The story starts with a physiological allegory of sexual excitement leading to the act of procreation in Plato's Timaeus:
And the seed, having life and becoming endowed with respiration, produces in that part in which it respires a lively desire for emission, and thus creates in us the love of procreation. Wherefore also in men the organ of generation becoming rebellious and masterful, like an animal disobedient to reason, and maddened with the sting of lust, seeks to gain absolute sway, and the same is the case with the so-called womb or matrix in women. The animal within them is desirous of procreating children, and when remaining unfruitful long beyond its proper time, gets discontented and angry, and wandering in every direction through the body, closes up the passages of the breath, and, by obstructing respiration, drives them to extremity, causing all varieties of disease, until at length the desire and love of the man and the woman, bringing them together and as it were plucking the fruit from the tree, sow in the womb, as in a field, animals unseen by reason of their smallness and without form; these again are separated and matured within; they are then finally brought out into the light and thus the generation of animals is completed (p. 1210).
This is a poetic mythical personification of the sexual instinct in both genders driving the urge to procreate and the propulsive sexual tension of the instinct in both men and women. But it is only in women that the inhibition of this mighty instinct causes a curious disease: what it does to men had to wait for Freud's formulating two actual-neuroses, anxiety neurosis and neurasthenia. Furthermore, Plato did not cite the noun “hysteria” or disease called hysteria but only point ed to an excited male organ desiring to have an emission into womb, hystera in Greek, desiring to be impregnated. There is of course a legitimate and genuine use of the womb in medicine when a surgeon performs a hysterectomy. On the other hand, the Leipzig psychiatry professor Paul Flechsig, immortalized by Freud as the doctor of Paul Schreber, literalized the
metaphorical womb-disease and prescribed surgery as a treatment for an imaginary disease hysteria.
This history clearly shows that a disease called hysteria does not exist, that there are only women and men called hysterics or hysterical. Furthermore, there was no clearly defined disease hysteria in the Hippocratic works either, but only an adjective of a condition called hysterike pnix, i.e., uterine suffocation (Gilman et al. 1993). According to the Oxford English Dictionary (OED) the word hysteria was first cited in 1801 as an abstract noun and has been employed ever since as a code word, label, and pathologizing libel of varieties of feminine and masculine conduct; however, for many years it was anathema among doctors to speak of male hysteria because, obviously, they had no womb!
In 1965 the medical historian Ilza Veith created a stir with her book Hysteria The History of a Disease, “in essence an expression of awareness of the malign effect of disordered sexual activity on emotional stability” (p. 2). Veith elaborated: “the connection of the uterus (hystera) resulting from its disturbances is first expressed by the term “hysteria”…in the thirty-fifth aphorism which reads “when a woman suffers from hysteria or difficult labor an attack of sneezing is beneficial” (p. 10). I checked aphorism XXXV and the word hysteria is explained in footnote 3: “Said by some commentators to refer to retention of the placenta. Galen rejects this interpretation, but Littré seems to accept it” (p. 167). Emile Littré was the famous 19th century lexicographer who also propagated the noun hysteria. Thus, a fictional disorder got adorned by Veith with a fancy Freudian interpretation.
While Plato's fable is one sort of fiction and Veith's is another, as compared to the fact of sex in procreation, both the tropes of Plato and the tricks of Veith have their usefulness: they provide an easy tag, hysteria, for visualizing the picture or image of kinds of conduct. The words hysteria and hysterical have become naturalized in common parlance as indicating a person whose conduct is wildly emotional, excited, uncontrolled and exaggerated, in a word, histrionic. Another usage is to speak of the excited behavior of a crowd, or a mass of people, as hysteria. On the other hand, the word histrionic derives from the Latin word histrio, a theatre actor, thus hysterical and histrionic are synonyms as well. Hysteria was the name of a faux disease that the young doctors at the
Salpêtrière hospital rehearsed and staged as a dramatic performance for the benefit of Professor Charcot, the Napoleon of the neuroses, during his legendary public lectures that were attended by the Parisian elite and the young Sigmund Freud and immortalized in the famous 1887 etching by A. Brouillet that hung in Freud's office. The etching shows a swooning Blanche Wittman falling into the arms of Dr. Joseph Babinski which Freud feared might be perceived as “theatrical by ill-disposed strangers” (Freud, 1893a, p. 18) (Lothane, 2009).
