Hysteria in the 21st Century

The term hysteria is often confused with other clinical manifestations of personality and behavior. In this article we explain what is understood by hysteria today, what theories support it, as well as the relationship between hysteria and psychopathy.

Written and verified by el psicólogo Bernardo Peña.

Last update: 06 July, 2023

Hysteria is a nervous disease characterized by psychological problems and emotional disturbances, which can be accompanied by a myriad of physical and psychosomatic symptoms. For example, seizures, paralysis, anesthesia, trance states, etc.

The term comes from ancient Greece. In fact, hystera means uterus in Greek. It was believed that the female uterus could move through the body and cause somatic symptoms.

In the late 19th century, Charcot, Freud, and others popularized the term and gave it a more psychological nuance. Thus, this disease arose from the repression of a trauma, the reminiscences of which reached the consciousness in the form of physical symptoms.

Hysteria and personality

There are a number of personality characteristics linked to hysteria. However, this doesn’t necessarily mean that people who have them have all the symptoms or its equivalent in personality disorders, the histrionic personality disorder.

Egocentrism

The person has the need to stand out from others and to be the center of attention. Histrionics, showiness and theatricality show a hyper-expressive and dramatic character, both in expression and content. Exhibitionists and imaginative, they cover up or deny the realites that they don’t like.

Lability or little emotional control

This is a characteristic that, at a popular level, is usually identified with hysteria. These people are unstable and uncontrolled in their affective expressions. They’re also very changeable regarding interpersonal relationships. They can go from unconditionality and overflowing affinity one day to contempt or ignorance the next.

Suggestibility

They’re very suggestible; that is, susceptible to external and internal influence. Both at a clinical level (they can vary the appearance and manifestation of symptoms), and at an interpersonal level (very vulnerable to the influence of other people).

• In fact, in the treatment of hysterias, techniques related to suggestion are usually used, such as hypnosis, placebos, interviews with sodium amital or truth serum, etc. Due to the easy suggestibility of these individuals, their symptoms can either be modified or disappear according to external stimuli.
• The great suggestibility is also evidenced by epidemic forms or collective hysterics. For example, the effect of the film The Exorcist, which led to hysterical episodes similar to those in the film.

Dependence

Deep down, they are extremely weak people, and they haven’t reached adult emotional independence. They need others on an emotional level, and always demand more than what can reasonably be given to them. They are people who have exaggerated emotional demands.

They are fixed in infantile relationships of dependency and aren’t able to get out of the situations set up by themselves to achieve a position of advantage, nor to renounce acquired situations of privilege and comfort.

The eroticization of social relationships

Seduction is the weapon that the hysteric uses to reach their goals and gain the center of attention. They usually go very well dressed, with impressive hairstyles, makeup, etc. On the other hand, they show a fear of sexuality. Despite giving the appearance of a sexually active person due to their seductive attitude, deep down, they have significant sexual problems.

Their knowledge of situations is global, imprecise, and impressionable, with a general dispersion in their knowledge and a lack of depth and concentration on issues of an intellectual nature.

In summary, hysterical personalities are characterized by their theatricality, their continuous egocentricity, their tendency to transform the reality of objective facts (they’re very subjective, they interpret everything according to their interests and defense mechanisms) and forget what they dislike.

Hysteria: explanatory theories and risk factors

In this section, we’ll examine some theories about hysterics and we’ll review some cultural, family, sexual, personality factors, etc. associated with them. Traditionally, most of these theories and studies have been about conversion hysteria. Therefore, the following observations must be applied and refer primarily to this disorder.

Psychoanalytic theory

Hysteria was the crucial disorder in S. Freud’s initial theory. Today, hysterical disorders are those most closely linked to a psychoanalytic interpretation. Initially, Freud proposed the theory of conservation of energy, which proposed that emotion that couldn’t be expressed could be turned into physical symptoms.

Later, Freud assumed that both conversion and dissociative hysterics have their etiology in an unresolved Oedipus conflict. In this way, it causes the necessary repression of sexual impulses. During adult life, sexual arousal would awaken these repressed urges, which turn into physical symptoms or psychological dissociations.

The defense mechanisms of repression, regression (to the phallic, oedipal stage) and displacement would be the bases of the conversion-type hysterical disorder, while the mechanisms of repression and dissociation would be the bases of the dissociative-type hysteria.

Regarding the first case, somatic conversion is organized according to its symbolic significance. The affected somatic zone is chosen by virtue of a displacement of the libidinal impulse, which produces an eroticization of the affected organ that would be the fundamental aspect in the conversion phenomenon.

