Guest guest Posted June 12, 2002 Report Share Posted June 12, 2002 http://www.nytimes.com/2002/06/02/magazine/02HYSTERIA.html Hysteria Hysteria By MARGARET TALBOT talbot@... Last fall, something peculiar began to happen at more than two dozen elementary and middle schools scattered across the country. Suddenly, groups of children started breaking out with itchy red rashes that seemed to fade away when the children went home -- and to pop up again when they returned to school. Frustratingly for the federal, state and county health officials who were working to explain this ailment, it did not conform to any known patterns of viral or bacterial illness. The children had no other symptoms: no fever, no runny noses, no headaches or joint pain or respiratory complaints. Moreover, they were not passing their rashes on to parents or siblings outside school. Large groups (a dozen here, several dozen there) came down with it simultaneously, or within hours, rather than over the course of days or weeks, as you would expect with person-to-person transmission of a contagious illness. Then there was the nagging fact that in many of the outbreaks, girls accounted for a majority of the cases. Since neither germs nor the other likely culprit, environmental poisons, make a habit of discriminating by sex, this was puzzling news indeed. Blood tests on a number of the children pretty much ruled out the possibility of one initial suspect, the virus that causes a mild rash known as fifth disease. Environmental investigations of the affected schools failed to turn up evidence of chemical or biological hazards. The media would soon dub the outbreak ''the mystery rash'' in reports that, inevitably, had epidemiologists ''scratching their heads'' over it. This year, of all years, a mysterious rash affecting schoolchildren in the United States was bound to generate a good deal of attention and anxiety. Parents didn't always say the words ''bioterrorism'' or ''anthrax'' when they called their doctors and principals to ask if they should keep their kids out of school, but it was often the subtext of the conversation. In another year, schools with rash outbreaks might not have warranted news vans planted in their parking lots for days. In another year, the rashes might not have fueled such florid, conspiratorial discussion on the Internet -- it was ''chemtrails'' from airplanes; it was books on Islam donated to schools by questionable Saudis; it was a terrorist attack coverup -- or engaged the attentions of overworked state health officials for months. The rash outbreaks might not have triggered an investigation by the Centers for Disease Control and Prevention, as these did. Or calls for Congressional hearings, like those demanded by a coalition of environmental organizations led by the Healthy Schools Network. Alarm about rashes might not have brought 1,000 parents out to a meeting with the school superintendent in Quakertown, Pa. But this year was different. This year, rashes -- or any unexplained physical symptom -- made people nervous in a way they did not before 9/11. Or maybe it was the other way around. Maybe it was nervousness that helped create the unexplained symptoms. And maybe children were more likely to somaticize a lingering, inchoate anxiety about 9/11. Studies completed on New York schoolchildren this spring, for example, showed that months after the terrorist attacks, many of them still suffered from recurrent nightmares and trouble sleeping. Kids in other parts of the country surely experienced similar anxieties. And maybe, just maybe, this latent disquiet sometimes manifested itself in a curious, corporeal way -- in the form of an itch. the rash outbreaks started in Indiana on Oct. 4, the same day The Associated Press first reported that a Florida man had come down with anthrax. It was not then clear how extensive the anthrax campaign would be, or who was behind it (we still don't know), or where it might turn up next. Throughout the fall, towns across the country were dealing with false alarms, white-powder hoaxes, sudden evacuations of buildings, runs on Cipro. By January, more than 1,200 specimens of suspected anthrax, none of which tested positive, had been sent to the Indiana State Department of Health alone. The school rash turned up next in northern Virginia, at Marsteller Middle School, where hazmat crews scoured the building and found no explanation. ''Official Diagnosis: Unknown,'' reported the local paper, in an eerie summation. Kids began refusing to go to school. One parent, a postal worker, explained her daughter's decision to a Washington Post reporter: ''This is not happening at a good time. They're afraid there's something behind it that no one knows about.'' During the winter holidays, the school rashes abated, but in January and February, they turned up again, notably in Pennsylvania and Oregon. Winter-dry skin may have left the affected kids more susceptible to itchiness, but there were few other clues for investigators to go on. In late February, Scanlon, the superintendent of schools in Quakertown, where 238 cases had been reported in nine schools, wrote in a letter to parents that all environmental testing had been negative and pleaded with them for help in ''bringing normalcy back to our community.'' But local news coverage of the ''mystery rash'' in Pennsylvania and elsewhere only intensified, especially on television. By early April, the rash or something like it had turned up in two Massachusetts towns, South