By Siri Hustvedt, from a keynote lecture delivered in Paris at this year’s winter meeting of the Société de Neurophysiologie, to be published in a special issue of Clinical Neurophysiology, “Conversion Syndrome and Its Boundaries.” Hustvedt is the author of several works of fiction and non-fiction. The Blazing World, a novel, will be published in March by Simon & Schuster.
In the mid-1980s Gretchen Van Boemel, director of clinical electrophysiology at the Doheny Eye Institute at the University of Southern California, began seeing dozens of patients complaining of blindness or severely compromised vision. A number of them had already visited optometrists and ophthalmologists who had accused them of malingering. Although Van Boemel could find no explanation for their failing vision, the women — they were all women — had a shared story: they were Cambodian refugees who had survived Khmer Rouge atrocities. One woman, who had seen her family taken away to their deaths in 1975, reported that she had cried for four years and when she stopped she was blind. Another woman had been forced to gather fellow inmates to watch executions in a Khmer work camp. The soldiers insisted that the witnesses show no emotion while their family members and friends were beaten to death, hanged, beheaded, or disemboweled. She attributed her blindness to the fact that she had been beaten so often by the Khmer Rouge that her spirit had left her body. Van Boemel and the psychologist Patricia D. Rozée, her coauthor, saw 150 Cambodian women suffering from what would eventually be diagnosed as hysterical blindness.
Despite shifting medical classifications, hysteria has long been characterized as an ailment that takes on the appearance of, or mimics, other ailments, can spread from one person to another, and is somehow related to strong emotions. In his epistolary dissertation of 1682, for example, the English physician Thomas Sydenham described the disease as “proteiform and chameleon-like” and linked it to a person’s “antecedent sorrows.” The word “hysteria” has embraced many symptoms over time, including blindness, deafness, paralyses, and fits, and has been traced to myriad causes. Most common as a diagnosis in the late nineteenth and early twentieth centuries, hysteria is perhaps now most closely associated with Freud. Although the illness played an important role in his theories about memory and repression, he left hysteria behind him as he developed and revised his model of the mind in psychoanalysis. By the latter part of the twentieth century, hysteria had become an embarrassment in both neurology and psychiatry, tainted by its connections to psychoanalytic ideas that had fallen from favor as well as the unpleasant truth that no one even had a hypothesis about what the phenomenon might mean in biological terms. It did not help, of course, that it was also considered a woman’s disease.
It was Jean-Martin Charcot (1825–93), the renowned French neurologist, who made hysteria famous, at Paris’s Pitié-Salpêtrière hospital. Charcot argued that hysteria was not exclusive to women, identified it as a neurosis — a neurological rather than a psychiatric disorder — and hypothesized that it was caused by elusive “dynamic or functional lesions” that left no trace on the brains he examined during autopsies. In his study of the illness, he nevertheless assigned a role to suggestion — a psychological factor often related to a shock. Charcot also believed that, through hypnotic suggestion, he could create “artificial hysteria” in his patients, a state that mimicked the mimicking disease. As my sister, Asti Hustvedt, describes in detail in her book Medical Muses, Charcot’s public demonstrations of hysterical female patients in front of fascinated audiences would become notorious as examples of blatant medical exploitation. But, she argues, the story is not so simple. “Located on the problematic border between psychosomatic and somatic disorders, hysteria was a confusion of real and imagined illness.” She is right. The spectacles Charcot staged have, I think, obfuscated his scientific contributions to understanding hysteria and created an idea among scholars, especially in the humanities, that hysteria was a medical invention in which ideology and the use of photography collided to create a purely socially constructed disease that has since disappeared.
Although no one today would recognize Charcot’s rigid description of grande hystérie, every neurologist has seen patients who suffer from what are now called conversion, functional, or somatoform disorders. The fundamental question remains: How does an idea or psychological factor — generated internally or externally, consciously or unconsciously — create symptoms that mimic neurological disorders — paralyses, seizures, muteness, deafness, and blindness? We can all imagine falling ill with stroke or epilepsy or a sudden paralysis; this is our human gift of reflective self-consciousness. But conscious fantasies cannot produce actual symptoms in me any more than dreaming I have a limp will cause me to wake up with one.
What role does the imagination play in the physiology of hysteria? Is hysteria an illness of unconscious acting, as so many neurologists seem to believe? In his lectures on hysteria at Harvard in 1906, Pierre Janet — philosopher, neurologist, and younger colleague of Charcot — explicitly connected the imagination to hysteria.
