases this contact was through medical agencies and, in a further 20-5%, through both medical and non-medical agencies. CASE MATERIAL
The sample comprised 120 patients and of these
15
The diagnosis of 'hysteria'
90 had a primary diagnosis of hysteria and 30 had hysteria as a diagnosis consequent to some other psychological or physical illness. The results of the comparison of these two groups on antecedent history, clinical picture, and outcome will be reported in detail elsewhere but show no essential differences between the two groups. For the purpose of further study the primary and secondary diagnostic groups were treated as a single group. The principal features of this group of 120 are set out in Tables 1 and 2. TABLE 2 PRINCIPAL SUBCATEGORIES OF HYSTERIA
(%) Hysteria N.O.S. Conversion/Dissociative Hysteria Pain Paralysis Convulsions Fugue Tic, tremor Vomiting Amnesia Other
35 65 12-5 100 91 91 7-5 V3 2-5 10-4
STATISTICAL ANALYSIS
These analyses, the subject of a separate report, revealed no consistency in the sample beyond the grouping together on principal components analysis of those items which are considered to comprise aspects of the 'hysterical personality'. CLINICAL ANALYSIS
After the re-examination of the patients' casenotes certain categories emerged depending on the presence or absence of certain of the six items noted (Table 3). Group A comprised those patients who TABLE 3 PRINCIPAL CATEGORIES
Groups A. Conversion/dissociation only B. Conversion/dissociation and affective symptoms C Affective symptoms only D. Other syndromes E. Uncertain
(7.) N=113 13 33 28 21 5
showed in their clinical state on admission only conversion/dissociative symptoms and belle indifference and gain—for example, only those symptoms generally accepted as being found in hysteria. Group B comprised those patients who showed conversion/dissociative symptoms, at times belle indifference and gain but who also showed affective symptoms, almost always of depression and anxiety. Group C comprised patients all showing affective symptoms and occasionally belle indifference and gains; conversion/dissociative symptoms were not present except for two cases of 'hysterical pain' in the presence of marked affective symptom aetiology—both had head and neck pain typical of tension headache. One case of 'hysterical stupor' followed an overdose of hypnotics and was recorded in the notes as probably being a physical consequence of the overdose. Group D comprised a wide variety of symptom aetiology from schizophrenia to agoraphobia. The 'conversion symptoms' in this group were such things as pain later found to be due to inoperable carcinoma of the uterus. Group E contained patients difficult to allocate to other categories because of disagreement among medical circles regarding the nature of a specific condition (a case of the stiff man syndrome) or where there was uncertainty as to whether an individual case was of physical or psychological illness (a case with clear neurological signs but no definite neurological diagnosis in which a diagnosis of 'hysterical convulsions' was made). The distribution of the case material between these five groups is shown in Table 3. DISCUSSION
The present study clearly has many areas in which it could be criticized. It is a retrospective case-note study relying on information recorded by others with, presumably, varying degrees of skill, though the final diagnosis was made by a senior physician. The total notes are, however, very extensive in nearly all cases and the fact that the patients were not examined by the investigator could be an advantage in minimizing the 'halo effect'. The 'halo effect' could clearly influence the categorization of the patients into groups A-E, though the criteria for the groups
16
John L. Reed
were decided before the categorization, as was the marking of the data sheets. The effect may have been lessened further by the fact that the investigator had expected that group A would contain no patients. A further criticism is that postal follow-ups are less satisfactory than personal. In this study, however, details of episodes of illness during the follow-up period were required rather than an assessment of the patient's current state at the end of the follow-up. Reliable information about health over a period of years is more likely to be found from medical records than from personal recollections of patients. Taken as a whole there is no doubt that the present sample studied supports the view of those who consider that hysteria is not a disease in its own right and may, at most, be a symptom. For the entire group there is no consistency of background, symptomatology, or outcome. However, it is clear that to treat the group as a whole may well be unreasonable. In the first place, if coded by the present LCD. instead of the previous one, the 35% who were diagnosed as 'Hysteria Not Otherwise Specified' would have to be assigned to some other diagnostic category. In the second place the present study shows a clear distinction between groups A and B and the remainder. Under the division into the present five groups all of the Hysteria N.O.S. group fall within groups C and D and could be more suitably included in other diagnostic categories. An examination of the cases in groups C and D suggests that behaviour which might best be described as 'histrionic' rather than 'hysterical'— demonstrative, attention-seeking, noisy behaviour, often associated with rapid mood swings— appears to have been influential in determining the diagnosis in most of group C patients and of the group D patients. Of the latter group particularly the comment was often made that the patient was 'over-reacting' or 'over-dramatising'. The danger that may result from this approach is shown by the high mortality rate in the early years after admission. One patient with 'hysterical' abdominal pain died during the index admission of pylonephrosis and five more died in the first year after discharge. Two deaths were by suicide and three from physical illnesses, later noted as adequately explaining their original
