[Hysteria laryngea; First thesis in the Netherlands on hysteria (1849)]

BACKGROUND

With the help of textbooks we may trace back the genesis of the concept functional neurological disorder in the Netherlands to the second half of the 19th century.
AIM: To extend this history to the first half of the 19th century.
METHOD: To study the thesis written in Latin defended in 1849 by F.S.R. Frima.
RESULTS: Frima described a 24-year-old woman who in 1849 was admitted to a hospital in Groningen with the diagnosis hysterical attacks and hysteria laryngea. He compared this case with five similar cases from the international literature in which one of the authors used the term neurosis laryngis. A physician of the hospital changed the diagnose from hysterical attacks to epilepsy. After the description of his case Frima abandoned the name hysteria laryngea and used neurosis laryngis instead. He described neurosis laryngis as a nervous disorder without pathological abnormalities around the pharynx, caused by haemorrhages, intestinal diseases, affections of the soul ('pathemata animi') and, in women the main cause, hysteria. Frima did not use the terms 'real' symptom, somatic or mental disorder.
CONCLUSION: Symptoms of neurosis laryngis may occur in the absence of hysteria. Frima made no distinction between real or not real symptoms and not between somatic and mental disorders.

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Zusammenfassung. Dieser Mini-Review präsentiert die nosologische Entwicklung der Hysterie. Ein Schwerpunkt liegt bei der Freud’schen Konzeptualisierung der hysterischen Disposition wie der Konversion psychischer Fantasien in Körpersymptome, ferner werden aktuelle Hysteriemodelle vorgestellt und diskutiert, weshalb die Hysterie heute nosologisch nicht mehr relevant zu sein scheint, gleichwohl aber Patienten weiterhin an hysterischen Symptomen leiden. Unabhängig von der jeweiligen Perspektive ist das Leid der Patienten ernstzunehmen: ihre existentiellen Ängste vor Ablehnung, Ausgeschlossensein und mangelnder Liebe, und ihr körpersymbolisches Ringen um Zuwendung und Hilfe. Die Hysterie-Debatte wird durch aktuelle neurobiologische Befunde abgerundet, welche die psychoanalytischen Konzepte aus heutiger Perspektive bestätigen. Der Artikel schliesst mit Hinweisen zur ärztlichen Grundhaltung und dem psychotherapeutischen Vorgehen.

Functional limb weakness and paralysis

Functional (psychogenic) limb weakness describes genuinely experienced limb power or paralysis in the absence of neurologic disease. The hallmark of functional limb weakness is the presence of internal inconsistency revealing a pattern of symptoms governed by abnormally focused attention. In this chapter we review the history and epidemiology of this clinical presentation as well as its subjective experience highlighting the detailed descriptions of authors at the end of the 19th and early 20th century. We discuss the relevance that physiological triggers such as injury and migraine and psychophysiological events such as panic and dissociation have to understanding of mechanism and treatment. We review many different positive diagnostic features, their basis in neurophysiological testing and present data on sensitivity and specificity. Diagnostic bedside tests with the most evidence are Hoover's sign, the hip abductor sign, drift without pronation, dragging gait, give way weakness and co-contraction.

'Hysteria' today and tomorrow

'Hysteria' (conversion disorder) remains in modern humanity and across cultures, as it has for millennia. Advances today in tools and criteria have afforded more accurate diagnosis, and advances in treatments have empowered patients and providers, resulting in a renewed interest in somatoform disorders. Future progress in understanding mechanisms may be influenced by developments in functional neuroimaging and neurophysiology. No animal model exists for somatoform symptoms or conversion disorder. Despite the absence of a known molecular mechanism, psychotherapy is helping patients with conversion disorder to take control of their symptoms and have improved quality of life, shedding light on what was once an enigma.

[Observations on the origins of the core thesis in Freud's "comparative study" of organic and hysterical paralyses (1893)]

Proceeding from two discrepant published transcriptions of a letter of Charcot to Freud, the author discusses the historical and theoretical background of Freud's paper. She emphasizes the influence of Charcot on Freud's early theory formation, as opposed to that of Janet.

