If you want to know what’s wrong with the diagnoses of “conversion disorder” and “mass psychogenic illness” recently given to high school girls with tic disorders in New York State, the place to start is not the rural villages of LeRoy and Corinth but the cosmopolitan metropolis of Vienna, Austria.
More than a century ago, Sigmund Freud treated a 17-year-old he called “Dora.” She had a cough, migraines, trouble talking, a weak left leg, depression, and other symptoms. After she passed out, her worried parents took her to Dr. Freud, a neurologist with a home office who was working on some interesting new ideas about unexplained illnesses. He was already treating Dora’s father.
Freud diagnosed Dora with “hysteria” – it was all in her head. She had unknowingly converted psychological stress into mental and physical symptoms, he believed. Based on his write-up of the case -- "Fragment of an Analysis of a Case of Hysteria ('Dora')" -- she became one of the best known of a dozen early cases that shaped the history of psychiatry.
Seventeen-year-old Thera Sanchez, and a dozen other girls who developed tics last year at LeRoy Junior/Senior High School, are in a sense Dora’s twenty-first century peers – teenagers suffering from a baffling disorder. In addition to the Tourette’s-like symptoms, Thera and the other girls repeatedly passed out, had trouble walking, and suffered from migraines, joint pain, rashes, breathing problems, and hair and weight loss.
The Buffalo neurology clinic that examined most of the girls and the state health department say they have “conversion disorder,” an updated but essentially identical diagnosis to Dora’s hysteria. Like Freud, the doctors didn’t find anything physically wrong with the girls in LeRoy, so they declared it must be psychological.
“We have conclusively ruled out any form of infection or communicable disease, and there’s no evidence of any environmental factor,” said Dr. Gregory Young of the New York Department of Health following a three-month investigation.
But in both Austria and New York, we believe, the doctors have misdiagnosed what is much more likely to be real physical illness that has nothing to do with stress or trauma. In Freud’s cases, the trigger was actually mercury poisoning from medicines that were in widespread use back then, a new idea we propose in detail in our book “The Age of Autism – Mercury, Medicine, and a Man-made Epidemic.” In New York, infections like strep or Lyme Disease, and/or environmental factors like toxic fungi or spills from gas wells on the school grounds, are the likeliest triggers for the illnesses.
What’s really sickening, though, is the use of this antiquated and unproven diagnosis in place of rigorous investigation and appropriate treatment.
Even though much of Freudian theory is now regarded as quaint, wrong-headed or downright destructive – blaming parents for serious biological illnesses like schizophrenia, for instance – hysteria and its successors have gotten the medical version of a hundred-year hall pass, reflecting the power of the psychiatric establishment to create its own version of reality.
To explain why – why Freud was wrong about hysteria and why today’s medical industry is making the same mistake and doing the same disservice to patients -- we need to take a trip back to a time and place not entirely unlike our own.
Vienna at the turn of the 19th century into the 20th was in the grip of cultural and political turbulence that created its own catchphrase, “fin de siecle,” or end of the century, usually followed by malaise or some other term denoting angst, uncertainty, upheaval. Amid the glitter of the ancien regime, the gears of the far-flung, polyglot Austro-Hungarian Empire were gnashing loudly. A young man named Adolph Hitler had come to the capital from the hustings, nurturing deep resentments toward the wealthy and artistic, many of them (like Freud) Jewish.
Ultimately, the ferment gave birth to much of what we now consider modern – in art, literature, philosophy, relations between the sexes – but the transition was chaotic. The Hapsburg Empire, of which Vienna was the resplendent seat, dissolved into the First World War that launched the savage century ahead.
Sigmund Freud was central to setting this world in motion and observing its effects, writing openly for the first time about the role of sexual desire (the libido) in people’s inner lives, and the reality of dark impulses (the id) barely held in check by culture and morality (the ego). The title of a recent book about him, “Inventor of the Modern Mind,” conveys the reach of those ideas. Freud believed these primal forces acted out a titanic struggle in hidden ways in everyday life, reflected in dreams and leading in some cases to the bizarre symptoms presented by patients who arrived in his office at 19 Bergasse.
