What Has Happened to Hysteria?

This article traces the history of the diagnosis of hysteria from the earliest medical formulations in the 17th century to the present, including the presence of this diagnosis in the five iterations of the Diagnostic Statistical Manual (DSM) of the American Psychiatric Association. Several different types of hysteria are discussed, with alternative causal explanations. Research focusing on this disorder is summarized.

La histeria clásica y moderna: una visión sinóptica Parte II Diagnóstico / Classic and modern hysteria: a synoptic view. Part II Diagnosis

Todo diagnóstico de un problema descubierto lleva implícito un proceso de análisis y síntesis. Todavía no se ha logrado encontrar una clara definición de la histeria, precisamente por su "psicoplasticidad", es decir, por la infinidad de expresiones clínicas en que se puede presentar. Además su eliminación de los códigos diagnósticos la fragmentó en diversos síndromes o conjuntos sintomáticos. El psicoanálisis, asociado al concepto, fue desperfilado por la psiquiatría americana con el advenimiento de la investigación biológica sobre trastornos mentales y nuevos descubrimientos como los sistemas de neurotransmisores. Quedaron atrás los criterios de Feighner, que abarcaban los diagnósticos de neurosis de ansiedad, neurosis obsesivo-compulsiva, neurosis fóbica, histeria. Se analiza clasificaciones CIE y DSM, en las que se puede rastrear la histeria. Palabras claves: histeria, neurosis, diagnóstico, CIE-10.

Every diagnosis of a discovered problem implies a process of analysis and synthesis. A clear definition of hysteria has not yet been found, precisely because of its "psychoplasticity", that is, by the infinity of clinical expressions in which it can be presented. In addition its elimination of the diagnostic codes fragmented it in diverse syndromes or symptomatic sets. Psychoanalysis, associated with the concept, was unburied by American psychiatry with the advent of biological research on mental disorders and new discoveries such as neurotransmitter systems. Feighner's criteria, which included diagnoses of anxiety neurosis, obsessive-compulsive neurosis, phobic neurosis and hysteria, were left behind. We analyze CIE and DSM classifications, in which hysteria can be traced.

Differentiation between seizure and hysteria in a tenth-century persian text: Hidayat of al-Akhawayni (d. 983 AD).

Although hysteria is associated largely with the nineteenth century, we find the subject treated in a tenth-century Persian medical text, the Hidayat al-Muta`allemin Fi al-Tibb [A Guide to Medical Learners] by al-Akhawayni Bukhari (d. 983 AD), a prominent physician in the Persian history of medicine. In this article, we discuss al-Akhawayni's views on seizure and hysteria and his differentiation between the two conditions, and we place it in a historical context.

Reconsiderando la clasificación psicopatológica desde el punto de vista psicoanalítico-relacional. Lo histérico/ histriónico como modelo / The psychopathological classification revisited from the psychoanalytic-relational standpoint. The hysterical / histrionic as a model

En el momento presente la clasificación psicopatológica destaca por su gran complejidad y confusión, que da lugar a incontables debates. Realizamos una indagación en este terreno partiendo del concepto de "histeria" por tratarse de un diagnóstico proteico y esquivo, que en cierta medida se solapa con el más de moda, pero no menos confuso, "trastorno límite", y con otros trastornos, como la psicosis, lo que hace de él un caso paradigmático dentro de la discusión diagnóstica en general y psicoanalítica en particular. Su presentación multiforme posiblemente ha llevado, en tiempos de positivismo dominante, a su desprestigio y práctica eliminación de los sistemas de clasificación oficiales. Sin embargo, cuando hablamos de "diagnóstico" al referirnos a la personalidad no debemos entenderlo tanto en el sentido de agrupación de signos y síntomas sino como la valoración y descripción de esas pautas complejas de comportamiento cuyo nivel privilegiado de análisis es el de la relación interpersonal, relación que cuando se constituye como área principal de desadaptación permite hablar de "Trastornos de la personalidad". Concluimos que, a pesar de su complejidad, la personalidad histriónica (PH) es un patrón relacional que conserva una presencia muy importante en la clínica psicoterapéutica, en salud mental y en otros ámbitos de la salud, y que precisamente su adecuada valoración y diferenciación de otros patrones relacionales permitirá afinar los sistemas clasificatorios futuros (AU)

