Is the Diagnosis of Hysterical Psychosis Justified?: Clinical Study of Hysterical Psychosis, Reactive/ Psychogenic Psychosis, and Schizophrenia Jiri Modestin and Kurt M. Bachmann Using the method of a “blind” retrospective evaluation of clinical charts, 21 female patients with hysterical psychosis were compared with 21 patients diagnosed as suffering from nonhysterical reactive/ psychogenic psychosis and 42 patients diagnosed as schizophrenic according to the Ninth Revision of the International Classification of Diseases (ICD-9). All three groups were restricted to first admissions and matched with regard to sex, age, and year of admis-
H
YSTERICAL PSYCHOSIS was well known at the turn of the century,‘.’ but the diagnosis later became less frequent. Hollender and Hirsch,’ in an effort to revive the conception, offered a comprehensive descriptive definition: hysterical psychosis is marked by a sudden and dramatic onset, temporally related to a profoundly upsetting event or circumstance; its duration seldom exceeds 3 weeks, and it most commonly occurs in women with hysterical personality. It recedes suddenly, leaves no residues, and its manifestations include hallucinations, delusions, depersonalisation, grossly unusual behavior, volatile affectivity, and only transient, circumscribed thought disorder. Since publication of their report, more attention has been given to hysterical psychosis. Other investigators pointed to the variability of the onset4.5 and the course’-” of the illness, its frequent start in close connection with an important sexual life-event or conflict”.’ and its special characteristics, such as the capricious, playful quality of the symptoms, the inner distance of the patient to his or her psychotic phenomena, the excellent contact with the patient,‘.“‘.” and the dependence of the symptoms on the response of the social environment,‘.5.” including the psychiatric milieu.” Considerable attention has been given to the conceptual issues. The concept of hysterical psychosis was said to be unclear, reflecting the conceptual difficulties we have with nonschizophrenic psychotic episodes in general.” Hirsch and Hollender’4 differentiated between (1) the culturally bound syndrome, (2) conversion psychosis, and (3) true psychosis; however, the differences between the three conditions do not COmprehenWe
Psychiatry, Vol. 33, No. 1 (January/February),
sion. Many significant differences were found between hysterical psychosis and schizophrenia; the only significant differences between hysterical and nonhysterical reactive/psychogenic psychosis were the presence of histrionic personality and the frequent shift in symptomatology in the former. Thus, both disorders seem to be identical. Copyright 0 1992 by W.B. Saunders Company
seem to have been elaborated convincingly. Mentzos’” considered hysterical psychosis to be an endogenous psychosis in the patient with a hysterical personality structure, whereas Mallett and Gold4 considered it to be a distinct clinical, fundamentally hysterical entity despite occasional schizophrenic symptoms. For Martin,‘j hysterical psychosis, having also an abreactive effect,16 affords the patient a temporary removal from a conflictual marriage and, according to Richman and White,” it represents psychologically understandable acting out by a patient of a family fantasy. Nevertheless, the literature on hysterical psychosis has also been claimed to relate to a heterogenous population of patients’*; even patients with epilepsy may present identical picture.” Finally, Gift et al.’ questioned the utility of the conception: among 217 first admission patients with functional psychiatric disorder, they were not able to identify any cases fulfilling all the criteria of hysterical psychosis delineated by Hollender and Hirsch3; however, they may have operationalized too rigidly a rather loosely described set of these criteria. Thus, in the light of the literature, hysterical psychosis appears as a multifaceted, benign psychotic episode, which lacks uniform conceptualization and is difficult to pin down. Moreover, with few exceptions,‘,‘“.“‘virtually no empirical work has yet been done on this topic. The From fhe Psychiatric University Clinic of Beme. Switzerland. Address reprint requests to Jiri Modestin, M.D., Psychiattic University Clinic, Bolligenstrasse I I I, CH-3072 Bernet Switzerland. Copyright 0 1992 by W.B. Saunders Company OOIO-440X19213301-0009$03.00l0
1992: pp 17-24
17
18
MODESTIN AND BACHMANN
