Hysterical neurosis or hysteria is a condition in which there are symptoms and signs of disease with three characteristics:
1 They occur in the absence of physical pathology.
2 They are produced unconsciously.
3 They are not caused by overactivity of the sympathetic nervous system.
The lifetime prevalence has been estimated at 3-6 per 1000 in women, with a lower incidence in men. Most cases begin before the age of 35 years and it occurs rarely after 40 years. However, hysterical symptoms commonly occur after this age as part of some other disorder.
The various symptoms are usually divided into dissociative and conversion categories (Table 19.24). The term dissociative indicates the seeming dissociation between different mental activities, and covers such phenomena as amnesia, fugues, somnambulism and multiple personality. The term conversion derives from Freud’s theory that mental energy can be converted into certain physical symptoms. Such symptoms include paralysis, fits, sensory loss, aphonia, blindness, deafness, disorders of gait and abdominal pain.
The main characteristics of hysterical symptoms include the following:
• They are not produced wilfully or deliberately.
• They often reflect a patient’s ideas about illness.
• They may imitate symptoms of a relative/friend who has been ill.
• There are obvious discrepancies between hysterical signs and symptoms and those of organic disease.
• The symptoms usually confer some advantage on the patient (so-called secondary gain).
• They are often accompanied by less than the expected amount of emotional distress (belle indifference).
Hysterical amnesia commences suddenly. Patients are unable to recall long periods of their lives and may even deny any knowledge of their previous life or personal identity. A proportion who present thus have concurrent physical disease, especially epilepsy, multiple sclerosis or the effects of head injury. In a hysterical fugue, patients not only lose their memory but wander away from their sual surroundings, and when found deny all memory of their whereabouts during this wandering. Apart from hysteria, fugue states are associated with epilepsy, depression and alcohol abuse. Hysterical pseudodementia involves a memory loss and behaviour that initially suggest severe and generalized intellectual deterioration. Simple tests are answered wrongly but in such a way as to suggest that the correct answer is in the patient’s mind.
The Ganser syndrome is a rare condition composed of four features:
1 The giving of approximate answers (i.e. almost correct)
2 Physical or mental symptoms of hysteria
4 Clouding of consciousness
The relationship of somnambulism, or sleep-walking, to other forms of hysteria is unclear, but its similarity to the condition arising through hypnosis suggests that it may be a form of dissociation.
In multiple personality, there are rapid alterations between two patterns of behaviour, each of which is forgotten by the patient when the other is present. Each personality appears to be a complex and integrated set of emotional responses. The condition is rare. A variation of hysteria is the epidemic or mass hysteria, seen mainly in institutions for girls or young women, in which the combined effects of suggestion and shared anxiety produce explosive outbreaks of sickness or other disturbed behaviour. Another variant is Briquet’s syndrome, which is said only to occur in women, follows an intractable course, runs in families and involves multiple somatic symptoms occurring in several different bodily systems for which no organic cause is found.
Patients with a hysterical personality are those who exhibit a particular set or cluster of personality traits that include a remarkable egocentricity, a manipulative skill and an ability to attract attention to themselves by dramatic initiatives, often of a sexually provocative or emotionally exaggerated fashion. Their emotions are described as shallow and labile and there is an ‘acting’ quality attached to much of what they do and say. Their personal relationships are often transient yet full of dramatic intensity. Such individuals, when they do develop genuine physical illness, may be dubbed hys.teric.al because they describe their symptoms and complaints in such an exaggerated manner.
The diagnosis of hysteria may be erroneously made because of:
UNDETECTED PHYSICAL DISEASE. The symptoms may be those of an, as yet, undetected physical disease, e.g. globus hystericus (see p. 183) may actually be difficulty in swallowing secondary to an oesophageal cancer.
UNDETECTED BRAIN DISEASE (e.g. a tumour in the frontal lobe or early dementia) may in some way produce hysterical symptoms.
PHYSICAL DISEASE may provide a non-specific stimulus to hysterical elaboration or an exaggeration of symptoms by a somewhat dramatic or histrionic patient.
Physical disease must be excluded. The di.stinction between hysteria and malingering (i.e. the conscious pretence of illness) should be considered but is difficult to make.
Studies have been inconclusive but reported rates in relatives of affected patients do appear higher than in the general population.
Central to the theory of psychoanalysis is the view that hysteria is the result of emotionally charged ideas lodged in the unconscious at some point in the past. Symptoms are explained as the combined effects of repression and the conversion of psychic energy into physical channels.
