Hysterical Psychoses

HYSTERICAL PSYCHOSES. The doctrine of hysterical mental disorders developed and changed in accordance with the general doctrine of hysteria in the direction of a gradual narrowing of the concept of hysterical psychoses and increasing limitation of their independence. During the period when hysteria was viewed as an independent constitutional disease with specific symptomatology, the diagnosis of hysterical psychoses was made extremely frequently, and alongside hysterical degeneration, transient, prolonged, and chronic hysterical psychoses (with outcome in dementia) were described, as well as "psychoses on a hysterical basis" (hysterical melancholia, hysterical mania, hysterical insanity). The basis for diagnosis was the combination of mental disorder phenomena with physical symptoms of hysteria. With the contrast between proper hysteria and so-called hysterical (hysteroid) symptoms, with the identification of manic-depressive psychosis and early dementia, and with the flourishing of the nosological direction in psychiatry, the diagnosis of hysterical psychoses began to be made significantly less frequently. Hysterical degeneration, hysterical dementia, and psychoses on a hysterical basis began to be questioned and disappeared from psychiatric practice, gradually giving way to the concepts of hysterical personality, psychogenies, and hysterical superimpositions. In recent years, with the development of the doctrine of psychogenic reactions and pathological constitutions and with the denial of hysteria as a disease, the content and scope of the concept of hysterical psychoses have become even more uncertain and conditional. The hysterical constitution has largely dissolved into other constitutional types, and hysterical psychoses came to be regarded as pure psychogenies, with their distinction from other psychogenic reactions becoming very difficult both in essence and in form. At present, according to the most accepted view, a psychogenic reaction is considered hysterical insofar as it contains, according to Bonhoeffer, an element of motive, the desire for one benefit or another to be or to appear sick, clearly revealing the purpose of the illness, and on the other hand, according to Kraepelin and Kretschmer, it instinctively or reflexively uses biologically prepared mechanisms. However, even in such a limited and conditional sense, hysterical psychoses at present are the most important type of psychogenic mental disorders in terms of purity and distinctness. Hysterical mental disorders (according to an opinion still shared by many) develop on the basis of those features of hysterical psychology that constitute the so-called hysterical character (see Hysteria). According to the latest views, on the contrary, they can arise on any constitutional basis in subjects who usually have nothing in common with the hysterical character, more often in mentally inadequate primitives with weak ethical and social inhibitions. Similarly, somatic hysterical symptoms (stigmata) are not characteristic or obligatory for hysterical psychogenic reactions, since they can occur in various pathological conditions and are internally not connected either with hysterical reaction or with hysterical character. The capacity for hysterical reaction is inherent to all people to some degree, and these reactions should be considered intercharacterological (K. Schneider). Connected with archaic mechanisms located apparently in the subcortical areas of the brain, psychogenic hysterical reactions are, according to the latest views (Krasnushkin, Braun), less a syndrome than a degree of reaction. From the point of view of the layered structure of personality, the hysterical reaction, as arising from semi-conscious, unformed motives, occupies the middle between reactions of extrapsychic, biological-somatic type (reactions of deep personality) on the one hand and conscious, purposeful reactions (simulation) on the other, and combinations of elements of these degrees of reaction and transition of reaction from one layer to another are possible: for example, the transformation of a hysterical reaction into purposeful behavior and vice versa—simulation into a hysterical reaction. To avoid misunderstandings, inevitably associated with the general term "hysterical," for three categories of phenomena that are essentially different (hysterical character, hysterical reaction, hysterical stigmata), Brown proposes to call the hysterical psychogenic reaction "epithymic" (from Greek epithymia—desire), since it is always based on an unconscious desire. In rudimentary form, hysterical mental disorders manifest in those transient changes in mental activity that arise either as a component of a hysterical attack, or as its equivalent, or finally independently. These include: the phase of hysterical delirium in the classical attack, attacks of sleep (narcolepsy), lethargy, catalepsy, noctambulism, hysterical fugues, etc. Such states are episodic, short-term, but sometimes can acquire a longer and more pronounced character, often combining or alternating with each other. Being connected with each other by a peculiar change in consciousness, they constitute a transition to those twilight states that are the main and primary form of hysterical mental disorders. Hysterical twilight states are extremely diverse and can be given here only in a