Dennis and Billerica. (The latter happens to be the headquarters of Bruker Daltronics, a company that manufactures detection devices for agents of biological warfare.) In Oregon, it all started on Feb. 4 at the Abraham Lincoln Elementary School in Medford, near the California border, on what its principal, Bob Hartwig, had figured for an uneventful Monday morning. At about 9:30, Hartwig noticed a group of second-grade girls -- perhaps 8 or 10 from the same classroom -- reporting to the office looking flushed on their faces, necks and arms. Hartwig, a genial silver-haired fellow with an office full of kid-friendly train memorabilia, said the girls seemed ''pretty miserable.'' Over the next several days, more kids showed up from various grades and from opposite sides of the building with rashes that looked quite different. Some were like clusters of tiny bumps or patches of dry skin; others looked more like sunburn. H. Chilcoat, a public health nurse who coordinated the county's investigation, noticed something similar. People who interviewed the kids would ''observe the rash sort of evolve before their eyes,'' she says. ''It would be there, and then you could actually see it fade away or reappear somewhere else on the body.'' That was a signal thing about it -- that and the fact that of the 67 children and 11 adults affected by it at Lincoln, 62 were female. Within the first few days, the County Health Department had combed through the school and found nothing to explain the rash. And Hartwig himself had been nervous enough to call in an outside environmental scientist. Investigators considered dozens of possible culprits -- cleaning supplies, furnace filters, fiberglass particles in the air, pesticides sprayed in the local orchards, even supplies brought from home for a puppet-making project -- but ruled out all of them. Some parents were worried that whatever this was might have unknown, long-term consequences and wondered whether the school ought to be closed down. One was upset enough to tip off the local news channel the second day of the outbreak; the next afternoon when school let out, a TV crew started interviewing parents and kids. To Hartwig's chagrin, somebody appeared to be circulating the theory that an allergic reaction to math books was causing it. Hartwig took state health officials' advice not to close Lincoln, but he couldn't help being preoccupied. ''I kept thinking about the AIDS virus,'' he says, ''how it started here with one guy flying in from Africa, how nobody knew what it was at first.'' His worry was mixed with bafflement. ''I kept asking myself: Why us? Why Medford, Ore.? Why girls? At one point, we were 100 percent girls.'' Why, he wondered, did the rash seem to go away so quickly when kids forgot to scratch, or stopped talking about it, or applied good old calamine lotion? Why did it break out in both the second and fourth grades, which shared no materials? It occurred to him at times that he might be dealing with something psychogenic, or at the least with a number of sympathy cases. Hartwig had never forgotten an incident he dealt with, as the principal at another elementary school, in 1984. Back then a teacher had begun complaining that the groundskeeper was spraying a pesticide outside her classroom window and that it was poisoning her and the children. She became ill, and within an hour many of the kids in the room were nauseated; a few were vomiting. ''But they weren't spraying anything toxic outside,'' Hartwig says. ''All I had to do was tell the kids in that classroom that nothing was going on, and it stopped.'' Still, this situation seemed to Hartwig more complicated. He had no doubt that there were sympathy cases of the rash at Lincoln, but he had a hard time wrapping his mind around the idea that psychological contagion could travel across different classrooms and grades -- or that there ''wasn't something real going on.'' A psychogenic explanation crossed Chilcoat's mind, too, though she ultimately found it implausible in such a large group of children. During the school-rash episode, Chilcoat exchanged e-mail with a public health nurse from St. s in Ontario who had helped investigate a rash outbreak in an elementary school there last March and had concluded that it was probably ''hysterical.'' But while the Ontario nurse, Hague, confirmed to me that hysteria ''was one of our hypotheses,'' it was not one, she says, that she ever shared with the affected children or their parents -- or, indeed, with the public at large. ''I guess it sounds strange, but I never thought about it till you asked,'' Hague says. ''People seem to deal better with concrete facts, and you sort of don't want to go there. You really don't like to cast that shadow.'' Two weeks later, Hartwig at least had the comfort of no longer being alone in Oregon with his medical mystery. A similar rash had popped up at a very different school, about an hour west of Portland. Hartwig's school is in a tidy five-year-old building with a bright, well-stocked library and a front office that looks like the parlor of an upscale bed and breakfast. The Chapman Grade School in Sheridan isn't as lucky. Though Sheridan is tucked into a beautiful valley lined with nut orchards and wineries, it is one of those rural Oregon towns that never quite recovered when the lumber industry bottomed out. The main employers nearby are the Spirit Mountain Casino and the federal prison. Sheridan is full of small, neatly tended clapboard houses