The clinical epidemiology of hysteria: vanishingly rare, or just vanishing?

EDITORIAL The clinical epidemiology of hysteria : vanishingly rare, or just vanishing ?" Vanish 1. intr. To disappear from sight or become invisible, esp. in a rapid and mysterious way (Shorter Oxford English Dictionary, 1972). There is a well-known view that hysteria has virtually disappeared in the Western world. There are two versions of this argument : one is that there was never a clinical disorder that coincided with the diagnosis, and hysteria has now been reconstructed as something else (e.g. Micale, 1993). The other is that hysteria did exist but has now become much rarer than it was (most famously, Veith, 1965). According to this view, hysteria is to be found in patients from developing countries, but in Western countries it is ' virtually a historical curiosity ' (BMJ, 1976). It is the latter view that is – in our experience – most commonly held by our colleagues in general psychiatry. Yet, this opinion is not shared by those who are involved in the clinical care of patients with neurological disorders : ' to a psychiatrist who sees patients on the medical and surgical services of a general hospital, it appears that hysteria remains a rather common phenomenon ' (Brownsberger, 1966). A number of descriptions from liaison psychiatry services support this opinion (Akagi & House, 2001). There are good reasons why it might be difficult to judge just how common (or rare) hysteria really is. Epidemiology depends on reliable case definition, case ascertainment and selection of a suitable population to study (Neugebauer et al. 1980), and each of these poses problems in the study of hysterical disorders. First, there is the well-known problem with case definition – arising from inconsistent use of terminology and changes in diagnostic practice. Hysteria has referred to an underlying disposition manifest as emotional instability, sexual dysfunction, relationship difficulties or suggestibility (Satowa, 1979). It has been used to ascribe aetiology – to describe physical illnesses which have a psychological provocation, and which develop as a means of adapting to (or defending against) that provocation. And it has been used descriptively for those with the condition now termed conversion disorder (in DSM-IV (American Psychiatric Association, 1994)) or dissociative (conversion) disorder (in ICD-10 (World health Organization, 1992)), as well as to describe the very different presentation of somatization disorder or Briquet's syndrome. In the latter (descriptive) usage the diagnosis depends on the presence of a physical syndrome, …