present study was undertaken in view of these facts and the importance the complicated issue of third psychosis acquired as a consequence of the DSM-1112’ restricted schizophrenia definition. The aim of this study was to investigate possible differences between hysterical psychosis and schizophrenia on the one hand and hysterical psychosis and nonhysterical reactive2’/ psychogenic23-25 psychosis on the other. Such differences, if found, would contribute toward confirming the validity of hysterical psychosis as an independent disorder. METHOD The study was performed at the Psychiatric University Clinic of Berne, which provides primary inpatient care for the entire population of the catchment area. No patient in need of psychiatric hospital treatment can be refused and patients of all diagnostic categories are admitted. As a first step, using the hospital statistics, all patients were sought who were hospitalized in the years 1978 to 1986 and for whom the clinical diagnosis of hysterical psychosis was made. The second step was to scrutinize the clinical charts of these inpatients and weed out the first admissions. In this way, a total of 22 first admission patients diagnosed with hysterical psychosis were identified; of these, only one patient was male and he was excluded from the study. Thus, the experimental group was comprosed 21 female patients aged 17 to 59 years (median, 38 years). Two control groups were constituted. The first control group was made up of 21 patients carrying the diagnosis of a reactive/psychogenic psychosis (Ninth Revision of the International Classification of Diseases [ICD-91, No. 298), but not diagnosed with hysterical psychosis. The second control group was made up of 42 patients diagnosed as suffering from schizophrenia (ICD-9, No. 295). The patients of both control groups were also first admissions and they were matched with the patients in the experimental group with regard to sex, age (‘_ 5 years), and time of the admission (f 1 year). If more patients qualified for the control groups, a random procedure was used to choose the patient. All patients included in the study suffered from a psychosis as defined by ICD-9 (disorder in which impairment of mental function interferes grossly with insight, ability to meet some ordinary demands of life or to maintain adequate contact with reality). None of the patients suffered from an organic disorder (ICD-9, No. 290-294) none qualified for the diagnosis of an endogenous affective disorder (ICD-9, No. 296), and all presented at least one of the Research Diagnostic Criteria (RDC)2b psychotic phenomena: delusions, hallucinations, incoherence, or grossly bizarre behavior. The method of a “blind” retrospective evaluation of clinical charts was used. The hospital clinical records, including reports by referring physicians, progress notes, etc., of all 84 inpatients were thoroughly scrutinized in random order by one of us (K.M.B.) after all indications regarding the diagnostic assignments had been deleted.
Thus, the investigator was “blind” with regard to the diagnosis previously given the patient. The relevant data were extracted. Only a limited set of variables was sought. All factors investigated were either hard data or an attempt was made to give them a precise and operationalized definition. The missing data were registered in six (mainly psychopathological) variables and they concerned maximally two patients per variable. The following demographic and clinical variables were investigated: (1) marital status, existence of children, and educational level; (2) time span between appearance of first symptoms (including nonpsychotic ones) and hospitalization and duration of hospitalization. (3) Life events in the year preceding admission, evaluated and classified according to Paykel et al.,” and occurrence of subjectively relevant sexual events in the 4 weeks preceding the onset of symptoms; (4) existence of histrionic personality according to DSM-III criteria; (5) psychopathology of the patient before admission and during hospitalization, including disorder of consciousness, disorientation, psychomotor disorder, disorder of formal thought, delusions, hallucinations, depersonalization, and emotional disorder; (6) occurrence before admission or during hospitalization of a behavioral pattern that could be classified as “theatrical”; (7) occurrence of regressive behavior characterized by a deterioration of the patient’s condition in the sense of clinging dependency during hospitalization, and shift in psychopathology, defined as a change of the leading symptoms at least once in the first week of hospitalization; (8) plausible psychodynamic interpretation of the psychotic decompensation based on the judgement of the investigator; (9) therapy the patient received during hospitalization, including pharmacotherapy with neuroleptics, antidepressants, and benzodiazepines, and intensive psychotherapy. Finally, all patients were rediagnosed with the help of the axis I DSM-III criteria. The experimental group (patients with hysterical psychosis) was compared with both control groups for the variables enumerated above. In the statistical analysis, nonparametric tests were used: the chi-square test (with continuity adjustment, if appropriate) and Fisher’s exact test for categorical variables and the Mann-Whitney CJ test for continuous variables. Results yielding a Pvalue of .05 or less were considered statistically significant.
