Hysterical Personality Traits

Psychological, Social, and Iatrogenic Determinants

Seymour L. Halleck, MD, Madison, Wis

MANY general medical and psychiatric (Throughout the remainder of this discus¬
patients consistently employ the same be- sion the terms hysterical personality, hyster¬
havioral responses to adapt to a wide vari- ical character, or hysteric will be used to
ety of stressful situations. When these re- designate a person who can be described as
sponses lead to a maladaptive life style, such demonstrating a preponderence of these per¬
patients are diagnosed as personality or sonality traits. Our usage of the term implies
character disorders. Hysterical personalities no judgment as to the relationship of this
are among the most interesting members of personality disorder to conversion or psycho¬
this group, but at the same time they are the somatic reactions. The question of a rela¬
most poorly understood. Physicians are gen- tionship between somatic complaints in gen¬
erally perplexed about how to understand eral and hysteria will be discussed in a later
hysterical personality traits or how to treat section.) Most psychiatrists accept the
hysterical patients. Unfortunately, much of above definition of the hysterical personali¬
this confusion is related to idiosyncrasies of ty; they also believe that this diagnosis is
the relationship between the doctor and the primarily applicable to women.24 I agree
hysterical patient. Although the major deter- that hysterical personality traits are rarely
minants of hysterical personality traits are found in men. In fact, as we will note later,
psychological or social, it is also true that many of the behaviors which describe this
such traits may be exaggerated or even per- condition are directly related to the social
petuated because of the patient's contact roles which are imposed upon American
with the physician. women.
The diagnosis of hysterical personality is The hysterical personality can also be
usually made on the basis of observable be- considered in terms of dynamic inferences as
havior. The most useful descriptive defini- to the meaning of her behavior. The
tion has been offered by Chodoff and Lyons.¹ ic's hyster¬
They list seven criteria, which are summa¬
demandingness, histrionics, and dishon¬
esty should be viewed as purposeful actions
rized as follows:
The hysterical personality is a term appli¬
designed to structure the interpersonal situa¬
cable to persons who are vain and egocentric, tion so that she can manipulate the re¬
who display labile and excitable, but shallow af- sponses of others in a manner which assures
fectivity; whose dramatic attention-seeking and their continued interest and affection. Limit¬
histrionic behavior may go to the extremes of ed in her capacity to relate to other persons
lying and even pseudologica phantastica; who in a free and open manner and fearful of
are very conscious of sex, sexually provocative,
yet frigid; and who are dependently demand¬
risking rejection, she seeks safety in at¬
ing in interpersonal situations. tempts to subtly dominate all relationships.
Her methods for obtaining control may be
Submitted for publication Dec 29, 1966. indirect, passive, or even self-destructive,
From the Department of Psychiatry, University but they nevertheless effective. Any doc¬
are
of Wisconsin, Madison.
Reprint requests to 1300 University Ave, Madi- tor who has ever dealt with a hysterical pa¬
son, Wis 53706. tient, who has had the experience of feeling

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 strangely indebted to her, totally responsible Patient: Well, you know what's bothering
for her, or uncomfortably trapped by her de¬
ceptive helplessness, can appreciate the The patient's attempt to control the inter¬
depth of this power. The hysteric's need to change is immediately apparent.
control others is especially apparent in her
interactions with men. Her sexual charms
are suitable weapons in a quest for power,
since she is less dominated by a need to grat¬
ify erotic drives than she is interested in ulti¬
mate control of the sexual object.
The hysteric is also characterized by a
tendency to communicate to others that "she
cannot help herself." She presents not only
her symptoms, but also her actions and her
thoughts as though they were external
agents involuntarily imposed upon her.
Statements such as "these things always
seem to be happening to me," or "with all
these horrible experiences, how could I have
done otherwise," or "it's all my parents'
fault" are common. A picture of aggrieved
innocence is tenaciously maintained and
reinforced by excessive utilization of the de¬
fense mechanisms repression and denial. In
effect, the hysteric seems to be saying "I am
not a responsible person and refuse to be
personally accountable for what happens to
me, for what I think or do."
