The Letter, Issue 3, Spring 1995, Pages 109 - 124
HYSTERIA: DOES IT EXIST?*
Whatever the outcome of our debate on the existence or non existence of hysteria, I think we can agree in advance that it will be a long time before the Hysteria Association of Ireland holds its first national appeal. This highlights the peculiar status of hysteria, which has nothing to do with the stigma of mental illness. Schizophrenia, autism and even the newly arrived M.E. all have their public profile. So why is it so incongruous to imagine a group of self-declared hysterics forming an association and delegating representatives to appear on some popular chat-show to describe themselves as suffering from hysteria and hoping to elicit public sympathy and support by detailing a list of somatic complaints which have baffled a multitude of specialists? (One man recently presented at a case conference had been under the care of 19 different consultants as well as having had a long history of impossible relationships with parents, spouses, children and colleagues.) What is this disease that dare not speak its name and which is now in the process of losing that name with the inexorable progress of scientific psychiatry?
I do not know if I am doing anything to arrest that progress by- pointing out, as psychoanalysis has done from its beginnings, the irreplaceable role of myth in coming to an understanding of human reality. The analyst is cautioned that, unless he is well at home in mythology as well as other fields, he will be unable to make anything of
much of the material the patient presents to him. So, after Oedipus and Narcissus and the many other figures of antiquity that Freud proposed for our meditation, let us follow a hint of Jacques Lacan's - one which unfortunately he did not develop - that hysteria is a chimera.
Now, a chimera is associated in Roget's Thesaurus with concepts like insubstantiality and inexistence, which seems to be yielding in advance to the thesis that hysteria does not exist. But Lacan's reference is rather to an enigmatic ancestor of the Sphinx whose life and death riddles Oedipus solved. In Greek mythology the chimera is a fire-breathing female monster of divine race, resembling a lion in front, a serpent behind and a she-goat in the middle - the sort of creature one would not find in DSM III, where lions, serpents and goats each have, quite sensibly, their own separate and distinct chapter headings and where notions like fire-breathing and divinity are given the wide berth they deserve.
But let us not turn away too quickly from our analogy, because it helps us to realise that investigators have always recognised two parts of the composite structure of the chimera hysteria: the sexuality aptly represented by the goat and the mercurial cunning of which the serpent is the eternal symbol. What I would hope to outline is the way in which recent psychoanalytic investigations have begun to focus also on qualities of intellectual courage and vision often obscured and overlooked in the enterprises of hysterics, and appropriately symbolised by the lion's head; on the note of divine inspiration which has led hysteria to be compared to a work of art; and on the purifying function of the fire of hysterical fury when it is directed against the hypocrisies and pomposities of individuals and organisations.
But this new approach which has led one author to write a paper entitled In praise of hysteria should not blind us to the fact that it was as a crippling illness that hysteria was first isolated in modern times and that in its protean manifestations and destructive effects it merits comparison with cancer -a cancer in the relationships of the individual sufferer with all forms of social organisation and, in particular, with the sexual role allotted to her or to him in the family and the wider socio-economic world.
Freud and hysteria
"To her or to him....." This is the starting point for the first truly scientific understanding of hysteria. Picture Freud, in 1886, having been forbidden access to the patients of the leading neurologists because he had betrayed their trust in his judgment by importing this chimerical Parisian notion into Vienna, searching high and low among his junior colleagues for a demonstrable case of male hysteria and eventually being able to present before the eyes of his critics a 29-year-old man suffering from severe hemi- anaesthesia for which no organic cause could be found. It was essentially this clinical evidence for the existence of male hysteria that enabled Freud to break with a 4,000 year history of attempts to understand the illness.
It was in trying to make sense of hysteria in males that Freud and Joseph Breuer came to formulate the first proposition of their new science: "Neurotics suffer from reminiscences". Over against a prejudice which had dominated the writing on hysteria ever since an Egyptian papyrus dating from 1900 BC described the etiology and treatment of globus hystericus, Breuer and Freud affirmed that these pathogenic memories could become operative in either sex. Hysterical symptoms no longer presupposed the existence of a wandering womb which could cause now palpitations, now epilepsy, now paralysis until, in its restless search for something to fill it, it finally began to consume the very substance of the brain and brought its unfortunate victim to the brink of insanity.
Hysteria emerged then, a century ago, as a defence neurosis, as a disease in which a specific etiology, mechanism of development and symptomatology could be demonstrated experientially in a way that gave it internal coherence and differentiated it from other neuroses. But I think we should be grateful to Freud for not describing it as "Defence neurosis - somatoform type" because, by retaining the ancient name that had been bestowed on it by Hippocrates in the golden age of Greek thought, he allowed it to continue to question psychoanalysts, to provoke them as hysterics themselves have done over the past hundred years and to deny them the illusion of mastery that a more objective classification affords psychiatrists and psychologists.
