Hysteria: a historical mirror in the misogyny of medicine?

Hysteria has traversed a complex historical trajectory from ancient civilisations to modern psychiatric understanding (Tasca et al., 2012). Originating from the Greek word for uterus, hystera, its historical interpretation has been deeply intertwined with societal perceptions of femininity, sexuality, religion and mental health. For this reason, there has never been a well-defined criterion for a diagnosis of hysteria, but the literature suggests three main classifications: epileptic-like states, paralysis and sensory disorders, and states of emotional outburst (Medeiros De Bustos et al., 2014).

Hysteria was viewed through the lens of bodily imbalance until medieval times, when, under the influence of Christianity, it became associated with demonic possession and sin. The Enlightenment era witnessed a resurgence of empirical observation and scientific inquiry, leading to a renewed understanding of hysteria within a medical framework. While hysteria no longer holds a distinct medical diagnosis, its historical journey underscores the persistent struggle against misogynistic views and highlights the ongoing evolution of scientific understanding in the realm of mental health.

Women and their wandering uteri

The oldest record of hysteria dates to 1900 BCE when Egyptians recorded behavioural abnormalities in women, which they attributed to a 'wandering uterus'. The therapeutic interventions of the time suggested the position of a woman's uterus could be returned to its 'natural' position. If it were too high, women smelled acrid herbs to encourage their uterus to flee to the lower abdomen or rubbed foul herbs around their vagina to prompt the uterus to move upwards if it were too low (Bailey, 1966).

The Greeks accepted the Egyptian explanation for hysteria, but their description added a psychological factor. In Greek mythology, the Argonaut Melampus cured the insanity of the daughters of Proteus with hellebore and urged them to join with young and strong men. Melampus believed woman's madness derived from their uterus being poisoned with 'venomous humors', due to a lack of orgasms. 

This concept of humorism dates to 500 BC – however, Hippocrates (460-370 BC) is credited with the application of this theory to medicine. He believed that the four humors (blood, phlegm, yellow bile and black bile) are vital bodily fluids. Hippocrates, and later Galen (129-216AD), suggested that an imbalance in these fluids produces behavioural patterns. 

Galen also recognised the existence of hysteria in men which he attributed to sexual abstinence, causing a fluid imbalance due to the retention of sperm. It was thought that excess 'black bile' may be responsible for the disease; hellebore was used to induce vomiting to purge the body of black bile until the Middle Ages. Hellebore retained a place in the therapy of mental disorders until the 19th century, although it was highly toxic in large doses. There remains no evidence that hellebore had psychogenic properties.

The demonic curse of womanhood

Hysteria was continually thought of as a primarily feminine disease, with its male counterpart as hypochondria or melancholia (Ross, 2022). Medicine and society continue to reflect each other, so when Christianity became increasingly popular across Europe, the explanation of the origin of disease, especially mental disorders, increasingly became linked to ideas of sin and demonology.

Hildegard of Bingen (1098-1179) was a female doctor who attempted to combine science and faith by suggesting that hysteria may be connected to the idea of the original sin. Women were considered inferior to men theologically and physically; Hildegard believed both sexes were responsible for the original sin, therefore both could suffer from hysteria. This example of the amalgamation of religion and science was one of many that would go on to influence religious management of hysteria.

The idea of male superiority at the time was based on Aristotle's teachings. St Thomas Aquinas embraced many ideas proposed by Aristotle and attempted to synthesise these with principles of Christianity. Aristotle believed the menstrual cycle was a sign of women's inferiority to men. Demonology was rooted in Aristotle and Aquinas' teachings and led to the belief that menstrual blood was toxic and linked to supernatural powers. This idea persisted and demonstrated how the female anatomy became tied to conversations around witchcraft and sexuality (see Brauner, 2001; Dannet, 1990).

