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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


HYSTERIA, A BOUNDARY CONCEPT BETWEEN PSYCHOANALYSIS AND DSM IV

Autor: Carmen Truţescu
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Hysteria – a concept with ancient origins, carefully analyzed and processed initially in the psychoanalytic school, continue to keep his place in medical school attention and mental health professionals by the variability and complexity of psychopathological situations in which is incriminated.

The term, originally used in connection with general symptoms and analytical aspects of its appearance, is gradually replaced with partially similar terms from the need to standardize the diagnostic criteria. From need of specialists to quantify similar aspects of psychopathology were born nosografice standardized instruments and international classifications of paramount importance. Classification of diagnostic entities leads however to a criteria separation of events with common psychogenetics mechanisms.This paper is intended as an analysis of data of historical evolution of the concept, a plea to align with new diagnostic approaches in child and adolescent mental health without abandoning the apprehension models, to the analyze of psichodymanic and complexity of the patient’s mental reality.

 


 

Introduction

Interest for manifestations reunited under the name of hysterical manifestations was kept alive over time, keeping unsolved question of the real cause. Long time has been believed that progress in medical science will bring the evidence of connection between symptoms and organic changes that underlies it.

In antiquity Hysteria was described as a result of displacement of the uterus from its normal position. Name of Hysteria today retains proof of the origin of syndrome (gr. Hystera). Galen, in century II, rejects the idea that the modifications occur due to this displacement of the uterus, suggesting as a cause excessive retention of uterine secretion (Dobrescu 2010).

Doubts about the origin of uterine hysteria began in the XVIII century. Thomas Syndenham recognized emotional disorder hysterical origin. Furthermore, Sydenham recognized disorder in men. In 1859 Briquet emphasized multisymptomatic aspects of the disease and recognizes hysteria in men, attributing it to emotional causes (Sadock et Sadock, 2000). Lander (1873) mentions participation of hysterical children in manifestations of “epidemics of possession” while Palmer (1882) describes the hysterical crisis of dissociative type (Dobrescu, 2010).

 

Hysteria in psychoanalytical theories

The French school, represented by J. M. Charcot emphasizes the importance of strong emotions in causing hysteria in predisposed subjects; it highlights the fact that similar phenomena could be induced by hypnosis, and also attacks of hysteria could be altered by suggestion. Pierre Janet emphasizes narrowing of field of consciousness specific to hysterical manifestations, responsible for suggestibility and other aspects of these symptoms (Gelder et al., 1983).

French authors consider that hysteria is the language of the unconscious which is expressed through the body to the extent that it becomes visible, it’s an alarm signal without cry, a non verbalized request, a holocaust without apparent pain, but in which pain is involved in a bivalent form (Gelder et al,1983; Zamfirescu, 2007).

1885 is the year when Freud and Charcot, carefully bend on hysteria, and after 1895 Freud published works About mental mechanisms of hysterical phenomena and later Studies on hysteria (Freud, 2005) laying the foundation for psychoanalytic theory. Freud defined the concept of hysteria: our hysterical patients suffer from reminiscences. Their symptoms are residues and mnesic symbols of certain experiences (traumatic) and link manifestations to sexuality (Freud, 2005; Zamfirescu, 2007).

While Charcot had observed that at hysterics emergence of the physical syndrome led to the disappearance of anxiety and replacing it with belle indifference, Freud believes that this is an incarnation of anxiety into a body system (Freud, 2002; Zamfirescu, 2007).

Hysteria provides thus the model of mysterious jump of psyche into physical. Localization of somatic manifestations led to the appearance theory of symbolic language of the organs developed by Georg Groddeck (Constantinescu et al, 1989), while Alfred Adler talks about organ inferiority. Adler is the one that de-sexualizes the unconscious and adds the social dimension and sense of satisfaction/dissatisfaction in relation to other members of the community (Zamfirescu, 2007).