on either side of the South Yamhill River. Outside the school, the bushes are fat with rain-happy rhododendrons. But the low-slung building itself is 60 years old, with scuffed linoleum floors and a tired-out look. When it came to the mystery rash, though, the experiences of the two schools weren't so different at all. Chapman's outbreak started on Feb. 21. There, too, the rash came on abruptly and struck mainly girls. Lindsey , a fourth grader, was heading for lunch with her friend Dora late that morning when she spotted a knot of people in the front office, across from the cafeteria. Among them were three sixth-grade girls she recognized: her sister, a, and ''two girls named Cherish and Shelby, who everybody knows.'' Lindsey ducked into the office right away to see what was up, and so she was one of the first to hear that the three older girls had suddenly come down with an itchy rash. Proceeding on her way, Lindsey, who is a peppy and talkative girl with stick-straight blond hair, quickly became a messenger. In the cafeteria, she and Dora ''told everybody about it. And we told them not to scratch, because that made it worse. At first they'd say, 'Eeeww, I don't want it.' And then after they heard more about it, they'd start scratching.'' Pretty soon, Lindsey had a rash, too, and so did a friend of hers who was sitting at the lunch table, and so did a ''bunch of other kids eating lunch.'' When Chapman's principal, Tim Graham, and his staff began noticing the rash, they quarantined the affected kids in the library, where, as Graham recalls: ''Teachers who couldn't stop scratching themselves -- it's very hard when you're seeing all these kids scratching -- kept telling kids to stop scratching. It was crazy.'' But by the end of that day, about 50 students were complaining of some kind of rash, and the library had gotten too crowded. So Graham moved the kids to the gym, and then had to move them again, this time outside. And Graham's day got still crazier. ''News trucks were here, and the kids started following them around trying to get on TV. And I started getting conspiracy calls -- people thinking it was a government coverup. Something to do with 9/11.'' Lindsey herself remembers thinking about anthrax. ''It was scary,'' she says, ''because maybe the anthrax got into our school, and then somebody touched it, and then if you touched that person you'd get it. It was scary because you didn't know what the rash was or where it came from.'' Lindsey and her friends talked over some other creepy possibilities. She and her schoolmate Phyllisha thought they'd noticed more of the local tree frogs, who sometimes get in through the drains at the school, around the Chapman building that first day. What was up with that? That was kind of weird, wasn't it? Phyllisha, who had the rash, though hers was only a small, reddened patch in the crook of one arm, had even seen a dead frog at the school that week. Another fifth-grade friend remembered the time she'd eaten a yucky rare hamburger in the cafeteria and thought maybe the rash was ''the mad-cow disease'' -- the thought of which caused her to reject the meat ravioli in the cafeteria the day I spoke with her. Lindsey and a's mom, , was eating lunch at the Spirit Mountain Casino, where she works, when she first heard there had been a rash outbreak at the school. She rushed over to pick up the girls, thinking first, and with panic, of meningitis, then of bioterrorism. ''What was it?'' wondered. ''Was it something in the air that came and went?'' She took the girls to their family doctor, who said it was probably a histamine reaction of some sort that would resolve itself and not to worry. But was still puzzled by her observation that the rash came out only at school and went away ''10 or 15 minutes after the girls left school.'' On Friday, the second day of the outbreak, Graham closed Chapman early, and on Monday he reopened it. But that day, as bad luck would have it, the nearby federal prison was dealing with an anthrax scare. , whose husband works at the prison, heard about the white powder sent to an inmate when she went up there to work out at the gym and thought, Oh, no. Her mind rocketed back to the school rashes. Maybe there was some anthrax connection after all. When paramedics who had rushed to the prison were called to the school shortly after to look at a new crop of itchy children, they promptly recommended that Chapman be closed again. Graham did so, which jazzed a lot of the kids but also generated a certain amount of chaos, since 310 of them had to be moved out in a hurry and their parents quickly located, all amid a tangle of buses and emergency vehicles. Lindsey (who along with her sister had been on the local news early in the outbreak) and her friends thought some of the kids who were getting the rash in this second phase ''were jealous,'' she says. I asked Lindsey and several of her friends whether they thought it was plausible that anxiety and sympathy could account for some of the rash cases. They accepted the suggestion with equanimity. ''Totally,'' one girl said. ''It's kind of like when somebody next to you is scratching their head and you get itchy.'' Another girl said knowingly that of the 12 mystery rash cases that cropped up at another local school following the Sheridan outbreak, ''8 were self-inflicted.'' And she added that when she got the rash, ''a kid tried to rub up against me because they were jealous that I had it and they didn't.'' Chapman was closed