shake-deshauer Layout 1 · 2010. 8. 23. · CMAJ Humanities The Shaking Woman Or A History of My...
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Humanities CMAJ The Shaking Woman Or A History of My Nerves Siri Hustvedt Henry Holt and Company; 2010. T here is a widely held conviction in medical circles that all can benefit from sharing the diverse fruits of scientific knowledge. Still, the term ‘scientific knowledge’ covers a lot of conceptual ground, and translating information from specialized branches of science to something most of us can make sense of can be tricky. One of the most enduring conceptual rifts in sci- ence has to do with the way we talk about the mind as if it were separate from the body, a division that colours the way doctors perceive their patients and even the way individuals express their suffering. In Siri Hustvedt’s latest book, a major literary talent takes a per- sonal journey into the borderland between mind and body, demonstrating dual proficiencies in the languages of neurosciences and psychoanalysis. Readers will be grateful for her efforts. Two and a half years after her father’s death, while giving a talk at the university where he had been a professor, Hustvedt began to shake uncontrollably on both sides of her body. She did not experience an aura or lose consciousness, and fin- ished her speech without assistance from members of her concerned audience. Was the shaking related to a seizure disorder or was it more closely related to a psychi- atric syndrome? Hustvedt’s previous his- tory of a shaking spell coupled with her recurrent migraine headaches might have implied a need for immediate neurologi- cal investigations. Curiously, her initial instinct was to think of a condition that has traditionally been tossed into the bin of psychiatric diagnoses: conversion dis- order. She had been researching the sci- entific literature from both psychiatry and the neurosciences for a novel and it seemed to fit; she had not lost conscious- ness, the circumstances of the talk were highly emotional and it was plausible that something repressed from her conscious- ness might now be shaking her body. The search to understand her shaking was just beginning and science, it would seem, was now becoming a character in her own life. Before the diagnosis of conversion disorder congealed in the late 1940s and early 1950s, its symptoms were covered under the much broader cate- gory of hysteria, which described a range of inexplicable neurological symptoms and amnesia. Sigmund Freud in Studies on Hysteria expressed his frustration with the condition: “The fact is that local diagnosis and electrical reactions lead nowhere in the study of hysteria, whereas detailed description of mental processes such as we are accustomed to find in the works of imaginative writers enables me … to obtain at least some kind of insight into the course of that affection.” According to the 19th-century French neurologist Jean Martin Charcot (1825– 1893), hysteria often involved a severe fright, which led patients to use a form of self-hypnosis to keep the painful memory out of their awareness. The philosopher and neurologist, Pierre Janet (1849–1947) was also interested in a relationship between psychic trauma and hysteria. He introduced the word ‘disso- ciation’ to describe a division among “systems of ideas and functions that constitute the personality.” Janet also introduced the term ‘la belle indiffer- ence’ to refer to a lack of concern about one’s own illness, a term now connected specifically to conversion disorder. In the mid 20th century, the concept of hysteria was parcelled into the somato- form disorders (including conversion dis- order) and the dissociative disorders. The somatoform disorders took the unex- plained neurological symptoms from hys- teria while the dissociative disorders got the cases of unexplained amnesia. As a diagnosis of exclusion, conversion disor- der is now surprisingly stable, with fewer than 10 per cent of patients eventually learning of a ‘physical’ explanation for their neurological symptoms. 1 But what of the 90 per cent for whom no cause can be found? Are they a left-over group of misfits with unresolved issues? Neuroscientists suggest not: These unresolved issues may be associated with brain scans that look different than most (see illustration on page two). 2 If these observations are eventually generalized CMAJ © 2010 Canadian Medical Association or its licensors 1 Books A well-grounded approach to the mind-body problem DOI:10.1503/cmaj.100645 Henry Holt and Company Hustvedt shows how scientific facts can be harmonized with the idiosyncrasies of an individual life. Early release, published at www.cmaj.ca on August 23, 2010. Subject to revision.
Transcript of shake-deshauer Layout 1 · 2010. 8. 23. · CMAJ Humanities The Shaking Woman Or A History of My...
HumanitiesCMAJ
The Shaking Woman Or A History of MyNerves
Siri HustvedtHenry Holt and Company; 2010.
There is a widely held convictionin medical circles that all canbenefit from sharing the diverse
fruits of scientific knowledge. Still, theterm ‘scientific knowledge’ covers a lotof conceptual ground, and translatinginformation from specialized branchesof science to something most of us canmake sense of can be tricky. One of themost enduring conceptual rifts in sci-ence has to do with the way we talkabout the mind as if it were separatefrom the body, a division that coloursthe way doctors perceive their patientsand even the way individuals expresstheir suffering. In Siri Hustvedt’s latestbook, a major literary talent takes a per-sonal journey into the borderlandbetween mind and body, demonstratingdual proficiencies in the languages ofneurosciences and psychoanalysis.Readers will be grateful for her efforts.
Two and a half years after her father’sdeath, while giving a talk at the universitywhere he had been a professor, Hustvedtbegan to shake uncontrollably on bothsides of her body. She did not experience
an aura or lose consciousness, and fin-ished her speech without assistance frommembers of her concerned audience. Wasthe shaking related to a seizure disorderor was it more closely related to a psychi-atric syndrome? Hustvedt’s previous his-tory of a shaking spell coupled with herrecurrent migraine headaches might haveimplied a need for immediate neurologi-
cal investigations. Curiously, her initialinstinct was to think of a condition thathas traditionally been tossed into the binof psychiatric diagnoses: conversion dis-order. She had been researching the sci-entific literature from both psychiatry andthe neurosciences for a novel and itseemed to fit; she had not lost conscious-ness, the circumstances of the talk werehighly emotional and it was plausible thatsomething repressed from her conscious-ness might now be shaking her body. The
search to understand her shaking was justbeginning and science, it would seem,was now becoming a character in herown life.
