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The writer discusses the relationship between physical illness and psychiatric disorders. He points out the relativity of the “psychosomatic” and “somatopsychic” concepts and the dynamic interaction between biological, psychological and social factors in initiating, predisposing to and influencing the course and outcome of all organic diseases. Psychiatric disorders causally related to physical illness include organic brain syndromes, reactive psychoses, neuroses and personality disorders, and deviant illness behavior. Some of the pathogenic mechanisms are discussed and the clinical importance of this area of psychosomatic medicine is stressed.

Four patients have been described who were believed to be suffering from hysterical attacks. The recent literature on hysterical seizures has been examined and the four new patients were added to two other reported series to provide a profile of 25 cases. Preceding or accompanying physical illness was a common finding, and 32 percent of subjects had a previous history of neurological disease. The existence of a substrate of CNS damage is supported by the finding of EEG abnormalities in 40 percent of patients. In other ways the cases resembled classical descriptions of subjects liable to hysterical illness. The operation of either dissociative or conversion mechanisms during the attacks was difficult to demonstrate, and suggestion was sometimes the only factor found to account for the form of the symptoms. Further studies to examine the nature of the relationship between brain damage and hysterical disorders appear justified.

The authors studied case records of 27 men who had been diagnosed as having hysterical personality, although they note that the current literature assumes that the diagnosis of hysterical personality applies predominantly to women. They believe that not recognizing the hysterical personality in men is not only a common diagnostic error but antitherapeutic and counterproductive as well.

Male monozygotic twins, one of whom developed subacute sclerosing panencephalitis (SSPE) are reported in detail. Both patients had measles at the age of 4 years and 6 months. The diagnosis of SSPE was based on clinical, electroencephalographic and laboratory findings. Titration of antibodies against measles was carried out in both cases. The healthy twin, who had been admitted with a clinical picture initially similar to that displayed by his brother, showed clinical manifestations mimicking those of the affected sib, but these vanished 4 days after his admission and were attributed to transient conversion hysteria. The genetic factors involved and the biological response of the antibodies against measles are discussed.

All the papers about flat dwelling (Central Housing Advisory Committee, 1952; Hopper, 1962; Hird, 1966; Fanning, 1967; Gunn, 1968; Gilloran, 1968 and Stewart, 1970) except one (Sheerboom, 1962) state that it has an adverse effect on mental health. They are almost unanimous in naming the care of children as a cause. The best study from a scientific point of view (Fanning, 1967) showed a significantly higher rate of psychiatric consultations among those living in the same flats as in the present study. This was thought to be due to social isolation caused by the nature of the flats and being confined in them by children. A widely held belief that bad housing can cause or aggravate mental illness is not justified by the evidence. Three investigations (Martin, Brotherston and Chave, 1957; Wilner, Walkley, Schram, Pinkerton and Tayback, 1960 and Hare and Shaw, 1965) failed to show any benefit to mental health from new housing. The only one (Taylor and Chave, 1964) to find an improvement studied new housing which was socially planned. All four studies failed to allow for two other variables. One was the adverse effect of the move itself (Maule and Martin, 1956; Hall, 1964 and Shepherd, Cooper, Brown and Kalton, 1966) on those in new housing. The other was moving to better old housing among controls (Wilneret al., 1960).

The concept of care-eliciting behavior is proposed as an essential part of the phenomenon of attachment. The origins of this behavior in man are examined in terms of both ontogenesis and phylogenesis. The relevance of the behavior for species advantage is considered. Finally, it is suggested that mo

In May, 1973, 95 students and 3 teachers at an elementary school in Alabama became ill with pruritus or rash and with one or more of the following symptoms: headache, cough, weakness, sore throat, abdominal pain, sore or burning eyes, arthralgia, shortness of breath, numbness, fainting, nausea, vomiting, and diarrhœa. More than 50 persons received care at a hospital emergency room. Four and seven days later, 18 and 14 individuals, respectively, most of whom had been ill on the first occasion, sought medical attention for the same problems. An extensive epidemiological investigation was undertaken, but infection, allergy, and other organic causes were incompatible with the epidemic. Hyperventilation, an apparent visual chain of transmission, and recurrences at widely scattered places and times suggest mass hysteria.