Any effort to categorize a patient as a hys¬
terical personality is based on judgments of
the extent to which hysterical behaviors are
used to solve problems in living. The diag¬
nosis is most appropriately made when it is
based on the obvious presence of four or five
of Chodoff and Lyons' seven traits. In my
opinion it can also be made on the basis of a
highly subjective judgment of the degree to
which a patient feels compelled to adopt a
seemingly helpless, nonresponsible role in an
effort to control her environment. Obviously
there is no such person as a pure hysteric,
but there are some people who use hysterical
behaviors excessively. Ideally it would be
most useful to describe patients as having a
certain amount of hysterical tendencies, per¬
haps rating them on a 1+ to 4+ basis. The
following excerpts from a therapy hour illus¬
trate the behavior of a person who might be
considered a severe, or 4+, hysteric.
The patient, a 30-year-old married wom¬
an, sought therapy because of nervousness,
depression, headache, and severe menstrual
cramps. She entered the office with a des¬
pondent air which contrasted sharply with
her colorful, almost flashy, dress. She wore a
low-cut blouse and crossed her legs in a se¬
ductive manner as she sat down. The follow¬
ing interchange took place.
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me. Why don't you talk today.
Therapist: Silent
Patient: I don't know why I come here. I
have been coming to see you for
six months now (actually four
months) and I feel worse than
ever. My head hurts so much (pa¬
tient dramatically touches head)
and I wonder more each day if
life is worth living.
This communication illustrates the patient's
attention-seeking and histrionic behavior;
there is also some obvious dishonesty.
Therapist: Silent
Patient : I keep thinking that fife isn't
worth living. I'm worrying that
I may kill myself.
Therapist: I have noticed that when I don't
respond to you immediately you
begin to complain more and feel
sicker.
Patient: (Suddenly angry) You get me so
mad. I come here for help and
all you can do is interpret. You
and your worship of Freud. I
know all about the years you
spent studying but I'm not im¬
pressed. Somebody like me is mis¬
erable and finds every minute of
life pure hell and you attribute
all kinds of unconscious motives
to my suffering. You don't know
how much courage it takes for me
to just go on from hour to hour.
The communication again illustrates the pa¬
tient's controlling and attention-seeking be¬
havior.
Therapist: Somehow I can't feel your misery
as that powerful or real. Can't we
go beyond it and look at what's so
unsatisfying in your life?
Patient: (Angrily exploding) I only wish
you could feel what I'm feeling.
(She reaches for an ash tray on
the desk and postures as if she is
going to throw it on the floor;
then she changes her mind and
shouts.) Damn you, nobody cares,
nobody, nobody, nobody. (Sobs for
several minutes while the thera¬
pist is silent, then slowly and
dramatically) I guess you win,
there's no beating you at your own
game while I am so sick and help-
 less. I need you too much. (Sud¬ other matters. Distrust of maternal figures
denly she perks up and smiles co- seems to be a prominent characteristic which
quettishly) Well, what do you develops in the earliest years of life. The
want me to talk about today.
hysteric is most accurately considered a seri¬
Here she is again controlling, playing as if ously damaged person who has been denied
helplessly dependent, and demonstrating a the basic nurturance and love which helps
reluctance to assume responsibility. develop a trusting person. In adult life she
Therapist: (Somewhat irritated) You know
is in her
as incapacitated
for intima¬ search
we've been cy, and sometimes lonely, as those we call
over that before.
schizophrenic.
Patient: (Teasingly) Sure, I'm supposed to As the future hysteric learns during child¬
talk about my conflicts, bare my hood to despair of finding closeness with her
soul, search out my hidden oedipal mother, she turns to her father for love and
wishes and my frustrations. (Sud¬ support. If the father is physically and psy¬
denly more dramatic) But I know chologically available he can temporarily
those things and so do you. You
know how my mother treated me
sustain the child's need for affection. As the
so cruelly, and how she paid more
child matures, however, her search for close¬
attention to my brothers, how my ness with the parent of the opposite sex be¬
father ignored me, and what a comes intertwined with sexual needs. Al¬
bastard my husband is. You know though she desires only nurturant love and
what the problem is and what the protection from the father, she is often inca¬
answer is, I'll always be miserable pable of persuading him to respond to these
and trapped with that no good needs unless she learns to relate to him in a
impotent husband of mine. Why mildly seductive manner. In reviewing the
didn't I marry John? I had my
choice and I goofed it. If only my histories of hysterics, it is often apparent
parents had helped me I wouldn't that closeness between father and daughter
have made such a miserable is sustained by a subtle mutual sexual inter¬
choice. Now I am trapped, est. Most often the erotic aspect of the rela¬
trapped, trapped. tionship of the future hysterical patient with
her father is unrecognized by either party.