RESULTS
During the 9-year period covered by our investigation, an average number of 15 female patients per year (3% of all female admissions) came for their first hospitalization and were diagnosed as suffering from reactive/psychogenic psychosis. Slightly more than two (15%) of them per year received the diagnosis of hysterical psychosis. Taking the number of the population in the catchment area of the hospital and the proportion of women into consideration, a l-year incidence of hysterical psychosis will be approximately one case per
HYSTERICAL
19
PSYCHOSIS
100,000 female population. The diagnosis of hysterical psychosis has been only rarely made in male patients. The proportion of first admissions was 34% in the female population suffering from reactive/psychogenic psychosis and 10% in female schizophrenics. The age of all 1978 to 1986 first-admission female patients with the diagnosis of reactive/ psychogenic (including hysterical) psychosis (n = 136) was 16 to 83 years (median, 37.5 years); the age of first-admission female schizophrenic patients (n = 115) was 16 to 80 years (median, 31 years), the difference being statistically significant (z = 2.40; P < .02). The age distribution of the patients is shown in Fig 1. Table 1 presents a comparison of the hysterical psychosis group with both control groups with regard to the demographic and clinical variables, including the occurrence of life events. In Table 2, the results of the comparison are given with respect to the psychopathology of the patient, the length of the hospital stay, and the inpatient treatment. Finally, the distribution of the patients of all three groups by DSM-III diagnoses is presented in Table 3. The hysterical psychosis group and the schizophrenia group differ from each other with regard to the course of the illness, the weight of the contributory factors, some psychopathologi-
Fig 1. Age distribution of all female first admissions (1978 to W66) diagnosed with hysterical psychosis (n = 21; hetched part of left side), reective/psychogenie psychosis (n = 136; left side), end schizophrenia In = 115; right side).
cal phenomena, and some treatment variables. Only two statistically significant differences could be found when comparing the patients with hysterical psychosis and nonhysterical reactive/ psychogenic psychosis: the DSM-III criteria of histrionic personality were fulfilled and a shift in the psychopathology during the first week of the hospital stay occurred more frequently in patients with hysterical psychosis. While the majority (74%) of schizophrenic patients were rediagnosed as schizophrenic or schizophreniform disorder with the help of the DSM-III criteria, the majority of patients with hysterical, as well as nonhysterical reactive/ psychogenic psychosis, fulfilled the DSM-III criteria for an atypical psychosis or a brief reactive psychosis. Regarding the category “others,” in one case of hysterical psychosis, DSM-III criteria for an atypical disorder of impulse control were fulfilled. In all three other cases, the criteria for an atypical depression were fulfilled. DISCUSSION
The retrospective evaluation of clinical records, the method we used in our study, can give information of sufficient reliability and validity, provided the charts are properly recorded.‘* Our clinical charts were of an accept-
20
MODESTIN AND SACHMANN
Table 1. Comparison of Hysterical Psychosis Group With Two Control Groups With Regard to Some Demographic and Clinical Variables Cl:
Nonhysterical Reactive/
Psychogenic
Psychosis
E: Hysterical
C2: Schizophrenic
Significance
Psychosis
Significance
Psychosis
EvCl
n = Zl(100)
EvCZ
n = 42 (100)
n = 21 (100)
Marital status: married
12 (57)
NS
12 (57)
NS
21 (50)
Children
15 (71)
NS
12 (57)
NS
19 (47)’
13 (62)
NS
15 (71)
NS
20 (50)”
l-365
NS
Educational level > elementary school Duration of illness (d) Range Mean
14.0
Life events (5 1 yr)
11 (52)
NS
l-720
z = 2.38
5.0
P < .02
24.5
xl = 5.18
12 (29)
13 (62)
l-1,500
P < .05 Life events
(2 6 wks)
7 (33)
NS
10 (48)
x2 = 4.29
8 (19)
P < .05 Life events regarding marriage
2 (10)
NS
5 (24)
Fisher
0 (0)
P < .Ol Undesirable life events
6 (38)
NS
10 (48)
x= = 7.97
5 (12)
P < .Ol Life events: social exits
2 (10)
NS
4 (19)
NS
2 (5)
Uncontrolable life events
3 (14)
NS
4 (19)
NS
4 (10)
Life events of major upset
4 (19)
NS
8 (38)
Fisher
4 (10)
P < .02 Sexual event
(s 4 wks)
2 (10)
NS
4 (19)
6 (29)
NS
10 (48)
NS
3 (7)
Fisher
4 (10)
Plausible psychodynamic explanation
P < .Ol NOTE. Percentages are given in parentheses. Abbreviations: Cl, control group 1; E, hysterical psychosis group; C2, control group 2.
ln = 40 for these variables.
