Chapter 4 - Freud's hysteria and its legacy

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Abstract

Though Freud was himself interested in neurologic disorders, the model of hysteria he developed – of the repression of painful experiences, and their conversion into physical symptoms – made the disorder psychiatric, as the increasingly complex explanations came to rely on the “meaning” of events, which could not easily be understood neurologically. This evolved to become a prototype for psychiatric illness more broadly, a model which, though challenged by the First World War, enjoyed great success, notably in the USA, dominating psychiatric thinking for most of the 20th century. Concerns about the empiric basis for his ideas latterly led to a rapid decline in their importance, however, exemplified by 1980's “etiologically neutral” DSM-III. Hysteria, now renamed conversion disorder, retained its Freudian explanation for another 30 years, but as psychiatry lost its faith in Freud, so psychiatrists stopped seeing the disorder he had made theirs, and returned it once more to neurology.

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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