In this communication the patient almost Quite frequently,
assumes responsibility for her choice, but however, such erotic feel¬
then backslides and blames it on her parents. ings become conscious and can lead to overt
sexual involvement. Incestual experiences or
Therapist: Sounds like you and your husband seduction by older men are not uncommon
have been fighting again. events in the early lives of hysterics.
Patient: (More seriously and sober) We No matter how close the relationship be¬
had an awful fight after a party tween father and daughter, it is not an ade¬
this weekend. Phil thought I was quate substitute for the longed-for maternal
paying too much attention to one love. To begin with, the erotic aspect of her
of our guests and. .
(Patient
. .
oedipal involvement tends to make the child
goes on to give a fairly nondra- anxious and guilty. Furthermore, her experi¬
matic account of her ffirtatious- ences with her mother have already pro¬
ness and ensuing verbal and phys¬
ical battle with her husband).
duced an attitude of basic distrust of others.
Anticipating rejection, she learns to ap¬
Psychological Determinants proach her father (and later other men) with
a fearful and angry demandingness which
coexists with her search for love and
affec¬
The earliest dynamic descriptions of the tion. She wishes to find a man who will be
hysterical personality emphasized unresolved her ideal but she also feels driven
oedipal conflicts as the primary determi¬ protector,
to use every aspect of seductiveness and ex¬
nant of this disorder.5 Recent studies have
focused on the presence of a more pervasive aggerated helplessness to bind that man to
and primitive disturbance arising during the her. Chotlos and Miller9 have described the
oral stage of psychosexual development.6·7 hysteric as a person who attempts to solve
Patients who utilize hysterical behavior traits the problems of her existence by denying her
excessively usually view themselves as hav¬ own importance as a responsible person and
ing experienced severe maternal deprivation.8 by searching for (but never finding) the an¬
They frequently describe their mothers as swers to life in the strength of an ideal man.
cold, distant, rejecting, or preoccupied with This picture is understandable in terms of

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 the dynamics we have described. The hyster¬ adaptational devices. When the intensity
ic turns to men for satisfaction of basic oral and frequency of hysterical behaviors are
needs. Unwilling to approach any man on an more restrained, they are generally per¬
open and free basis, however, she struggles ceived by men as a sign of charm rather than
to control the relationship. To the extent a symptom of illness. Hysteria is actually a
that she is successful in using her femininity reaction, a "final common defensive path¬
to control men, she destroys the possibility way" for women who perceive themselves as
of finding the same strength for which she deprived and oppressed. It follows that any
searches. She leads a life in which she is tan¬ woman under sufficient stress can be expect¬
talized by her perceptions of strength in ed to occasionally demonstrate behaviors
men, but in which all men eventually disap¬ associated with the hysterical adaptation.
point her. When a man uses similar coping devices, he
runs the risk of being ridiculed for his effem¬
Social Determinants
inacy. Those few men who are diagnosed as
There are many ways in which a person
hysterical personalities are individuals who
have some comfort with feminine roles.
can adapt to an actual or perceived depriva¬ Often they are homosexuals.
tion of love. Two of the commonest adapta¬ When an oppressed woman searches for
tions are heavily influenced by the social
roles which our society imposes on the sexes. closeness, her social role allows her to use
A man in our society who feels deprived can sexuality as
a vehicle for initiating, and later
controlling,
deny his needs for others, and perhaps turn dishonesty contributerelationships. Histrionics and
those to an exaggerated
upon and attack he perceives having
as
of herself
presentation
rejected him. Such behavior is usually char¬ Through clinging to this
as a helpless person.

acterized as a form of sociopathy. The mas¬ image she is indi¬

culine role in American culture supports a rectly able to command the attention of oth¬
It ers, since the helplessness implied in her
certain amount of direct aggressiveness.
