The Canadian Journal of Psychiatry

‘Hysteria' is a term with confusing uses covering a variety of conditions often with little or no functional relationship. Some salient historical aspects of the term are reviewed. The three listed categories of so-called hysterical reaction are: Dysmnesic and Conversion Reactions and Hysterical Personality. The first is discussed in summary form; the second and third in greater detail.

Dysmnesic reactions such as amnesia, fugue, twilight and trance states and multiple personality are explained on the basis of gross dissociation. Somnambulism, once included here, has now been shown to be associated with gross EEG. changes, and suggests that modern neurophysiological techniques may yet contribute factual data on the nature of presently obscure cerebral events.

Conversion reactions still remain explicable only in psychological terms, such as suggested by Freud. Present-day views include a wide range of interpersonal events as causal. The tacit association of conversion symptoms with the hysterical personality is no longer tenable. Such symptoms occur in many diagnostic categories. Organic brain disease may favour a predilection to the formation of conversion symptoms. Pain, as a common conversion phenomenon, should be labelled ‘psychogenic regional pain’, as suggested by Walters, but never ‘hysterical’. While conversion may be part of a communication process and often symbolic, it is not necessarily restricted to somatic motor and sensory systems. Certain symptoms, mediated in part or totally by autonomic pathways, may be symbolic or include conversion reactions in their chain of events. The psycho- or physiodynamics of conversion remain obscure.

Attempts to hew a syndrome out of the coincidence of multiple conversion symptoms in women with so-called hysterical personalities are unjustified and becloud thinking about the events involved.

The type of personality called ‘hysterical' or ‘histrionic' is only related to the dysmnesic or conversion categories by the semantic misdemeanor of confused usage of the word hysteria. It impies a person with childlike egocentricity and affective lability, on which is superimposed the more adult skills of melodrama and coquettishness. The psychodynamics of such personalities is discussed and a comparison made to Harlow's parent-deprived monkeys. The common difficulties in sexual relationships are commented on.

The origin of the concept of conversion reactions and the development of ideas concerning it are discussed. The presence of pre-œdipal components in this reaction, as described by various writers, is noted. Attention is directed to the important paper of Rangell, who has endeavoured to separate the blind linkage of the words ‘conversion’ and ‘hysteria’. His considerations on the psychodynamics of the conversion process are discussed in detail.

Conversion is a psychological concept and can only be seen as one step toward a symptom or lesion and depends upon other factors such as previous disease or injury. The possibility of predisposing factors being present at birth which help determine the development of conversion symptoms is emphasized. The attitude taken originally by Alexander that conversion symptoms are confined to the sensory motor system is found to be too restrictive, for there are many accounts of conversion symptoms occurring in structures innervated by the autonomic nervous system. The important recent work of Miller and his associates on the capacity of animals to alter heart rate or intestinal contraction for a reward is considered as effectively demolishing the artificial distinction between the somato-sensory and autonomic nervous system in so far as learning is concerned.

Psychological theories of the etiology of conversion reactions are reviewed, beginning with Janet's concept of dissociation and Freud's emphasis on the importance of the Œdipus complex. Other opinions which are dealt with, view conversion as somatized activity below the symbolic level. The conflict in theory between those who see conversion reactions as a manifestation of dissociation and those who see repression as the principle mechanism, for example Fairbairn, is noted. The emphasis placed by Engel on perception of memory traces as a result of experience giving rise to an anlage of body language, is pointed out.

Significant traits of the hysterical or histrionic personality are reviewed. Particular attention is paid to the important paper of Lazare, Klerman and Armor, in which the traits are factor analysed, and five of the seven were found to have a high degree of correlation in the patients examined. Two other traits, namely aggression and oral aggression, which had not been anticipated as belonging to this group, were found to have a high degree of correlation, thereby supporting Marmor's concept of the basic importance of oral fixation in the hysterical personality.