An individual has his legs in a state of contracture because, he says, a carriage ran over them. After verification it is found that the carriage passed beside him, and that he felt nothing at all. A real shock would do less than this imaginary shock.
Janet implies that the hysterical response is a kind of physiological metonymy. The thought or idea that one’s legs are crushed instigates actual contractures, just as hypnosis might.
In Studies on Hysteria (1895), the book he wrote with Freud, Josef Breuer noted about his most famous patient, Anna O. (whose real name was Bertha Pappenheim), that “even when she was in a very bad condition — a clear-sighted and calm observer sat, as she put it, in a corner of her brain and looked on at all the mad business.” In other words, Pappenheim seemed to have a form of double consciousness — a duality reminiscent of hypnosis, which Breuer used, among other techniques, in her treatment.
Was Charcot right that hypnotic trance reproduces or imitates hysteria? Studies have demonstrated that while under a hypnotic suggestion to feel no pain, subjects insist they feel nothing, despite the fact that pain is registered in their sensory-perceptual systems. Ernest Hilgard, who wrote extensively on hypnosis, used the term “hidden observer” to refer to a figurative homunculus the hypnotist can call on to bring to consciousness the experience of pain that had previously been processed unconsciously. Hilgard’s “observer” sounds tantalizingly like Pappenheim’s. In a 2000 study that compared the PET brain scans of conversion patients with those of people under hypnosis, Peter Halligan and his colleagues concluded that “hypnotic phenomena provide a versatile and testable model for understanding and treating conversion hysteria symptoms” — a statement that echoes Charcot, Janet, and the early Freud but does not constitute a theoretical advancement on any of them.
“In reality what has disappeared is not the elementary sensation,” Janet writes, “it is the faculty that enables the subject to . . . say clearly, ‘It is I who feel, it is I who hear.’ ” The hysteric who suddenly goes deaf or blind has not lost the physiological equipment needed to hear or see; he has lost the connection between his feeling of agency and the sense of hearing or sight. Is the hysteric, like the hypnotized subject, somehow unhinged from his own will via suggestion, which turns an imaginary state into an actual one?
The suspicion that conversion disorder is a fictional, unreal complaint continues to plague both medicine and neuroscience research. Yet several neuroimaging studies devoted to distinguishing between conversion and malingering have concluded that conversion patients have brain activation that is different from those asked to fake equivalent symptoms. The visible differences between pretending to be paralyzed and a conversion paralysis have helped make hysterical conversion “real,” or more real, anyway. It is safe to say that without the new technology, hysteria would have remained in the dustbin of medical history.
Conversion disorder forces us to examine the Janus face of what neuroscientists and philosophers have come to call the mind-brain. What is psychological and what is physiological? If we are monists, as nearly everyone these days claims to be, how can the two be different? Conversion is not the only mind-body riddle in medicine. What exactly is the material reality of the belief that triggers the placebo effect? It has been discovered that placebos cause opioids to be released in the brain, which make a person feel better. How does my imagination release opioids?
S., the subject of A. R. Luria’s case study The Mind of a Mnemonist, explained that he could alter his heart rate via mental imagery. By imagining himself running to catch a train, he went from a resting state of seventy heartbeats per minute up to one hundred and then, by imagining himself lying in bed falling asleep, down to sixty-four. Although Luria could not see the pictures in S.’s brain, he monitored the effects.
To summon another example, how can an emphatic wish to be pregnant result in abdominal swelling, uterine enlargement, labor contractions, and measurable changes in neuroendocrine hormone levels? Although common in dogs and some other mammals, the phenomenon of pseudocyesis, or false pregnancy, in human beings is tied to both imagination and culture. The once familiar phenomenon is now rare in the developed West, probably due to the routine use of sonograms during pregnancy. In a 1978 study of pseudocyesis, the authors Murray and Abraham wrote that “the role of psychogenic factors in the control of the neuroendocrine system is becoming one of the most exciting areas of psychosomatic medicine.” What does a wish look like in a brain?
In neuroscientific brain-imaging research (mostly MRI and PET scans), the implicit spatial metaphor that appears again and again is of two horizontal planes hanging in empty space: neural brain functions occupy the lower plane, and hovering above them are psychic or mind functions. Between them is a theoretical no-man’s-land. As the neuroscientist Vittorio Gallese has pointed out, “Chances that we will find boxes in our brains containing the neural correlates of beliefs, desires, and intentions as such probably amount to next to zero.” Because philosophical debates continue to rage over what we mean by the psychological as opposed to the physiological, there is no consensus about what the brain-mind construct currently in use everywhere actually means.
