NeuroRehabilitation An Interdisciplinary Journal
ELSEVIER
NeuroRehabilitation 8 (1997) 157-162
The history of pain and hysteria Harold Merskey University of Western Ontario. London. Ontario. Canada
Abstract Although hysteria is connected with the idea of the womb causing illness, including headache, pain was only one of many symptoms which have been classed under the term hysteria. Patterns of anxiety with bodily symptoms and depression contributed to ancient and early modern concepts of the diagnosis. Pain became moderately prominent as a hysterical symptom from about the 18th century onwards. Only in the 19th century, with advances in anatomy, physiology and clinical medicine did it become possible to prove that there was a limited group of symptoms which resulted from the patient's idea of illness. The explanation of hysterical symptoms has depended substantially upon Freudian theory which is now undergoing a serious challenge. Hysterical pains can only be diagnosed rarely, if at all, and different efforts to describe hysteria in patients with pain have only been partially successful. Attempts to classify pain as a behavioral disorder have also been substantially unsuccessful. This may be because the psychological causes of pain are not so common as previously thought. There is also increasing reason to believe that unexplained pains have a physiological basis. © 1997 Elsevier Science Ireland Ltd.
Keywords: Pain; Hysteria; Psychological; Pathophysiological; Repression; Post-traumatic illness
1. Introduction
The notion that pain and hysteria are connected is quite old. In the Hippocratic collection headache was attributed to the influence of the uterus [1]. Specific mention of hysteria in medieval times is rather rare and I have not encountered any evidence of pain being described regularly as due to hysterical symptoms prior to the seventeenth century. Piso (1618) denied a relationship with the uterus and argued that hysteria, including headache, affected both men and women [2]. Sydenham (1697) specified, that pains
might occur which appeared to have a psychological origin [3]. Thus Sydenham wrote 'When the Mind is disturbed by some grevious (sic) accident the animal spirits run into disorderly motion; ... At other times they are miserably tormented with the hysterical clavus [nail] in which there is the most vehement pain in the head which you may cover with your thumb, the sick person in the meantime vomiting up green matter.. .'. The physical symptoms here such as migraine are being attributed to a psychological cause. No clear link was offered of a relationship between pain in particular and what was under-
1053-8135/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PH S 1 053-8135(96) 00219-9
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H. Merskey jNeuroRehabilitation8 (1997) 157-162
stood to be hysteria. However it is important to note that both pain and hysteria had special implications in previous centuries. Pain was long thought of as due to the emotions. The earliest example I have found dates from Jeremiah bemoaning the sack of Jerusalem (Lamentations 1:12-13) and saying 'Is it nothing to you all ye who pass by? Behold and see if there be any pain like unto my pain, which is done unto me, wherewith the Lord has afflicted me in the day of His fierce anger. From above he has sent fire into my bones ... ". For various reasons, this quotation is best understood as an indication of depression occurring in response to severe loss, deprivation, destruction of the city and the death and enslavement of its inhabitants. It suggests that pain may be due to depression, although we would use other words. Hysteria is not in mind here. However, it is hard to say when hysteria was in mind because the concept has changed. 2. The meaning of hysteria Recent discussions take the view that the notion of a formal illness 'hysteria' being due to the migration of the womb around the body was not strictly what the Greeks thought about 'hysteria' [4,5]. Indeed, they did not seem to have a substantive noun for such a condition and that was only introduced by the nineteenth century medical translator Littre, who translated the Hippocratic corpus into French, giving the text certain titles in front of paragraphs or sections, of which 'Hysteria' was one. It seems that it was only in the 17th or 18th centuries that a widely accepted picture really emerged with respect to what was thought of as hysteria. According to that picture the hysterical patient had ideas which resulted in bodily symptoms. Those ideas might be influenced by stressful events and they might also somehow be the consequence of a subtle disturbance of brain function. In these cases hysteria would be a general nervous disorder with constitutional components such as heredity and (usually) gender, as well as psychological causes. Hysteria in the early 18th century remained a broad concept in which it was still sometimes thought that the womb moved, or at least rose
