The term “hysteria” was the commonly used name for all psychogenic disorders, both neurologic and nonneurologic manifestations, until only recently, when terms such as “functional,” “nonorganic,” “psychogenic,” and several others began to be used. Perhaps the switch was because “hysteria” became a pejorative word, and terms more acceptable to patients were desired. Whether “psychogenic” should be the preferred term is debatable, and is the subject of subsequent discussions in this book. Its use has the advantage that it emphasizes an etiologic cause of the disorder, one coming from the psyche.

The term “functional” might be more acceptable to patients, as well as to neurologists and psychiatrists who are evaluating the patient and prefer not to confront the patient and family members with the etiologic term psychogenic. But “functional” had been used by early neurologists and psychiatrists not only to refer to a psychogenic disorder, but also to one due to abnormal physiology rather than physical structural deficits, such as those that might come from trauma, tumors, and infection. For
example, Putzel’s monograph dedicated solely to common functional nervous diseases (1) has chapters on chorea, epilepsy, neuralgias, and peripheral paralysis. Bastian, an English neurologist at the National Hospital in London and slightly older than Gowers, condemned the practice of using the terms “hysterical” and “functional” synonymously (2). Bastian maintained that “if hysteria were defined as a neurosis in accordance with the views of Charcot and Briquet, then all cases of functional spinal paralysis should be placed in some other category” (30). Thus, the term “functional” could result in ambiguity, at least in terms of trying to distinguish between its current and past meanings. If the objection to using “psychogenic” is because of concern that the patient and family would react negatively to this term, then perhaps explaining that the symptoms are due to an altered brain physiology and not to a structural problem of the nervous system would satisfy. At a later time, when the clinician feels more comfortable, the term “psychogenic” can be introduced to emphasize the etiologic nature of the symptoms.

“Medically unexplained symptoms” as a substitute term has a vagueness that implies the clinician could not come up with an acceptable diagnosis. There are certainly medical conditions that are difficult to classify or in which there is considerable controversy on their etiology—reflex sympathetic dystrophy and chronic fatigue syndrome are two examples—and these could be listed as medically unexplained symptoms. But if psychogenesis is the etiology, why not use the term “psychogenic,” even though there remains unexplained the physiology in the brain that underlies most cases?

In reviewing the history of psychogenic movement disorders, one needs to look back and determine what early neurologists and psychiatrists were referring to when they discussed hysteria. Hysterical paralysis and sensory loss (including blindness) have been known probably back in antiquity, and had been discussed before the era of Charcot and Freud, two well-recognized neurologists who gave considerable thought to the study of hysteria. In this review we will obtain an understanding of psychogenic movement disorders by studying neurology textbooks written in the 19th and early 20th centuries. This review is limited to English-language books. This is unfortunate because some of the great scholars of hysteria were French, such as Charcot and Briquet. Nevertheless, the Anglophones do offer us a perspective on the evolving thoughts of neurologic manifestations due to a psychogenic etiology. Thus, such a review provides us a perspective as to how today’s views of psychogenic movement disorders came to be.

Topics to be discussed in this chapter will seek to answer the following questions. When were psychogenic abnormal movement phenomenologies first recognized? Were any movement disorders that are now recognized as organic at one time considered to be psychogenic? When were psychogenic movement disorders fully appreciated as a major differential diagnosis to be considered when evaluating patients with a movement disorder? After reviewing 19th and early 20th century English-language neurology textbooks to learn what clinical features were considered hysterical and how the diagnosis was made, I will review more modern texts, but those that were published before the field of movement disorders evolved into a subspecialty. Finally, I will review developments in psychogenic movement disorders after the field became a subspecialty. One should keep in mind that many neurologists until the mid-20th century were both neurologists and psychiatrists, a feature of the close relationship between these two specialties in the early development of both fields. These neuropsychiatrists had considerable interest in hysteria, and the textbooks up to about 60 years ago elaborated considerably on their ideas of the causation of hysteria.

In one of the earliest textbooks of clinical neurology translated into English, Romberg (3) comments mainly on ideas of etiology, and does not provide much on the description of the clinical neurologic features seen in hysteria. He briefly mentions paroxysms, spasms of different body parts (including globus hystericus and trismus), and movements ranging from tremor to convulsions. Thus, seizures, tremor, and sustained muscle contractions (i.e., dystonia) were recognized by him to occur in patients with hysteria.