The work of Aristotle and Aquinas lead to the publication of Malleus Maleficarum by Heinrich Kramer, known as The Hammer of Witches in 1487. Essentially, Kramer rebranded 'witchcraft', which was widely disputed at the time as 'heresy', punishable under the rule of the Church, enabling the prosecution of 'witches'. He argues women are more susceptible to demonic temptations due to the weakness of their sex. 

Hysteria, epilepsy and depression were illnesses that were frequently confused with witchcraft or demonic possession. This text is the worst condemnation of depressive illness in women in Western history, and lead to the death of thousands of innocent women based on 'confessions' obtained through torture. The women affected often were bereaved or victims of trauma and were condemned to die at the stake.

During the 16th and 17th centuries, the work of physicians such as Charles Le Pois and Thomas Sydenham changed the perception of hysteria from a demonological disorder to a mental disorder. Despite this view, the demonological vision of medicine persists and there are many written accounts of outbreaks of hysteria, such as the one in Salem, Massachusetts in 1692. The witch hunts finally ended during the 18th century, when a better understanding of epilepsy and mental health were understood (Quintanilla, 2010).

It's mental illness, but it's also women

Joseph Raulin (1708-1784) suggested that hysteria was linked to air quality in cities and suggested that both men and women could be affected. This observation is supported by modern literature, as it is understood that urbanicity increases risk of developing depression, anxiety and psychosis (Mechelli, 2019). He did, however, suggest women were more likely to have it due to laziness.

Philippe Pinel (1745-1826) theorised that sensitivity and kindness are essential parts of care in the treatment of hysteria. He believed that 'mad' and 'healthy' were similar, and it was the illness that broke this balance. However, he considered hysteria to be an exclusively female disorder (Alexander & Selesnick, 1975).

In 1859, Paul Briquet defined hysteria as a syndrome manifesting in many unexplained symptoms throughout the body's systems. This later became known as somatisation disorders. Briquet regarded the brain to be the source of hysteria, laying to rest hysteria's historic association with disease of the female genitalia (Mai & Merskey, 1981). His work is supported by Jean Martin Charcot, who pushed for the systematic study of mental illnesses.

Charcot shows that this disease is more common in men than women. He noted that environmental factors such as emotional stress could provoke hysteria and his studies offered a basis of functional neurologic disorders applicable to the 21st century (Goetz, 2016). Despite his thought, Charcot has been linked to controversial treatment methods of hysteria including electronic massages of the vagina (Mantawy, 2016). It is unclear why he subjected women to these treatments when he agreed that hysteria was a disease of the mind…
After a stay with Charcot, Sigmund Freud developed an interest in hysteria. Freud developed the concept of the conversion of psychological problems into somatic manifestations. He believed that hysteria occurred in patients with a history of abuse; yet Freud is accused of often diagnosing hysteria to cover up a woman's experience of sexual abuse, thus delegitimising her claims (Powell & Boer, 1995). 

His theory of hysteria went on to influence the birth of psychoanalysis (Bogousslavsky & Dieguez, 2014), based on a model where there was generally no place for femininity unless directly related to masculinity, believing that females, due to their nature, develop a more submissive, insecure personality (see Showalter, 1993).

During this time, much progress was made as physicians gleaned better understanding the factors influencing the development of a mental health disorder by using systematic studies. Despite this, many highly regarded physicians at the time allowed their work to be affected by prevailing biases against women and treatment of female mental health suffered as a result.

Weaponised hysteria in men and women

During the early 20th century, women were thought to be unfit for politics as their biology made them prone to hysteria. The suffrage movement became linked to hysteria and mental disorder, due to propaganda from the press and the government (Iglikowski-Broad, 2018). Attempts at militancy in their pursuit for equality were branded as hysteria by anti-suffrage supporters, demonstrating how use of mental health could be used to belittle the efforts of the women at the time (Thompson, 2016).

In contrast, during World War I, hysteria manifested amongst soldiers garnered interest amongst psychiatrists in the 20th century. Symptoms that previously had been considered somatic – trembling, paralysis, nightmares, apathy – were grouped into a psychological disorder known as 'war neurosis'. This challenged the British ideals of masculinity at the time – soldiers, particularly officers, were expected to be unafraid.