The origins of factitious disorder

Factitious disorder is the deliberate simulation of illness for the purpose of seeking the sick role. It is a 20th-century diagnosis, though the grounds for its introduction are uncertain. While previous authors have considered the social changes contributing to growth in the disorder, this article looks at some of the pressures on doctors that may have created the diagnostic need for a disorder between hysteria and malingering. The recent history of those disorders suggests that malingering would no longer be acceptable when applied to the potentially larger numbers involved in workers' compensation or in mass conscription. Equally, the absolution given to hysteria on the basis of the Freudian subconscious would survive only as long as that model retained credibility. Growing egalitarianism and changing doctor-patient relationships in the 20th century would no longer tolerate a sharp division between culpable malingering and exculpated hysteria, which may previously have been made on grounds of class or gender. They would contribute to the need for a mediating diagnosis, such as factitious disorder.

[Pierre Janet's views on the etiology, pathogenesis and therapy of dissociative and conversion disorders ("hysterias")]

Pierre Janet (1859-1947) is one of those more or less forgotten authors whose approach differed significantly from Freud's psychoanalysis. In the first part of this paper, Janet's conception of hysteria is discussed and his place in French psychiatry described. Different aspects of Janet's diathesis-stress-approach are presented (particularly his important pathogenic concept of fixed ideas) which refer not only to a conception of hysteria, but also to traumatic (stress) disorders and other psychological disturbances. The second part of the paper details the varieties of Janetian therapeutic treatments for these disorders: the 'liquidation' of fixed ideas by hypnosis and suggestion, confrontation techniques which resemble contemporary cognitive behavioural approaches, and special cognitive ("logagogic") interventions. Finally, we also discuss the various treatment strategies Janet proposes for dealing with symptoms, such as asthenic or depressive states, from his psycho-economic perspective.

Paul Blocq and (psychogenic) astasia abasia

The Greek term astasia-abasia literally translates to mean inability to stand and to walk. Although today we would classify the syndrome as a conversion disorder, it was considered a separate disease by Paul Blocq (1860-1896), who described this phenomenon as the inability to maintain an upright posture, despite normal function of the legs in the bed. Paul Blocq's original 1888 articles on astasia abasia were read, partly translated from French to English, and the cases were summarized. A review of a selection of the literature following Blocq's description on astasia abasia was performed. Present day literature was consulted as well. Blocq reviewed what was known about astasia abasia in two papers. Although he was the first to use the combined term astasia abasia, he referred to similar descriptions of Charcot, Richer, Mitchell, Jaccoud, Roméi, and Erlenmeyer. Blocq's contribution was in compiling the experiences and observations of preeminent 19th century neurologists. He recognized that paralysis, jumping, fits, tremor, and bizarre behavior could all be associated with the syndrome. He distinguished the disorder from hysteria. Moreover, he presented a formal delineation of the gait disorder and provided a pathophysiologic concept. Prognosis was considered favorable. Paul Blocq directed attention to psychogenic gait disorders by publishing a small case series on astasia abasia. Today, these case descriptions would be likely considered cases of conversion or psychogenic gait disorder, with or without other conversion/psychogenic movement disorders.

J.-M. Charcot and simulated neurologic disease: Attitudes and diagnostic strategies

BACKGROUND

Neurologists have long wrestled with the diagnosis of elaborated or feigned disease. Studies have not focused on early techniques utilized to diagnose malingering.

OBJECTIVE

To analyze cases of purposeful neurologic malingering among patients treated by the 19th century neurologist J.-M. Charcot, describe his attitudes, and study his methods to separate malingering from primary neurologic diseases.

METHODS

A study was conducted of Charcot's printed and original documents from the Bibliothèque Charcot, Paris, and added documents on American neurology.

RESULTS

Charcot recognized that purposeful simulation occurred in isolation as well as in established neurologic disorders. Charcot was strict with subjects motivated by greed or spite, but showed forbearance and wonder in those who created illness as "art for art's sake." Charcot developed diagnostic equipment that measured inspiratory depth and muscle activity as a strategy to identify malingerers. His approach strikingly contrasted with contemporary military medical treatises on malingering and S.W. Mitchell's civilian neurologic approaches that unmasked patients through more aggressive strategies.

CONCLUSION

Charcot provided an academically professional approach to the assessment of neurologic malingering, with a stern, often patronizing attitude, but without categorical condemnation. His diagnostic techniques are echoed by contemporary approaches and emphasized an attention to enhanced and inconsistent patterns of behaviors by malingerers.

[Is Akinesia algera by Paul Julius Möbius (1891) as a coenästhetic appearance a still up-to-date phenomenon?]

OBJECTIVE

Considering as example Akinesia algera - postulated in 1891 as a disease by Paul Julius Möbius, the relevance for diagnosing body-related mental disturbances will be demonstrated .

METHOD

Relevant original works of Möbius and of some of his well known contemporaries for instance Kraepelin, Binswanger, Erb were explored. The correlation of the described phenomenon to current textbook doctrine has been attempted.