In 1885, he and co-author Josef Breuer, an early mentor, published “Studies on Hysteria,” describing how such diverse and serious physical problems as paralysis, narrowing of the visual field, loss of sensation in the limbs, convulsions, and psychosis could all be explained by analyzing the individual’s psyche. Key among the concepts was repression, in which trauma or painful emotions were unconsciously suppressed, re-emerging as strange physical problems and mental illnesses.
Most of these patients were women, mostly young women from the upper rungs of Viennese society. Many of them – he noted with surprise – had just recently been nursing sick relatives, especially fathers with longstanding cases of syphilis they contracted before marriage.
In 1892 a prominent and wealthy Viennese manufacturer named Philip Bauer was referred to Freud after suffering an attack of confusion, “followed by symptoms of paralysis and slight mental disturbances."
It didn't take long for Freud to recognize the signs of syphilis, which Bauer acknowledged acquiring before marriage. While Freud is remembered for founding psychoanalysis, his academic training was in neurology and anatomy. As an intern at the Vienna General Hospital, he regularly saw male patients with syphilis in the dermatology ward; PP -- for progressive paralysis or general paralysis of the insane, a terminal variant of syphilitic illness -- is written in his own hand in the hospital’s admission rolls.
Freud prescribed Bauer "an energetic course of anti-luetic (syphilitic) treatment, as a result of which all the remaining disturbances passed off." In 1892, such treatment could only have been mercury, and its “energetic” application probably involved both mercury inunctions (rubs) and injections of mercuric chloride.
Bauer was impressed by “this fortunate intervention of mine,” as Freud put it, so impressed that four years later he brought his daughter, Ida, "who had meanwhile grown unmistakably neurotic," for psychological help. That visit did not lead to ongoing treatment, but two years after that, her condition had further deteriorated; she had become despondent and wrote a note that her parents interpreted as suicidal. So in October 1900, according to Freud, her father “handed her back to me for psychotherapeutic treatment.” She stuck with it for three months that became a turning point in the history of psychiatry.
Freud changed her name to “Dora” and wrote about her in a case study formally titled “Fragment of an Analysis of a Case of Hysteria,” one of the foundational works of psychoanalysis and modern psychiatry. "After 'Dora,'" writes Freud biographer Peter Gay, "psychoanalytic technique was never the same.”
Freud attributed Dora’s symptoms to emotional and sexual conflicts triggered by improper advances from Herr K., the family friend who accompanied her father on his initial visit to Freud in 1892 (the incidents with Herr K. occurred the next year, when Dora was only 13). Also stirring the plot was Dora’s belief (probably correct) that her father was having an affair with Herr K.’s wife. And Freud was more than a little suspicious that Dora had sexual feelings for the wife as well.
It was, in modern terms, a real soap opera
Freud wrote that one reason Dora cut off treatment while exploring these intimate issues was because “I neglected the precaution of looking out for the first signs on transference” -- in which patients unconsciously transfer strong feelings about key figures in their lives onto the therapist. "I did not succeed in mastering the transference in good time."
But Freud may have missed something more important -- the real reason for Dora’s decline. The clue is in the quotes at the top of the chapter and in Footnote 6 to “Dora”: “Now a strikingly high percentage of patients I have treated psychoanalytically come from fathers who have suffered from tabes or paralysis [italics Freud’s]. In consequence of the novelty of my method, I see only the severest cases.”
Sometimes in medicine, the most crucial evidence can be found in a footnote and this is a remarkable example. In that same footnote, Freud describes “the conclusion to which I have been driven by my experience as a neuro-pathologist -- namely, that syphilis in the male parent is a very relevant factor in the aetiology of the neuropathic constitution of children.”
