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
widely used in many branches of
medicine, and “hysteria is one of the
few psychiatric diagnoses when non-
psychiatrists commonly make with
any confidence. We all think we
know what the words mean and that
we can recognize a hysteric when we
see one. Unfortunately, this
confidence does not withstand
As the diagnosis of hysteria had,
from the beginning, been coupled
with an organic diagnosis in 24
patients, only 33 (39%) had no
significant organic disease, and even
these formed a heterogeneous group,
in which:
 4 had committed suicide
 2 had become schizophrenic
 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
do not have to go to school and
adults do not have to go to work.
They are also exempt from
responsibility for their condition and
so cannot simply be told to pull
themselves together. Moreover, other
people may feel obliged to be kind
and sympathetic to them, and often
to take over their responsibilities.
The only obligation on the patient is
to seek, and accept, appropriate
treatment so that he utilizes the
privileges of the sick role for as short
a time as possible.
Illness behavior: one of the most
basic principles of learning theory is
that patterns of behavior which are
rewarded tend to increase in
frequency at the expense of those
which are not. The rewards of the
sick role are so substantial, and are
experienced by all of us so often in
childhood, childhood, that is hardly
surprising that not all those who
develop symptoms and consult
doctors have objective evidence of
disease. Although this has been
recognized for along time, it has
generally been attributed by doctors
unused to thinking in behavioral
terms either to malingering or to
mysterious unconscious forces. It is
probably more accurate, and
certainly more straight-forward, to
regard it simply as a matter of
training. People who behave as if
they were ill when the demand of
everyday life become too heavy for
them may do so for the same reason
that they feel hungry three times a
day and look both ways when
passing of the pavement because
they have been trained to do so in the
past.
Figure 2 shows a tentative
classification of illness behavior in
the form of Venn diagram. Although
reality is undoubtedly more complex
than this, the relationship between
the three overlapping population
illustrate some important principles.
Most illness behavior is generated by
recognized disease, including well-
defined psychiatric syndromes, such
as schizophrenia and depression. A
substantial amount is generated,
however, either by fear of disease, or
by the ‘positive reinforcement’
provided by the advantages of the
invalid role. All three population
overlap with one another, both singly
and in combination, and the
recognized disease population is
surrounded by penumbra of
unrecognized but genuine disease.
These consist partly of accepted but
as yet undiagnosed illnesses, such as
occult neoplasm, and of
subpopulations with as yet
unrecognized syndromes, like patient
with narcolepsy in Janet’s day. The
management of individual patient
depends on which of the 11
populations formed by the
intersections of these four circles
they belong to, rather than on which
of a few mutually exclusive
diagnostic categories they come
from. Broadly speaking, illness
behavior motivated by the fear of
disease corresponds to
hypochondriasis, and illness
behavior motivated by the
advantages of the invalid role
corresponds to hysteria (though, of
course, fear also plays an important
part in some hysterical phenomena,
especially mass hysteria).
Psychoanalytic concept of hysteria:
for most of this century, the
dominant explanatory hypothesis for
the phenomena of hysteria has been
the classical psychoanalytic theory
that hysterical symptoms are
produced by the ‘conversion’ of
repressed anxiety into a bodily
symptom which has a symbolic
meaning to the patient and
commonly also involves ‘secondary
pain’. As some psychoanalysts have
pointed out, this hypothesis has its
origin in an analogy with theories in
physics which have now been
discarded; and because it cannot be
falsified, it is fundamentally
unscientific, (Alternatively, it can be
held to imply that patients with
‘conversion’ symptoms should be
relatively free of anxiety and it is
doubtful whether this is so. Nor have
therapies based on this hypothesis
been conspicuously successful in
alleviating hysterical symptoms.
Resorting to the ‘sick role’: a more
convincing explanation of many of
the phenomena of hysteria can be
provided in terms of learning theory
and role theory. The sick role is
attractive, and so liable to be
adopted, when ever the balance of its
advantages and disadvantages
outweighs that of health. Some
people prefer the sick role most of
the time, because they find the
normal demands of life too onerous
(because they lack of ability or the
energy to cope successfully) or
because they only receive sufficient
love, sympathy or attention from
other people when they are ill. To
many more the sick role becomes
attractive only when:
 Their responsibilities are
abnormally great (e.g.
soldiers in battle)
 They are in trouble (e.g.
impending examination,
debt, the fear of prosecution)
 The possibility of financial
gain increase the attractions
of illness further still
(‘compensation neurosis’)
The very high incidence of hysterical
phenomena in time of war suggests
that nearly everyone is potentially
capable of developing hysterical
symptoms (in the same way that
everyone is capable of developing
epilepsy), but that people vary in
their liability to do so. This variation
depends partly on constitutional
variables like suggestibility and
capacity to dissociate, but the
patient’s current social role and past
experience are probably equally
important.
