The way we view certain syndromes has changed depending on the medical knowledge, moral values, and social norms of the era surrounding them.

By Peter J. Koehler

Figure 1. Cover of “Framing Disease: Studies in Cultural History,” by Charles E. Rosenberg and Janet Golden.

Editor’s note: This article is the first in a two-part series. The second part will appear in the August 2026 issue of World Neurology.

When considering diseases from a cultural-historical context, one must examine two aspects: the relationship between “views on health and illness, perceptions of risks posed by health threats, and therapeutic and preventive traditions” and, on the other hand, “cultural characteristics of a society or population groups.”¹

This includes the emergence of disease patterns in relation to “sociocultural changes, the existence of taboos and shame surrounding certain n diseases and the breaking down of these, differences in treatment for the same ailment across different countries, and forms of preventive medicine that were supported in the compartmentalized, paternalistic society, but which are no longer successful in an individualized culture.” It also includes “the difference between Anglo-Saxon surgical culture and German-speaking surgical culture.”¹

Just as in the philosophy of science — think of Kuhn’s “The Structure of Scientific Revolutions” (1962) and Ludwig Fleck’s “Entstehung und Entwicklung einer wissenschaftlichen Tatsache” (1935) — there has been considerable interest in this sociocultural context since the end of the 20^th century. This interest is in part due to the work of the American medical historian Charles E. Rosenberg (b. 1936) who identified this historical process as “framing disease.”¹

In the introduction to “Framing Disease: Studies in Cultural History,” which is essentially a collection of essays, Rosenberg noted that, in certain respects, illness only exists when people agree that it exists — by observing it, naming it, and responding to it. (See Figure 1.) According to Rosenberg, illness is not only a biological event, but also a social phenomenon. In addition to patients, doctors, families, and social institutions, the government, employers, and insurance companies find ways to frame the biological event in terms that make sense to them and serve their own goals.

Many diseases discussed in the book, such as end-stage kidney disease, rheumatic fever, parasitic infectious diseases, and epilepsy, have been defined, redefined, and renamed over the course of several centuries. Interestingly, as the essays in the book demonstrate, the concept of disease is also used to frame culturally resonant behaviors, with examples including anorexia nervosa, suicide, and chronic fatigue syndrome.

According to Rosenberg, illness is shaped by government policy, as case studies on disability and forensic psychiatry demonstrate. Moreover, medical institutions, as managers of people with illnesses, have vested interests in diagnoses, as the history of institutions for the treatment of tuberculosis or epilepsy shows. Finally, the existence and conquest of diseases serve to frame a society’s perception of its own “health” and to guide social reforms.

Framing “Hysteria” and Neurasthenia

I will examine two afflictions that had an interesting history in this two-part series: “hysteria” and neurasthenia. Both conditions have been treated by neuropsychiatrists in the past. Originally, they were considered organic disorders, but before they were removed from the nosology, it was assumed that they had a functional cause.

In this article, we will examine “hysteria,” a condition that was already known in classical antiquity, albeit under a different name. Throughout history, it has been framed in different ways and in different contexts, eventually loosening its medical meaning and disappearing over the course of the 20th century. The term itself, however, remained reserved for behavior that exhibits overwhelming or uncontrollable fear or emotional outbursts. In other words, it took on a nonmedical meaning as for instance in “mass hysteria” or “political hysteria.”

In the second part of this article, we will discuss neurasthenia. At first glance, it appeared to have had a relatively short history (1870-1930). But if we examine the various symptoms, one could argue that its history is much longer and that only the terminology has changed over time.

Both “hysteria” and neurasthenia can be cited as examples of the fact that diseases are not immutable natural phenomena, but socially and culturally constructed concepts. They reflect contemporary medical knowledge, moral values, and social norms. Diagnoses may eventually become obsolete due to new insights, or they may no longer align with certain societal views regarding health and illness.