RESULTS

Möbius, case histories, described as Akinesia algera, can be subsumed under the typology of coenästhetic schizophrenia.

CONCLUSION

Akinesia algera is by primary source to be evaluated as a coenästhetic symptom and remains in daily practice a diagnostic challenge.

Hysterical conversion and brain function

Hysterical conversion disorders represent "functional" or unexplained neurological deficits such as paralysis or somatosensory losses that are not explained by organic lesions in the nervous system, but arise in the context of "psychogenic" stress or emotional conflicts. After more than a century of both clinical and theoretical interest, the exact nature of such emotional disorders responsible for hysterical symptoms, and their functional consequences on neural systems in the brain, still remain largely unknown. However, several recent studies have used functional brain imaging techniques (such as EEG, fMRI, PET, or SPECT) in the attempt to identify specific neural correlates associated with hysterical conversion symptoms. This article presents a general overview of these findings and of previous neuropsychologically based accounts of hysteria. Functional neuroimaging has revealed selective decreases in the activity of frontal and subcortical circuits involved in motor control during hysterical paralysis, decreases in somatosensory cortices during hysterical anesthesia, or decreases in visual cortex during hysterical blindness. Such changes are usually not accompanied by any significant changes in elementary stages of sensory or motor processing as measured by evoked potentials, although some changes in later stages of integration (such as P300 responses) have been reported. On the other hand, several neuroimaging results have shown increased activation in limbic regions, such as cingulate or orbitofrontal cortex during conversion symptoms affecting different sensory or motor modalities. Taken together, these data generally do not support previous proposals that hysteria might involve an exclusion of sensorimotor representations from awareness through attentional processes. They rather seem to point to a modulation of such representations by primary affective or stress-related factors, perhaps involving primitive reflexive mechanisms of protection and alertness that are partly independent of conscious control, and mediated by dynamic modulatory interactions between limbic and sensorimotor networks. A better understanding of the neuropsychobiological bases of hysterical conversion disorder might therefore be obtained by future imaging studies that compare different conversion symptoms and employ functional connectivity analyses. This should not only lead to improve clinical management of these patients, but also provide new insights on the brain mechanisms of self-awareness.

Lewis and Clark treat a case of paralysis: speculation on the etiology of the problem

In their monumental journey across North America and back, the explorers Lewis and Clark encountered and treated a Native American Chief with flaccid paralysis of about five years duration. The etiology of the paralysis is unclear from the historical sources. Intracranial, spinal cord, neuropathic, neuromuscular and muscular diagnoses are possible. The diagnosis that appears best to fit the case, however, is conversion disorder. In spite of limited diagnostic and treatment resources, the unfortunate man was apparently treated successfully.

[Somatoform disorders. Historical development and modern diagnostic conceptualization]

Patients with "medically unexplained" bodily symptoms form a major group in the medical care system. Diagnostic and therapeutic problems very often arise, and the concept of "somatization" promotes a better understanding of this patient group. Important historical stages in the development toward a modern diagnostic classification of somatoform disorders are outlined. A critical comment on the diagnostic approaches according to DSM-IV and ICD-10 follows.

Epidemic hysteria in Virginia: the case of the phantom gasser of 1933-1934

OBJECTIVE

We studied an example of epidemic hysteria occurring outside a closed community and involving fear of being "gassed." The description presented is that of a previously unrecorded case of epidemic hysteria in the state of Virginia during 1933-1934.

DATA SOURCES

Data were gathered from contemporary newspaper accounts.

CONCLUSION

The case of the Virginia "gasser" is one in a long series of epidemic hysteria incidents during the 20th century, coinciding with heightened awareness of environmental pollution and triggered by imaginary or exaggerated contamination threats. A recommendation is provided on how physicians should approach such episodes.

Hysterical conversion. I: A history

'Hysterical conversion' dates from a century before Freud, from an important attempt to rationalise the nosological status of hysteria. Freud's own concept of 'conversion' followed as a quite independent synthesis of 19th-century medical thinking on the subject. Subsequent analytical usage of 'conversion' which has influenced the description of hysterical syndromes within mainstream psychiatry, has not been consistent with Freud's own.

