Hysteria, Somatization Twelve of the 85 patients had died,

three of disease which, in retrospect,

and the Sick Role
had been responsible for their
R E Kendell original “hysterical” symptoms.

The terms hysteria and hysterical are As the diagnosis of hysteria had,
widely used in many branches of from the beginning, been coupled
medicine, and “hysteria is one of the with an organic diagnosis in 24
few psychiatric diagnoses when non- patients, only 33 (39%) had no
psychiatrists commonly make with significant organic disease, and even
any confidence. We all think we these formed a heterogeneous group,
know what the words mean and that in which:
we can recognize a hysteric when we
 4 had committed suicide
see one. Unfortunately, this  2 had become schizophrenic
confidence does not withstand  7 had developed recurrent

objective scrutiny. depressions.

Follow up studies: in a study by At that time some psychiatrists were

Slater at the National Hospital, tempted to regard these findings as

London, UK, 85 patients were given evidence of the inability of

a diagnosis of hysteria. At follow-up, neurologists to recognize hysteria,

9 years later, the diagnosis had been rather than the evidence of the

replaced by an organic one in 28 inherent defects of the concept.

patients (33%). However, a similar follow-up study

of 113 patients, diagnosed as
 Hysterical pain was rediagnosis hysterical by psychiatrists, produced
as trigeminal neuralgia or basilar similar results. Over 60%
artery migraine. subsequently developed, or already
 Hysterical fits were rediagnosed
had prominent affective symptoms
as epilepsy
 Bizarre paraesthesiae and and in only 13% did the clinical
weakness were rediagnosed as picture remain purely that of
Takayasu’s disease. hysteria.
Genetic studies: there is little Slater observed “all the signs of
evidence for genetic basis of hysteria are the signs not of disease
hysteria. A study of the close but of health”, the hysterical
relatives of 381 patients with personality is little more than a
conversion symptoms showed that caricature of femininity, and the only
the incidence of hysteria was higher characteristic common of those
than in the general population. In a attracting the label hysteria is that
report on 12 monozygotic and 12 they are all patients. Restricting the
dizygotic twins with a diagnosis of diagnosis to those with neurological
hysteria, none had a co-twin with the conversion symptoms reduces the
same diagnosis. heterogeneity, but does not eliminate
the high incidence of subsequent
Multiple meanings
organic disease or the common
Part of the problem encountered in coexistence of anxiety and
studies such as those outlined above depression. Restricting the diagnosis
is that the term hysteria has been to women meeting criteria for
used in at least seven different, albeit somatization disorder preserves
related, ways. homogeneity at the expense of
eliminating, and leaving unclassified,
It is easy to see the connections
most of those commonly labeled as
between the various meaning listed
hysterics.
in figure 1. Hysterical personality
traits are often found in patients with It is hardly surprising in view of this
conversion symptoms or women diversity of meaning and usage that
with somatization disorder. Many it has been suggested many times in
women with somatization disorder the past hundred years that the terms
also have conversion symptoms, and hysteria and its ridiculous uterine
member of most of this categories connotations should be abandoned.
are liable to irritate their doctors. It is Until recently the plea came from
clear that as long as the term hysteria distinguished but isolated
is used indiscriminately, in any or all individuals. Now most psychiatrists
of these diverse situations, the are also convinced and hysteria will
concept will remain in disrepute. As not appear in the new (10th) revision
of the International classification of anxiety generated by sexual conflicts
Disease (ICD-10). In its place into a symptom with symbolic
somatization disorder (f45.0) and meaning for the patient. Some use
histrionic personality disorder the term conversion hysteria more
(F60.4). Neurologists, in particular, widely to include any bodily
are probably going to want to retain symptom believed to be produced by
the adjective “hysterical” to describe this mechanism.
patients with neurological symptoms
Dissociative states include amnesic
which they are convinced are not
states and fugues which serve top
attributable to neurological disease.
express, or resolve, some
Hypochondriasis intrapsychic conflict.