“Hysteria” in Classical Antiquity

It has been suggested that in Ancient Egypt certain behavioral disorders in women were viewed as resulting from abnormal movements of the uterus — as an organ that floats independently. This has been disputed by others.² In any case, we encounter it in the “Corpus Hippocraticum,” where it is still referred to as “suffocation of the womb.” It is also found in Plato’s work (c. 427-347 BCE), in particular his “Timaeus.” The idea was that if the womb remains barren for a long time, it becomes irritated and wanders throughout the body. It would block the patient’s airways, and because it prevents her from breathing, it puts her in extreme distress and causes all manner of other illnesses. It was therefore viewed as a condition resulting from a lack of sexual relationships.

Reported symptoms included dizziness, paralysis, sensory disturbances, difficulty breathing, globus sensation, and extreme emotional behavior. At the time, “hystero-epilepsy” was not considered part of the diagnosis. Treatment included disinfection, abdominal bandages, and immediate marriage. As anatomical knowledge of the ligaments surrounding the womb increased, the idea of a “wandering uterus” eventually became untenable. Nevertheless, there were still authors in the second century (CE) who adhered to the concept of the moving womb.³

Galen of Pergamon (129-199 CE) listed the following symptoms: immobility, a pulse that was difficult to feel, and paroxysms accompanied by contractures of the limbs. He believed the cause lay in tensions within the membranes, associated with the retention of menstrual blood and “female seed.” This was said to cause noxious vapors that rise within the body. As a treatment, he mentioned, among other things, aromatic substances and the induction of an orgasm by a midwife.

From the fourth to the seventh century, disagreement persisted regarding the cause — whether the uterus was moving or not — but the symptoms remained more or less consistent: loss of speech and sensation, limbs drawn together, an irregular pulse, and cessation of breathing. The treatment involved presenting a foul odor to the nose and a sweet odor to the vulva, so that the uterus would return to its proper place. In Arabic medicine, the concept of the mobile uterus made a full comeback.⁴

Medieval Period: The First Paradigm Shift

During the Middle Ages, there was a paradigm shift from naturalistic interpretations to supernatural conceptions.⁴ Although the exact cause of this is unknown, various suggestions have been put forth, including the collapse of the (Western) Roman Empire, the spread of Christianity, and the complex interplay between religious doctrines, limited medical knowledge, and societal views on suffering.

Church Father Augustine of Hippo (353-430) viewed suffering as a manifestation of innate evil resulting from original sin. From the fifth to the 13th century, all sorts of dramatic manifestations occurred that were seen as signs of demonic possession. Patients were believed to be victims of witchcraft or soul mates of the devil. Anesthesia, mutism, and convulsions were regarded as so-called stigmata diaboli.

When it comes to healing practices of that time, we should think of supernatural invocations, prayers, incantations, amulets, and exorcism. There was also widespread persecution, particularly toward the end of the Middle Ages. In the late Middle Ages and the Renaissance, the diagnostic process shifted from the hospital to the church and the courtroom. Spectacular interrogations took place, often accompanied by misogynistic directives regarding the investigation, torture, and sometimes execution of witches. In modern times, this is often viewed as a way they explained and controlled deviant behavior, particularly among women.⁴

The Second Paradigm Shift: Localization in the Brain

Figure 4. Thomas Sydenham © Rijksmuseum Amsterdam.

Figure 3. Ambroise Paré, © Rijksmuseum Amsterdam.

Figure 2. Joannes Wier(us); © Rijksmuseum Amsterdam.

Reactions from the medical community emerged at the height of the witch hunts in the late Renaissance. These led to the reconceptualization of “hysteria” on scientific and humanitarian grounds. Among the physicians who played a role in this were Paracelsus (1493-1541), Joannes Wier (c. 1515-1588; see Figure 2), Ambroise Paré (1510-1590; see Figure 3), and Edward Jorden (1569-1633). This led to the cause of “hysteria” shifting from the realm of religion and magic to that of medical pathology and natural causes.

In the 17th century, the term “hysteria” replaced that of suffocation of the womb. Furthermore, the French physician Charles Lepois (1563-1633, also known as Carolus Piso) noted the uterus appeared normal upon pathological-anatomical examination, and he argued that “passions” were the cause. (Today, we would use the term “emotions.”) The Italian Giorgio Baglivi (1668-1707) realized that the words and actions of physicians played an important role in the treatment of hysterical patients.

