Chapter 4 - Freud's hysteria and its legacy
Introduction
In the long history of hysteria, its brief time as a psychiatric illness begins, and in a sense ends, with Freud. Though he, and his work, inevitably had antecedents and collaborators, his contribution was unrivaled in its novelty, scope, and impact. He made hysteria a psychiatric illness with a model that dominated psychiatry's thinking for over half a century, and rendered it seemingly inescapably different from the rest of medicine. Such was the grip of that model on generations of psychiatrists that even when his ideas were finally rejected, wholesale, by the Diagnostic and Statistical Manual of Mental Disorders (3rd edition) (DSM-III) in 1980 (APA, 1980) a special case for a Freudian hysteria was made for 30 years more. I shall outline that model and how it fared in the 20th century, charting the rise and fall of a “golden age” for hysteria, when it stood as a paragon of illness, instead of as a reproach.
Section snippets
Freud's hysteria
At the time when he began working with hysteric patients, hysteria was effectively a neurological disorder, and Freud was a neurologist. It was a time of great interest in hysteria (Shorter, 1986), which had become a particular focus of the greatest neurologist of his time, Jean-Martin Charcot. Freud undertook a fellowship with him, and was clearly inspired (Freud, 1953c), though his own work in hysteria soon surpassed that of his teacher.
Those works were among Freud's earliest,1
Repression
Repression is one of Freud's most enduring notions. He started from the principle that we normally know what it is that upsets us – what makes us cry, for example – so that if we accept that something has upset someone without them recognizing it, then we should accept that there are unconscious ideas (Breuer and Freud, 1953, Freud, 1953c). Of the many metaphors that were used to describe such unconscious ideas, the first was of a “foreign body” in flesh:
her love … was present in her
Conversion
Exploring the mechanics of conversion, we find a similar progression. Initially, the conversion – the transformation of the traumatic idea into symptoms – was little more than a behavioral description: problems lead to symptoms. Of course, there was that word “transformation” in addition, but neither “transformation” nor “conversion” told us much. Both suggested an almost alchemic process where substances were changed into one another, and at least initially this seems to have been Freud's
The third ingredient
There was initially a third component whose nature varied over the course of Freud's work (Breuer and Freud, 1953, Part 3; Freud, 1953d, lectures 1 and 2) before it was eventually eliminated. This was the special state the patient needed to be in or conditions she needed to meet in order to develop the symptoms as she did; to answer the questions “why her, why then, why that symptom?” At first Freud used the idea of the “hysterical disposition,” an idea adopted from the neurologist Paul Julius
Shell shock and psychosomatics
In the First World War (1914–1918) there was an epidemic of functional neurological symptoms. Of the huge number of casualties from that unimaginable slaughter – one million from the Battle of Somme alone – 40% were deemed psychiatric, mainly functional symptoms of one type or another (Young, 1995). The extraordinary explosion of what came to be called shell shock was unprecedented, and has never been repeated. In the field of hysteria it had several consequences: it confirmed that such
Scientists and philosophers
Psychoanalysis never had the same grip on psychiatry in the UK as it did in the USA, though it benefitted from émigré analysts too, notably Freud himself. Though his ideas were cautiously received before 1914 (Loughran, 2008), they were championed during the war by W.H.R. Rivers (Young, 1995), Charles Myers, and Ernest Jones (Forrester, 2008). But attempts to institutionalize an analytic model of medicine at Cambridge after the war foundered with Rivers’ early death. Instead, the newly founded
Hysteria is dead; long live functional neurologic symptoms
In the 1960s there appeared a number of psychiatric articles noting the disappearance of hysteria (Kanaan and Wessely, 2010). Outside of psychiatry, too, hysteria came to be treated as an historical entity, an odd cultural phenomenon ripened by, if not born from, particular Victorian medical and sexual mores (Micale, 1995). By way of illustration, a Hollywood romantic comedy was released in 2011 with the simple title Hysteria: one only has to contemplate the impossibility of a similar comedy
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2022, Seminars in Pediatric NeurologyCitation Excerpt :This repression then led to conversion of those psychological problems into physical symptoms, effectively renaming hysteria as conversion disorder. For decades, Freud's ideas and the psychoanalytic school became the leading paradigm, particularly in the United States, by which hysteria was treated.23 In the latter half of the 20th century, Freud's ideas were eventually rejected as unscientific though the term conversion disorder is still commonly used interchangeably with FND today.23
Functional movement disorder comorbidity in Parkinson's disease: Unraveling the web
2021, Parkinsonism and Related DisordersCitation Excerpt :The definition, nomenclature and diagnostic criteria for functional neurological disorders (FND) have been revisited and renewed in the past two decades to reflect their current understanding. Hysteria was the term used to label these syndromes throughout most of the 18th and 19th centuries while in the past century, they have been called dissociative, conversion, non-organic, medically unexplained, somatoform and psychogenic disorders [1]. However, the purely psychological model established in the past has progressively shifted to an integrated biopsychosocial paradigm as a result of research efforts mainly driven by modern cognitive neuroscience.
Treatment of Functional Movement Disorders
2020, Neurologic ClinicsCitation Excerpt :It is sometimes stressed that patients perceive their symptoms as dysfunctional rather than functional but prefer this term as less stigmatizing among other options.16 The historically used term hysteria has been abandoned,17 and the use of medically unexplained symptoms is discouraged because of its vague nature and possible overlap with symptoms caused by unrecognized neurologic illness. Over the past decade, there has been an emphasis away from considering FMD a diagnosis of exclusion toward phenotype-specific, positive diagnostic criteria.18,19
Pathogenesis and pathophysiology of functional (psychogenic) movement disorders
2019, Neurobiology of DiseaseCitation Excerpt :Moreover, the weight of evidence suggests that FMDs and FNES are more likely a continuum of functional neurological disorders [Erro et al., 2016; Kanaan et al., 2017]. The terminology used to describe these patients has evolved from the time when “hysteria” was the term in vogue to modern views (Table 1) [King, 1993; Fahn, 2005; Trimble and Reynolds, 2016; Goetz, 2016; Kanaan, 2016]. Some investigators have argued that the term “psychogenic”, used in the first two international conferences on this topic, should be changed to the term “functional” and, in a compromise, the 3rd international conference used the term “functional (psychogenic)” [Edwards et al., 2014; Jankovic, 2014; Fahn and Olanow, 2014].
Post-traumatic Stress Disorder Symptom Substitution as a Cause of Functional Neurological Disorder
2020, PsychosomaticsCitation Excerpt :Patients with FND are encountered commonly in clinical practice; their symptoms can be disabling, and the condition is challenging to manage.2 Many psychological theories have been invoked to explain the etiology of FND, none more prominent than Sigmund Freud's model of “hysteria” that focused on the repression of painful/traumatic experiences and “conversion” into physical symptoms.3 More contemporary neuropsychiatric approaches to FND have moved away from psychodynamically-based frameworks because many patients with FND disavow a relationship with psychological factors and clinicians raise concerns that an undue emphasis on such factors can be counterproductive with regard to management.4