also encourages men (particularly of the symptoms assures at least a limited supply
of concern. Although the hysteric is some¬
lower class) to behave as if they did not
times referred to as an aggressive person, the
have dependent needs toward others. The
American girl, however, is not expected to means by which she "pushes people around"
are indirect and determined by definitions of
deny her dependency needs and has little the female
opportunity to express aggression directly. A sexuality, role. Controland is obtained through
dishonesty, and
female child is more likely to adapt to depri¬ histrionics,
vation by seeking to bind people to her rarely through a direct imposition of her will
upon others. The female role, furthermore,
through relationships in which she assumes a
allows a certain degree of disavowal of
highly dependent role. When she does attack personalforresponsibility. Women in our socie¬
those who frustrate her, her social position
ty are not expected to be as responsible as
requires her to be indirectly aggressive. She men.12 As the hysteric learns to
must mask aggressiveness under the guise of exaggerate
and intentions. So-
her image of irresponsibility, she increases
helplessness benevolent the likelihood others will take care of
ciopathic roles are sometimes available to her. There are that many men who do not seek
lower-class and adolescent women. It is mature
interesting to note, however, that girls who a relationshippartners, but who prefer the safety of
with a childlike woman. En¬
resort to delinquent behavior have difficulty
counters with such men will reinforce the
in sustaining this role. Institutionalized fe¬
male delinquents who are deprived of access hysteric's tendency to deny her importance
as a responsible person.
to antisocial actions very quickly turn to
hysterical behavior as an adaptational de¬ The Hysteric and the Physician
vice.10 The inmates of schools for girls can
be characterized by their dependency, de¬ Although the hysteric's life may be char¬
mandingness, histrionics, dishonesty, and acterized by a frenetic search for affection,
preoccupation with sexuality. an unacceptable self-concept, and a continu¬
The relationship of hysteria to the femi¬ ous hovering on the edge of despair, she is
nine role has been noted by some writers able to avoid becoming a patient as
who describe the hysteric as representing al¬ she can exert a sufficient degree of control
long as
most a caricature of femininity.11 The hys¬ over her environment. If she can retain the
teric, in effect, exaggerates and repeatedly affection of a man who interests her, and if
utilizes certain aspects of the female role as she remains secure of her attractiveness to

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 other men, she experiences a tolerable level tendency to complain vigorously about so¬
of comfort. Her difficulties arise when men matic discomfort, like other traits associated
disappoint her, dominate her, reject her, or with the hysterical personality, is an atten¬
leave her. The hysteric comes to the physi¬ tion-seeking social behavior which is more
cian when she is bored with the inadequacies acceptable for women than for men. No one
of her husband (or other important men in is too surprised when women complain about
her life), when she finds that she cannot con¬ their health. One is reminded of George Ber¬
trol men, and particularly when she discov¬ nard Shaw's definition of a woman as "a con¬
ers that her control is diminished to the stipated biped with a backache."
point where she cannot hold their affections. The physician is in a peculiarly sensitive
The issue of separation from a man is espe¬ position to reinforce the defensive needs of
cially poignant to her. Even when she ini¬ the hysterical patient. Most doctors in the
tiates such separations, she still experiences United States are men committed to provid¬
considerable anxiety and tends to portray ing care for those who appear to be helpless.
herself as victimized. When the hysterical patient presents herself
A common indicator of failure of the hys¬ to the physician, he is often charmed by her
terical adaptation is the development of femininity and challenged by her obvious
physical symptoms, often in the form of demand for help. He is therefore likely to
psychophysiologic disorders or conversion invest himself heavily in pleasing her. (Un¬
reactions. These symptoms usually bring her fortunately, the patient's youth and attrac¬
to the internist or general physician. (Some tiveness are often crucial variables in
middle- and upper-class patients who are influencing the doctor's attitude. The young,
more psychologically sophisticated do go di¬ attractive hysteric is likely to be viewed as
rectly to the psychiatrist. Generally, howev¬ an interesting patient, while the less attrac¬
er, most patients are unwilling to acknowl¬ tive middle-aged woman is more likely to be
edge an emotional problem until anxiety is viewed as a hopeless hypochondriac.) The
increased through repeated failures of medi¬ hysterical patient, on the other hand, per¬
cal treatment to alleviate symptoms. Even ceives the doctor as not only a strong, excit¬
when the patient verbalizes a belief that her ing person, but also as a person capable of
troubles are due to "nerves," she still tends providing her with the nurturance and affec¬
to conceptualize her disorder as an external tion she desperately craves. Her initial reac¬
affliction or malady. ) There has been consid¬ tion to him is often one of admiration and
erable disagreement on the extent to which respect. Such positive feeling may be tinged
women with hysterical character disorders with fantasies of romance. In this initial
develop physical disabilities. Chodoff and phase of encounter, many physicians are
Lyons13 found little association between the likely to convince themselves that they will
hysterical character and conversion reac¬ have a favorable effect upon the patient.
