Mass sociogenic illness: It’s real, yet it isn’t

The call comes in: possible gas leak at a high school, two teachers and about 15 students presenting with nausea, vomiting, headache and difficulty breathing. The hazmat team is on the scene, and 12 more students and another teacher start exhibiting symptoms.

As more and more people start getting sick, the media shows. Rumors are starting about chemical warfare and terrorist attack. Or there’s something terribly wrong with the building that the administration has refused to do anything about. And more women and girls are getting sick.

Except that, way in the back of the school building, a group of students in the auto shop are working away, perfectly well and oblivious to the chaos in the rest of the school. Which is the second clue that there is not, in fact, a gas leak. That there isn’t even a physical cause for the illness striking the school.

Real symptoms
The incident described above happened in Tennessee in 2000, explains Timothy Jones, M.D., deputy epidemiologist for the State of Tennessee. At the time he investigated the case, he was an epidemic intelligence officer for the Centers for Disease Control and Prevention.

“Off in the auto shop, where it was noisy, ano one got sick,” Jones says. “If it was a toxic gas, it’s going to get everyone. It doesn’t prove anything one way or another, but it can be a clue.”

Dos and don’ts for emergency responders This sidebar accompanied an article by Robert E. Bartholomew on mass psychogenic illness, published in the March 2006 issue of Crisis Response Journal . Do Remain calm and offer reassurance. Speak to the media to dispell rumors and offer factual information, through a limited number of spokespersons who provide a uniform message. Whenever possible, separate patients from nonpatients and attempt to keep them from visual and audio contact. Try to determine if the episode more closely fits the pattern of anxiety hysteria or motor hysteria, and realise that cases are likely to recurr unless the source of the underlying anxiety is addressed. Realize that the majority of MPI reports will become the subject of public controversy, and that emergency personnel should avoid taking sides. Don’t Speak to the media individually. Say that it was “all in their heads,” as the symptoms were real. Confirm the presence of a toxic substance without objective findings to support these claims. Alter prearranged emergency response plans. Rely on early media reports, as they are often inaccurate. Use the term “mass hysteria.” Instead substitute “mass anxiety” or “mass psychogenic illness,” as these terms are less likely to evoke an emotional backlash among victims. Suggest to patients what you think their symptoms should be (based on the suspected agent involved). For example, if a natural gas leak is the suspected cause of symptoms, let patients disclose their symptoms without prompting them.

Because the problem is, with incidents such as this, the victims are suffering a genuine physiological response. Their symptoms are real. It’s just that what’s causing them isn’t a chemical or a disease. The cause is seeing everyone else get sick, then seeing the emergency response teams rushing through the location, then media attention spreading the story.

It’s a little-studied phenomenon that used to be called mass hysteria (and still is in some circles), in which a group of people suddenly become ill, believing they’ve been exposed to a toxin or disease, even though there’s no evidence that such an exposure has occurred.

Schools and workplaces tend to be the most common locations for such outbreaks, but there are records of entire cities feeling the effects. Symptoms can mimic panic attacks and generally include nausea, vomiting, dizziness, headache and hyperventilating. The incidents come on very suddenly, and the symptoms usually resolve themselves within an hour or two.

But because there hasn’t been a lot of study on the phenomenon, there isn’t really a single name for it. It’s referred to as epidemic hysteria, mass psychogenic illness or mass sociogenic illness, with the latter two terms becoming more common.

Paula Madrid, Psy.D., a clinical psychologist at Columbia University who is currently in Mississippi working with victims of Hurricane Katrina, says the confusion stems from the fact that not a lot is known about the syndrome. “There are different ways of looking at epidemic hysteria, because it’s not very widely studied. It’s not in the diagnostic books. But it can impact large numbers of people very quickly.”

A long history
Sociologist Robert E. Bartholomew, formerly of James Cook University in Queensland, Australia, has written more than most about the subject and says interest is growing.

“Mass hysteria is not as widely studied as say, PTSD [post-traumatic stress disorder], but it is becoming an increasingly scrutinized subject, especially in light of recent terror attacks and scares and the potential for mass disruption caused by social delusions.”

And in fact, many historical cases of mass psychogenic illness have occurred in times not unlike ours, in terms of social upheaval, nervousness due to an active war, not to mention economic uncertainty.

