Book Review

The following book review was written by Dr. Ellen Goudsmit, a Dutch psychologist who has studied both hysteria and CFS. Dr. Goudsmit is currently editor of the ME and CFS Medical Update. She also writes articles for InterAction, published by Action for ME, and the ME Association, Kingston and Richmond Group. You can see some of these articles on this web-site.

Showalter, E. Hystories. Hysterical epidemics and modern culture.

London: Picador. Hb. 244 pp. £16.99

Elaine Showalter is a professor of English with an interest in medical history. She has a formidable reputation as a writer and scholar following books like "The Female Malady" which discussed mental illness in women from 1830 to 1980. In Hystories, she narrows her focus on twentieth century forms of hysteria. She reminds us that hysteria tells a story, that it is a form of body language; a way in which people express their emotional distress when unwilling or unable to use words or deeds. She emphasises that it is not a sign of weakness or irresponsibility but a cultural symptom of anxiety and stress. Particularly common among the uneducated and inarticulate, it used to manifest itself in symptoms such as deafness, blindness or paralysis.

Showalter's thesis is that the hysterical disorders of today have different symptoms and that the epidemic forms are spread by the media. What apparently happens is that vulnerable personalities read about an illness and then unconsciously develop those complaints. Once developed, the condition is perpetuated by sympathetic doctors, self-help groups and further publicity. Among the "psychogenic syndromes of the 1990s" she discusses are: alien abduction, multiple personality disorder, satanic ritual abuse and surprisingly, CFS and Gulf War syndrome.

Space does not permit me to discuss all these phenomena except to say that I share her scepticism about alien abduction and satanic ritual abuse. I also accept that some cases of multiple personality disorder may be a by-product of therapy. However, the first two aren't illnesses, so I'm not sure why they've been included in this book. According to DSM-IV (the guidelines for the diagnosis of psychiatric disorders), somatisation disorder (as hysteria is now known) refers to physical symptoms which are not related to disease. Stories of alien abduction and ritual abuse may be a result of fertile imaginations, but this does not amount to hysteria in the medical sense of the word.

This brings me on to the more controversial chapters in the book.

Showalter's claim that CFS is a modern form of hysteria is primarily based on the following 'evidence':

One anecdote of a patient cured by a faith healer.
One anecdote about a CFS patient suffering from depression.
Simon Wessely's view that CFS patients look down on psychogenic illness.
The view that patients have no objective clinical signs of disease except for low grade fevers and swollen glands.
The view that there are no consistent neurological or cardiovascular abnormalities.
Her belief that no one has died from CFS (except through suicide).
The observation that symptoms tend to fluctuate.
The presence of a large number of symptoms in addition to fatigue.
A claim that the illness is commonly seen in the upper social classes and in younger people. The fact that it also affected individuals in Hollywood.
The observation that an outsider who met patients thinks that psychological factors play a role (Jon Kaplan).
The fact that early American reports suggesting Epstein Barr virus or retroviruses as the cause turned out to be incorrect.
The fact that no single cause (bacteria, virus, chemical) has been identified.
One study which revealed that patients led frantic lives before they became ill.
The angry reaction of the audience who took part in the Rantzen Report when former GP Thomas Stuttaford claimed that depression was the cause of ME. (The implication here is that their anger is proof of their prejudice against mental illness, not an indication that Dr. Stuttaford might have been wrong).
The claim that patients won't try antidepressants or psychotherapy.
A quote from Dr. Dowsett (source unclear) where she apparently advocates 'total rest'.

To put it another way, Showalter regards CFS as a hysterical condition because scientists have not found a single organic cause, because patients refuse to think what some doctors want them to think, because a number of patients show signs of emotional distress and at least one may have been suggestible, because some were very active prior to their illness (i.e. they needed the rest, evidence of secondary gain), the prevalence amongst the upper classes (they can afford the time off), her claim that it doesn't kill and the large number of subjective symptoms (also found in anxiety/stress, another link to hysteria).

So what are the facts which she uses to back-up her claims? Well, the first thing one notices is that there aren't a lot of those. Indeed, the majority of the supportive 'evidence' doesn't even come from scientific texts. Here are the stats: out of the 54 references she cites, 21 are from medical publications. They represent eight separate sources - mostly reviews - of which six were written by Simon Wessely or those who agree with him. The only counter arguments were provided by Drs. Komaroff and Bell (six citations from two sources, no original research). The rest of her 'evidence' is taken from newspaper cuttings (including the ever reliable Evening Standard) and glossy magazines. She also quotes from books written by patients, but she uses them primarily to illustrate their anger (i.e. over-emotionality, a sign of hysteria), and rejection of the psychological explanation (the implication being that their narrow-mindedness did not enable them to express their emotions in the normal way, as anxiety, depression etc.) What Showalter tries to show is that CFS is the body language for 'I need a break, I need attention, I need a rest'.

