Studies in Hysteria*
SAMUELB. GUZE,M.D. 1
This paper describes how the idea ofsubstituting"Bri-
quet Syndrome'tfor "Hysteria" developed. It emphasizes
the need to base the diagnosis firmly on clinicalfeatures
and also the value of differentiating "polysymptomatic"
forms (Briquet Syndromejfrom "conversion" symptoms
(unexplained neurological symptoms). Other studies
have shown that there is a preponderance of Briquet's
Syndrome in women, and thatfemale relatives ofpatients
have an increased prevalence of Briquet's Syndrome,
while male relatives have an increased prevalence ofanti-
social personality and ofalcoholism. Conversely, a study
offemale relatives ofa male prison population reveals a
high prevalence of Briquet's Syndrome amongst them.
It is suggested that the association between Briquet's
Syndrome and antisocial personality may explain many
clinical and epidemiologic observations.
I f I had been more of a scholar when I began my studies
in hysteria, they might never have been continued.
Tracing out the complexity and the contradictions of the
field might have led to the decision that it was hopeless
and that one had better do something more likely to be
productive. The reader may yet conclude that the time
and effort were wasted.
Historical reconstructions are very difficult. Neverthe-
less, a description of how I got into the field may prove
more useful than a simple recital of data, though the
precise numbers may be verified by consulting the cited
references. It may be helpful to refer here to an exchange
of letters with Eliot Slater when he was Editor of the
British Journal of Psychiatry. Though skeptical about
our work, his intellectual integrity led him to offer us a
chance to publish some of our seemingly peculiar ideas.
When he wrote his own widely read paper seriously ques-
tioning the existence of hysteria as a valid entity (1), I
argued that the absence of agreement on the definition or
the diagnosis of hysteria was not sufficient reason to
*Presented at the Symposium on Hysteria at The University of West-
ern Ontario, London, Ontario, March 10, 1982.
Manuscript received July 1982;revised November 1982.
IHead, Department of Psychiatry, Washington University School of
Medicine, St. Louis, Missouri, U.S.A.
Address reprint requests to: Dr. Samuel B. Guze, 4940 Audubon
Avenue, St. Louis, Missouri, 63110 U.S.A.
Can. J. Psychiatry Vol. 28, October 1983
434
conclude that it didn't exist. I noted that the then current
disagreement between British and American psychia-
trists about the diagnosis of schizophrenia did not cause
any of us to conclude that there was no such thing as
schizophrenia. After some exchanges, perhaps concerned
that a lifelong correspondence about the subject was
beinglaunched, Slater suggested that my colleagues and I
might be dealing with a valid syndrome but proposed that
we give it a different name. Having by that time received
this suggestion more than once, I began to consider it
seriously. At first, the suggestion seemed unfair because
we believed that the patients we diagnosed as having
hysteria were considered hysterics by almost all other
psychiatrists. Furthermore, it seemed that the cases we
were describing were very similar to patients that Briquet
had written about a century or more before. Historical
precedent thus seemed to be on our side. In the interest of
reducing unnecessary confusion, however, we decided to
refer to the syndrome we were studying as Briquet's Syn-
drome, in recognition of Briquet's comprehensive de-
scription.
My approach to hysteria stemmed from my original
training in internal medicine and my early work as a
faculty member in the Department of Medicine. When I
first became interested in psychiatry, trying to explain to
the two senior Professors of Medicine why someone who
had completed training in internal medicine and who was
respected by them as an internist wanted to become a
psychiatrist, I remember emphasizing that psychiatry
was a very important field that needed more than any-
thing else the discipline and systematic approach to clini-
cal disorders that characterized internal medicine. (In
retrospect, this may have been a little unfair to psychiatry
and a little too generous to internal medicine).
After completing psychiatric training, I was appointed
director of the psychiatric consultation service at Barnes
Hospital, and I began to see many patients referred from
other services with the diagnosis of hysteria. I knew that
the referring physicians had as little basis for diagnosing
hysteria as I had had a few years before when I also
referred patients in the same careless way. Now, however,
having the benefit of a medicine residency and still feeling
competent at that point about my general medical
knowledge, I wasn't quite ready to accept the clinical
judgement of the referring physician. At the same time, I
was impressed by the work of Purtell, Robins, and Cohen
(2), which, in turn, led me to Briquet.
