A Follow-Up of Patients Diagnosed as Suffering from "Hysteria"

With E. Glithero. Journal of Psychosomatic Research 9: 9-13 (1965)

In 1962 we tried to follow up all the patients who had gone through the wards of the National Hospital during the years 1951, 1953 and 1955, and had been given a diagnosis of "hysteria." We tried to contact 99 patients, and actually succeeded finding out the after‑histories of 85 of them, 32 men and 53 women. One third the women and one quarter of the men had been diagnosed as hysterical by one other of the Hospital's psychiatrists; in the remainder the diagnosis had been ma. on the neurological side. In the course of the follow‑up 5 patients were admitted to the National for re‑assessment, 35 came up and were seen in an out‑patient capacity, 30 were visited (by E. G.) at home, and in 15 cases we depended for information on relatives, doctors, letters and records. In 12 cases the patient had died.

   One does not expect patients suffering from hysteria to die in considerable numbers after a relatively short interval, and you will ask for some further explanation. Our patients were mainly a middle‑aged group, with mean age for the men of 42 years and 37 years for the women. Three men and one woman committed suicide at intervals of 3 to 6 years after their illness in the National Hospital. Eight patients were aged 31 to 57 years on admission, and died of natural causes at a mean interval of 3 years after the diagnosis of hysteria was made. We can be reasonably sure that all the conditions which eventually proved fatal had been present at the time when the diagnosis of "hysteria" had been made. In some cases one might say, either that the clinician was aware of the existence of the killing disease, or that, as with two patients who later had coronary thromboses, the cause of death was related some­what indirectly with the presenting symptoms. In other cases the effective cause, both of the presenting symptoms and of eventual death, was present but overlooked. These include a case of generalised vascular disease, a case of old brain injury and epilepsy, and two neoplasms, a renal carcinoma and an angioma of the brainstem.

    The four suicides also make an interesting group, and it is unfortunate that we know practically nothing about the one woman among them. One of the three men was in the National for "barbiturate intoxication and hysteria," and committed suicide by gas three years later. The second was a man admitted to the National at the age of 52 years with unsteadiness of gait, pain in the legs, urgency of micturition and impotence. There were no abnormal physical signs and both neurologist and psychiatrist agreed in a diagnosis of "hysteria." He gassed himself four years later; but in the interval had twice been in the Maudsley Hospital, where on each occasion a diagnosis of disseminated sclerosis with hysterical elaboration was made. The last case is that of a man of 38 years who came into hospital complaining of weakness of the legs and abdominal cramps. In an amytal interview he confessed that he was an exhibitionist, and that the present symptoms had begun after an episode in which he had been chased and nearly caught by a park‑keeper. He was diagnosed as suffering from "hysteria," and his symptoms of weakness were thought to be without organic basis. However, five years later he was re‑admitted to the National, and was then found to have an atypical myopathy. He was a man who was subject to depressions, and more than once had been in psychiatric hospitals. It was in a recurrence of depression that he finally killed himself. To summarise, in this group also we see organic disease, a myopathy and disseminated sclerosis, eluding diagnosis; but we also get a hint that cyclothymic mood changes may underlie hysterical manifesta­tions or hysterical appearances.

   After we have eliminated the patients who died, we can classify the remaining 73 patients into three groups. First are those for whom the diagnosis of "hysteria" was coupled with an organic diagnosis. Second are those who were regarded as purely hysterical at the time, but whose subsequent history indicates that organic illness was present and undetected all along. Third are those who, even now, are free from any evidence of organic disease.

   In the first group we have eight men and eleven women. These are the cases in which the clinician is inclined to talk of a "hysterical overlay," or to regard some symptoms as not determined by the known physical disorder. Typical examples of this group are the epileptics some of whose fits are thought to be hysterical; and the sufferers from disseminated sclerosis, multiple disc lesions, etc., whose pains, or anaesthesia, or disturbance of gait, do not fit the expected picture. From a prognos­tic point of view, the addition of "hysteria" to the diagnosis seems to make little difference. The hysterical admixture is of temporary duration, and in the long run the course of the illness is that of the basic organic process.

