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The masks of hysteria

Psychic disorder that helped the birth of psychoanalysis is presently mistaken for epilepsy

EPILEPSIA/ELZA M. T. YACUBIANThe intellectual revolution in Paris of 1795: the doctor and psychiatrist Philippe Pinel orders that the chains be removed from the patients at the Salpetriere Hospital, up until then a deposit for the mad and evil-doersEPILEPSIA/ELZA M. T. YACUBIAN

On the morning of the 21st of November 2001, a Wednesday, the neurologist Carmen Lisa Jorge was analyzing images and the electroencephalogram of two supposed epileptic crises that Visconde Oliveira had presented during the previous dawn. “Most definitely he doesn’t have epilepsy”, she concluded. The forty-seven-year old man had already spent two days in a nearby room in front of a camera that had registered his image, synchronized to the electroencephalogram. The 29 electrodes that remained all of the time fixed to his head followed his brain activity, but at not a single moment did they register the electrical discharges that describe epilepsy. The realization excluded the possibility of surgery that the doctors at the São Paulo Hospital das Clinicas (HC) had been contemplating as a way of soothing the convulsions that had begun some seventeen years earlier, which lasted from thirty minutes to an hour and only ended when he fainted into unconsciousness. Some seven times the man had awoken tied down to a bed within the intensive care unit, where he had to remain sedated for some days.

Three days later, Luiz Henrique Martins Castro, the doctor responsible for the HC unit in which the examinations was carried out, commented: “Mr. Oliveira, what you have is another type of crisis, one of emotional origin. Your crises may be the result of some conflict, recent or not, which is not always conscious. At this moment, you need psychological treatment”. When Castro said that he could stop taking the medicine to counteract epilepsy,  Oliveira began to cry. He left the hospital crying, he arrived at home crying and cried compulsively for a further two days.

“I was finally free”, said Oliveira. Because of the convulsions he had lost his job. The medication – in ever increasing doses, since the crises had not ceded – made him fall asleep almost all of the time and had left him with fear of leaving his home. After having begun his psychological treatment, he never again felt the strong trembles that used to knock him to the floor and that in the latter stages had been occurring daily. In January of 2002, the psychoanalyst Mara Cristina Souza de Lucia, the director of the psychology division at the HC, who accompanied the patient’s treatment, concluded that the agitation crises, the fainting spells and even the paralysis of his left arm were unequivocal symptoms of hysteria, a disturbance of psychic origin whose mysteries had seduced the Austrian neurologist Sigmund Freud and had led him to the founding of psychoanalysis.

Hysteria, that many had believed to be extinct, has not died. It had only hidden itself. At the end of the 19th century, it was still viewed as an expression of fragility and exclusively of a female want. By the way, the word hysteria comes from the Greek hystera, which means uterus, from where the contaminated blood would flow, and on arriving at the brain would lead to convulsions. During that era women with hysteria lived in the same institutions the epileptics and the mentally ill. Both in the asylums and in public, in front of a audience of doctors who had delighted themselves with the spectacle, women, generally young and pretty, had thrown themselves to the floor, rolled about and even ripped their clothes until, exhausted, they lost consciousness. Supposedly, the isolation that was imposed upon them as a form of treatment should have been able to resolve the problem.

Gradually, throughout the 20th century, hysteria stopped attracting doctors’ attention. As a consequence of successive reformulations of the mental health diagnostics manuals, it was lost as a concept. But it did not disappear. It only sought refuge under other names in the offices of psychiatry, neurology and, as a matter of fact, in any other medical specialization. For example, convulsions went on to be seen as signs of psychic disturbances, as panic or anxiety disorders. They could also be confused with an epilepsy of difficult control.

However, normally epilepsy spawns from alterations in the brain’s neurons – therefore, guarding a defined physical origin. And, from what is known up until this moment, hysteria does not have its roots in any organic cause. According to psychoanalysis, it is a body expression, inconsistent with psychic conflicts and with intense emotional suffering, as if the very body itself became a volcano that let the lava flow continually, while waiting for an eruption that seems to never take place. Freud called this mechanism, by way of which repressed conflicts and non-verbal expression found corporal expression, conversion. This conversion does not show itself only through convulsions. It can also be expressed by way of symptoms such as breathing crises, paralysis, blindness, deafness, headaches, psychological pregnancy, muscular pains or an inability to swallow food, to which the name digestive hysteria was given. The very symptoms become themselves into the problems to be treated, whilst the conflicts that originated them remain hidden. Conversion in an unconscious defensive mechanism that looks to avoid suffering.

