March 25, 2000 The Anthropology of Hysteria Laurence J. Kirmayer, M.D. Radhika Santhanam, Ph.D. Culture & Mental Health Research Unit Sir Mortimer B. Davis — Jewish General Hospital & Division of Social & Transcultural Psychiatry McGill University Kirmayer, L. J., & Santhanam, R. (2001). The anthropology of hysteria. In P. W. Halligan, C. Bass & J. C. Marshall (Eds.), Contemporary Approaches to the Study of Hysteria: Clinical and Theoretical Perspectives (pp. 251-270). Oxford: Oxford University Press. Address correspondence to the first author at: Institute of Community & Family Psychiatry 4333 Côte Ste. Catherine Rd. Montreal, Quebec H3T 1E4 Tel: 514-340-7549 Fax: 514-340-7503 E-mail: [email protected]
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March 25, 2000
The Anthropology of Hysteria
Laurence J. Kirmayer, M.D.
Radhika Santhanam, Ph.D.
Culture & Mental Health Research Unit
Sir Mortimer B. Davis — Jewish General Hospital
&
Division of Social & Transcultural Psychiatry
McGill University
Kirmayer, L. J., & Santhanam, R. (2001). The anthropology of hysteria. In P. W. Halligan, C. Bass & J. C. Marshall (Eds.), Contemporary Approaches to the Study of Hysteria: Clinical and Theoretical Perspectives (pp. 251-270). Oxford: Oxford University Press.
Address correspondence to the first author at: Institute of Community & Family Psychiatry 4333 Côte Ste. Catherine Rd. Montreal, Quebec H3T 1E4 Tel: 514-340-7549 Fax: 514-340-7503 E-mail: [email protected]
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Abstract
This chapter reviews the cross-cultural literature on hysteria and conversion
disorders. Ethnographic research suggests that conversion symptoms remain common
around the world, particularly in primary care medical settings. Sociocultural processes
may influence conversion disorder at several different levels: (1) the nature of illness
beliefs and practices and the expression of distress; (2) the salience and availability of
dissociative mechanisms; (3) the response of the family, health care system, and larger
social systems to specific types of symptom. The higher prevalence of conversion
symptoms in some societies can be attributed to the fit of symptoms with local
ethnophysiological notions and cultural idioms of distress as well as the stigma
attached to frankly psychological or psychiatric symptoms. The distinctive nature of
conversion symptoms, compared to other forms of culturally patterned somatic distress,
resides in the experience and ascription of agency or volition, which in turn, depends
on cultural knowledge and social practices that shape cognitive processes of bodily
control. While current psychiatric theory tends to view dissociation (and by extension,
conversion) as a consequence of trauma, dissociation can be understood as culturally
patterned or scripted and depends on specific modes of narrating the self.
Contemporary anthropology approaches hysteria as a mode of self-construal in which
narratives of not-knowing and not-doing fit with prevalent cultural conceptions of the
person and serve to convey serious distress and disablement.
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The Anthropology of Hysteria
Introduction
Hysteria in its various guises has been a staple of anthropological studies of illness
and healing. This is so both because of the dramatic and colourful performances
associated with many hysterical conditions and because of their obvious links with
cultural beliefs and practices. A cross-cultural comparative perspective has much to
offer researchers and clinicians approaching the problem of hysteria. A wealth of
ethnographic research shows that culture influences the clinical phenomena of hysteria
in three basic ways: (1) shaping the form and content of symptoms; (2) regulating
underlying mechanisms of dissociation; and (3) informing psychiatric nosology and
diagnostic practices and their wider social consequences.
In this chapter, we summarise some current perspectives on hysteria derived from
ethnographic work. First, we acknowledge the wide prevalence and persistence of
various forms of hysterical or conversion symptoms. Although epidemiological data are
lacking, there are clear clinical impressions that conversion disorders remain prevalent
in many developing countries. In some cases, this may parallel a general tendency for
people to make clinical presentations of somatic symptoms in place of emotional
distress in order to avoid psychiatric stigmatisation. More commonly, there is a close fit
between hysterical symptoms and prevailing cultural beliefs about illness. Local notions
of how the body works (ethnophysiology), of the nature of the person and emotion
(ethnopsychology), and culturally prescribed patterns of illness behaviour and help-
seeking all serve to shape bodily reactions. These processes affect all somatic symptoms
and in this regard, hysteria is no different than any other bodily illness.
What may be distinctive about hysteria is the use of cognitive mechanisms of
dissociation which manifest as complexly organised and motivated behaviour of which
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the person claims no conscious intention or control. Hence, our second aim is to explore
the fit between the mechanisms of dissociation, which may underlie hysteria, and
specific aspects of social structure, cultural belief and practice. This fit with culture does
not imply that hysteria always has a social function or is adaptive for the individual.
