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A history of mass hysteria

Mass Hysteria: Introduction


Periodically throughout recorded history, puzzling instances of psychiatric and neurologic symptoms have presented
en masse: outbursts of thrashing and screaming, or jerky spasms and abrupt vocal tics affecting a group of
individuals at once and often attributed to causes like possession, witchcraft, and malingering. Such occurrences of
so-called "mass hysteria" continue to confound the medical community, but growing experience has improved the
understanding and approach to these seemingly contagious psychogenic events. Episodes of mass hysteria cross
many scientific disciplines and are of interest to emergency physicians, epidemiologists, psychiatrists, psychologists,
and those who study behavioral, environmental, and occupational health.[1] The following slideshow explores some
of the more prominent and interesting instances of this phenomenon, from the infamous Massachusetts witch hunt of
the 1600s through the recent episode affecting teenage girls in upstate New York.

An Ancient Diagnosis
Derived from the Greek word for "womb," hysteria has existed as a diagnosis for millennia. The first documented
case is recorded on an Egyptian papyrus dating from 1990 BC, reporting abnormal movements of the uterus
that resulted in unusual mental and physical symptoms.[2] A similar condition was described by Hippocrates and
colleagues and was also attributed to abnormal uterine movements. This theory, although misplaced anatomically
and likely disrespectful to modern ears, did recognize that hysteria was more common in women. In the Christian
era, demonic possession replaced the uterus as an etiology for hysterical symptoms.[2] And in the late 1800s, French
neurologist Jean-Martin Charcot proposed that hysteria represented dysfunction of the cerebral cortex.[3] Joseph
Babinski, one of Charcot's students, disagreed with his professor and argued that hysteria was a psychological rather
than neurologic disorder, subject to suggestion and cured by persuasion.[3] Photo courtesy of Wikimedia

Bedlam in Salem
The most well-known instance of mass hysteria in history is that which occurred in Salem, Massachusetts, in 1692.
Numerous young girls exhibited fits of screaming and contortions characterized by a local minister as "beyond the
power of epileptic fits or natural disease to effect." These initial cases seeded a flood of witchcraft accusations.
Many of the girls who were jailed or hanged for supposed supernatural possession may have been unlucky victims
of financial and class resentment, but the social upheaval and accusations were initially incited by mass hysterics
characterized by symptomatic mimicry.[4] Photo courtesy of Wikimedia

Enter Freud
Sigmund Freud (1856-1939) was one of the first clinicians to use the term "conversion hysteria" and proposed the
mechanism of psychological trauma "converting" into a somatic symptom.[2] Freud's book collection reflects his
interest in hysteria. A review of Freud's personal library of 3725 books revealed 125 French medical books published
before 1900. Of these, the largest number is devoted to hysteria and hypnotism.[5] Freud clearly distinguished
between symptoms caused by malingering (conscious) and conversion hysteria (unconscious).[6] Photo courtesy of
Wikimedia

The Road to Conversion Disorder


Hysteria is now viewed as a psychiatric disorder, consisting of signs and symptoms of illness with no organic basis.
It is classified as a somatoform disorder, which may be further categorized as a conversion disorder or hysterical
neurosis, conversion type.[7]Mass hysteria is also known as collective hysteria, epidemic hysteria, mass psychogenic
illness, or mass sociogenic illness, terms that highlight its psychosocial origins.[1,8] The term "hysteria" gradually
fell out of favor, and drafters of 1952's DSM opted for "conversion reaction," later changed to "hysterical neurosis
(conversion type)" in DSM-II (1968), and finally to "conversion disorder" in DSM-III, the theory being that negative
thoughts or psychological conflicts are converted to physical manifestations. Symptoms generally result in response
to an anxiety or fear trigger and can occur in groups as so-called "mass hysteria." While the current DSM-IV-TR
doesn't include a separate multiperson diagnosis, the conversion disorder entry does state, "In 'epidemic hysteria,'
shared symptoms develop in a circumscribed group of people following 'exposure' to a common precipitant."