Physical correlates of the hysterical character may be found in the work of Shagass on the sedation threshold. It is found to be low in this type of individual. The sexuality of the hysterical character was examined in reports from the literature and considerable weight was given to the report of Prosen on two cases considered hysterical characters, in which there was a high degree of orgastic activity reported. In both instances there was a severely unresolved œdipal situation.

Recent important contributions to the psychoanalytic study of the hysterical personality from the studies of Easser and Lesser and of Zetzel are considered in detail. Many of the cases of the former authors could be called cryptic, because the diagnosis became manifest only during therapy. A more severe type of case with extreme bizarre emotional lability and poor relationships was characterized as hysteroid. These latter cases were difficult or impossible to treat. Zetzel divided a large series of cases into four groups, depending on their suitability for analysis. Her fourth group called ‘florid hysterics' coincides relatively well with the hysteroids of Easser and Lesser.

In 1959 I suggested that the term ‘hysterical pain’ be replaced by the term ‘psychogenic regional pain’. Now, with this innovation having proved useful, I am suggesting that the term ‘psychogenic and regional' replace the term ‘hysterical' for the following sensory and motor symptoms and signs: pain, tenderness, sensory deficits, motor deficits of power, movement and posture, ataxias, involuntary movements and fits. These are the sensory and motor phenomena which have been called ‘hysterical’ or due to ‘conversion hysteria’ or due to ‘conversion reaction’.

‘Psychogenic' means being evoked by psychical factors. ‘Regional' indicates a bodily region of contiguous parts as a strip, area or volume with boundaries defined by psychical circumstances. This is a bodily region of psychological reference with all the parts in the contiguous locality co-operating together in regional behaviour that has psychical significance.

By dropping the term ‘hysteria' from all these symptoms and signs we avoid the confusing fact that the phenomena occur in all sorts of psychoses and neuroses and are not confined to any clinical condition which might be called ‘hysteria’. The phenomena also often occur in persons who do not have a personality which could be called ‘hysterical’. Furthermore, persons with ‘hyterical personalities' do not necessarily develop such symptoms and signs. Incidentally the term ‘psychogenic regional' releases these phenomena from any implication that they are necessarily ‘conversion' reactions. While a conversion process may be one way such sensory and motor features come about, the conversion mechanism may produce other symptoms and signs and the sensory and motor signs may be produced by other processes than conversion.

The term ‘psychogenic regional' has the advantage that it leaves these symptoms and signs as natural phenomena, defined and denoted descriptively, free of any concept of specific disease entity or psychodynamic process. By this means the natural history of these sensory and motor features can be elucidated independently of other considerations. By the same means such concepts as hysteria, conversion, dissociation, symbolization and regression can be varied from time to time without disturbing the identity of these signs. With the new clinical, neurophysiological and psychosomatic knowledge we can expect the usefulness of the term ‘hysteria' to decline and the meaning of the term ‘conversion' to be extended. We can also expect new knowledge of the representation at bodily sites by remote localization, by symbolization, by somatic hallucination or by somatic excitation or inhibition. We can expect new knowledge of the involuntary action of the voluntary nervous system and of the voluntary and behavioural action of the involuntary autonomic nervous system. The role of affective, schizophrenic, regressed, dissociated and disintegrated states is relevant to much of the psychopathology and calls for attention. The new neurophysiology of behaviour will be likely to provide models which will help us to understand how somatic analogues can be related to psychic experience as non-verbal body language.

In the past it has been a matter of historical accident that these sensory and motor symptoms and signs have been called ‘hysterical' and related to ‘hysteria’. It is now recommended that such terms be dropped and that these symptoms and signs be given the simple descriptive designation ‘psychogenic regional’. With this, we should speak of ‘psychogenic regional' pain, tenderness, anesthesia, paralysis, fixed posture, ataxia, involuntary movement or fit or convulsion. When such symptoms and signs occur with ‘la belle indifférence’ they can be denoted as ‘complacent re-actions’. This will make for accuracy in clinical descriptions and clarity in thinking of pathological processes.