Before the diagnosis of conversiondisorder congealed in the late 1940sand early 1950s, its symptoms werecovered under the much broader cate-gory of hysteria, which described a
range of inexplicable neurologicalsymptoms and amnesia. SigmundFreud in Studies on Hysteria expressedhis frustration with the condition:
“The fact is that local diagnosis andelectrical reactions lead nowhere in thestudy of hysteria, whereas detaileddescription of mental processes such aswe are accustomed to find in the worksof imaginative writers enables me … toobtain at least some kind of insight intothe course of that affection.”
According to the 19th-century Frenchneurologist Jean Martin Charcot (1825–1893), hysteria often involved a severefright, which led patients to use a formof self-hypnosis to keep the painfulmemory out of their awareness. Thephilosopher and neurologist, Pierre Janet(1849–1947) was also interested in arelationship between psychic trauma andhysteria. He introduced the word ‘disso-ciation’ to describe a division among“systems of ideas and functions thatconstitute the personality.” Janet alsointroduced the term ‘la belle indiffer-ence’ to refer to a lack of concern aboutone’s own illness, a term now connectedspecifically to conversion disorder.
In the mid 20th century, the conceptof hysteria was parcelled into the somato-form disorders (including conversion dis-order) and the dissociative disorders. Thesomatoform disorders took the unex-plained neurological symptoms from hys-teria while the dissociative disorders gotthe cases of unexplained amnesia. As adiagnosis of exclusion, conversion disor-der is now surprisingly stable, with fewerthan 10 per cent of patients eventuallylearning of a ‘physical’ explanation fortheir neurological symptoms.1 But whatof the 90 per cent for whom no cause canbe found? Are they a left-over group ofmisfits with unresolved issues?
Neuroscientists suggest not: Theseunresolved issues may be associated withbrain scans that look different than most(see illustration on page two).2 If theseobservations are eventually generalized
CMAJ© 2010 Canadian Medical Association or its licensors
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Books
A well-grounded approach to the mind−body problem
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Hustvedt shows how scientific facts canbe harmonized with the idiosyncrasies ofan individual life.
Early release, published at www.cmaj.ca on August 23, 2010. Subject to revision.
(current studies involve very small num-bers of patients), how will this changethe way people with conversion disorderexperience their symptoms? Part of theanswer may involve revisiting the ques-tion of free will, the extent to which wecontrol not only our broader destinies,but also our immediate physical move-ments. That we all have some sense ofagency is undeniable, but the variabilityof this experience and its links to observ-able differences in brain functioning maybe greater than philosophers of the pasthad assumed.
Part of the challenge of translatingscience is that all abstraction comes at acost and, in the case of translating theneurosciences to the level of personalexperience, that cost can be a reductionof rich life experiences to a few general-izations. For many whose medical prob-lems defy a scientific explanation, heal-ing seems to involve a subtlerecalibration of identity, of how an indi-vidual remembers her past and how sheimagines her future. The ShakingWoman is a deceptively sophisticatedapproach to the mind−body problem,written in a style similar to Oliver Sackswith a critical slant more characteristic ofthe philosopher of science, Ian Hacking.It gives us an example of how scientificfacts can be harmonized with the idio-syncrasies of an individual life.
By the end of her book, Hustvedt hasnot found a definitive answer to hershaking. Some treatments have helped,but do not cure, and she comes to accepther condition, to experience herself asThe Shaking Woman. Scientific explana-tion does not have to be the leading char-acter in her life but rather takes its placeamong several equally important ones.
This is required reading for all med-ical doctors and for their patients withinexplicable neurological conditions.
Dorian Deshauer MD MScAssociate EditorCMAJ
REFERENCES1. Stone J, Smyth R, Carson A, et al. Systematic
review of misdiagnosis of conversion symptomsand “hysteria”. BMJ 2005;331:989.
2. Ghaffar O, Staines WR, Feinstein A. Unexplainedneurologic symptoms: An fMRI study of sensoryconversion disorder. Neurology 2006;67:2036-8.
3. Hacking I. The Social Construction of What? Cam-bridge (MA): Harvard University Press, 2000.
CMAJ© 2010 Canadian Medical Association or its licensors
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Humanities
A lesson on hysteria (André Brouillet,1887). This painting, which Sigmund Freud tookback with him to Vienna following studies with Jean Martin Charcot, shows Charcot (tothe right of the patient), pioneer of neurology at the hospital ‘la Salpetriere’ in Paris.The patient is Blanche Wittmann, held by Joseph Babinski, who hypnotized her.
These functional magnetic resonance scans show 3 patients with unilateral sensory con-version disorder. Stimulation of the affected limb does not cause the expected activationof the contralateral S1 brain region (middle column, arrows) while stimulation of theunaffected limb results in the normally expected S1 activation (left column, circle). Bilat-eral limb stimulation results in the normally observed S1 activation on both sides of thebrain (right column). Normal controls are not illustrated here. (from: Ghaffar O, StainesWR, Feinstein A. Unexplained neurologic symptoms: An fMRI study of sensory conversiondisorder. Neurology 2006;67:2036-8.)
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