But why? In “Three Essays on the Theory of Sexuality,” Freud wrote: "I should like to make it perfectly plain that the children [of fathers with syphilis] who later became neurotic bore no physical signs of hereditary syphilis, so that it was their abnormal sexual constitution that was to be regarded as the last echo of their syphilitic heritage.”
But syphilis is not inherited, though it can be contracted from the mother during birth (just like HIV). And the “abnormal sexual constitution” notion is at once vague and bizarre. While having a father with syphilis certainly could create psychological problems, and counseling could help resolve them, this does not seem to be Freud’s argument. Furthermore, the symptoms these offspring developed go way beyond what Freud in another case called “commonplace emotional upheavals.”
On this, however, we agree with Freud: the connection was neither accidental nor unimportant. It offers new insight into the underpinnings of psychoanalytic theory.
Let’s take a look at the chronology of Dora’s illness and how it parallels her father’s. In the popular imagination, Victorian-era hysteria is perceived as the convenient fainting spells and histrionic behavior of upper-crust women. Most people believe that hysteria was triggered by the emerging conflict between female self-empowerment and traditional roles. (“Hysterical is what men call women they can’t control,” says one modern scholar of German literature, and in casual parlance that’s a good definition). But both the mental and physical symptoms of clinically diagnosed hysteria were severe, and they were precisely defined.
Dora had these symptoms, although not to the totally disabling extent of some other patients. According to Freud, "When she was about 12 she began to suffer from unilateral headaches in the nature of a migraine, and from attacks of nervous coughing. … The most troublesome symptom during the first half of an attack of this kind, at all events in the last few years, used to be a complete loss of voice.” Other signs and symptoms included “piercing gastric pains” and sometimes dragging her right foot.
Now let’s look at the timing of Dora’s troubles and her father’s treatment for syphilis: “About 12” was Dora’s age when he saw Freud for neurosyphilis and was given “an energetic course” of what was undoubtedly mercury.
Who tended him? Dora. "The nature of her disposition has always drawn her towards her father,” Freud wrote, “and his numerous illnesses were bound to have increased her affection for him. In some of these illnesses he would allow no one but her to discharge the lighter duties of nursing."
It gives an entirely new meaning to “transference” if the treatment Freud prescribed for the father inadvertently poisoned Dora as she nursed him in his sickbed. All her symptoms -- headaches, persistent cough, trouble walking and talking, gastric crises, depression -- are also symptoms of mercury poisoning (and reminiscent of GPI itself). Their appearance entirely coincides with her involvement with her father’s treatment.
Rereading Freud with this in mind, his psychosexual explanations for Dora’s symptoms seem much less plausible. Consider her persistent cough, or tussis nervosa as Freud called it. He believed it represented her obsession with her father’s probable affair with Frau K. and the thought of them having oral sex. “The conclusion was inevitable. … She pictured to herself a scene of sexual gratification … between the two people whose love-affair occupied her mind so incessantly.” She also:
declared she could still feel upon the upper part of her body the pressure of Herr K.’s embrace. … I believe that during the man’s passionate embrace she felt not merely his kiss upon her lips but also the pressure of his erect member against her body. This perception was revolting to her; it was dismissed from her memory, repressed, and replaced by the innocent sensation of pressure upon her thorax, which in turn derived an excessive intensity from it repressed source. Once more, therefore, we find a displacement from the lower part of the body to the upper.
Dora may well have been revolted by Herr K.’s behavior and distressed by images of her father’s possible affair, but the constellation of severe physical and mental symptoms Freud attributes to that distress seems unlikely. (Freud actually went so far as to suggest Dora would have been better off giving in to Herr K.’s advances!)