somewhat, but that many of the symptoms were nevertheless of the mind. Blackmore (1725) observed that 'Terrible ideas, formed only in the imagination, will affect the brain and the body with painful sensations" [6]. The general description of numerous symptoms however was more favored than the specific linking of pain to hysteria. The evolution of the concept of hysteria is best understood by relating it to certain 18th Century categories of mental or psychological illness. These include the phrensy which was apparently a collection of illnesses involving excitement such as mania and some schizophrenic states, but could also include agitated depression and excited confusional states. Senile illnesses, recognized as organic brain disease had also been identified while melancholia was often commented upon and its origins were still taken to be vaguely humoral. Part of the territory which today we would include under the title 'major affective disorder' or reactive depression and anxiety states was described under the word hypochondriasis which also covered some concerns with bodily symptoms. In contrast to these diagnoses, hysterical symptoms seemed to include a miscellaneous collection of changes in the body which were thought to have been introduced either by emotional causes or by subtle changes in the brain. These changes in the brain might be familial and degenerative, perhaps provoked by emotional stress. In 1821 Georget called hysterical complaints a brain neurosis [7], an idea echoed by Briquet (1859) and meaning a disturbance 'of nervous function of an organic type producing varied symptoms [8]. Pain would, of course, have been among these. That it was well identified with multiple complaints is exemplified in the work of Pomme (1765) where it was part of 'A crowd of symptoms' [9]. This notion of neurosis for what we would consider to be an organic disorder was used in the 19th century by Charcot (1872) when he described paralysis agitans as a 'neurosis' because no location had been found for a lesion with it in the brain [10]. Micale (1990) sums it up as follows: 'In the eighteenth century, the disorder slid imperceptively into hypochondria, 'the vapours' and 'the
H. Merskey /NeuroRehabilitation8 (1997) 157-162
spleen', and in the 19th century it often overlapped with neurasthenia, nymphomania, general nervousness and out and out insanity. Many ... have used the word in reference to any nervous malady with spastic or convulsive complications.... Many physicians have coQlplained vociferously about the vagueness and indefinability of hysteIja' [11]. As far as we can tell here hysteria did not mean what we mean by it today. It meant multiple bodily symptoms often including pain with some sort of relationship to subtle brain dysfunction. 3. Modem concepts of hysteria Today, previous notions of hysteria have been disentangled and reshaped. The concept now essentially covers three main topics of which the first two are particularly relevant to clinical practice. One is the development of so called conversion symptoms, i.e. symptoms which affect the body but which lack a physical explanation (even a psychophysiological explanation) and which can be understood in terms of the patient's thoughts producing the change. The second is psychological symptoms of the same nature, i.e. due to the patient's thoughts, for example a psychological loss of memory because of an emotional difficulty. The third is a personality pattern or disorder. The above distinctions, only began to be made during the 19th century. They depended upon advances in knowledge of anatomy and physiology and in the application of those advances to clinical examination. They depended also upon the discrimination of automatic and involuntary effects in the autonomic nervous system from changes that could be due to voluntary, albeit unwitting, production of symptoms. By the end of the 19th century the work of Sir John Russell Reynolds (1869) and Charcot (1877) had lead to the strengthening of the view that some types of thoughts or ideas could give rise to physical symptoms [12,13]. Russell Reynolds described three cases of paralysis dependent upon idea (actually following accidents). Charcot took up Reynolds' idea and patients within his clinic were given hysterical symptoms by means of suggestion under hypnosis. This confirmed that cer-
159
tain types of apparent hysterical complaints could be produced by suggestion. Next followed the most influential explanation of the way in which the mind might produce such symptoms. Breuer and Freud (1893-1895), working with ideas which Freud developed argued that individuals might develop symptoms as a result of emotional conflict which could not be acknowledged [14]. Symptoms such as pain in the face were quite common in the early days of hysteria and were said to serve a function. Unpleasant conflict, in theory, would be repressed into an unconscious portion of the mind and only released again when circumstances were propitious or some other occurrence reminded the individual in a way which was too overwhelming for the idea to be kept unconscious. This idea of the repression of conflicts gradually gained great sway and most psychiatrists in the developed world accepted it. until about five years ago. The first major crack in the domination of the theory began with articles by Holmes [15, 16] which pointed out that experimental psychological efforts to produce evidence of repression had failed and that the idea depended heavily upon anecdotal evidence and had no other support. The notion that repression was an inadequate concept gained much greater strength after it became evident that the theory of repression was being used in conjunction with attempts to recover supposed memories of early childhood abuse from a variety of individuals. This modem change, described in detail by Pendergrast [17] has lead to the proliferation of false accusations of sexual abuse based upon theories of recovered memory which apparently were due in the first instance to suggestive procedures in treatment, and subsequently to the popularization of the idea through books and other elements of the media. The evident falsehoods and excesses of the recovered memory movement produced such absurdities as Multiple Personality Disorder (MPD) with as many 'personalities' as 4000 [18], allegations of satanic ritual abuse involving multi-generational gangs of perpetrators, tales of alien abduction and belief in past lives. This reductio ad absurdum with the theory of repression and the recovery of lost memories lead to a keenly critical look both at