Sexual impotence, stemming from a sense of powerlessness, also affected many soldiers. War neurosis formed a basis of what we now understand to be post-traumatic stress disorder. After the rise of mental health issues amongst the male population, the catch all term of 'hysteria' fell in popularity and interest in mental health disorders after the war increased.

After a prolonged period of research, in 1980, the American Psychological Association (APA) changed 'hysterical neurosis' to 'conversion disorder'. Today, the diagnosis of hysteria has been abandoned in favour of somatic disorder, conversion disorder or dissociative disorder. Other diagnoses, such as epilepsy and personality disorders, which fell under the diagnosis of hysteria many years ago – have become much better understood.

Borderline personality disorder – a hysterical rebrand?

NICE estimates that around 2 per cent of people have borderline personality disorder, of which 75 per cent are women. Although personality disorder is widely diagnosed, Shaw and Proctor (2005) argue that a diagnosis of borderline personality disorder (BPD) may be a continuation of sexist understandings of female mental illness. Both hysteria and BPD typically affect women who have experienced social neglect because of sexual assault (see also Dourfman & Reynolds, 2023). A diagnosis of BPD can lead to a discreditation of a woman's experience, just as previous accusations of hysteria and witchcraft did.

The DSM-5 diagnostic criteria for BPD refers to a 'pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity… in a variety of contexts'. Included in the impulsivity criteria is spending, sex, substance abuse, reckless driving and binge eating. It is important to highlight that across many categories, standards for men and women are not viewed as equal in society, and clinicians can be influenced by unconscious bias. 

Women are held to a different standard of promiscuity, for example, and are judged more harshly for having a larger number of sexual partners than their male counterparts (Marks et al., 2018). Furthermore, types of spending that are considered 'frivolous' are purchases typically associated with women, such as handbags and beauty treatments. Instead of pathologising female behaviours, perhaps we need to see some BPD patients as a variation of the female normal, which has historically been poorly understood in medicine.

Challenge our own prejudices

Hysteria has been used to encompass a variety of mental health conditions such as epilepsy, somatisation disorders and personality disorders. What is difficult to assess is where the line lies between pathology and variation of normal – prevailing biases against women preclude many physicians from making an accurate assessment of the mental state of their patients.

Physicians such as Paulin, Charcot and Freud all made important steps in helping shape the current understanding of disease. However, their conclusions were limited by persistent bias about the inferiority of the female sex. Diagnoses can be useful and can enable access to treatment and support, but still carry stigma for patients and society. It would be foolish to assume that an element of implicit bias towards female mental health is not still present, and it is of the utmost importance that we challenge our own prejudices before assigning a diagnosis to our female patients.

Dr Emily Alexander, MBChB, BSc (Hons)
Foundation Doctor, Royal Devon and Exeter Hospital
[email protected]

Image: A Clinical Lesson at the Salpêtrière conducted by Jean Martin Charcot

References

Tasca, C. Rapetti, M., Carta, M.G. & Fadda, B. (2012). Women and hysteria in the history of mental health. Bentham Open, 8, 110-119.    

Medeiros De Bustos, E., Galli, S., Haffen, E. & Moulin, T. (2014). Clinical manifestations of hysteria. Front Neurol Neuroscience, 35, 28-43.

Bailey, P. (1966). Hysteria: The History of a Disease. Archives of General Psychiatry, 14(3), 332-333.

Sigerist HE. A history of medicine. Primitive and archaic medicine. New York : Oxford University Press ; 1951.

Hajar, R. Medicine from Galen to the Present: A Short History. Heart Views. 2021;22(4):307-308. doi: 

van Sertima, Ivan (1992). The Golden Age of the Moor. Transaction Publishers.
p. 17. ISBN 978-1560005810.