for a week of thorough cleaning. The state health department in Portland had told Graham that it wasn't necessary to shut down, that there was no risk to the children. But Graham felt that was easy for the state doctors to say when they didn't have to take calls all day from panicky parents wondering if their kids were safe. When school reopened the following Monday, some students were still complaining of a rash, an itch or both, but the symptoms subsided over the next two days. A few weeks later, I sat down in the dimly lighted cafeteria with Blakley, an eighth grader at Chapman, and her schoolmate Nick Mull, who is in the fifth grade. At that distance from the whole weird episode, they did not seem unnerved. They remembered being uncomfortable, but they seemed to relish -- as who wouldn't at that age? -- the gross-out details of their ordeal. ''When I first noticed it was right during lunch,'' recalled Nick, who was one of the few boys to get the rash. ''My friend , she started getting it, and she showed me hers. It was itching her real bad. And then I was messing around with her and touching it and stuff, and I started messing with my neck, and then my arms and legs started itching and I got it. It really burned.'' ''We had a good time in the library,'' said , an amiable ginger-haired girl who blushes easily. ''But it got kind of stuffy because everyone started itching so much and they were sweating. I saw people itching their backs up against the bookshelves. People were saying: 'Ooh, will you scratch my back?' 'Will you scratch mine?' It was on the news that night, and there was no school the next day. That was the best part. We heard about the rash. We heard how it started somewhere else -- Georgia, maybe?'' Nick interjected: ''They say it isn't contagious, but then how did we all get it at once?'' Both Nick and thought it was quite possible that their schoolbooks were to blame. ''I didn't get it when I was at home, except when I'd hold my books from school,'' volunteered. ''Yeah,'' Nick agreed. ''We have such old books here. We have chapter books from, like, 1962 in the library.'' ''Ooh,'' said, ''just talking about it makes me itchy. I'm itching now.'' ''Yeah, I don't want to think about it,'' said Nick, who was polite and greyhound-thin and wore cool, super-baggy orange shorts. and Nick said they knew kids who had faked the rash to get out of school or maybe to make fun of people who did have it. ''Like they'd scratch really hard till it bled,'' explained. ''Or else they'd put red marker and white-out on their arms and say: 'Ooh, I've got the rash! I've got the rash!''' Not long after visiting Chapman, I spoke with off, a resident in preventive medicine who had interviewed and examined 15 kids at Chapman on behalf of the Oregon health department. All 15 had identified themselves or been identified by teachers as having the rash. But off did not see anything unusual or even similar in these conditions. She saw, she says, ''early acne, dry skin and quite a few insect bites.'' Still, off dutifully administered a lengthy questionnaire with, among many, many other queries, a number of items about glitter gel, paste-on tattoos, skin preparations and the like. (In a vain attempt to find a common agent that might explain why far more girls than boys got the rash, off had brainstormed with her Britney Spears-loving niece to come up with all the products that girls in the fourth through seventh grades might possibly use on their skin.) ''One child told me that she and her friends would point at girls they didn't like and say: 'You've got it! You've got it!' So that girl would essentially get quarantined. One kid told me he didn't even know he had the rash until a teacher told him he had it. One girl said she wasn't itching until she got near the school, because she knew that's where the rash would be. Somebody said, 'I wasn't itching till I saw my friend itching.''' off pauses. ''It was,'' she says, ''a very interesting experience.'' In the nine months since the rashes were first reported, very few of the outbreaks have been conclusively explained. By mid-May, Mississippi's small outbreak was the only one that could be attributed to parvovirus, which causes fifth disease. (''We got lucky,'' says Currier, a state epidemiologist. ''We had positive blood results for something.'') In Pennsylvania, a dermatologist named Norman Sykes who examined 40 of the children with rashes there suspects ''a new virus'' -- probably a mutation of the parvovirus -- though he is at a loss as to how to explain the predominance of female cases or the paucity of secondary cases in families of the affected children. Lab work on the virus theory is proceeding in Pennsylvania. Many of the rashes that wound up being reported to the C.D.C. were almost certainly the kinds of everyday skin conditions -- poison ivy, eczema, incipient acne, dry skin irritated by overheated classrooms, atopic dermatitis -- that in another year would never have aroused concern, let alone have been written up by the agency. Granted, there could yet be an environmental cause found, though it is highly unlikely to be the same cause in all the schools. No one has been able to establish links between the affected schools in any one state, let alone across states. The ''mystery rash'' is a misnomer that surely covers all sorts of conditions. And then there is the awkward but unavoidable possibility, the one that health officials try their best to dance around -- which is that the