able quality and, in addition, we restricted our investigation to a relatively small number of variables that we defined as precisely as possible and assumed would be found in our records. This proved to be the case, and it was only rarely that complete information was not available. Also, the allocation of the patients to all three groups occurred independently of the recording of the data and we have no reason to consider the quality of the data systematically worse in one group than in another. To eliminate the possible bias and increase the reliability of the ratings, the evaluation of all case records was done in a random order by the same investigator, and we carefully prepared every chart so the investigator remained “blind” during the entire study with regard to the clinical diagnoses given to the patient. Our data indicate a one-peak age distribution in schizophrenic patients and a different, twopeak’age distribution in the patients suffering from reactive/psychogenic psychosis, the age distribution of the patients with hysterical psy-
chosis following the same two-peak pattern. They also confirm schizophrenia as an illness of the younger age. The quite similar age distribution of patients with hysterical and nonhysterical reactive/psychogenic psychosis points to the basic similarity of both groups. During the entire investigational period, the diagnosis of hysterical psychosis was given to 21 female patients, but only one male patient, which prompted us to confine our investigation to the female population only. Both hysterica14*” and reactive/psychogenic231’9 psychosis were said to occur significantly more frequently in women than in men, in contrast to schizophrenia. In almost half of our patients with hysterical psychosis, the DSM-III diagnostic criteria for histrionic personality were fulfilled, whereas this was the case in only one patient in each of the control groups. Furthermore, in nine (43%) other patients with hysterical psychosis (but in no patients with reactive/psychogenic psychosis or schizophrenia), a hysterical personality disorder was diagnosed clinically. Thus, in only two
HYSTERICAL
PSYCHOSIS
21
Table 2. Comparison of Hysterical Psychosis Group With Two Control Groups With Regard to Psychopathology and Hospital Stay Including Therapy Cl. Nonhysterical Psychosis ” = 21 (100)
C2: Schizophrenic
E: Hysterical
Reactive/Psychogenic Significance E v Cl
Psychosis
Significance
Psychosis
” = 21 (100)
EvC2
” = 42 (100)
0 (0)
NS
1 (5)”
NS
4 (191 15 (71)
NS
NS
2 (5) 13 (31)
NS
7 (33) 14 (67)
NS
29 (69)
Disorder of formal thought
15 (71)
NS
13 (65)t
NS
35 (83)
Delusions
16 (76)
NS
12 (57)
x2 = 11.58
40 (95)
Disorder of consciousness Disorientation Psychomotor
disorder
P < ,001
6 (29)
NS
4 (191
x2 = 10.87
28 (67)
P < ,001 Depersonalization Disorder of emotion “Theatrical”
behavior
6 129)
NS
21 (100)
NS
1 (5) 20 (100)t
8 (38)
NS
13 (62)
NS NS x2 = 9.72
4 (10) 41 (98)
8 (19)
P < .Ol “Regressive”
behavior
Shift in psychopathology
0 (0)
NS
4 (19)
0 (0)
Fisher
8 (38)
P < .Ol DSM-III histrionic
personality
1 (5)
x2 = 7.88
NS x2 = 5.67
6 114) 4 (10)
P < .02 10 (48)
P < .Ol
Fisher
1 (2)
P < ,001
Length of hospital stay(d) Range
4-57
Median
NS
14.0
Neuroleptic
medication
17 (81)
NS
5-35
z = 3.33
3-408
16.0
P < .OOl
28.5
15 (71)
x2 = 10.15
42 (100)
P < .Ol mg equiv. CPZld 32-615
Range Median
NS
Antidepressant Benzodiazepine No psychotropic
medication medication agents
45-749 260
279
z = 3.83 P < ,001
82-1173 526
2 (10)
NS
2 (10)
NS
5 (12)
5 (24)
NS
5 (24)
NS
6 (14)
2 (10)
NS
4 119)
Fisher
0 (0)
P < .02 Intensive
psychotherapy
2 (10)t
NS
5 (24)
NS
2 (5)
*n = 19; tn = 20 for these variables.
patients, no histrionic or hysterical personality was diagnosed. Hysterical psychosis has repeatedly been reported to be most commonly-but not exclusively3”-encountered in hysterical personalities.i.7.‘~.‘5Acute reactive compared with acute nonreactive psychotics presented more hysterical behavior during examination and suffered from a more disturbed premorbid person-
ality, including emotional and unstable features.” Thus, while the hysterical or histrionic personality is not a necessary prerequisite for a hysterical psychosis, this psychosis and possibly reactive/psychogenic psychosis in general will more frequently be encountered in personality disorders gathered in cluster B (emotional instability) of DSM-III-R.3’
Table 3. Comparison of Hysterical Psychosis Group With Two Control Groups With Regard to DSM-III Diagnostic Distribution Cl: Nonhysterical Reactive/Psychogenic Psychosis DSM-III
diagnosa
” = 21(100)
E: Hysterical Significance E v Cl
C2, Schizophrenic
Psychosis
Sigmficance
Psychosis
” = 21 (100)
EvC2
n = 42 (1001
0 (0)
2 (10)
10 (24)
2 (10) 14 (67)
2 (10)
21 (50)
11 (52)
4. Brief reactive psychosis
3 (14)
3 (14)
5. Schizoaffective
1 (5)
0 (0)
1 (5)
3 (14)
1. Schizophrenic
disorder
2. Schizophreniform disorder 3. Atypical psychosis disorder
6. Others *For the statistical
evaluation,
DSM-III categories
1 and 2 and 4,5, and 6 were put together.