Despite its continued usefulness as a general guide to psychotherapeutic treatment, the notion of hysteria as a defence neurosis, whose symptoms disappear when the repressed memory of the traumatic seduction has been uncovered, needs to be considerably refined if we are to make sense of, and therapeutic progress with, the kind of hysteria that we encounter today. Hysterics have always been one step ahead of any attempt that medical, psychological or theological science has made to master their illness and it was only to be expected that, once psychoanalysis constituted itself into an organised body of knowledge, it too would be shown by these highly subtle and non-conformist patients to be as pretentious and impotent as the others.
What has in fact been emerging, as the dialectic between hysterics and psychoanalysis unfolds, is that the notion of hysteria as an illness with its own specific etiology, mechanism and symptomatology must be subsumed under the notion of hysteria as a discourse aimed at creating a particular kind of social bond, one based on a display of frustration and dissatisfaction about one's place in the sodal order, whether that order be the family or a wider social grouping.
From that point of view the hysterics who present themselves, and most usually their bodies, for medical or psychological treatment are only the pathological manifestation of a very wide-spread human condition, an understanding of which can throw light on the problem of hysterical illness, but which the analysis of hysterical illness can in its turn help to illuminate in its social and political manifestations. I am thinking, for example, of the contagion of fear which swept many European cities in the early days of the Gulf War, bringing financial ruin to theatres, restaurants and airlines and giving us a glimpse of the way in which even more sinister contagions of racism or witch-hunting can suddenly contaminate a collectivity.
Hysteria in contemporary psychoanalysis
This brings us from the 1890's to the 1990's and, in particular, to a number of studies published mainly in France, mainly in the past decade, which have, I believe, brought our understanding of the hysterical process a step further and have highlighted the need not to use this advance in knowledge to manipulate or outmanoeuvre the patient. Indeed, it is only by preserving the inviolable mystery of the individual hysterics who present themselves for analytic treatment that we can allow them to find a way out of their confusion and suffering.
These studies form part of an attempt to re-formulate the originality of the method discovered by Freud. "Psychoanalysis began with hysteria," writes one author "and psychoanalytic knowledge will always only be worth what our knowledge of this structure is worth."
But how can the psychoanalytic method, which is not one of objective observation and classification, enable us to advance in the knowledge of the structure of hysteria, while at the same time adhering to its ethical goal of preserving and transforming the intrinsic subjectivity of the hysteric? How can an analyst construct hypotheses that are testable by other practitioners of the same method and which may eventually become building blocks in a science of human subjectivity?
The specificity of the analytic method lies in the fact that, having recognised that human beings are essentially beings of language, it invites patients to speak in a way designed to highlight the flaws that may have emerged as they tried to find their place in the linguistically-determined structures of the human world. The patient's speech, then, is to be governed by the laws of non-omission and non-systematization which are the preconditions for obeying the rule of free association. The analyst's task is to respond to the patient, but again in a rather unusual way - one which helps there to be articulated in an ever-fuller way the unconscious desire which has determined their lives beyond any of their conscious intentions and which, because it has not been adequately acknowledged by themselves or by the key figures in their lives, has been forced to express itself in the painful and burdensome language of physical or mental symptoms.
In order to respond in this way the analyst must above all listen in a fashion that allows him to hear in the patient's discourse a message that goes beyond his conscious intention. Now, even the most reductionist psychiatric or psychological observer can scarcely fail to notice a particular subjective phenomenon which appears to be the quasi-universal experience of those who enter into a one-to-one relationship with hysterics. This is a tendency to be drawn out of your neutrality, to become involved with the hysteric either in terms of sympathy or annoyance. Indeed, what an. authoritative American study has called the "core descriptors" of the hysterical personality seems to be less an objective scientific assessment than a listing of the outraged reactions of the observer - the hysteric is vain, egocentric, affectively shallow, attention- seeking, histrionic, sexually provocative, frigid, dependently demanding, untruthful, manipulative, and so on. What is it in the hysteric's discourse that provokes the observer in this way and allows such moralistic, judgmental and frankly insulting descriptions to find their way into text-books as a guide for diagnosing, as a personality type, a particular kind of mental suffering? "You," goes the story of a psychiatrist who was being driven to distraction by repeated demands for a diagnosis of the patient's condition, "you are what we call-in technical language - a hysterical bitch!"
