Like Sydenham, Charcot insisted hysteria was not exclusive to women, categorized it as a neurosis, a neurological not a psychiatric disorder, and hypothesized that it was caused by an elusive “dynamic or functional lesion” that left no trace on the brains he examined during autopsies. He nevertheless assigned a role to suggestion in hysteria, a psychological factor often related to a shock. The shock caused an autosuggestion, which resulted in a paralysis or seizure or some other “copy” of neurological disease. Furthermore, Charcot believed that through hypnotic suggestion he could create “artificial hysteria” in his patients, a state that mimicked the mimicking disease.
Although no one today would recognize Charcot’s nosology of grande hystérie with its precise, lawful phases, nearly every neurologist has seen cases of people with conversion symptoms, and the fundamental question then and now remains, how does an idea or psychological factor—generated internally or externally, consciously or unconsciously—create paralyses, seizures, muteness, deafness, and blindness? We can all imagine falling ill with stroke or epilepsy or a sudden paralysis. This is the human gift of reflective self-consciousness, our highly developed ability that allows us to move in time, to remember ourselves as characters in the past and project ourselves into an unknown future.9 And this backward or forward time travel appears to depend on the same neural processes, serving a brain that makes it possible for us to make predictions.10 While I am imagining my future, I might spin out a sad story of a frightening disability—but these conscious fantasies and daydreams do not produce actual symptoms in me any more than dreaming I have a limp causes me to wake up with one.
What role does the imagination play in the physiology of hysteria? Is hysteria just one step away from pretending, as so many neurologists seem to believe? Is it an illness of unconscious acting? Charcot regarded theatricality as a symptom of the disease, and the image of the dramatic actress still haunts the everyday use of the word “hysteria.” In the late 1880s, William Gowers called hysteria “the great mimetic neurosis,”11 and in his lectures on hysteria at Harvard in 1906, Pierre Janet explicitly connected the imagination to hysteria. “An individual has his legs in a state of contracture because, he says, a carriage ran over them. After verification, it is found that the carriage passed beside him, and that he felt nothing at all. A real shock would do less than this imaginary shock.”12 Janet implies that the hysterical response is a kind of physiological metonymy. The thought or idea that one’s legs are crushed instigates actual contractures, just as it might under hypnosis.
In Studies on Hysteria, the book he wrote with Freud, Josef Breuer noted about his most famous patient, Anna O. (Bertha Pappenheim), that “even when she was in a very bad condition—a clear-sighted and calm observer sat, as she put it, in a corner of her brain and looked on at all the mad business.”13 Pappenheim admitted to having a double consciousness, one part of her looking at the other, not unlike the actor on the stage who is at once himself and the role he is playing. Pappenheim’s duality is also reminiscent of hypnosis, which was one of the treatments Breuer used.
To what degree was Charcot correct that hypnotic trance reproduces or imitates hysteria? In response to suggestions from another person, the hypnotized subject experiences changes in his phenomenal consciousness. Studies have shown that in the analgesia produced by hypnosis, pain is registered in the sensory-perceptual system even though the person claims to feel no pain. Ernest Hilgard, who has written extensively on hypnosis and advanced a neodissociation theory in which hypnosis alters a person’s executive functions, used the term “hidden observer” to refer to a figurative homunculus who lurks behind an “amnestic barrier,” one the hypnotist can call upon to bring to consciousness the experience of pain that had previously been processed unconsciously.14 Hilgard’s “hidden observer” sounds tantalizingly like Pappenheim’s “calm observer” sitting in the corner of her brain. My husband, who was once hypnotized onstage as a twelve- or thirteen-year-old, described his experience under hypnosis as similar. He shivered when the hypnotist suggested the room was cold, but he told me another part of him was perfectly aware of what was happening. He, too, had a form of double consciousness.