It is not only at the São Paulo Hospital das Clinicas that manifestations such as these are being detected. What the psychoanalysts call hysteria, the neurologists call conversion disturbances and the psychiatrists name dissociated conversion disorder. In eight specialist medical centers in the States of Goiás, Sao Paulo, Paraná and Rio Grande do Sul that can count upon the video electroencephalograph (V-EEG), an exam used to differentiate what is and what is not epilepsy, around one hundred cases of the so-called Psychogenic nonepileptic seizures are diagnosed every year, according to a study published in 2004 in the Journal of Epilepsy and Clinical Neurophysiology. As well as hysteria, these crises can also appear in other psychiatric disturbances such as bipolar disorder, panic syndrome or anxiety disorders or even in food disorders such as anorexia and bulimia.

At the São Paulo, nonetheless, hysteria has prevailed, diagnosed in 25 of the 26 patients who finished the year-long psychotherapy treatment. The neurology team remitted 35 patients with psychogenic crises to the psychology division, but some patients interrupted their treatment and others did not even begin. Women predominated as they corresponded to 23 cases, with men much rarer. Besides Mr. Oliveira, the first to have been diagnosed with hysteria by the HC group was another guy, also a 47 year old, who had presented both epileptic crises and those of emotional origin.

The women suffering from hysteria themselves have said that, in general, the attacks begin with a warmth that spreads up the body and rapidly reaches their head. The convulsions make their whole body tremble and send them onto the floor. Shortly afterwards they will not feel anything else as they will lose consciousness and will awake remembering nothing. Most have their crises close to their menstrual period, one of the moments of greatest oscillation in their levels of sexual hormones. But it may be just a simple relationship of cause and effect between the hormone variation and the hysterical attacks. It is also at this moment, the psychoanalysts point out, that the feminine nature reveals itself with more clarity and pain.

Lack of air
“Freud had already stated that hysteria is associated to sexuality, not only with women, as he himself has demonstrated, but also with men, who are not free of unconscious conflicts”, comments Mara Lucia. Even today, patients diagnosed with hysteria very often tell episodes of physical and sexual abuse – not always real, as Freud had discovered on noting that fantasies of this nature had also brought about symptoms of hysteria in his patients. This was what had happened to a 39-year-old woman – whom we shall call Dolores -, sent to the HC for a medical evaluation with the suspicion of suffering from asthma. She had breathing crises, closure of the vocal chords, coughing and a squeaking in the larynx, but the exams had not registered any sign of asthma.

Throughout the psychological treatment at the HC she had paralysis of a leg, intense coughing and breathlessness when speaking about difficult moments in her life to the psychoanalyst Niraldo de Oliveira Santos: she had believed that she had suffered sexual abuse from her father. But later, as the sessions progressed, she herself had concluded that the sexual abuse that she had told had not been real. “For her, when still a child”, concluded Santos, “the strong hug that her father had given her, when arriving home intoxicated with drink and arguing with her mother, presented a risk and approximated her to a sexual desire”. Then came the fear of lust, censured by  the closure of the vocal chords. At the end of her treatment, Dolores recovered her voice and today sings in the choir of the Church that she goes to.

As yet hidden behind many masks, hysteria is revealing itself principally inside neurology clinics. It is estimated that one in every four people previously diagnosed with epilepsy in specialized medical centers had in truth non-epileptic crises of emotional origin – and one in every three, both problems. In accordance with the study published in the Journal of Epilepsy and Clinical Neurophysiology, at least 60,000 patients could be suffering from non-epileptic crises, of emotional origin in Brazil, yet they are generally treated as epileptics.

Carelessness
“Throughout the world”, comments Luciano De Paola, the epilepsy program director at the Hospital de Clínicas of the Federal University of Paraná and the coordinator of this survey, “non-epileptic seizures are much more common than we think, and as yet we hear little spoken about them in Brazil”. André Luís Fernandes Palmini, a neurology professor at the Catholic Pontifical University of Rio Grande do Sul, believes that many mistaken cases would be avoided with a more in-depth and careful conversation with the patient and his or her family. “When the consultations are very brief, the doctors generally don’t manage to diagnose non-epileptic crises”, he says. ‘One cannot simply conclude that a person has epilepsy only because he or she has convulsions.”