The concept of hypochondriasis is Hysterical personality: an

also controversial. There has been important minority of patients with
the same confusion about whether it conversion symptom exhibit a
is: particular constellation of personality
traits. They tend to be dependent,
 A personality trait
 A symptom capable of manipulative and egocentric.

developing in a wide variety of Mass hysteria is an epidemic

settings phenomenon, seen mainly in
 An independent disorder.
institutions for girls or young
It carries similar pejorative overtones women, in which the combined
to hysteria, and has also survived effects of suggestion.
mainly because a better, alternative
Anxiety hysteria is a psychoanalytic
concept has not yet been suggested.
term for phobic anxiety, implying
Different meaning of the term that repressed anxiety is displaced
hysteria into a neutral object or situation,
instead of being converted into a
Conversion hysteria involves a
symptom.
neurological symptom which,
according to psychoanalytic theory, The need for definitions
is produced by the conversion of
Medicine has never had an adequate Concepts of the sick role and
understanding or classification of the illness behavior
many patients who consult doctors
Physicians are conditioned by what
with symptoms for which no organic
social scientists call their medical
cause can be found. Clarification is
model to assume that every bona fide
badly needed throughout this area,
patient must have a disease of some
and attempts to provide this need to
kind. If the patient’s complaints can
be directed at this population as a
be related to a physical lesion no
whole rather than at individual
problem arises, but if they cannot,
categories, such as hysteria or
most doctors tend to oscillate
hypochondriasis. It is also probably
uneasily between the following two
more fruitful to ask why people
attitudes.
behave in this way than to ask what
is the matter with them.  There is nothing wrong with the
patient: this may be true in terms
In this confused area, six or seven
of organic disease, but it provides
different terms are now used more or
no explanation for the patient’s
less interchangeably. In addition to
behavior and no relief of his
the many meanings of hysteria and
suffering
hypochondriasis there is:  The patient is psychiatrically ill:

 Neurasthenia and its modern this is easily taken to imply that

he must have some sort of mental
equivalents, the chronic fatigue
illness, with a discrete cause of
syndrome and myalgic
its own.
encephalomyelitis
 The functional overlay of the
The concepts of the sick role and
family physician
 The transatlantic terms, illness behavior developed by

psychophysiological reaction and sociologists provide the basis of a

psychosomatic reaction better understanding of hysteria.

