Feel Sick? Diagnosis Hysteria

In Maryland, a deranged man sprays a substance inside a subway, and several dozen frightened passengers suddenly experience headaches, nausea and sore throats.

In Tennessee, an office worker opens a foul-smelling envelope. She complains of dizziness, and soon 16 co-workers are reporting similar symptoms.

And in Washougal, Wash., more than a dozen middle-school students and a teacher say they smell fumes and complain of feeling faint.

After investigating each of the three cases--which occurred within the last month--public health officials found no evidence of exposure to a dangerous substance, chemical or germ. The liquid sprayed in the subway, in fact, turned out to be a cleaning solution.

The incidents are what scientists call mass psychogenic illness, a well-documented phenomenon in which real symptoms are triggered by false information or fear. With anxiety over anthrax thick in the air, experts on the subject say that conditions are ripe for additional mass hysteria outbreaks.

“In this type of situation, where there is concern over physical illness from bioterrorism, I think mass hysteria is a real risk,” said Dr. Gary Small, a UCLA psychiatrist who has studied the condition. “People under psychological stress tend to over-interpret everyday experiences, such as talcum powder spilling on your shoe or having symptoms of the flu. When we become hyper-vigilant, we start looking everywhere for a germ.”

If Americans begin “looking everywhere,” outbreaks of mass hysteria could burden public services at a time when the nation can least afford it. More than 2,000 false anthrax scares have been reported since the first confirmed case killed a Florida man.

Investigating false reports is time-consuming and costly because mass hysteria can be hard to distinguish from real illness. Investigators typically would not cite mass hysteria as the likely explanation for an incident until they could eliminate other causes by conducting environmental and medical tests.

“Anthrax is a poor weapon to kill millions of people, but it’s a good choice for terrorizing millions of people. It sends shivers up and down our spines,” said Robert E. Bartholomew, a Vermont sociologist and author of a new book on mass hysteria.

Cases of mass hysteria often start with an environmental trigger, such as an odor or the appearance of a suspicious-looking substance. In some instances, an individual is truly ill. Then others imagine they are ill, said Dr. Timothy F. Jones, a Tennessee Department of Health epidemiologist and an expert on the condition.

“They have real symptoms. This is not something ‘in your head,’ ” he said. “But there is not a germ or chemical causing it. It is due to the anxiety itself. It is a testament to how powerful the mind is over the body.”

The most common symptoms in mass hysteria outbreaks are dizziness, shortness of breath, nausea and headache. Once people afflicted with such hysteria are separated from each other, the symptoms dissipate, usually within minutes or hours.

True Hysteria Needs Element of Plausibility

Mass hysteria occurs more often among women and young people. About 60% of all U.S. outbreaks occur in schools, according to UCLA’s Small.

In 1993, for example, 10 Harbor City Elementary School students complained of nausea after smelling a strong odor. Emergency workers were called in, and the school was evacuated as a precaution. When students exiting the building saw the array of ambulances and firetrucks, dozens more began suffering headaches, nausea and stomachaches. In all, 66 students and seven teachers were taken to hospitals, according to a medical journal article about the case. The cost to evaluate and treat the cases was an estimated $33,050.

Several years earlier, 2,500 people were evacuated from the Santa Monica Civic Auditorium one evening when performers in a student concert began to faint and become nauseated. While some students and parents complained of a strange odor and “toxic fumes,” researchers concluded that the April 1989 incident that felled 200 people was mass hysteria.

For mass psychogenic illness to occur, there must be a strong element of plausibility. With several cases of anthrax infections now confirmed in the United States, it is easy for people to believe it could happen to them, Bartholomew said.

“You can’t see anthrax. You can’t smell it. It could potentially be anywhere, any time,” he said. “Everyone is a potential victim.”

In retrospect, outbreaks of mass hysteria often appear silly. But, said Jones: “You can’t blame people when, in the background, really scary things are actually happening.”

The case of the Tennessee office workers, Jones said, “absolutely was related to the fear of terrorism.” The workers’ symptoms vanished shortly after their admission to hospital emergency rooms. Tests of the suspicious envelope turned up nothing.

Other possible mass hysteria cases are being investigated, including a rash of respiratory problems and headaches among students and faculty at Stuyvesant High School, just a few blocks from the site of the World Trade Center attack in New York.

Epidemiologists are monitoring the school for signs of air-quality problems that might explain the students’ symptoms. But investigators are not ruling out the possibility that the students’ illnesses have been triggered by the psychological trauma of the Sept. 11 attacks, district officials said.

The phenomenon of mass hysteria dates to the Middle Ages, when the fear of demons and witches (which were generally accepted as real) occasionally made people ill or hysterical. Since the dawn of the Atomic Age, cases of mass hysteria have been tied to the fear of nuclear contamination. One famous outbreak in the 1950s involved Seattle residents who noticed windshield pitting and thought they were being exposed to nuclear fallout.

“It turned out those pits had been there for years,” Small said. “It was from another cause, but people didn’t start noticing them until there was this anxiety about nuclear fallout.”

More recently, mass hysteria has centered on environmental contamination. For instance, Small said, sick building syndrome occurs when people suspect their work environment is making them ill. In some cases, the source of the illness, such as mold or fumes, is identified, he said. In many other cases, however, no obvious cause is found.

Mass hysteria can also unfold when people believe they have ingested a harmful substance. In 1998, three Pacoima fourth-graders became sick at school after ingesting LSD. Eleven classmates who also fell ill had no drugs in their systems. They simply panicked at the thought of being poisoned, health officials later explained.

Another highly publicized case occurred in 1999 in Belgium when fears spread that contaminated Coca-Cola was causing widespread illness. No contamination was found, and health authorities later blamed the illness on mass hysteria.

Bioterrorism, however, has become a modern-day springboard for the condition, health experts say. In 1991, 17 Rhode Island middle-school students fell suddenly ill about three weeks after the start of the Persian Gulf War. Although authorities first suspected toxic gas exposure, investigators concluded that mass hysteria was to blame.

A Thin Line Between Informing, Frightening

Modern society may be increasingly vulnerable to the condition because of the speed by which information travels. The media may fuel mass hysteria, researchers said, simply by writing about frightening topics without putting them in the proper context. In the anthrax scare, such context might include noting the relatively small number of infections nationwide.

If thousands of individuals flock to emergency rooms or doctors’ offices this winter complaining of anthrax-like symptoms--which is already beginning to occur, health authorities say--it could severely strain the nation’s health care system. Even if they suspect hysteria, health officials may be unprepared to handle the intense anxiety. Often, officials are pressured into performing expensive tests in search of an elusive diagnosis.

Public health authorities, as well as the nation’s leaders, need to be as attuned to mass psychogenic illness as they are to anthrax, some experts suggest. For example, health officials, politicians and other authorities should avoid making ambiguous or conflicting comments.

But officials walk a delicate line between informing people and frightening them.

“Educating people on anthrax should help alleviate anxiety,” Bartholomew said. “You want firm reassurance from authority figures.”