symptoms. The situation of this group is summed up by one patient who explained that she behaved in the way that she did through frustration at being unable to convince doctors that she was physically ill—she died within a year of carcinoma of the uterus. It appears unjustified to use the term hysteria or hysterical reaction in relation to these groups C and D. It is in these patients that we must look more deeply to avoid errors of diagnosis and treatment. Groups A and B present a different problem; both show conversion/dissociative symptoms and group B show affective symptoms also. It is generally agreed that the mental mechanisms of dissociation or conversion are available to most, if not all, people and can occur in times of stress to normal people ('purposeful forgetting' of affect-laden material or the failure to feel pain of people injured under highly stressed conditions such as battle). Since we accept that people may react to stress with the other universal mechanisms of depression and anxiety, it appears unreasonable to refuse to accept that some may react with conversion/dissociation. This reaction could occur alone as in group A or in association with affective symptoms as in group B. In the latter case, two patterns of reaction would have to be considered. Patients might react simultaneously with affective and hysterical symptoms or initial affective symptoms might provoke secondary hysterical symptoms. What decides the mode of reaction is more difficult to define. Certainly not all the patients in either group A or B were of 'hysterical personality' or indeed of markedly abnormal personality. Indeed, two of group A were stated to have had normal premorbid personalities. While in group B it may be reasonable to speak of 'hysterical symptoms' or 'hysteria associated with' an affective illness, in group A there is a group of patients who, on admission, show symptoms which are generally considered to be found only in hysteria and no other symptoms. There is then uniformity of clinical picture exclusive to these group A patients. The follow-up study shows that group A differs from the other groups in the pattern of health on follow-up. In groups B and C affective illness commonly preceded and/or followed the
The diagnosis of'hysteria'
index admission. In group A there is a consistency of diagnosis. Two of the 13 had had hysterical reactions of the same type before the index admission. On follow-up, two had had recurrences of the same type of hysterical reaction as at index admission and two others continued to experience symptoms similar to those noted at index admission but in such a regular way as to suggest a continuation of the original reaction rather than a recurrence. All the other patients in group A had a single illness only. It seems reasonable, therefore, to suggest that in group A the pattern of the illness remains consistent. This small but significant group of patients fulfils the criteria put forward by Lewis as being important to establish the validity of hysteria as a diagnosis, and to withhold the use of the term hysteria as a diagnosis in these cases involves unjustifiable feats of semantic juggling. Though the number of patients showing 'true' hysteria may be small, it is clearly of importance that it should be recognized and the present study suggests that the diagnosis can be made with some confidence in the presence of conversion/dissociative symptoms and of belle indifference and gain when other symptoms are
17
absent. Cutler and Reed (1975) report an illustrative case. As the clinical picture may change rapidly, either spontaneously or after medical intervention, it is essential that these points be determined in the acute stage of the illness. Lewis has said that hysteria 'tends to outlive its obituarists'. It has outlived many and, if used for a carefully selected group of patients, is likely to outlive many more. REFERENCES Cutler, B. D., and Reed, J. L. (1975). Multiple personality: a case report with 15 year follow-up. Psychological Medicine. Guze, S. B., and Perley, M. J. (1963). Observations on the natural history of hysteria. American Journal of Psychiatry, 119, 960-965. Lewis, A. J. (1975). The survival of hysteria. Psychological Medicine, 5, 9-12. Slater, E. (1961). Hysteria 311. Journal of Mental Science, 107, 359-381. World Health Organization (1957). Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. 7th revision, 1955. 2 Vols. WHO: Geneva. World Health Organization (1967), and (1969). Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. 8th revision, 1965. 2 Vols. WHO: Geneva.