The series of PET-scan studies conducted by P. W. Halligan et al. (2000) that compared an earlier study of a conversion patient with a left leg paralysis to a person with a hypnotically induced paralysis showed marked similarities in brain activation. The authors concluded, “Hypnotic phenomena provide a versatile and testable model for understanding and treating conversion hysteria symptoms,”15 a statement that echoes Charcot, Janet, and the early Freud, but that, let us be frank, does not constitute a theoretical advancement on any of them. The old idea that hypnosis and hysteria are related states, possibly even the same state, which now has some confirmation in imaging studies, turns on questions of human agency, volition, and how it can be altered by suggestion—just saying a few words to a subject.
Janet theorized a split of consciousness or dissociation in hysteria, which he posited as a psychobiological phenomenon that caused a pathological “retraction of consciousness,” and he specifically related this retraction to the problem of agency.16 In my book The Shaking Woman, I quoted the following passage from Janet’s lectures, and I have never stopped thinking about it: “In reality what has disappeared is not the elementary sensation. It is the faculty that enables the subject to say clearly, ‘It is I who feel, it is I who hear.’ ”17 In a strikingly similar formulation of human consciousness, William James wrote in his Psychology, “The universal conscious fact is not ‘feelings and thoughts exist,’ but ‘I think’ and ‘I feel.’ ”18 The hysteric who suddenly goes deaf or blind has not lost the physiological equipment needed to hear or see. He has lost the connection between his feeling of agency and the sense of hearing or sight. There is a vast difference between feeling my arm suddenly shoot up in the air during a seizure and reaching for a glass on a kitchen shelf. Is the hysteric, like the hypnotized subject, somehow unhinged from his own will via a suggestion, which then turns an imaginary state into an actual one?
The suspicion that hysteria or conversion disorder is a fictional, pretend, unreal complaint continues to plague both medicine and neuroscience research. Almost every reference to “conversion” in the contemporary literature is followed immediately by reference to factitious disorder and malingering and the task of differentiating one from the other. The hysteric as trickster has not vanished from medicine. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is typical. The last of six criteria for conversion reads: “The symptom is not intentionally produced or feigned (as in Factitious disorder or Malingering).”19 Indeed, several neuroimaging studies have been devoted to distinguishing between conversion and malingering and have concluded that conversion patients with sensorimotor deficits have brain activation that is different from those asked to fake the losses.20 Does this mean that contemporary neuroscientists have discovered Charcot’s functional lesion? Do the brain regions implicated in these studies tell us how conversions work? I think it is safe to say that without the new technology neuroscientists would not be discussing hysteria today. The visible differences between pretending to be paralyzed and a conversion paralysis seen in brain imaging have made hysterical conversion real or a bit more real, anyway. Of course these pictures cannot tell us why horrifying sights made those Cambodian women blind. In his 1913 Psychopathology of Hysteria, Charles D. Fox comments on the mystery: “Naturally the whole subject revolves around the ancient and ubiquitous problem of the relation between brain and mind; the time honored question of monism and dualism.”21 The whole subject still revolves around this relation.
As a moving target of heterogeneous positive and negative symptoms, hysteria forces us to examine the Janus face of what we now call the mind-brain. What is psychological and what is physiological? If we are monists, as nearly everybody these days claims to be, how can the two be different? How does the subjective first-person
phenomenal experience of a handicap relate to objective third-person neurophysiology? In hysteria, this dilemma is particularly urgent because the illness appears to reside in the hyphen between brain and mind, obfuscating what we call psyche and what we call soma. A 2006 paper, “Conversion Disorder: Towards a Neurobiological Understanding,” published in Neuropsychiatric Disease and Treatment, articulates the problem in a way I have found typical: “The lack of understanding of the neural mechanism by which psychological stressors can unconsciously result in physical symptoms is an important reason for the ongoing controversy and stigma surrounding the diagnosis.”22 The authors are saying that they do not know how specific psychic content—a combat soldier’s memory of his comrade beheaded in a mine explosion—turns into hysterical seizures. Or, as Phillip Slavney rearticulates the problem in his book Perspectives on “Hysteria”: “How is the meaning of events translated into the pathophysiology of neurons?”23 The same mystification pertains to the placebo effect. When I imagine the pill will help me, it does. My feeling better may be mediated by endogenous opioids released in my brain, but what exactly is the material reality of the belief that triggers the effect? And although placebo effects are various, they are not identical neurobiologically to hypnotic analgesia.24 How does my imagination release opioids? The subject of A. R. Luria’s case study The Mind of a Mnemonist, S, explained that he could alter his heart rate via mental imagery. By imagining himself running to catch a train, he raised his heart beat rate from a resting state of 70 to 72 up to 100 and then, by imagining himself lying in bed falling asleep, he lowered it to 64 to 66 beats a minute.25 Although Luria could not see the pictures in S’s brain, he monitored the effects.