October, 1983 STUDIES IN HYSTERIA
Everyone who does consultation work in a busy gen-
eral hospital recognizes a peculiar conflict that arises
between psychiatrists and neurologists about certain
kinds of patients. The neurologist says: "Yes, this patient
has epilepsy," or, "Yes, this patient has multiple sclero-
sis," or, "Yes, this patient has a stroke, but some of the
neurological symptoms are not due to the stroke," or
"multiple sclerosis," or "epilepsy and are manifestations
of hysteria." The psychiatrist is usually uncertain about
how to approach such problems. He is reluctant to call all
such cases hysteria, but he often does not feel he can
challenge the neurologist's judgement. As we developed
our ideas about Briquet's Syndrome, to avoid fruitless
arguments with our neurology colleagues, we proposed
to distinguish between Briquet's Syndrome and "conver-
sion" symptoms. (The former was a polysymptomatic
disorder typically, but not always presented in a dramatic
or histrionic fashion, going back to early adolescence or
even to childhood, with recurrent or chronic symptoms in
multiple organ symptoms, "doctor shopping," frequent
hospitalization, frequent surgery, multiple pains, sexual
disturbances, menstrual difficulties). The latter were
unexplained neurological symptoms. By unexplained
neurological symptoms we meant simply that the symp-
toms suggested neurological disease but that the usual
history, physical and neurological examinations, and x-
ray or laboratory studies failed to identify a satisfactory
explanation for the symptoms. We excluded unexplained
pains because we did not want the term conversion symp-
tom to involve the differential diagnosis of all of
medicine.
Why did we feel justified in using conversion symptom
in that context? Some have suggested that since the idea of
conversion symptom comes out of psychoanalytic theory,
it may be inappropriate to use it in a purely descriptive
way. The answer is that regardless of the hypothesized
basis of conversion symptoms, physicians have never
delayed a diagnosis of hysteria or conversion symptom
until the psychological significance of the symptoms
(unconscious or otherwise) was better understood. The
average doctor, including the average psychiatrist, decides
that the patient has a conversion symptom on the basis of
routine examination. The nature of the symptom and its
clinical context lead to the diagnosis. We therefore felt
justified in distinguishing between Briquet's Syndrome (or
hysteria) and conversion symptoms.
Now, let us review quickly what we have done over the
past 25 years. Early on, we appreciated the importance of
systematic research interviews, which meant a protocol
covering all items of interest in the history, with appro-
priate ways of recording answers and specific criteria for
scoring individual symptoms. In addition, we used gen-
eral criteria to guide the examiner about the significance
of symptoms. We were interested in using criteria that
would make sense to the average practicing doctor. A
physician would pay attention to symptoms that caused
disability (not working, not going to school, needing
additional help at home, etc.); that led to consulting a
435
health professional (usually a physician), or that led to
repeatedly taking medicine. In addition, certain symp-
toms, even if not associated with disability, professional
consultation, or the taking of medication might be signifi-
cant, such as vomiting or spitting blood, episodes of
unconsciousness, amnesia or blindness. In all studies our
interviewers recorded verbatim what the patient said so
that a review ofthe records permitted the use of generally
uniform standards.
We started first with a group of patients who more or
less met the criteria for Briquet's Syndrome and showed
by follow-up years later that the great majority still pre-
sented the same picture and that no new illness had
developed which in retrospect might have accounted for
the initial clinical features (3).
Next, we were interested in knowing something about
the prevalence of this syndrome in the general population
and since everybody had emphasized that it was pre-
ponderantly a disorder of women (in our hands no more
than 5% of the patients with this syndrome are men), we
studied a population of healthy young women in two
general hospitals who had just given birth to a healthy
baby after a normal full term pregnancy. Between I and
2% of these women met the criteria for Briquet's Syn-
drome (4).
The first degree relatives of the index patients were
then studied and we found a tenfold increase in the fre-
quency of the same syndrome in female first degree rela-
tives and an increased frequency of antisocial personality
and of alcoholism in the first degree male relatives (5).