The diagnosis of'hysteria' JOHN L. REED From the Department of Psychological Medicine, St. Bartholomew's Hospital, London SYNOPSIS A study of 120 inpatients diagnosed as suffering from hysteria is presented and the validity of the diagnosis questioned. Clinical study showed that 13% showed only hysterical symptoms, 33% showed hysterical symptoms occurring with affective symptoms, 28% showed affective symptomatology only, and the remainder were either of other or uncertain diagnostic grouping. It is concluded that the 13% are suffering from a condition that can only be diagnosed as hysteria. Hysteria, together with paranoia, has been mentioned by Lewis (1975) as one of the forms of psychiatric illness 'with a name going back two and a half millenia, which have had sentence of death passed upon them more than once, yet they survive'. In reviewing the literature of the last 100 years he has considered the many writers who have proposed that hysteria is not a disease, nor even a syndrome, and the few who have pleaded the cause of its retention. One may perhaps add to the list of those who have argued for the retention of the term Guze and his coworkers who have shown in their patients the uniformity of clinical picture and consistency of course that other studies of groups of patients with the diagnosis of hysteria have failed to find. Guze's group of cases, which he designates 'hysteria (Briquet's syndrome)' show a syndrome with early onset, occurring in females, and characterized by chronic ill-health, multiple somatic symptoms, anxiety, and depression and, at times, conversion symptoms which does not correspond with what most writers about hysteria are considering, whether they support the retention of the term or not.
position has almost been reached where to make a diagnosis of hysteria alone is a sign of bad psychiatric practice. Slater (1961), in an influential address, has said 'If in our patients we find the signs of hysteria and no more, then these are signs that we have not yet looked deeply enough'. The present paper is an attempt to examine the validity of the objections to the use of the terms hysteria and hysterical reaction. By studying the notes of a group of patients admitted to hospital with a diagnosis of 'hysteria' and by following up these patients an attempt is made to determine what factors, if any, the group of patients have in common, which might have influenced physicians in making the diagnosis of hysteria. An attempt is made to answer the two essential questions raised by Lewis: 'Is the clinical picture uniform, and does the course of the disorder show that its pattern remains consistent?'
The influence of the arguments of the impressive list of the opponents of the use of the term 'hysteria' diagnostically has been considerable. In the 1957 version of the International Classification of Diseases hysteria was accorded nine subcategories—Hysteria Not Otherwise Specified and eight varieties of conversion or dissociative state. The 1967-69 revision limits diagnosis to 'Hysterical Neurosis' comprising dissociative states and conversion phenomena only. The
CASE MATERIAL
METHOD
All patients who were admitted as inpatients to the Professorial Unit of the Maudsley Hospital between 1 January 1949 and 31 December 1964 and on whom a diagnosis of hysteria either as a primary illness or secondary condition had been made by the physician responsible for their care, formed the case material. The LCD. diagnostic codes 311.0-311.8 (excluding 311.1 anorexia nervosa) were included. Only those patients whose education and upbringing had been exclusively in Great Britain were included. 13
14
John L. Reed
RECORDING OF DATA
Data regarding antecedent history, clinical state, treatment, and immediate outcome were recorded on a special data sheet from all sources of information in the notes. Where patients had been previously under hospital care information about this was obtained from the hospital concerned. A sample data sheet is published elsewhere. TECHNIQUE OF FOLLOW-UP
Follow-up was almost exclusively postal. Letters were sent to the patients' general practitioners and to their nearest relative (or, if no near relative was known, to the patients themselves). When patients had been subsequently admitted to hospital, information was obtained from the hospital notes. Only those patients about whom information over a minimum of three years from index discharge or until death were included in the follow-up study.
was specified in the notes. Similar stringency was employed in marking symptoms as present. DEFINITIONS
Since subsequent discussion involves the use of the terms dissociation and conversion, the author is using them in the following sense. By dissociation is meant a condition where, in the absence of organic brain disease there is a degree of loss of personal awareness. This may be extensive, as in fugue states or some alternate personalities, or limited, as in the amnesia of an affect-laden single event. By conversion symptom is meant psychogenic disturbance of the function of an organ or organs of the body, for example, convulsions or paralysis that differs from the common disturbances of function— that is, tachycardia in anxiety—in that the conversion symptoms are never seen as concomitants of normal anxiety.
ANALYSIS OF RESULTS
RESULTS
Statistical The data were subjected to various statistical analytic procedures including direct comparisons of groups by chi-square and Student's t test, principal components analysis, and discriminant function analysis.
It is not proposed to include all the findings of the study in this paper, only those relating to the validity of the diagnosis of hysteria. Therefore, only outlines of information on some aspects of the case material will be presented.
