Thus, according to the organic theory of hysteria, the condition is basically similar to diseases of the central nervous system , such as multiple sclerosis. In this frame of reference, hysteria is a disease that happens to a person: he suffers from it and may be cured of it. Logically, this is a sound position. Factually, I consider it false. Psychopathological theory. Few behavioral scientists accept the theory of the organic causation of hysteria.
Those who consider hysteria an illness usually qualify it as a mental illness. The specific content of these hypotheses varies with the theories of particular schools of psychodynamics. There is general agreement, however, that hysterical bodily signs represent an unconscious conversion of repressed ideas, feelings, or conflicts into symptoms. Thus, the psychopathological theory of hysteria also regards this condition as a disease, but with psychological causes rather than physiological.
This explanation is weak logically Ryle and is not adequately testable. Communicational theory. Finally, there is the communicational theory of hysteria. It is based on the proposition that not all types of disability should be classified as illness; and, further, that so-called hysterical symptoms are a form of communication and game playing. Hysteria is a game with a theme of helplessness and helpfulness. The hysteric acts disabled and sick: however, his illness is not real, but is merely an imitation of a bodily illness. Because the hysteric impersonates the sick role, the result is genuine disability.
But if we call this condition an illness, we use this term metaphorically, whether or not we realize it Szasz , pp. Thus, according to the communicational approach to hysteria, the phenomena that the patient presents are examined and interpreted not only in the context of his past, but in the context of his total human situation. Through body language , the hysteric communicates with himself and others —but especially with those who are willing, and often eager, to assume the role of being protective and controlling. This explanation is logically sound and testable.
To date, I consider it our most adequate theory of hysteria. It is appropriate to raise certain questions now, such as: Is hysteria the same as it has always been or has it changed during the past fifty to eighty years? Is it more, or less, common today than it was in the past? Our answers will depend, in part, on our concept of hysteria.
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It has been widely suggested for example, by Chodoff ; Wheelis ; and others that hysteria was more common in Austria toward the end of the last century than it is in America today. The evidence for this view is unconvincing.
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What has changed, without any doubt, is the sociology of medical practice. Thus, in the Paris or Vienna of the s, persons with bodily complaints were seen by general practitioners or neurologists. Today, such patients still seek the help of the general practitioner and the medical specialist. In the meantime, however, there developed a new medical specialty: psychiatry.
Because hysterical patients consider themselves medically, not mentally, ill, they do not usually consult psychiatrists. As psychiatry became a separate discipline, hysteria and other mental disorders became a specifically psychiatric diagnosis much as, for example, myelogenous leukemia is a specifically hematologic diagnosis. It is expected, therefore, that this diagnosis will be attached to so-called psychiatric patients. However, persons who consult psychiatrists voluntarily or who are committed to their care involuntarily rarely suffer from what appears to be bodily illness; more often, they feel anguished or they annoy others.
But this does not mean that the incidence of hysteria in the population at large has decreased. I believe it has not. The evidence suggests that hysteria is as common as ever, and perhaps more so. Instead they go where—to paraphrase the signs that announce Aqul se habla espanol or lei on parle frangais —the sign proclaims, We speak the language of illness. Where are such signs displayed? In the offices of general practitioners, internists, dermatologists, neurologists, and so forth; in medical clinics, and especially in famous diagnostic centers; in clinics where compensation for illness is awarded, such as those operated by the Veterans Administration; and in the offices of lawyers and in courts, where money damages may be sought and obtained for illness, both organic and mental, real and counterfeit.
Because of these radical changes during the past half century in the sociology of medical and psychiatric practice, I consider it misleading to speak simply of the incidence of hysteria. We must specify the particular situation, with respect to the social identity of both the observer and the observed, in which the incidence of the disorder is to be established. Working as a physician, Freud developed his theory of hysteria to account for, and to help him cope with, some of the practical problems that faced him.
What were these problems? In the autumn of , I was asked by a doctor I knew to examine a young lady who had been suffering for more than two years from pains in her legs and who had difficulties in walking…. All that was apparent was that she complained of great pain in walking and of being quickly overcome by fatigue both in walking and… standing, and that after a short time she had to rest, which lessened the pains but did not do away with them altogether….
I did not find it easy to arrive at a diagnosis, but I decided for two reasons to assent to the one proposed by my colleague, viz. What was wrong with this young woman? Because of the absence of neurological and other medical illness, and for certain other reasons as well, Freud concluded that she suffered from the disease called hysteria. How is this disease brought into being?
