La histeria moderna: Parte III trastornos disociativos y conversión / The modern hysteria: Part III dissociative disorders and conversion

La conciencia: característica esencial de esta dimensión de autorepresentación es la interpretación de ciertos estados internos del propio cuerpo como identidad mental y somática. La neurociencia de la conciencia sugiere fuertemente que un nivel de sincronización y unión entre varias partes del cerebro hasta cierto punto refleja la accesibilidad de varios contenidos mentales. Janet (1889) propuso el término désagrégation para referirse a los fenómenos de «no integración¼ y lo situó en el terreno de la anormalidad. Trastornos disociativos: en estos trastornos hay pérdida parcial o completa de la integración normal entre ciertos recuerdos del pasado, la conciencia de la propia identidad, ciertas sensaciones inmediatas y el control de los movimientos corporales (conversión)

The conscience: essential feature of this dimension of self-representation is the interpretation of certain internal states of the body itself as mental and somatic identity. The neuroscience of consciousness strongly suggests that a level of synchronization and union between various parts of the brain to some extent reflects the accessibility of various mental contents. Janet (1889) proposed the term désagrégation to refer to the phenomena of "non integration" and placed it in the terrain of abnormality. Dissociative disorders: in these disorders there is partial or complete loss of normal integration between certain memories of the past, awareness of one's own identity, certain immediate sensations and control of bodily movements (conversion)

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.

Neurologic approaches to hysteria, psychogenic and functional disorders from the late 19th century onwards.

The history of functional neurologic disorders in the 20th century from the point of view of the neurologist is U-shaped. A flurry of interest between the 1880s and early 1920s gave way to lack of interest, skepticism, and concern about misdiagnosis. This was mirrored by increasing professional and geographic divisions between neurology and psychiatry after the First World War. In the 1990s the advent of imaging and other technology highlighted the positive nature of a functional diagnosis. Having been closer in the early 20th century but later more separate, these disorders are now once again the subject of academic and clinical interest, although arguably still very much on the fringes of neurology and neuropsychiatry. Revisiting older material provides a rich source of ideas and data for today's clinical researcher, but also offers cautionary tales of theories and treatments that led to stagnation rather than advancement of the field. Patterns of treatment do have a habit of repeating themselves, for example, the current enthusiasm for transcranial magnetic stimulation compared to the excitement about electrotherapy in the 19th century. For these reasons, an understanding of the history of functional disorders in neurology is arguably more important than it is for other areas of neurologic practice.

Neurophysiology of conversion disorders: a historical perspective.

The aim of this paper is to present a short historical perspective on the neurophysiological approach to hysteria and conversion disorders. The body of this paper will be constituted of three main parts. In the first part, we will present the significant progress due to some pioneers of neurology/psychiatry during the XIXth century. As we shall see, this period was particularly rich in personalities whose work gradually laid the foundations to a true medical approach to hysteria. In the first half of the XXth century, different factors have led to a long eclipse of the neurological approach to hysteria. In the second part, we will show how, by the 1960's-1970's, the conceptual and methodological advances in neurophysiology, as well as the turning point of cognitive sciences (and cognitive psychology in particular) allowed a gradual reinstatement of hysteria within the fields of neurology and clinical neurophysiology. Finally, and this is the third part of this paper, we will show how over the past three decades, an entirely new neurophysiological approach to hysteria and conversion disorders has emerged.

'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.

Hysteria to conversion disorders: Babinski's contributions.

The main objective of this paper is to present the importance of hysteria on Babinski's oeuvre, and the conceptions of pithiatism from Babinski until the one of conversion disorder. Babinski gave a mental basis for hysteria in the place of Charcot's encephalopatic one, and several important semiotic tools to differentiate organic from hysterical manifestations based on studies from 1893-1917/8. His teachings were spread worldwide, and in Brazil they were also appreciated in the work on hysteria by Antonio Austregesilo, the first Brazilian neurology chairman. The neurobiological basis of hysteria conceived by Charcot is nowadays reappraised, and Babinski's neurosemiological contribution is everlasting. The patients believed to be hysterical, and the two outstanding neurologists, Charcot and Babinski, gave support for the development of the modern neurology.

Hysteria to conversion disorders: Babinski's contributions / Histeria aos transtornos de conversão: contribuições de Babinski

The main objective of this paper is to present the importance of hysteria on Babinski's oeuvre, and the conceptions of pithiatism from Babinski until the one of conversion disorder. Babinski gave a mental basis for hysteria in the place of Charcot's encephalopatic one, and several important semiotic tools to differentiate organic from hysterical manifestations based on studies from 1893-1917/8. His teachings were spread worldwide, and in Brazil they were also appreciated in the work on hysteria by Antonio Austregesilo, the first Brazilian neurology chairman. The neurobiological basis of hysteria conceived by Charcot is nowadays reappraised, and Babinski's neurosemiological contribution is everlasting. The patients believed to be hysterical, and the two outstanding neurologists, Charcot and Babinski, gave support for the development of the modern neurology.

O objetivo principal deste trabalho é apresentar a importância da histeria na obra de Babinski e a concepção de pitiatismo de Babinski até a de transtorno de conversão. Babinski deu uma base mental para histeria no lugar da encefalopática de Charcot, e várias ferramentas semiológicas importantes para diferenciar manifestações orgânicas de histéricas, com base em estudos de 1893-1917/8. Seus ensinamentos foram disseminados em todo o mundo, e no Brasil eles também foram apreciados no trabalho sobre a histeria por Antonio Austregésilo, o primeiro catedrático da neurologia brasileira. A base neurobiológica da histeria concebida por Charcot é reavaliada hoje em dia, e a contribuição neurosemiológica de Babinski é perene. Os pacientes considerados histéricos e os dois grandes neurologistas, Charcot e Babinski, deram suporte para o desenvolvimento da neurologia moderna.