 

Hysteria as a reflex mechanism

Kretschmer, in 1961 defines the hysterical attacks as being instinctive reactions preformed by the nervous system to excessive stress, emphasizing the contribution of external factors and condition that can influence symptom duration and intensity. Persistence of events is related to two aspects, namely: getting an advantage from the symptoms and generating over time of a neurological mechanism through which the behavior constantly recurring becomes habitual (Gelder et al., 1983).

Hysterical manifestations described by Freud and Breuer studied patients are affected by implicit memories of some events that cannot be remember clearly (Freud, 2005). Neuro Analiza, tries to bring scientific arguments for the observed clinical manifestations and to avoid speculative route, (Peled, 2008) and highlights the role of processing early emotion, experienced by children up to 2 years. Immaturity of the prefrontal cortex makes, that based on these early emotions, to form neural schemes in areas of emotional response (amygdale, basal ganglia, hippocampus), which does not involve the participation of higher brain structures (Gainotti, 2006; Peled, 2008).

Laterality of the conversion manifestations, as demonstrated by Stern in 1977, shows that the asymmetry of conversion symptoms is related to different organization of the left and right hemispheres, and not on the level of involvement in activities of the two parts of the body. Thus, both left and right hand patients who presented symptoms with hysterical component describe in higher proportion conversion symptoms in left body regions (Stern, 1977).

Hysterical syndrome, as exists in psychiatric practice is a complex of symptoms in the field of motility, sensorial, speech, visceral vegetative functions and psyche, symptoms having the common characters :

  • emotional origin (psychogenic), 
  • atypical (compared with organic syndromes), 
  • theatricals and demonstration, 
  • complete and rapid reversibility, 
  • suggestibility by environmental attitude or suggestion (Constantinescu et al., 1989).

In clinic hysterical manifestations do not belong to a single mental illness, hysterical syndrome may occur in different clinical circumstances with progressive degrees of severity and duration, defined as Hysterical reaction, Hysterical neurosis, Neurotic development, Disharmonic psychopathic personality development and Hysterical psychosis (Milea, 1988).

We are dealing with a psychopathological syndrome rather than a unitary clinical entity, with an inexhaustible variety of manifestations, more or less paroxysmal (Milea, 1988), including excito-motor crisis, paralysis, anesthesia, abnormal movements, sensory manifestations and sensory somato-visceral disorders (disorders of phonation, vomiting, dysphasia), neurovegetative disorders or algiae (pain) with different localizations, amnesia, run, twilight states, Ganser syndrome (Dobrescu, 2010).

Hysterical child has some characteristics that may be useful in specifying the diagnose: suggestibility, imaginative exaltation (the regression in reverse), theatrical expression with the desire to be admired, extreme sensitivity with emotional avidity, discontent with exaggerated reactions to the smallest frustration , superficial relationships, emotional oscillations with the difficulty of establishing normal emotional bonds with parents or others. This child lives disease with belle indifference for what it offers (Dobrescu, 2010). However hysterical symptoms are rarer in children under 10 years than in adolescence, where the frequency of this symptom is similar to that seen in adults (Marcelli, 2003).

In young children, hysterical manifestations often take the form of a motor symptom which exists quasi-constant in close entourage: limping of a parent, a motor deficit of a grandparent, motor disability of another family. At this age category, when family interview cannot lead to the identification of a similar context and cannot identify the secondary benefit is recommended to use with caution diagnosis of conversion and carry out a somatic thorough balance (Marcelli, 2003; Dobrescu, 2010).

Episodes of loss of consciousness, syncope, various forms of narrowing of conscience, vertigo, parenthesis, headache or algae with other localizations – require a thorough differential diagnosis of epileptic syndromes and with other neurological disorders, especially since the coexistence of epileptic crisis and hysterical manifestations in the same patient is not unusual. EEG can help establishing the diagnosis although there are some studies that have shown that transient localized discharges can occur predominantly in the frontal lobe, or with diffuse character during the manifestations of psychogenic origin (Ramchandani et Schindler, 1993).