df=2* x2 = 17.22 P
H
YSTERICAL PSYCHOSIS was well known at the turn of the century,‘.’ but the diagnosis later became less frequent. Hollender and Hirsch,’ in an effort to revive the conception, offered a comprehensive descriptive definition: hysterical psychosis is marked by a sudden and dramatic onset, temporally related to a profoundly upsetting event or circumstance; its duration seldom exceeds 3 weeks, and it most commonly occurs in women with hysterical personality. It recedes suddenly, leaves no residues, and its manifestations include hallucinations, delusions, depersonalisation, grossly unusual behavior, volatile affectivity, and only transient, circumscribed thought disorder. Since publication of their report, more attention has been given to hysterical psychosis. Other investigators pointed to the variability of the onset4.5 and the course’-” of the illness, its frequent start in close connection with an important sexual life-event or conflict”.’ and its special characteristics, such as the capricious, playful quality of the symptoms, the inner distance of the patient to his or her psychotic phenomena, the excellent contact with the patient,‘.“‘.” and the dependence of the symptoms on the response of the social environment,‘.5.” including the psychiatric milieu.” Considerable attention has been given to the conceptual issues. The concept of hysterical psychosis was said to be unclear, reflecting the conceptual difficulties we have with nonschizophrenic psychotic episodes in general.” Hirsch and Hollender’4 differentiated between (1) the culturally bound syndrome, (2) conversion psychosis, and (3) true psychosis; however, the differences between the three conditions do not COmprehenWe
Psychiatry, Vol. 33, No. 1 (January/February),
sion. Many significant differences were found between hysterical psychosis and schizophrenia; the only significant differences between hysterical and nonhysterical reactive/psychogenic psychosis were the presence of histrionic personality and the frequent shift in symptomatology in the former. Thus, both disorders seem to be identical. Copyright 0 1992 by W.B. Saunders Company
seem to have been elaborated convincingly. Mentzos’” considered hysterical psychosis to be an endogenous psychosis in the patient with a hysterical personality structure, whereas Mallett and Gold4 considered it to be a distinct clinical, fundamentally hysterical entity despite occasional schizophrenic symptoms. For Martin,‘j hysterical psychosis, having also an abreactive effect,16 affords the patient a temporary removal from a conflictual marriage and, according to Richman and White,” it represents psychologically understandable acting out by a patient of a family fantasy. Nevertheless, the literature on hysterical psychosis has also been claimed to relate to a heterogenous population of patients’*; even patients with epilepsy may present identical picture.” Finally, Gift et al.’ questioned the utility of the conception: among 217 first admission patients with functional psychiatric disorder, they were not able to identify any cases fulfilling all the criteria of hysterical psychosis delineated by Hollender and Hirsch3; however, they may have operationalized too rigidly a rather loosely described set of these criteria. Thus, in the light of the literature, hysterical psychosis appears as a multifaceted, benign psychotic episode, which lacks uniform conceptualization and is difficult to pin down. Moreover, with few exceptions,‘,‘“.“‘virtually no empirical work has yet been done on this topic. The From fhe Psychiatric University Clinic of Beme. Switzerland. Address reprint requests to Jiri Modestin, M.D., Psychiattic University Clinic, Bolligenstrasse I I I, CH-3072 Bernet Switzerland. Copyright 0 1992 by W.B. Saunders Company OOIO-440X19213301-0009$03.00l0
1992: pp 17-24
17
18
MODESTIN AND BACHMANN
present study was undertaken in view of these facts and the importance the complicated issue of third psychosis acquired as a consequence of the DSM-1112’ restricted schizophrenia definition. The aim of this study was to investigate possible differences between hysterical psychosis and schizophrenia on the one hand and hysterical psychosis and nonhysterical reactive2’/ psychogenic23-25 psychosis on the other. Such differences, if found, would contribute toward confirming the validity of hysterical psychosis as an independent disorder. METHOD The study was performed at the Psychiatric University Clinic of Berne, which provides primary inpatient care for the entire population of the catchment area. No patient in need of psychiatric hospital treatment can be refused and patients of all diagnostic categories are admitted. As a first step, using the hospital statistics, all patients were sought who were hospitalized in the years 1978 to 1986 and for whom the clinical diagnosis of hysterical psychosis was made. The second step was to scrutinize the clinical charts of these inpatients and weed out the first admissions. In this way, a total of 22 first admission patients diagnosed with hysterical psychosis were identified; of these, only one patient was male and he was excluded from the study. Thus, the experimental group was comprosed 21 female patients aged 17 to 59 years (median, 38 years). Two control groups were constituted. The first control group was made up of 21 patients carrying the diagnosis of a reactive/psychogenic psychosis (Ninth Revision of the International Classification of Diseases [ICD-91, No. 298), but not diagnosed with hysterical psychosis. The second control group was made up of 42 patients diagnosed as suffering from schizophrenia (ICD-9, No. 295). The patients of both control groups were also first admissions and