The 'disappearance' of hysteria: historical mystery or illusion?

Abstract

There is a widespread belief that the symptoms of ‘hysteria’, as used to describe neurological symptoms such as paralysis or blackouts unexplained by disease, has become less common over the last 100 years.1-3 For example, in From Paralysis to Fatigue, his history of psychosomatic medicine, Edward Shorter argues that symptoms such as hysterical paralysis, which were common in the 19th century and famously demonstrated by Charcot, have now given way to more elusive symptoms such as fatigue.1 Common theories given for this ‘disappearance of hysteria’ include societal emancipation from repressive Victorian culture, increasing ‘psychological literacy’ in the 20th century and advances in understanding of neurological disease. Mark Micale, another historian of hysteria, also accepts the view that the more ‘florid’ types of hysteria are ‘regarded today as extreme rarities’.2 But as Jan van Gijn, Professor of Neurology in Utrecht, has recently commented, anyone who thinks that hysteria disappeared with the death of Charcot cannot know what goes on in neurology outpatient clinics.4 Ample data exists to show that conversion symptoms remain very common in neurological practice,5-8 a clinical reality that is curiously not reflected in research activity, teaching or public awareness. It is puzzling, to say the least, that there should be such a discrepancy between medical historians and clinical neurologists. So what has happened? Did hysteria wane and is it now increasing again? Or has it always been common? In this essay we explore, using data where possible, some of the factors at work in this story. We conclude that there is no good evidence for a change in the frequency with which conversion symptoms (neurological ‘hysteria’) have presented to neurologists over the last 120 years. Instead, we propose that when the neurological study of disease and the psychiatric study of neurosis became divergent endeavours at the start of the 20th century, hysteria fell into a no-man's land between these two specialities. Neurologists were not interested in seeing the patients and the patients were mostly not interested in seeing psychiatrists. Scientific obliteration had become almost complete by the 1960s when flawed data was published which appeared to indicate that the diagnosis of hysteria usually turned out to be incorrect.9 We argue that it was not hysteria that disappeared, but rather medical interest in hysteria.