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human memory and at the idea of repressed experiences. The end result has been to challenge the whole notion of repression, so that psychiatry is now faced with the interesting, difficult and important problem of determining how to handle the theory of motivated forgetting now that repression has been shown to lack adequate scientific controls - or tests that keep it within the bounds of common sense. This is not to say that differential attention, motivated forgetting, or preferential recall, do not exist but simply that the way that they have been explained to date is seen to be profoundly inadequate. The field of post-traumatic illness has been one, besides hysteria, in which ideas of repression and emotional conflict operated quite prominently. This was most notable during the First World War when soldiers in enormous numbers were faced with the expectation of almost certain death or injury from remaining in the trenches or charging out of them or tried and executed for running away. Many hysterical type symptoms developed in men at that time including the classical symptoms of blindness, deafness, loss of memory, loss of speech, paralysis of one or more extremities, astasia and abasia. Some, but a lesser proportion, of the patients developed painful syndromes also. In retrospect many of those may have been Complex Regional Pain Syndrome Type II (formerly described as Reflex Sympathetic Dystrophy). However, pain was not a strong feature of the overt conversion symptoms observed during the Second World War, although tens of thousands of men were diagnosed as having 'Shell shock' which today we would call post traumatic stress disorder, perhaps sometimes with the complications of conversion symptoms as well. 4. Hysterical pains Pain did not playa large part in this theoretical development and yet it also figured in some quarters as a frequent sign of hysteria. It was accepted routinely without discussion. This is exemplified from the time of Pomme onwards by a number of authors and became very obvious with mid-19th century French writers who described a host of symptoms as characteristic of hysteria [8,19]. Lan-
douzy (1846) described hysteria as an illness exclusive to women, occurring during reproductive life with episodes of marked change, including crying without cause, deep sighing, a sense of constriction or even a ball (globus hystericus) in the throat and numerous other symptoms which included migraine headaches, and semi-localized head pain as well as tetanic attacks and fits [19]. Hypochondriasis in men was held to be the equivalent, and marked also by a variety of complaints including dysphasia, gastralgia and enteralgia. Some authors called a variety of bodily pains neuralgia and then explained them as being hysterical in many instances [20]. This evolution of the distinction between neuralgia and other types of pains shows an ebb and flow of ideas, sometimes limiting neuralgia fairly strictly to pain along the course or in the territory of a particular nerve and at other times regarding it as an effect of an organ such as the spleen or the stomach [21]. Although, for reasons which will be discussed shortly it is very hard to prove that pain is an hysterical symptom the temptation to include it in the list of hysterical symptoms has been great, particularly when pains are diffuse and poorly explained on organic grounds and the patient appears to be emotionally distressed. After the First World War there was an increasing tendency for individual writers to attempt to assimilate cases of pain to the model of repressed emotional conflicts. More than 30 such individual reports appeared mostly developing the idea that pain and resentment and harsh treatment in childhood lead to pain of psychological origin in adult life [22]. This idea was developed in influential papers by George Engel [23, 24] dealing first with facial pain and then with pain in general. They became popular and still have an influence. They were partly confirmed in that resentment, among other things, was shown to be a feature of patients with chronic pain. This may be as much for physical and biological reasons as for any matter related to a repressed idea, and it also happens when patients feel let-down or rejected on being given to understand that they are complaining unduly while the pain is in their mind. Aggression and resentment are normal responses in people with pain. They are one part of
H. Merskey / NeuroRehabilitation8 (1997) 157-162
the fight or flight reaction which would be appropriate if the body has been damaged. The writer supported Engel's ideas to the extent of confirming some of his findings but not demonstrating more than a very modest influence of childhood upon the adult experience of pain. In a series of psychiatric patients with a primary psychiatric diagnosis and no current evidence of physical illness, Merskey reached the conclusion that much chronic pain was hysterical [25,26]. More stringent modern criteria would probably have changed the diagnosis in many of those patients to mild or atypical affective disorder and might have raised the possibility of regional from poorly recognized physical causes. Spear [27] in a parallel study found that the presumed hysterical complaints were more common in psychiatric patients whose pain was more protracted. Mter publication of that work additional support seemed to appear from the patterns of the Minnesota Multiphasic Personality Inventory (MMPI) findings observed in patients with chronic pain (Sternbach, [28]). These views of pain and hysteria