they were matched with the patients in the experimental group with regard to sex, age (‘_ 5 years), and time of the admission (f 1 year). If more patients qualified for the control groups, a random procedure was used to choose the patient. All patients included in the study suffered from a psychosis as defined by ICD-9 (disorder in which impairment of mental function interferes grossly with insight, ability to meet some ordinary demands of life or to maintain adequate contact with reality). None of the patients suffered from an organic disorder (ICD-9, No. 290-294) none qualified for the diagnosis of an endogenous affective disorder (ICD-9, No. 296), and all presented at least one of the Research Diagnostic Criteria (RDC)2b psychotic phenomena: delusions, hallucinations, incoherence, or grossly bizarre behavior. The method of a “blind” retrospective evaluation of clinical charts was used. The hospital clinical records, including reports by referring physicians, progress notes, etc., of all 84 inpatients were thoroughly scrutinized in random order by one of us (K.M.B.) after all indications regarding the diagnostic assignments had been deleted.
Thus, the investigator was “blind” with regard to the diagnosis previously given the patient. The relevant data were extracted. Only a limited set of variables was sought. All factors investigated were either hard data or an attempt was made to give them a precise and operationalized definition. The missing data were registered in six (mainly psychopathological) variables and they concerned maximally two patients per variable. The following demographic and clinical variables were investigated: (1) marital status, existence of children, and educational level; (2) time span between appearance of first symptoms (including nonpsychotic ones) and hospitalization and duration of hospitalization. (3) Life events in the year preceding admission, evaluated and classified according to Paykel et al.,” and occurrence of subjectively relevant sexual events in the 4 weeks preceding the onset of symptoms; (4) existence of histrionic personality according to DSM-III criteria; (5) psychopathology of the patient before admission and during hospitalization, including disorder of consciousness, disorientation, psychomotor disorder, disorder of formal thought, delusions, hallucinations, depersonalization, and emotional disorder; (6) occurrence before admission or during hospitalization of a behavioral pattern that could be classified as “theatrical”; (7) occurrence of regressive behavior characterized by a deterioration of the patient’s condition in the sense of clinging dependency during hospitalization, and shift in psychopathology, defined as a change of the leading symptoms at least once in the first week of hospitalization; (8) plausible psychodynamic interpretation of the psychotic decompensation based on the judgement of the investigator; (9) therapy the patient received during hospitalization, including pharmacotherapy with neuroleptics, antidepressants, and benzodiazepines, and intensive psychotherapy. Finally, all patients were rediagnosed with the help of the axis I DSM-III criteria. The experimental group (patients with hysterical psychosis) was compared with both control groups for the variables enumerated above. In the statistical analysis, nonparametric tests were used: the chi-square test (with continuity adjustment, if appropriate) and Fisher’s exact test for categorical variables and the Mann-Whitney CJ test for continuous variables. Results yielding a Pvalue of .05 or less were considered statistically significant.
RESULTS
During the 9-year period covered by our investigation, an average number of 15 female patients per year (3% of all female admissions) came for their first hospitalization and were diagnosed as suffering from reactive/psychogenic psychosis. Slightly more than two (15%) of them per year received the diagnosis of hysterical psychosis. Taking the number of the population in the catchment area of the hospital and the proportion of women into consideration, a l-year incidence of hysterical psychosis will be approximately one case per
HYSTERICAL
19
PSYCHOSIS
100,000 female population. The diagnosis of hysterical psychosis has been only rarely made in male patients. The proportion of first admissions was 34% in the female population suffering from reactive/psychogenic psychosis and 10% in female schizophrenics. The age of all 1978 to 1986 first-admission female patients with the diagnosis of reactive/ psychogenic (including hysterical) psychosis (n = 136) was 16 to 83 years (median, 37.5 years); the age of first-admission female schizophrenic patients (n = 115) was 16 to 80 years (median, 31 years), the difference being statistically significant (z = 2.40; P < .02). The age distribution of the patients is shown in Fig 1. Table 1 presents a comparison of the hysterical psychosis group with both control groups with regard to the demographic and clinical variables, including the occurrence of life events. In Table 2, the results of the comparison are given with respect to the psychopathology of the patient, the length of the hospital stay, and the inpatient treatment. Finally, the distribution of the patients of all three groups by DSM-III diagnoses is presented in Table 3. The hysterical psychosis group and the schizophrenia group differ from each other with regard to the course of the illness, the weight of the contributory factors, some psychopathologi-
Fig 1. Age distribution of all female first admissions (1978 to W66) diagnosed with hysterical psychosis (n = 21; hetched part of left side), reective/psychogenie psychosis (n = 136; left side), end schizophrenia In = 115; right side).
