“She was hysterical!” Women and the politics of Mental Health.

Ihave had the misfortune of encountering several men (and women) who have called me ‘hysterical’ or ‘too emotional’ at the slightest provocation. I refer to debates with men who claim to be guardians of a country’s cultural fabric- which is somehow solely contingent on a woman’s uterus. I also talk of the generation that cannot fathom how people younger than them can have a different opinion, or the army of ‘trollers’ behind screens, who have miraculously discovered and hackneyed the word ‘triggered’. And lastly, a person of significance who discredited grief by claiming that women may derive pleasure from hysteria. Let us put this mystery to rest, once and for all. Why are women so hysterical? They can be so many other things- sensitive, passionate, pained, distressed. Why hysterical?

The term ‘hysteria’ comes from the word ‘hustera’ in Greek, which translates to ‘womb’ in English. Unsurprisingly, it was first used in Greek and Egyptian descriptions of mental disorders, which supposedly arose from some form of imbalance in the uterus. Melamphus, a Greek physician, called it the ‘Uterine Melancholy’; which is a fancier take on ‘Sexually frustrated’. As endearing as that term is, physicians throughout the middle ages up until a few centuries ago considered hysteria a common illness. Thomas Sydenham, a British Physician in the 1600’s, believed that hysteria (supposedly caused by irregular motions of the animal spirits) was the second most common malady of the time after fevers. However, despite the many winds of change that affected the psychiatric community in history, the causes and cure of hysteria remained under-propped by sexual meanings. Physicians believed that they could be cured with pelvic massages, high-pressure showers, or an “electromechanical medical instrument” (a vibrator). Perhaps, the content of this article reeks of historical amusement as if it happened in some archaic coffee stained film where women wore kirtles. But it was not until 1980 that the American Psychiatric Association dropped the term ‘hysterical neurosis’ from the DSM-III (Diagnostic and Statistical Manual). It would be tempting to conclude that we had suddenly and completely slipped out of gender biases in mental health. However, the (now) President of the United States of America in 2004, discussing Lindsay Lohan, jokingly asked, “How come the deeply troubled women, you know, deeply, deeply troubled, they’re always the best in bed?” And so, on went the whimsical stories of damsels in distress.

While we’re on this page, one disorder that requires focus is Borderline Personality Disorder. Characterized by intense emotional dysregulation, a damaged sense of self, and volatile interpersonal relationships, BPD is disproportionately over-diagnosed in women. The female to male ratio of diagnosis in multiple studies is 3:1, which is significantly uneven for any psychological disorder. However, contemporary studies attribute these differences to sampling bias, which means that the atypical characteristics of the chosen sample may distort results. Therefore, if one is determining gender differences in the diagnosis of BPD in a clinical population, chances are that the results may not generalize to a non-clinical population. This is because other factors such as disproportionately more women even showing up for clinical diagnosis may be important. Another debated issue in diagnosing BPD in adults is child sexual abuse. While it is not an essential marker for BPD, research suggests that somewhere between 40–70% of people with BPD have experienced childhood sexual abuse. More so, one 2014 study suggests that 40% women with mental illnesses have suffered sexual abuse, and around 69% reported some form of domestic violence. And despite what the flag-bearers of Men’s Rights Movement in India tell you, the statistics are massively skewed towards one gender in this case.

A better-known psychological illness in today’s day and age is depression. Like BPD, even in depression, there exists what Harvard Health Publishing calls a ‘gender gap’. But unlike BPD, the proposed reasons for the same accompany more research. While depression does involve intense sadness, it is much more than having a rough couple of days. Depression can look like a lot of things- hopelessness, loss of interest in once favored activities, decreased self-worth or perhaps, an overt semblance of normalcy. Women are twice as likely as men to be diagnosed with major depression. Some clinicians believe that this may be due to gender roles and corresponding ‘normal’ behavior. A survey of heterosexual romantic couples suggests that while 73.5% of women share their diagnosis with their partners, only 52% of men do the same. Men are less likely to present themselves as ‘vulnerable’ or ‘in need of social support’. Having said that, it would be unfair to discredit other possible factors like specific genetic mutations in women, hormonal changes across the lifespan (puberty, menstruation, pregnancy, and menopause to name a few) and lastly, unfortunate gender biases in other areas(sexual abuse, poverty, caregiver stress etc) that may contribute to depression in women.