Thomas Sydenham (1624-1689; see Figure 4) should be regarded as a physician who introduced important insights into the clinical picture of the condition, some of which were not confirmed until much later. In fact, he employed a neuropsychological model. Regarding the cause, he viewed the condition as an imbalance in the distribution of the spirites animales between body and mind. Passions such as anger, fear, love, and sadness played a significant role in the onset of symptoms.

Sydenham was aware of the clinical fluidity and mimetic capacity with respect to the symptomatology, which made reaching the correct diagnosis quite a challenge for the physician. Furthermore, he observed that, in addition to women, “hysteria”-like symptoms could also be observed in men, in which case, he referred to it as hypochondria.⁴

At the end of the 18th and the beginning of the 19th century, various concepts coexisted attributing the cause to the uterus, the brain, and the ovaries (the discovery of ovulation took place in the 1840s). It is interesting to note that, regarding female sexuality, there was no revival of the teachings from the “Corpus Hippocraticum,” but rather a shift from sexual deprivation to sexual overindulgence. In the meantime, “hysteria” found its place in the various nosological systems of François Boissier de Sauvages (1706-1767),⁵ William Cullen (1710-1790),⁶ and Philippe Pinel (1745-1826).⁷

Charcot and the Salpêtrière

In the middle of the 19th century, several physicians, including Wilhelm Griesinger 1794-1870), and Paul J. Möbius (1853-1907), came up with the concept of the hysterical temperament and constitution. This led to the description of several rather negative character traits, including eccentricity, impulsiveness, emotionality, coquetry, deceitfulness, and hypersexuality.

At the time, a considerable number of monographs on the disease “hysteria” were published in France, including the ones by Jean-Louis Brachet (1789-1858),⁸ Ernest Mesnet (1825-1898),⁹ and Pierre Briquet (1796-1881).^10,4 A few decades later, Jean-Martin Charcot (1825-1893) was working at the Salpêtrière and became interested in this condition. In fact, this was due to the fortuitous circumstance that the St. Laure ward had to be closed because the building was dilapidated, and the noninsane epileptics and hysterics had to be accommodated in his own ward in 1872.^11,12

Over the next six years, Charcot developed the nosographic category of “hysteria.” He sought to identify patterns and distinguish between phases, types, and formes frustes. One challenge was the lack of pathological-anatomical findings, unlike what he had observed in other conditions, including multiple sclerosis, amyotrophic lateral sclerosis, and tabes dorsalis.

Starting in 1878, he shifted his focus regarding “hysteria” from the anatomo-clinical method to physiological experimentation. He studied sensory symptoms using electrical instruments and employed hypnosis as a diagnostic tool. In all, he studied no fewer than 120 cases. He described hysterical paroxysms and distinguished four different phases. Regarding the cause, he hypothesized a hereditary predisposition combined with triggers (agents provocateurs). In women, these were often emotionally overwhelming experiences; in men, whom Charcot also diagnosed with this condition, they were usually physical traumas.

He believed that the absence of pathological-anatomical findings could be explained by the concept of a functional, dynamic lesion. However, he was still assuming the presence of an organic lesion. Although speculative, he suspected a cortical substrate. He observed that the sensory abnormalities did not follow any anatomical pattern. In Charcot’s last years, there was a growing tendency to view “hysteria” through a psychological lens. Autosuggestion was thought to play a role in religious healings at pilgrimage sites.^13,4 In that context, he wrote an article, titled “La Foi qui Guérit (The Faith that Heals).”^14,15

Another Paradigm Shift: From Neurology to Psychiatry

Sigmund Freud © Freud Museum London.

In the winter of 1885-1886, Sigmund Freud (1856-1939), who had studied medicine in Vienna under physiologist Ernst Brücke (1819-1892) and neuroanatomist Theodor Meynert (1833-1892), visited Charcot’s clinic with the intention of studying neuropathology and gaining clinical experience. His visit coincided with a period when Charcot was frequently demonstrating cases of “hysteria.”