When we studied the husbands of women with Bri-
quet's Syndrome, we again found an increased frequency
of antisocial personality and alcoholism (6). This was an
interesting example of what population geneticists call
assortative mating. These women, not unexpectedly,
married men very much like their brothers and fathers,
even with regard to psychopathology.
At this point, we again reviewed the literature and
noted that the diagnosis of hysteria, when used to refer to
what we were now calling conversion symptoms, was
associated with a wide range of outcomes. In one study of
former soldiers, a long term follow-up showed that
almost all of the men were now well, had no intervening
psychopathology and seemed to be going about their
lives as well as could be expected (7). On the other hand, a
follow-up of mental hospital patients diagnosed as hy-
steric (because of conversion symptoms) found that
between a third and a half suffered from a chronic psy-
chotic illness, most likely schizophrenia (8). A report
from a neurological service by Eliot Slater indicated that
between a third and a half of patients initially called
hysterical because of conversion symptoms now had
obvious neurological disease that, in retrospect, probably
accounted for some if not all of the initial clinical picture
(9). A similar report by Gatfield and Guze on a group of
neurological and neurosurgical patients discharged with
a diagnosis of hysteria indicated that about a third of
these patients met criteria for Briquet's Syndrome and
436 CANADIAN JOURNAL OF PSYCHIATRY
about a third had neurological disease that, in retrospect,
could account for some or all of the index clinical picture.
The other third had a variety of outcomes: some were
entirely well, and some had apparently isolated unex-
plained neurological symptoms from which they had re-
covered (10).
At that point, an unusual opportunity presented itself
to carry out a study of convicted Missouri felons. In
addition to a systematic index study, we carried out a
follow-up study and a study oftheir first degree relatives
and spouses. After we began investigating male felons we
initiated a parallel study of female felons. The cases were
selected to eliminate psychiatric bias; that is, we did not
select subjects because of any psychiatric or psychologi-
cal criteria. Instead, they were chosen consecutively from
various prison and parole rosters. (There was one possi-
ble loophole through which certain subjects could have
escaped selection; those who, having been sent to the
penitentiary, were considered to have had a psychiatric
illness and were therefore referred to the state hospital for
the criminally insane where they remained. A second
loophole involved individuals who might have been sent
directly from the courts to the hospital for the criminally
insane. Fortunately, for the period during which we
selected our subjects, a maximum of only I ~% of the
felons were lost in this way).
What did we learn from this study of convicted crimi-
nals? First, we found a very high rate of antisocial per-
sonality tendencies in male felons and in their first degree
male relatives, associated with high rates of alcoholism
(11). When we studied their female first degree relatives
and their wives, we found about a fivefold increase in the
rate of Briquet's Syndrome (12). In the study of female
criminals, we found an unusually high frequency of Bri-
quet's Syndrome and a high frequency of antisocial per-
sonality in addition (13). The percentage offemale felons
who received a diagnosis of either antisocial personality
or hysteria was the same as the percentage of male felons
who received a diagnosis of antisocial personality!
At about this time, we started our so-called "Clinic 500
Study," which involved evaluating 500 consecutive
patients from our psychiatry clinic, a completely blind
study of their first degree relatives and a further blind
follow-up, 6 to 12 years later of the original cases. The
team which did the follow-up was different from the team
which did the family study and different from the team
involved in the index study. From this group of 500
psychiatric patients, we selected those who gave a history
of conversion symptoms in an effort to see which diag-
noses were associated with conversion symptoms and
found that only two diagnoses showed a statistically sig-
nificant association: hysteria and antisocial personality
(14).
Further in this clinic study, we found that male patients
who received a diagnosis of antisocial personality
reported as many symptoms of Briquet's Syndrome as
the average female psychiatric patient. This was quite
striking because previous studies of all kinds had gener-
Vol. 28, No.6
ally shown that women report more symptoms than men,
whether studied in the field, in physicians' offices, or in
hospitals. This was also true in our psychiatry clinic
population, except for the male patients with antisocial
personality. We have not yet published these data
because our analysis indicates that educational achieve-
ment is inversely correlated with these symptoms and our
sample wasn't large enough to stratify for educational
achievement.