rash outbreaks may have been, at least in some measure, psychogenic. What may have caused at least some of the cases, in other words, was not a toxin or a virus but anxiety. The agents of contagion may have been the shared suspicion that people around you were falling victim to some sort of noxious substance and the powerful sympathetic reaction to seeing other people scratch. The skin is notoriously reactive to stress -- many people flush when they are nervous; hives and eczema are triggered or worsened by tension. Scratching begets more scratching, as anyone who has ever tried to stop worrying an insect bite knows, and sometimes, says , a public health doctor with the state of Tennessee, we talk about ''the itch that causes the rash, rather than the other way around.'' There are even extreme itch-scratch syndromes in which sufferers fall into a relentless cycle of compulsively scratching some part of their bodies -- frequently the back of the neck -- which only makes it itch all the more. ''I tend to think that kids hearing all the news stories about rash illness and bioterrorism could get something like this outbreak started,'' says Alfred De, an epidemiologist with the state of Massachusetts. ''Especially in middle school, where kids are impressionable and certainly more conformist in the sense that they have to have the thing the next kid has. Maybe a few kids had a viral illness of some sort, but with most, it was sympathetic.'' Besides, De adds -- and nearly every other health official I spoke with agreed -- itching, like yawning, is a very suggestible symptom. Several officials told me anecdotes about investigating lice outbreaks or examining rashes and helplessly starting to scratch, even when they knew for certain they were lice and rash free. ''Personally,'' De says, ''I can get itchy just talking about scabies.'' Says : ''When you see a patient with lice, there's no way your head doesn't get itchy. It happens to me, and I recognize it, and I keep scratching anyway.'' André Weltman, a public health doctor with the state of Pennsylvania, says: ''I'm sure that there were sympathy cases. We want to be careful because we like to have our hands on solid facts. But I have no doubt that went on. Human beings are social creatures. Like monkeys. Have you ever seen a group of monkeys scratching?'' The first time I interviewed Southwick, the Oregon state epidemiologist who coordinated the investigation there, she told me: ''We feel there is a very substantial sympathetic component to these rashes. We're still very much trying to see if there is some other trigger. But so far we have not been successful.'' Terms like psychogenic illness and hysteria have such a checkered history that even talking about them in connection with real people can quickly become a fraught pursuit. It was the ancient Greeks who first identified hysteria as the manifestation of physical symptoms with no discernible organic cause. The word ''hysteria'' comes from the Greek for uterus: at the time, it was thought that the womb could wander restless through the female body, wreaking havoc. In the late 19th century, the heyday of the hysteria diagnosis, it was seen as the female complaint par excellence -- and not because anxious women might plausibly be rebelling in one of the only ways they could, by incapacitating themselves for their duties, but because they were assumed to be the helpless victims of their reproductive systems. The French neurologist Charcot, and later Freud, defined hysteria as a nervous-system disorder unleashed by emotional trauma. Until psychoanalysis came along, the accepted antidotes were isolating rest periods and a cessation of intellectual activity -- cures designed, it seemed, to replicate the very conditions of cosseted ennui that drove upper-middle-class women to hysteria in the first place. The smart and sensible feminist critique of hysteria -- a huge academic literature exists on the subject -- has led to a good deal of healthy skepticism about the diagnosis. But it has also made many people unduly suspicious, perhaps, of the very notion that the mind can generate symptoms that only the body manifests. And this may be all the more true when we consider this phenomenon among groups of people in the grip of unexplained symptoms. Part of the problem with making a diagnosis of mass hysteria is that it carries such a freight of pejorative associations. Ever since the Salem witch trials, it has been seen as the kind of phenomenon that occurs only in ''backward'' communities or among religious zealots. It hasn't helped that several modern incidents of mass panic leading to physical symptoms have depended on bizarre collective delusions -- the belief in alien landings, for example. (One recent book on mass psychogenic illness carries the uncomfortably vivid title ''Little Green Men, Meowing Nuns and Head-Hunting Panics.'') More recently, a fear of environmental contamination has become the most common source of psychogenic illness, but this complicates matters still further since, after all, there is such a thing as a real environmental hazard. People who are ill with multiple-chemical sensitivity and chronic-fatigue syndrome -- syndromes that many doctors dispute the existence of -- reject any discussion of a psychological component to these ailments as ignorance or insensitivity. But none of this should blind us to the fact that well-documented outbreaks of mass psychogenic illness do occur -- and not all that rarely. Between 