False epilepsy can escape by way of anamnesis – an interview – rushed with the doctor, but it is difficult for it not to be detected using the video electroencephalograph. This examination, which registers the brain’s electrical activity simultaneously with the person’s image, began to be used only a few years ago and is providing real dimensions to this problem, also detailed out by way of other forms of diagnosis, especially nuclear magnetic resonance (NMR) imagery.

In the video electroencephalograph, the patients, with electrodes fixed to their heads and not on medication, remain from one to seven days in a room in front of a camera that films their movements. The exam manages to discover whether or not the convulsions are of neurological or emotional origin by firstly accompanying the electroencephalogram, which registers the peaks of the electrical activity of the neurons, when one is dealing with an epileptic crisis and remains normal in other situations.

Another important sign is the duration of the crisis. On average, epileptic convulsions last one minute, whilst the psychogenic crisis can last up to an hour. Also, movements in their totality are evaluated. In the crises of emotional origin, the head moves intensely from side to side, the arms tremble asymmetrically, the pelvic region is pushed forward – this is called pelvic impulse – and the body curves, forming what is denominated as the hysterical arc. But it is not recommended to trust first impressions. For example, the pelvic push can also occur with a type of epilepsy that originates in the frontal region of the brain, according to Elza Márcia Targas Yacubian, a neurology professor and head of the epilepsy out patients clinic at the Hospital Sao Paulo, linked to the Federal University of Sao Paulo (UNIFESP). Among the 120 patients who went through a video electroencephalograph test over the last two years at UNIFESP, at least 20 have shown psychogenic nonepileptic seizures  and at least six had hysteria. In the Federal University of Parana’s hospital and at the Hospital XV, both in the city of Curitiba, neurologists have registered a further 45 cases of non-epileptic crises, although they have not provided more detailed statistics.

The accumulated experience and the group work of the health professionals are revealing the profile of the persons who carry with them these forms of suffering that result(s) in a loss of movement control. “The patients with psychogenic crises have difficulty in verbalizing the anxieties that they feel”, comments Gerardo de Araújo Filho, a psychiatrist with UNIFESP. “Their personal relationships are marked by blackmail and theatrics.” Whilst people with epilepsy have convulsions in whatever place and at whatever hour, even whilst asleep, men and women with hysteria appear to intuitively make use of the most adequate circumstances, such as their need for an audience or attention.

For the psychoanalyst Christopher Bollas, author of the book entitled Hysteria, “an indelible image of hysterics suffering” is the young woman fainting into the arms of the French neurologist Jean-Martin Charcot, one of the researching pioneers into this disturbance, to which he attributed hereditary origin. Freud, a disciple of Charcot at the  Salpetriere Hospital in Paris, did not content himself with this explanation and studied feverishly until he concluded that the convulsions had resulted from unconscious processes, and that they disappeared when the conflicts had turned themselves conscious. By creating a new method of treatment, based on evoking the ideas that had propitiated the emergence of these conflicts, Freud alleviated the symptoms of hysteria of a twenty one year old woman, Bertha Pappenheim, whom he called Anna O. in his case files, having made her relive disagreeable experiences through hypnotism. At that time, hysteria was considered to be essentially a female spectacle. “It is as if the couch had been invented to secure the cadent body of a hysteric”, wrote Bollas.

On appearing before a doctor, women and men with hysteria show on the marks of their very body an enigma to be revealed and that provides a purpose for their very existence. In April of 2000, Milberto Scaff, a neurology professor at the Medical School of the University of Sao Paulo (USP), linked to the HC, felt himself challenged during the treatment of a young-sixteen year old female from the upper class of São Paulo, whose crises had lasted as long as one hour. Without detecting any sign of epilepsy in the examinations, he sent her off to the psychology division. Before having received a diagnosis of hysteria, she had appeared with her face speckled with red merthiolate, although she has suffered only a small cut during yet another of her (his) convulsions. “We can understand the constant visits of the hysterical ones to the hospital’, wrote psychoanalyst Bollas, “as a continual appeal for the mother to return and to look after them and so that she would rediscover the body of the baby as something now desirable”.