tions, while others have found that these two Symptoms sometimes disappear quickly and
disorders occur together with some frequen¬ the subtly romantic aspect of the doctor-
cy.14 Still other writers have noted the cor¬ patient relationship is experienced as thera¬
relation of hysterical character traits and a peutic by both parties.
tendency to functional somatic complaints, There are, however, other possible out¬
and lump all these behaviors together under comes of the early phase of the relationship
the single rubric of hysteria.15 In my experi¬ which are not so salutary. Often the doctor is
ence, women who use hysterical character fascinated by some of his patient's symp¬
defenses tend to develop somatic complaints toms, particularly by conversion reactions or
(but not necessarily conversions) with great promiscuous or aberrent sexual behavior. As
frequency. Even those hysterical characters he focuses his attention upon such behavior,
who come directly to a psychiatrist, patients the doctor may unintentionally convince his
whose initial difficulties are viewed as pri¬ patient that his continued concern is depend¬
marily psychological, eventually complain to ent upon her maintaining her symptomatolo¬
their therapists of symptoms such as head¬ gy. When he accepts the patient's plea that
ache or menstrual cramps. Minor somatic she cannot help experiencing her symptoms
discomforts are invested with the status of or cannot help behaving the way she does,
symptoms which are then viewed as alien, he may reinforce her tendency to remain a
external, and unrelated to the patient's prob¬ helpless person. It is true that the physician's
lems in living. Such symptoms are presented need to investigate his patient's symptoms in
in an exaggerated and demanding manner. A a thorough and compassionate manner is

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 based on sound medical principle. Neverthe¬
less, the physician also runs the risk of sug¬
gesting to his patient that their continued
relationship is dependent upon her main¬
taining, or even increasing, her maladaptive
responses.
Many doctors, of course, are neither will¬
ing to the roles which their hysteri¬
assume
cal patients demand of them, nor to respond
to their patient's symptoms with the degree
of attention that is anticipated. Some doc¬
tors are inclined to be firm and even abrupt
in dealing with hysterical characters; such
physicians usually lose their hysterical pa¬
tients very quickly.
Whether the initial physician-hysterical
patient encounter produces symptom reduc¬
tion or exaggeration, the future course of
their relationship is usually stormy. The pa¬
tient is frequently unable to make changes in
her life which increase her interpersonal gra¬
tification outside the doctor's office. At the
same time, her physician can never be the
perfect giving parent she desires. Inevitably
frustrations arise which exaggerate the hys¬
teric's basic distrustfulness. If she experi¬
ences her need for the doctor as a profound
one, she eventually feels compelled to use
the same weapons to control him that she
has used to control other men. The doctor is
in an exceptionally vulnerable position. He
has difficulty in confronting his patient with
his own honest feelings. He is wary of hurt¬
ing her, and although he may quickly tire of
her demanding he is bound by his oath not
to reject her. As her sticky dependency in¬
creases, he finds himself being sucked into
an uncomfortable and one-sided relation¬
ship. When the patient's complaints of pain
become more intense, or when suicidal
threats become more ominous, the physician
experiences increasing difficulty in maintain¬
ing a proper professional involvement with
his patient. If he wishes to adhere to an om¬
nipotent helping role, he must be constantly
available and extraordinarily versatile in
solving each new problem. It is the hysteri¬
cal patient who troubles him, who he worries
about when the day's work is over, and who
calls him in the middle of the night for reas¬
surance. Often he has difficulty in resisting
overt sexual involvement. Eventually one of
three things happens: the patient gets much
worse and is hospitalized, the physician be¬
comes disinterested or rude enough to drive
his patient away, or the patient is sent to an¬
other doctor. The new doctor is likely to be a
psychiatrist.
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A relationship with a hysterical patient
may be especially painful for the psycho¬
therapist-physician. His involvement with
the patient is likely to be more intense than
that of other doctors. Yet he too is easily de¬
ceived into believing that he is helping his
patient, when too often he is only con¬
tributing to a strengthening of her neurotic
defenses. Young psychotherapists in particu¬
lar come to experience therapy with the hys¬
teric as disillusioning. They select hysterical
patients with enthusiasm and sometimes
with a faint awareness of the possibility of
romance. In a short time, however, they
come to feel manipulated, angered, and de¬
ceived. As the young psychiatrist fails to
meet his patient's demands, he begins to
worry about the sincerity of his own motiva¬
tions. He may find himself extending thera¬
peutic hours, adding hours, exhorting rather
than listening, and providing reassurance at
times when he should be firm. Sometimes his
frustration leads to angry withdrawal and
subtle rejection of his patient. It is the hys¬
terical female patient who is most likely to
challenge the young psychiatrist's sense of
adequacy, and who may seduce him into
abandoning a professional role. When a psy¬
chiatric resident voices doubts that he will
ever be a competent psychotherapist, or
when he seems to be massively preoccupied
and depressed over his therapy cases, the
wise supervisor supects problems with a
hysterical patient.
