Dr. LaFrance took a detailed history of Gloria’s medical and psychosocial past. I was struck by the even and professional demeanor he maintained while conveying empathy. Gloria initially denied major stressors in her life but did admit that her parents’ recent divorce weighed on her. She glanced frequently and guiltily at her father during the series of questions but acknowledged that she felt disloyal to one parent when spending time with another. She felt that her mother had become increasingly distant in the last couple of years.
Gloria’s voice cracked as she spoke. “I understand why she doesn’t want to be with Dad, but I don’t understand why she doesn’t want to be with me.”
I felt sorry for Gloria. In that moment she seemed more like a child than a young woman. And as I was watching her, I realized that for the last many minutes—maybe even as long as half an hour—she had not once been besieged by any of her tics. She didn’t seem to notice. Eventually she paused after a particularly emotional response and said, “This actually feels good to talk about.”
Dr. LaFrance nodded. Gloria suddenly looked startled. “I haven’t had a tic in a while, have I?”
“I wondered if you noticed that,” LaFrance replied warmly. Then he continued with the interview and examination. When I spoke with him afterward, I was longing to have observed some in-the-moment cure.
“I couldn’t believe it,” I said. “First she denied feeling stressed about anything. Then she started talking. Really talking about her parents’ divorce and about how she felt rejected by her mother, and the movements and noises suddenly stopped.”
Dr. LaFrance gently brought me back down to earth. “It’s great that she had that response,” he began, “and especially great that she noticed it herself. But I wouldn’t expect her movements to stop completely at this point.” In fact, LaFrance cautioned, if a patient appeared to have been cured after one visit, the core issues that gave rise to the movements might not have been reached, rendering it likely that the symptoms would return over time.
Gloria’s movements were symptoms of a somatoform disorder, like nonepileptic seizures. The treatment would therefore be similar to the treatment of psychogenic nonepileptic seizures. First Dr. LaFrance would help her begin to understand that her condition was psychogenic rather than neurologic. Once she accepted that, then they would work together to try to understand the precursors in her life, the circumstances and the precipitants or stressors that gave rise to Gloria’s symptoms, as well as the factors that were perpetuating the abnormal movements. Identification of these contributing factors would shape Gloria’s treatment, which might involve individual, group, or family therapy. It might also include combined pharmacologic treatment of depression, anxiety, or other psychiatric illnesses that could exacerbate Gloria’s symptoms.
In other words, despite my hopes and initial excitement, Gloria’s treatment would be neither as dramatic nor as neat as a sudden cure.
“But, hey,” LaFrance interjected, “it’s a good sign for her treatment that she acquired some insight as readily as she did.” He paused. “A good sign.”
Gloria’s illness offers a clear example of how unfair and misguided it is when psychiatric symptoms are misinterpreted as volitional. There is a common and erroneous belief that psychiatric illness is not real, that mental illness is “all in your head” and can therefore be cured by force of will. Such a belief has no credibility; stacks of scientific and anecdotal evidence oppose it. And yet even for psychiatrists—who know well the capacity of the diseased mind to produce problematic behavior—it can be a challenge to remember that a patient’s actions may not be a reflection of his or her will. When my catatonic patient Joseph did not respond to Henry’s or my attempts to wake him, it was difficult not to feel as if he were being intentionally obstructive. Gloria’s symptoms reminded me that these afflictions—which may well be a body’s desperate cry for psychological healing—frequently bring added pain and suffering to the person experiencing them. Gloria would never have chosen to have an awkwardly flailing arm, a jutting neck, and an intermittent honking cry. Their existence brought her humiliation. Her symptoms cost her a job. They kept her in her house and away from her friends. They robbed her of joy.
• • •
One of the most puzzling manifestations of these kinds of somatoform illnesses occurs when, instead of manifesting in symptoms reflecting the private stress of an individual, they bloom and emerge in an entire group of affected people. Examples of this kind of outbreak, now deemed “mass psychogenic illness,” have occurred across cultures, continents, and centuries, from Charcot’s Salpêtrière to modern America.
In 1952 the New York Times reported one such event, with the headline 165 GIRLS FAINT AT FOOTBALL GAME; MASS HYSTERIA GRIPS “PEP SQUAD.” The story reported that at the end of the first quarter of a high-school football game, the Natchez, Mississippi, Tigerettes prematurely began to march out onto the field to perform the halftime routine that they had prepared. An announcement was made over the loudspeaker clarifying that it was not yet halftime and calling the girls back to the bleachers, at which point the girls began to faint, presumably from mortification. In a description more reminiscent of the review of an action movie than a journalistic piece, the Times article reads, “Football players dodged ambulances and autos that raced across the gridiron to take the girls to a hospital. . . . ‘It looked like the race track at Indianapolis,’” Mr. Thornton Smith, a spectator, is quoted as saying. “‘They fainted like flies. Men swarmed right around the girls, picking them up and taking them to the foot of the stands.’” Calls for doctors issued forth from the loudspeaker. Apart from describing the mayhem of the scene, the Times reports next to nothing about the girls, who they were, or how they began to faint. Instead the article takes note that they were wearing “snappy, gold-trimmed black jackets and white skirts.” The girls were diagnosed at the local hospital with “overheating and mass hysteria”—and meanwhile, “Natchez won the game, 21 to 8.”