1973 and 1993, there were 70 reports of mass hysteria in medical journals; most took place in self-contained communities, like schools, barracks and factories. Sixty percent of the incidents of epidemic hysteria written up in English-language journals this century occurred in schools. ''I continue to be struck by how much more common mass psychogenic illness is than people generally think,'' says , who was the lead author of an article in The New England Journal of Medicine two years ago in which he identified a psychogenic outbreak of nausea and dizziness among 170 students and staff members at a Tennessee high school. ''I bet you there are a ton of cases when professionals back in their office are saying, 'This is what we think it is.' But maybe in only one out of 100 cases is it going to leave the office, and when it does it will be maybe two or three years later in a journal article that the local community is never going to read. Public health people are going to be extremely hesitant about labeling an illness as psychogenic. Because as soon as you say that aloud, people are telling you, 'You're not taking it seriously, you don't believe us, you missed something, you're covering something up.' It makes people really, really mad to hear that diagnosis. So a lot of times when mass psychogenic illness occurs, you don't hear about it as such. Public health people will continue to say, 'We're looking at all the possibilities and not finding anything, and we're waiting for the final results.' And privately, they sort of just hope it goes away and people stop asking about it.'' Mass psychogenic illness, or epidemic hysteria, is usually defined as a set of unexplained symptoms affecting two or more people; in most cases, victims share a theory of some sort about what is causing their distress. Often, somebody smells something funny, which may or may not be a chemical and which may or may not be there, but which in any case does not account for the subsequent symptoms. Relapses tend to happen when the people affected congregate again. And, notably, the mechanism of contagion is quite different from what you would expect in, say, a viral illness: symptoms spread by ''line of sight,'' which is to say, people get sick as they see other people getting sick. Some element of unusual psychological stress is often at play -- which may account for why several of the documented cases in schools took place while students were preparing for standardized tests, in an anxious wartime atmosphere or weeks or months after an actual but resolved environmental event, like a natural gas leak. Adolescents and preadolescents are particularly susceptible. And girls are more likely to fall ill than boys. That last finding, striking and consistent as it is, might seem like an artifact of misogynist bias. But in a way, and not necessarily an offensive way, it makes sense. ''I've been hissed at medical conventions when I say there's a preponderance of women in these outbreaks,'' says Small, a psychiatrist at the University of California at Los Angeles. ''But women are more likely to talk to each other about symptoms and how they're feeling. They're more social, and so that may facilitate the spread among friends. Social relationships determine the spread of these kinds of symptoms.'' Girls' heightened susceptibility to mass psychogenic illness need not be seen, in other words, as a function of a delicate constitution or a more ''hysterical'' nature, but of their propensity to talk among themselves about their health. And the observation that women are more likely to seek medical attention, and presumably to take note of their own symptoms than men, is well documented. Most cases of epidemic hysteria are characterized by symptoms like nausea, abdominal pain, dizziness and lightheadedness -- all of which can be produced or aggravated by anxiety and hyperventilation. But there are also several documented cases of rash as a psychogenic symptom. In 1982, for example, 57 children at a West Virginia elementary school experienced an outbreak of sudden itching. The rash showed up at 9:15 in the morning, when 2 fourth-graders began complaining of itchiness; by noon, 32 students had the same symptoms. Frequently, outbreaks of psychogenic illness begin with one or more people falling ill from actual organic causes, setting in motion a fast-rolling wave of sympathy. In 1989, for example, 63 children attending a day camp in Florida came down with abdominal cramps and nausea. The affected children, 75 percent of whom were girls, became ill 2 to 40 minutes after eating a prepackaged lunch. All recovered within eight hours. Meal samples tested by the F.D.A. revealed no telltale bacteria, pesticide contamination or heavy metals. Investigators did learn, however, that the incident started when one 12-year-old girl complained that her food tasted bad and promptly vomited -- she was probably sick when she came to camp that morning -- after which the staff members began wondering aloud if the food was contaminated. After the fact, the Florida Department of Health concluded that the episode was an example of ''mass sociogenic illness.'' However many cases of psychogenic illness are reported, the label remains a deeply vexed and often disputed one. In part, this is because mass psychogenic illness is a diagnosis of exclusion -- it is what investigators are left with when they have exhausted every plausible physical explanation (though they may suspect it from the