 Malingering
Sick role: sociologists have
All these overlap with one another emphasized that the sick role in our
and all are inadequately defined. society carries with it many
privileges. Invalids are exempt from
normal social obligations – children they were ill when the demand of
do not have to go to school and everyday life become too heavy for
them may do so for the same reason
adults do not have to go to work.
that they feel hungry three times a
They are also exempt from day and look both ways when
responsibility for their condition and passing of the pavement because
they have been trained to do so in the
so cannot simply be told to pull
past.
themselves together. Moreover, other
Figure 2 shows a tentative
people may feel obliged to be kind
classification of illness behavior in
and sympathetic to them, and often the form of Venn diagram. Although
to take over their responsibilities. reality is undoubtedly more complex
than this, the relationship between
The only obligation on the patient is
the three overlapping population
to seek, and accept, appropriate illustrate some important principles.
treatment so that he utilizes the Most illness behavior is generated by
privileges of the sick role for as short recognized disease, including well-
defined psychiatric syndromes, such
a time as possible. as schizophrenia and depression. A
substantial amount is generated,
Illness behavior: one of the most
however, either by fear of disease, or
basic principles of learning theory is
by the ‘positive reinforcement’
that patterns of behavior which are
provided by the advantages of the
rewarded tend to increase in
invalid role. All three population
frequency at the expense of those
overlap with one another, both singly
which are not. The rewards of the
and in combination, and the
sick role are so substantial, and are
recognized disease population is
experienced by all of us so often in
surrounded by penumbra of
childhood, childhood, that is hardly
unrecognized but genuine disease.
surprising that not all those who
These consist partly of accepted but
develop symptoms and consult
as yet undiagnosed illnesses, such as
doctors have objective evidence of
occult neoplasm, and of
disease. Although this has been
subpopulations with as yet
recognized for along time, it has
unrecognized syndromes, like patient
generally been attributed by doctors
with narcolepsy in Janet’s day. The
unused to thinking in behavioral
management of individual patient
terms either to malingering or to
depends on which of the 11
mysterious unconscious forces. It is
populations formed by the
probably more accurate, and
intersections of these four circles
certainly more straight-forward, to
they belong to, rather than on which
regard it simply as a matter of
of a few mutually exclusive
training. People who behave as if
diagnostic categories they come attractive, and so liable to be
from. Broadly speaking, illness adopted, when ever the balance of its
behavior motivated by the fear of advantages and disadvantages
disease corresponds to outweighs that of health. Some
hypochondriasis, and illness people prefer the sick role most of
behavior motivated by the the time, because they find the
advantages of the invalid role normal demands of life too onerous
corresponds to hysteria (though, of (because they lack of ability or the
course, fear also plays an important energy to cope successfully) or
part in some hysterical phenomena, because they only receive sufficient
especially mass hysteria). love, sympathy or attention from
other people when they are ill. To
Psychoanalytic concept of hysteria: many more the sick role becomes
for most of this century, the attractive only when:
dominant explanatory hypothesis for
the phenomena of hysteria has been  Their responsibilities are
the classical psychoanalytic theory abnormally great (e.g.
that hysterical symptoms are soldiers in battle)
produced by the ‘conversion’ of  They are in trouble (e.g.
repressed anxiety into a bodily impending examination,
symptom which has a symbolic debt, the fear of prosecution)
meaning to the patient and  The possibility of financial
commonly also involves ‘secondary gain increase the attractions
pain’. As some psychoanalysts have of illness further still
pointed out, this hypothesis has its (‘compensation neurosis’)
origin in an analogy with theories in
The very high incidence of hysterical
physics which have now been
phenomena in time of war suggests
discarded; and because it cannot be
that nearly everyone is potentially
falsified, it is fundamentally
capable of developing hysterical
unscientific, (Alternatively, it can be
symptoms (in the same way that
held to imply that patients with
everyone is capable of developing
‘conversion’ symptoms should be
epilepsy), but that people vary in
relatively free of anxiety and it is
their liability to do so. This variation
doubtful whether this is so. Nor have
depends partly on constitutional
therapies based on this hypothesis
variables like suggestibility and
been conspicuously successful in
capacity to dissociate, but the
alleviating hysterical symptoms.
patient’s current social role and past
Resorting to the ‘sick role’: a more experience are probably equally
convincing explanation of many of important.
the phenomena of hysteria can be
Hysteria is seen mainly in the
provided in terms of learning theory
young and the immature probably
and role theory. The sick role is
because the role of child and of incidence of conversion symptoms
invalid have much in common. Also, and manipulative behavior in woman
the adoption of a role in which the than in men should have waned
individual is dependent and cared for steadily as the social roles of the two