had to be jettisoned for the most part for the following reasons. First, it became evident in further studies that many patients with chronic pain persisted in suffering from it long after any motivation related to compensation (which was the principal explanation available) had ceased to be operative. Mendelson (1982) showed that 10 successive studies had all reached this conclusion [29]. Second, the associations of personality and psychiatric illness with such physical problems as asthma, spastic colitis, migraine and other pain came to be recognized as partly artifactual and based upon a selection process in which patients who were more concerned about physical problems were liable to present differentially often for the help of physicians. While evidence existed that pain could occur in conjunction with psychiatric illness and perhaps be a consequence of it this did not appear to apply very much to the troublesome chronic pain observed in many rehabilitation settings for patients with musculoskeletal complaints, and it was also shown that individuals in pain were at significant risk of going on to develop depression subsequently. This work, in a
161
long term epidemiological study, provided one of the stronger bases for the assumption that depression tends to follow pain somewhat more often than psychological factors may cause pain (Magni et aI., [30]). Equally important it became clear from neurophysiological work that it was possible for a lesion causing pain in one part of the body to have more widespread effects which overlap anatomic boundaries. Thus, the traditional method of distinguishing hysterical complaints as being 'non-anatomical' and regional were challenged. Dermatomes, regional loss of pin prick and regional increases in pain or hypersensitivity were all capable of being explained in terms of plasticity of nervous function in the spinal cord after the onset of nociception [31]. This means that while, in theory, regional symptoms may be classified as hysterical on the basis of the patient having an idea which involves a particular part of the body, the mere occurrence of regional symptoms can no longer be taken almost automatically to be evident of psychological dysfunction (except in cases of polyneuritis or sympathetic nerve involvement). At the present time, each case has to be decided on its merits. It is evident that pain and hysteria have had a checkered mutual interaction. Pain on the whole was not prominent in classical or medieval writing as a consequence of emotional factors, although there are one or two outstanding cases where this may happen. It was included much more often in the concept of hysteria from the late 17th Century on. Attempts to attach the diagnosis of Hysteria or a supposedly equivalent term such as Pain Behaviour to pain symptoms have largely failed. This may be for three reasons. First, they lacked good signs of the sort which can be used in motor disorders to demonstrate that a loss of function corresponds to the patient's beliefs about physical conditions, rather than to anatomical facts. Second, as mentioned above, the evidence of plasticity in the nervous system provides a source for the view that regional pains are liable to be physiological in origin and type. Third, the rules of motivation which should have applied to patients with psychological problems were violated when it was realized that many people with a financial motive continued to have comparable
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symptoms. Meanwhile, a radical revision of psychiatric theory is in process and there is little expectation that psychological explanations for pain will be strengthened by the process. References [1] [2]
[3]
[4]
[5] [6] [7] [8] [9] [10]
[11] [12] [13]
Littre E. Oeuvres Completes d'Hippocrate, Vol. V, Epidemics bk. 5, para. 64. Paris: J.B. Bailliere, 1839-1861. Piso C. Selectiorum Observationum et Conciliorum de Praetervisis Morbis Affectibusque Praeter Naturam, ab Aqua seu Serosa Colluvie et Diluvie Ortis. Leyden: Boutestein and Langerak, 1714. Cit. Cesbron, 1909 [31]. Sydenham T. Discourse concerning hysterical and hypochondriacal distempers. In: Dr. Sydenham's Compleat Method of Curing Almost all Diseases, and Description of their Symptoms, to which are now Added Five Discourses of the Same Author Concerning Pleurisy, Gout, Hysterical Passion, Dropsy and Rheumatism, 3rd edn. London: Newman and Parker, 1697. First published as part of Processus Integri (1693). King H. Once upon a text: the Hippocratic origins of hysteria. In: Gilman S, King H et al. eds. Hysteria in Western Civilization. Berkeley: University of California Press, 1994;, pp. 3-90. Merskey H. The Analysis of Hysteria: Understanding Conversion and Dissociation, 2nd edn. London: Gaskell, 1995. Blackmore R. A Treatise of the Spleen and Vapours: or, Hypochondriacal and Hysterical Affections. London: 1. Pemberton, 1725. Georget M. De la Physiologie de la Systeme Nerveux. Paris: 1.B. Bailliere, 1821;2:261-262, 265-286. Briquet P. Traite Clinique et Therapeutique de I'Hysterie. Paris: Bailliere et Fils, 1859. Pomme P. Traite des Affections Vaporeuses des Deux Sexes, 2nd edn. Lyon: Benoit Duplain, 1765. Charcot J-M. Clinical Lectures on Diseases of the Nervous System Delivered at La Salpetriere, Vol. 1 (trans. T. Savill, 1887). London: The New Sydenham Society, 1872. Micale M. Hysteria and its historiography. The future perspective. Hist Psychiat 1990;1 :33-124. Reynolds lR. Remarks on paralysis and other disorders of motion and sensation, dependent on idea. Br Med 1 1869;ii:483-485, Discussion, 378-379. Charcot J-M. Clinical Lectures of the Diseases of the Nervous System, Vol. 3 (trans. T. Savill, 1889). London: The New Sydenham Society, 1877.