Or, to summon another example, how can an emphatic wish to be pregnant result in false pregnancy, known in the medical literature as pseudocyesis? Although common in dogs and some other mammals, the phenomenon in human beings is tied to both imagination and culture. It is far more rare today than it once was, at least in the West, probably because pregnancy is now highly medicalized and sonograms are routine, but there are many well-documented cases in the literature, complete with amenorrhea, abdominal and breast swelling, uterine enlargement, labor contractions, and measurable changes in neuroendocrine hormone levels.26 In a 1978 study of pseudocyesis, the authors Jane Murray and Guy Abraham wrote, “The role of psychogenic factors in the control of the neuroendocrine system is becoming one of the most exciting areas of psychosomatic medicine.”27 What does a wish look like in a brain?
There have also been cases of false pregnancy in men and, in some cultures, a pregnant woman’s husband shares his wife’s pregnancy in a ritual known as the couvade. A people in the Sepik Province of New Guinea refer to the spouse of a pregnant woman as “the pregnant father.”28 He observes food taboos specific to women, he adopts a female name during the gestation period, his belly is purported to swell along with hers, and during his wife’s labor he lashes himself with nettles until he bleeds to participate in her pain. He adopts the squatting birth position as his child is born and is spent and exhausted once it is over. Pseudocyesis is a pathological phenomenon. The couvade is not. It is a ritual of imitation, empathy, and identification that prepares a man for paternity, but during that preparation at least some men develop actual signs of pregnancy. Ritual theater and bodily metamorphoses cannot be easily separated in the couvade. I am underscoring this point. The imagination must be understood as a corporeal reality, one that can move from one person to another.
In Phantoms in the Brain, V. S. Ramachandran and Sandra Blakeslee refer to pseudocyesis as providing “a valuable opportunity for exploring the mysterious no-man’s-land between mind and body.”29 But what do they mean by this? The problem is insistent and omnipresent. The vocabulary of contemporary science reinforces and confirms dualism at every turn. Is a floating, disembodied mind really influencing the endocrine system? How are thoughts and fantasies related to neurons? Many researchers subscribe implicitly to a version of Hughlings Jackson’s doctrine of concomitance, which he posited in his third Croonian Lecture in 1884 as a parallelism of mind and brain, in which neither touched the other, but which he then concluded was a purely pragmatic distinction. Even if the mind and brain are identical, Hughlings Jackson argued that the neurologist could still practice good medicine by keeping mental and physical functions distinct.30 Sigmund Freud adopted the Jacksonian theory of concomitance in his early book on aphasia and then famously tried to bring neuronal function and psyche together in his 1895 Project for a Scientific Psychology.31 When he finished it, he felt he had failed. In later years while continuing to insist on the physiological ground of all psychical functions, he elaborated a psychological theory free of neurons, synapses, and brain chemistry, nonetheless hoping that biological science would eventually confirm his ideas.
Many brain-imaging studies implicitly or explicitly endorse a form of pragmatic parallelism. Without claiming that the psychological level and the neural level are one and the same and without claiming they are different either, researchers map one onto the other through a system of correspondences, hence the terms “correlates,” “underpinnings,” and “substrates.” As I have pointed out numerous times, the term “neural correlate” for this or that, whether it is fear or a hysterical deficit or malingering, exposes the psyche-soma gap; it does not close it. This does not mean that imaging studies on conversion are uninteresting or lack value. Several studies appear to show that hysterical paralysis involves the inhibition of relevant sensorimotor areas and the activation of frontal inhibitory mechanisms, directly echoing Janet. A 2010 fMRI study by Valerie Voon et al. published in Brain compared patients with positive conversion symptoms to normal controls as they looked at emotional pictures—happy, sad, and neutral. The authors concluded, “Greater functional connectivity of limbic regions influencing motor preparatory regions during states of arousal may underlie the pathophysiology of motor conversion states.”32 In other words, if emotion plays a crucial role in conversion, as has long been suspected, the differences seen between conversion patients and normal controls make sense. What is not answered is why do these patients have greater connectivity in the first place, which then results in tremor or dystonia? None of these studies addresses etiology.