Many of the earliest recorded incidences of mass hysteria were the “dancing plagues,” or “dancing manias.” From the ninth to the sixteenth centuries, reports emerged periodically across Europe of groups of citizens who began to dance and could not bring themselves to stop. Sometimes the dancers were isolated, as was the case of the Swiss monk who danced himself to death in his monastery’s cloisters in 1442. More often they thronged in groups. And though some of the descriptions seem to describe a bacchanal in which drunken dancers claimed they could not stop the party, many are accounts of whirling horrors. Villagers danced until their feet were bloodied and sinew was exposed. They screamed to bystanders for help. They prayed for succor. They danced until they collapsed. Some danced until they died. Some jumped into rivers for relief, only to drown therein. Figures range widely as to how many people actually perished from dancing manias, but the written history of the Imlin’sche family of Strasbourg claimed that as many as four hundred people had died in a 1518 dancing plague there. Another chronicle from that same outbreak reported a period in which fifteen dancers died every day. The medical historian John Waller estimates that from the eleventh to the sixteenth centuries “several thousand [people] had probably succumbed to a terrifying compulsion to dance.”
It is not known why or how these outbreaks began. There are certainly some reports of “contagion,” when tormented dancers would travel from one town to another and in each village new townspeople would find themselves afflicted. Yet there are broad gaps of both geography and time between epidemics. Direct contact—or even word of mouth or lore—does not sufficiently explain the symptoms’ occurrences.
In Asia a fascinating psychiatric phenomenon called koro has emerged from time to time over the last century. Beginning in 1907 but occurring as recently as in 1987, episodes have been described in which groups of men became convinced that their genitalia were shrinking from a contagious illness. Thailand, India, China, and Singapore—all have recorded
episodes in which groups of men, from a collection of co-workers to the entire male populations of certain villages, have been overtaken by the belief that their penises are shrinking, shriveling up, or being pulled into their bodies. The victims believe that once their penises disappear, they will die.
According to Robert E. Bartholomew in his book on mass psychogenic illness, entitled Little Green Men, Meowing Nuns, and Head-Hunting Panics, episodes of koro can last “from a few days to several months and can affect thousands” of people. Bartholomew writes, “Those affected often place clamps or strings onto the precious organ or have family members hold the penis in relays until appropriate treatment is obtained.” The exact nature of “appropriate treatment” varies. In 1985, in the midst of what Bartholomew deems “a major penis-shrinking scare,” an eighteen-year-old Chinese agriculture student described his encounter with koro and the treatment he received: “I woke up at midnight and felt sore and numb in my genitals. I felt . . . [my penis] was shrinking, disappearing. I yelled for help, my family and neighbors came and held my penis. They covered me with a fishnet and beat me with branches of a peach tree. . . . The peach tree branches are the best to drive out ghosts or devils. . . . They were also beating drums and setting off firecrackers. . . . They had to repeat the procedure until I was well again, until the ghost was killed by the beating.”
Parents may diagnose their sons with koro in the midst of epidemics, and their protective measures may in fact do real harm. During a three-month outbreak in Darjeeling, India, some parents were noted to have “tied strong thread to their young sons’ penises.” They anchored the thread by then tying it around their sons’ waists. As a result some children developed penile ulcers. Of the Darjeeling outbreak, Bartholomew writes, “The panic reached such levels that medical personnel toured the region, reassuring people by loudspeaker. . . . Doctors measured penises at intervals to allay fears by demonstrating there was no shrinkage.”
In Nigeria a rather different form of “magical genital loss” has been recorded as recently as 1990, in which men walking in crowds believe that incidental contact with other men can cause their own genitals to vanish. A Nigerian psychiatrist reported that a police officer brought two men in to be evaluated. One claimed that in walking past the other man on the street, he “felt his penis go” and went to the police, claiming that the man, whose robes had brushed him as they passed one another, had caused his penis to disappear. The “victim” called upon the police officer to settle the matter. The psychiatrist describes examining the man in front of the officer and the accused. When the man’s anatomy was pronounced normal, the “victim” responded as if his penis had at that very moment been returned to him, though apparently with some concern as to whether it “would function normally” after its recent disappearance.
The Daily Times of Nigeria reported that men began walking “in the streets of Lagos holding onto their genitalia either openly or discreetly with their hands in their pockets” to defend against having their penises vanish or be stolen in these chance encounters.
Comical as the symptoms may seem, the results were sometimes tragic. When a man believed that his penis and scrotum had been stolen, he would shout, “Thief! My genitals are gone!”—causing a swarm of sympathizers to rally to his defense. A paper in the Transcultural Psychiatric Review reports that crowds would “immediately take steps to punish the ‘genital thief’ by beating, clubbing, or even burning” him, believing that “the rougher the treatment, the more likely it was that the ‘thief’ would relent and ‘return the seized genital.’”