Incidents do not appear to be on the rise, however. Jawaid Akhtar, M.D., an emergency physician and medical toxicologist at the Pittsburgh Poison Center, as well as the University of Pittsburgh Medical Center Presbyterian Hospital, says he hasn’t seen an increase in cases.

“We hear about it once or twice a year through the poison center.”

“I have not noticed an increased number of reports, but no one keeps track of them,” says Jones. He notes that during the anthrax scares right after Sept. 11, 2001, there would be incidents at post offices, where employees became sick after handling suspicious packages, and cites another case that occurred during the first Gulf War. “It’s sort of hard to say it’s going up or down.”

That said, it’s probably far more common that most people think.

“If you talk about it to a room full of public health people, they all know about it,” Jones says.

Madrid even mentions that she may have had a psychogenic reaction recently while living in a trailer home in hurricane-ravaged Mississippi. Public concerns about the safety of the tap water in the area had her wondering if she really had a stomach ache from drinking it.

Response and treatment
Because the only way to make a diagnosis of mass sociogenic illness is to exclude all other causes, and because there is always the possibility that there is a physical cause for an incident, first responders must investigate the incident right away, which in turn, usually makes the situation worse.

“You’re damned if you do and damned if you don’t, in terms of the actions you take,” Bartholomew says. “You have to assume a worst-case scenario in the initial assessment of any situation.”

Unfortunately, part of what’s making the people sick is seeing fire-fighters and police tearing around in gas masks, looking for leaks.

Another problem for EMTs called to an incident is that, with rare exceptions, the worst thing they can do is insist that the victims are reacting to a psychological stimulus and will be all right as soon as they calm down. People simply do not like being told that their symptoms are all in their heads.

“It’s a very difficult thing to explain,” Jones says, partly because patients really are feeling dizzy and nauseous, and their hearts really are racing. “They’re not faking them. It’s a true physiological response.”

It’s just that the cause is not what they think it is.

“They feel like they’re being told, ‘I have a psychiatric disease,’” Jones says.

The irony, he points out, is that people who do have psychiatric diseases, such as schizophrenia and bipolar disorder, don’t tend to fall prey to mass psychogenic illness.

The good news is that the symptoms themselves almost always resolve very quickly on their own. But that in itself creates problems for first responders on a couple of levels.

“It takes away a lot of resources,” Akhtar says, and not only among police, fire fighters and emergency departments. “The place where it happens closes down. School hours are lost. Work hours are lost.”

And while there is no evidence this has happened, because events can and do recur, the possibility exists that later events may not be investigated as thoroughly.

“I think that can go either way,” Jones says. “Either they blow off something that turned out to be real, or the other fear is that after it happens one or two or three times, every time school is back in session, people are going to be so nervous and scared, it’s going to happen again.”

No labeling
Awareness among first responders is probably the best antidote.

“Early recognition helps save resources,” says Akhtar, which is why he recommends contacting a poison control center early on, especially if victims are transported to several different hospitals. “It can help coordinate the care, if we’re getting four to five calls about the same thing.”

Jones says that while all calls must be handled as if there is a true physical threat, having the possibility of sociogenic illness in the back of people’s minds would help. So, for example, first responders notice that victims are getting sick within minutes of each other, that most of the victims are female, that victims start getting better when they’re separated from other victims and are given oxygen.

“If all those things are going for you, I would hope that it would be in the minds of the providers,” Jones says.

The tricky part is in not labeling the syndrome, as such, while still being reassuring and caring.

“How do you respond?” asks Madrid. “You try to calm people down, help people to feel safe. People will react in a more positive way if they feel that they’re being take care of. There’s something in the placebo effect.”

Bartholomew also insists that EMTs, when interviewing patients, not volunteer any symptoms, as that almost always leads to those symptoms showing up.

“First responders need to treat the symptoms and be sympathetic, even when it becomes obvious that it was mass hysteria,” he says. “I think a better-tolerated term to use would be anxiety response or reaction, as it would tend to reduce the stigma associated with ‘mass hysteria.’”

In fact, some have suggested that even “psychogenic illness” can produce patient backlash and are leaning toward using “sociogenic illness.”

But no matter what the phenomenon is called, it is a very real event, and it calls for very real processes to help victims and the surrounding community heal.