Nowadays psychopathological classification is characterized by a great complexity and confusion, which produces innumerable debates. We make here an inquiry focusing on the concept of "hysteria" as starting point, for it is an elusive and protean diagnostic term, which overlaps to some extent to the more fashionable - but not less fuzzy - one of "borderline disorder", as well as to other disorders, the psychosis for instance, making it a paradigmatic case inside the general discussion in psychopathology and psychoanalysis. In these times of positivist thinking the multiform presentation of hysteria has led to its discredit and virtual elimination from the official classification systems. However, when we use the word "diagnostics" for the personality we should not take it as a mere aggregate of signs and symptoms but as the appraisal and description of those complex behavioral patterns whose privileged level of analysis is the interpersonal relationship. When the relationship is the main area of maladjustment constitutes just what is called "personality disorder". We reach the conclusion that histrionic personality is, in spite of its complexity, a relational pattern with a huge presence in the psychotherapeutic clinic, in mental health and in other domains of the health care system, and that its accurate assessment and differentiation from other patterns will improve future classification systems (AU)

A reconceptualization of the somatoform disorders.

Since its introduction in DSM-III, the Somatoform Disorders category has been a subject of controversy. Critics of the grouping have claimed that it promotes dualism, assumes psychogenesis, and that it contains heterogeneous disorders that lack validity. The history of these disorders is one of shifting conceptualizations and disputes. A number of changes in the classification have been proposed, but few address problems that arise with the current formulation. The authors propose a dimensional reconceptualization based on marked and persistent somatic distress and care-eliciting behavior. This formulation is based on the interpersonal model of somatization. The authors propose testing of this conceptualization and indicate how this might be done.

Dissociative disorders and other psychopathological groups: exploring the differences through the Somatoform Dissociation Questionnaire (SDQ-20)

OBJECTIVE: The Somatoform Dissociation Questionnaire is a self-report questionnaire that has proven to be a reliable and valid instrument. The objectives of this study were to validate the Portuguese version and to determine its capability to distinguish patients with dissociative disorders from others with psychopathological disorders. METHOD: 234 patients answered the translated version of Somatoform Dissociation Questionnaire. The Portuguese Dissociative Disorders Interview Schedule was used to validate clinical diagnosis. Patients with dissociative disorder (n = 113) were compared to a control group of 121 patients with various anxiety and depression disorders. RESULTS: Reliability measured by Cronbach's a was 0.88. The best performance of the Portuguese form was at a cut-off point of 35, which distinguishes between dissociative disorder and neurotic disorders with a good diagnostic efficacy (sensitivity = 0.73). The somatoform dissociation was significantly more frequent in dissociative disorder patients, conversion disorder patients and post-traumatic stress disorder patients. CONCLUSIONS: These findings suggest that dissociative disorders can be differentiated from other psychiatric disorders through somatoform dissociation. The Portuguese version of the Somatoform Dissociation Questionnaire has fine psychometric features that sustain its cross-cultural validity.

OBJETIVO: O objetivo deste estudo foi adaptar, validar e determinar a confiabilidade da versão portuguesa do Somatoform Dissociation Questionnaire e determinar a sua capacidade de discriminar doentes que dissociam de outros doentes. Método: O Somatoform Dissociation Questionnaire foi traduzido para o português e retrovertido para o inglês de forma a garantir a sua base conceitual. Os sujeitos responderam também à versão portuguesa do Dissociative Disorders Interview Schedule de forma a validar o seu diagnóstico clínico. O estudo incluiu 234 sujeitos divididos entre 113 doentes com patologias dissociativas e 121 doentes com outras patologias do foro ansioso e depressivo. RESULTADOS: O Somatoform Dissociation Questionnaire versão portuguesa mostrou o seu melhor desempenho no ponto de corte 35, apresentando uma sensibilidade de 0,73. O alfa de Cronbach revelou uma consistência interna de 0,88. A dissociação somatoforme foi significativamente mais freqüente nos doentes com patologias dissociativas, patologias conversivas e distúrbio de stress pós-traumático. CONCLUSÕES: A versão portuguesa do Somatoform Dissociation Questionnaire mostrou-se um instrumento útil para discriminar doentes com patologia de foro dissociativo de outros doentes.