Clinical analysis The case notes were re-examined, each case being considered in detail with a view to determining clinical groups, if such existed. By the original coding the material divided into those who showed conversion/dissociative symptoms (coded 311.2-311.8) and those hysteria N.O.S. (coded 311.0) who did not. In view of Slater's views and those of Kraepelin, it was decided to see if there were cases where symptoms of conversion/dissociative occurred in the absence of symptoms of other syndromes. The cases of hysteria N.O.S. were also examined to see if they formed a clinically homogeneous group or whether other diagnoses were tenable. The case notes of all 120 patients were re-examined to determine the presence or absence of the following six items: conversion/dissociative phenomena, belle indifference, gain, depression, anxiety, and other psychiatric symptoms—for example, of schizophrenia or organic mental states. During this re-examination 31 symptoms relating to other psychiatric syndromes were assessed as present or absent. This re-examination was made before any treatment had begun. Criteria were rigorous and, for example, depression and anxiety were marked as absent only when this
FOLLOW-UP
One hundred and thirteen patients (94-2%) were followed-up for three years or to death. The length of the follow-up was between three and 19 years with a mean of 11-3 years. Of the patients with whom contact was established, in TABLE 1 AGE AND SEX (WHOLE SAMPLE) Age (mean) (yr) range Sex (%) Male Female
35-2 15-69 27-5 72-5
63-2% of cases this contact was through medical agencies and, in a further 20-5%, through both medical and non-medical agencies. CASE MATERIAL
The sample comprised 120 patients and of these
15
The diagnosis of 'hysteria'
90 had a primary diagnosis of hysteria and 30 had hysteria as a diagnosis consequent to some other psychological or physical illness. The results of the comparison of these two groups on antecedent history, clinical picture, and outcome will be reported in detail elsewhere but show no essential differences between the two groups. For the purpose of further study the primary and secondary diagnostic groups were treated as a single group. The principal features of this group of 120 are set out in Tables 1 and 2. TABLE 2 PRINCIPAL SUBCATEGORIES OF HYSTERIA
(%) Hysteria N.O.S. Conversion/Dissociative Hysteria Pain Paralysis Convulsions Fugue Tic, tremor Vomiting Amnesia Other
35 65 12-5 100 91 91 7-5 V3 2-5 10-4
STATISTICAL ANALYSIS
These analyses, the subject of a separate report, revealed no consistency in the sample beyond the grouping together on principal components analysis of those items which are considered to comprise aspects of the 'hysterical personality'. CLINICAL ANALYSIS
After the re-examination of the patients' casenotes certain categories emerged depending on the presence or absence of certain of the six items noted (Table 3). Group A comprised those patients who TABLE 3 PRINCIPAL CATEGORIES
Groups A. Conversion/dissociation only B. Conversion/dissociation and affective symptoms C Affective symptoms only D. Other syndromes E. Uncertain
(7.) N=113 13 33 28 21 5
showed in their clinical state on admission only conversion/dissociative symptoms and belle indifference and gain—for example, only those symptoms generally accepted as being found in hysteria. Group B comprised those patients who showed conversion/dissociative symptoms, at times belle indifference and gain but who also showed affective symptoms, almost always of depression and anxiety. Group C comprised patients all showing affective symptoms and occasionally belle indifference and gains; conversion/dissociative symptoms were not present except for two cases of 'hysterical pain' in the presence of marked affective symptom aetiology—both had head and neck pain typical of tension headache. One case of 'hysterical stupor' followed an overdose of hypnotics and was recorded in the notes as probably being a physical consequence of the overdose. Group D comprised a wide variety of symptom aetiology from schizophrenia to agoraphobia. The 'conversion symptoms' in this group were such things as pain later found to be due to inoperable carcinoma of the uterus. Group E contained patients difficult to allocate to other categories because of disagreement among medical circles regarding the nature of a specific condition (a case of the stiff man syndrome) or where there was uncertainty as to whether an individual case was of physical or psychological illness (a case with clear neurological signs but no definite neurological diagnosis in which a diagnosis of 'hysterical convulsions' was made). The distribution of the case material between these five groups is shown in Table 3. DISCUSSION
The present study clearly has many areas in which it could be criticized. It is a retrospective case-note study relying on information recorded by others with, presumably, varying degrees of skill, though the final diagnosis was made by a senior physician. The total notes are, however, very extensive in nearly all cases and the fact that the patients were not examined by the investigator could be an advantage in minimizing the 'halo effect'. The 'halo effect' could clearly influence the categorization of the patients into groups A-E, though the criteria for the groups
16
John L. Reed