[14] Breuer 1, Freud S. (1893-1895) Studies on Hysteria. Harmondsworth: Penguin Books, 1974. [15] Holmes DS. Investigations of Repression Differential recall of material experimentally or naturally associated with ego threat. Psychological Bulletin, 1974;81:632-653. [16] Holmes DS. The Evidence for Repression: An Examination of sixty years of research. In: Singer lL: Repression and Dissociation. Ed. Singer lL. Chicago. University of Chicago Press, 1990. pp. 85-102. [17] Pendergrast M. Victims of Memory: Sex Abuse Accusations and Shattered Lives. 2nd Edn. Hinesburg, VT, Upper Access Books. 1996. [18] Kluft RP. The phenomenology and treatment of extremely complex multiple personality disorder. Dissociation 1988;1:47-58. [19] Landouzy H. Traite Complet de I'Hysterie. Paris: 1.B. Bailliere, 1846. [20] Laycock T A. Treatise on the Nervous Diseases of Women. London: Longman, Orme, Brown, Green & Longmans, 1840. [21] A1am CN, Merskey H. What's in a name? The cycle of change in the meaning of neuralgia. Hist Psychiat 1994;5:429-474. [22] Merskey H, Spear FG. Pain: Psychological and Psychiatric Aspects. London: Bailliere, Tindall & Cassell, 1967. [23] Engel GL. Primary Atypical Facial Neuralgia. An hysterical conversion symptom. Psychosom Med 1951 ;13:375-396. [24] Engel GL. 'Psychogenic' pain and the pain prone patient. Amer J Med, 1959;26:899-918. [25] Merskey H. The characteristics of persistent pain in psychological illness. 1 Psychosom Res 1965;9:291-298. [26] Merskey H. Psychiatric patients with persistent pain. J Psychosom Res 1965;9:299-309. [27] Spear FG. Pain in psychiatric patients. 1 Psychosom Res 1967;11:187-193. [29] Mendelson G. Not 'cured by a verdict'. Effect of legal settlement on compensation claimants. Med 1 Aust, 1982;ii:219-230. [30] Magni G, Moreschij C, Rigatti-Luchini Sand Merskey H. Prospective Study of the Relationship between depressive symptoms and chronic musculoskeletal pain. Pain 1994;56:289-297. [31] Merskey H. Regional pain is rarely hysterical. Arch Neurol 1988;45:915-918. [32] CesbrM H. Histoire Critique de I'Hysterie. Paris: Asselin et Houzeau, 1909.
ELSEVIER
NeuroRehabilitation 8 (1997) 157-162
The history of pain and hysteria Harold Merskey University of Western Ontario. London. Ontario. Canada
Abstract Although hysteria is connected with the idea of the womb causing illness, including headache, pain was only one of many symptoms which have been classed under the term hysteria. Patterns of anxiety with bodily symptoms and depression contributed to ancient and early modern concepts of the diagnosis. Pain became moderately prominent as a hysterical symptom from about the 18th century onwards. Only in the 19th century, with advances in anatomy, physiology and clinical medicine did it become possible to prove that there was a limited group of symptoms which resulted from the patient's idea of illness. The explanation of hysterical symptoms has depended substantially upon Freudian theory which is now undergoing a serious challenge. Hysterical pains can only be diagnosed rarely, if at all, and different efforts to describe hysteria in patients with pain have only been partially successful. Attempts to classify pain as a behavioral disorder have also been substantially unsuccessful. This may be because the psychological causes of pain are not so common as previously thought. There is also increasing reason to believe that unexplained pains have a physiological basis. © 1997 Elsevier Science Ireland Ltd.