To summarize: hysteria is an abstract noun, a myth, what exists and is observed are people and conducts labeled hysterical. Like gravitation, which cannot be seen, for only falling things can be seen, so hysteria is utilized as pointing to forms of conduct along a continuum from common to clinically pathologized. In the wake of Charcot, Josef Breuer and Sigmund Freud, solved the two thousand years old conundrum of hysteria by describing disorders they called, in the wake of Charcot, traumatic neuroses: reactions to traumatic life events, in their epochal 1895 Studies on Hysteria. The first case of a traumatic neurosis was Breuer's Anna O, the other women were patients of Freud.
Rereading that book around 2007, when I was visiting professor at the Heidelberg Institute for the History of Medicine directed by Prof. Wolfgang Eckart, I made a discovery: Strachey did not fully understand the meaning of a word used by Breuer to describe the conduct of Anna O., aka Bertha Pappenheim, the co-discoverer of psychoanalysis. The word in question, used in the 19th century and since obsolete, was the verb tragieren meaning to act and to perform a role.
Breuer offered this general observation of Anna O.:
With her puritanically-minded family, this girl of overflowing mental vitality led a most monotonous existence, although she probably exaggerated it to an excessive degree for her illness. She systematically nurtured day-dreaming, which she called her “private theater” (Breuer and Freud, 1909b, italics added, p. 14).
Her illness was a syndrome of withdrawal from her family life due to the trauma of having been roped into the role of caring for a moribund father while the day-dream-dreaming was a mode of surviving under
these conditions and Breuer's almost daily visits kept her from being hospitalized.
Breuer described the following event:
Unfortunately, I had to leave the city the same evening, and when I returned after many days, I found that the patient's condition was markedly aggravated. Throughout the whole time she was entirely absentminded and full of anxiety. Her hallucinatory absences were filled with terrifying images of skulls and skeletons. As she lived through these things and dramatized them partially in speech, the people around her could understand most of the content of her hallucinations. In the afternoon she remained somnolent, and at sunset in a deep hypnosis, for which she coined in English the name of “clouds” (italics added p.18).
Freud focused on two kinds of dramatization: (A) dreaming of scenes while asleep, (B) fantasizing in waking day-dreams and noted in the 1900 The Interpretation of Dreams that “phantasies or day-dreams are the immediate forerunners of hysterical symptoms” (p. 491).
Dreams then think predominantly in visual images, but not exclusively. They use auditory images as well…The transformation of ideas into hallucinations is not the only respect in which dreams differ from waking life. Dreams construct a situation out of these images, represent something as an event happening in the present,…they ‘dramatize’ an idea … [I]n dreams … we appear not to think but to experience … we attach complete belief to the hallucinations. Not until we wake up does the critical comment arise that … we have merely been thinking in a particular way” (Freud, 1900, pp. 49-50; three italics by Strachey, the second in the German original and without single quotations marks) (cited in Lothane, 2009).
Freud quotes Hildebrandt on “the dramatic representation mode [Darstellungsweise] in dreams” (, p. 72). In a later text Freud defines again: “the transformation of thoughts into situations (‘dramatization’) is the most peculiar and important characteristic of dream work” (Freud, 1900, p. 653).
as described in the aforementioned vignette by Breuer. But dramatization in act and in dramatic monologue or dialogue is the very essence of the art form called drama, a word derived from the Greek root dran = ‘to do,’ thus doing versus dreaming. Drama was invented in Greece as dramaturgy, i.e., the art of composing dramas and performing dramas in a theater, e.g., the tragedies by Aeschylus, Sophocles, and Euripides, which were analyzed by Aristotle. But life itself was the source of these invented dramas, as it is today for the dramas of theater plays, television plays, and films. There is a need for a domain to accommodate both real life and invented dramas for which I proposed the term dramatology (Lothane, 2009), a word still not found in the dictionaries.
Moreover, the aforementioned Breuer's interaction with Anna O. pointed to the fact that the treatment situation was a drama, too, a dramatic conversation and interaction between the patient and the doctor. Breuer employed Aristotle's idea of catharsis, purging the emotions of pity and terror for the spectators, to call his treatment of trauma as cathartic purging, also called abreaction, of strangulated emotions. Freud defined psychological treatment as an interaction with “words…the essential tool of mental treatment [having] magical power” (Freud, 1905, p. 283). As I showed, this essay was written by Freud in 1892 (Lothane, 2014), which I discussed in 2007, a foreshadowing of dramatology in 2009.
In that essay Freud described “what is known as the ‘expression of the emotions’”:
A man's states of mind are manifested, almost without exception, in the tensions and relaxations of his facial muscles, in the adaptation of his eyes, in the amount of blood in the vessels of his skin, in the modifications in his vocal apparatus and in the movements of his limbs and in particular his hands (p. 286).
