Abstract
The authors take inspiration from a case of hysterical psychosis to illustrate a typical condition of this evocative disease: the symbolic language of hysteria, conjurer of archetypical images. The authors encourage the clinician not to decode such aspects in rational analytical terms, rather to have a more wide-open approach that promotes the emergence of the individual unconscious, reconnecting with the collective imagination. This approach could help psychiatrists better understand a subject’s inner experiences and interpersonal behavior.
Keywords: symbolism, crow, hysterical psychosis, collective imagination
Clinical Case
A female patient, 28 years of age, presented to the Emergency Room of a General Hospital for a severe psy-chomotor agitation and self-harm (superficial cuts to the forearm). The patient was accompanied by her mother, who stood by her during the visit.
Written informed consent was obtained from the patient according to the Hospital ethical protocol.
The patient was already in treatment for a diagnosis of schizoaffective disorder, currently in therapy and was prescribed Aripiprazole 30 mg/day, Haloperidol 2 mg/day. The patient, according to her mother, had been well compensated until the previous month. Then, having expressed to the psychiatrist the desire to become pregnant, she was granted a gradual reduction of Oxcarbazepine dosage from 600 mg/day until discontinuation.
In conjunction with the therapeutic change, there was a gradual reoccurence of a symptomatology character-ized by reported auditory and visual disperceptions, psy-chogenic deafness and muscle spasms, for which Haloperi-dol 2mg/day was added to Aripiprazole 30 mg/day.
From the medical history, provided by the mother, it turned out that the patient was delivered by caesarean section, after a long and exhausting labor (the mother was then 28 years old, the same age as the patient now).
The onset of the psychopathology was established as having occurred at age 16, with the occurrence of epileptic seizures and symptoms of conversion disorder (transient loss of vision and hearing). The patient was evaluated by various neurologists and underwent EEG and brain MRI, that ruled out a convulsive pathology.
The mother reported a stressful life event: the patient at age 15 suffered a psychological abuse by a school professor (“he was cruel”).
At age 19, the patient was first hospitalized in a psychiatric ward; she was diagnosed with a schizoaffective dis-order and began pharmacological therapy with neuroleptics and mood stabilizers, with a fairly beneficial result. In-deed, the patient had graduated from high school, and since then had carried out various jobs, and currently worked as a saleswoman. At age 20, she engaged in a stable emotional relationship.
At the age of 25, the patient underwent a second psychiatric hospitalization, for which the mother did not report any treatment discontinuation, nor any apparent stressful life event.
The patient had been in a relationship for about 8 years, and had gotten married the year before, at age 27. For a couple of months they had been planning to have a baby.
A psychiatric family history was denied.
During the visit at the Emergency Room, the patient appeared well dressed and was attentive to personal hy-giene. She appeared in a crepuscular state of consciousness, and manifested notable gestural behavior by appearing restless and trembling, and she moved her hands theatrically to her ears, as if responding to the reported auditory despairs; at times she cried. She kept the examiner’s gaze for short periods of time and sometimes closed her eyes, as if to escape the reported terrifying visions. There was hys-terical deafness which made her poorly accessible to the interview, which was therefore mediated by her mother, who was present and communicated with the patient via text messages or by silent alphabet. The patient reported the distressing presence of auditory and visual disperceptions (“frightful voices in my ears”; “there are crows who want to hurt me”).
Infusion and intramuscular therapy were carried out: Delorazepam 4 mg iv in fs 100 cc; Aripiprazole 7.5 mg IM., during which the patient took on an arched pose that she kept in a flexible manner. This clinical picture only receded after 30 minutes; she seemed quieter and more accessible to the interview, being able to answer the questions, expressing herself in a feeble and puerile voice, with a childish behavior. No sindicative logical-formal disturbances of thought emerged, the mood was labile, oriented towards the low polarity, and without the reported self -harm ideation. She superficially criticized the previous self-harm gesture. She expressed an ambivalent feeling (fear/desire) towards hospitalization.
Diagnostic hypothesis: hysterical paroxysmal access.
Discussion
An intriguing aspect of this clinical case is the symbolism of the raven.
In the poem “The raven”, by E.A. Poe [1], dedicated to the young wife who disappeared, a crow visits the woman, symbolizing the message of passing.
In Goethe’s [2] “Faust”, two crows are represented on Mephistopheles’ shoulders, symbolizing his messengers.
In a poem by the Russian symbolist Mandel’stam [3], the crow represents a messanger: “The calling of the crow and the harp comes to mind in the gloomy silence; I re-ceived a blessful heritage: the wandering dreams of other poets”.