However, the meanings of hysterical symptoms in the family or wider social context
may help account for their prevalence and persistence even where the medical response
is scepticism or stigmatisation.
Hysteria can be approached as a medical phenomenon and as a social process. The
medical perspective seeks to describe diseases and disorders that are understood as
entities with specific pathophysiology and a ‘natural history’, which includes its
distribution, course and prognosis. The social perspective emphasises the fact that
illness occurs to individuals with a personal biography and history, in an interactional
matrix that includes families, the health care system and larger social institutions. As
such, the identification of problems and pathology emerges out of the life world and
social context of the individual. A social perspective does not preclude attention to
neurology, biology and psychological processes but the social history of medicine
shows how much diagnostic entities are creatures of particular cultural times, political
ideologies, religious concerns and other institutional interests. Indeed, the history of
hysteria provides some of the most dramatic examples of the cultural and social
shaping of psychiatric nosology. And yet, we will argue, hysteria is not simply a
cultural construction or a bodily expression of local power dynamics that is
misappropriated by medicine: there is something distinctive going on in the psychology
and social interaction of people with conversion symptoms.
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Defining Hysteria
Historically, the term “hysteria” referred to a congeries of physical symptoms and
behaviours in women attributed to erratic wandering of the womb. In seventeenth
century medicine, hysteria was distinguished from hypochondriasis, with the latter
found more commonly in men (Boss, 1979). By the nineteenth century, hysteria had
become an affliction of the working class (Shorter, 1992). Paralyses, sensory loss and
alterations of consciousness characteristic of hysteria were common among soldiers in
the First World War. While enlisted men received the diagnosis of shellshock or
hysteria, officers exposed to similar traumatic events tended to be diagnosed with
neurasthenia. Evidently, these nosological distinctions reflect the ways that
symptomatology is interpreted on the basis of psychiatric theories and diagnostic
practices that reflect cultural assumptions about gender, social class and character
(Young, 1995). To think clearly about whatever may lie behind our historically
contingent constructions of hysteria, we must critically examine these assumptions.
The colloquial use of the term hysteria refers to agitated and dramatic displays of
strong emotion, often with the implication that these are frivolous, foolish, exaggerated
and irrational. As such, the term ‘hysteria’ has strongly pejorative connotations. This
notion of hysteria also carries a strong gender bias, not only in its etymology which
implies troubles due to a wandering womb but because it is closely linked to
stereotypical notions of women as more emotionally expressive and less rational than
men. The narrower definitions of hysteria employed in psychiatry have never
completely escaped from this gender bias and moral opprobrium (Chodoff, 1982;
Micale, 1995; Winstead, 1984).
The introduction of the term “conversion disorder” reflected a psychodynamic
model in which emotional conflict and distress were “converted” into somatic
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symptoms. The term was retained in DSM-III, at a time when other psychoanalytic
terminology like “neurosis” was jettisoned, in the hope that this would disentangle the
conceptually and empirically distinct clinical problems of discrete pseudoneurological
symptoms (conversion disorder), polysymptomatic high health care utilisers
(somatisation disorder), and patients with a dramatic style of symptom presentation
(histrionic personality) (Hyler & Spitzer, 1978). There is evidence that most patients
with conversion symptoms do not have multiple medically unexplained somatic
symptoms or a histrionic personality (Kirmayer, Paris & Robbins, 1994; Singh & Lee,
1997). However, the symptoms and behaviours of hysteria must challenge some deeply
rooted cultural values and attitudes about human agency because any new, sanitised
term quickly takes on the same negative connotations.
The narrow definition of conversion disorder in ICD or DSM refers to interference
with motor or sensory function that cannot be accounted for by neurological disorder.
Conversion symptoms thus, are one type of medically unexplained symptom. They
share with other unexplained symptoms a common social predicament, namely, that
doctors are frustrated in their efforts to make a definite diagnosis, and that patients,
consequently, face a crisis of legitimating their distress and finding effective treatment.
Is there anything distinctive about conversion symptoms that sets them apart form
other medically unexplained symptoms? Where should the boundaries be drawn
between conversion disorder and other medically unexplained symptoms? To make the
question more specific, should chronic idiopathic pain or fatigue be considered forms of
conversion disorder? If it is simply that conversion symptoms are
“pseudoneurological,” does this reflect some underlying process or only more or less
arbitrary disciplinary boundaries in medicine? The answer to these questions hinges on
our understanding of the mechanisms of conversion.