According to the view suggested by the conversion theory what happened may be described as follows: She repressed her erotic idea from consciousness and transformed the amount of its affect into physical sensations of pain. A cautious reply would be: Something that might have become, and should have become, mental pain.
If we venture a little further and try to represent the ideational mechanism into a kind of algebraical picture, we may attribute a certain quota of affect to the ideational complex of these erotic feelings which remained unconscious, and say that this quantity the quota of affect is what was converted. The mechanism of the pathogenesis of hysteria was subsequently elaborated and refined by Freud and other psychoanalysts and came to include certain other features.
According to Glover , pp. Symptoms are localized in accordance with the distribution and fixation of body libido; body parts or organs, overli-bidinized by previous organic disease or continuous hyperfunction, become the media of expression. If there is frustration of instinctual drives in adult life, the libido tends to turn from reality to fantasy. Fantasy is subject to the laws of regression.
Infantile fantasies, especially those associated with the Oedipus complex, are reactivated through regression. Repression, faulty to begin with, cannot cope with the additional charge of the reactivated infantile fantasies. The defense crumbles and the repressed content breaks through: the return of the repressed. The result is an inhibition or exaggeration of bodily functions, giving rise to crippling or painful symptoms. These constitute a somatic dramatization of unconscious fantasies. The psychoanalytic theory of hysteria contains rudimentary suggestions for a communicational approach to this phenomenon.
However, a systematic account of hysteria as language or communication was not developed until recently Szasz , pp. To understand this view requires acquaintance with certain technical concepts, which I shall summarize here. A physical thing—a chalk mark, a dark cloud, a paralyzed arm—is a sign when it appears as a substitute for the object for which it stands, with respect to the sign user. The three-part relation of sign, object, and sign user is called the relation of denotation. Classes of signs.
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Three classes of signs may be distinguished: indexical, iconic, and symbolic, or conventional, signs. In the indexical class belong signs that acquire their sign function through a causal connection.
For example, smoke is a sign of fire and fever a sign of infectious disease. In the iconic class belong signs that acquire their sign function through similarity. For example, a photograph is a sign of the person in the picture; a map is a sign of the territory it represents. In the third class, symbolic, or conventional, signs, belong signs that acquire their sign function through arbitrary convention and common agreement—for example, words and mathematical symbols.
Symbols do not usually exist in isolation, but are coordinated with each other by a set of rules called the rules of language. The entire package, consisting of symbols, language rules, and social customs of language use, is sometimes referred to as the language game.
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Hysteria and the language of illness. Communicational situations may comprise one, two, three, or a multitude of people. A semiotic and game-playing view of hysteria Szasz , pp. For example, hysteria and other so-called mental illnesses may occur in a one-person situation. An individual who feels pain in his abdomen and concludes, falsely, that he suffers from acute appendicitis illustrates this phenomenon. Such a person fools himself, not others. He plays a game by disguising his personal problem as a medical disease.
The advantage derived from such a one-person game corresponds closely to the psychoanalytic idea of primary gain. However, since people generally do not live in isolation, the interpersonal and social aspects of hysterical hypochondriacal, neurasthenic, etc. Indeed, it is the complexity of communications among people that accounts for much of the complexity of hysteria as a so-called clinical syndrome Szasz Thus, if a person complains to his physician of abdominal pain and insists that it is due to an inflamed appendix, even though there is no other evidence to support this view, first his interpretation will be discredited, and then he himself will be discredited.
The more he enlarges the social situation where he makes this claim, the more he risks being seriously discredited for example, by being labeled schizophrenic and committed to a mental hospital. In a sense, such a person plays a game of fooling others.
To the extent that he succeeds and is accepted as sick, he derives an advantage from his strategy. This advantage corresponds closely to the psychoanalytic idea of secondary gain.
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From a communicational point of view, the traditional problem of differentiating hysteria from organic disease becomes one of distinguishing iconic signs from indexical ones. The physician and psychotherapist observe signs, not diseases—the latter being inferences drawn from the former. Thus, an analysis based on sign discrimination is likely to be more testable, as well as more serviceable, than one based on disease differentiation. How, then, do we distinguish indexical signs from iconic signs?
Iconic signs resemble conventional ones because both are manufactured, more or less deliberately, by a person; indexical signs are passively given off, rather than actively emitted, by the signaling organism.