beginning), and diagnoses of exclusion can feel unsatisfying to the doctors in charge. Besides, no one wants to be too hasty to label an illness psychogenic if doing so would foreclose the search for a real environmental danger. It's true that in most cases of actual chemical spills or water contamination, environmental investigations do reveal something amiss. In an article for Psychiatric Times, reviewed outbreaks of mass psychogenic illness and compared them with incidents of confirmed toxic exposures; he ''was unable to identify any outbreaks of acute illness from toxic exposures, with minimal physical findings, where the cause was not quickly apparent to investigators.'' Still, there is always the possibility that something has been overlooked -- and who wants to be the guy who missed the hidden poison, and in an elementary school of all places? Sometimes a psychogenic diagnosis is difficult to make even when people on the scene suspect it. Frequently, outbreaks have very short durations, with symptoms dissipating before investigators arrive on the scene. (That was the case with this year's first mystery-rash outbreak, among 17 Indiana third graders. As one investigator reported, ''Their little faces were all smooth by the time we got there.'') Potential episodes are often evaluated after the fact and on the basis of self-reported symptoms. And the teams looking into them rarely include behavioral scientists or psychiatrists. In theory, you might think that a psychogenic diagnosis for a mild, transient illness would come as a relief to those concerned, lifting the specter of mystery viruses and hidden toxins. But in practice, such diagnoses are often taken as an insult and met with charges of a coverup. In March 2000, J. Settipane, an allergist affiliated with Brown University, examined a number of children who had broken out in a rash at an elementary school in East Greenwich, R.I. Settipane became convinced that the rash was psychogenic -- a conclusion not endorsed by the local health department -- and related to stress among the mostly fourth-grade girls it affected, who had been struggling with a difficult math book and had standardized testing coming up. ''They kept moving the classes to other locations, other buildings, eventually to a local bookstore -- trying to stay one step ahead of this rash -- and it kept following them,'' Settipane recalls. But when he announced his conclusions, ''the parents were irate,'' he says. ''How could I say such a horrible thing? How could I say their children were hysterical? This was an affluent school, a very involved group of parents. They could not accept even considering this. I was persona non grata.'' Some parents thought Settipane had overlooked an environmental explanation at the school, and several homed in on the theory that their children were allergic to the math textbooks. Settipane was skeptical, but other allergists in his office dutifully tore up book pages, mixed them with water and concocted a slurry in order to do skin tests with them. (The tests were negative.) ''A few parents became zealots on this issue,'' Settipane says. ''They stirred it up continuously, and it became a matter of, 'Are we taking our kids seriously?''' Of course, it probably didn't help that Settipane had a tendency to mention that 9-year-old girls were susceptible to magical thinking and that ''this was the same demographic that had started the Salem witch scare.'' Delicate he was not. He thought he had to be blunt. ''You can only stop these things by being honest,'' he says. ''I could get caught up in this kind of thing, too, as a parent or just a person. We all could. It's a very powerful thing, and it needs to be respected and understood. And health officials shouldn't be so scared to call a spade a spade.'' Back in Sheridan, Ore., there has been no such tumult -- for the hysteria diagnosis has never been publicly voiced by investigators there. Officially, they say that the rash probably had, as Southwick puts it, ''a whole variety of causes,'' none of them serious. By now the rash is almost, but not quite, receding into the murky realm of Weird Things That Happened Once (and Most People Gave Up Trying to Explain). A report by a private environmental company showed the presence of mold at the school, which some people in Sheridan now think might have caused the rash. But it is not clear that the mold levels are unusually high, especially for Oregon, which is a wet and moldy state, after all. And Southwick does not buy the theory that mold explains the rash. Mold allergies are common, certainly, and can be severe, but they generally cause respiratory symptoms, not otherwise asymptomatic rashes. Still, some parents in the community think it might finally be the time to retire the old Chapman school building and erect a new one. The matter will come up for a vote on the local ballot in November. And some parents are still worried and suspicious. , Lindsey and a's mother, likes the way the school handled things but frets about the future. ''It's almost the end of the school year,'' she says, ''but I wonder, Is it safe to send my girls back to Chapman next year? You hear a lot about medical stuff that doesn't affect you till maybe six months or a year down the road. Is that going to be what happens with this? Even though the rash hasn't come back, we're kind of waiting to see if it does come back.'' Dale , Phyllisha's father, thinks that ''they -- the school, somebody -- might know what it