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Purely descriptive or behavioural definitions tend to suggest that there is little other
than arbitrary convention to distinguish conversion symptoms from other sorts of
medically unexplained symptoms. However, there are some distinctive features of
conversion symptoms that argue for the value of considering the category different
from such common—and commonly unexplained—somatic complaints as pain or
fatigue (Table 1). Conversion symptoms involve observable behaviour, they interfere
with voluntary function, they closely follow patients’ idiosyncratic or cultural models
for illness, and they are extremely malleable and responsive to suggestion. In addition
to the absence of physiological explanation, these features have contributed to the
assumption that conversion symptoms are psychogenic, that is, they involve specific
psychological mechanisms.
The term ‘psychogenic’ has many potential meanings with different epistemological
and pragmatic implications (Kirmayer, 1988; 1994a). These include the notion that the
symptom is caused by psychological processes that may be conscious or non-
unconscious, [1] wilful or outside the control of the person, due to explicit plans and
ideas or implicit consequences of images and metaphors, and so on. There are many
more or less automatic psychological processes that could give rise to conversion
symptoms, complicating the simple dichotomies of wilful/accidental,
motivated/unmotivated, and conscious/non-conscious. These distinctions have
important cultural dimensions related to the sense of self, and consequent
configurations of self-awareness, self-deception, and control (Ames & Dissayanake,
1996). However, these subtle distinctions are largely ignored in biomedical practice so
that, for both professional and layperson, to call something ‘psychogenic’ is to imply it
is somehow ‘not real’ or ‘all in your head’ or worse, that it is due to psychological
weakness or moral failing on the part of the patient (Kirmayer, 1988). This stigma arises
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from the pervasive effects of a dualistic cultural concept of the person, in which bodily
illness is fundamentally different from mental or psychological problems. Even where
the same dualistic notions of the person do not prevail, the stigma attached to severe
psychiatric disorders ensures that patients will struggle to have their condition defined
as somatic and medical rather than psychiatric (Raguram, et al., 1996).
The psychological processes that might contribute to medically unexplained
symptoms can be roughly divided into two groups: (1) exacerbation of symptoms by
attentional focus (amplification); and (2) ignoring, suppressing, denying, and
dissociating (strategies for not attending and for not attributing cause to oneself)
(Kirmayer, 1999). Hysterical symptoms usually are assumed to involve the mechanisms
of denial and dissociation. Indeed, the alterations of sensory of experience and motor
control seen in conversion disorder commonly co-occur with alterations of
consciousness characteristic of dissociative disorders.
An emphasis on mechanisms would suggest that, ultimately, the specific form of
conversion symptom is less crucial for definition than the underlying cognitive process,
interpersonal interaction, and social context. Conversion symptoms are directed by
patients’ own construal of the body as vulnerable and by social factors that make the
body a credible site of affliction as well as an effective expressive medium.
The Cross-Cultural Prevalence of Conversion Symptoms
Cross-cultural study of the prevalence of hysteria requires that we define it in a way
that is comparable in different cultural contexts. There is a wide range of culture-
specific somatic symptoms that might qualify as conversion symptoms. The
compendium by Simons and Hughes (1985) lists some 150 culture-bound syndromes
idioms of distress, and folk psychiatric terms, of which about 22 involve primarily
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dissociative symptoms, and at least 8 conversion symptoms in the narrow sense.
Simons attempted to group the better-studied conditions into major taxons
characterised by startle-matching behaviour (e.g. latah), sleep-paralysis, genital
retraction (koro), sudden mass assault (amok), and running wild. With the possible
exception of sleep paralysis, all of these culture-related conditions have been viewed as
types of individual or epidemic (“mass”) hysteria by many authorities. The largest
group of culture-related conditions, unnamed by Simons and Hughes, involves
multiple somatic and dissociative complaints. Epidemiological studies of the prevalence
of somatoform disorders have generally ignored this evidence for culture-specific
syndromes in favour of simple counts of common somatic symptoms. Unfortunately,
this does not provide sufficient information to make meaningful cross-cultural
comparisons since it may leave some of the most salient symptoms and illness
categories untapped.
Although it is commonly asserted that the prevalence of conversion symptoms has
declined in this century, particularly in urban westernised settings, there are few clear
data to support this claim (Leff, 1988; Singh & Lee, 1997). Clinicians working in
developing countries share the impression that conversion symptoms remain common
in general medical settings. The WHO Cross-National Study of Mental Disorders in
Primary Care found a high prevalence of medically unexplained symptoms, including
conversion symptoms, in all 14 countries (Simon & Gureje, 1999).
In one of the few longitudinal studies, Nandi and colleagues (1992) compared
changes in the prevalence rates for hysteria and depression in two rural Indian villages
near Calcutta, from 1972 , when the first survey was undertaken, to follow-up surveys
1in 1982 and 1987. A research psychiatrist interviewed all the families of the two
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villages with a Bengali Case Detection Schedule tapping a wide range of
psychopathology.
Over a 10 to 15 year follow-up period, there were no significant changes in total
psychiatric morbidity or in the male/female prevalence ratios, which were comparable
to figures found elsewhere in India. There were, however, very significant changes in
the rates of specific disorders. The prevalence of hysteria fell dramatically from 32.3 per
1000 in one village and from 16.9 to 4.6 per 1000 in the other. Although hysteria was
and remained much more common in women, similar declines in its rate were seen in
both genders. At the same time, rates of depression rose significantly, from 61.9 to 77.2
per 1000 in one community from 37.7 to 53.3 per 1000 in the other.
While there was no change at follow-up in individual socioeconomic level,
substantial changes in the communities had occurred with improvement in housing,
educational facilities and health care delivery. Nandi and colleagues attributed much of
the decrease in rates of hysteria to improvements in the status of women. In a previous
survey of villages in West Bengal, they found that hysteria was more common among
women of lower social and economic status. In some cases, hysteria occurred in local
clusters as a result of emotional contagion or an expression of solidarity. The authors
conjectured that the improved social status of women able to work outside their home
for wages for the first time, made them less dependent on their husbands and hence,
less vulnerable and more self-confident. This had the effect of reducing the prevalence
and frequency of conversion symptoms.
Chakraborty (1993) pointed out various methodological problems with Nandi’s
study [2] but, based on her research and clinical experience in Calcutta, reached the
same conclusion that some types of conversion symptoms are decreasing in prevalence:
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“There is no doubt that we are seeing less of dramatic conversion symptoms.
Nowadays young girls complain more of somatoform symptoms… Education,
upgrading of the status of women and changes in public credulity certainly have
contributed to changes in the form of expressions of anxiety, and probably made
it more ‘free floating’…” (Chakraborty, 1993, p. 398).
It is safe to conclude that while classic conversion symptoms of motor paralysis and
sensory loss are see more commonly in clinics in many developing countries, they have
diminished in westernised health care settings. However, if disorders of pain, fatigue,
dizziness or vague malaise are understood as equivalent, then conversion disorders
have not so much disappeared as changed shape to fit common health beliefs and
expectations in the health care system. This transformation is striking evidence both of
the malleability of conversion symptoms and of the importance of social and cultural
factors in hysteria.
The Cultural Shaping of Somatic Distress
In surveys of the history of hysteria, both Shorter (1992) and Showalter (1997) have
argued that prevailing cultural models of illness give shape to the inchoate suffering of
people subjected to psychological disturbance and social stress. Hysteria is the outcome
of a contagion of ideas, which in recent times often has its origin in the medical
profession. These accounts suggest there is a more or less direct link between medical
nosology and the shaping of bodily distress in hysteria and other medically
unexplained symptoms.
Many mental health professionals share a tacit assumption that people who are
more psychologically aware will not express their problems in physical terms.
Psychoanalytic theory posited a hierarchy of sophistication in which somatic
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expressions of distress are more primitive than explicit talk about psychological conflict.
However, somatic symptoms remain extremely common in all cultures and are found
among individuals with all levels of education and psychological-mindedness
(Kirmayer & Young, 1998). The changing nature of conversion symptoms may reflect
the ability of medical authority to legitimate certain forms of distress rather than any
general change in psychological sophistication. This is illustrated by the recent epidemic
of chronic fatigue in the U.S. and U.K. in which viral infection serves as a folk
explanation for otherwise inexplicable states of enervation, weakness, dysphoria and
debilitation. While infectious agents or immunologic disorder eventually may be found
in some patients, it seems likely that much chronic fatigue is related to depression,
anxiety, and to wider social problems involving alienation in the workplace and what
Sir William Osler called “the habit of using the body as a machine” (Rabinbach, 1990).
However, many sufferers and clinicians prefer viral explanations to psychological
attributions, such as depression, which are widely seen as morally stigmatising.
In addition to the response of the health care system, conversion symptoms reflect
specific ethnophysiological ideas about how the body works. In many cultures, the
body is viewed as vulnerable to spirit attack or malign magic which can result in
sudden losses of function including paralyses, sensory alterations and seizures. Such
bodily conditions are not viewed in psychological terms as evidence for personal
conflicts or failings of the individual but as the outcome of social and spiritual forces.
As a result, afflicted persons do not receive the stigma usually associated with