Van Gogh [4] represented gloomy black crows flying over a cornfield in one of his last paintings, just before his suicide.
In Norse mythology, two crows are Odin’s servants, they informed him of the mundane events. One is Hugin (thought) and the other is Munin (memory) [5].
In Greek mythology, the raven is present on the bust of Athena, the goddess of wisdom; representing intelligence, the raven is the messenger of truth [6].
The figure of the crow, therefore, represents an archetype, which in the various traditions and in art takes on the meaning of messenger, or symbolizes metamorphosis, the transformation from one state to another: life/death, girl/woman; girl/mother [7].
The passage to motherhood is a crucial event in the patient’s life. “When black crows give birth to white doves in your house then you will be called wise.” This inscription appears on the alchemical door of Piazza Vittorio in Rome [8].
The language of hysteria is the language of images, symbols, metaphors, and myths, of “pars per toto”. This analogical language/thought contrasts with the logical, an-alytical language of conceptual reason [9,10].
The psychiatrist should let the fantasies and images of the psyche of hysterics emerge, rather than translating them into a rational, descriptive and categorized language, they should be allowed to evoke archetypical images, that are universally shared. By doing that, the individual unconscious would be reconnected with the collective imaginary of archetypes, myths, as Jung taught [11,12].
It is necessary to listen and interpret this language ac-cording to an analogic approach which is intrinsic to the psyche’s structure. Such symbolic language, like the one of dreams, is made up of words-things, words-images. The symbol itself makes sense. The psychiatrist has to employ a listening attitude (epochè), catching what spontaneously comes from the patient’s unconscious. In other words, the image told by the patient must be conveyed in the least prej-udicial way, only then it will start to communicate some-thing meaningful.
What emerges, by applying this type of approach, is an orientation that assimilates mythology and psychopathol-ogy. This way psychopathology regains its own approach through images, integrated with the psychic reality [12-14].
The analogical/symbolic approach makes it easier for the psychiatrist to get in touch with the mental suffering of the hysterical patient. Regarding the therapeutic value of the alchemic language, this approach also gives the psychiatrist the possibility of understanding its inner meaning and return it clarified to the patient, through an archetypical im-age [13,15].
Hysteria is apparently as old as humanity. Hence, by over 4000 years ago, as texts of ancient Egypt document, there was knowledge of hysterical symptoms, described as: convulsions, functional paralysis, anesthesia, sexual frigid-ity, hysterical bolus, etc.
Plato talks about hysteria in Timus. Additionally, Hippocrates describes about 600 symptoms leading to hys-teria, and distinguishes it from epilepsy. Celso, Galeno and Boerhaave reported descriptive pictures of hysteria and discussed its causes.
In the 19th century, Charcot [16] defined hysteria as a disease of psychic origin and nature (in the absence of an organic lesion of the nerve, marrow, or brain) often deter-mined by emotions (previous psychic trauma), influenced by the suggestion, isolation, and moral treatment, the latter introduced by Pinel.
Mobius [17] and Strumpell [18] claim that Hysteria is a “condition of representation” manifesting as a flaw of normal representation.
Janet [19] talks about “flaws of capacities of personal synthesis”, namely a “narrowing of the field of consciousness” (dissociative/crepuscular).
The lowering of the state of consciousness allows one to reach deeper levels of the psyche (the unconscious). Hys-terical psyche simulates and acts in the deepest sense of “Mimesis”, representing itself, realistically, and providing the material to interpret and decode psychic discomfort, ex-actly as it occurs for each symbolic language, which draws fromthe collective unconscious [11,12].
Conclusion
The authors encourage the psychiatrist to decode sym-bolic aspects and language of hysterical psychosis by using an integrated approach which unveils the unconscious from the patient’s psyche and reconnects it to the collective imag-ination made of archetypes and myths. This orientation assimilates mythology and psychopathology.
Acknowledgment
The authors wish to thank the patient for her collaboration, and Mrs Piedimonte F. for her precious help with the English language, and Dr. Sanè-Schepisi M. for her precious help in the Spanish translation.
Availability of Data and Materials
Not applicable.
Author Contributions
FdM: acquisition of data; preparation of the manuscript; discussion, editorial changes. FR: discussion and revision. Both authors read and approved the final manuscript. Both authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Ethics Approval and Consent to Participate
This manuscript is a purely clinical observational study that does not involve intervention other than routine medical care and can receive ethical exemption. Full written informed consent was obtained from the patient and anonymity was preserved according to the PTV ethical protocol.
Funding
This research received no external funding.
Conflict of Interest
The authors declare no conflict of interest.
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