To activate Hysteria, Alice must be near "the edge of sanity," to be on her last health Rose. However, if Alice is in the Fleshmaiden dress, she can enter Hysteria at anytime, disregarding the amount of health she currently holds.
When Alice enters Hysteria, she screams, sending a deadly sound-wave. All of Wonderland is seen through a gray slate, and Alice herself gains new-found superhuman strength and temporary invincibility. This phase also removes the heat-up effect on the Pepper Grinder.
Alice is all in white (except her black hair and eyes), and appears to have blood running out of her eyes and mouth. Her arms are stained with red, her dress has a hole on her breast (Resembling a gunshot wound) and is stained with blood, and her Omega necklace changes to the astronomical symbol for Pluto. Her weapons become twice as violent, the Hobby Horse seems alive with vengeance and the Vorpal Blade is soaked in fresh blood from some new killings.
Hysteria is a term used to describe unmanageable emotional excesses. People who are "hysterical" often lose self-control due to an overwhelming fear that may be caused by multiple events in one's past that involved some sort of severe conflict. As Alice enters Hysteria only when she is close to death, this state could be caused by a fear of dying, or a fear of losing in a fight.
Diamond Select Toys released a posable figure of Hysteria Alice in their Alice: Madness Returns line. While it was not included in the case assortments with Alice, Cheshire Cat and Card Guard, it was sold individually to comic shops and specialty stores via Diamond Comic Distributors' Previews catalog as a catalog exclusive. It comes with a bloody Vorpal Blade as well as deep red versions of the Pepper Grinder and Hobby Horse.
There are some mild differences between the Hysteria figure and the game edition, such as the fact that Alice is wearing her original Omega necklace rather than the astronomical symbol for Pluto. This is due to the fact that all editions of the Alice doll are created with the same mold, but painted differently. The same problems are present in the Royal Suit edition of the figure.