Hysteria has been a diagnosis under siege for longer than most of us can remember. Eliot Slater, foremost among the hatchet men, believed that hysteria was a fertile source of clinical error and advocated that the term be dropped. Aubrey Lewis, in a more sober judgement, thought that psychiatrists would be hard-pressed if they were unable to use the term and predicted that hysteria would outlive its obituarists. Despite Slater's attempts to abolish the concept, hysteria has survived although it is now thinly disguised in modern classifications as conversion disorder or dissociative disorder. Neurologists, even more than psychiatrists, find the term helpful both diagnostically and therapeutically.
This book is a welcome addition to the literature on hysteria and provides a balanced and generally critical review of contemporary theories on classification, epidemiology, aetiology and management. The boundaries between hysteria and conditions such as factitious disorders, malingering and somatisation disorder are acknowledged and discussed at length. In this context, there is a particularly useful chapter by Christopher Bass, who discusses the diagnostic pitfalls involved in trying to distinguish between unconscious and conscious motivation. There is also an intriguing but speculative account of a possible neuropsychological substrate extrapolated from observed changes on a positron emission tomography (PET) scan.
Therapeutic interventions are also well reviewed. The clinician looking for evidence-based studies will struggle to find them, but several chapters discuss the role of psychodynamic psychotherapy, abreaction, hypnosis, cognitive—behavioural therapy and rehabilitation. These will be very helpful to the psychiatrist to whom is referred a patient with hysterical symptoms but who has not much experience of managing them, a common scenario in contemporary psychiatry where most clinical experience is acquired well away from the wards of a general hospital.
Recent follow-up studies have shown that the diagnosis of hysteria is much more reliable than Slater led us to believe. Much of this results from increased neurological acumen and particularly from the availability of non-invasive imaging investigations. There is also now greater awareness, acknowledged by several of the contributors to this volume, that dual diagnosis is common and that the presence of coexisting neurological or psychiatric disease does not exclude a diagnosis of hysteria. Maria Ron, one of Slater's successors at the National Hospital for Neurology and Neurosurgery, Queen Square, concludes that the diagnosis of hysteria can be made safely and accurately. Although its aetiology is uncertain, clinicians continue to find it a useful concept without believing that there is a single aetiology or therapeutic approach. Hysteria is thus best considered to reflect a clinical syndrome, very much in keeping with all other psychiatric diagnoses such as neurasthenia or schizophrenia. The psychiatrist's skill involves elucidating the underlying causal factors and coordinating an appropriate treatment plan.
This book can be recommended to all those interested in the bewildering yet fascinating hinterland between neurology and psychiatry. It will be particularly useful to neurologists, neuropsychologists and liaison psychiatrists. Hysteria has indeed survived, even if it is living under an alias.
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