Responding to Mass Psychogenic Illness

In this issue of the Journal, Jones and colleagues report onan episode of mass psychogenic illness that had a devastatingimpact on a high school in McMinnville, Tennessee.1 They providean elegant description of the outbreak. Such outbreaks, unfortunately,are not novel. In 1787, St. Clare ended a similar epidemic amongmill workers in Lancashire, England, by declaring the episode"merely nervous, easily cured and not introduced by the cotton."2Since then, there have been many reports in the medical literatureof similar outbreaks, most often in closely congregated groupsin enclosed settings, such as schools, factories, hospitals,and army barracks.3,4 Many more outbreaks have not been reported.

In a previous era, spirits and demons oppressed us. Althoughthey have been replaced by our contemporary concern about invisibleviruses, chemicals, and toxins, the mechanisms of contagiousfear remain the same. The rapid outbreak of illness describedby Jones et al., the particular symptoms involved, the unusualodor that triggered the outbreak, and the spread of illnessalong lines of sight and through social networks are all characteristicfeatures of mass psychogenic illness.3,5 Although the Tennesseecase may not be unique, the message that not all such outbreakshave toxic causes bears frequent repetition.6

Eventually, the services and authorities called to the highschool in McMinnville emergency medical services, environmentaland public health agencies, and so on were convincedof the psychological nature of the episode (and it appears thatmany thought so from the outset but did not say so). They packedtheir bags and went home, perhaps with regrets about the enormouscost of the investigations. But it ended happily ordid it? There are hints in the report that all was not wellafter the episode. Some of those affected continued to reportsymptoms after the outbreak. There were rumors of incompetenceand a coverup. This episode may not be over yet.

Indeed, managing the aftermath of such an outbreak may be thegreatest challenge. Research has consistently shown that acute,short-term, epidemic anxiety is a common phenomenon that canaffect normal people and that is not associated with any majorpsychological or personality disturbance. It is probably partof the behavioral repertoire in all of us, triggered by theright conditions of fear and uncertainty. If mishandled, however,what should be a transient, harmless phenomenon affecting normalpeople may become a chronic illness in a smaller number of people.

The difficulty is evident in the title of the report. The term"psychogenic illness" and its predecessor, "mass hysteria,"exemplify the problem, both in the meaning of the words themselvesand in their interpretation. One of the less welcome aspectsof the Freudian tradition has been the widespread acceptanceof the existence of symptoms that are, in that destructive phrase,"all in the mind." Yet psychogenic symptoms are physiologicexperiences that are based on identifiable physiologic processesthat cause pain and suffering.7 The children at McMinnvilleHigh School experienced genuine symptoms. That the cause ofthese symptoms was probably anxiety about toxic exposure, ratherthan any exposure itself, does not detract from their reality.By labeling the episode psychogenic or hysterical, however,that is precisely what we are doing. To the majority of observers,including most professionals, these symptoms are indeed allin the mind. The compelling intellectual arguments against suchcrude dualism8,9 have had little effect on the views of laypersonsand professionals alike.

When those who have been caught up in episodes similar to theone described by Jones and colleagues learn that others believethe symptoms were not due to a mystery gas after all, they arelikely to feel that their credibility is being challenged. Thecurrent report may not be well received in McMinnville. In someepisodes and let us hope this one is an exception a minority of those affected remain ill. The only way to provethe veracity of their distress, in the face of doubt, disbelief,and stigma, is to continue to experience it not leastin order to prove the investigators wrong. As Hadler observed,"If you have to prove you are ill, you can't get well."10

Those in McMinnville face an additional kind of jeopardy. Itis possible that they will be caught up in a wider social debateand will become the subject of controversy, media attention,and special-interest advocacy. Their personal experiences maybecome evidence in a political process.11 It is now commonplaceto blame our environment for many of our ills. Episodes suchas the one described by Jones et al. can be understood onlyin the context of widespread fears about the deteriorating qualityof our environment and communities. The belief that one is possessedby demons has little resonance nowadays, but the belief thatone is the victim of a mystery gas does, in part because ofthe all-too-frequent accounts of episodes in which such fearswere justified. The explanations made by the affected personsin McMinnville make sense when we remember the legacy of Seveso,Bhopal, and Chernobyl.

Given the frequency of mass psychogenic illness, the lack ofempirical knowledge about its management and prevention is particularlyunfortunate. There are several case studies of how not to managesuch episodes, but we rarely, if ever, hear about incidentshandled sensitively, with no long-term repercussions involvingill and embittered people and ambitious investigative reporters.Should we investigate at all? Does the deployment of large numbersof emergency, public health, and environmental specialists merelyadd fuel to the fire, convincing people that there really issomething serious going on? Or does public reassurance dependon an exhaustive investigation that rules out every possibleexternal cause, however improbable? How do we convey in a respectfulmanner the message that the main mechanisms for the transmissionof distress are psychosocial and behavioral rather than toxicologic?Should we even try? When symptoms similar to those describedby Jones and colleagues and almost certainly with the same causedeveloped in 34 workers on the Triborough Bridge in New York,their employer was reluctant to endorse the medical conclusionthat the symptoms were psychogenic. A spokeswoman for the TriboroughBridge and Tunnel Authority said, "No, I don't think we wantto prove it as hysteria. These people work very hard, and wedon't want to make light of what happened to them."12

A firm public message that certain symptoms are probably psychologicalin origin will probably help prevent their spread, but possiblyat the cost of alienating those already affected and their families.The challenge is to convey the scientific reality without beingseen as blaming or demeaning the victims. At present, we havelittle information on which to base crucial decisions aboutmanaging mass psychogenic illness.

Simon Wessely, M.D.
Guy's, King's, and St. Thomas' School ofMedicine
London SE5 8AF, United Kingdom


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