In “the first textbook on nervous diseases in the English language” (4), Hammond (5) devoted a full chapter to the topic of hysteria and presented several references, including that of Briquet (6), whose writings were influential to the field. The particular neurologic phenomena mentioned by Hammond can be divided into (a) sensory (hyperesthesia, anesthesia, pain), (b) motor weakness (paralysis, paraplegia, aphonia), and (c) abnormal movements (clonic spasms simulating chorea, tonic spasms, convulsions, globus hystericus, and tetanoid paroxysms). Hammond did not mention hysterical tremor. Although Hammond states that clonic spasms simulated chorea, today one would probably consider such clonic spasms to more likely be classified as dystonia with patterned movements of the spasms.

Hysteria as a cause of neurologic symptoms must have become fairly common because subsequent 19th century neurology texts also have chapters exclusively covering hysteria in varying degrees of detail. Wilks (7) has a fairly extensive section, but deals mainly with his ideas on etiology and behavior, and presents only anecdotal descriptions of some of his cases. He does mention pain, analgesia, and seizures. An English translation of Duchenne (8) devotes a small chapter to hysterical paralysis, concentrating on faradic stimulation of the affected muscles.

In his book covering lectures on localization of signs and symptoms of neurologic problems, Gowers (9) mentions
in discussing hysteria, “there are few organic diseases of the brain that the great mimetic neurosis may not simulate.” He emphasizes that one must not make a diagnosis of hysteria without first excluding organic disease. He also provides some general principles characteristic of hysteria, such as onset after emotion, increase on attention, grave symptoms of one type that will cease suddenly and be replaced by others which could not result from the same organic cause as the first, and differences in the symptoms of hysterical origin from the corresponding symptoms of organic disease. In this short section on hysteria, Gowers gives some “pearls” relating to hemiplegia, contractures, reflexes, spurious clonus, ocular convergence, hemianesthesia, ptosis, aphonia, and convulsions.

In a neurology textbook with chapters written by American authors and edited by Pepper and Starr, there is a very large chapter on hysteria written by Mills (10), followed by a second chapter by him on “Hystero-Epilepsy.” Mills wrote a very thorough review, including a discussion of the historical development on the concept of hysteria. He mentions that the Catalog of the Surgeon-General’s Library of 1885 lists up to 318 books and 914 journal articles on hysteria, dating back to references from Hippocrates. Mills states that the greatest work on the subject is that of Briquet (6), and in America the most prominent authority was Weir Mitchell. Mills gives a marvelous historical treatise on hysteria in his chapter. Dancing mania occurred in various mass hysterical outbreaks affecting children in Europe in 1237, 1278, 1374, and 1418. The last occurred in the chapel of St. Vitus in Strasburg. The name St. Vitus’ dance was given to this condition, which later got transposed to the choreic disorder described by Sydenham, now known as Sydenham chorea. Dancing mania has continued into more modern times. Mills mentions that the New England “witchcraft” incidences were considered to be episodes of epidemic hysteria and hystero-epilepsy. Mills considered hysterical symptoms to be of four categories: (i) symptoms that are involuntary; (ii) symptoms that are artificially induced and then become involuntary; (iii) symptoms that are acted or simulated, but because of impaired mental power, are irresistibly performed; and (iv) symptoms that are purely acts of deception under the control of the patient. Neurologic hysterical phenomena described by Mills are convulsions, paralysis, aphonia, gait ataxia, chorea, rhythmical chorea, tremor, contractures, local spasms, and sensory phenomena, especially anesthesia. What he was describing as rhythmical chorea is not clear, for chorea today is considered as random brief contractions that tend to flow from one body part to another.

Gowers (11) had a large section devoted to hysteria in his textbook, which I will describe in some detail. He divided the clinical manifestations into the continuous and the paroxysmal. He gave descriptions of a number of clinical phenomena, including globus hystericus (a feeling of something suddenly closing the throat and stopping the breath), which when intense may have the pharynx in spasm; hysterical convulsions; a range of sensory symptoms; and motor symptoms. Of the last, paralysis was most common, and can involve limbs and cranial muscles, including the larynx (mutism and aphonia). In terms of movement disorders, he mentioned ataxia of gait, as previously described by Briquet, and jerky voluntary movements. He mentioned spasmodic contractures that can even persist in sleep, that relax only with chloroform narcosis, and if continued over years, can lead to permanent contractures that are no longer responsive to chloroform. Today, these would be considered true contractures, whereas the use of the term in earlier textbooks would be considered sustained contractions. Trismus, paroxysmal rigidity, and tremor are other motoric features that would fit with psychogenic dystonia, paroxysmal dyskinesias, and tremor in today’s classification. Gowers pointed out that hysterical tremor is rarely constant, but is usually evoked by movement and excitement, and tends not to appear on the initiation of the movement. He pointed out that such tremor differs from that of paralysis agitans (today known as Parkinson disease), while the fineness of the tremor differs from tremor of disseminated sclerosis, but not always. Hysterical tremor can involve the arms, legs, and head. Gowers also mentioned hysterical chorea and rhythmical movements. He further described symptoms that can involve the digestive, respiratory, urinary, and circulatory systems. In terms of diagnosis, Gowers emphasized that the most important diagnostic consideration is the absence of any unequivocal symptom of organic disease. The element of second importance is age and gender of the patient, for it was known from the work of Briquet (6) and Landouzy (68) that hysteria is most common in women, generally between the ages of 10 and 40, particularly in the teens.

