Mass psychogenic illness -- The social role

Like the way "stage fright" can cause nausea, shortness of breath, headache, dizziness, a racing heart, a stomachache or diarrhea, our body can react strongly to other stressful situations. Outbreaks of mass psychogenic illness show us how stress and other people's feelings and behavior can affect the way we feel.
In July, the whole nation observed how a so far unfamiliar disease has wracked the nation with panic. On July 11, 21 students of Aliabad Islamia High School and College, Narsingdi, suddenly developed convulsions, but recovered within 30 minutes. The same thing happened on July 14, when 28 more students experienced the illness.
Subsequently, it spread to Ashulia, Narayanganj, Rupganj, Magura, Bagherhat, Satkhira, Gazipur, Natore, Barisal, Jhalokathi, Jhenidah, Khagrachari, Faridpur and Chapainabaganj, making the whole nation stupefied. Since July, the total number of cases, as reported countrywide, is 550 (Xinhua, August 2). Experts opine that it is "mass psychogenic illness" (MPI), not a new event in Bangladesh but so far it had remained overlooked and unnoticed in our vast backward community.
Mass psychogenic illness occurs when groups of people (such as a class in a school or workers in an office) start feeling sick at the same time, even though there is no physical or environmental reason. MPI has occurred for hundreds of years, all around the world and in many different social settings.
Less recorded, but probably a lot more common than we realize. There is collective human behaviour, which produces different kinds of activities and phenomena (Kerekhoff, 1968). These include crowd or mob behaviour, panics, crazes and fads. These types of behaviour often occur under stress or when the ordered reality of a culture or group is disrupted (Conner, 1989).
Mass hysteria illnesses have been found throughout history (Sirois 1982). Hippocrates in 400 BC introduced the Greek term "hysteria," meaning illness caused by a wondering womb. During the middle ages, outbreaks of mass psychogenic episodes, called the St. Vitus's dance, were common.
The twitching accompanying this illness was considered a curse due to sinfulness. Later, in early colonial America, illness among young girls in Salem was attributed to witches' curses (Pennebaker, 1982). Twentieth century examples of this phenomenon have been generally found in factories, workplaces, and schools.
Outbreaks of mass psychogenic illness usually start with an environmental "trigger." The environmental trigger can be a bad smell, a sound, a suspicious-looking substance, or something else that makes people in a group believe they have been exposed to a danger. After the triggering event, many of them begin to experience signs of sickness at the same time.
Mass psychogenic illness is characterized by symptoms occurring among a group of persons with shared beliefs regarding those symptoms, that suggest organic illness but have no identifiable environmental cause and little clinical or laboratory evidence of disease.
They can spread rapidly through apparent visual transmission, and may be aggravated by a prominent emergency or media response, but are frequently resolved after patients are separated from each other and removed from the environment in which the outbreak began.
Children and adolescents are frequently affected (Boss, 1997), and the phenomenon commonly involves groups under stress (Philen et al, 1989). Females are often disproportionately affected (Boss, 1997). From 1973 to 1993, one half of the reported outbreaks of psychogenic illness occurred in schools, followed by factories (29%), towns and villages (10%), families and other institutions.

Predominant symptoms
MPI manifests itself with the occurrence of headache (67%), dizziness (46%), nausea (41%), abdominal pain (39%), fatigue (30%), convulsion (23%), sore throat (19%), difficult breathing (13%), watery/itching eyes (12%), chest pain (11%), trouble in thinking (10%), vomiting (10%), tingling/numbness (10%), anxiety (8%), diarrhoea (7%), trouble with vision (7%), rash (4%), loss of consciousness (4%) and itching (3%) (Source: Timothy FJ, 2006).

Common characteristics of MPI
Often exposure to an environmental trigger (e.g. odour, rumour, emergency response) precedes MPI. Those at risk are females, adolescents and children, and patients with psychological or physiological stress. The causes may be boredom, or perceived boredom, a felt lack of emotional or social support, victims often knowing each other or moving in the same friendship circles; the symptoms spread by "line-of-sight" transmission (i.e. seeing or hearing of another ill person causes the symptoms).
MPI has unique characteristics; the symptoms spread and dissipate rapidly, they are associated with minimal physical or laboratory findings, no environmental changes in scientific tests may recur with return to the environment of the initial outbreak, but they may escalate with vigorous or prolonged emergency or media response, and the victims may experience shortness of breathing and syncope (Grundy SM, 1997).

Events of mass psychogenic illness in the past
Biting and dancing manias that spread throughout parts of Europe between 13th and 17the century.
* In 1981, in a school in Montreal, Canada, 500 students aged 13-14 years fainted.
* In 1983, in the West bank of Gaza, more than 900 people, mostly schoolgirls, lost consciousness following a rumor of gas poisoning.
* In 1988, in a military school in USA, 375 were evacuated for medical emergency because of MPI.
* In 1991, 26 girls in a school in Iran developed psychomotor syndrome.
* In 1996, in a large fish-packing plant in New Brunswick, Canada, 208 people were affected by MPI.
* In September 1998, almost 800 young people in Jordan had suffered from mass psychogenic illness following tetanus-diptheria toxoid vaccination.
* In November 1998 in UK, a teacher noticed a gasoline-like smell in her classroom, and she along with 80 students and 19 staff members developed MPI.
* On December 18 2001, 234 children at a primary school in Ca Mau City in Vietnam received the cholera vaccine and 97 were affected by MPI.
* In 2003, a 31-member family displayed mass hysteria in East Delhi, India.
* In April 2007, 600 girls in a Mexican boarding school suffered collective hysteria.

Recommended approach to patients with MPI
* Attempt to separate persons with illness associated with the outbreak.
* Promptly perform physical examination and basic laboratory testing to exclude other causes.
* Monitor and provide oxygen as necessary.
* Minimise unnecessary exposure to medical procedures or other potential anxiety-stimulating situations.
* Notify public health authority.
* Promptly communicate the results of the laboratory and environmental testing.
* While maintaining confidentiality, propagate the message that cases are improving.
* Acknowledge that the symptoms experienced by the patients are real.
* Explain potential contribution of anxiety to the patient's syndrome.
* Reassure the patients.
* Encourage the media to show the real scenario, not to create panic.
* Create social awareness.
In a previous era, spirits and demons oppressed us. Although they have been replaced by our contemporary concern about the fear of invisible viruses, chemicals, toxins, the fears of social origin remain the same. Mass Psychogenic Illness is a social disorder, the outcome of deprivation, social norms and taboos, faulty child-rearing practices, rigid religious and cultural beliefs which manifest themselves as psychogenic expressions which can only be dealt with by appropriate social behaviour, media campaign and mass awareness, to prevent further onslaught in our society.
(I gratefully acknowledge the valuable suggestions of my friend Dr Abdullah Al Mamun, Head, Department of Psychiatry, DMCH).

Dr Zulfiquer Ahmed Amin is a physician, and a specialist in Public Health Administration and Health Economics.