Thread by @FndPortal

Mark Micale’s paper “On the ‘Disappearance’ of Hysteria” is a very neat piece of scholarship I do not agree with at all.

Here’s why it’s useful, and an alternate perspective.

So to start with, Micale is a historian who has done some very interesting work examining historical sources about “Hysteria”, the grossly-named disorder we now know as FND.

This particular paper, like his book “Hysterical Men”, is agnostic about what Hysteria “really is.” For the most part, he doesn’t really deal w that question.

What he examines is what people THOUGHT Hysteria was, and how they got there.

To be very very clear, we know today that FND is a real disorder, to the extent that a lot of us are kinda tired of having to point that out.

But it is true that belief in “Hysteria” dropped like a stone in the 20th century. Why? That’s what he seeks to answer.

To summarize, Micale argues that Hysteria, as a reputable diagnosis, was “deconstructed” over time.

In his view, where there was once a big pool of patients doctors labeled w “Hysteria”...

... as medical knowledge and diagnostic techniques improved, that happened less and less, and they started making other diagnoses instead: epilepsy, syphilis, MS, and so on.

And finally, “those bits and pieces of the historical hysterias that were not gathered up and used in the construction of fresh categories were conveyed more or less intact to the present...

... where they form the specialized and enormously reduced usages of the hysteria concept in current-d ay psychiatric medicine.”

Micale wrote this in 1993. It was an accurate summary of mainstream medical views at the time. Those views were wrong.

We now know that FND is real, common, and arises from intrinsic properties of the brain, which can go wrong.

But, it’s very valuable to recognize that, per Micale’s framing, diagnoses are “constructions.”

They’re like idea-buckets we make up to name and explain groups of things we see.

That’s true for all diagnoses, not just FND.

So if it’s possible that the original Hysteria docs were partially or totally wrong, or that their constructions always didn’t work very well to explain what’s going on, the same is true of doctors in the 1990s when it comes to functional disorders.

And as Lisa Feldman Barrett points out, when your brain can’t use its predictions to construct a proper category for something, you can’t properly perceive it. It’s called “experiential blindness.”

ted.com/talks/lisa_fel…

Maybe that explains the social invisibility of FND in recent decades.

Anyway, I agree with Micale that Hysteria was dismantled conceptually, but disagree on the details.

Here’s my breakdown, which we might call the “10 Fates of Hysteria”

So, given the group of people labeled “hysterics” 🤮 in the late 1800s (lets say, circa Charcot), what really happened to this group of people? Where is their equivalent today?

I think it’d break down into 10 groups.

1. People who would be correctly given a different diagnosis today (say, epilepsy, or a rare disorder)

2. People who have FND but are given an incorrect alternate diagnosis (like epilepsy when they have functional seizures)

3. People who are given insufficient alternate diagnoses (like people w Parkinson’s who have functional overlay)

4. People who are labeled “medically unexplained”, whether euphemistically or not

5. People who are simply not given a diagnosis of any kind

6. People who are given a “conversion disorder” diagnosis under the old vaguely Freudian paradigm

7. People, especially women, whose symptoms are non-specifically ascribed to “stress”

8. People who are labeled “malingerers” (which happens distressingly often to people w genuine FND)

9. People given a proper FND diagnosis under a scientifically-informed, biopsychosocial framework (yay!)

10. People given an FND diagnosis when they really have a rare disorder, which is revealed over time

Just a little thought experiment of how it might break out.

It’ll be interesting to see what our next constructions, created by our brains to approximately explain their own activities, reveal.

One extra little thought: this thread isn’t meant address what proportion of people have FND vs other disorders. But we know FND is quite common, which makes sense given a current perspectives across the brain sciences on how the brain likely works