To gain admission into Charcot’s inner circle, he offered to translate Charcot’s books into German. A sort of father-son relationship developed, in which Freud expressed both criticism and admiration for Charcot’s work. He later named his son Jean-Martin (1889-1967) and kept a copy of the famous painting by André Brouillet (1857-1914), “Une Leçon Clinique à la Salpêtrière,” with him for the rest of his life. (See Figure 5.)¹⁶

Figure 5. Une Leçon Clinique à la Salpêtrière by André Brouillet © Musée d’Histoire de la Médecine Paris.

When Freud left Paris, Charcot asked him to write an article on the distinction between organic and hysterical paralysis. It was not published until 1893, with the first three parts being “neurological” and the fourth “psychological.” The latter was likely written just before publication.¹⁷ Freud’s article remains instructive and useful in the study of functional disorders.¹⁸

After Charcot’s death, an intellectual impasse arose regarding “hysteria,” as researchers were unable to pinpoint the lesion, and a sense of therapeutic nihilism prevailed. At the same time, however, there was a growing tendency to approach the concept of “hysteria” from a psychological perspective, which ultimately led to a paradigm shift from a neurological to a psychological perspective.⁴ A recent article revealed that Charcot was, in fact, on the verge of accepting a psychological basis for traumatic “hysteria,” as he had written in an unpublished lecture shortly before his death.¹⁹

In addition to Freud, Pierre Janet (1859-1947), one of Charcot’s students, played an important role in the development of the psychodynamic model of “hysteria.” Rather than the physical symptoms, he was primarily interested in the psychological symptoms caused by emotional trauma. Freud’s further development of the concept of “hysteria” is well known for its ideas regarding repressed traumatic memories, hysteric conversion, and ultimately, after 1905, a purely psychological theory about sexual desires and fantasies that remain unconscious as a form of self-defense.

His treatment method in the meantime had shifted from electrotherapy to hypnosis and temporal massage, eventually settling on free association. Through psychotherapy, the patient must become aware of the event that caused the hysterical repression. One could argue that the condition known as “hysteria” was dominated by psychoanalysis during the first half of the 20th century.

Meanwhile, a marked decline in the number of cases of “hysteria” was observed. Moreover, the clinical pictures were simpler and less flamboyant. Various causes have been suggested, such as social and sexual emancipation. Here, “hysteria” was seen as being caused by a psychological effect of the 19th-century English and German social system characterized by sexual repression, suppression of emotions, and social suffocation. The disappearance of these factors was referred to as “de-Victorianization.”

Another hypothesis was the increasing psychological literacy, whereby emotions had previously been somatized, but could eventually be better articulated. Medical historian Marc Micale, however, presented arguments to show that the causes are better sought in the realm of nomenclature and nosology. He posited that the lack of a sound etiological concept and the expansion of the symptomatology led to broad and vague diagnostic categories.

He also said “hysteria” was ultimately absorbed into three other diagnostic categories, namely epilepsy, dementia praecox (later termed schizophrenia by the Swiss psychiatrist Eugen Bleuler (1857-1939)), and psychoneurosis. The latter was a purely psychological category, including obsessions and phobias, and should not be confused with Cullen’s original concept of neurosis, which was still considered an organic nervous disorder for which no pathological substrate had (yet) been found.²⁰

“Hysteria” in ICD and DSM

In the various editions of International Classification of Diseases (ICD), which evolved from the International List of Causes of Death and was adopted by the World Health Organization following its establishment in 1948 (ICD-6), we see that “hysteria” was already included in ICD-2 (1909). It was later renamed conversion “hysteria” (ICD-8 and -9; 1965 and 1975, respectively). In 1992 (ICD10), it became dissociative disorder, hysterical, and in 2020 (ICD-11) “hysterical disorder” was only mentioned in the supplementary chapter of Traditional Medicine Conditions.

In the Diagnostic and Statistical Manual of Mental Disorders (DSM), we see a similar trend, albeit at an earlier stage. In 1952 (DSM-I), it was mentioned among the psychoneurotic disorders, in 1968 (DSM-II) in class IV, neuroses, and in 1980 (DSM-III), among the somatoform disorders. The DSM-IV (1994) mentions somatization disorder (“historically referred to as “hysteria” or Briquet’s syndrome”). The disorder is no longer listed in the DSM-5 (2013).