If the natural history of an illness were dependent for its characteristics only upon the nature of the pathological changes which underlay it, doctors would experience a professional existence of remarkable simplicity and predictability. We know full well, however, that such a state of affairs is incompatible with the nature of man, whose capacity for symbolic activity renders his every experience uniquely his own. While this fact has long been appreciated by many physicians, particularly as far as psychological disorders are concerned, it has taken longer for the non somatic dimensions of organic dysfunction, to receive the sort of systematic attention they so clearly deserve. This long-neglected “psychosocial dimension’’ of disease or, to be more precise, a particular facet of it, is the subject of my presentation today. As my title indicates, it is illness behaviour upon which I propose to focus my attention. The phenomenon of illness behaviour may be numbered amongst those whose ubiquity has rendered them virtually invisible. One may speculate, that in times when medical men were few and health care systems rudimentary, the many ways in which individuals reacted to bodily dysfunction, were of far less concern than the understanding of the pathological processes presented by those who were fortunate enough to actually reach medical assistance. Nonetheless, extreme reactions to bodily functioning were noted by physicians from the Hippocratic era onward, and not a few recorded cases of individuals who manifested pathological attitudes to their state of physical health.

The clinical and social characteristics of criminals with conversion symptoms are noted and compared to those of other criminals. The possible association between hysteria and sociopathic personality is considered briefly.

1. This paper is part of a larger research project guided by the following questions: What is the nature of psychiatric symptoms in adolescent patients? How do the symptoms in this group compare with those of a non-patient group? What happens to the symptoms of both groups as they pass through a substantial part of their adolescence? 2. The method consists of a 5-year study of 101 adolescent outpatients and a matched control group of 101 non-patients. 3. This paper presents the results of the initial evaluation of the patient group as follows: i) Five syndromes have been defined that represent 84 of the 101 patients as follows: thinking disorder—16, psychoneurosis—38, acting-out—17, depression—7, and hysterical personality disorder—6. ii) The clinical and dynamic relationships of the 5 syndromes are presented. For example, acting-out showed more prevalence in boys, 15 or under, had an early age of onset, a long duration, and an impaired relationship with mother. iii) For several syndromes this information...

The patient with the tubular fields of hysterical amblyopia poses an interesting series of problems for the ophthalmologist. Since the size of his peripheral fields does not vary either as a function of distance from stimulus objects or as a function of the size of stimulus objects, his visual process is incompatable with optical laws. On the other hand, there is some sort of lawful relationship present, since the fields of these patients are relatively stable. This observation leads to the question as to what variables determine this phenomenon. It is a question with many aspects. We desire to know, for example, if the constricted fields are peculiar to the test situation and, if not, whether the person is unaware of all objects in the periphery or merely some. If he is unaware of only some objects, what sort of objects are they? The possibility must also be considered that

Current concepts of depression recognize that it may have many roots including genetic, constitutional, biochemical, neurophysiological, sociocultural and psychodynamic factors. Depression can be overt and quite evident; yet in many instances it can be masked, hidden by more noticeable somatic symptoms and even somatic disease. Concepts of psychosomatic illness have undergone considerable change in that the ‘specificity’ theories which prevailed 30 years ago have been superseded by the current belief that all illness is psychosomatic and not limited to a few chosen ones. Depression is often intertwined and interwoven with psychosomatic illness since it can be the trigger that precipitates a somatic illness. It can also be the result.