Dissociative disorders and other psychopathological groups: exploring the differences through the Somatoform Dissociation Questionnaire (SDQ-20).

OBJECTIVE: The Somatoform Dissociation Questionnaire is a self-report questionnaire that has proven to be a reliable and valid instrument. The objectives of this study were to validate the Portuguese version and to determine its capability to distinguish patients with dissociative disorders from others with psychopathological disorders. METHOD: 234 patients answered the translated version of Somatoform Dissociation Questionnaire. The Portuguese Dissociative Disorders Interview Schedule was used to validate clinical diagnosis. Patients with dissociative disorder (n = 113) were compared to a control group of 121 patients with various anxiety and depression disorders. RESULTS: Reliability measured by Cronbach's a was 0.88. The best performance of the Portuguese form was at a cut-off point of 35, which distinguishes between dissociative disorder and neurotic disorders with a good diagnostic efficacy (sensitivity = 0.73). The somatoform dissociation was significantly more frequent in dissociative disorder patients, conversion disorder patients and post-traumatic stress disorder patients. CONCLUSIONS: These findings suggest that dissociative disorders can be differentiated from other psychiatric disorders through somatoform dissociation. The Portuguese version of the Somatoform Dissociation Questionnaire has fine psychometric features that sustain its cross-cultural validity.

The clinical characteristics of possession disorder among 20 Chinese patients in the Hebei province of China.

OBJECTIVE: This paper describes the clinical characteristics of 20 hospitalized psychiatric patients in the Hebei province of China who believed they were possessed. METHODS: A structured interview focused on clinical characteristics associated with possession phenomena was developed and administered to 20 patients at eight hospitals in the province. All patients had been given the Chinese diagnosis of yi-ping (hysteria) by Chinese physicians before being recruited for the study. RESULTS: The subjects' mean age was 37 years. Most were women from rural areas with little education. Major events reported to precede possession included interpersonal conflicts, subjectively meaningful circumstances, illness, and death of an individual or dreaming of a deceased individual. Possessing agents were thought to be spirits of deceased individuals, deities, animals, and devils. Twenty percent of subjects reported multiple possessions. The initial experience of possession typically came on acutely and often became a chronic relapsing illness. Almost all subjects manifested the two symptoms of loss of control over their actions and acting differently. They frequently showed loss of awareness of surroundings, loss of personal identity, inability to distinguish reality from fantasy, change in tone of voice, and loss of perceived sensitivity to pain. CONCLUSIONS: Preliminary findings indicate that the disorder is a syndrome with distinct clinical characteristics that adheres most closely to the DSM-IV diagnosis of dissociative trance disorder under the category of dissociative disorder not otherwise specified.

Psychogenic (reactive) and hysterical psychoses: a cross-system reliability study.

The aim of this study was to investigate the concepts of reactive and hysterical psychoses and how they are classified in standardized diagnostic systems. To this end we identified all of the patients who had been admitted to a psychiatric in-patient unit and diagnosed as suffering from psychogenic psychosis, reactive psychosis, hysterical psychosis or hysteria, using ICD-9 criteria. The case notes of these patients were then re-examined and diagnoses reached using DSM-III-R, DSM-IV and ICD-10 criteria and the Present State Examination (PSE)/CATEGO computer program. The objective of this study was to evaluate the agreement between the diagnoses of reactive and hysterical psychosis obtained using ICD-9 criteria with those obtained using the DSM-III-R, DSM-IV, ICD-10 and PSE diagnostic systems. A total of 67 case notes were identified in which the above diagnoses had been made: 27 cases with ICD-9 'hysteria' and 26 cases with 'other reactive and not otherwise specified psychoses'. Using the DSM-III-R criteria, 27 cases were diagnosed as psychotic disorder NOS, 12 as brief reactive psychosis and 11 as bipolar disorder. Using the DSM-IV criteria, 21 cases were diagnosed as psychotic disorder NOS, 11 as mood disorder, 7 as brief disorder without stressor, and 12 as brief disorder with stressor. Using the ICD-10 criteria, 18 cases were diagnosed as unspecified non-organic psychosis, 12 as mood disorder, 10 as acute and transient psychotic disorder without stressor and 13 as acute and transient psychotic disorder with stressor. Using the PSE/CATEGO program, the most common diagnoses were class 'S' schizophrenia (17), class 'P?' uncertain psychosis (16) and class 'M+' mixed and manic affective disorder (11). Using the kappa coefficient a very low level of agreement was found between ICD-9 'hysteria' and 'other reactive and non-specified psychoses' and the corresponding categories of DSM-III-R and the PSE/CATEGO program. We concluded that, although DSM-III-R provides operational criteria for brief reactive psychosis, and DSM-IV and ICD-10 provide such criteria for brief or acute psychotic disorder, these bear little relationship to the original concept of the disorder. The PSE/CATEGO program provides a very systematic approach to symptomatology, but the diagnostic classes have little clinical usefulness.