Hysteria is seen mainly in the
young and the immature probably
because the role of child and of
invalid have much in common. Also,
the adoption of a role in which the
individual is dependent and cared for
is most tempting to those who have
only recently given up the privileges
of childhood and who are least
experience at coping with the
demands of the adult world. The
predominance of conversion
symptoms and manipulative behavior
in woman probably has similar
explanation. Until recently, women
were expected to be dependent on
men and few position of power were
open to them. Manipulative behavior
is essentially a strategy for achieving
power in a role which does not
normally provide it. This is why it is
exhibited by children towards their
patents and by patients towards their
doctors, and not vice versa. Those
who are able to command have no
need to manipulate. Successful
manipulation, however, requires
some degree of cooperation by the
person manipulated and usually this
is forthcoming only if manipulator is
attractive, or accepted as seriously
ill. It is not accident that so many
hysterics are strikingly good-looking,
or at least were so when they were
young.
Manipulative behavior, like
most other types of behavior, is
learned by being rewarded in
childhood, and is usually adequately
rewarded only in those who are
physically attractive or brought up by
particularly indulgent parents. If this
analysis is correct, the higher
incidence of conversion symptoms
and manipulative behavior in woman
than in men should have waned
steadily as the social roles of the two
sexes became less distinct, and this
should have been apparent over the
last 80 years. Early this century, it
was widely believed that this female
predominance was much greater then
than it is now. The overall incidence
of conversion symptoms has also
fallen steeply, at least in industrial
countries.
Determinants of recovery
Recovery is dictated primarily by the
balance of advantages and
disadvantages involved. If the
situation which precipitated the
symptom resolves itself, recovery
will follow quickly, particularly if
the patient is provided with a setting
in which this can take place in
response to treatment. If it situation
persists, or if the enduring
inadequacies of the individual are
paramount, the advantages and
disadvantages of the chosen
symptom became important, as well
as those of the invalid role. Thus,
disabling symptoms (e.g. blindness
and inability to stand or walk) have a
comparatively good prognosis,
whereas those which can be switched
on and off as occasion demands (e.g.
fits and vomiting) or cause little
disability (e.g. tremor) are more
intractable.
Textbook generally describe
the choice of symptom as being
determined by its symbolic meaning
for the patient, and doubtless this is
some times true. More mundane
explanation are, however, generally
available. Often the choice is
determined by the individual’s past
experience or by his experience of
illness in others. For example, the
nurse with hysterical blindness may
have had severe conjunctivitis ad a
child, and the young man who cannot
walk may had a grandfather who was
bedridden after a stroke. In mass
hysteria the choice of symptom is
determined entirely by example,
except in the case of instigators. The
common coexistence of organic
disease and hysteria may have the
similar explanation, though other
mechanism may also involved.
Those who are genuinely ill are
likely to have difficulty in coping
with the demands and obligations of
normal life, and will also be aware of
the advantages of being an invalid.
This is the most plausible
explanation of the liability of
epileptics to hysterical fits, or
‘pseudoseizures’ which puzzled
neurologist for so long.
Management of hysteria
This view of hysteria has several
implications for patient management
which are rather different from those
of traditional theories.
 The patient’s adoption of the
sick role is more important than his
actual symptoms, which often
change.
 Physical examination and
laboratory investigation should be
complicated as quickly as possible
and then the symptoms themselves
should be ignored as much as
possible.
 The main strategy of
management should based on an
attempt to minimize the
disadvantages of health and the
advantages of sickness. This will
require careful and detailed inquiry
(which will always involves talking
to people other than the patient) to
elucidate the full implications of
both states. If the stress which
caused the patient to adopt the sick
role is temporary, little will be
needed beyond a firm prediction of
recovery and the provision of a
treatment setting in which this can
take place. If the advantages of the
sick role are substantial and
enduring, however, a carefully
planned regimen will be needed
which will involve the patent’s
relatives and may even require a
‘token economy’ in the early stages
(i.e. paying the patient with tokens,
which can subsequently be used to
buy privileges, for normal and
appropriate behavior).
 It is immaterial or not the
patient is aware that his symptoms
are feigned. As Miller and others
have pointed out, one of the great
weaknesses of the psychoanalytic
concept of hysteria is that it
requires a distinction between
conscious motivation (which is an
illness-hysteria-and so worthy of
sympathy and concern) in spite of
the fact that it is usually impossible
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.