Contagious psychogenic symptoms resulting in epidemics have erupted periodically since the original descriptions of the dancing manias of the Middle Ages (Sirois 1982). They have been investigated by epidemiologists (Cole et al. 1990) and sociologists (Bartholomew 1990), as well as by psychiatrists and other physicians. Various terms have been used or proposed for this phenomenon, including mass hysteria and epidemic hysteria. Mass psychogenic illness is the term currently favored for describing the phenomenon.

Characteristics of an epidemic include a relatively closed social system, the presence of some underlying tension (e.g., start of the school year), and the development of symptoms in index cases in response to a stimulus (e.g., exposure to nontoxic fumes), with a rapid spread of symptoms via sight or sound to others, who then become similarly afflicted. The probability for modeling will be enhanced if the index case is a leader of the group affected or held in high esteem by peers. Most symptoms, such as nausea and dizziness, can be accounted for by anxiety and hyperventilation (Small et al. 1991). Symptoms tend to wane with dispersal of the group and recur with restoration of the group setting. Publicity and attention generated by the media may intensify the epidemic, as does the presence of emergency equipment such as ambulances and unnecessarily prolonged and detailed medical evaluations (Selden 1989).

Although most outbreaks of mass psychogenic illness have been described in women, particularly adolescent girls, an epidemic in male military recruits suggests that the setting may be more important than sex (Struewing and Gray 1990).

The phenomenon of mass psychogenic illness overlaps with other disorders such as sick building syndrome, fashionable illness, and somatization (Ford 1997b; Rothman and Weintraub 1995). A contemporary version, reflecting our electronic global village, is the influence of mass media personalities (e.g., Oprah Winfrey or Phil Donahue), whose discussions of various illnesses and symptoms may prompt some patients to seek treatment for vague subjective symptoms (Ford 1997b; Shorter 1995).

The treatment of mass psychogenic illness is relatively simple and straightforward. Gamino et al. (1989) reported success with separating the most symptomatic patients from the rest of the group and treating symptomatic patients in a calm, reassuring manner with words that suggested improvement rather than implied danger or more symptoms. Struewing and Gray (1990) noted that keeping nonaffected members of the group busy with a task may help reduce the contagion effect. Education of members of the group and their families as to the benign nature of the “epidemic” may help reduce anxiety and the probability of recurrence when the group reunites (Cole et al. 1990). Amin et al. (1997) reported that with an episode of epidemic hysteria in a women’s college dormitory, the techniques of rapidly separating affected women and avoiding any media publicity were effective in rapidly quelling the epidemic. These authors observed that the large majority of affected women had rapid symptom relief in response to symptomatic supportive treatment, and those few women who had persistent symptoms were characterized by a history of psychiatric problems or significant medical illness.

The effects of mass psychogenic illness are usually self-limiting and benign to the individuals, but the effect on institutions may be more serious. It is of interest to note that such an epidemic in 1955 closed the Royal Free Hospital in London (McEvedy and Beard 1970). An episode of mass psychogenic illness in a Canadian fish-packing factory had economic repercussions in that the plant had to be shut down several times, efficiency was decreased, and numerous employees sought medical care. Measures recommended to prevent recurrence of similar episodes included more attention to job-contact factors (e.g., repetitive, boring work assignments) and more employee involvement in health and safety issues (House and Holness 1997).

The high personal and financial costs of an episode of mass psychogenic illness at a Tennessee high school followed by a recurrence 5 days later were detailed by Jones et al. (2000). Wessely (2000) responded to this communication with cogent comments about the complex problems of the management of such outbreaks and the potential adverse effects of labeling them as “psychogenic.”

Conclusions
Medically unexplained physical symptoms have long fascinated and, occasionally, irritated clinicians. Examples of such symptoms may include the dramatic presentation of paraplegia, signs and symptoms of pregnancy in a nonpregnant woman, or epidemic nausea and dizziness in a girls’ school. The common thread among these symptoms is the presence of precipitating stressors in susceptible individuals who have difficulty with directly articulating their distress. The task of the clinician is to decode the disguised communication and formulate a treatment plan that addresses the specific needs of the individual patient, including giving attention to environmental stressors and concurrent psychiatric disorders. Effective treatment usually involves the coordinated use of multiple therapeutic modalities: various psychotherapies, behavioral modification techniques, physical-somatic therapies, hypnosis, and environmental interventions. Treatment also must address ways to reduce reinforcement of the symptom and to provide face-saving opportunities that allow the patient to relinquish the symptom.

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Charles V. Ford, M.D.
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