The spatial metaphor that reappears again and again in imaging studies is one of two horizontal planes hanging in empty space: neural brain functions occupy the lower plane, and hovering above them at a separate level are psychic or mind functions. Between them is a theoretical no-man’s-land. As Vittorio Gallese has pointed out, “The chances that we will find boxes in our brains containing the neural correlates of beliefs, desires and intentions as such probably amount to next to zero. I am afraid that such a search might look like an ill-suited form of reductionism leading us nowhere.”33 Or, to put it somewhat differently, as Jaak Panksepp comments, “All neural links to psychological issues must be inferential.”34 The philosophy is not simple, nor is there any consensus about what the mind-brain construct currently in use almost everywhere actually means. And it’s good to remember that there are physicists such as Henry Stapp who believe that a mechanically evolving mindless material structure does not describe reality.35 I cannot propose a definitive answer. In fact, I don’t even believe in definitive answers, but rather in multiple perspectives that may shake up the rigid assumptions that have resulted in this static two-horizontal-planes model that resembles nothing so much as a cartoon version of Cartesian dualism. Descartes’s dualism, as we know, was far more subtle.
In the Phenomenology of Perception, Maurice Merleau-Ponty addressed the physiological-psychological gap in his critique of mechanistic physiology. “What has to be understood, then,” he writes, “is how the psychic determining factors and the physiological conditions gear into each other.”36 Rather than charting correspondences between two distinct realms, psyche and soma, we can look for meanings in a lived body that is socio-psycho-biological, with each hyphenated segment mingled into the others, ra
ther than neatly stratified. Nevertheless, creating a model for this merging is difficult. Where does one start and another begin? Human beings seek out patterns, boundaries, and hierarchies, and we, as speaking and writing beings, often get lost in semantics and mistake a map or model for the thing the map or model represents. And yet simple, everyday human experiences fly in the face of rigid dualism. We all live our emotions (supposedly psychological faculties) bodily—in a flush of shame, in the genital burn of lust, in hot, breathless fury, or the lift of elation when a good idea hits us. Such states may be born in the actual moment of the encounter with another person, but they can also be triggered in memory or by simply imagining humiliation, a sexual encounter, a betrayal, or the brilliant thought that changes history. And while we are always conscious of our feelings and use them to guide us, whether we are choosing a sweater or writing a treatise, we are not conscious of the emotional processes that have produced them.
In fact, the unconscious currently in vogue is immense and includes all kinds of sophisticated knowledge that has become automatic. It makes me chuckle when I think that not so long ago, behaviorism dismissed the very idea of unconscious processes, so even Hermann von Helmholtz’s astute theory of “unconscious inference” in perception was deemed irrelevant.37 In 1987, John Kihlstrom neatly summarized “the cognitive unconscious”: “Research on perceptual-cognitive and motoric skills indicates that they are automatized through experience, and thus rendered unconscious. In addition, research on subliminal perception, implicit memory, and hypnosis indicates that events can affect mental functions even though they cannot be consciously perceived or remembered.”38 The emphasis on human cognition as a computational latter-day Enlightenment clockwork, however, with inputs and outputs, led to the exclusion of emotion from the cognitive mental machine. Emotion research is now booming, but mechanistic metaphors endure. There is also a curious tendency to depict the brain as a subject, rather than an organ inside a human subject. Phrases such as “the brain sees, chooses, knows . . .” have become commonplace. The hyperfocus on the organ and its regions, encouraged by scanning technology, can result in a kind of abstraction, a brain isolated from the rest of the body, from human development, and from other brains.
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