Meanwhile, in 1958, the characteristics of the hysterical personality disorder were described, including vanity, theatrical behavior, and flirtatiousness. These were likely linked to the concept of the hysterical constitution/temperament from the mid-19th century (Griesinger, Falret, Möbius, as mentioned above). In 1968 (DSM-II), it was designated as the primary diagnosis of hysterical personality disorder (with “histrionic” — from the Latin histrio, meaning “actor” — in parentheses after it). In DSM-III (1980), the two terms were exchanged (hysterical between parentheses).

“Hysteria” in Medical Journals and Press

If we trace the history of the word “hysteria” in a dictionary, we see an interesting development that reflects advances in medical knowledge. The term does not appear in an authoritative Dutch dictionary from 1864. In the fourth edition in 1898, we encounter the entry for “hysteria” for the first time, defined as: (medical) a certain female ailment, manifesting itself in mood swings, paralysis, cramps, nervousness, etc.

In the 14th edition (2005), it has two meanings, namely:

• (medical) a set of conversion symptoms for which no physical cause can be found
• compared to “hysteria,” excessive excitement.

By 2021, however, the term no longer had a medical meaning; instead, it is defined as a state of mind in which a person loses self-control, for example, due to fear, panic, or intense admiration.

Historical Dutch newspapers reveal an interesting phenomenon. (See Figure 6.) Between 1850 and 1930, we see a rise followed by a decline in the total number of mentions, advertisements, and articles. However, as the number of advertisements declined in the 1920s and 1930s, the number of articles began to rise, continuing into the 1990s. Sampling shows that this effect is caused by the two different meanings the term acquired in the 20th century.

Figure 6. “Hysteria” frequency in Dutch newspapers (orange: total number of hits; green: ads; blue: articles).

This increase in articles containing the terms “hysteria” or “hysterical” can be explained by their nonmedical use. A newspaper, for example, ran the headline “A Bricklayer From Wales Became a Global Superstar. Wherever Tom Jones Appears, Women Become Hysterical.” Another described the “gold hysteria” caused by the high price of gold.²¹ The peak in the number of advertisements in the 1880s was caused by the use of the medical meaning of “hysteria.” At that time, the articles also focused on that meaning. The subsequent increase in the number of articles is caused by the nonmedical meaning that gained the upper hand after about 1930. I expect the same phenomenon will be found in American newspapers.

The rise and fall of the medical use can be confirmed by examining the occurrence of the term in the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine; see Figure 7). The New England Journal of Medicine (Boston Medical and Surgical Journal before 1928) has 2,342 entries between 1814 and 2024. This search yields 117 pages, with 20 references per page (plus two references on p.118). The last 14 pages cover the period between 1941 and 2024, which means that most of the articles were published between 1814 and 1940 (96%).

Figure 7. “Hysteria” frequency in the Ned Tijdschr Geneesk (1857-2005); the peak in 1995 is due to a special issue marking the centennial of Studien über Hysterie (1895).

“Hysteria” in Fiction and Art

Emile Zola, © Rijksmuseum Amsterdam.

“Hysteria” was also a popular theme in fictive literature during the period mentioned earlier. We see this particularly in novels from the literary Naturalist movement. In the novels of the French writer Émile Zola (1840-1902), who can be regarded as the founder of literary Naturalism, and his followers, many aspects of this condition, which was widespread at the time, can be found.^22,23 

Joris Karl Huysmans (1848-1907), for example, writes in his novel “Là-bas”: “My mother’s housemaid had a daughter who suffered from paralyzed arms and legs, severely suffering from the chest, roaring when she was touched … .” She had been suffering for two years.

“Dismissed from the Lyon hospitals as being incurable, she came to Paris, followed a treatment at the Salpêtrière, she went without anybody knowing what she had and without any drug giving relief.”

She was brought to an exorcist in Paris. “Miss, you’re a victim of the evil of consanguinity.” He let her remember the quarrel she had with her aunt two years previously, when the paralysis started, and cured her without touching her or prescribing drugs.²⁴

Sarah Bernhardt © Rijksmuseum Amsterdam.