This paper is based on a review of the English language medical literature over the past 35 years on Indian Hemp, with direct reference being made to the more significant articles published during that time. The paucity of direct experimental observation is noted and the difficulties in experimental studies are highlighted by descriptions of the wide variations in the potency of Indian Hemp derivatives. Specific references are provided for the wide range of observations made in relation to acute and chronic physical and psychological effects, personal characteristics of the users and possible factors in causation. It is concluded that marihuana is a poorly defined intoxicant which varies in potency, deteriorates with time and whose chemical composition is largely unknown at present. There are wide variations in human response and the state of intoxication itself carries with it varying degrees of unpleasant physical and psychological experiences. The association between hashish and, to a lesser extent, marihuana and short-term and long-term complications is discussed in relation to complex variables, of which the drug is but one factor.

The author reports on a recent nationwide survey concerning various aspects of child psychiatry in Canada: services, manpower, training and research.

Only 150 (out of 1500) psychiatrists devote most of their clinical time and interest to children: the scarcity of manpower and services is found to be more serious for young patients than for adults.

Child psychiatry is a well-recognized specialty in the U.S.A. and in most European countries, with its own training requirements and certification criteria. The Canadian Psychiatric Association has endorsed the proposal of its own Section on Child Psychiatry and Mental Retardation, that child psychiatry be considered by the various accreditating bodies (for example The Royal College of Physicians) as a sub-specialty with its own certification mechanisms.

Most areas of Canada are now in a position to provide very adequate training in child psychiatry and the present number of annual graduates (25) could easily be increased if an official status and recognition could be granted to those colleagues whose careers will be dedicated to the care of children.

Canadian child psychiatrists form a rather eclectic and heterogeneous group as their sources of training have been quite diversified including mainly the academic centres of three countries: U.S.A., Great Britain and France. Such a diversity has proved to be beneficial and has contributed to the dynamic development of this sub-group (if not, sub-specialty) among our psychiatric fraternity.

The addicting influence of morphine sulfate on the nervous tissue of new-born rabbits and puppies was studied by using the tissue culture technique. Certain low concentrations of morphine seemed to stimulate the growth of the cells as mitosis and proliferation increased. Nerve cells subjected to morphine sulfate developed increasing tolerance and physical dependence, which was tested through the processes of exposure to higher concentrations of morphine sulfate, withdrawal and reintroduction of this drug to the tissue cultures.

The purpose of this study is to explore some of the psychodynamics of concentration camp survivors. There is growing evidence that in reactions due to extreme environmental stress we are dealing with a condition akin to psychosis or a borderline state. The chronicity of the condition, the clinical symptoms observed and poor response to treatment support the hypothesis that severe trauma results in unmodifiable ego changes. Two related ego alterations are discussed, namely, ego exhaustion and changes in the ego-superego boundary as a result of overwhelming guilt and shame. Ego exhaustion seen here is similar to that encountered in aging. In the aged continued losses and anatomical and physiological decline prevents reparation. Restitution in the concentration camp survivor is difficult because of the continuing ego-superego conflict.

A case is presented and problems encountered in the treatment of survivors are briefly outlined.

Further longitudinal studies and particularly reports of long-term treatment of survivors would help us gain further insight into the problems of massive traumatization.

A case of a forty-seven year-old male with a three-year history of daily prolonged exposure to perchlorethylene has been reported. Acute symptoms included nausea, vomiting, dizziness, staggering gait and disorientation followed by deep sleep. Chronic symptoms were fatigue, irritability, lability of mood, inappropriate affect, mild disorientation, difficulty with recent memory and perserverative stammering speech, which remained over a twelve-month follow-up period despite lack of further exposure.

The literature on perchlorethylene intoxication was reviewed and a marked similarity of the patient's symptoms to those described by other authors was noted. This case differed in the length of exposure and the persistence of symptoms a year after exposure had ceased.