We can see the similarity between ancient Greek theories and psychoanalytic theory. It’s enough to substitute the uterus for the sexual impulse to make them similar.

Finally, it should be noted that the concept of conversion still carries a theoretical psychoanalytic burden or remnant, as it presupposes an unconscious emotional etiology that is manifested in the physical symptoms of the disorder.

Psychosocial and cultural theories

The family and social organization of these patients is striking, marked by great tolerance. The mastery of the situation that they obtain through their peculiar personality form or using their symptoms to manage the environment and manipulate and control the situation is striking.

Hysterical behavior needs an audience. It’s the means used, through the resources of the theater, to satisfy the excessive demands for affection that characterize these patients. The husbands and wives of patients with hysteria are often passive, condescending, and solicitous of their ever-excessive demands. This facilitates and favors the continuity of the disorder by functioning as a reinforcer.

Hysteria is related to ethnic and cultural factors. Primitive cultures are more given to expressive and bulky hysterical manifestations. For example, blindness, paralysis, seizures, etc. On the other hand, industrialized cultures, where people are less naive and have more medical knowledge, channel pathology in a more subtle way, through somatizations.

At present, it seems that cultural development tends to mask the clinical signs of hysteria and to create a pathology in which the phenomenon appears blurred. In this way, depressive symptoms, eating disorders, diffuse somatic complaints, etc. appear. This means that this disease is diagnosed much less frequently nowadays.

The prevalence of these disorders has decreased considerably in the last century in industrialized societies. The epidemic forms, such as collective madness, described in the 14th century (for example, tarantism, Saint Vitus’ dance, etc.) are uncommon today and only emerge in closed communities such as boarding schools or convents during stressful situations or times.

Gender aspects

The great gender differences are striking in these disorders: there is one case of male hysteria for every four females. Some authors believe that this may be due to social factors. Given the pejorative connotation of the term hysteria as a sign of weakness and simulation, its diagnosis is experienced as being humiliating.

It’s still more socially tolerated for women to act and behave weakly, but in men this type of behavior causes rejection. This can make men tend to seek expression of their problems through other channels more in line with the expectations of their gender. For example, through externalized behaviors such as drinking, aggressiveness, antisocial tendencies, etc.

Likewise, some authors think that doctors, who until today have been men, have created some complicity in this, avoiding the diagnosis of hysteria in men. Male hysteria usually manifests itself more through hypochondriacal manifestations, depression, anxiety, etc., in a more indirect way.

However, despite these interpretations, clinicians note that women report a greater number of symptoms and also more physical symptoms. Traditionally, it has been thought that this could be because they suffer from more anxiety and depression. However, recently, the reports of physical symptoms were modified by controlling the levels of depression and anxiety, in addition to age, race, education, suffered illnesses, etc.

However, women still report 50% more physical symptoms. Somatoform symptoms, without physical explanation, were also more frequent. The conclusion is that gender is an independent factor in explaining these differences in the frequency of physical symptoms.

Behavioral model of hysteria

It is a clear fact that hysterical symptoms are limited in their occurrence. In this way, an important relationship is usually observed between the symptoms developed and the normal jobs of those who suffer from it. For example, temporary blindness in pilots in times of war, paralysis of the hand in musicians before the concert, etc.

For learning theory, hysterical behavior would be avoidance behavior that reduces anxiety. Its conceptualization would be similar to the placebo effect.

The person, in an attempt to reduce their anxiety, responds in a socially appropriate way, accepting and playing a role that allows them, in a self-accepted way, to reduce their anxiety; for example, not having to go out to fight. At the same time, they have their honor and responsibility intact by saying: “I’m not a coward, I’m sick.”

The representation of the role of a sick person is socially reinforced. Once the individual has played their role, given this reinforcement, the hysterical behavior will continue.

Therefore, one goal of the treatment must be to diminish the benefits gained from hysterical behavior i.e. not allowing hysterical behavior to be reinforced. On the contrary, while reinforcement such as attention or affection is provided, the disorder will be sustained or increased.

Conditions that can facilitate the development of hysteria are the following:

• The existence of a clear and visible model of conduct. In general, these people have had somatic difficulties of the same nature as hysteria or have observed them in other people.
• Reinforcement of hysterical behavior in the form of attention and concern from the audience (positive reinforcer) or avoidance of responsibilities or threatening situations (negative reinforcer).
• An increase in the level of contextual arousal caused or accompanied by fears about the occurrence of some threatening event.
• The lack of general psychological and medical culture. However, this is not a requirement, as there are known cases of hysteria in psychiatrists.