Casualties of War
It took war to bring men into the fold. Investigations of "combat neurosis" in shell-shocked World War I soldiers
revealed significant symptomatic overlap with "hysterical" women. An episode of hysterical blindness, for example,
could transport a fearful soldier far from the battlefield.[6] The multitude of soldiers with "war neurosis" in WWI
sparked an interest in Freud's new science of psychoanalysis.[5] According to the 1946 documentary film Let There
Be Light, produced by the US Army, "About 20% of all battle casualties in the American Army during WWII were of a
neuropsychiatric nature." This stark black-and-white film depicts hospitalized WWII soldiers with conversion disorders
affecting their ability to walk, speak, or remember, among other psychiatric symptoms. Photo courtesy of Wikimedia

Phantom Anesthetist of Mattoon


Strange odors or gases are one of the most common contemporary inciting events for episodes of mass hysteria. [1]
In the 1944 case of the Mad Gasser of Mattoon, Illinois, a woman smelled something odd outside her window,
felt that her throat and lips were burning, and developed lower extremity paralysis.[9] After calling the police,
her symptoms resolved. Her husband observed someone outside the house, a possible instigator of the "gas
attack." After gossip and the local newspaper spread news of the event, others in the small town developed similar
symptoms. No gas or "mad gasser" was ever found. Photo courtesy of Thinkstock/Getty Images

Mass Sociogenic Illness by Proxy


In this example, parental anxiety seems to have magnified symptoms of routine childhood illness into an
apparent "outbreak." Parents complained of a toxic gas at a Georgia school that they believed caused illness in their
children.[10] Several gas leaks had occurred, but all had been trivial and promptly corrected. The children complained
of headache, sore throat, cough, nausea, fatigue, and other nonspecific symptoms, which peaked 2-4 weeks after a
known gas leak occurred. However, a record review revealed that there was no increased illness in teachers, medical
referrals, or absenteeism caused by childhood illness during this time. It appeared that the parents' anxiety had led
to "mass sociogenic illness by proxy." A CDC investigation failed to find any toxic gas or other environmental cause
for the symptoms, which appeared to be merely common childhood illnesses. Photo courtesy of Thinkstock/Getty
Images

Culture-Bound Symptoms
Many conditions mass hysteria included manifest within specific cultures and/or geographic regions. The
neurobiological pathophysiology of mass hysteria is unknown, but the recently described mirror neuron system has
been proposed as a possible contributing factor, in which neurons associated with a particular action or behavior
fire when someone witnesses that action or behavior.[8] Mass hysteria which typically occurs in relatively closed
communities[9,11] may be an extreme example of emotional contagion, the phenomenon whereby people tend to
share the emotions of those around them.[8] Seventy such outbreaks were identified worldwide between 1973 and
1993 alone.[1] Photo courtesy of Thinkstock/Getty Images

Koro
Sufferers of the culture-bound condition Koro believe that their genitals are disappearing into their bodies, often as
a result of inappropriate sexual acts. This symptom, distressing enough in itself, causes further anxiety because it
is believed that the organ's disappearance will result in death. An outbreak of Koro in Singapore in 1967 resulted in
hundreds of Chinese men seeking help at hospitals, some going so far as to tie pieces of string to their penises in
hope of preventing the precious appendage from receding into their abdomens.[12] Photo courtesy of Thinkstock/
Getty Images

A Military Malady
Episodes of mass hysteria almost always include only females or a mix of females and males, usually with female
predominance.[1] Male-only cases are extremely rare. However, one such episode was reported in a San Diego
military barracks.[13] This was also one of the largest cases of mass hysteria ever documented, with approximately
1000 military recruits complaining of cough or other symptoms and 375 evacuated by ambulance. A few even
received CPR for presumed heart attacks or respiratory arrest. Those who witnessed the CPR efforts had the highest
risk of developing symptoms themselves. Nearly all recovered spontaneously within 24 hours and no environmental
toxin was identified. Photo courtesy of Wikimedia