is most tempting to those who have sexes became less distinct, and this
only recently given up the privileges should have been apparent over the
of childhood and who are least last 80 years. Early this century, it
experience at coping with the was widely believed that this female
demands of the adult world. The predominance was much greater then
predominance of conversion than it is now. The overall incidence
symptoms and manipulative behavior of conversion symptoms has also
in woman probably has similar fallen steeply, at least in industrial
explanation. Until recently, women countries.
were expected to be dependent on
men and few position of power were Determinants of recovery
open to them. Manipulative behavior Recovery is dictated primarily by the
is essentially a strategy for achieving balance of advantages and
power in a role which does not disadvantages involved. If the
normally provide it. This is why it is situation which precipitated the
exhibited by children towards their symptom resolves itself, recovery
patents and by patients towards their will follow quickly, particularly if
doctors, and not vice versa. Those the patient is provided with a setting
who are able to command have no in which this can take place in
need to manipulate. Successful response to treatment. If it situation
manipulation, however, requires persists, or if the enduring
some degree of cooperation by the inadequacies of the individual are
person manipulated and usually this paramount, the advantages and
is forthcoming only if manipulator is disadvantages of the chosen
attractive, or accepted as seriously symptom became important, as well
ill. It is not accident that so many as those of the invalid role. Thus,
hysterics are strikingly good-looking, disabling symptoms (e.g. blindness
or at least were so when they were and inability to stand or walk) have a
young. comparatively good prognosis,
Manipulative behavior, like whereas those which can be switched
most other types of behavior, is on and off as occasion demands (e.g.
learned by being rewarded in fits and vomiting) or cause little
childhood, and is usually adequately disability (e.g. tremor) are more
rewarded only in those who are intractable.
physically attractive or brought up by Textbook generally describe
particularly indulgent parents. If this the choice of symptom as being
analysis is correct, the higher determined by its symbolic meaning
for the patient, and doubtless this is complicated as quickly as possible
some times true. More mundane and then the symptoms themselves
explanation are, however, generally should be ignored as much as
available. Often the choice is possible.
determined by the individual’s past  The main strategy of
experience or by his experience of management should based on an
illness in others. For example, the attempt to minimize the
nurse with hysterical blindness may disadvantages of health and the
have had severe conjunctivitis ad a advantages of sickness. This will
child, and the young man who cannot require careful and detailed inquiry
walk may had a grandfather who was (which will always involves talking
bedridden after a stroke. In mass to people other than the patient) to
hysteria the choice of symptom is elucidate the full implications of
determined entirely by example, both states. If the stress which
except in the case of instigators. The caused the patient to adopt the sick
common coexistence of organic role is temporary, little will be
disease and hysteria may have the needed beyond a firm prediction of
similar explanation, though other recovery and the provision of a
mechanism may also involved. treatment setting in which this can
Those who are genuinely ill are take place. If the advantages of the
likely to have difficulty in coping sick role are substantial and
with the demands and obligations of enduring, however, a carefully
normal life, and will also be aware of planned regimen will be needed
the advantages of being an invalid. which will involve the patent’s
This is the most plausible relatives and may even require a
explanation of the liability of ‘token economy’ in the early stages
epileptics to hysterical fits, or (i.e. paying the patient with tokens,
‘pseudoseizures’ which puzzled which can subsequently be used to
neurologist for so long. buy privileges, for normal and
appropriate behavior).
Management of hysteria  It is immaterial or not the
patient is aware that his symptoms
This view of hysteria has several
are feigned. As Miller and others
implications for patient management
have pointed out, one of the great
which are rather different from those
weaknesses of the psychoanalytic
of traditional theories.
concept of hysteria is that it
 The patient’s adoption of the requires a distinction between
sick role is more important than his conscious motivation (which is an
actual symptoms, which often illness-hysteria-and so worthy of
change. sympathy and concern) in spite of
 Physical examination and the fact that it is usually impossible
laboratory investigation should be to distinguish the two. Indeed, the
patient’s degree of awareness often
varies from time to time, and what
starts as unconscious may become
conscious, and vice versa.
 Patients are always sensitive
to insinuation that their symptoms
are not genuine, particularly when
they have doubts about this
themselves. Discussions with the
patient about the cause of his
symptoms therefore often and in
disaster, with accusations that the
doctor does not believe him. The
best strategy is generally to
emphasize that the symptoms are
familiar, that serious ill ness has
been excluded, and that full
recovery can be expected, and to
avoid discussing their cause, if
necessary by a confession of
ignorance.