cal phenomena, and some treatment variables. Only two statistically significant differences could be found when comparing the patients with hysterical psychosis and nonhysterical reactive/ psychogenic psychosis: the DSM-III criteria of histrionic personality were fulfilled and a shift in the psychopathology during the first week of the hospital stay occurred more frequently in patients with hysterical psychosis. While the majority (74%) of schizophrenic patients were rediagnosed as schizophrenic or schizophreniform disorder with the help of the DSM-III criteria, the majority of patients with hysterical, as well as nonhysterical reactive/ psychogenic psychosis, fulfilled the DSM-III criteria for an atypical psychosis or a brief reactive psychosis. Regarding the category “others,” in one case of hysterical psychosis, DSM-III criteria for an atypical disorder of impulse control were fulfilled. In all three other cases, the criteria for an atypical depression were fulfilled. DISCUSSION
The retrospective evaluation of clinical records, the method we used in our study, can give information of sufficient reliability and validity, provided the charts are properly recorded.‘* Our clinical charts were of an accept-
20
MODESTIN AND SACHMANN
Table 1. Comparison of Hysterical Psychosis Group With Two Control Groups With Regard to Some Demographic and Clinical Variables Cl:
Nonhysterical Reactive/
Psychogenic
Psychosis
E: Hysterical
C2: Schizophrenic
Significance
Psychosis
Significance
Psychosis
EvCl
n = Zl(100)
EvCZ
n = 42 (100)
n = 21 (100)
Marital status: married
12 (57)
NS
12 (57)
NS
21 (50)
Children
15 (71)
NS
12 (57)
NS
19 (47)’
13 (62)
NS
15 (71)
NS
20 (50)”
l-365
NS
Educational level > elementary school Duration of illness (d) Range Mean
14.0
Life events (5 1 yr)
11 (52)
NS
l-720
z = 2.38
5.0
P < .02
24.5
xl = 5.18
12 (29)
13 (62)
l-1,500
P < .05 Life events
(2 6 wks)
7 (33)
NS
10 (48)
x2 = 4.29
8 (19)
P < .05 Life events regarding marriage
2 (10)
NS
5 (24)
Fisher
0 (0)
P < .Ol Undesirable life events
6 (38)
NS
10 (48)
x= = 7.97
5 (12)
P < .Ol Life events: social exits
2 (10)
NS
4 (19)
NS
2 (5)
Uncontrolable life events
3 (14)
NS
4 (19)
NS
4 (10)
Life events of major upset
4 (19)
NS
8 (38)
Fisher
4 (10)
P < .02 Sexual event
(s 4 wks)
2 (10)
NS
4 (19)
6 (29)
NS
10 (48)
NS
3 (7)
Fisher
4 (10)
Plausible psychodynamic explanation
P < .Ol NOTE. Percentages are given in parentheses. Abbreviations: Cl, control group 1; E, hysterical psychosis group; C2, control group 2.
ln = 40 for these variables.