Treatment of the Hysterical Patient
Patients who use hysterical mechanisms
only under situations of severe stress can of¬
ten be helped by a firm but kindly physician
who does not allow himself to be manipu¬
lated, who discourages preoccupation with
symptoms, and who is able to suggest alter¬
native methods for coping with the problems
of life. Treating the patient with highly de¬
veloped hysterical personality traits, howev¬
er, is far more difficult. Physicians who at¬
tempt to treat such patients generally adopt
one of two strategies. Either they accept
their patient's dishonesties or they vigorous¬
ly attack them. In the former case treatment
is supportive, palliative, and only temporari¬
ly effective. The physician accepts the pa¬
tient's presentation of herself and allows her
to deny responsibility for her actions. He im¬
plicitly agrees with her message that she
cannot help herself and allows her to view
herself as a victim. In such treatment the
physician uses drugs, electric shock therapy,
 reassurance, flattery, encouragement, and seem to hold some patients in therapy dur¬
even interpretations to sustain his patient. ing this crucial stormy phase is the patient's
He does not acknowledge the covertly sexual fascination with the therapist's honesty and
nature of their relationship, but allows it to a growing awareness that she, too, can be
remain viable through subtle flirtation. He honest without endangering herself. In my
does not discourage the patient's inclination experience, once some of the more blatant
to hold an idealized image of him, but in fact hysterical traits have been scrutinized and
presents himself as an omnipotent, all-giving attacked, the patient is quite willing to di¬
person. Such therapy is able to sustain some rectly acknowledge the depth of her needs
hysterical patients for long periods of time. for affection and attention. It is at this point
It requires that the physician have some per¬ she is capable of breathing a sigh of relief
sonal charm, a considerable need to give to and settling back to enjoy a relationship in
dependent people, and an exceptional capac¬ which she can be honestly dependent. Psy¬
ity to tolerate infringements upon his time chotherapy then becomes a matter of pro¬
and energy. Supportive therapy does not viding an opportunity for some regression
change the hysterical patient, but may keep within the therapeutic relationship and for
a certain number of such individuals func¬ working through the various manifestations
tioning and out of hospitals. It also assures of maladaptive defenses with which she has
that they will remain patients. structured her life. This is facilitated by the
Therapy which produces useful personali¬ therapist's efforts to present himself as a fal¬
ty change is possible with the hysteric only lible, nonomnipotent person. The patient
if the therapist is rigidly honest. Ideally, he must eventually learn that the physician is
should begin treatment with a precise knowl¬ an ordinary mortal who struggles with the
edge of the state of his patient's health, and same existential issues which plague her. If
with an accurate picture of the nature of his therapy is eventually successful, the patient
patient's family relationships. The patient is able to find gratifying relationships with a
should be told at the beginning that the pur¬ man other than her physician—relationships
pose of therapy is to understand herself, and which are characterized by an active, honest
that permanent symptom relief will come interest in sex and a mature willingness to
only if she is able to change her style of liv¬ acknowledge her own importance as a per¬
ing. Her insistence that she will change son.
when she feels better should be countered by Obviously this brief synopsis of the
the suggestion that she will not feel better process of psychotherapy does not begin to
until she changes. No dishonesty should be describe the patience, tact, and degree of in¬
allowed to pass unnoticed. The therapist volvement which the therapist must sustain
must protest every exaggeration, every his¬ if he is to have good results. Successful ther¬
trionic outburst, and every attempt at sexual apy with the hysteric is not likely unless the
seductiveness. He must almost religiously therapist has considerable experience and
exhort the patient to take responsibility for enough maturity to deal with his patient's
all her thoughts and actions, and must at¬ demands in a professional manner.
tack every defensive effort to relate her The question of suicide threats is a special
plight to external circumstances. At the source of anguish to therapists of hysterics.