If it is certainly too early to answer the different questions which we have asked in this presentation, we can at least resume and analyse many points in the analysis of the facts which we have examined. — The first would be to underline the importance of psycho-pharmacology in modern psychiatry. The example which we have chosen today shows that it constitutes an important approach for the understanding of the neuroses, as well as for those of the psychoses. — A second point concerns particularly those neuroleptic drugs in which we have been interested since their discovery. The observation which we have reported shows that all types of stages intermediary between the truly neurological reaction and those psychomotor manifestations produced by the drug, from Parkinsonism to the hysteroid reactions, from the excito-motor syndromes to catalepsy exist, and it is impossible to establish limits. — A third point touches on the problem of hysteria, considered not as a disease but as a type of reaction inequally developed in various patients. If it is presently impossible to completely equate in a pure and simple manner the hysteroid states of organic origin, or of pharmacological origin, with the neurotic reaction, it is also difficult to believe that the similarities between these are completely fortuitous. In particular, we have seen that the psycho-motor reactions undergone by the patient, under the influence of the medication, produces a rupture in the unity of volition, alterations in the level of awareness, and in the field of consciousness; increase in suggestibility, and even produces infantilism, which elements have in the past been regarded as the essential components of the hysterical mentality. That which is missing is the mythomania and, in part, the symbolic and verbal expression of the affective disorder. Or, in other words, there are two aspects of hysteria: One is the utilization of the symptom by the patient for secondary gain; the other is the derangement suffered due to certain nervous disequilibrium. The study of the hysteroid side effects permits a better understanding of this last aspect, which in certain cases seems to be primordial. For if it sometimes seems that the hysteric develops and plays on his symptoms, it must not be forgotten that he is also victimized by them.

In an attempt to distinguish organic cerebral disease from the conditions called “hysteria,” it is suggested that patients suffering from organic cerebral lesions demonstrate specific behaviour reactions (some of which have been described by Goldstein), and that patients suffering from hysteria do not show these reactions. Organically diseased patients attempt to preserve the integrity of body and mind, and to maintain a normal existence. Hysterical patients tend to dissociate and to disintegrate. A patient with organic cerebral disease, if forced to become aware of his disability, is liable to suffer from a “catastrophic reaction.” He tries to protect himself from this reaction by orderliness, trick movements and manoeuvres, the avoidance of situations which would expose his disability, the use of other senses to take the place of the affected ones, and the finding of excuses for his failure. Organically diseased patients may have difficulty with the description of unusual symptoms (in contrast to hysterical patients), they preserve an anxious attitude towards their disabilities, and require reassurance; they demonstrate great variability of signs, symptoms and performance. Finally, organic disease of the cortex diminishes a patient's power to deal with abstractions. These behaviour reactions may help to confirm the presence of organic cerebral disease in those patients who suffer from symptoms which are subjective in nature and are not accompanied by physical signs.