An Upstate Uproar
In January 2012, 14 teenaged girls (and one boy) in Le Roy, New York, began reporting Tourette's-like symptoms
of spasms, twitches, and vocal tics. Various causes were suggested and ruled out, including vaccine exposure,
infection, and drug use. Environmental activist and legal consultant Erin Brockovich even joined the fray, claiming
that the symptoms might be due to spilled toxins from a train derailment in 1970. Multiple neurologists examined the
patients and came to a more plausible explanation: conversion disorder and mass psychogenic illness. A number of
clinician participants in a recent Medscape Discussion felt differently, with one psychiatrist calling the "mass hysteria"
diagnosis "taking the easy way out" and "turning a back on science." Another preferred a noncommittal approach,
stating, "The reality here is that none of us knows what is really going on up there." Photo courtesy of Thinkstock/
Getty Images

PANDAS and Zebras


One pediatric neurologist suggested the controversial diagnosis of PANDAS (pediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections) as a possible cause of the Le Roy outbreak. PANDAS is a newly
described neuropsychiatric syndrome consisting of symptoms such as acute-onset obsessive-compulsive behavior,
tics, and hyperactivity associated with streptococcal infection.[14] Eight Le Roy girls have been diagnosed with
PANDAS and treated with antibiotics. So far, 3 have been "cured." The very existence of PANDAS is questioned by
some in the medical community.[15] The diagnostic criteria include prepubertal onset, making this diagnosis highly
suspect in the teenage Le Roy girls.[14] The HPV vaccines Gardasil and Cervarix have also been implicated by
antivaccinationists as a cause for the illness, despite the salient fact that not all of the affected girls received the
vaccine. Photo courtesy of Wikimedia

An Expensive Phenomenon
The economic resources consumed by episodes of mass hysteria may be considerable. For example, the New York
State Department of Health conducted an investigation into the Le Roy incident while the school commissioned a
separate report to rule out environmental toxins. Some parents have been reluctant to accept the diagnosis, insisting
on additional investigations. In 1998, an episode of mass hysteria in a Tennessee high school affected 186 students,
teachers, and others and cost almost $100,000 in emergency care alone.[16]Photo courtesy of Thinkstock/Getty
Images

Contagion
Episodes of mass hysteria often begin with one affected individual whose symptoms spread to others. Lori Brownell,
from Saratoga County, New York, was the first girl to demonstrate the tic-like symptoms in the Le Roy outbreak.
An "index case," like Lori, has been observed in more than half of reported cases of mass hysteria. [1] Another
example of apparent contagion of hysteria occurred in Taiwan, where a reportedly popular student in the school
developed difficulty breathing, swallowing, dizziness, fainting, and verbal outbursts, after which some of her teenage
classmates reported similar symptoms.[17]Neuropsychological testing revealed that interpersonal conflict, attribution
to "evil forces," and neurotic traits were more common in those affected.[17]
Contagion may be facilitated by many factors, including physical and visual proximity in the setting of dramatic
situations or occurrences. In particular, the drama engendered by emergency response teams coupled with eager
newscasters can lend credence to false beliefs that something serious has occurred, and it can fuel what is perhaps
the real disease agent in many cases of mass hysteria: anxiety.[1] Photo courtesy of Thinkstock/Getty Images

Mass Hysteria and Social Media


In the weeks following the Le Roy outbreak, today's fast-paced social-media culture came under fire. Physicians
involved in the case felt that the patients' own use of Facebook and other social networking outlets was propagating
symptoms, as was the constant exposure via news media. On February 6, Buffalo's NBC affiliate announced that
they would no longer air video of the afflicted girls. Evidence suggests that witnessed behaviors can incite or reinforce
similar behaviors in others, particularly when a common background, anxiety, or stressor is shared. For example, in
a 1989 episode that affected 400 adolescent schoolgirls in Russia, media reports helped spread the symptoms to the
wider community.[7] Cases similar to the Le Roy episode have not yet been reported in other regions. Photo courtesy
of Thinkstock/Getty Images