In general, outside the behavioral field, we could point out that hysterical symptoms can develop in these ways:

• Allowing the expression, albeit in a masked way, of a forbidden desire or impulse.
• Self-punishing for a forbidden desire through an incapacitating symptom.
• Freeing yourself from a threatening and overwhelming life situation.
• Assuming the role of a sick person and thus making it possible to gratify dependency needs.

Personality and linking hysteria with psychopathy

In Eysenck’s personality theory, hysterics are characterized by a high level of neuroticism. That is, a great sensitivity and emotional and vegetative reactivity. They’re also very outgoing. Due to their neurotic condition, they’re predisposed, like dysthymics, to experience anxiety reactions.

Due to their condition as extroverts, like psychopaths, they’re predisposed to externally express emotions through externalized behaviors, rather than to experience or feel this anxiety internally as occurs in dysthymics.

From this and other theories, hysteria is linked to psychopathy or sociopathy, the antisocial personality. Some authors think that at the base of all this may be the same disorder that manifests itself according to sex: hysteria in women and psychopathy in men.

Both disorders are related to dysfunctions of the non-dominant hemisphere, usually the right, more related to emotion, specifically negative at the frontal level, and a more global and synthetic analysis of the information.

In this sense, there’s a lateralized pattern of somatic symptoms in relation to all emotional disturbances, not just hysterical ones. The main somatic symptoms are usually on the left side, especially with headaches and other forms of pain.

This has been observed in patients with depressive, anxiety, and somatoform disorders. Likewise, patients with symptoms on the left side have higher scores on depression or anxiety tests.

In conclusion, the right hemisphere (related more to emotions and, at the frontal level, to negative emotions that provoke inhibition and withdrawal) is more involved than the left in the formation of somatization symptoms related to emotional disturbances.

Explanatory models on the relationship of hysteria with psychopathy

Somatoform disorders, such as conversion and somatization disorders and antisocial personality disorder, together with attention deficit hyperactivity disorder and alcohol dependence, have a much higher intraindividual and intrafamilial comorbidity or association than is expected in the general population.

Many authors have theorized to try to explain this relationship. The postulated explanatory models are the following:

1. Frontal lobe model

People with these disorders perform worse on tests that measure frontal lobe capabilities, making typical frontal failure errors.

They show perseverance, little self-awareness, impulsiveness when responding, little anxiety, not following social conventions, inability to plan things sequentially, apathy, indifference, little sustained attention, etc.

2. Model of efferent inhibition

Both psychopaths and hysterics have a higher tolerance for pain. This has been explained as an increased ability to ignore or attenuate aversive stimulation. There is a phasic inhibition of reticular formation by cortical efferences, which attenuates the impact of aversive stimuli.

For example, it is known that the cortical potentials evoked by touching an anesthetized limb in a hysterical patient are lower than when the unaffected limb is touched.

Eysenck argues that both hysterical and psychopathic patients are highly extrovert and rapidly develop cortical inhibition and this dissipates slowly compared to introverts.

3. Model of behavioral disinhibition

In the aforementioned disorders, a weakening of the control of the behavioral inhibition system (SIC) is postulated, leading to a predominance of the behavioral activation system (SAC) over behavior and less inhibitory control over it (the SIC inhibits the SAC in the presence of signals of uncertainty, punishment, novelty, etc.).

This explains the deficits in passive avoidance, the slow acquisition of fear response conditioning and impulsivity.

4. Model of negative emotionality

The association of these disorders could be due to the fact that they have high levels of negative emotionality or affectivity. Furthermore, in both disorders, authors such as Eysenck postulate high levels of neuroticism.

Therefore, these people are more likely to experience depression and anxiety. This can be contradictory to psychopathy.

Conclusions about the current state of hysteria

Somatoform hysterical manifestations are on the decline in Western society. Today, the prevalence is less than 0.1%. They are more frequent in social classes with less education and in places that are more isolated or far from health services.

Currently, it is far more acceptable for women to openly show their hostility and aggression. Thus, while hysterical disorders are declining, female crime rates and the prevalence of other disorders closely related to antisocial personality disorder are increasing sharply.

An example is borderline and narcissistic personality disorders, which co-vary greatly with antisocial and histrionic (hysterical). In this way, sociocultural factors are altering the phenotypic expression of a s imilar underlying predisposition.