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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
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
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
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
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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