was, but not be being honest about it.'' And there are evidently other Oregonians who share his hunch -- or have their own theories about an etiology that health officials have missed or ignored. Southwick has received more calls from ''the public, suggesting where we should be looking, than I have on any investigation I've ever done.'' On an Internet forum about so-called airplane chemtrails, ''Anonymous'' from Portland, Ore., said he'd heard speculation that the rashes might be psychosomatic and resented it enormously. In his view, it suggested that children in Oregon were ''messed up psychologically.'' Why, exactly, the idea of psychogenic illness should be so offensive is a little baffling. In many other areas of life and health, we recognize and even celebrate the mind-body connection: think of alternative therapies, yoga, the placebo effect, endless magazine articles about reducing stress to improve physical health, meditation, the power of positive thinking. Sympathy reactions to other people in physical distress are rather touching phenomena, really, revealing us for the social and interconnected creatures that we are. Yawning, queasiness, malaise, vague ''funny feelings'' and certainly itching are suggestible symptoms for adults -- I felt itchy every time I did an interview for this story, even if it was on the phone -- and probably all the more so for young adolescents, who pay such close attention to one another and who may have trouble sorting out the signals from their rapidly changing bodies. None of that seems shameful. It seems understandable; a little funny; and very human. Suggesting to people that their physical symptoms might have originated partly in the mind is not, of course, at all the same as saying they are crazy or malingering. Mass psychogenic illness produces real, not sham, physiological effects. That they may not be attributable to a physical pathogen does not make them any less distressing to their sufferers, nor does it mean that their sufferers are ''imagining things'' in a way that should inspire worry about their long-term psychological health. Indeed, as Simon Wessely noted in a New England Journal of Medicine editorial: ''Acute, short-term, epidemic anxiety is a common phenomenon that can affect normal people'' and is ''not associated with any major psychological or personality disturbance. It is probably part of the behavioral repertoire in all of us, triggered by the right conditions of fear and uncertainty.'' Nonetheless, few public health officials are prepared to take on the task of parsing such a diagnosis for audiences unaccustomed and even hostile to it. And this reluctance may well leave the American public ill equipped for dealing with future outbreaks of psychogenic illness, at a time -- of vague terrorist threats and emergent infectious diseases -- when it would be entirely reasonable to expect them. Whether the great post-9/11 rash outbreak turns out to be partly psychogenic or not -- and we may well never know for certain -- it seems highly probable that we will be dealing with incidents of mass hysteria in the future. There are doctors, like Settipane, who believe that the best way to stop a psychogenic outbreak is to diagnose it as quickly as possible. But this approach can be risky. ''There are a lot of articles written that say you've got to just walk in and tell everyone, and it will stop,'' says. ''Well, that's easy to write and very hard to do. It takes a while to exclude everything else, and that's never going to be in the first 10 minutes.'' Still, there are tactful ways of handling what may be a psychogenic outbreak -- experiments, of a sort, that also help to control it. In South Dennis, Mass., when several dozen, mostly female, students at iel H. Wixon Middle School came down with a rash over the course of about 10 days in late March, the school was closed and sanitized. Environmental investigators did air-quality tests and bacterial cultures, checked out the food service, looked into the possible local use of pesticides or fertilizers or of new chemicals in science labs -- and came up with nothing. So Tony Pierantozzi, the school superintendent, tried a different tack: ''We began a triage system. Instead of automatically sending any kid with the rash home, we tried to keep them there. If we could identify a rash that was severe or covered a large part of the body, the school nurse sent them home. If it was only a small amount of rash or just scratch marks, we recommended the kids stay. We sent those kids into their own common area and kept them away from everybody else. At the same time, we stopped treating the rashes with calamine lotion, which sort of marked the kids, and started treating them with ice, which was just as effective. And at that point, the incidence and the spread of the rash stopped almost immediately.'' It's a paradox: suggesting that symptoms might be psychogenic can help stop them, but it often does so at the risk of alienating, even embittering people. Maybe Pierantozzi had hit on a way of finessing the problem, acting on a hunch without quite making it explicit. When I told about Pierantozzi's triage scheme, he chuckled appreciatively. ''I'd say that's an excellent experiment,'' he said. ''I'd say he's a very smart guy.'' Margaret Talbot, a contributing writer for the magazine, is a fellow at the New America Foundation. Quote Link to comment Share on other sites More sharing options...
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