Freud's keen interest in drama was described in his 1942 essay on psychopathic characters on the stage. Drama was also an interest of the American neurologist, psychiatrist and psychoanalyst Smith Ely Jelliffe in the first chapter “The drama and psychotherapy” of his 1934 monograph:
The drama has always been an important handmaid of culture, and in every age of human history its development has kept pace with that of culture. Its direct appeal to the senses, as well as its growing intellectual and artistic value, have made it always a leader of the thought of the race and of its form of expression. It has stimulated the people, educated them, directed their religious aspirations, and has served for their amusement and recreation. So well has it done the latter that the danger has increased of forgetting that these in themselves are conventional terms for something deeper and more significant. This is something that lies in the mental life below the surface and gives to the drama in its very function of amusement and recreation a far more serious purpose for which it intrinsically stands… It also permits a constructive representation of the emotions (pp. 1-2).
In 1979 the Swedish professor of the history of literature Gunnar Brandell documented Freud's interest in drama but was unaware of Freud's 1942 essay.
Back to Breuer: he not only participated in and observed Anna O.'s dramatizations (and those belonged to dramatology, a word not yet found in dictionaries), Breuer also transformed the dramatic situations into a story, a narrative (and narratives belong to a domain called narratology, a word that is found in dictionaries). What then is the domain of dramatization? Dramatology and narratology are thus the two complementary sides of the same coin: one represents a life story in action and the other in story-making and story-telling.
In the aforecited Freud's remark about dreams, that “phantasies or daydreams are the immediate forerunners of hysterical symptoms,” the word symptom is a medical coinage. But phantasies and day dreams are not really forerunners, they are the so-called hysterical symptoms themselves. Hallowed by the medical model, we speak of ‘symptoms’ of paranoia the way we speak of the symptoms of pneumonia. But pneumonia is monadic, it takes one to develop pneumonia but paranoia is dyadic, it takes two to develop paranoia. But it was Freud himself who redefined neurosis psychologically and sociologically as action, or drama, as a continuum of health and disease:
Symptoms—and of course we are dealing with psychical (or psychogenic) symptoms and psychical illness—are acts detrimental, or at least useless, to the subject's life as a whole …‘being ill’ is in its essence a practical concept…you might well say that we are all ill—that is, neurotic, since the preconditions for the formation of symptoms can also be observed in normal people” (Freud, 1916-1917, 358; my italics).
Eventually Freud emphasized the sociological dimension of interpersonal conduct: “in the individual's mental life someone else is invariably involved, as a model, as an object, as a helper, as an opponent; and so from the very first individual psychology … is at the same time social psychology as well” (Freud, 1921, p. 69), all this having dramatological implications.
It should be helpful to show how Breuer and Freud solved the 2500 years old enigma of hysteria: having “[investigated] over a number of years [its] many forms and symptoms…with a view to discovering the precipitating cause—the event which provoked its first occurrence” (Preliminary Communication, 1893, p. 3; italics added). The precipitating causal event turned out to be “a precipitating trauma…a girl, watching beside a sick-bed in a torment of anxiety fell into a twilight state and had a terrifying hallucination” (p. 4). The event was a historical fact with time and place and person(s), it was a scene, a situation, with a monologue or a dialogue, and as such could fairly be called a drama. And they concluded: “Observations such as these seem to us to establish an analogy between the pathogenesis of common hysteria and that of traumatic neuroses and to justify the extension of the concept of traumatic hysteria” (p. 5, their italics). On an analogy with Charcot's neurological neuroses caused by train accidents, Breuer and Freud described reactions to interpersonal traumatic events and faute de mieux, for lack of something better, called it traumatic hysteria. Today we have a different label for a reaction to trauma: post-traumatic stress disorder. Therefore, I submit, there is good reason to cancel continuing to use the convenient cliché hysteria, one can instead speak of traumatic reactions.
Two more matters were found relevant: not only the nature of the precipitating event, sometimes quite “trifling, but the affect of fright—the psychical trauma” (p. 6), both the stimulus and the response. And it is this psychic trauma that persisted long after the event: “the psychical pain
that is remembered in waking consciousness still provokes a lachrymal secretion after the event. Hysterics suffer mainly from reminiscences” (p. 7, their italics). And there are sufferers from posttraumatic stress reactions, both civilian and veterans.