Jackson, W.A. A short guide to humoral medicine. 2001;487-489. doi:10.1016/S0165- 6147(00)01804-6

Foley, P. (2022). Psychopharmacology: A Brief Overview of Its History. In: Riederer, P., Laux, G., Nagatsu, T., Le, W., Riederer, C. (eds) NeuroPsychopharmacotherapy. Springer, Cham. 

Maieron, M.A. On the hellebore trail an anthropolocial research into madness.
Medicina Historica. 2018;2(1):5-18.

Ross, K. The Performance of a Social Disease: Hysteria and Melancholia in Eighteenth- Century Britain through William Hogarth's A Rake's Progress (c. 1732-5) and Henry Fuseli's The Nightmare (1781). Honors College. University at Albany, State University of    New    York.    2022.    

Brauner, S. Fearless Wives and Frightened Shrews: The Construction of the Witch in Early Modern Germany. 2001; University Massachussets Press

Danet A. In: The Inquisitor and his witches. Kramer HJ, editor. Grenoble: Millon : Sprenger The Witches' Hammer ; 1990.

Elphick, C. Aristotle, Witchcraft and Witch Hunts. Historic UK. 2024. 

North, C.S. The Classification of Hysteria and Related Disorders: Historical and Phenomenological Considerations. Behav. Sci. 2015;5(4):496-517. Doi:10.3390/bs5040496

Quintanilla, B. Witchcraft or Mental Illness? Psychiatric Times. 2010. 

Mechelli, A. Cities increase your risk of depression, anxiety and psychosis – but bring mental    health    benefits    too.    King's    College    London.    2019. A

Alexander FG, Selesnick ST. History of Psychiatry. Rome : Newton & Compton ; 1975.

Mai FM, Merskey H (February 1981). "Briquet's concept of hysteria: an historical perspective". Canadian    Journal    of    Psychiatry. 26 (1):    57–63. doi:10.1177/070674378102600112

Goetz,  C.G. (2016). Charcot, hysteria, and simulated disorders. Handb Clin Neurol., 139, 11-23.

Mantawy, M. E. Hysteria: The Persistence of Patriarchy. 2020. The History of Emotions Blog. 

Powell, R. A. & Boer, D.P. (1995). Did Freud Misinterpret Reported Memories of Sexual Abuse as Fantasies? Psychology Report 77 (2): 563–70.

Bogousslavsky, J. Dieguez, S. Sigmund Freud and hysteria: the etiology of psychoanalysis? Front Neurol Neurosci. 2014;35:109-25. doi: 10.1159/000360244.

Cohler, B. J., & Galatzer-Levy, R. M. (2008). Freud, Anna, and the Problem of Female Sexuality. Psychoanalytic    Inquiry, 28(1),    3–26. 

Allan Bullock, Stephen Trombley The New Fontana Dictionary of Modern Thought Harper Collins:London (1999) pp. 259, 705

Showalter, Elaine (1993). "Hysteria, Feminism and Gender". Hysteria Beyond Freud. University of California Press. ISBN 9780520080645.

Iglikowski-Broad, V. Myth-busting the women's suffrage movement. National Archives. 2018. A

Thompson, J. Militant suffragettes: morally justified, or just terrorists? The Conversation. 2016. 

American    Psychological Association.    Shell    Shocked.    2012. 

Cherry, K. Diagnosis of Hysteria. What Is Hysteria? 2022. 

Shaw, C. & Proctor, G. (2005). Women at the Margins: A Critique of the Diagnosis of Borderline Personality Disorder. Feminism & Psychology, 15(4), 483– 90.

Dourfman, N. Reynolds, J. The New Hysteria: Borderline Personality Disorder and Epistemic Injustice. Internation Journal of Feminist Approaches to Bioethics. 2023;16(2) 

Australian BDP Foundation Limited. DSM-5 diagnostic criteria for BPD. 2024. 

Marks, Michael J., Tara M. Young, and Yuliana Zaikman. 2018. "The Sexual Double Standard in the Real World." Social Psychology 50: 67–79. 

National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management [CG78]. 2009.