able quality and, in addition, we restricted our investigation to a relatively small number of variables that we defined as precisely as possible and assumed would be found in our records. This proved to be the case, and it was only rarely that complete information was not available. Also, the allocation of the patients to all three groups occurred independently of the recording of the data and we have no reason to consider the quality of the data systematically worse in one group than in another. To eliminate the possible bias and increase the reliability of the ratings, the evaluation of all case records was done in a random order by the same investigator, and we carefully prepared every chart so the investigator remained “blind” during the entire study with regard to the clinical diagnoses given to the patient. Our data indicate a one-peak age distribution in schizophrenic patients and a different, twopeak’age distribution in the patients suffering from reactive/psychogenic psychosis, the age distribution of the patients with hysterical psy-
chosis following the same two-peak pattern. They also confirm schizophrenia as an illness of the younger age. The quite similar age distribution of patients with hysterical and nonhysterical reactive/psychogenic psychosis points to the basic similarity of both groups. During the entire investigational period, the diagnosis of hysterical psychosis was given to 21 female patients, but only one male patient, which prompted us to confine our investigation to the female population only. Both hysterica14*” and reactive/psychogenic231’9 psychosis were said to occur significantly more frequently in women than in men, in contrast to schizophrenia. In almost half of our patients with hysterical psychosis, the DSM-III diagnostic criteria for histrionic personality were fulfilled, whereas this was the case in only one patient in each of the control groups. Furthermore, in nine (43%) other patients with hysterical psychosis (but in no patients with reactive/psychogenic psychosis or schizophrenia), a hysterical personality disorder was diagnosed clinically. Thus, in only two
HYSTERICAL
PSYCHOSIS
21
Table 2. Comparison of Hysterical Psychosis Group With Two Control Groups With Regard to Psychopathology and Hospital Stay Including Therapy Cl. Nonhysterical Psychosis ” = 21 (100)
C2: Schizophrenic
E: Hysterical
Reactive/Psychogenic Significance E v Cl
Psychosis
Significance
Psychosis
” = 21 (100)
EvC2
” = 42 (100)
0 (0)
NS
1 (5)”
NS
4 (191 15 (71)
NS
NS
2 (5) 13 (31)
NS
7 (33) 14 (67)
NS
29 (69)
Disorder of formal thought
15 (71)
NS
13 (65)t
NS
35 (83)
Delusions
16 (76)
NS
12 (57)
x2 = 11.58
40 (95)
Disorder of consciousness Disorientation Psychomotor
disorder
P < ,001
6 (29)
NS
4 (191
x2 = 10.87
28 (67)
P < ,001 Depersonalization Disorder of emotion “Theatrical”
behavior
6 129)
NS
21 (100)
NS
1 (5) 20 (100)t
8 (38)
NS
13 (62)
NS NS x2 = 9.72
4 (10) 41 (98)
8 (19)
P < .Ol “Regressive”
behavior
Shift in psychopathology
0 (0)
NS
4 (19)
0 (0)
Fisher
8 (38)
P < .Ol DSM-III histrionic
personality
1 (5)
x2 = 7.88
NS x2 = 5.67
6 114) 4 (10)
P < .02 10 (48)
P < .Ol
Fisher
1 (2)
P < ,001
Length of hospital stay(d) Range
4-57
Median
NS
14.0
Neuroleptic
medication
17 (81)
NS
5-35
z = 3.33
3-408
16.0
P < .OOl
28.5
15 (71)
x2 = 10.15
42 (100)
P < .Ol mg equiv. CPZld 32-615
Range Median
NS
Antidepressant Benzodiazepine No psychotropic
medication medication agents
45-749 260
279
z = 3.83 P < ,001
82-1173 526
2 (10)
NS
2 (10)
NS
5 (12)
5 (24)
NS
5 (24)
NS
6 (14)
2 (10)
NS
4 119)
Fisher
0 (0)
P < .02 Intensive
psychotherapy
2 (10)t
NS
5 (24)
NS
2 (5)
*n = 19; tn = 20 for these variables.
patients, no histrionic or hysterical personality was diagnosed. Hysterical psychosis has repeatedly been reported to be most commonly-but not exclusively3”-encountered in hysterical personalities.i.7.‘~.‘5Acute reactive compared with acute nonreactive psychotics presented more hysterical behavior during examination and suffered from a more disturbed premorbid person-
ality, including emotional and unstable features.” Thus, while the hysterical or histrionic personality is not a necessary prerequisite for a hysterical psychosis, this psychosis and possibly reactive/psychogenic psychosis in general will more frequently be encountered in personality disorders gathered in cluster B (emotional instability) of DSM-III-R.3’
Table 3. Comparison of Hysterical Psychosis Group With Two Control Groups With Regard to DSM-III Diagnostic Distribution Cl: Nonhysterical Reactive/Psychogenic Psychosis DSM-III
diagnosa
” = 21(100)
E: Hysterical Significance E v Cl
C2, Schizophrenic
Psychosis
Sigmficance
Psychosis
” = 21 (100)
EvC2
n = 42 (1001
0 (0)
2 (10)
10 (24)
2 (10) 14 (67)
2 (10)
21 (50)
11 (52)
4. Brief reactive psychosis
3 (14)
3 (14)
5. Schizoaffective
1 (5)
0 (0)
1 (5)
3 (14)
1. Schizophrenic
disorder
2. Schizophreniform disorder 3. Atypical psychosis disorder
6. Others *For the statistical
evaluation,
DSM-III categories
1 and 2 and 4,5, and 6 were put together.
df=2* x2 = 17.22 P
