In view of the suggestions that classical hysteria is decreasing in incidence in urban Western society, and that the pattern of symptomatology changes with the cultural milieu, the author considered that a study of his current experience in Seoul, Korea would be of some general interest.
The records of 50 in-patients diagnosed and discharged as hysteria at the Seoul National University Hospital Department of Psychiatry between the periods from 1958 to 1963 were studied. Among the 50 hysteria patients, 42 were diagnosed as conversion reaction and 8 dissociative reaction. Of the 50 patients, several of them were re-admitted and discharged and the total number of discharges of the 50 patients counted in were 56. This is 5.44% of the 1,030 discharges from 1958 to 1963. Thus, hysteria was found to be relatively frequently diagnosed among its in-patients in Korea in comparison to the findings, for instance, of the Johns Hopkins which revealed the cases of hysteria to be 1.84% of the 2,873 patients discharged between 1945 and 1960 and 2.14% of 2.661 patients discharged from 1913 to 1920.
About one-half of our conversion patients had classical hysterical symptoms in terms of "loss of function" and "hystero-epilepsy" and only in 2 of the 42 conversion patients the predominant symptom was pain alone. Thus, in Korea, the "classical" symptoms are the most common expression of the illness at the present time and this makes a contrast to the urban Western society whose reported most common and persistent complaint is pain. The patient appeals for help with pain whereas the patient with loss of function or hystero-epilepsy need not to do so since the symptoms speak for themselves. This variation of clinical reaction may have some bearing in the cultural difference with the suggestion that loss of face is the basic important factor to Koreans.
All of the 50 patients studied were female and a significantly greater propertion of them were either the oldest or the oldest girl in the family than would have been expected by chance alone. This is another interesting point of Korean hysteria patients in contrast to the Western patients of whom many were found to have occupied the position of the youngest child, or the youngest child of one sex in the family. In Korean cultural milieu where the female are emancipated only on legal level and their sex more strictly inhibited than male, a mother is expected to give a birth to a first son. A mother too wants a first son not only for her emotional satisfaction in him but because it is only as a mother of a first son or sons that she gains status in an Oriental extended family system. When the first born is a girl, the infant naturally suffers from overt and covert affectional deprivation. The postulation is that such experience as a little girl and growing up in this cultural milieu gives rise to a shifting role and difficulties in role stabilization in her later life.
Including the foregoing impressions, above all, our attention should be directed to the fact that hysteria is very frequently diagnosed in Seoul, Korea. Some anthropologists and psychiatrists have classified cultures as "shame" and "guilt" cultures. It is also suggested thats in the Orient, where the threat of loss of face in all its myriad ramifications is so central as a sanction, some of them concluded that the sense of guilt or sin is practically absent. The reasoning is that to exhibit anxiety meant a loss of face to the Orientals, whereas classical hysterical symptoms such as loss of function or hystero-epilepsy were face-saving. Quite keen observations as they are, they, including the suggestion such as Orientals "superb oral hold on life," do not solve the fundamental and important philosophical differences lying between the two cultures and different ways of clinical manifestations in response to different stresses. The answer to this fundamental question is crucial in understanding the cultures and the penetrating insight has been achieved by the author of "The Meeting of East and West," Prof. F.S.C. Northrop of Yale.
Northrop summarizers the meaning of Oriental civilizations as follows : -The Oriental portion of the world has concentrated its attention upon the nature of all things in their emotional and aesthetic, purely empirical and positivistic immediacy. It has tended to take as the sum total of the nature of things that totality of immediately apprehended fact which has been termed the differentiated aesthetic continuum. Whereas the traditional West began with this continuum and still returns to local portions of it to confirm its syntactically formulated postulational prescribed theories of structures and objects, of which the complex aesthetic continuum are mere correlates or signs, the East tends to concentrate its attention upon this differentiated aesthetic continuum in and for itself for its own sake.
He then refers to Confucius’ teaching of the three means for the good life; (1) chih, arrived at by ch’eng, i.e. positivistically given "realness," or truth; (2) jen, the indeterminate, aesthetically felt, passionately warm man-to-man-ness, continuos with and hence common to all things which realness exhibits and truth designates: and (3) courage or fortitude, to which, Confucius says, the "sense of shame" is akin.
He continues and refers to our central problem : The precise character of this sense of shame must be grasped if the concrete behavior and psychology of Oriental people are not to be misunderstood. This sense of shame is experienced by the Oriental in two forms : One, when, treating jen, tao, Nirvana, or Brahman as though it were a determinate transitory thing, he denies it: or, two, when, treating a determinate, transitory things or plan of conduct as though it were a non-transitory, immortal principle, he commits himself to it for the future, for a time longer than the circumstances inherent in all transitory determinate things will warrant. It is the latter sense of shame which is at the basis of the Orental’s "loss of face." This shame is nearer to chagrin, the chagrin at failing to remember the most elementary truth drilled into one by centuries of teaching; the truth namely that all determinate things are transitory. It is also the fear of the latter sense of shame which is behind the Cantonese rickshaw boy’s response with an indefinite wock jeh (Perhaps!) instead of a determinate "Yes, Sir" ; and the traditional Oriental aristocrat’s hesitation to commit himself to any determinate line of conduct for the future, unless plenty of bridges have been left standing behind so that he can retreat gracefully, should altered, circumstances tomorrow make the proposed determinate plan less wise than it seems today.
From the foregoing, a newer and real understanding of the ambiguous usage of the terms such as "shame, guilt, loss of face, oral paradise, absence of sin, relativistic moral, shifting role and dissociation rises and hence clearer understanding of the meanings of the present investigation. There may be still another factor should be included in considering the relative abundance of hysteria in Seoul, Korea. The country is "dissociated" into the South and North and there is a constant military threat from the North. Accordingly, the mechanism of dissociation may provide considerable psychological protection for the people of Seoul whose present day life is under the constant threat and tension. When one studies the psychopathology of any society, he should be equipped with thoroughgoing anthropological understanding of a given community and he should be warned by a statement like "the mental illness in this society shows no difference in its incidence and psychodynamics from that of any other society."
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