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Hysteria Demystified

"Hysteria" is a much abused word. It is commonly misapplied, by the media and in common usage, to extreme laughter or crying or unmanageable emotions in women. However, extreme emotional outbursts are not "Hysteria".  I shall deal with extreme emotional instability and outbursts in the next issue. In this issue, we will see what Hysteria actually refers to. 

Hysteria is a mental disorder that causes bodily symptoms which cannot be traced to any physical cause and cannot be explained by a general medical condition. It is characterized by multiple persistent physical complaints that are associated with excessive and maladaptive thoughts, feelings, and behaviors related to those symptoms. The symptoms are not intentionally produced or feigned and may or may not accompany known medical illness. The father of medicine – Hippocrates - gave hysteria its name, as he thought it was limited to women and therefore connected to the uterus (Greek: hysteron). He postulated that, in affected women,  the uterus wanders around the body and produces toxic fumes that cause anxiety, sense of suffocation, tremors, sometimes even convulsions and paralysis or dysfunction in the 
part in which it settled. Today we know that the disorder is not confined to women (though it 
predominantly occurs in women), and has nothing to do with the uterus. 

The human mind has three virtual compartments. The "Conscious” which hold the thoughts and emotions that you are dealing with currently, the "Sub-conscious” which holds those thoughts and emotions that you do not want to deal with at present, but which you want to deal with later, and the "Unconscious” which holds thoughts and emotions that are too unpleasant or unacceptable. It is like an iceberg, with the "Conscious” part being evident to people around, while the sub-conscious is just below the surface, and the unconscious DEEP down below. Thoughts and emotions move freely between the Conscious and the Sub-consious. But, there is a barrier between the Unconscious and the Conscious mind (that deal with day to day experiences) which prevents repressed thoughts from surfacing into the conscious mind. 

These repressed thoughts are, therefore "forgotten" and cannot be remembered. The mind literally "has a mind of its own”. It takes protective action against thoughts / experiences that are too painful and threaten to disrupt the mind. When such thoughts occur and threaten to cause a severe breakdown, the protective defense mechanism of the mind, called "Repression” kicks in. Repression results in the offending thoughts / emotions / experiences being pushed deep into a "virtual” compartment of the mind called the 'Unconscious". 

In some situations the barrier between the Unconscious and the Conscious becomes weakened. This happens normally during sleep, and this is the cause of frightful dreams as the painful memories surface. The barrier is also weakened by intoxication or sedation and this is the reason for drunken rambling / rehashing of painful past experiences. The barrier breaks in delirium due to toxins created by certain illnesses, and causes terrifying hallucinations. However, once the person wakes up, or recovers from the intoxication, or illness, the barrier is back in place and the repressed memory cannot be brought into the Conscious. 

In some extremely stressful situations, however, the barrier is breached even while the person is conscious. When this happens and the painful thoughts surface, the mind disables a function of the body thereby preventing harmful outcomes of the thoughts. Hysteria is, therefore, caused as a response to painful surfacing of repressed of thoughts or emotions. Latha married Kumar after a stormy courtship, against her family's wishes. The marriage appeared to be made in heaven till her husband began to be jealously possessive of her, and began to drink. Soon he 
began to come home drunk every day and beat, insult, and abuse her for what he perceived as flirtations with men in the neighbourhood. Latha's parents and siblings tried to intervene, but after being publicly humiliated by Kumar, washed their hands off. Latha tried to put pass off her husband's behaviour as the outcome of his affection for her, but began to harbour murderous thoughts. These thoughts were so painful that they were Repressed by her mind. 
One fine night Kumar began to accuse her of a liaison with her neighbour. In his intoxicated state, he pulled off her saree and attempted to push her out of the house screaming at her to go and sleep with the neighbour. Latha's murderous thoughts now surfaced with a vengeance when she spied a knife on the nearby table. As she reached out to pick up the knife to stab her husband, her mind took protective action by disabling the function of her right hand. To Kumar, it appeared that his beating had resulted in a paralysis of his wife's hand. He immediately rushed Latha to the hospital where she continued to be unable to use her right hand. The doctors evaluated her, could find no organic lesion that could explain the paralysis and concluded that it was a hysterical "Conversion Disorder". 