The case of Anna O.: a neuropsychiatric perspective

Previous interpretations have not adequately explained the presence of focal neurological signs, delirium, and a variety of highly specific disturbances of perception, language, and sensorium in the case of Anna O. Examination of the neurological details suggests that Anna suffered from complex partial seizures exacerbated by drug dependence, and that she developed conversion symptoms patterned after the preexisting organic pathology. Hysterical conversion symptoms that mimic ictal events are not uncommon in psychomotor epilepsy. Recent neuropsychiatric models of hysteria are remarkably similar to the hypnoid states theory Breuer formulated, based on his observation of Anna O. The hypothesis presented here does not conflict with previous psychodynamic interpretations. I submit that it was the development of a conversion disorder patterned on actual organic phenomena, which highlighted for Breuer and Freud the "psychical mechanism" of somatic symptoms, thus paving the way for the important psychodynamic discoveries for which the case is remembered.

Whose hysteria: Briquet's, Janet's or Freud's?

Somatisation disorder (Briquet's syndrome) is a recent addition to psychiatric nosology. It represents an attempt to describe a syndrome of 'hysteria', the term initially applied to this polysymptomatic disorder by Guze and his colleagues. The manner of identification of this syndrome, however, has been the subject of criticism. This brief review suggests that the ideas of Janet, who worked at Salpetriere 30 to 40 years after Briquet, may provide a more precise approach to diagnosis. Furthermore, his hypotheses about predisposition to this disorder are seen to offer a preliminary way towards its understanding. Recent experimental evidence lends some support to Janet's hypotheses.

Psychogenic regional sensory and motor disorders alias hysteria

In 1959 I suggested that the term ‘hysterical pain’ be replaced by the term ‘psychogenic regional pain’. Now, with this innovation having proved useful, I am suggesting that the term ‘psychogenic and regional' replace the term ‘hysterical' for the following sensory and motor symptoms and signs: pain, tenderness, sensory deficits, motor deficits of power, movement and posture, ataxias, involuntary movements and fits. These are the sensory and motor phenomena which have been called ‘hysterical’ or due to ‘conversion hysteria’ or due to ‘conversion reaction’.

‘Psychogenic' means being evoked by psychical factors. ‘Regional' indicates a bodily region of contiguous parts as a strip, area or volume with boundaries defined by psychical circumstances. This is a bodily region of psychological reference with all the parts in the contiguous locality co-operating together in regional behaviour that has psychical significance.

By dropping the term ‘hysteria' from all these symptoms and signs we avoid the confusing fact that the phenomena occur in all sorts of psychoses and neuroses and are not confined to any clinical condition which might be called ‘hysteria’. The phenomena also often occur in persons who do not have a personality which could be called ‘hysterical’. Furthermore, persons with ‘hyterical personalities' do not necessarily develop such symptoms and signs. Incidentally the term ‘psychogenic regional' releases these phenomena from any implication that they are necessarily ‘conversion' reactions. While a conversion process may be one way such sensory and motor features come about, the conversion mechanism may produce other symptoms and signs and the sensory and motor signs may be produced by other processes than conversion.

The term ‘psychogenic regional' has the advantage that it leaves these symptoms and signs as natural phenomena, defined and denoted descriptively, free of any concept of specific disease entity or psychodynamic process. By this means the natural history of these sensory and motor features can be elucidated independently of other considerations. By the same means such concepts as hysteria, conversion, dissociation, symbolization and regression can be varied from time to time without disturbing the identity of these signs. With the new clinical, neurophysiological and psychosomatic knowledge we can expect the usefulness of the term ‘hysteria' to decline and the meaning of the term ‘conversion' to be extended. We can also expect new knowledge of the representation at bodily sites by remote localization, by symbolization, by somatic hallucination or by somatic excitation or inhibition. We can expect new knowledge of the involuntary action of the voluntary nervous system and of the voluntary and behavioural action of the involuntary autonomic nervous system. The role of affective, schizophrenic, regressed, dissociated and disintegrated states is relevant to much of the psychopathology and calls for attention. The new neurophysiology of behaviour will be likely to provide models which will help us to understand how somatic analogues can be related to psychic experience as non-verbal body language.

In the past it has been a matter of historical accident that these sensory and motor symptoms and signs have been called ‘hysterical' and related to ‘hysteria’. It is now recommended that such terms be dropped and that these symptoms and signs be given the simple descriptive designation ‘psychogenic regional’. With this, we should speak of ‘psychogenic regional' pain, tenderness, anesthesia, paralysis, fixed posture, ataxia, involuntary movement or fit or convulsion. When such symptoms and signs occur with ‘la belle indifférence’ they can be denoted as ‘complacent re-actions’. This will make for accuracy in clinical descriptions and clarity in thinking of pathological processes.