Keywords: Pain; Hysteria; Psychological; Pathophysiological; Repression; Post-traumatic illness
1. Introduction
The notion that pain and hysteria are connected is quite old. In the Hippocratic collection headache was attributed to the influence of the uterus [1]. Specific mention of hysteria in medieval times is rather rare and I have not encountered any evidence of pain being described regularly as due to hysterical symptoms prior to the seventeenth century. Piso (1618) denied a relationship with the uterus and argued that hysteria, including headache, affected both men and women [2]. Sydenham (1697) specified, that pains
might occur which appeared to have a psychological origin [3]. Thus Sydenham wrote 'When the Mind is disturbed by some grevious (sic) accident the animal spirits run into disorderly motion; ... At other times they are miserably tormented with the hysterical clavus [nail] in which there is the most vehement pain in the head which you may cover with your thumb, the sick person in the meantime vomiting up green matter.. .'. The physical symptoms here such as migraine are being attributed to a psychological cause. No clear link was offered of a relationship between pain in particular and what was under-
1053-8135/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PH S 1 053-8135(96) 00219-9
158
H. Merskey jNeuroRehabilitation8 (1997) 157-162
stood to be hysteria. However it is important to note that both pain and hysteria had special implications in previous centuries. Pain was long thought of as due to the emotions. The earliest example I have found dates from Jeremiah bemoaning the sack of Jerusalem (Lamentations 1:12-13) and saying 'Is it nothing to you all ye who pass by? Behold and see if there be any pain like unto my pain, which is done unto me, wherewith the Lord has afflicted me in the day of His fierce anger. From above he has sent fire into my bones ... ". For various reasons, this quotation is best understood as an indication of depression occurring in response to severe loss, deprivation, destruction of the city and the death and enslavement of its inhabitants. It suggests that pain may be due to depression, although we would use other words. Hysteria is not in mind here. However, it is hard to say when hysteria was in mind because the concept has changed. 2. The meaning of hysteria Recent discussions take the view that the notion of a formal illness 'hysteria' being due to the migration of the womb around the body was not strictly what the Greeks thought about 'hysteria' [4,5]. Indeed, they did not seem to have a substantive noun for such a condition and that was only introduced by the nineteenth century medical translator Littre, who translated the Hippocratic corpus into French, giving the text certain titles in front of paragraphs or sections, of which 'Hysteria' was one. It seems that it was only in the 17th or 18th centuries that a widely accepted picture really emerged with respect to what was thought of as hysteria. According to that picture the hysterical patient had ideas which resulted in bodily symptoms. Those ideas might be influenced by stressful events and they might also somehow be the consequence of a subtle disturbance of brain function. In these cases hysteria would be a general nervous disorder with constitutional components such as heredity and (usually) gender, as well as psychological causes. Hysteria in the early 18th century remained a broad concept in which it was still sometimes thought that the womb moved, or at least rose
somewhat, but that many of the symptoms were nevertheless of the mind. Blackmore (1725) observed that 'Terrible ideas, formed only in the imagination, will affect the brain and the body with painful sensations" [6]. The general description of numerous symptoms however was more favored than the specific linking of pain to hysteria. The evolution of the concept of hysteria is best understood by relating it to certain 18th Century categories of mental or psychological illness. These include the phrensy which was apparently a collection of illnesses involving excitement such as mania and some schizophrenic states, but could also include agitated depression and excited confusional states. Senile illnesses, recognized as organic brain disease had also been identified while melancholia was often commented upon and its origins were still taken to be vaguely humoral. Part of the territory which today we would include under the title 'major affective disorder' or reactive depression and anxiety states was described under the word hypochondriasis which also covered some concerns with bodily symptoms. In contrast to these diagnoses, hysterical symptoms seemed to include a miscellaneous collection of changes in the body which were thought to have been introduced either by emotional causes or by subtle changes in the brain. These changes in the brain might be familial and degenerative, perhaps provoked by emotional stress. In 1821 Georget called hysterical complaints a brain neurosis [7], an idea echoed by Briquet (1859) and meaning a disturbance 'of nervous function of an organic type producing varied symptoms [8]. Pain would, of course, have been among these. That it was well identified with multiple complaints is exemplified in the work of Pomme (1765) where it was part of 'A crowd of symptoms' [9]. This notion of neurosis for what we would consider to be an organic disorder was used in the 19th century by Charcot (1872) when he described paralysis agitans as a 'neurosis' because no location had been found for a lesion with it in the brain [10]. Micale (1990) sums it up as follows: 'In the eighteenth century, the disorder slid imperceptively into hypochondria, 'the vapours' and 'the
H. Merskey /NeuroRehabilitation8 (1997) 157-162