According to psychoanalysis, the origins of hysteria do not go back only to the mother but also to the father. Both can create the conditions for the development in their son or daughter of an identity that is not their own. “The hysteric is the daughter of another hysteric who has not managed to value her own femininity and, as a consequence of this, will have transmitted a vision of lesser value in relation to the body”, underlines Silvia Alonso and Mário Fuks, professors at the Sedes Sapientiae Institute, in Sao Paulo city, in the book Hysteria. Hysteria can also be fermented when the father omits his responsibilities and does not impose limits that help to define the identity as well as the social and sexual roles of his children – thus not realizing or not performing that which the psychoanalysts call symbolic castration. He could well react in this manner because of being afraid “of the possibility that the recognition of the sexuality of his daughter (can) lead him to incest”.

Freud showed that the origin of hysteria is found in sexual repression. And  today? “It continues to be so, as it always was, even before Freud”, says the psychoanalyst Rubens Marcelo Volich, a professor at the Sedes Sapientiae Institute. “The forms of sexual repression have merely transformed themselves into others” According to Freud, sexuality is wider than sexual activity in itself. It transcends the biological function of the preservation of the species and covers all of the pleasure and displeasure circuit that involves desire and human experience. Currently, in the opinion of  Volich, “in spite of sexual liberation and of the banality of sex and eroticism, sexuality remains as a potentially disturbing experience”. It is exactly this characteristic that, according to him, makes it become the source of conflicts, and therefore, can be repressed. One of the possible consequences is hysteria.

In conformity with psychoanalysis, the hysteric organization, understood as a mode of psychic functioning, describes itself through a permanent, untiring and unconscious search of a person to be the object of desire of another. It is for this reason that a man or a woman with hysteria frequently finds himself/herself involved in a lovers’ triangle, whose configuration is not always the most obvious. As stated by Volich, very often the woman does not desire the man of a rival, but the position that he occupies in the desire of his woman, thus appropriating the role that he has for the rival. Consequently, subconsciously she wants the rival to desire her. And, it is because of this relationship established with the other’s desire, that the tremors and the fainting spells of the hysteric ones in the arms of Charcot can be understood as expressions of an unconditional surrender or of the supreme gesture of love, even at the cost of renouncing one’s own identity or of damaging one’s own health. “That which in the hysteric is shown as identity is, in truth, a mounting or a caricature of that which she imagines the other expects from her”, says Volich. A person with hysteria lives without his own location, harnessed to the supposed desire of another person. The person’s life is an insupportable vacuum.

Silvia Alonso and Mário Fuks have described the mechanisms by which today hysteria is generated and fed. In men, they can be perceived, for example, by way of the excessive concern for building a well shaped body and by their frantic search for better and better performances. As well, according to these diffusers of current psychoanalysis, in women these mechanisms can be seen by way of their anxiety in presenting themselves as always impeccably beautiful, in agreement with the most recent fashion tendencies. “The attempt to correspond at whatever price to an idea of beauty”, suggests Volich, “could be a manner of molding the identity and of attempting to fill an existential void”. Masculine hysteria also manifests itself in game compulsion, in rage crises and in violence towards women. “Whilst hysterical women are found in consulting rooms”, the authors of Hysteria remembered, “hysterical men are frequently found in police stations”.

A cloudy morning
Hysteria, which has now come out of the shadows and returns to be openly recognized, creates an uncomfortable situation for doctors, principally neurologists and psychiatrists, who for a long period of time and for various reasons had stopped looking for the emotional origin of crises, having believed that hysteria had died. There is discomfort as well with patients, who having lived with anguish, social discredit and debilitated self esteem, while on a pilgrimage for health services, passed through unnecessary treatment (and) taking medicines that did not work. The psychiatrist and psychoanalyst Fábio Hermann, a researcher at the Medical Faculty of USP and a member of the HC team, nonetheless sees in this new situation “an opportunity for developing investigations of high level, in an area that has been stagnant because of theoretical repetition”.

Two things appear certain. The first is that only a multi-professional team, including neurologists, psychologists and psychiatrists, will (be able to) manage to find the best form of dealing with these expressions of the unconscious. The other is that hysteria is still a stigma, as if the people with this emotional imbalance had been challenging the specialists with an enigma whose solution would free them a voice or complete a gesture. The paralysis of Visconde Oliveira’s arm perhaps reflects the pains of a not realized/not performed act gesture: that of trying to save a friend who decided to swim in the Riacho Grande river, in greater Sao Paulo, during a cloudy morning one Thursday in 1980, and drowned.

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