Episodic Neurological Dysfunction Due to Mass Hysteria

ORIGINAL CONTRIBUTION Episodic Neurological Dysfunction Due to Mass Hysteria

E. Steve Roach, MD; Ricky L. Langley, MD, MPH

e describe 10 students from a small rural secondary school with episodes resembling seizures or syncopal attacks. Several students were initially treated for epilepsy or syncope, but the temporal pattern of the attacks, the simultaneous resolution of the episodes during a school holiday, and the fact that 4 students subsequently Whad pseudoseizures confirmed by video-electroencephalography strongly suggest mass hysteria. Seven students were treated with antiepileptic medications, and most underwent multiple diagnostic studies. Prompt recognition of mass hysteria allows physicians to avoid unnecessary tests and treatments and to reassure those affected as well as the general public. Arch Neurol. 2004;61:1269-1272

Mass hysteria is the simultaneous occur- slightly more than 500 students. The initial in- rence of related signs or symptoms with vestigation was conducted by 1 of us (R.L.L.) a psychogenic basis in multiple individu- under the auspices of the Occupational and En- als in a group. Various neurological signs vironmental Epidemiology Branch of the North and symptoms have been described in the Carolina Department of Health and Human Ser- vices (Raleigh) at the request of the county health context of mass hysteria, including a few department where the high school was lo- reports of cases with seizurelike epi- cated. The research aspects of the investigation 1 sodes. However, earlier reports of mass were approved by the institutional review board hysteria with this seizurelike phenom- for human research at Wake Forest University enon generally predate the availability of School of Medicine (Winston-Salem, NC). The modern diagnostic studies or lack details high school’s buildings were inspected and tested about clinical features. We describe a group for possible environmental contaminants. Sev- of adolescents from a small rural high eral students and parents were interviewed by school who for 4 months exhibited psy- 1 of us (E.S.R.). The students and their parents chogenic seizures or syncopal-like epi- completed questionnaires about the seizurelike episodes as well as the students’ general sodes. This group is remarkable not only health and social habits. because of the rarity of mass hysteria with The students’ daily schedules were re- neurological symptoms but also because viewed to determine if there was a common pat- these individuals have been more thor- tern of classes or activities. The school nurse oughly studied than most previously de- and several teachers who had witnessed the at- scribed clusters. tacks were interviewed, and records of these episodes that were compiled by the school nurse were reviewed. In addition, we evaluated most PATIENTS AND METHODS students’ recent medical records. Several treat- ing physicians were interviewed, paying spe- We investigated a group of generally healthy ado- cial attention to the results of pertinent diag- lescents who developed paroxysmal episodes re- nostic studies such as neuroimaging and sembling epileptic seizures, syncope, or hyper- electroencephalography (EEG), physician- ventilation attacks in a rural coeducational North assigned diagnoses, and treatments. Carolina high school with an enrollment of