As another example, I mention Guy de Maupassant (1850-1893), who attended lectures at the Salpêtrière during the period 1884-1886. As early as 1882, he criticized the general use of the term “hysterical” by the press. “We are all hysterics, … since Charcot, that breeder of chamber hysterics, maintains in his model establishment the Salpêtrière, at the expense of a number of nervous women, in whom he inoculates madness and of whom he makes demoniacs in no time… . All great men became like this. Napoleon I (not the other), Marat, Robespierre, Danton were like this. One often hears about Mrs. Sarah Bernhardt (1844-1923; well-known French actress). ‘This is a hysteric.’ The physicians also teach us that talent is a sort of “hysteria,“ and that it results from a cerebral lesion. Consequently, genius must arise out of two adjacent lesions; that’s double ‘hysteria.'”²⁵

Many other examples could be mentioned, including from more recent novels.²¹ André Breton (1896-1966), a former medical student under Joseph Babinski (1857-1932), who became a writer and poet (he was a founder of Surrealism) had a special interest in “hysteria” as can be found in the manifesto “Le Cinquantenaire de L’Hystérie (1878-1928) [The Fiftieth Anniversary of “hysteria” (1878-1928)]” that he wrote with Louis Aragon (1897-1982).²⁶

It has been argued that not only did medicine and “hysteria” influence fiction, but the reverse was also true — a situation that is more relevant to the framing of diseases. The publication of “Madame Bovary” (1857) by Gustave Flaubert (1821-1880) may have influenced diagnostic theories regarding the hysterical personality in the 1860s.⁴

As for “hysteria” and the visual arts, a link between Impressionism and hysterical dyschromatopsia was described in “Charcot, Impressionism, and Functional Dyschromatopsia. If we consider the reverse situation — that is, if we ask whether the visual arts might influence medicine — one might point to the book “Les Démoniaques Dans L’Art” by Charcot and Paul Richer (1849-1933),²⁷ in which the authors describe works of art from earlier centuries depicting possessed individuals, who strongly resemble the patients they observed at the Salpêtrière.

“Hysteria” and Feminism

Although various time periods have been cited for the first and second waves of feminism, I will assume here that the first wave took place from approximately 1870 to 1930 and the second from 1965 to 1985. During the latter period, we witnessed a significant reinterpretation of the concept of “hysteria” in history.

A significant portion of the so-called new studies on “hysteria” in the second half of the 20th century consists of a revisionist historical examination from a feministic perspective of the subject. The history of “hysteria” was viewed as an important metaphor for the condition féminine. Historians have written, among other things, about the misogynistic prejudices surrounding the history of “hysteria” within the male-dominated medical world. The field of psychiatry was seen as having significant prescriptive power over social and moral values.

In the late 19th and early 20th century, women in England who fought for suffrage, education, and the right to divorce were often labeled with a psychiatric diagnosis. On the one hand, this served as an explanation for their behavior, and at the same time, it could be seen as a means of control. We recognize the influence of French philosophers such as Michel Foucault (1926-1984) and academic feminism in Paris. Micale noted that “hysteria” can be seen as a kind of metaphor for both the position of women in patriarchal societies in the past and the image of women in the history of scientific discourse.⁴

Summary and Conclusions

The history of the concept of “hysteria” spans a period of 2,500 years, initially under a different name (uterine suffocation). Several paradigm shifts have occurred, in which sociocultural factors prevalent at the time played a significant role. Around the time it was localized in the brain, in the Renaissance, the term “hysteria” was introduced. In the 17th century, it was recognized that this condition also affected men, but the term “hypochondria” was used.

In the second half of the 19th century, the prevalence appeared to be increasing, and the condition was also diagnosed in men. Over the course of the 20th century, after it was assumed that the condition had a psychological cause, the disease began to subside and eventually disappear.

Although the medical meaning of the word “hysteria” faded, its popular meaning grew. The symptoms were still described under other terms; today, they are primarily classified as functional neurological disorders. Over the past 20 years, Jon Stone, consultant neurologist at the Royal Infirmary of Edinburgh and the University of Edinburgh, U.K., has conducted extensive research on this condition in collaboration with international colleagues and has created a multilingual website for patients with functional neurological disorders.²⁸

References: