HYSTERIA (FALLING SICKNESS, morbus sacer).
- Psychoneurosis characterized by particular abnormalities of neuropsychological equilibrium, disposition, and character, which, combining and reacting with one another in various ways, give rise to the most diverse clinical symptomatology on a functional basis. U. Cerletti defines it as “a morbid syndrome characterized by a psycho-emotional complex that generates exaggerated or abnormal somatic and psychic reactions and tends to reproduce and fix them.”
There are innumerable hypotheses concerning the genesis of hysteria. Of historical importance is that of Hippocrates, accepted throughout the Middle Ages, which held that the disease was caused by the wanderings of the uterus (ὕστερος), which, having gone mad, moved about the abdomen and thorax. In 1618 Lepois was the first to classify hysteria among the nervous diseases. Little more than half a century later (1681), Sydenham, having observed the innumerable forms in which the disease presents itself, stated that it was a functional nervous disorder. At the end of the nineteenth century, Charcot gave new impetus to the understanding of hysteria through his research at the Salpêtrière Hospital in Paris. In 1908 Babinski called hysterical manifestations “pithiatism” (πίδηνος = monkey), considering them a collection of disorders that can be reproduced through suggestion or imitation in certain subjects, and that are liable to disappear under the influence of counter-suggestion. Babinski’s conception is incomplete, since hysteria includes manifestations that are certainly not due to suggestion. For fanet, the disintegration of consciousness and mental depression are important; Kraepelin makes it depend on intense and exaggerated sensations caused by violent emotions. More recent authors (Haskovec, Pienkowski, Dezwarte) maintain the subcortical origin of hysteria. In Italy, Buscaino holds that hysteria originates in an abnormal condition of the midbrain and the basal ganglia of the brain, which are capable of reacting paradoxically to psychic stimuli. According to others, hysteria develops in individuals with a constitutionally labile nervous system, following emotions (emotional shock); these would be capable of blocking the cortico-mesencephalic connections and inhibitions and releasing the automatism of the subcortical nuclei. For Freud, hysteria is caused by the seething and attempt to bring into the light of consciousness psychosexual complexes, distorted and badly oriented during childhood development, repressed in the subconscious (v. PSICANALISI). Still more recent authors deny that it is a disease and admit only a hysterical character.
The disease occurs predominantly in females, but is not rare in men and may appear as early as childhood (8–10 years); it spares neither race nor social class. Among the causal factors of hysteria are neuropathic heredity, the influence of the environment, and faulty education; psychic traumas act rather as occasional factors triggering the hysterical episode. Physical traumas (falls, blows, accidents, etc.) act particularly through the disturbances of consciousness and the intense emotional states they are capable of provoking; thus arise accident neuroses and traumatic hysteria. Contributory causes may include infectious diseases (syphilis, tuberculosis, typhoid, scarlet fever, etc.), intoxications (alcoholism, carbon-monoxide poisoning), and dyse endocrinopathies (Flajani-Basedow’s disease). It is erroneous to assign predominant causal importance to disorders concerning the sexual sphere; sexual abstinence should not be considered a cause, particularly when consciously and freely chosen and lived as a lofty ideal of life.
Hysteria presents a highly varied number of symptoms that share certain characteristics making them recognizable. They do not depend on gross anatomical lesions of the nervous system; they may appear and disappear rapidly and altogether, without displaying the constant and characteristic symptomatology associated with genuine anatomical alterations; the clinical picture is usually extremely rich and variable.
Psychic disorders are characterized by the considerable influence exerted by suggestion in determining them, by the period of “expectation” presented by the psychic process, and by the tendency toward reproduction.
Among motor manifestations, the following are frequent: hysterical torticollis; spasm of the glottis, pharynx, and esophagus (hysterical globus); contractures; flaccid or spastic paralyses, localized or affecting half the body (hysterical hemiplegia); and paralysis of the vocal cords with sudden aphonia.
Among sensory disorders, hysterical aberrations are innumerable and manifest themselves in the most bizarre ways, with no territory of innervation, or even the sense organs themselves, being spared.
Among the most frequent visual disorders, due to autosuggestion, are achromatopsia, that is, loss of the sensation of colors; narrowing of the visual field; diplopia, that is, double vision; unilateral or bilateral blindness; etc. With regard to hearing, diminished hearing often occurs, sometimes progressing to complete deafness. As for taste and smell, anesthesia to certain substances is frequent: sugar, salt, vinegar, quinine; likewise, diminished sensitivity of the mucous membranes (conjunctivae, throat). Important is the absence of the pharyngeal reflex, very frequent in hysteria. Sensory alterations of the skin appear in generalized form, sparing no territory; or in segmental form, assuming a configuration like a glove, stocking, shoe, star, leaf, or an entire half of the body, more often the left, etc.; these sensory disorders are always characterized by failing to correspond to those zones that should be related to the clearly defined territories of distribution of the peripheral nerves or spinal roots.
Pains or algias, also extremely frequent, may be localized anywhere: in the head, spinal column, limbs, or joints; they may be violent or take the simple form of hyperesthesia, that is, exaggerated sensitivity. Abnormal or paradoxical sensations are paresthesias (tingling, burning, a sensation of an electric shock, of spasm, particularly between the esophagus and the upper valve of the stomach [hysterical globus]).
Secretory disorders concern the paroxysmal overproduction of saliva (ptyalism); of sweat, often limited to a particular and clearly demarcated area of skin; of urine (polyuria, oliguria, or complete anuria); or of tears or milk.
