Hysterical psychoses are related to epileptic psychoses in many respects, for example in their tendency to so-called twilight states. Some variety is often seen in this, especially among hystero-epileptics in connection with seizures, which French authors defined as a unique stage—the hystero-epileptic attack. However, it is not so much the ‘pre-syncope’ [Ed] of the sensorium, as the total allopsychic disorientation—usually of only short duration—that forms the main feature of these conditions. Patients behave as if they are in a fantastically altered situation, intensely Affect-laden. In particular, any misfortune that has befallen them—loss of relatives etc—plays a role. This so-called emotional stage of hystero-epileptic seizures thus falls within the area of delirious allopsychoses.

The so-called hysterical delirium corresponds even more closely to this concept—it being an acute psychosis that occurs independently, with an urge to move induced by sensory factors, and with total allopsychic disorientation, but with no definite prevailing Affective state. Due to their multiple sensory distractions, spontaneous expressions of these patients are also highly incoherent, reflecting their hypermetamorphosis. Only occasionally and momentarily can patients’ attention be fixed sufficiently to obtain answers from them. Tactile hallucinations and phonemes, localized with abnormal precision, play a major role. Addition of asymbolia is likely, as indicated by the patient’s behaviour towards food intake and bodily care. General muscle tremor, occurrence of the so-called lateral column symptoms [1], and physical decline can accompany the psychic symptoms, and lead to death within a few weeks. Moreover, mainly hypochondriacal symptoms may be seen during hysterical delirium. In like manner, in a severe case, after 6 weeks, the sensory agitation made way for a typical picture of agitated motor confusion, namely a hyperkinetic motility psychosis with manic features. This reversal appeared to be attributed to recovery of strength and general condition as a result of continued artificial feeding. An equally rapid reversal led to full restitution with insight into the illness; but a recurrence happened 18 months later. I am not aware of the outcome.

I have already mentioned (p. 253) the so-called catalepsy of hysterics [W], that is, a relatively short-duration akinetic motility psychosis. The sensorium usually becomes deeply insensitive, and often, to judge from the rapturous facial expression, is filled with ecstatic, religious dream experiences. A residual condition of weakness, without a paranoid stage, passes rapidly into healing. However, it also happens that such ecstatic states recur, and merge into a clinical picture of continued total immobility. I saw such a case end in death: These cases are serious psychoses. Often enough cases of illness are seen that have not so much the pattern of acute psychoses, but rather, represent transitional cases, or mixed ones between hysterical degeneration or impoverished personality, and isolated psychotic symptoms. In psychiatric wards in big cities, such as in our Clinic, prostitutes make up a very large proportion of these very troublesome cases of illness, because of their lax discipline. However, illnesses arising in quite civilized situations raise similar doubts: Is it misbehaviour and moral deficit, or illness? Tests on their spiritual endowment [W] and memory retention often show the former to be strikingly restricted, the latter to be significantly reduced. However, these are not necessarily lasting deficits. Treatment of such cases is extremely difficult, with a chance of success only if one always starts by assuming that a patient’s behaviour is conditional on some pathology. Quite recently, cases have been described by Ganser [2], in which patients with apparently clear sensorium, and quite sound mind, answered questions put to them in such an inaccurate and twisted manner that one had to assume an intent to deceive, the more so since some of them were prisoners. However, detection of the so-called hysterical stigmata led the author, justifiably we believe, to assume that a so-called twilight state exists in such cases. This is supported by the fact that previously-described, undoubtedly hysterical patients, often present the same symptom of deliberately meaningless answers. The only objection is to the name ‘twilight state’ [W] for such cases, for reasons mentioned earlier: The sensorium is not impaired, although existing mental material is restricted in its extent. There is a ‘narrowing’ [Ed] of consciousness, suggesting being hypnotized in a waking state. Thus, one sees in otherwise hysterical patients, quite atypical cases of psychoses, such as a delusion of persecution directed against only one person, where the sensory presence of this person is hallucinated, while allopsychic orientation is retained. I have already said what is necessary on the specific hysterical ‘second state’ [W].

Far more common in our area of interest than hysterical psychoses, are hysterical neuroses. I mention only obsessional neuroses and anxiety neuroses. Exceptionally however, these can lead to corresponding genuine psychoses.

The psychoses of puberty, or hebephrenic psychoses [W] have already been mentioned a number of times. You will remember, gentlemen, that I have earlier referred to the term hebephrenia, and have acknowledged the particular type of illness described by Kahlbaum and Hecker [3]. However, from experiences in our clinic, I have become increasingly dissatisfied with this viewpoint, and can now deal only with hebephrenic aetiology, which is [Ed] of great importance. Rather than ‘hebephrenia’ [Ed], I am inclined to accept Kahlbaum’s ‘heboidophrenia’ [Ed] or, for short, ‘heboid’ [Ed], as a specific psychosis of puberty. This clinical picture is defined far more sharply, as one in which ‘Affectuosity’ [Ed] (generally uniquely related to puberty but accentuated here) plays such an important role, and which seems to occur only in the context of puberty. Of course, I must then assume that certain symptoms that are consistently present have not been adequately observed by Kahlbaum. I mean mainly experiences of anxiety, outward signs of anxiety, and hypochondriacal sensations. Otherwise, I refer you to Kahlbaum’s descriptions of relevant cases; they are relatively rare, so that I have encountered only a few such.