Hysterical paralysis and premature burial: a medieval Persian case, fear and fascination in the West, and modern practice.

Premature burial (taphophobia) is an ancient fear, but it became especially common in 18th and 19th century Europe and may have a modern-day counterpart. Examination of a well-documented case from medieval Persia reveals the importance of funeral practices in the risk of actual premature burial and sheds light on the question of why taphophobia became so prevalent in Europe during the early industrial revolution period. The medieval Persian case was attributed to hysterical paralysis (conversion). We discuss the relationship between hysterical paralysis and premature burial more generally and show that although understanding of conversion syndrome remains incomplete, modern knowledge and practices have limited the risk of any similar tragedy today.

[Observations on the origins of the core thesis in Freud's "comparative study" of organic and hysterical paralyses (1893)]. / Zur Entstehung der Kernthese in Freuds "vergleichender Studie" uber organische und hysterische Lähmungen (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.

Una perspectiva neurocientífica sobre la histeria / A neuroscientific approach to hysteria

En la última década, el desarrollo y la puesta en marcha de las modernas técnicas de neuroimagen en el campo de la neurociencia cognitiva han proporcionado una nueva vía de acercamiento al estudio experimental de algunos trastornos mentales. Dentro de esta perspectiva, denominada por algunos autores “neuropsiquiatría cognitiva”, la histeria (o trastorno de conversión, de acuerdo con la clasificación psiquiátrica actual) ha cobrado un amplio protagonismo. De acuerdo con lo anterior, el objetivo del presente trabajo consiste en introducir estudios pioneros basados en una perspectiva neurocientífica de la histeria. Conviene destacar que, si bien estos aportan evidencia significativa sobre algunas de las áreas cerebrales y las disfunciones cognitivas comprometidas en el mencionado trastorno, los resultados obtenidos a la fecha distan aún de ser concluyentes.

In the last decade, the development and implementation of modern neuroimaging techniques in the field of cognitive neuroscience have provided a new way to approach the experimental study of mental disorders. Several authors have proposed the name of “cognitive neuropsychiatry” for this alternative approach. In this context, hysteria (or conversion disorder, according to the current psychiatric classification) has reached a huge protagonism. Therefore, this paper is intended to introduce pioneer studies about hysteria from a neurocientific perspective. It is necessary to highlight that, although these studies offer significant evidence about some of the brain areas and cognitive dysfunctions involved in the above mentioned disorder, results are still far from being conclusive.

[Pierre Janet's views on the etiology, pathogenesis and therapy of dissociative and conversion disorders ("hysterias")]. / Atiologie, Pathogenese und Therapie der dissoziativen und Konversionsstörungen (Hysterien) nach Pierre Janet.

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.

In the psychiatrist's chair: how neurologists understand conversion disorder.

Conversion disorder ('hysteria') was largely considered to be a neurological problem in the 19th century, but without a neuropathological explanation it was commonly assimilated with malingering. The theories of Janet and Freud transformed hysteria into a psychiatric condition, but as such models decline in popularity and a neurobiology of conversion has yet to be found, today's neurologists once again face a disorder without an accepted model. This article explores how today's neurologists understand conversion through in-depth interviews with 22 neurology consultants. The neurologists endorsed psychological models but did not understand their patients in such terms. Rather, they distinguished conversion from other unexplained conditions clinically by its severity and inconsistency. While many did not see this as clearly distinct from feigning, they did not feel that this was their problem to resolve. They saw themselves as 'agnostic' regarding non-neuropathological explanations. However, since neurologists are in some ways more expert in conversion than psychiatrists, their continuing support for the deception model is important, and begs an explanation. One reason for the model's persistence may be that it is employed as a diagnostic device, used to differentiate between those unexplained symptoms that could, in principle, have a medical explanation and those that could not.

[What do we really know about how lance-corporal Adolf Hitler was treated by german military psychiatry?]. / Was wissen wir wirklich über die militärpsychiatrische Behandlung des Gefreiten Adolf Hitler?

OBJECTIVE: This paper inquires the hypothesis that Hitler's rise to power was in part due to a hypnotic therapy he had undergone when being treated for hysterical blindness at an army hospital in the town of Pasewalk in October 1918 - as recent contributions have argued. Edmund Forster, his psychiatrist at that time, is supposed to have suggested to Hitler that he would be ordained as Germany's redeemer in times of defeat, thus causing a profound change in his patient's personality. METHODS: Following three lines of argument, this paper examines if such an assumption can be made plausible. Firstly, it takes a close look at the main historical source which is the novel THE EYEWITNESS, written in German language by the Czech-Jewish author Ernst Weiss. Then it asks if Forster is likely to have chosen hypnosis as a method of treatment. Finally, it exploits the work of the even lesser known author Alexander Moritz Frey who happened to serve close to Hitler as a medical orderly in WW I, thus trying to validate whether or not Hitler really underwent a change of personality in autumn 1918. RESULTS: Although the eventualities of such a hypnotic treatment or a profound change in Hitler's behaviour in that time cannot be disproved, both seem highly unlikely. CONCLUSION: S One should altogether abandon the notion of Hitler having suffered a permanent change of personality in 1918, be it due to psychiatric treatment or to psychological trauma itself.