In the past, cingulotomy produced symptomatic improvement in both phobic and obsessional neuroses and was considered a reasonable procedure. This measure is largely outdated as the implantation of electrical stimulating electrodes (deep brain stimulation) in this region or in the subthalamic nucleus has proved effective for intractable and disabling obsessive compulsive disorder but without affecting the degree of anxiety and at the expense of a moderate number of surgical complications (Mallet et al).
This subject is of great importance to neurologists and general physicians because of its frequency. Any sense that this was a disorder of the Victorian era belies any modern neurologist’s daily experience. What has changed for the better is the reduced stigmatization of the disorder and a more straightforward, non-judgmental approach to treatment.
Although hysteria has been known since ancient times, many writers credit the first description of the syndrome to the French physician Briquet in 1859. Charcot later elaborated certain manifestations of the disease, particularly those with a theatrical aspect, and thereby interested Freud and Janet in the problem. Charcot demonstrated that the symptoms could be produced and relieved by hypnosis (mesmerism). There have been many extensive expositions of Charcot’s work in this field and his consideration of hysteria as an organic disease, perhaps allied with epilepsy but representing in any case a “functional” disorder of brain. One of the authors of this text has devoted a book to the subject (Ropper and Burrell). Charcot’s acolyte, Janet postulated a dissociative state of mind to account for certain features, such as trances and fugue states, a term that has reappeared in modern psychiatry. Freud and his followers conceived of hysterical symptoms as a product of “ego defense mechanisms” in which psychic energy, generated by unconscious sexual conflicts, was “converted” into physical symptoms. This latter concept was widely accepted, to the point where the term conversion became incorporated into the nomenclature of the neuroses and the terms conversion symptoms and conversion reaction came to be equated with the disease hysteria. We see no merit in the dichotomy, based on unsubstantiated psychodynamic theory, of a conversion type as separate from a dissociative type of hysteria, as claimed by the DSM classification. Nemiah, who is in other respects partial to the psychoanalytic interpretation, agrees. The term hysteria is probably best reserved for a disease and is characterized by a distinctive age of onset, sex predilection, natural history, and certain somatic symptoms and signs, which typically include physical symptoms that cannot be explained on the basis of the structure and function of the nervous system, dissociative reactions, or states of “multiple personality.” We use the term “psychogenic” in this chapter and throughout the book as an etiologic term broadly attached to such dramatic neurologic signs and symptoms that are not explicable on the basis of a lesion of the nervous system.
In clinical neurology one encounters two types of psychogenic neurologic signs, both identified as having no possibility of explanation in disease of the nervous system: (1) a chronic illness marked by multiple and often dramatically presented symptoms and somatic abnormalities of “classic hysteria,” almost limited to girls and women and (2) an illness predominantly of men but also of women who develop physical symptoms or remain inexplicably disabled for the purpose of obtaining compensation, influencing litigation, avoiding military duty or imprisonment, or for the manipulation of some other interpersonal or societal situation. This latter state is called compensation neurosis, compensation hysteria, or hysteria with sociopathy, in other words, malingering.