spleen', and in the 19th century it often overlapped with neurasthenia, nymphomania, general nervousness and out and out insanity. Many ... have used the word in reference to any nervous malady with spastic or convulsive complications.... Many physicians have coQlplained vociferously about the vagueness and indefinability of hysteIja' [11]. As far as we can tell here hysteria did not mean what we mean by it today. It meant multiple bodily symptoms often including pain with some sort of relationship to subtle brain dysfunction. 3. Modem concepts of hysteria Today, previous notions of hysteria have been disentangled and reshaped. The concept now essentially covers three main topics of which the first two are particularly relevant to clinical practice. One is the development of so called conversion symptoms, i.e. symptoms which affect the body but which lack a physical explanation (even a psychophysiological explanation) and which can be understood in terms of the patient's thoughts producing the change. The second is psychological symptoms of the same nature, i.e. due to the patient's thoughts, for example a psychological loss of memory because of an emotional difficulty. The third is a personality pattern or disorder. The above distinctions, only began to be made during the 19th century. They depended upon advances in knowledge of anatomy and physiology and in the application of those advances to clinical examination. They depended also upon the discrimination of automatic and involuntary effects in the autonomic nervous system from changes that could be due to voluntary, albeit unwitting, production of symptoms. By the end of the 19th century the work of Sir John Russell Reynolds (1869) and Charcot (1877) had lead to the strengthening of the view that some types of thoughts or ideas could give rise to physical symptoms [12,13]. Russell Reynolds described three cases of paralysis dependent upon idea (actually following accidents). Charcot took up Reynolds' idea and patients within his clinic were given hysterical symptoms by means of suggestion under hypnosis. This confirmed that cer-
159
tain types of apparent hysterical complaints could be produced by suggestion. Next followed the most influential explanation of the way in which the mind might produce such symptoms. Breuer and Freud (1893-1895), working with ideas which Freud developed argued that individuals might develop symptoms as a result of emotional conflict which could not be acknowledged [14]. Symptoms such as pain in the face were quite common in the early days of hysteria and were said to serve a function. Unpleasant conflict, in theory, would be repressed into an unconscious portion of the mind and only released again when circumstances were propitious or some other occurrence reminded the individual in a way which was too overwhelming for the idea to be kept unconscious. This idea of the repression of conflicts gradually gained great sway and most psychiatrists in the developed world accepted it. until about five years ago. The first major crack in the domination of the theory began with articles by Holmes [15, 16] which pointed out that experimental psychological efforts to produce evidence of repression had failed and that the idea depended heavily upon anecdotal evidence and had no other support. The notion that repression was an inadequate concept gained much greater strength after it became evident that the theory of repression was being used in conjunction with attempts to recover supposed memories of early childhood abuse from a variety of individuals. This modem change, described in detail by Pendergrast [17] has lead to the proliferation of false accusations of sexual abuse based upon theories of recovered memory which apparently were due in the first instance to suggestive procedures in treatment, and subsequently to the popularization of the idea through books and other elements of the media. The evident falsehoods and excesses of the recovered memory movement produced such absurdities as Multiple Personality Disorder (MPD) with as many 'personalities' as 4000 [18], allegations of satanic ritual abuse involving multi-generational gangs of perpetrators, tales of alien abduction and belief in past lives. This reductio ad absurdum with the theory of repression and the recovery of lost memories lead to a keenly critical look both at
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human memory and at the idea of repressed experiences. The end result has been to challenge the whole notion of repression, so that psychiatry is now faced with the interesting, difficult and important problem of determining how to handle the theory of motivated forgetting now that repression has been shown to lack adequate scientific controls - or tests that keep it within the bounds of common sense. This is not to say that differential attention, motivated forgetting, or preferential recall, do not exist but simply that the way that they have been explained to date is seen to be profoundly inadequate. The field of post-traumatic illness has been one, besides hysteria, in which ideas of repression and emotional conflict operated quite prominently. This was most notable during the First World War when soldiers in enormous numbers were faced with the expectation of almost certain death or injury from remaining in the trenches or charging out of them or tried and executed for running away. Many hysterical type symptoms developed in men at that time including the classical symptoms of blindness, deafness, loss of memory, loss of speech, paralysis of one or more extremities, astasia and abasia. Some, but a lesser proportion, of the patients developed painful syndromes also. In retrospect many of those may have been Complex Regional Pain Syndrome Type II (formerly described as Reflex Sympathetic Dystrophy). However, pain was not a strong feature of the overt conversion symptoms observed during the Second World War, although tens of thousands of men were diagnosed as having 'Shell shock' which today we would call post traumatic stress disorder, perhaps sometimes with the complications of conversion symptoms as well. 4. Hysterical pains Pain did not playa large part in this theoretical development and yet it also figured in some quarters as a frequent sign of hysteria. It was accepted routinely without discussion. This is exemplified from the time of Pomme onwards by a number of authors and became very obvious with mid-19th century French writers who described a host of symptoms as characteristic of hysteria [8,19]. Lan-