same time, lest the patient be driven away When the physician fears the loss of his pa¬
by this seemingly aggressive stance, the phy¬ tient's life, he is often driven into a pattern
sician must also somehow communicate that of unprofessional solicitousness which ren¬
he cares about the patient, that he is willing ders him therapeutically impotent. Although
to accept some of her demands for depen¬ skill in managing suicide threats is ultimate¬
dency, and that he wants her to feel better. ly determined by the therapist's maturity
The first several months of therapy with and experience, there are two specialized
such patients is likely to be characterized by therapeutic approaches which are especially
much direct conflict between patient and useful in such situations. One approach re¬
therapist. Some hysterical patients will not quires that the doctor see the married pa¬
put up with an honest approach and will tient together with her husband. The hus¬
leave therapy. This outcome is not necessari¬ band's presence diminishes the patient's
ly an unfortunate one, however, since many tendency to see the therapist as the sole an¬
disenchanted patients come away from their swer to her problems. Anxiety engendered
experience with more ability to abandon un¬ by suicide threats can be directly shared
realistic expectations of men. What does with the patient's spouse. Couple therapy

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 has the additional advantage of helping the son to question whether a psychiatric resi¬
husband understand his wife's needs, and dent or other relatively untrained physician
helping him learn how he has unconsciously should undertake treatment of such patients
reinforced her tendency to utilize hysterical without intensive supervision.
behavior. A second approach involves the
use of two therapists who see the patient at References
the same time. When the patient is confront¬
1. Chodoff, P., and Lyons, H.: Hysteria: The Hys-
ed with two therapists, sticky romantic terical Personality and Hysterical Conversion, Amer
transferences do not develop. The patient's J Psychiat 114:734-740, 1958.
manipulative use of suicide threats are par¬ 2. Purtell, J.J.; Robins, E.; and Cohen, M.E.: Ob-
servations on Clinical Aspects of Hysteria, JAMA
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therapists can give each another. These less 3. Guze, S.B., and Perley, M.J.: Observation on
conventional techniques are especially useful the Natural History of Hysteria, Amer J Psychiat
in times of crisis. They are sometimes used 119:960-965, 1963.
4. Binder, M.: The Hysterical Personality, Psy-
to prepare the patient for later individual chiatry 29:227-235, 1966.
psychotherapy, but often they are sufficient 5. Reich, W.: Character Analysis, New York: Or-
treatment in themselves. gone Institute Press, 1949.
6. Marmor, J.: Orality in the Hysterical Person-
ality, J Amer Psychoanal Assoc 1:656-671, 1953.
Conclusions 7. Lazare, A.; Klerman, G.L.; and Armor, D.J.:
Oral, Obsessive, and Hysterical Personality Patterns,
It is one of the ironies of medical practice Arch Gen Psychiat 14:624-630, 1966.
8. Binder, M.: The Hysterical Personality, Psy-
that the physician's need to be helpful can chiatry 29:227-235, 1966.
sometimes contribute to making his patient 9. Chotlos, J., and Miller, M.: Obsessive and Hys-
worse. I have seen dozens of hysterical pa¬ terical Syndromes in the Light of Existential Con-
tients (and have undoubtedly contributed to siderations, J Existential Psychiat 1(3):315-329,
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molding many such patients myself) whose 10. Halleck, S.L.: and the Dilemmas
emotional conditions have sharply deterio¬ of Crime, New York:Psychiatry
Harper & Row Publishers,
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11. Chodoff, P. and Lyons, H.: Hysteria, the Hys-
with a physician. Mildly hysterical patients terical
Personality and Hysterical Conversion, Amer
can be treated by the average physician. J Psychiat 114:734-740, 1958.
Other severe hysterical patients may be be¬ 12. Friedan, B.: The Feminine Mystique, New
yond help through an honest and direct ap¬ York: W.W. Norton Publishers, & Co., Inc. 1963.
and 13. Chodoff, P., and Lyons, H.: Hysteria, the
proach, can benefit only by some form of
Hysterical Personality and Hysterical Conversion,
supportive therapy. Most hysterics, howev¬ Amer J Psychiat 114:734-740, 1958.
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their lives. The key to success is an experi¬ Conversion Hysteria, Arch Gen Psychiat 13:275-282,
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the pitfalls for the inexperienced therapist Stability and Usefulness of Clinical Criteria, New
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