Psychoanalysis has made painfully slow progress in trying to understand these transferential effects that every clinician experiences, but a century of dialogue with hysterics has led to a sense that the core of their message can be best understood as a demand made on their interlocutors, not simply as a demand indicative of a general style of dependency but a demand which is a question and, what is more, a riddle. The fact that the form in which the hysterical symptom is presented puzzles the investigator is therefore no accident, since the unconscious intention of the hysteric is precisely to produce such bafflement. This has therapeutic consequences. If you listen with the assumption that you are being posed a riddle by this pain in the face, rather than simply asked for help in the alleviation of the pain, you have some chance of being able to situate yourself appropriately in the interchange that is taking place and of avoiding serious practical and theoretical mistakes.
But what is this riddle that is being posed in the symptoms and spoken discourse of the hysteric? It is not easy to circumscribe precisely and to give it a simple formula is likely to be misleading, but it may be helpful to think of it as arising from two apparently distinct but inter related questions: Question one, "In the light of these symptoms, who do you say I am?" and question two, "Am I, and in particular is my body, lovable as male or female?" Our hypothesis then is that hysterics, through their illness, express a desire to find someone who can answer these two vital existential questions about their existence and their sexual identity. It is the persistence with which they pose these questions and their continual search for what is called, in the jargon of contemporary French psychoanalysis, a master, that allows us to describe particular human beings as steering from hysteria.
But there is a further twist to the tale - the serpent's tail of our chimera -which is that hysterics are further dominated by an unconscious determination to frustrate themselves and the therapist of finding any answer to the questions they are posing. Hence the growing bitterness and defiance of hysterics and the inquisitorial contempt with which they can finally come to treat themselves, as well as the man and woman of good will who have attempted to respond to these questions with their science or their love. Hence also the judgmental tone of the descriptions in the literature: to be rewarded for all one's efforts by obstinacy and egocentricity is surely a sign not just of illness but of some congenital moral flaw.
Again, a formula whose verification you may look for in your own clinical practice: "Hysterics are looking for a master whom they in turn can master". And just in case you may think that this characterisation comes from the wrong side of the English Channel and is a little bit too redolent of post-structuralist psycho-babble, listen to the remark of Thomas Sydenham, the seventeenth-century English physician who is usually credited with being the first in modern times to recognize conversion hysteria: "with them", he writes, "all is caprice, they love without measure those whom they will soon hate without reason." Experts whose response to appeals for help has been welcomed in so many other cases find it hard to believe that the hysteric may have chosen them precisely to show the limits of their expertise.
This is the point at which we might well throw up our hands in hysterical despair and either send the hysteric packing -which sometimes works for reasons that are theoretically explicable -or raise the dosage of the medication to a level that ensures that he or she will stop asking these, or indeed any other, questions and give us and their unfortunate families a bit of peace.
The unity and coherence of hysteria as a clinical entity lies in the dominance of the features we have been describing -features which of course rarely appear in an undisguised fashion and which are subject to the infinite transformations made possible by the particular historical and genetic dimensions of each individual's life and also the scientific baggage with which the investigator approaches hysteria at different periods in history.
An existential theory of hysteria
If we turn now to the theoretical status of hysteria we are first led to ask how it happens that the questions we have outlined above can come to dominate an individual's life to the extent of producing serious pathology. Can an unresolved question produce mental illness? I think we can answer "yes" if the question concerns your very existence and your sexual identity.
The human subject is characterised by the fact that he not only lives his life but is aware of his existence and questions himself and his entourage about it. This questioning fulfils a vital function because of the extreme dependence of the human being on his fellows. That extreme dependence is understood by analysts in terms of two dramatic existential crises which confront every human being who comes into the world as a result of two moments, two phases of prematurity which are constitutive of human existence as such. Can we isolate the moments of prematurity which give rise to such crises and such dependency?
The first such moment is birth and the months that follow it. The new-born human organism is particularly unadapted to the struggle to sustain life outside the womb and the continuation of life can be ensured only by a prolonged recreation of intrauterine conditions which allow the infant to lead a parasitic existence under the protection of a mothering figure who attends to all its vital needs and responds to its demands -the Latin demandare means to entrust oneself to another. The demandingness of hysterics and their tendency to express themselves in physical symptoms is rooted in the helplessness of these first months and in the reliance on demands addressed to the caring other, not only for the satisfaction of one's immediate physiological requirements but also for the love with which, just as much as food, the child demands to be nourished.
The influence of constitutional and genetic factors in preventing the child from surmounting satisfactorily this critical time gives a theoretical basis for the effectiveness of anti-depressant medication in treating some hysterics, but the analytic argument is that this may mask rather than resolve the underlying intersubjective dilemma of desire, which is what distinguishes the infancy of the human child from that of animals.