douzy (1846) described hysteria as an illness exclusive to women, occurring during reproductive life with episodes of marked change, including crying without cause, deep sighing, a sense of constriction or even a ball (globus hystericus) in the throat and numerous other symptoms which included migraine headaches, and semi-localized head pain as well as tetanic attacks and fits [19]. Hypochondriasis in men was held to be the equivalent, and marked also by a variety of complaints including dysphasia, gastralgia and enteralgia. Some authors called a variety of bodily pains neuralgia and then explained them as being hysterical in many instances [20]. This evolution of the distinction between neuralgia and other types of pains shows an ebb and flow of ideas, sometimes limiting neuralgia fairly strictly to pain along the course or in the territory of a particular nerve and at other times regarding it as an effect of an organ such as the spleen or the stomach [21]. Although, for reasons which will be discussed shortly it is very hard to prove that pain is an hysterical symptom the temptation to include it in the list of hysterical symptoms has been great, particularly when pains are diffuse and poorly explained on organic grounds and the patient appears to be emotionally distressed. After the First World War there was an increasing tendency for individual writers to attempt to assimilate cases of pain to the model of repressed emotional conflicts. More than 30 such individual reports appeared mostly developing the idea that pain and resentment and harsh treatment in childhood lead to pain of psychological origin in adult life [22]. This idea was developed in influential papers by George Engel [23, 24] dealing first with facial pain and then with pain in general. They became popular and still have an influence. They were partly confirmed in that resentment, among other things, was shown to be a feature of patients with chronic pain. This may be as much for physical and biological reasons as for any matter related to a repressed idea, and it also happens when patients feel let-down or rejected on being given to understand that they are complaining unduly while the pain is in their mind. Aggression and resentment are normal responses in people with pain. They are one part of
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the fight or flight reaction which would be appropriate if the body has been damaged. The writer supported Engel's ideas to the extent of confirming some of his findings but not demonstrating more than a very modest influence of childhood upon the adult experience of pain. In a series of psychiatric patients with a primary psychiatric diagnosis and no current evidence of physical illness, Merskey reached the conclusion that much chronic pain was hysterical [25,26]. More stringent modern criteria would probably have changed the diagnosis in many of those patients to mild or atypical affective disorder and might have raised the possibility of regional from poorly recognized physical causes. Spear [27] in a parallel study found that the presumed hysterical complaints were more common in psychiatric patients whose pain was more protracted. Mter publication of that work additional support seemed to appear from the patterns of the Minnesota Multiphasic Personality Inventory (MMPI) findings observed in patients with chronic pain (Sternbach, [28]). These views of pain and hysteria had to be jettisoned for the most part for the following reasons. First, it became evident in further studies that many patients with chronic pain persisted in suffering from it long after any motivation related to compensation (which was the principal explanation available) had ceased to be operative. Mendelson (1982) showed that 10 successive studies had all reached this conclusion [29]. Second, the associations of personality and psychiatric illness with such physical problems as asthma, spastic colitis, migraine and other pain came to be recognized as partly artifactual and based upon a selection process in which patients who were more concerned about physical problems were liable to present differentially often for the help of physicians. While evidence existed that pain could occur in conjunction with psychiatric illness and perhaps be a consequence of it this did not appear to apply very much to the troublesome chronic pain observed in many rehabilitation settings for patients with musculoskeletal complaints, and it was also shown that individuals in pain were at significant risk of going on to develop depression subsequently. This work, in a
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long term epidemiological study, provided one of the stronger bases for the assumption that depression tends to follow pain somewhat more often than psychological factors may cause pain (Magni et aI., [30]). Equally important it became clear from neurophysiological work that it was possible for a lesion causing pain in one part of the body to have more widespread effects which overlap anatomic boundaries. Thus, the traditional method of distinguishing hysterical complaints as being 'non-anatomical' and regional were challenged. Dermatomes, regional loss of pin prick and regional increases in pain or hypersensitivity were all capable of being explained in terms of plasticity of nervous function in the spinal cord after the onset of nociception [31]. This means that while, in theory, regional symptoms may be classified as hysterical on the basis of the patient having an idea which involves a particular part of the body, the mere occurrence of regional symptoms can no longer be taken almost automatically to be evident of psychological dysfunction (except in cases of polyneuritis or sympathetic nerve involvement). At the present time, each case has to be decided on its merits. It is evident that pain and hysteria have had a checkered mutual interaction. Pain on the whole was not prominent in classical or medieval writing as a consequence of emotional factors, although there are one or two outstanding cases where this may happen. It was included much more often in the concept of hysteria from the late 17th Century on. Attempts to attach the diagnosis of Hysteria or a supposedly equivalent term such as Pain Behaviour to pain symptoms have largely failed. This may be for three reasons. First, they lacked good signs of the sort which can be used in motor disorders to demonstrate that a loss of function corresponds to the patient's beliefs about physical conditions, rather than to anatomical facts. Second, as mentioned above, the evidence of plasticity in the nervous system provides a source for the view that regional pains are liable to be physiological in origin and type. Third, the rules of motivation which should have applied to patients with psychological problems were violated when it was realized that many people with a financial motive continued to have comparable
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symptoms. Meanwhile, a radical revision of psychiatric theory is in process and there is little expectation that psychological explanations for pain will be strengthened by the process. References [1] [2]
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