Is Hysteria RealHysteria is a 4,000-year-old diagnosis that has been applied to no mean parade of witches, saints and, of course, Anna O.
But over the last 50 years, the word has been spoken less and less. The disappearance of hysteria has been heralded at least since the 1960’s. What had been a Victorian catch-all splintered into many different diagnoses. Hysteria seemed to be a vanished 19th-century extravagance useful for literary analysis but surely out of place in the serious reaches of contemporary science.
The word itself seems murky, more than a little misogynistic and all too indebted to the theorizing of the now-unfashionable Freud. More than one doctor has called it “the diagnosis that dare not speak its name.”
Nor has brain science paid the diagnosis much attention. For much of the 20th century, the search for a neurological basis for hysteria was ignored. The growth of the ability to capture images of the brain in action has begun to change that situation.
Functional neuroimaging technologies like single photon emission computerized tomography, or SPECT, and positron emission tomography, or PET, now enable scientists to monitor changes in brain activity. And although the brain mechanisms behind hysterical illness are still not fully understood, new studies have started to bring the mind back into the body, by identifying the physical evidence of one of the most elusive, controversial and enduring illnesses.
Despite its period of invisibility, hysteria never vanished — or at least that is what many doctors say.
“People who say it is vanished need to come and work in some tertiary hospitals where they will see plenty of patients,” Kasia Kozlowska, a psychiatrist at the Children’s Hospital at Westmead in Sydney, Australia, and the author of a 2005 review of the subject in The Harvard Review of Psychiatry, wrote in an e-mail message.
But it did change its name. In 1980, with the publication of the third edition of its Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association officially changed the diagnosis of “hysterical neurosis, conversion type” to “conversion disorder.”
“Hysteria, to me, has always been a pejorative term, because of its association with women,” said Dr. William E. Narrow, the associate director of the research division of the American Psychiatric Association. “I think the fact we got rid of that word is a good thing.”
Unofficially, a host of inoffensive synonyms for “hysterical” have appeared: functional, nonorganic, psychogenic, medically unexplained.
“Medically unexplained” and “functional” encompass a broader swath of distress than just conversion disorder — by some accounts, patients with medically unexplained symptoms account for up to 40 percent of all primary care consultations. But clinicians seeking to avoid the wrath of patients who do not appreciate being told that their debilitating seizures are hysterical in origin also use these blander terms.
Throughout that cloud of shifting nomenclature, people have kept getting sick. “The symptoms themselves have never changed,” said Patrik Vuilleumier, a neurologist at the University of Geneva. “They are still common in practice.”
Common, perhaps. Well studied, no. There is still no consensus on how conversion disorder should be classified, and not all physicians agree on diagnostic criteria. The epidemiology is hazy; one commonly cited statistic is that conversion disorder accounts for 1 percent to 4 percent of all diagnoses in Western hospitals. In addition, patients have heterogeneous symptoms that affect any number of voluntary sensory or motor functions, like blindness, paralysis or seizures.
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