schematic representation. Their characteristic feature is a dreamlike state of consciousness, in which actual impressions partly do not reach consciousness at all, and partly are perceived indistinctly, not giving a corresponding reaction and intertwining in the strangest way with extremely variegated, whimsical, fantastic experiences. Patients as if live a double life: now returning to a certain degree to the real world, now plunging into their fantasies and reveries. They are disoriented, see themselves in a completely different setting—in hell, in a dungeon, in the sky; around them occur strange, remarkable, mysterious events. Often truly experienced or only imagined heavy events and scenes, sexual assaults, violence, insults, etc., are reproduced. In other cases, the fulfillment of a desire, unfulfillable in life, is experienced. Sometimes, on the contrary, actual unpleasantnesses or misfortunes, along with everything connected with them, are excluded from consciousness and asserted as non-existent. In some cases, instead of dreamlike, hallucinatory-delusional experiences predominate, often of an extremely terrifying character, in which it is difficult to find a logical connection or uncover complex mechanisms. The emotional state of patients is usually very unstable, representing states of fear, then depression, then angry excitement, then ecstasy, then childish cheerfulness, etc. Correspondingly to this, their behavior is also different: sometimes excited, sometimes with a tendency to aggressiveness and destruction, sometimes exalted, sometimes absurd or childish, sometimes cynical, sometimes theatrical. In general, the behavior of patients usually bears the imprint of some unnaturalness, affectation, licentiousness, suggesting simulation or play, which the patient can discontinue at will. Certain elements of the twilight state in some cases can play a dominant role, come to the forefront, giving the twilight state picture a special coloring and making it possible to isolate some of the most typical forms of hysterical twilight states. These include: 1) so-called puerilism, in which the psyche and behavior of patients take on the character of childishness and imitation of a child, representing a return to childhood experiences; 2) Ganser's syndrome, when in the twilight state the phenomenon of incorrect answers to the simplest questions and the utterance of seemingly deliberately absurd and ridiculous assertions come to the forefront; 3) pseudodementia, characterized by incomprehension of simple questions, ignorance of the most elementary things and relationships, loss of everyday knowledge, producing the impression of grossly simulated dementia; 4) hysterical stupor with an inaccessible, indifferent mood, psychomotor retardation, interrupted by incoherent delirium, transient excitement. Hysterical twilight states apparently include certain states of religious ecstasy in mystical sects (khlystovshchina and others), attack-like states in klukushas, phenomena of splitting of personality, mediumistic trances, and also (to a certain extent) some episodic psychogenically arising states in backward peoples ("meryachenie" in Siberian peoples). - Hysterical mental disorders usually arise in connection with one or other experiences that shake the psyche: danger to life, fright, violence, loss of close ones, family conflict and especially—imprisonment with the prospect of trial and responsibility. Their course and duration are largely determined by the conditioning experiences and situation. Usually they are short-lived: from several hours and days to several weeks, but sometimes, depending on the conditions of the situation (especially in legal cases) they can be prolonged for a long time (from several months to a year or more). The memory of twilight states usually either completely disappears or is indistinct, but in some cases it is discovered with sufficient clarity. Sometimes what was experienced in the twilight state is remembered only in a similar state, sometimes it can be evoked in hypnosis.

The prognosis and outcome are usually favorable, although depending on the constitutional basis, living conditions, and situational factors, there is a danger of prolonged course, recurrences, and habituation to hysterical states.-- Recognition of hysterical psychoses can present considerable difficulty: firstly, because the hysterical symptom complex can complicate various pathological conditions and processes (schizophrenia, epilepsy, organic psychoses, etc.) and arise on different constitutional grounds, and secondly due to the conventional and indefinite nature of the concept of 'hysterical psychoses' themselves. In addition to the general criteria important for recognizing hysteria, for the diagnosis of hysterical psychoses the following are important: the presence of a motive, a desire to be or appear sick, a corresponding system of behavior in relation to the environment, liveliness of emotional reactions, the possibility of positive or negative contact with the patient, and the obvious dependence of the state on experiences and situational changes.-Prevention and treatment of hysterical psychoses in general coincide with those for hysteria (see): it is extremely important to eliminate the cause of traumatic experiences, to appropriately change situational factors; in most cases, hospitalization is necessary.