   The second group, in which an organic basis for the symptoms was eventually disclosed, though it had been missed at the time of admission to the National, includes eight men and fourteen women. In most of these cases what follow‑up has brought is a changed interpretation of medical facts that have not changed. But in some cases the observations on which the diagnosis of hysteria was made were incomplete. Examples of the pathology which has since been uncovered are, duo­denal and gallbladder disease, Takayashu's syndrome, meningitis serosa circum­scripta, and three cases of generalized brain disease ‑ a young woman with cortical atrophy and two men who have steadily deteriorated into presenile dementia.

   We are finally left with the third group of 8 men and 24 women in whose cases no evidence for organic illness has yet been found. Two of these patients have developed into unambiguously schizophrenic states. No fewer than eight of them have shown themselves as liable to cyclothymic depression.

   These are instructive cases, since it seems probable that the patients were in a depressed state at the time that the diagnosis of "hysteria" was made, even though the mood change was not recognised. The complaints these patients made were rather nebulous and usually included weakness and exhaustion. Physical symptoms included giddiness, pains and paraesthesiae, and faints or black‑outs. Specifically depressive symptoms, other than insomnia, could hardly be expected and are not mentioned in the records. All but two of these patients were quite well at the time of follow‑up, although recovery in one case was not achieved until after a leu­cotomy, and in another is only maintained with the aid of imipramine. Several of these patients have had recurrences of affective illness in the interval. One woman had had clear cut depressive illnesses at the age of 18, 30, and 48, in the last of which conversion symptoms appeared. She has had two further hospital admissions since for the same hysterical difficulties in walking; and it seems that in her case any relapse into depression potentiates the tendency to dissociation.

   The aetiological breakdown of the material finally leaves us with 21 patients, less than a quarter of the group with which we started, in which no underlying pathol­ogy can be traced. Among them are seven patients whose illnesses were in the nature of acute psychogenic reactions. These patients were very young, and included chil­dren of 9, 11 and 13, two young men of 18 and 21, and only two adults aged 35 and 45. There was definite psychogenesis in every case, but in two cases it was never discovered in hospital. All these patients had typical conversion syndromes; all of them were well on follow‑up, but three of them have shown tendencies to develop symptoms when stressed.

   More chronic states were shown by 14 patients, 3 men and 11 women. The long‑term course of these illnesses has not been encouraging. One girl came into the National at the age of 15, with a very short history of two weeks' pain behind the car and double vision for two days. We didn't do her any good, and she went on to the Maudsley Adolescent Unit. Since then she has attended about twenty‑five differ­ent hospitals; and though she is now married with two children, she spends much of her time in hospital.

   Not all have done so badly. One woman is virtually symptom‑free after 28 yea of periodic attacks of weakness. One woman, who never forgave us for diagnosing "hysterical" her right facial pain of eighteen years' duration, has forsworn hospital. ever since, and rarely even goes to see her G.P. When she gets the pain, as she doe.. for instance, after exposure to cold, she puts up with it. Another woman of 5 years, who had suffered from weakness of the legs all her life, was eventuali persuaded to put up with her trouble when she was advised that it was due to "sixth sense nervousness." "If only I had known that all along!" she said.

   All the other patients in this group are attending hospitals or doctors. Four of them are partially disabled and three are totally disabled, one of them after a disastrous prefrontal leucotomy. These severe and chronic states remain an unsolved mystery. In some cases one can content oneself by regarding the patients as invalids of choice; in other cases one cannot do so with conviction. With these last one has the impression that at any time might emerge some physical factor, on which the whole tremendous hysterical superstructure had grown up. But one may wait for this in vain.