Lloyd (12) wrote a large chapter on hysteria in the neurology textbook edited by Dercum that was filled with American authors. Much of Lloyd’s efforts are similar to those discussed by prior authors. But Lloyd elaborates more on tremor, stating it is one of the most important motor stigmata of hysteria. But Lloyd associates it to trauma, alcohol, lead, and mercury, so it is not clear if he had distinguished between organic and psychogenic tremor. Lloyd also describes hysterical ataxia under the term of astasia-abasia, a term first attributed to Blocq.

Sachs (13), in his textbook on pediatric neurology, mentioned that hysteria is rare in adults and even rarer in children. He also stated hysteria is much less common in the United States, England, and Germany than in France and Russia. He divided clinical manifestations into three categories: (i) psychic (e.g., hysterical mania, epilepsy, and trances), (ii) motor (paralysis and spasms) and (iii) sensory (hyperesthesia and anesthesia). Like Gowers, Sachs emphasized that the diagnosis should be made only in case an organic affection can be positively excluded and if the symptoms are well recognized to fit that of hysteria.

Dana’s textbook (14) also contains a chapter on hysteria. He divides the condition into hysteria minor and hysteria major. The former is characterized by the interparoxysmal state of emotional weakness, nervousness, hyperesthesia, and pains. There is no anesthesia or paralysis, and no convulsions. Hysteria major is characterized by the interparoxysmal manifestations of anesthesia, paralysis, contractures, tremors, peculiar mental conditions, and by paroxysms of an emotional, convulsive, or other serious nature. He includes prolonged attacks of coughing, hiccoughing, sneezing, and rapid breathing. Photographs of patients with so-called hysterical “contractures” resemble dystonia of the limbs. One cannot be certain that in these years prior to the first major description of organic dystonia (15,16), the condition as recognized today was not mistaken for a psychogenic spasm disorder.

Chapters on hysteria continued to be included in neurology textbooks published in the early part of the 20th century. In the chapter on hysteria in their textbook, Church and Peterson (17) describe the hysterical motor stigmata as being retarded, maladroit, and uncoordinated, with the inability to perform several acts simultaneously, weakness, and a tendency to rigidity and contractures. They also cover the sensory and convulsive phenomena. Of particular interest in this chapter are the reproductions of Richer’s drawings of the various postures of hysterical seizures and movements; some of the tonic ones could be considered dystonia today (18).

Pearce (19) devotes a small section to hysteria in his textbook. It contains a helpful table comparing different features of organic and psychogenic seizures, but otherwise is rather scanty in its coverage of other phenomena of hysteria.

Ziehen (20), like a number of his predecessors, linked the etiology of hysteria for the most part to hereditary factors. It should be mentioned that Lloyd (12) was opposed to this view, and related hysteria to social factors. Ziehen elaborated on paralysis, contractures, and clonic spasms. But it appears that Ziehen did consider hemifacial spasms and facial tics as features of hysteria. This appears to be another example in which diseases recognized today as being organic could have been mistaken for hysteria a century or more ago. Ziehen expands on hysterical tremor and states that hysteria can take on any form of tremor, including rest and action tremor. Other motoric aspects covered in this chapter are hysterical chorea and incoordination.

Jelliffe (21) wrote a large chapter on hysteria for Osler’s textbook of medicine. He reviews the history of hysteria from the time of Hippocrates, Pliny, Willis, and Sydenham up to his own time. Besides discussing views on etiology (his own and those of others) of hysteria, Jelliffe describes clinical features, including rhythmic (e.g., tremor and coordinated impulsive movements) and arrhythmic movements (e.g., chorea and tetany). This is a thorough chapter, with coverage of epilepsy, weakness, and sensory disturbances.