Studies in Hysteria

"This was the starting point when people first considered the idea that stress and psychological distress can be ‘converted’ into physical symptoms. There are so many ideas and studies in this book that I absolutely don’t agree with any longer. It’s more than 100 years since it was written, but it laid down this basic premise on which we still operate in neurology; we now call these disorders conversion syndromes. This book was also the birthplace of the idea that if you can trace a symptom to the underlying psychological factors then perhaps you can give some sort of relief. For a long time people had considered that symptoms like this might be rooted in madness, there had been lots of conjecture about them being related to the womb, or to humours. This was the first text to articulate the idea that these symptoms are absolutely real but have a psychological basis. It was hugely influential. Many of the ideas in Studies of Hysteria are now outdated, however. Freud presented the patients as being cathartically cured in a lot of cases. But many of them relapsed, and were not cured. I don’t believe in this kind of absolute catharsis. There is also a huge emphasis in the book on sexual trauma or abuse. While a proportion of patients who suffer in this way have experienced significant sexual or physical abuse, that isn’t always the case. The symptoms would sit very nicely with Pauline, the patient I was talking about a moment ago. Her symptoms flitted around her body: she started with urinary symptoms, then moved to pain, then seizures. Some of the patients Freud and Breuer wrote about were very similar to that. They described not being able to speak, perhaps because there’s something you’re withholding, that you want to say but don’t feel you can say. One woman had pain in her knee. She was caring for her sick father and Freud believed this was the root of her illness. Where she had bathed her father’s foot on her knee, night after night, she began to develop pain. Another woman, who for many reasons was struggling in life, saw a dog drinking from her cup. She developed an aversion to water and couldn’t swallow. Freud believed that you could literally trace every symptom back to that one moment and the minute you realized that the reason you had pain in your leg was because your father’s foot was resting there when he was dying, or you realized you saw the dog drinking from the cup, that would cathartically cure you. I’m not sure I believe in that. The symptomatology he described is identical to any of the patients that I might care for now. But I wouldn’t trace the root cause in the way that he did. We would think about it quite differently now. When Studies on Hysteria was written it was considered that everything was due to psychological trauma. Very often that trauma was related to repressed sexuality or something sexual. Today we see these conditions as much more varied in their origin. It doesn’t necessarily follow that everybody who suffers with psychosomatic disability has suffered a psychological trauma or sexual abuse. Some people have, and then something as detailed as psychoanalysis would definitely be useful. But you can become ill just through ideas, through paying too much attention to your body, for example, or through injuring yourself and behaving in particular ways that prolong the injury rather than promoting recovery. Then maintenance factors are more important to address. Perhaps you need cognitive behavioural therapy to help you break the pattern of fear and avoidance. Or if you can’t walk, you don’t want six years of psychoanalysis, you want a physiotherapist to teach you how to walk again. We look at the individual and try to figure out what caused the disability, what’s maintaining the disability, and what are the main things that are needed to get people back on their feet again."