were decided before the categorization, as was the marking of the data sheets. The effect may have been lessened further by the fact that the investigator had expected that group A would contain no patients. A further criticism is that postal follow-ups are less satisfactory than personal. In this study, however, details of episodes of illness during the follow-up period were required rather than an assessment of the patient's current state at the end of the follow-up. Reliable information about health over a period of years is more likely to be found from medical records than from personal recollections of patients. Taken as a whole there is no doubt that the present sample studied supports the view of those who consider that hysteria is not a disease in its own right and may, at most, be a symptom. For the entire group there is no consistency of background, symptomatology, or outcome. However, it is clear that to treat the group as a whole may well be unreasonable. In the first place, if coded by the present LCD. instead of the previous one, the 35% who were diagnosed as 'Hysteria Not Otherwise Specified' would have to be assigned to some other diagnostic category. In the second place the present study shows a clear distinction between groups A and B and the remainder. Under the division into the present five groups all of the Hysteria N.O.S. group fall within groups C and D and could be more suitably included in other diagnostic categories. An examination of the cases in groups C and D suggests that behaviour which might best be described as 'histrionic' rather than 'hysterical'— demonstrative, attention-seeking, noisy behaviour, often associated with rapid mood swings— appears to have been influential in determining the diagnosis in most of group C patients and of the group D patients. Of the latter group particularly the comment was often made that the patient was 'over-reacting' or 'over-dramatising'. The danger that may result from this approach is shown by the high mortality rate in the early years after admission. One patient with 'hysterical' abdominal pain died during the index admission of pylonephrosis and five more died in the first year after discharge. Two deaths were by suicide and three from physical illnesses, later noted as adequately explaining their original
symptoms. The situation of this group is summed up by one patient who explained that she behaved in the way that she did through frustration at being unable to convince doctors that she was physically ill—she died within a year of carcinoma of the uterus. It appears unjustified to use the term hysteria or hysterical reaction in relation to these groups C and D. It is in these patients that we must look more deeply to avoid errors of diagnosis and treatment. Groups A and B present a different problem; both show conversion/dissociative symptoms and group B show affective symptoms also. It is generally agreed that the mental mechanisms of dissociation or conversion are available to most, if not all, people and can occur in times of stress to normal people ('purposeful forgetting' of affect-laden material or the failure to feel pain of people injured under highly stressed conditions such as battle). Since we accept that people may react to stress with the other universal mechanisms of depression and anxiety, it appears unreasonable to refuse to accept that some may react with conversion/dissociation. This reaction could occur alone as in group A or in association with affective symptoms as in group B. In the latter case, two patterns of reaction would have to be considered. Patients might react simultaneously with affective and hysterical symptoms or initial affective symptoms might provoke secondary hysterical symptoms. What decides the mode of reaction is more difficult to define. Certainly not all the patients in either group A or B were of 'hysterical personality' or indeed of markedly abnormal personality. Indeed, two of group A were stated to have had normal premorbid personalities. While in group B it may be reasonable to speak of 'hysterical symptoms' or 'hysteria associated with' an affective illness, in group A there is a group of patients who, on admission, show symptoms which are generally considered to be found only in hysteria and no other symptoms. There is then uniformity of clinical picture exclusive to these group A patients. The follow-up study shows that group A differs from the other groups in the pattern of health on follow-up. In groups B and C affective illness commonly preceded and/or followed the
The diagnosis of'hysteria'
index admission. In group A there is a consistency of diagnosis. Two of the 13 had had hysterical reactions of the same type before the index admission. On follow-up, two had had recurrences of the same type of hysterical reaction as at index admission and two others continued to experience symptoms similar to those noted at index admission but in such a regular way as to suggest a continuation of the original reaction rather than a recurrence. All the other patients in group A had a single illness only. It seems reasonable, therefore, to suggest that in group A the pattern of the illness remains consistent. This small but significant group of patients fulfils the criteria put forward by Lewis as being important to establish the validity of hysteria as a diagnosis, and to withhold the use of the term hysteria as a diagnosis in these cases involves unjustifiable feats of semantic juggling. Though the number of patients showing 'true' hysteria may be small, it is clearly of importance that it should be recognized and the present study suggests that the diagnosis can be made with some confidence in the presence of conversion/dissociative symptoms and of belle indifference and gain when other symptoms are
17
absent. Cutler and Reed (1975) report an illustrative case. As the clinical picture may change rapidly, either spontaneously or after medical intervention, it is essential that these points be determined in the acute stage of the illness. Lewis has said that hysteria 'tends to outlive its obituarists'. It has outlived many and, if used for a carefully selected group of patients, is likely to outlive many more. REFERENCES Cutler, B. D., and Reed, J. L. (1975). Multiple personality: a case report with 15 year follow-up. Psychological Medicine. Guze, S. B., and Perley, M. J. (1963). Observations on the natural history of hysteria. American Journal of Psychiatry, 119, 960-965. Lewis, A. J. (1975). The survival of hysteria. Psychological Medicine, 5, 9-12. Slater, E. (1961). Hysteria 311. Journal of Mental Science, 107, 359-381. World Health Organization (1957). Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. 7th revision, 1955. 2 Vols. WHO: Geneva. World Health Organization (1967), and (1969). Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. 8th revision, 1965. 2 Vols. WHO: Geneva.