Another matter not dealt with in the Preliminary Communication was the pejorative use of the label hysteria to characterize imaginary illness of the mind, as in Molière's Malade Imaginaire, versus the real—and respectable—organic illness of the body. In 1893 Freud made the distinction between organic paralyses and hysterical paralyses, the latter “completely independent of the anatomy of the nervous system, since in its paralyses and other manifestations hysteria behaves as though anatomy did not exist or a though he had no knowledge of it” (1893, p. 169). Note Freud's allegorically personifying hysteria as a female entity or essence, fit for Occam's razor. For in fact there is no such thing as non-organic paralysis, what exists are persons imitating, enacting and playing the part of a patients afflicted with an organic paralysis who simply will not raise their arms or use their legs to walk.
Ideas can be likened to seeds planted in mind and memory that may lie dormant for years until they sprout one day to yield the fruit of previous insights. When I was a resident in psychiatry in Rochester, NY I heard and read my teacher George Engel (1962) comparing a “conversion reaction to the game of charades. In this game one is asked to translate a verbal (cognitive) message into bodily terms, as pantomime, as gestures or other bodily movements. They are meant symbolically to represent the cognitive content the player had in mind” (p. 369). Conversion reactions, Engel taught, “are most common in and characteristic of hysteria, a condition in which there is a predilection for the use of the body for expression of feelings, wishes, and ideas, but it is not correct to equate the conversion reaction with hysteria, as has been customary in the past” (p. 369), without saying why this is so. But the inescapable conclusion back then was that hysteria is not a condition, that it is conduct and as such no different from ordinary people expressing their emotions with their bodies in gestures, tone and volume of voice, let alone pantomime, grimace, laughter, and tears, as did Freud in the aforementioned 1905 essay. Thus, conversion failed as an adequate explanation as indicated by Engel himself: “a forbidden wish is kept out of consciousness but at the same time is translated (“converted”), not into words, but into some
bodily activity or sensation which suitably represents it in a symbolic form” (p. 369). Putting conversion in quotation marks and adding the synonym of translation suggested that hysteria, too, was nothing but “hysteria,” a façon de parler, a turn of phrase. In retrospect Engel's teaching was the seed of my dramatology.
Now dramatology is not a theory to explain a disease labeled hysteria but a method to understand the person, however labeled, the person's character and conflicts, the person's outward appearance and inward thoughts, feelings, and motives of acting. Consider the example of the only male case of a traumatic reaction in the Studies on Hysteria:
An employee who had become a hysteric as a result of being ill-treated by his superior, suffered from attacks in which he collapsed and fell into a frenzy of rage, but without uttering a word or giving any sign of a hallucination. It was possible to provoke an attack under hypnosis and the patient then revealed that he was living through the scene in which his employer had abused him in the street and hit him with a stick. A few days later the patient came back and complained of having another attack of the same kind. On this occasion it turned out under hypnosis that he had been re-living the scene to which the actual onset of the illness was related: the scene in the law-court when he failed to obtain satisfaction for his maltreatment (1893, p. 14, italics added).
With or without the word, hysteria would enable a writer like Chekhov or Maupassant to compose a short story built on these same scenes.
Another example is the case of Dora, aka Ida Bauer, whom Freud treated in 1900, wrote up mostly in 1901, and published in 1905. Dora's family and family drama were replete with scenes of seduction, sexual manipulation, intrigues of infidelity, love barters, and betrayals so that Freud wished he could write her story more as “a man of letters engaged in the creation of a mental state like this for a short story, instead of being a medical man engaged upon its dissection” (Freud, 1905b, p. 59). But at this point in his life Freud did not listen to Dora, as he did to his patients who were his teachers prior to 1895, but used her as a test case to prove his oedipal theory of hysteria (p. 56) and a sexual theory of hysteria, bombarding her with interpretations which resulted in dramatic verbal duels. Seeing Dora as “a girl of intelligent and engaging looks”
(p. 23), “sharp-sighted” (p. 34) and firing “arguments,” “rejoinders,” “objections,” and “contradictions,” Freud, was just as sharp in his rejoinders; while not feeling justified “to attack” her thoughts, he nevertheless repeatedly confronted Dora, for “to make an omelet you have to break the eggs” (p. 49). However, the main reason for Dora's breaking off her treatment after three months, I submit, was that Freud was not loyal to her rebuffing a sexually exploitive and unscrupulous adult like Herr K. and others but was siding with them and critical of the patient. And Freud admitted himself: “Might I perhaps have kept the girl under my treatment if I myself had acted a part, if I had exaggerated the importance to me of her staying on, and had shown a warm personal interest in her—a course which, even after allowing for my position as her physician, would have been tantamount to providing her with a substitute for the affection she longed for? I do not know” (p.109).