   What have we to learn from this enquiry about the bodily conditions which may predispose to states liable to be called hysterical? Organic disease appears capable of doing this in two principal ways. The less interesting is by the production of a local lesion or disorder of function which is liable to be misunderstood, for instance, because the symptoms are atypical, because there is no evidence of a physical basis, or because the symptoms could be understood as a conversion reaction. Naturally, in the National Hospital material, these local lesions are predominantly neurological. Thus we have three cases of minor damage to an eye which caused a defect of vision thought to be hysterical, three cases of facial pain, two of them later successfully dealt with by the neurosurgeon, four cases of local spinal lesions, two cases of minor damage to the vestibular system, a basilar vessel migraine, etc.

   Alternatively organic disease may bring about a general disturbance involving the personality. This personality change may then be a basis for hysterical conversion reactions, or by causing affective lability, hypo chondriasis, attention‑seeking, self­concern, suggestibility, variability of symptoms, etc., lead directly to an unfavour­able reaction on the part of the clinician. In 1961 (94), I wrote, "In some sense it is true to say that "hysteria" is a label assigned to a particular relationship between observer and observed; it appears on the case‑sheet most readily if the doctor has found himself at a loss, if the case is obscure and if treatment is unsuccessful." These are conditions which are especially likely to be fulfilled if the patient has a person­ality disorder.

   Conditions which were noted as producing effects in this way included six cases of epilepsy, four cases of cerebral vascular disease, three cases of brain damage in childhood, and cases of damage done by head injury, subarachnoid haemorrhage, encephalitis, meningitis, polyneuritis and pre‑frontal leucotomy. Disseminated sclerosis is particularly frequently associated with a diagnosis of "hysteria" since it operates at two levels. It both produces an organic personality change, and also causes focal symptoms which are variable, of temporary duration, and likely to be highly unpleasant to the patient while still difficult to confirm by objective methods. Despite the alertness on the part of the clinician which this condition inspires, two cases found their way into the National Hospital material.

   Among the functional syndromes which especially predispose to hysterical mani­festations, endogenous depression occupies a place of importance, with schizo­phrenia also playing a part.

   It is not easy to generalise about the nature of the organic noxa nor its site of impact. But it does seem as if frontal and central sites of impact, possibly classifiable as parts of the visceral brain, are the most likely ones. At least one, and probably more than one of our epileptics had a temporal lobe epilepsy; and our material included two lesions of the brain‑stem. All the other disorders found are such as cause widespread effects.

SUMMARY

In 1962 an attempt was made to follow up 99 patients who in the years 1951, 1953, and 1955, had left the in‑patient department of the National Hospital, in­cluding the psychiatric ward, with a diagnosis of "hysteria." Of these patients it was possible to contact 85 (32 men and 53 women).

   Since leaving hospital, 4 patients (3 men and 1 woman) had committed suicide and 8 patients had died of organic disease which must have been present at the time when the diagnosis of "hysteria" had been made.

   Of the 73 living patients, 19 (8 men and 11 women) had received in hospital the diagnosis of "hysteria" coupled with an organic diagnosis. In 22 cases (8 men and 14 women) the subsequent history indicates that organic illness was present but unde­tected when the diagnosis of "hysteria" was made. Finally, there remain 32 patients (8 men and 24 women) who still show no evidence of organic disease. The last group comprise 2 patients who have developed clear‑cut schizophrenia, 8 who have shown themselves liable to cyclothymic depression, 1 woman whose conversion symptoms appeared in the course of a severe depressive illness, and 21 patients who still have no demonstrable underlying pathology. Of the patients "without pathology," 8 are severely disabled (5 partly and 3 totally).  

   Organic disease appears to predispose to conditions liable to the risk of diagnosis as hysterical, mainly in two ways. It may cause a lesion with accompanying symptoms which at one stage are atypical or without demonstrable evidence of a physical basis, but which could be understood as a conversion reaction. Alternatively organic disease may bring about a general disturbance involving the personality which results in modes of behaviour (exaggeration, attention‑seeking, etc.) which we naturally think of as the typical manifestations of "the hysterical personality."