However, the dynamics of gender are not always tilted towards over-diagnosis among females. A flip-side is when women are under-diagnosed for certain disorders in which symptoms are gender typed. One such disorder is Autism Spectrum Disorder. Persistent deficits in social communication and interaction, restricted and repetitive behaviors, and sensitivity to sensory stimulation are common specifiers for autism in DSM 5.

Sharing her story with the National Autistic Society, Rosanna Rosetti talks about living with autism as a woman, “When I go to a café, I like my latte a certain way. I’ve had full-blown meltdowns because the barista thinks I’m being awkward and refuses to make me a ‘warm’ latte. I can’t stand how this makes me feel, but to them I’m just being difficult and should get out of the way.” An artist, Rosetti uses Russian dolls to visually present her story, “Russian dolls are traditionally female, they also appear to be hiding within one another. This I thought represented how some autistic women and girls attempt to conceal their behavior and autistic traits by hiding them from plain sight.”

Individuals with autism struggle to read social cues that may seem effortless for others to apprehend. For instance, perceiving a change in the dining schedule, or socializing at the work place. The reason women are massively under-diagnosed for autism may have something to do with the expectations we place on them. Women are more likely to act in a neurotypical or socially conventional manner — usually exerting more effort in learning to act socially. If you’re familiar with shows that have released in the past decade, you may remember Sheldon Cooper from The Big Bang Theory. The behaviors depicted by the character are very similar to individuals with autism, and with superior intelligence (Yes, both can occur together and are not exclusive). Sheldon was obsessed with routine, structure and regularity. He also had his favorites- trains!

Dr. Claire Jack, a therapist who works with women with ASD, mentions that instead of things, women are more likely to invest in people, especially romantic partners. It is also common to find women with ASD focusing much more on celebrities and bands because obsession with ‘people’ is considered more ‘normal’. However, ‘masking’ their discomfort is not beneficial to their quality of life and costs much more than a diagnosis. They are likely to be diagnosed with depression and anxiety, possibly due to the double-edged sword of trying to hide distress, and coping with a neurotypical world. Like men with ASD, women are also frequently exhausted with the pressures of keeping up with the social needs of their environment.

Another flip-side of the discourse is the paradoxical bias towards diagnosis of physical illnesses. A growing body of research in healthcare calls this bias an implicit bias– unconscious biases that are usually not linked to consciously held prejudiced attitudes. In this complicated maze of diagnoses of various mental illnesses, women also seem to face biases in diagnoses of physical illnesses. A 2015 study revealed a longer lag time from the onset of symptoms to diagnosis in female patients in six out of 11 types of cancer. A 2013 study concluded that more than twice as many women as men had to make more than three visits to a primary care doctor in the UK before getting referred to a specialist for suspected bladder cancer; and nearly twice as many with renal cancer.

Maya Dusenbery, author of ‘Doing Harm’ writes, “I heard from dozens of women with a range of conditions who, at some point during their search for a diagnosis, were told that their symptoms were due to anxiety, depression, or that all-purpose catch-all: “stress”. In fact, studies in the 1990’s (on which we unfortunately rely for most undergraduate syllabus) suggest that as many as 30–35% of women were misdiagnosed with depression and many more are misdiagnosed with personality disorders such as BPD.

In the six years of my higher education in Psychology, I have often found discourses to be absent of political fervor. The politics of gender, culture, religion, caste, class and policy-making seem to become subaltern discussions. It is good practice for psychologists to not merge the personal with the professional. My political opinions must not make their way into my counselling room, and the dissonance between my client’s views and mine must not disrupt the session. Having said that, psychology, like any other field of expertise, does not exist in vacuum. It is impacted by social, economic, and environmental forces. It is not my business to ‘correct’ my client’s political opinion. However, when political forces impact how my 13-year-old client gets discerned by religion, it is my business. when a 24-year-old woman does not understand why she has always found it difficult to interact with people, it is my business. And when a 50-year-old woman is sent to me with suspected symptoms of hypochondria when her doctor dismisses a headache, politics become my business as well. Someone asked me, “Can Psychology remain apolitical?” Going by the dominant pattern of practice, the simple answer is “Yes”. But I say this with utmost confidence that the subject has only taught me to continue introspecting, inquiring and reflecting. Therefore, I suppose the real question is, “Psychology CAN stay apolitical, but should it?”