The best investigators of the first six to twelve months of life - Klein and Lacan -hypothesise that the infant's first experience of its body is that of fragmentation and incapacity and that a mental sense of one's own unity is achieved only after a long struggle in which the role of the mother cannot be overestimated. The hysteric's sense of this unity is particularly precarious and analysts point to the analogy between the somatic complaints of the hysteric and the difficulties with nutrition, respiration, body temperature, balance, perception and other somatic systems which characterise the first months of life. This is also the universal basis for that somatic compliance which Freud noted as always being what determined the particular organic system involved in individual cases of conversion hysteria. The complaints of panic and despair, of depression and helplessness, of being so easily knocked off balance, which we continually hear from hysterical patients again point to this vulnerable period of human existence. The lack of a firm sense of unity and identity is at the root of the first form taken by the questioning of the hysteric: "Who am I? What am I? What is happening to me, to my body?" And it is usually by working through the patient's perception of the mothering figures in their history and in their current life that some understanding of the condition and some alleviation of the symptoms can be obtained.
But to understand how a properly hysterical structure emerges, as opposed to one of depression, for example, it is necessary to understand the second major organic prematurity, the one first discovered by Freud and the focus of most of his efforts to understand and treat hysteria. Freud's early investigations led him to conclude that hysteria always arose from a premature sexual seduction which traumatized the young child at a time when it was still struggling to affirm its own sexual identity as male or female in the complex series of identifications, repressions and sublimations that define the oedipal phase. It is the partial failure of this struggle to achieve what the analysts call an ego-ideal and the continued question that this leaves behind as to one's sexual identity that can be seen in the symptoms associated with the sexual behaviour of the hysteric - provocativeness, frigidity, sexual dependency - and also in the somatic disturbances of the male and female sexual systems. Recent American investigators have tried to capture the core of the hysterical personality in terms of the individual's need to mimic in a caricatural way - the macho man or the seductive vamp -the sexual identity that they have never fully understood or laid hold of.
But what is more fundamentally at stake here is a repetition of the demand for representation in the symbolic order -primarily that order which lays down the law governing the roles of the respective sexes and the relationships between them -and of the protest that essential aspects of their being have not been acknowledged in the representation that has been accorded them. So it becomes understandable that the sex which in a patriarchal society has for so long been deprived of its own voice -and what could be more essential than the right to speak? -seems to have a special affinity for hysteria. This lack of acknowledgement is conveyed to them either by the inequalities they perceive to exist between their parents or siblings by virtue of their gender, or by the accidents of seduction or abuse which leave them with a sense of oppression and vulnerability and tempt them to have recourse to the mechanisms of repression or dissociation which again can be found at the root of many adults' symptoms of hysteria.
This is not to say that even a Utopia in which the rights of all were equally honoured would see an end to hysteria, because the fundamental problem of assuming one's sexualised ego-ideal lies elsewhere. There is no social system imaginable which can respond to the individual's demand for a full recognition of his being, and in particular his sexual being, because such a social system would have abandoned its essential humanising function of enforcing the law governing the relationship between the sexes and, in particular, its most fundamental law: the prohibition of sexual relations with members of your own family and, above all, of mother-son and father-daughter incest. So, in advancing towards a humanised sexual identity, something every child experiences as essential has to be sacrificed -the tender intimacies with parents which dominated the first years of life.
Thus, while we may praise hysteria for its refusal to compromise, we must also recognise that this refusal-a refusal often expressed as a demand for a pure, unsullied love, an intolerance of any imperfections or substitutes -is ultimately anchored in a refusal to accept what Freud (to the great scandal of many) named castration: the complete abandonment of an involvement with one's parents as sexual objects -in particular, the renunciation of the ambition to be the one who can supply for what is lacking to the inadequate father of the oedipal phase -and the adoption of one's own sexual destiny and desire. This task is clearly not within the unaided compass of the young child and even the partial success which is the usual outcome depends on the desire of the parents, who may be only too willing to collude with the beloved son or daughter in their efforts to subvert this law of their being. It is here that the importance of the father is particularly highlighted and the perverse or humiliated fathers whom our hysterics frequently describe make it especially difficult for this vital existential question of their sexual identity to be resolved. In the case histories of Dora or Little Hans we find the most accessible accounts of Freud's struggle to clarify what is at stake in the process of becoming male or female, as well as the account of his perplexities and the theoretical and therapeutic problems he left to us and our successors.