Rather than charting correspondences between two distinct realms, psyche and soma, we can look for meanings in a body that is socio-psycho-biological. The brain is an organ of the body, after all. This unified approach has been impeded, however, by another conventional, disembodied metaphor for (or even literal description of) the mind: the computer. Computational theory of mind, which first came to prominence in the 1960s, has had a powerful influence on neuroscience research, an influence seen even in the terminology for the brain; scientists speak of “processing,” “inputs,” and “outputs.” Although computation may describe part of what our minds do, neither human emotion nor development fit easily into the machine model. Human beings are born helpless and dependent, and our plastic brains develop through our experiences, including our emotional relations with important others. Shocks and deprivations in early life affect the nervous system in ways that dictate a person’s reactions to stress in later life. Traumatic experiences have also been implicated in gene expression. Nurture cannot be separated from nature. Nurture becomes nature.
Everyday human experiences constantly challenge mind-body dualism. We live our emotions bodily — in a flush of shame, in the genital burn of lust, in hot, breathless fury, or the lift of elation when a good idea hits. And, although these states may be born in the actual moment of an encounter with another person, they can also be triggered by watching someone else’s joy or shame or lust, or simply imagining our own.
Hysteria, like hypnotic trance, may involve knowledge at a subliminal level, which can become conscious. The disturbance of hysteria might interfere with reflective self-consciousness — knowing that we know — or what the neuroscientist Antonio Damasio has called “the self as witness . . . the something extra that reveals the presence, in each of us, of events we call mental.” It is not strange to think that emotional shocks might derange this sense of self as witness. Research in post-traumatic stress disorder has shown numerous physical changes in people who suffer from it, including altered levels of the stress hormone cortisol.
No doubt the largest number of reported cases of hysteria occurred among soldiers during World War I. Charles S. Myers, who was among the first to use the term “shell shock,” proposed that the military men in his care suffered from a “snap or fission, whereby certain nervous or mental processes” became “functionally dissociated” or “unconsciously repressed” through inhibition. He also noted that his patients demonstrated alternately what he called an “apparently normal” personality and an “emotional” personality. The apparently normal personality — not the emotional one — presented with hysterical symptoms. For Myers, hysteria was adaptive. An involuntary physical handicap appears in place of an intolerable emotion or memory and, by doing so, restores the patient’s consciousness to an apparently normal condition. He further observed that hysteria occurred more often in ordinary soldiers than in officers, which he explained by noting that while an officer is busy issuing orders and worrying over his responsibilities, “his men can do nothing during the shelling but watch and wait until the order is given for an advance.” It is here that we find a link between the combat soldier with hysterical symptoms and the women, past and present, who have suffered from the same symptoms outside of war: a sense of helplessness in the face of overwhelming, uncontrollable circumstances. Women have traditionally had far less to say about their fates than have men. This is still the case in many places in the world. Hysteria might be described as a crisis of agency and volition.
There is no pharmacological treatment for hysteria. However, hypnosis and verbal suggestion, as well as psychotherapy, have been effective for some patients. If hysteria involves an imaginative embodiment of traumatic emotional experience, it makes sense that restoring a perception of agency — the feeling of “I” in “I move” — may begin the process of healing. Every conversion patient has a story, and his or her personal narrative is vital to understanding the physiological theater of the symptom. The woman who saw her family taken away from her said that she wept for four years, and when she stopped weeping she was blind. In her case, and in the case of her fellow refugees, the transformation from witnessing horror to experiencing blindness can be described as symbolically perfect: the women’s bodies have become ambulatory metaphors of unbearable experience.
Understanding hysteria will require an upheaval in our understanding of what the mind-brain actually is, a change that is already under way. It is the body that carries meaning, meaning that is at once felt and symbolized. Our brains are in that body, and the language we share is one of the body’s communicable gestures. A deep comprehension of hysteria will require multiple methods — brain imaging certainly, and the neural locationism it inevitably inspires, combined with more dynamic, narrative models that include self-reports and case studies. It will also involve taking ideas from the past seriously and discarding the hubris of the present. It is well worth remembering what William James wrote in his Psychology: Briefer Course. The only hope for science is “to understand how great is the darkness in which we grope, and never to forget that the natural-science assumptions with which we started are provisional and revisable things.”