Finally, we compared women with anxiety neurosis
from this clinic sample to women with hysteria; in both
cases no other diagnoses having been made. Fortunately,
the two groups were very well matched with regard to age
and education. We analyzed the two groups of women
with regard to a personal history of any delinquency or
antisocial behavior or a family history of such behavior.
We found that the women with hysteria reported many
more items of delinquent or antisocial behavior in their
personal histories and in their first degree relatives than
did the women with anxiety neurosis (15).
Now what have we concluded from all these studies?
First that it is clinically useful to distinguish between
individual conversion symptoms and Briquet's Syn-:
drome or hysteria. Conversion symptoms may be seen in
all kinds of psychiatric disorders, but they are also seen in
individuals who have no other indication of psychiatric
illness. They are also seen often in patients with neurologi-
cal disease. Thus, a conversion symptom by itself does
not tell us what to expect in the patient's future course.
On the other hand, Briquet's Syndrome (or hysteria)
appears to be a consistent, familial disorder. It is often
associated with delinquent and antisocial behavior in the
same individual and with an increased frequency of
delinquency and antisocial behavior in the family. We do
not know yet all the factors that predispose to either
hysteria or antisocial personality but it looks as though
the same mixture offactors contribute to both disorders,
and that, depending upon the sex of the individual, two
different pictures may emerge. In males, one sees an
increased frequency of antisocial personality and of
symptoms that go with hysteria but not enough of the
latter to warrant a diagnosis; and an increased frequency
of antisocial personality in male relatives and of hysteria
in female relatives. In females, with a mild to moderate
predisposition, one sees the picture of hysteria; with a
more severe predisposition, a tendency towards anti-
social personality (16).
According to the assumption of the multifactorial
model of disease transmission within families, and in
keeping with the above observations one would expect
among relatives of women with antisocial personality a
higher percentage of males with antisocial personality
and a higher percentage of women with Briquet's Syn-
drome than is true for women with only Briquet's Syn-
drome. And, in fact, the data are consistent. This associa-
tion between Briquet's Syndrome and antisocial
personality explains many clinical and epidemiologic
observations. It offers a basis for conceptualizing the
October, 1983 STUDIES IN HYSTERIA
nature of the disorder in Briquet's Syndrome, and it
provides an explanation for the difference in the sexual
distribution of the two disorders.
References
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2. Purtell J, Robins E, Cohen M. Observations on clinical
aspects of hysteria. JAMA 1951; 146: 902-9.
3. Perley M, Guze SB. Hysteria: the stability and usefulness
of clinical criteria. A quantitative study based upon a 6-8
year follow-up of 39 patients. N Engl J Med 1962; 266:
421-6.
4. Guze SB, Allen DH, Grollmus JM. The revalence of hype-
remesis gravida rum: a study of 162 psychiatric and 98
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5. Arkonac 0, Guze SB. A family study of hysteria. N Engl J
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6. Woerner PI, Guze SB. A family and marital study of hy-
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8. Ziegler DK, Paul N. On the natural history of hysteria in
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13. Cloninger CR, Guze SB. Psychiatric illness and female
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Resume
L'auteur decrit dans cet article comment s'est dive-
loppee l'idee de substituer Ie terme "syndrome de Bri-
quet" acelui de "hysterie." Il souligne ensuite la necessite
defonder solidement le diagnostic sur des traits cliniques
et /'importance de differencier les formes "polysympto-
matiques" (syndrome de Briquet) des sympuimes de
"conversion" (sympuimes neurologiques non expliques).
Certaines etudes ont demontre /'incidence du syndrome
de Briquet chez /es femmes, de meme qu'une incidence
accrue de ce syndrome chez les parentes des patientes,
alors que chez les parents masculins, on remarquait une
incidence accrue de symptomes de personnalite antiso-
ciale et d'alcoolisme. D'autre part, une etude effectuee
parmi les parentes des detenus masculins d'une prison a
demontre une incidence elevee, chez elles, du syndrome
de Briquet.
L'auteur suggere qu'une association entre Iesyndrome
de Briquet et /a personnalite antisociale peut exp/iquer
plusieurs observations cliniques et epidemiologtques.