But however much more work remains to be done in the theoretical domain, and however uncertain our therapeutic success, I think it is reasonable to hypothesize that this dialectical sequence, which begins with a fixation arising from the specifically human prematurity of birth, and culminates in a refusal to submit to the castration required by the law governing the relationships between the sexes, accounts to a large degree for the complex structures that we find in hysteria. In particular, it helps to make sense of the two major clinical forms in which hysteria presents itself and between which individual hysterics often oscillate: the depressive form in which mental and physical suffering predominates and the sthenic form in which the hysteric appears with all the force and intolerance of the revolutionary or the inquisitor.
A formalization of the hysterical position
By way of conclusion, let me give you a brief indication of the way in which Jacques Lacan has tried to introduce some precision and rigour into our way of talking about hysteria. Lacan uses the symbol Ꞩ (S barred) in order to denote the necessary split introduced into the "natural" human subject by the fact that, in order to become humanised s/he must submit to the law, and, in particular, the law governing the relationship between the sexes -the law that ensures that, whatever the structures of a particular society, the words boy or girl, son or daughter, when they are applied to a human being, profoundly influence the whole destiny of that person. The hysteric is someone who, for whatever accidental or structural reasons in their history, attempts to evade this submission to the law in a very particular way - by denying and repressing their castration through an excessive use of the normal mechanism of identification with their fellows. This is the source of the histrionic and suggestible aspects of the hysteric, the style of taking on a role or acting a part which fascinates because it seems in some way to express their own dilemma in confronting the law. This Lacan symbolises by the formula o over minus phi (-φ), where o indicates the imaginary other, some mode or other in the person's entourage or some moment of their own difficult history, and (p stands for the imaginary phallus -φ for an acceptance of castration. We can write this as:
But this is an alienating and maladaptive way of living in the human world and it is for this reason that hysterics suffer and continually address themselves to those who are supposed to be able to relieve suffering - traditionally to priests and doctors, and increasingly today to therapists of all kinds. This other who is supposed to know Lacan denotes as O (the big Other, the inheritor in particular of the role of the Mother) so that the full formula for the subjective position of the hysteric includes this reference to the Other and is written as:
I spoke earlier of recent and ongoing efforts to subsume hysteria as an illness under a more general form; that of hysteria as a discourse which aims at creating a particular kind of social bond. The notion of a discourse creating a social bond is based on the fact that when I address someone, I produce an effect in him. This can be expressed as:
But since, in the analytic way of understanding things, an agent is always moved by factors of whose true nature he is unaware, the components of any discourse must include a further element:
In hysteria the agent is the subject who presents him or herself as suffering from the effects of the symbolic order and is written as Ꞩ. The Other to whom he addresses himself is a Master whom we write as S¹ and the effect that he is trying to produce is a knowledge regarding his own which is presumed to be in the Master's possession. But the hysteric, more than any other agent, is unaware of the truth which is the motor of this discourse, and which we have seen to be the persistence of the unconscious wish to refuse the abandonment of a privileged sexual position with regard to the father. This, for reasons that would take us too far afield to go into, we write as o, the object cause of desire. The components of the hysteric's discourse are, therefore, written as:
or more usually in the form:
The sign / / is meant to remind us of the impossibility of any scientific discourse opening up to the hysteric the truth of his or her situation and of the corollary that our power as analysts is limited to providing the means that will enable hysterics to undo the repression which, by barring them from their truth, condemns them to a life of alienation and suffering.
And finally, what of our chimera? Well, you will be glad to know
that this fire-breathing monster was exterminated by one of those mythological heroes whom the Greeks portray as being at the source of the transition from matriarchy to patriarchy which, for them, marked the beginnings of rationality and civilization. It was Bellephoron, the grandson of Sissyphus, of rolling stone fame, who overcame the chimera by riding above her on the back of Pegasus and thrusting between her jaws a lump of lead which he had fixed to the point of his spear. The chimera's fiery breath melted the lead, which trickled down her throat and seared her vitals -a proof that physical medicine too can find its titles of nobility in mythology. But the rest of the story may also have its relevance. Bellepheron, in his pride at having overcome this divine creature, thought that he himself could fly to the heights of Olympus until Zeus put a gadfly under the tail of Pegasus and they both fell ingloriously to earth.
In our presumptuous assumption that we have mastered the mysteries of hysteria and have reduced the hysteric to silence, perhaps we should not forget that hysteria has an infinite capacity for transforming itself, and that, if we fail to recognise it as a wondrous chimera, we may be condemning ourselves to experience it as nothing more than an exasperatingly persistent gadfly.
* This paper was delivered in the course of a debate on hysteria organised in 1991 by the Royal Academy of Medicine in Ireland.
 cf P. Verhaeghe's paper in the present issue.