Some syndromes described by classical psychiatry have been taken entirely under the form of diagnostic criteria. Others have changed, others have been assimilated to other entities or even removed from the list of disorders. It the case of Neurasthenia, which was included in DSM I (under the name of Psychological reaction of the nervous system) and DSM II (as Neurasthenic neurosis), but never been found in DSM III and DSM IV (Sadock and Sadock, 2000). DSM IV-TR recognizes diagnostic entities that have as primary symptom a psychogenic expression, represented mainly by the somatoform and dissociative disorders.

Somatoform disorders include conversion disorder, somatization disorder, algic disorders, hypochondrias is, and dismorfophobic disorder. In somatoform disorders the patient has physical symptoms such as back pain or limb paralysis without apparent physical cause (DSM-IV-TR, APA, 2000)

Somatization disorders as well as conversion are usually conditions intensively investigated, especially because of the multitude of symptoms presented. EEG studies conducted by Pierre – Henry and his colleagues have shown, related ethiopathology of conversion disorder, using bipolar EEG derivatives, that there is (1) hypofunction in the dominant hemisphere, (2) a hyperactivity in nondominant hemisphere, and (3) abnormal inter-hemispheric relations. Especially to women, appears to be a secondary disorganization of non-dominant hemisphere, which in turn is able to produce characteristic somatic symptoms observed in a conversion reaction (Koles et Flor-Henry, 1981).

An EEG study of a woman with a hysterical paralysis on the left side was eloquent. Attempt to move the paralyzed leg has failed to activate right motor cortex. Instead, there were significantly activated orbitofrontal right cortex and right anterior cingulum which suggests that these two areas inhibit prefrontal cortex effects (willing), on the right motor cortex when the patient tries to move his left leg (Sadock and Sadock, 2000).

Dissociative disorders in DSM-IV-TR include dissociative amnesia, dissociative flee, dissociative identity disorder, depersonalization disorder and other dissociative disorder not otherwise specified (DSM-IV-TR, APA, 2000) In many cases, dissociation mechanisms are related to an avoidance of responsibility with regard to a given situation. The etiology involving exposure to a event with traumatic valence. Intensity, duration and age at which exposure to the traumatic event took place seem to be critical factors in the development of dissociative amnesia, in general, the stronger, the longer and the earlier was exposure, the more severe will be amnesia (Sadock and Sadock, 2000; Prelipceanu, 2003).

Dissociative flee may be understood as a state of amnesia in which forbidden wishes can be expressed symbolically and which protect their self’s. The relationship between the occurrence of these disorders and stressful event is evident if we consider the significant increase in the prevalence of these disorders during the World War II (Sadock and Sadock, 2000).

Histrionic personality, Narcissistic personality, Borderline personality described in DSM IV-TR as personality disorders belonging to Cluster B are characterized by the dramatic pattern, emotional and disorganized / unpredictable (DSM-IV-TR, APA, 2000), characteristics superposable those of classical hysteria (Prelipceanu, 2003) ; generalized grandeur (in fantasy or in behavior), need for admiration, lack of empathy are common expressions of attention directed towards themselves, most narcissistic people are talented, beautiful, or very intelligent, these characteristics constituting the nucleus around which is organized the feeling of being different, special, their common characteristic is represented by the use of dissociation, denial, splitting and transitions to act – as defensive mechanisms (Sadock and Sadock, 2000).

 

Conclusions

Terms of Hysteria is now used in everyday language, has a pejorative connotation and stigmatizing, in connection with a state of extreme nervous excitement manifested by a violent behavior and lose control over yourself. Today medical world use the term with caution to avoid stigma, preferring the psychogenic, convenient alternative to avoid Hysteria.

Psychiatric clinic can combine today the psychoanalytic concepts with neuroimaging evidence to explain the symptom, involving human psyche in development of cerebral structures being substantiated scientific.

Large clinical variability of hysterical symptoms, in the context of the current need of separating diagnostic entities as individuals, has made that the features of the syndrome defined centuries ago to form the basis for many diagnostic codes listed in DSM IV and ICD 10 classifications disorders. However, beyond the diagnostic criteria, psychiatric practice requires multidimensional assessment of the patient, therapeutic approach being directly related to the mechanism of occurrence of pathological condition.

 

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