Sensationalism and Mass Hysteria


Sensationalism has long been recognized as a successful strategy to sell newspapers,[18]and news outlets may
exaggerate the importance of unusual medical cases.[19] In a poll of 2256 adults commissioned by the National
Health Council, medical and health news stories in the media were powerful influences, causing more than half of
viewers and readers to take some action regarding their health.[19] In the case of the Le Roy girls, attention from the
news media seemed to increase symptoms and add to the number of affected individuals.[20]

Diagnosis
According to one expert, mass hysteria may be divided into 2 types: anxiety symptoms that are usually short-lived
(typically 1 day), and motor symptoms that may persist for weeks to months.[21] Mass hysteria appears to result
from environmental factors such as social and cultural stressors that create anxiety.[7] Susceptibility to mass hysteria
has not been consistently associated with any specific personality or intelligence profile, although female gender is
a definite risk factor. One theory suggests that mass hysteria is a "social phenomenon involving otherwise healthy
people."[1] Photo courtesy of Thinkstock/Getty Images

Management Approaches
Egyptian treatments for hysteria focused on relocating the "wandering womb" thought to be responsible for the
symptoms.[22] One of Hippocrates' recommendations was marriage, a seemingly chauvinistic but perhaps insightful
approach to this mysterious ailment, as interventions potentially quelling anxiety could be of benefit. [23]Although
our concept of the pathophysiology of hysteria is more modern, treatments remain empiric and unrefined. [11]
The symptoms may be psychogenic, but they can still be very real to the sufferer and should be taken seriously.
Treatment includes separation of sufferers, ruling out possible environmental or other causes for symptoms, and
reducing the perceived stress that is at the core of the symptoms.[7,17] The latter may not be evident to the observer
or patients, constituting a significant barrier to effective treatment. Relapses are common. [1] Photo courtesy of
Thinkstock/Getty Images

Conclusions
Instances involving the propagation of seemingly irrational anxieties might seem at odds with an increasingly
educated general public, but episodes of mass hysteria continue to occur, and conversion disorder remains a
common phenomenon in neurology clinics.[1,24] Modern communication methods such as television, texting, social
media sites, and YouTube provide near-instantaneous pathways for symptoms to be witnessed by others, facilitating
apparent "contagion." News and social media sites also provide a ready platform for special interests, such as
antivaccinationists and others who wish to promulgate their views. Dramatic media reports are likely to exacerbate
cases of mass hysteria and could steer subjects away, rather than towards, proper diagnosis and treatment.
Charcot's patients did not have access to the power of the Internet, but some of today's researchers speculate that
his theatrical demonstrations of hysteria spurred the development of even more cases.[25,26]
Mass hysteria appears to be psychiatric illness that imitates a medical one. Diagnosis requires an accurate history
of the events, thorough physical and neurologic examination of those affected, and investigation for possible
environmental toxins or other causes. It lies in the borderland between neurology and psychiatry and requires skilled
physicians who can engage with patients and families on the nature of the disorder and pursue appropriate treatment.

Authors
Andrew N. Wilner, MD, Neurohospitalist, Lawrence and Memorial Hospital, New London, Connecticut
Disclosure: Andrew N. Wilner, MD, has disclosed the following relevant financial relationships: Served as consultant
for: Accordant Health Services Received royalties from book: Epilepsy: 199 Answers (Demos)
Bret S. Stetka, MD, Editorial Director, Medscape from WebMD
Disclosure: Bret S. Stetka, MD, has disclosed no relevant financial relationships.

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