The origin of the concept of conversion reactions and the development of ideas concerning it are discussed. The presence of pre-œdipal components in this reaction, as described by various writers, is noted. Attention is directed to the important paper of Rangell, who has endeavoured to separate the blind linkage of the words ‘conversion’ and ‘hysteria’. His considerations on the psychodynamics of the conversion process are discussed in detail. Conversion is a psychological concept and can only be seen as one step toward a symptom or lesion and depends upon other factors such as previous disease or injury. The possibility of predisposing factors being present at birth which help determine the development of conversion symptoms is emphasized. The attitude taken originally by Alexander that conversion symptoms are confined to the sensory motor system is found to be too restrictive, for there are many accounts of conversion symptoms occurring in structures innervated by the autonomic nervous system. The important recent work of Miller and his associates on the capacity of animals to alter heart rate or intestinal contraction for a reward is considered as effectively demolishing the artificial distinction between the somato-sensory and autonomic nervous system in so far as learning is concerned. Psychological theories of the etiology of conversion reactions are reviewed, beginning with Janet's concept of dissociation and Freud's emphasis on the importance of the Œdipus complex. Other opinions which are dealt with, view conversion as somatized activity below the symbolic level. The conflict in theory between those who see conversion reactions as a manifestation of dissociation and those who see repression as the principle mechanism, for example Fairbairn, is noted. The emphasis placed by Engel on perception of memory traces as a result of experience giving rise to an anlage of body language, is pointed out. Significant traits of the hysterical or histrionic personality are reviewed. Particular attention is paid to the important paper of Lazare, Klerman and Armor, in which the traits are factor analysed, and five of the seven were found to have a high degree of correlation in the patients examined. Two other traits, namely aggression and oral aggression, which had not been anticipated as belonging to this group, were found to have a high degree of correlation, thereby supporting Marmor's concept of the basic importance of oral fixation in the hysterical personality. Physical correlates of the hysterical character may be found in the work of Shagass on the sedation threshold. It is found to be low in this type of individual. The sexuality of the hysterical character was examined in reports from the literature and considerable weight was given to the report of Prosen on two cases considered hysterical characters, in which there was a high degree of orgastic activity reported. In both instances there was a severely unresolved œdipal situation. Recent important contributions to the psychoanalytic study of the hysterical personality from the studies of Easser and Lesser and of Zetzel are considered in detail. Many of the cases of the former authors could be called cryptic, because the diagnosis became manifest only during therapy. A more severe type of case with extreme bizarre emotional lability and poor relationships was characterized as hysteroid. These latter cases were difficult or impossible to treat. Zetzel divided a large series of cases into four groups, depending on their suitability for analysis. Her fourth group called ‘florid hysterics' coincides relatively well with the hysteroids of Easser and Lesser.

The results of a number of recent studies of hysteria are summarized. There is evidence that hysteria, defined by objective criteria, is a syndrome distinct from other psychiatric syndromes, distinct from medical illness in which there are multiple complaints, and distinct from cases in which conversion symptoms occur in relative isolation. The central clinical feature of hysteria is an array of complaints spread throughout the sympton review. This concept of hysteria has been useful as an instrument of research; in addition, it serves as an important aid to the process of decision making for a group of patients whose management is difficult.

Seven patients (five women and two men) with paralysis of the legs and/or ataxia were seen by the psychiatric consultation service of a city hospital. Only one gave a history of frequent prior somatic complaints (Case 4). Four were overtly depressed. Only one was considered an hysterical character (Case 1). Intervention was limited to dealing with the current conflict, out of which the symptom grew. Four patients made a rapid, complete recovery, and one improved minimally. It was felt that each case represented a reaction to a crisis in the life situation.

‘Hysteria' is a term with confusing uses covering a variety of conditions often with little or no functional relationship. Some salient historical aspects of the term are reviewed. The three listed categories of so-called hysterical reaction are: Dysmnesic and Conversion Reactions and Hysterical Personality. The first is discussed in summary form; the second and third in greater detail. Dysmnesic reactions such as amnesia, fugue, twilight and trance states and multiple personality are explained on the basis of gross dissociation. Somnambulism, once included here, has now been shown to be associated with gross EEG. changes, and suggests that modern neurophysiological techniques may yet contribute factual data on the nature of presently obscure cerebral events. Conversion reactions still remain explicable only in psychological terms, such as suggested by Freud. Present-day views include a wide range of interpersonal events as causal. The tacit association of conversion symptoms with the hysterical personality is no longer tenable. Such symptoms occur in many diagnostic categories. Organic brain disease may favour a predilection to the formation of conversion symptoms. Pain, as a common conversion phenomenon, should be labelled ‘psychogenic regional pain’, as suggested by Walters, but never ‘hysterical’. While conversion may be part of a communication process and often symbolic, it is not necessarily restricted to somatic motor and sensory systems. Certain symptoms, mediated in part or totally by autonomic pathways, may be symbolic or include conversion reactions in their chain of events. The psycho- or physiodynamics of conversion remain obscure. Attempts to hew a syndrome out of the coincidence of multiple conversion symptoms in women with so-called hysterical personalities are unjustified and becloud thinking about the events involved. The type of personality called ‘hysterical' or ‘histrionic' is only related to the dysmnesic or conversion categories by the semantic misdemeanor of confused usage of the word hysteria. It impies a person with childlike egocentricity and affective lability, on which is superimposed the more adult skills of melodrama and coquettishness. The psychodynamics of such personalities is discussed and a comparison made to Harlow's parent-deprived monkeys. The common difficulties in sexual relationships are commented on.