Symptoms of neuroses: profile patterns and factor structure of clinic attenders with non-psychotic functional psychiatric disorders.

Consecutively referred out-patients (n = 102) with non-psychotic functional psychiatric disorders were examined. Nine syndrome scores (panic attack, phobic anxiety, generalized anxiety, obsessive-compulsive, dissociative, conversion, somatoform, depersonalization, and depressive) showed patterns corresponding to ICD-10 diagnoses. However, some also showed moderate correlations between each other. Factor analysis revealed that the nine syndrome scores could be accounted for by three factors-anxiety and somatic, depression and obsessive-compulsive, and hysterical. These findings cast doubt on the nosological specificity of the recent categorization of neurotic disorders. Furthermore, the symptom constellations identified in this study may be culture-bound.

[Phenomenology of hysterical pseudopsychoses]. / Phänomenologie der hysterischen Pseudopsychosen.

Clinical observation shows that hysteria can produce states that are difficult to differentiate from all forms of endogenous psychoses. Using phenomenological methodology, the elements and qualities of these hysterical states are analysed and described. It is demonstrated that the phenomena are properties of hysterical personalities, intensified and pronounced, but nevertheless intra- and extrapsychically targeted as "useful", i.e. serving a purpose. Phenomena that would be characteristic of real psychoses, are never seen. There is no "deprivation" of ego poser, and structural deformations are always absent. Considering the phenomenologico-psychopathological definitions of "psychosis", these hysterical states must be considered as pseudopsychoses.

Dissociation: the clinical realities.

An attempt was made by the authors of DSM-III to restrict its focus to the experimental, the observable, and the measurable. The intention was to free the nosology from the influence of unproven theories, and the philosophy was driven largely by the importance of research being able to identify diagnostic categories to facilitate the study of homogeneous groups. So it is of interest that the authors accepted dissociation-an ambiguous event linked to an explicit theoretical concept that had been introduced by Janet-as the basis for classification of clinical presentations that were formerly included under the rubric of hysteria, a similarly unclear category. Since DSM-III, there have been an increasing number of reports of dissociative experiences and dissociative identity disorder (formerly known as multiple personality disorder), but neither of these clinical presentations seems able to withstand the concern that it is dramatically influenced by environmental cues, e.g., the expectations of the therapist. Thus, a restricted phenomenological perspective does not fully appreciate the distorting potential of suggestibility and imagination on the nature of the emerging clinical picture. These factors might well have contributed to and laid the conceptual groundwork for the growth in the number of reports of dissociation.

Mass hysteria: one syndrome or two?

BACKGROUND: It has been suggested that mass hysteria can be divided into two syndromes; one with predominant features of anxiety and the other with predominant abnormalities of motor behaviour. In the former condition, prior tension is absent and spread is by visual contact. In the latter, prior tension is present, initial cases can be identified and spread is gradual. METHOD: The development and resolution of neurological symptoms in 156 Nigerian school girls were studied and a diagnosis of 'mass hysteria' made. RESULTS: The signs and symptoms manifested by the school girls during the outbreak of illness had features of both 'anxiety' and 'motor' predominant forms of mass hysteria. CONCLUSIONS: Although there may be two patterns of symptom presentation in mass hysteria, other supposedly discrete features overlap. This weakens the argument that there are two separate syndromes.