Hema had an arranged marriage. The wedding was a stormy one with her in-laws demanding a whole lot of things and creating scenes when their demands were not wholly met. After the wedding the in-laws  continued to be overbearing, making her do all the house work in a joint family of 10 members, constantly making adverse comments about her work, her upbringing, her parents and her brothers. Hema’s husband was unsupportive, turning a deaf ear to her reports of the abuse and telling her to learn to be a good daughter-in-law and adjust to his parents. Attempts at intervention by her parents turned into a ding- dong battle with her parents being assaulted. Hema began to harbour thoughts of running away or committing suicide. But these were painful for a girl from a conservative background, and so her mind Repressed them.
As the abuse continued and the thoughts of running away began to surface intensely, her mind took protective action by switching off her consciousness. To her husband and in-laws, it appeared that  Hema fell unconscious. They rushed her to the hospital, where supportive treatment was given, but all investigations came out negative. After a few more such episodes and going into the detailed history, the doctors concluded that Hema suffered from hysterical "Dissociation disorder".

In view of the lack of a unified understanding of the mechanism of hysteria, and its varied manifestations the disorder is currently classified under three different disorders according to the manifestation viz, "Conversion disorder” manifested as a dysfunction of a part of the body (paralysis, fits etc), "Dissociation disorder” manifested as an alteration in the consciousness (fainting) or personality (multiple personality), and "Somatisation disorder” manifested as physical symptoms (such as pain). The symptoms of Hysteria immediately produce relief from the painful thoughts. In Latha’s case, the inability to use the arm prevented her from picking up the knife and stabbing her husband, thereby protecting her from the pain of the murderous thought. In Hema’s case, the loss of consciousness prevented her from acting on her urge to run away or commit suicide. The symptoms also have the added advantage of producing much needed care and sympathy from loved ones.

The essence of Hysteria, therefore, is the manifestation of physical symptoms or a loss or alteration of function of a part of the body or mind, which cannot be traced to any physical cause and cannot be explained by a general medical condition, and which occur in response to painful, excessive or maladaptive thoughts, or feelings, that the affected person is unaware of. The intensity and persistence of symptoms may reflect a strong desire to be cared for. Symptoms may help patients avoid responsibilities but may also act as self inflicted punishment. The biological basis of Hysteria is poorly understood due to limitations of currently available technology to study the brain.

Hysteria usually begins at a young age and is usually seen before age 30; Common presentations include:   Partial or total paralysis of one or two limbs, sensory disturbances like loss of the sense of sight, smell, touch etc.; involuntary movements of one or more limbs (trembling, shaking, jerking etc), eyeball rolling inwards, contracted facial muscles, abnormal posturing of the body; sudden loss of consciousness; loss of speech; or convulsions of part of the body or the entire body. The important point to note here is that the symptoms are not intentionally produced or feigned and the person actually experiences the symptoms. The person is not doing it deliberately or acting. Patients may become dependent on others, demanding help and emotional support and becoming angry when they feel their needs are not met. Attempts at reassurance are often interpreted as the physician not taking their symptoms seriously and the patients typically go from one physician to another or seek treatment from several physicians concurrently. 

The primary treatment is psychotherapy, particularly cognitive-behavioral therapy. The goal of 
psychotherapy is to explore and bring out the underlying causative factor and make the affected person recognize the link between the causative factors and the symptoms that are developed. Faulty cognitions that have led to the disorder are corrected using CBT. Family and psychosocial engineering is undertaken to correct causative factors if possible. Patients also benefit from having a supportive relationship with the mental health expert who sees them regularly and provides symptomatic relief. However, psycho-therapy and CBT are slow and time consuming, and the patient may also resist treatment overtly or covertly. Therefore, medicines may be used for providing quick symptomatic relief thereby developing faith of the 
patient in the treating doctor, establishing a therapeutic relationship, breaking down resistance and facilitating psychotherapy.

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