Hysteria is sometimes associated with physical disease. However, it also quite clearly occurs in the absence of such pathology.
Psychotherapy of a psychodynamic kind often un overs striking memories of early childhood sexual expenences and other problems relevant to the patient’s presenting condition. Psychodynamic psychotherapy is derived from psychoanalysis and is based on a number of key analytical concepts. These include Freud’s ideas about psychosexual development, mechanisms of defence (including repression, projection and denial), free association as the method of recall, and the therapeutic techniques of interpretation including that of transference, defences and dreams. Such therapy usually involves once-weekly 50- min sessions, the length of treatment varying between 3 months and 2 years. The long-term aim of such therapy is twofold: symptom relief and personality change.
Psychodynamic psychotherapy is classically indicated in the treatment of the neuroses and personality disorders, but to date there is a lack of convincing evidence concerning its superiority over other forms of treatment. Simpler forms of psychotherapy involving more straightforward reassurance and explanation, greater involvement of the therapist in the actual sessions, and the elimination of factors that appear to reinforce symptoms, are as effective and probably more so than the more complex and time-consuming forms. Group psychotherapy involving six to eight patients, which facilitates the development of confidence, the recollection of painful experiences and the growth of social and interpersonal skills, is also useful in a number of neurotic and personality disorders, although its usefulness in hysterical neuroses is doubtful.
Abreaction brought about by hypnosis or by intravenous injections of small amounts of amyls barbitone with or without amphetamine may produce a dramatic, if short-lived, recovery. In the abreactive state, the patient is encouraged to relive the stressful events that provoked the hysteria and to express the accompanying emotions, i.e. to abreact. Such an approach has been useful in the treatment of acute hysterical neuroses in wartime, but appear to be of much less value in civilian life.
Drug treatments have no part to play in hysteria unless the symptoms are secondary to a depressive illness or anxiety neurosis requiring treatment.
Most cases of recent onset recover quickly. Those that last longer than a year are likely to persist for a very long time.
This is a neurotic disorder in which the conspicuous features are an excessive concern with one’s health in general, in the integrity and functioning of some part of one’s body or, less frequently, one’s mind. Hypochondriasis may coexist with actual physical disease; the important point is that the patient’s concern is out of all proportion and is unjustified. The symptoms of hypochondriasis occur in a variety of psychiatric disorders, particularly in depression and anxiety. When hypochondriacal tendencies are lifelong, the condition is more usually termed hypochondriacal personality.
Reaction to severe stress
Acute stress reactions occur in individuals without any other apparent psychiatric disorder in response to exceptional physical and/or psychological stress. While severe, such reactions usually subside within hours or days. The stress may be an overwhelming traumatic experience (e.g.accident, battle, physical assault, rape) or an unusually sudden change in the social circumstances of the individual, such as multiple bereavement. Individual vulnerability and coping capacity playa role in the occurrence and severity of acute stress reactions, as evidenced by the fact that not all people exposed to exceptional stress develop symptoms. These symptoms show considerable variation but usually include an initial state of ‘daze’ with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli and disorientation. This state may be followed either by further withdrawal from the surrounding situation to the extent of a dissociative stupor or by agitation and overactivity.
Autonomic signs of panic anxiety, including tachycardia, sweating and hyperventilation, are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus and disappear within 2-3 days.
Post-traumatic stress disorder (PTSD)
This arises as a delayed and/or protracted response to a stressful event or situation of an exceptionally threatening nature and likely to cause pervasive distress in almost anyone. Causes include natural or human disasters, war, serious accident, witnessing the violent death of others, being the victim of sexual abuse, rape, torture, terrorism or hostage-taking. Predisposing factors such as personality traits or previous history of psychiatric illness may lower the threshold for the development of the syndrome
or may aggravate its course. They are, however, neither necessary nor sufficient to explain its occurrence.
Typical symptoms of PTSO include:
• ‘Flashbacks’ -the repeated reliving of the trauma in the form of intrusive memories or dreams
• Intense distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma
• Avoidance of activities and situations reminiscent of the trauma
• Emotional blunting or ‘numbness’
• A sense of detachment from other people
• Autonomic hyperarousal with hypervigilance, an enhanced startle reaction and insomnia
• Marked anxiety and depression and, occasionally, suicidal ideation
The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may show a chronic course over many years and a transition to an enduring personality change. Treatment involves exploration of memories of the traumatic event, relief of associated symptoms and counselling.