As someone who has studied hysteria for many years, I found this all highly unconvincing. Basically, Showalter's interpretations are incredibly biased and amateurish. This is pop psychology at its worst. For instance, just because one person was cured by a faith healer, one can't conclude that every person with CFS is suggestible. And just because this illness was common in Hollywood, one cannot deduce that it only affects the decadent, with more money than sense. As sociologist David Mechanic has pointed out, if CFS was just an excuse for those needing a rest but not able to articulate their wishes using words, there are easier and less incapacitating ways to get what one wants. He also questioned why so many well educated and articulate patients would choose such an inefficient solution. I agree. In the past, hysterical disorders resembled uncontroversial physical diseases, not conditions thought to be psychiatric. Moreover, they did not persist unless they were reinforced by 'secondary gains', e.g. attention, a significant reduction in emotional distress etc. Contrast this with the consequences of having CFS: the doubts, the disbelief, the stress of the symptoms, the fight for benefits, the lack of support etc.

In fact, Showalter actually contradicts herself. In earlier sections, she notes how hysterical epidemics are perpetuated with the help of sympathetic doctors. Yet in the chapter on CFS, she acknowledges that many physicians don't accept CFS as a disease. So given that there is a dearth of understanding doctors and since society as a whole is also pretty sceptical, who then is reinforcing the hysteria? Does the odd positive item in the papers make up for the mountain of offensive and stigmatising features? Does a kind word from a fellow patient make people forget the lack of support from family and friends? I doubt it!

Another argument against Showalter's theory comes from research. There have been many studies which have looked for somatisation disorder in patients with CFS. To date, the consensus is that only a minority are affected and that these tend to have an atypical form of CFS. Suffice to say, you won't find this information in the book.

Aside from the unreliable sources and the curiously one-sided discussion of the issues, Showalter sometimes gets her facts wrong. For instance, she states that no one dies of CFS but this is not true. Admittedly, fatalities are rare, but they do occur. She also makes a mess of the Royal Free epidemic in terms of who became ill and when. It makes one wonder who checked her manuscript.

Given that there is little evidence which actually supports her thesis, Showalter has to resort to good old fashioned reductionism and the mind/body split. Indeed, her theory is largely based on the following reasoning: if it ain't physical, then it must be psychological and to be physical, pathology must be detectable in every patient. All Prof. Wessely's comments about multifactorial causes clearly passed her by. And even though she was told by top notch sceptic Dr. Stephen Straus that CFS was "a mixed bag of entities" (p. 130), she obviously didn't realise the significance of this. Indeed, the simplicity of her reasoning proves, if proof were needed, that the analysis of modern medicine requires a scientific background. This is no terrain for English professors, however eloquent and well-meaning they may be.

Since CFS doesn't seem to be a single entity, it is of course ridiculous to be hunting for a single cause. It also means that scientists no longer expect to find "consistent abnormalities" on neurological and cardiovascular tests, particularly when studying heterogeneous groups. Anyone else would have noticed the evidence of pathology in subgroups and adapted their arguments accordingly. Science and medicine is all about changing theories to fit the evidence. However, Showalter is not so ambitious. She's happy with any bits of information which appear to support a psychological cause and simply ignores the rest. This is not what one expects of scholars, and especially not of those with Showalter's experience.

Let's imagine for a moment that she'd adopted a more objective stance. Citing a number of reasonably sound studies, she could have argued that hysteria was relevant to a subgroup of patients with chronic fatigue. This wouldn't have been particularly controversial, and her once formidable reputation would still be intact.

Finally, some minor points. Firstly, I'd like to challenge her claims of the universal prejudice against mental illness and a mass resistance to psychotropic drugs. Ironically, one of the few studies which she actually cited not only revealed frantic lifestyles, but also some very positive attitudes towards the role of psychological factors in CFS. Secondly, if publicity is the main source of the current 'epidemic', why has the incidence of PVFS/ME fallen since 1991? And since when are fluctuating symptoms a sign of hysteria? Many symptoms reported by people with MS and rheumatoid arthritis fluctuate as well.

Alas, the chapter on Gulf War Syndrome (GWS) is not much better. Out of 38 references, only one is from a medical publication (JAMA). The rest of her evidence is taken from the likes of the Guardian, Life and Esquire.

As with CFS, Showalter doesn't think that the patients are lying; they're just not telling the truth. In this case, the real problem is probably "war neurosis" and patients are doing themselves no favours by denying this. The growing evidence relating to vaccinations etc., are dismissed as 'rumours' and again there is the uncritical acceptance of anything supporting a psychological cause. The chapter left me with the following thought. If GWS is a result of stress (the heat of the desert, "the cumbersome protection suits" etc.), why did it not affect the soldiers from countries such as Holland and France? Are the Dutch and the French better able to deal with heat or the fear of death? And why is GWS the only 'neurosis' which seems to be associated with higher rates of cancer and birth defects?

This is a truly sad book. Many who admired her previous work will find it hard to believe that the same person could write something so unscientific, so reliant on newspaper cuttings, so selective and so uncritical of psychiatry. From the perspective of psychological medicine, the sections on CFS and GWS are amateurish psychobabble, the kind one expects from charlatans. I can understand how reviewers like Ruth Rendell, who have no specialised knowledge of CFS or GWS, might be convinced by Showalter's arguments. However, it won't impress scientists or anyone else interested in balanced and accurate descriptions of medical information. In short, this is not a book which advances our understanding of hysteria or chronic fatigue syndromes. My advice: spend your money on something else.

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