The entire population of Tristan da Cunha (264 islanders and 29 temporary inhabitants) was evacuated in October, 1961, after a volcanic eruption which, although it occurred in close proximity to the settlement, only damaged one out of the 70 buildings and caused no casualties. The evacuees were taken first of all to Capetown and thence by sea to England, where they arrived in November, 1961. Temporary hutted accommodation was found for them at Pendell Camp, an army establishment near Redhill, Surrey, where they spent the first eight weeks of their first English winter in conditions of some discomfort. In January, 1961 they were transferred to more permanent homes in R.A.F. married quarters at Calshot, a small place situated on the western bank of Southampton Water near its junction with the Solent.

This paper outlines a specialised use of hypnosis as a complement to counselling or interpretive psychotherapy in suitable cases. The techniques capitalise on the ease of manipulating emotions and on the vividness of fantasy experience in hypnosis, to allow patients to learn more adaptive patterns of affective response and to rehearse more adequate repertoires of social behaviour. Implications of the authors' work with a sample of 37 non-psychotic patients is discussed.

Throughout medical history we find evidence that hysteria has predominated over all other psychological disorders in attracting the attention of philosophers and physicians, yet despite the leading part which the study of hysteria has played in building up our present-day knowledge of psychopathology, it is remarkable how little we have advanced in acquiring an understanding of the cause of the hysterical syndrome itself. Even the wisdom of Freud has failed to offer us a readily acceptable explanation of hysteria, and to this day medical literature contains many theses suggesting that hysteria is related to disorders of the diencephalon, or to glandular dysfunction, and other such organic approaches to the problem. Seemingly we have no yardstick by which we can measure to what extent the hysteric is born, predestined by some elusive factor to develop the malady, and to what extent hysteria is imposed on persons by environmental circumstances. Much significant information on hysteria may be neglected by those who study it as an isolated phenomenon or disease entity, whereas it may well be that the truth of the matter is that at least a little bit of the hysterical reaction goes to form most of the neurotic syndromes met with in practice, and that the pure hysterical reaction is only an academic concept.

What appears to me as fundamental in the genesis of the psychosomatic symptom is that this genesis is linked to an original psychic structure totally opposed to that of the neuroses. This structure is characterized by a deficiency, more or less marked, of the phantasmic activities which no longer, or very imperfectly, fulfil their functions of elaboration and integration.

Describing a phase in the therapeutic process of a psychosomatic patient with a borderline ego structure the author exemplifies the analogous function of somatic syndromes and acting-out in groups. Bo

Summary The nature of conversion hysteria, as interpreted by Structural Analysis, was presented. Principles were then derived which specify the kind of patterning to be expected from conversion hysterics on projective techniques. Two cases were reported which illustrate these principles. Implications were briefly discussed.

Since 1962, a series of studies have appeared in the psychiatric literature which define hysteria with increasing precision, differentiating that syndrome from the presence of conversion symptoms alone. Hysteria was described in a recognizable fashion more than a century ago by Briquet (1859). Some fifty years later, the syndrome was redescribed by Savill (1909). After a further period of nearly fifty years, Purtell, Robins and Cohen described hysteria as it occurred in a controlled series of patients (1951). Working from Purtell's clinical data, Perley and Guze introduced specific checklist criteria for the diagnosis of hysteria in 1962. These criteria defined a female population homogeneous in prognosis, a population to be distinguished from that defined by conversion symptoms alone. Conversion symptoms are seen in a variety of medical and psychiatric illnesses, and by themselves, conversion symptoms are of little prognostic value (Gatfield and Guze, 1962; Perley and Guze, 1962; Slater and Glithero, 1965).