While our proposal that mercury poisoning caused many of Freud’s most formative cases appears to be new, the idea of toxic exposures among Freud’s cases is not a “fringe” proposition. Another patient, Anna O., whose symptoms were similar to but much more pronounced than Dora’s, is actually considered the very first case in psychoanalytic literature. In the 1984 anthology “Anna O. -- 14 Contemporary Reinterpretations,” one essayist wrote: “In considering a speculative, retrospective diagnosis, I believe one cannot exclude the possibility of a toxic psychosis -- perhaps based on a morphine-opium addiction.” Anna had used these drugs to overcome severe facial pain, and this conjecture comes from George H. Pollack, who was at the time, director of the Institute for Psychoanalysis in Chicago, and had been a past president of the American Psychoanalytic Association. (Nothing “fringe” about him.)
When we typed two key physicals symptoms of classic “hysteria” – sensory neuropathy and tunnel vision – into an online search engine, a single diagnosis was returned: “Mercury chronic toxicity/poisoning.”
But of course, Freud wasn’t looking. He was looking to prove his hysteria hypothesis – and that’s all it was – could explain the inexplicable and bring him the “great nimbus” or halo of fame he acknowledged craving.
It’s not surprising that theories created more than one hundred years old don’t age well. Freud also went through phases in which he trumpeted the therapeutic powers of cocaine, and fell under the spell of a colleague who believed women’s sexual problems originated in the sinuses and could be corrected with nasal surgery.
What’s surprising is that conversion disorder, built on the same arid foundation of guesswork and supposition as these dangerously wrong ideas, has grown and thrived as a diagnosis.
The current edition of the Diagnostic and Statistical Manual of Mental Disorders states, “The essential feature of Conversion Disorder is the presence of symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. Psychological factors are judged to be associated with the symptom or deficit, a judgment based on the observation that the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.” The symptoms are not intentional – no one is faking it – but the cause is psychological.
This rigorous-sounding diagnosis goes on to establish four subtypes – motor symptoms, sensory symptoms, seizures or convulsions, and mixed presentation. The New York state clusters would fall under mixed presentation, as all those symptoms are present in most of the affected girls even though tics have become the defining disorder.
The occurrence of clusters is mentioned only in passing: “In ‘epidemic hysteria,’ shared symptoms develop in a circumscribed group of people following ‘exposure’ to a common precipitant.” For example, one member of a choir might faint and say she smelled a strange odor, causing others to believe they did, too, and also pass out. (Interestingly, that was not the case in New York state – the onset was independent of any proposed cause.)
Despite the modern nomenclature, the phrase “epidemic hysteria” points to origins in a much more primitive “understanding” of how the mind and body interact.
In “Studies on Hysteria,” Freud’s co-author Josef Breuer wrote the chapter titled “Theoretical Issues” that attempted to put some philosophical meat on the bare-bones case histories that led them to their new ideas.
“Are all hysterical phenomena ideogenic?”, Breuer asks, meaning are all physical symptoms that have no apparent cause the result of powerful ideas and emotions? Not all, he answers, but enough that the theory is valid. And it’s plausible, too, he claims: “It is a matter of everyday observation that in people with normal nerves pathological processes that are not in themselves painful cause peripheral pains in other organs; as, for example, headaches caused by relatively insignificant changes in the nose and sinuses.”
In other words, because a sinus infection can give you a headache, it’s reasonable to believe that stress over your parents’ divorce could make your arm twitch. Breuer then attempts to construct a biologically plausible pathway from painful emotions to hysterical manifestations in a section called “Intracerebral Tonic Excitation – Affects.”
In short, strong ideas or emotions lead to excitement in the brain and – as described in the next section, “Hysterical Conversion” – are transmuted into physical symptoms. In normal people, natural “resistances” prevent that excitation from affecting other organs of the body.
Comparing this resistance to insulation on an electric cable, Breuer writes that “under high tension, cerebral excitation breaks occur at those points that are abnormally weak and this, the excitation of the affect, passes over to the peripheral organ.” So the stress caused by painfully excited thoughts in the brain, this theory goes, escapes to another part of the body and becomes “an abnormal expression of emotion” – a physical symptom of a psychological problem. Hysteria.