Particular phenomena are represented by so-called hysterical fever, which some authors (Babinski) always consider feigned through skillful maneuvers during measurement, while others relate it to crises of violent hyperemotionality or to nervous disturbances of the vasomotor and thermoregulatory centers; this fever may even assume the appearance and course proper to certain infectious diseases. Vasomotor phenomena, involving dilation or spasm of the cutaneous arterioles and capillaries, may produce generalized or local redness or pallor, or irregular, figured, or striated patches, raised or not, red or white, on the skin, following local mechanical stimulation (dermographism).
The hysterical person is capable of a subjective sensation of the internal viscera, in their form, position, and function, and by this route may come to feign internal diseases of an organic nature (gastroduodenal ulcers, tumors, etc.), sometimes even pregnancy. This entire symptomatology may be permanent (“hysterical stigmata”) or paroxysmal.
The picture of h. is completed by the psychic symptoms, truly essential and constant, linked to the particular temperament and character of the hysteric. Among such symptoms should be noted: the tendency to attract and fix the attention of others upon one’s own person (egocentrism); to exaggeration, systematized lying (mythomania, v.), and simulation; to being excessively influenced by one’s own mental representations and remaining subject to suggestion, whether one’s own (autosuggestion) or that of others; and to the breaking up and disintegration of the unity of the block of psychological consciousness. Particularly after the attacks, phenomena of dissociation, amnesia, sensory illusions, and hallucinations follow. The individual also displays, among his characteristic features, with regard to affective tone, apathy or hyperemotivity, and a lack of energy and persistence of will (aboulia).
Particularly in the past (in the time of Charcot), acute episodes readily appeared in the form of “major” hysterical crises, generally recalling an epileptic seizure. Under the action of suggestion, or following occasional external causes (fright, anguish, etc.), the individual begins to feel various disturbances, feels incapable of influencing his own body, complains of a sense of oppression and anguish, labored breathing, a sense of palpitations, general trembling, and noisy hiccupping; finally he is seized by a convulsive crisis. The hysteric struggles, shaken by tonic-clonic convulsions, contortions, and contractures in acrobatic postures (hysterical arc of a circle); characteristic are the theatricality of the crisis, the need for an audience to be present for it to unfold, and the ability not to cause oneself any harm, despite falls and violent beating. After a more or less prolonged period, the hysterical attack ceases with a fit of weeping, or the patient falls asleep. In the hysteric, catalepsy (v.), catatonia (v.), lethargy (v.), hypnotism (v.) readily occur.
The moral personality of the hysteric is profoundly altered; Krafft-Ebing asserts that hysterics are affected by very great libidinal exaltation, although there are also some who are incredibly frigid. They no longer possess the moral sense of charity and humanity; the will and moral energy weaken, and free will is affected. Anomalies of sensation influence the moral order and affective life. Thus there arise vehement impulses, passions, and simulations. Not all acts committed by hysterics, however, are devoid of responsibility, since they are not always carried out under the influence of the illness; indeed, many times they are performed freely and knowingly, and the morbid influence is not always so grave as to eliminate all responsibility.
With regard to prognosis, h. must, in the present state of medicine, be considered incurable in its particular neuropsychological configuration, especially if faulty upbringing has allowed the hereditary defects and morbid tendencies of the character to develop and become fixed over the course of life. On the contrary, properly conducted treatment and education can attenuate the morbid tendency,
prevent or rapidly interrupt the symptoms and crises that are in progress.
Apart from strictly medicinal treatment, which can sometimes produce unexpected results, the greatest benefit may be derived from psychotherapy (v.), whose value is undoubtedly more closely related to the intuition, patience, and often heroic charity of the person who applies them than to the intrinsic value of this or that method. As regards psychoanalysis (v.) and its moral character, this will be discussed under the corresponding entry.
In general, one must beware of attaching excessive importance to hysterical disturbances; one must not, however, fall into the opposite extreme of neglecting, or worse, crudely mocking and mistreating the patients, accusing them of being visionaries or simulators. For although the illness of hysterics has a purely ideational origin, it develops independently of the conscious will of the sufferers, for whom it represents a real cause of suffering. Moreover, affectivity, always abnormally developed in hysterics, if improperly repressed, would constitute an insurmountable barrier preventing any attempt at therapy.
Of the greatest importance is the prevention of h. in the children of hysterics. Their education should aim especially at suppressing excessive sensitivity, educating young people firmly, without harshness, but also without sentimentality, teaching them early to exercise self-control and developing their excessively weak will. It is of great importance not to encourage the development of the imagination, especially by avoiding books and performances capable of provoking violent emotions or powerful suggestions. In cases of serious familial predisposition, education outside the environment and influence of the relatives may prove useful.
With regard to those hysterical manifestations that can simulate phenomena of a preternatural and supernatural order, or that, though genuinely of such a nature, are falsely judged to be hysterical (stigmata, bloody sweats, mystical states, etc.), v.: DEMONIACHE MANIFESTAZIONI; MEDIANICHE MANIFESTAZIONI; METAPSICHICA; MIRACOLO.
BIBLI: J.-M. Charcot, Leçon sur les maladies du système nerveux faites à la Salpêtrière, Paris 1874; P. Janet, Etat mental des hystériques, there 1893; U. Cerletti, Riassunto delle lezioni di clinica delle malattie nervose e mentali, Rome 1946; G. Moglie, Manuale di psichiatria, there 1946; L. Scrimin, Dizionario di morale professionale per i medici, 4th ed., Rome 1949, pp. 422 ff., 482 ff.; A. Vallejo Nágera, Tratado de psiquiatria, Barcelona 1949. Giuseppe de Ninno-Adele Pignatelli