Proceeding to rationalize the termination Freud argued: “the factor of ‘transference’ did not come up for discussion during the short treatment” (p. 13). Only after Dora left him did Freud realize that “the transference took [him] unawares” (p. 118) and got dramatic: “She took her revenge on me as she wanted to take her revenge on [Herr K.], and deserted me as she believed herself to have been deceived and deserted by him. Thus, she acted out [sie agierte] an essential part of her recollections and fantasies instead of reproducing it in treatment” (p.119; italic Freud's), self-pityingly “demonstrating the helplessness and incapacity of the physician” (p. 120). ‘Agieren,’ from the Latin agere, to act, does in German mean both doing and acting a role in a play, reverberating with Breuer's ‘tragieren,’ and thus overdetermined consciously and unconsciously. Dora's termination was not just acting out but her own decisive action to stop treatment and was blessed by Freud: “You know that you are free to stop the treatment at any time” (p. 105), showing that Freud conflated acting out with action. Moreover, Freud viewed acting out as an antonym of remembering, for acting out is an unconscious enactment of a memory of a past event. I recall a point made by Brenner in a presentation in 1968 that not it is only dreams, enactments can also be a royal road to the unconscious.
But there was a silver lining to Freud's lament:
Dora dramatized her conflict with Freud, as other women before her;
Page 105but here confrontation, contest (agon), and combat occupied center stage: she acted and—[according to Freud]—she acted out. Hence the new conception of analysis as a transference drama played out between two protagonists turned antagonists, in which “this latest creation of the disease must be combated like the earlier ones. This happens, however, to be by far the hardest part of the whole task. It is easy to learn how to interpret dreams, to extract from the patient's associations his unconscious thoughts and memories, and to practice similar explanatory arts: for these the patient will always provide the text” (1905, p. 116; my italics). Interpretation alone is no longer sufficient: “since a whole series of psychological experiences are revived not as belonging to the past but as applying to the physician at the present moment” (p. 116), since “all the patient's tendencies, including hostile ones, are aroused” (p.117), explanation needs to be amplified by confrontation. In this way, “transference, which seems ordained to be the greatest obstacle of psycho-analysis” (p. 117), became a crisis, a challenge, and an opportunity (Lothane, 2009, p.141).
Here, too, dramatology, in agreement with Freud's confrontational approach, makes a contribution to the tradition of psychoanalytically-oriented psychotherapy.
So far dramatology has been cited positively by Philip Bromberg (personal communication), James Grotstein (Brown, 2011, p xvii), Galit Atlas and the late Lewis Aron (, p. 47, 54, 84). New ideas tend to arouse suspicion: if it is true, it is not new is a common reaction. Dramatology is both old and new and calls for a rediscovery and a reaffirmation.
Some objections to dramatology as method might be raised in the spirit of entries in the psychoanalytic dictionary of Moore and Fine (1990). The author of the entry “Hysteria,” citing four references (the Studies, the Dora case, Fenichel's The Psychoanalytic Theory of Neurosis, and a paper by Rangell on conversion), does not mention the word trauma and starts by claiming that “involved in psychic mechanisms in hysteria [Freud] discovered unconscious fantasy, conflict, repression, identification, and transference, marking the beginning of psycho-analysis” (p. 89). This heterogeneous list is incorrect: psychoanalysis began with the Preliminary Communication and The Studies on Hysteria. One statement seems to support the idea of dramatization: “The hysterical spells
often pantomime complicated fantasy stories that can be analyzed in the same way as can the elements of the manifest dream, both phenomena are products of the distortion resulting from mechanisms of the primary process” (p. 90). But this correct insight is immediately vitiated by claiming that “the bodily symptoms of hysteria involve motor, sensory, or visceral phenomena—anesthesia, pain, paralysis, tremors, deafness, blindness, vomiting, hiccoughing, and so on” but also that “the symptoms therefore represent an expression in “body language” of specific unconscious fantasies” (p. 90). This is another mixture of quasi-neurological descriptions of physiological sequelae of strong emotions and the symbolic nature of body language (see chapter 32 and 33 on compensated and uncompensated states). The term acting out is often used colloquially as a synonym for acting up, to behave in an unruly or capricious manner.
Finally, the author of the entry “action” claims that “analysts think of action as something opposing the psychoanalytic process, for example when psychopathology takes the form of disruptive, maladaptive, or inappropriate behavior” (p. 3). I disagree: action is not inimical to psychoanalysis; any action or enactment can be grist to the mill. Here Wilhelm Reich's character analysis of identifying and confronting habitual character attitudes, both traits and states (Lothane, 2009, p. 146), and dramatology offer an approach and a method: all forms of action can benefit from applying the psychoanalytic method of analyzing enactments the way one analyzes dreams, that is with the help of free association (Lothane, 2018).