The Diagnosis of Hysteria

I must confess at the outset that the subject of hysteria still awaits an adequate definition but the following one is as good as any so far produced. "Hysteria is a person's response to environmental difficulties, which makes it impossible for that person to perform his duties." Hysteria can be considered as subconscious malingering, but this concept too, fails to be comprehensive. In making the diagnosis of hysteria the following aspects should be


THE DIAGNOSIS OF HYSTERIA
Based on a Dissertation read before the Royal Medical Society on Friday, 24th October 1958.
By A. B. CRADDOCK I must confess at the outset that the subject of hysteria still awaits an adequate definition but the following one is as good as any so far produced."Hysteria is a person's response to environmental difficulties, which makes it impossible for that person to perform his duties."Hysteria can be considered as subconscious malingering, but this concept too, fails to be comprehensive.In making the diagnosis of hysteria the following aspects should be considered: The personality of the patient.Dissociation.Suggestion.The actual clinical features.The role of organic and psychological factors.
Perhaps the most salient feature of hysteria is its propensity to occur more commonly in people with what is known as a hysterical personality.
Some people seem to fall into this group because of their childhood environment and experience.Thus, a child who escapes from difficulties through illness, real or imagined, is liable to use this pattern of escape behaviour in adult life.Children who find in their illness, a good method of attracting attention will do the same thing.If the child's upbringing makes it plain that all one has to do to escape from a difficult situation is to develop some incapacity, then, the child will simply develop the incapacity and this is thought to be the explanation of the highly developed fainting ability of Victorian ladies.Training and education are also important at later stages of development, for example the habit of implicit obedience in soldiers has been shown to facilitate the production of hysterical symptoms.
Hysteria is commoner in people whose central nervous integration is unsatisfactory.This term includes immaturity and deterioration of the CNS.The following groups of people tend to develop hysteria therefore:-Mental defectives and others of low intelligence, children, cases of presenile dementia due for example to arteriosclerosis and atheroma, people with cerebral tumours, GPI, and meningovascular syphilis.
An action which is normal in a child would often be termed hysterical in an adult.This pseudohysteria in children is distinguished from true childhood hysteria, which is comparatively uncommon, by its emotional accompaniment.The "belle indifference" is found only in the true hysteric.
The traits of the hysterical personality can best be understood if they are considered as being caused by emotional immaturity and instability.The reaction to emotional stimuli is superficial and short lived.The person is immune from deep emotions and withstands stormy situations better than other people because their conflicts and consequences do not reach him.He is quick to forgive and forget and fails to understand people who are not.One well marked feature is an incapacity for insight into the reasons which prompt his actions and other people's.Thus he does not recognise outright lying for what it is and believes himself to be a very candid person-which is not true.He is sexually immature and despite a long series of flirtations he fails to establish permanent relations with members of the opposite sex.He may suffer from underdeveloped secondary sex characteristics, although the reverse is not necessarily true.A histrionic tendency often leads to success as an actor, a salesman, or popular lecturer.Similarly occupations such as nursing which are popularly associated with strong sentimental appeal attract a large quota of potential There. is .always.aneed to exaggerate and, in combination with the typical lack of insight, this often produces a paranoid quality.Failure is due, not to lack of ability, but to the blindness, ill will and stupidity of others.A hysterical personality has no core but only an ever changing series of masks.
A constant feature of hysteria is an abnormal dissociation.By this I mean an abnormal disconnection of groups of functioning elements.Not only is there isolation of function, as for example hysterical paralysis, but there can also be independence of function as for example hysterical tremors and vomiting.In some cases hysterical dissociation is almost spontaneous and it is in this group that a hysterical personality is most typically found.
In most cases there is some degree of mental conflict and where mental conflict is extreme even the more normally composed person may become a hysteric.Mental conflict arises when a person must reconcile factors which are for him irreconcilable, and for this reason the more highly intelligent and experienced members of society run less risk than their less fortunate cousins.In some cases the conflict is between the patient's conscious desires and his subconscious desires, or even between different subconscious desires.The hysterical reaction may not solve the problem in a rational or a satisfactory manner but the mental conflict is abolished and the patient's attitude is one of belle indifference." The hysterical patient is suggestible.Suggestion is neither a highly reasoned action nor a simple reflex.It is a reaction to a symbol.Thus a patient who on being shown a patellar hammer, produces a knee jerk, is demonstrating suggestibility.Now the presence of this phenomenon depends on three main components.Firstly-previous experience-a patient whose knee jerks have never been tested could not be the subject of this suggestion.Secondly-the presence of an adequately suggestive symbol in this case the tendon hammer.Thirdly-the absence of inhibition of the pathological development.The hysterical personality lacks insight.For this reason he does not try to remain a healthy person.An alternative point of view regards hysteria as a mental dissociation into logic tight compartments so that insight into the condition is precluded by its very nature.Dissociation of this kind has been produced experimentally in students by subjecting them to mental conflict.Now I wish to consider the symptomatology of hysteria.Any disease or symptom may be simulated.The symptoms may be emotional such as unreasonable disgust, fear, anxiety, depression or elation, or physical diseases may be simulated, and it would take a large text indeed to include even the main possibilities.In general one can say that the hysterical imitation always has some bizarre and erroneous element.Moreover the diagnosis is usually made simpler by the presence of other features of hysteria itself.An interesting aspect of symptomatology that tends to be forgotten is that the hysterical features may be symbolic of the mental conflict which has been solved.It has already been mentioned that hysteria may merge into malingering and in hysterical people elements of both may often exist, or, hysteria may develop from and replace malingering.Hysteria may also merge into obsessional states and the symbolism associated with the latter may be found in some cases of hysteria.For example vomiting may symbolise the patient "being sick of pregnancy."physiological vomiting of pregnancy having suggested the hysterical vomiting.On other occasions symbolism can be extremely complex and have meaning for the patient only.
In the causation of hysteria, organic cerebral disease or a psychotic disease may play a part.Hysteria in pure culture is, according to some, a rare condition.A diagnosis of hysteria must be accompanied by suspicion that another disease is present and this other disease should be sought out.Hysteria occurring in a previously well balanced, non hysterical adult is always very suggestive of another disease.At the same time one must not allow the suggestible nature of the hysteric to produce in him the features of diseases which he does not have.Bad management at this stage may cause the patient to develop incapacities which are worse than those he had before seeing the doctor.Alternatively the patient may simulate the organic diseases more accurately than before.Hysteria may precede or accompany schizophrenia, anxiety states, psychopathic states, and possibly epilepsy and tuberculosis.
Probably the commonest type of hysteria occurs as an overlay or exaggeration of an organic illness.At other times the hysterical disability may follow an organic or mental illness which has been cured and take on its features.
Hysteria is a condition which should be recognised more often than at present-especially below the consultant psychiatrist level.Paradoxically, cerebral diseases which have contributed to the production of the hysterical state are often overlooked when hysteria itself is recognised.It must be admitted however that the tremendous variety of hysterical features, particularly when they are associated with organic disease, presents a difficult diagnostic problem-but it is the more interesting because of this.