And those symptoms can persist. “If the original affect [emotion] has been discharged has been discharged in an abnormal rather than a normal reflex … the excitation emitted by the affective idea is ‘converted’ [italics in original] into a physical phenomenon.” Breuer then adds “Freud” in parenthesis to show this is his formulation.
“We have been able,” he asserts, “ to trace various symptoms back to precipitating factors of this kind – all kinds of neuralgias and anaesthesias [pain and numbness], which have often persisted for many years, contractures and paralyses, hysterical attacks and epileptoid convulsions that all observers had taken for genuine epilepsy, petit mal and tic-like affections, persistent vomiting and anorexia to the point of refusing all food, a great variety of visual disturbances, constantly recurring visual hallucinations and so on.”
All those ailments, then, can have a “psychogenic” basis, a basis that only a trained psychiatrist can deduce. They go on to give the example of “a girl, who, tormented by anxiety, is watching over a sick bed, falls into a twilight state and has a terrifying hallucination, while her right arm, which is hanging over the arm of the chair, goes to sleep; this develops into a paresis [paralysis] of the arm with contracture and anesthesia.”
Watch what Freud and Breuer are saying here: A young woman is tending to a sick relative and starts hallucinating, her arm becoming numb and paralyzed, a severe neurological problem. They blame anxiety; we point to mercury poisoning and its known effects as a much simpler explanation that was never considered.
This, then, is the biomedical basis for the modern-day diagnosis of conversion disorder – anecdote after anecdote supported by what Freud and Breuer presented as a step-by-step proof but today seems more like mumbo-jumbo.
And from that came the misdiagnosis that doctors now defend as well-established and conclusive.
“It’s happened before, all around the world,” said Dr. Laszlo Mechtler, the Amherst, N.Y., neurologist who has examined most of the girls in LeRoy. It’s a rare phenomena. Physicians are intrigued by it.”
The fact this mistake has been repeated rather than recognized does not make it any the less mistaken. But the medical industry, as we learned in writing our book, can be glacially slow to self-correct, especially when – as in any other industry – prestige and profits are on the line. So hysteria has endured (albeit converted into “conversion disorder”) against all reason as a catchall category, one that usually ensares women, especially young women.
"It is difficult not to draw the conclusion that, in formulating its criteria” for conversion disorder, the American Psychiatric Association “did little more than take an old diagnostic error and give it a new name together with a new aura of respectability,” writes Richard Webster in his mammoth revisionist history of Freudianism, “Why Freud Was Wrong.”
“Since the very concept of 'conversion' is specifically psychoanalytic, and since it is historically indivisible from Freud's own idiosyncratic theories of 'hysteria', it further seems that the creation of the category 'conversion disorder' was a politically astute way of preserving the old concept of 'hysteria' in euphemistic disguise.”
“The only strict criterion,” Webster concludes, “is that the patient’s symptoms should be medically inexplicable.”
We take a different view from Freud and his modern-day successors. In situations like this, we need to listen to and trust the victims and not the medical authorities that routinely resist inconvenient problems. Labels like “conversion disorder,” “mass psychogenic illness” and “hysteria” are simply protocols that project a false posture of competence in the face of a complex problem. The real label should be, “Our normal tools don’t work and we want this problem to go away because we have no idea what caused it or what to do about it.”
The attention needs to be on those who are affected, because we need to figure out what is different about the people who become victims from their close neighbors who escape injury.
We will explore those issues in our next articles.
Dan Olmsted and Mark Blaxill are Editor and Editor at Large of AgeOfAutism.com and co-authors of the “The Age of Autism – Mercury, Medicine, and a Man-made Disorder” (Thomas Dunne Books, 2010.) Portions of the discussion of “Dora” are from the book.