Similarly violent and tragic consequences have accompanied other outbreaks of mass psychogenic illness. In seventeenth-century Loudun, France, Jeanne des Anges, the mother superior of a convent of Ursuline nuns, fell in love with a priest named Urbain Grandier. Initially the mother superior attempted to punish herself and eradicate her feelings through mortification—the religious process of exacting penance by means of self-injury. Though Jeanne flagellated herself and prayed throughout the day, Father Grandier came to her, unbidden, in lust-filled dreams at night. She was consumed by guilt and was eventually overcome by a trancelike state in which her body succumbed to bizarre movements and her speech issued forth in tongues. In the midst of this transformation, the mother superior claimed that she had become possessed and that Father Grandier was to blame.
In the days and months that followed, several other nuns in the Loudun convent began demonstrating symptoms attributable to demonic possession. The women fell into hysterical fits of all sorts, trembling and calling out in tongues, vomiting up worms and hair. One nun claimed to have spit up a portion of the heart of a child who had been sacrificed by witches. The nuns’ displays, and the attempts to stop them via exorcism, drew a great deal of attention to the convent. Visitors and community members, in a manner that would seem to foretell Charcot’s demonstrations of hysteria in the Salpêtrière, would come to watch the spectacle of possession. Robert Bartholomew writes that the nuns “used the public exorcisms to draw attention to [Father Grandier’s] immoral overtures and [to their own] pious sufferings.” With the evidence of his devilish influence compounding for all to see, Father Grandier was formally accused of witchcraft and was burned at the stake.
Other convents in other countries and centuries fell victim to similar episodes of mass psychogenic illness. Bartholomew postulates that the atmosphere in a convent was one in which the young female inhabitants were subjected to numerous constraints and regulations that they were powerless to protest. Accusations of witchcraft, therefore, “were often a way to settle scores under the guise of religion and justice.” To the horror of observers and religious figures alike, afflicted nuns “released frustrations by using foul, almost blasphemous language, by engaging in crude sexual behavior such as rubbing private parts or thrusting their hips to denote mock intercourse.” Bartholomew describes outbreaks in other convents: Sixteenth-century Spanish nuns convulsed and began to bleat like sheep; in a different region of France, nuns “meowed together every day at a certain time for several hours.”
Strict or otherwise unpopular priests were often targeted, but fellow nuns were not immune from blame. In Germany in 1749, a young nun was accused of causing convulsions and trances among her sisters. She was charged with sorcery and “beheaded in the market place to the cheers of an enthralled crowd.”
Crowds gathered, too, to observe Cree and Ojibwa teenagers in a remote Canadian community in the 1970s. The teens would fall into hysterical fits and run into the woods or hold their breath until they were given artificial respiration. The displays became a cause for the community to gather and to watch. Refreshments were served. Unsurprisingly, as long as the audiences persisted, so, too, did the symptoms. When the refreshments and gatherings were halted on the advice of psychiatrists, the fits suddenly halted as well.
As recently as 2012, girls in New York State were overcome by tics and other abnormal movements, prompting town residents (and eventually Erin Brockovich) to search for potential environmental causes for their new and terrifying neurological symptoms. The girls went on the Today show and were featured on the cover of the New York Times Magazine. Controversy swirled as to why—or whether—these popular, well-adjusted girls might be experiencing a mass psychogenic-movement disorder. As of this writing, no other definitive cause has been identified.
• • •
In the same way that we understand individual somatoform disorders to be physical manifestations of psychic conflict, so group disorders are thought to arise in disempowered populations that lack other means of making their collective distress known. Hence nuns who gyrate and bark; hence young and overtired factory workers who begin, one by one, to convulse and collapse. Extrapolating further still, theories turn to political or sociological stress to explain cultural group afflictions: The medieval dancing manias occurred within the context of the Black Plague or during crop failures and resulting famines. Outbreaks
of koro have tended to correspond with periods of economic fragility or political unrest. And yet, what of the subjugated millions who do not begin clamping their penises or dancing themselves to death? What of the war-torn countries that yield no groups of convulsing citizens? And how great was the degree of mass distress, really, of erroneously marching out after the first quarter to perform a halftime routine in snappy, gold-trimmed black jackets and white skirts? The theories feel as if they are trying too hard to fit. They do not snap into place with satisfying clicks.
When I told Dr. LaFrance that I wasn’t entirely convinced by these explanations of powerlessness, he shrugged. “One deer in a group perceives a threat and its tail goes up. Another deer reacts. It bolts. And suddenly the whole group takes off like a shot.” He cautioned me, “Don’t forget we’re also animals.”
• • •
One late-winter evening, it is barely dusk and I am driving my children home from swimming lessons. They are buckled into their car seats, wrapped in terry-cloth sweatshirts, and smelling of chlorine. A library audiobook plays for the hundredth time out of the car speakers. I realize with horror that I can recite this story, in which siblings travel through time and end up in a monastery in the Alps training Saint Bernards. I think, If I have to listen to this story one more time . . .
Outside the car window, strip malls and chain restaurants slide by in the gray-purple light of February. “Why are swim lessons in Massachusetts?” my daughter asked once with a fatigued sigh, though the drive across the border takes us fifteen minutes tops. Why indeed? I think as we pass Chili’s and Walmart and iParty.
Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis Page 21