RESULTS Author Affiliations: Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC (Dr Roach), and North Carolina Department of Health and Human Services, Occupational and Environmental Epidemiology Twelve teenagers, 11 girls and a boy, were Branch, Raleigh (Dr Langley). initially thought to have developed sei-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 zures or other paroxysmal episodes during the first few side. A review of the nurse’s notes tends to support this weeks of the 2002 school year. After further investiga- observation: about half of the episodes with a docu- tion, 2 of these individuals were clearly different from mented time of occurrence took place around lunch- the remaining adolescents and were excluded from the time. final analysis. The sole boy had well-characterized ab- The appearance of these attacks was not identical across sence epilepsy (starring episodes, a generalized spike and individuals, nor did each student consistently exhibit the wave bursts on EEG, and complete resolution of the at- same pattern with each attack (Table). All 9 question- tacks with medication). His episodes were not observed naire respondents noted headache and dizziness, al- at school, and a loss of awareness while driving caused a though not necessarily at the time of their attack. Eight single car accident that led to his diagnosis of epilepsy. reported numbness and tingling or shortness of breath. In retrospect, his episodes started well before those of Seven of 9 respondents reported muscle jerking or twitch- his peers. One girl was also excluded. Her episodes typi- ing, and another reported muscle tightness. Eight stu- cally occurred while standing and resembled syncope; pos- dents experienced reduced responsiveness during at least tural hypotension and tachycardia were demonstrated dur- some of the attacks, and 7 described anxiety, lighthead- ing a tilt-table EEG study. Her episodes resolved after the edness, or overt hyperventilation. The school nurse wit- treatment of postural hypotension. The other 10 stu- nessed several attacks and did not consider them to be dents shared a pattern of recently developed paroxys- typical of epileptic seizures, noting the lack of a recov- mal episodes resembling seizures, syncope, or hyperven- ery period afterward, the appearance of the episode, and tilation for whom an organic underlying disorder could the fact that a couple of individuals cringed in response not be verified or who had pseudoseizures confirmed by to smelling salts. The mothers of 2 other girls indicated the results of video-EEG (Table). These 10 students are that they could “talk her out of it” as the episode started analyzed in this article. to develop. All 10 students were girls, and 5 were currently or for- All but 1 of the students saw a physician for evalua- merly cheerleaders. Otherwise they seemed fairly typi- tion and treatment of the episodes, and most saw 1 or cal of students in the school. One student was African more neurologists in consultation. Six of the 9 students American, similar to the racial mixture of the school. Four who provided medical records were initially thought to students were in the 9th grade, 3 were in the 10th grade, have epilepsy, possible epilepsy, or “spells” by a physi- and 3 were in the 11th grade. Thus, it is not surprising cian. The other 3 individuals were suspected to have that only 2 students shared a classroom. One girl had ex- syncope or hyperventilation. Physicians suggested panic perienced febrile seizures as a young child; none of the attacks, depression, or anxiety in 4 students (some others had a history of epileptic seizures. Two girls had records listed more than 1 possible diagnosis). Numer- taken over-the-counter diet pills at some point prior to ous diagnostic studies were performed (Table). Six indi- the onset of the episodes, and another admitted to hav- viduals underwent 10 standard EEGs, and 4 of these 6 ing tried alcohol, but none of the other students admit- subsequently had a video-EEG study as well. The EEG ted to drug use. A few had tried smoking tobacco, and at result was normal or showed only nonspecific changes least 1 used tobacco regularly. Potentially stressful fac- in 5 individuals. All 4 girls who underwent video-EEG tors (eg, divorced parents, parental substance abuse, his- during a typical episode were shown to have pseudosei- tory of depression, and a recent argument with a brother) zures, including the student said to have isolated spikes were documented in a few adolescents, but the overall on a routine EEG. Seven students were treated with 6 frequency of such problems did not seem unusual. different antiepileptic medications (4 with valproate One student began having seizurelike attacks in mid sodium, 3 with levetiracetam, 2 with carbamazepine, August 2002. During the following few weeks, both the and 1 each with zonisamide, topiramate, lamotrigine, number of affected individuals and the overall fre- and oxcarbazepine). quency of the episodes increased steadily. By October, episodes occurred up to 4 times per school day. With 2 exceptions, each student had only 1 episode in a given COMMENT day. The number of attacks per adolescent varied from 1, in 3 girls, to 30 or more in 1 student, and most of the Mass hysteria is strongly suggested in these 10 students attacks occurred in 4 of the students. By December, the because of the tendency for the episodes to occur at school, frequency of these attacks began to decline; after a 2-week the absence of an adequate organic explanation for them, holiday break, during which there was limited student the fact that video-EEG proved 4 of the girls to have pseu- contact, only the index subject and 2 other students con- doseizures, and the near simultaneous development and tinued to have periodic attacks for several more months. resolution of the attacks. A strong female predominance Most of the attacks occurred at school, but several girls has been noted in previous reports of mass hysteria, and reported occasional episodes in other settings, includ- children and adolescents are affected more often than ing 2 whose initial attack occurred while in church. Ac- adults.1,2 Some episodes of mass hysteria are triggered by cording to the teachers, the attacks were unlikely to oc- otherwise harmless odors or by the onset of symptoms cur during a classroom session and often developed in 1 or 2 prominent individuals.2,3 Although we did not between classes in the hallways, in the cafeteria, or dur- identify specific environmental triggers in the school, the ing breaks when most of the students were in the school fact that the index subject and several other girls were yard. They also believed that the episodes were less likely cheerleaders could have encouraged additional stu- to occur on rainy days when the students remained in- dents to develop similar episodes.

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Patient Age, y/Sex Episode Description Physician Diagnosis EEG Results Imaging Studies Other Test Results 14/F Jerking extremities, hit Epilepsy EEG 1: normal; EEG 2: CT without contrast: ECG normal; 24-h ECG head with hands, bit paroxysmal; bifrontal normal except for 1: occasional atrial tongue, shortness of slowing during possible venous and ventricular breath drowsiness; no angioma; ectopy but primarily spikes MRI and MRV normal sinus rhythm; 24-h ECG 2: occasional dropped beats, intermittent second-degree atrial ventricular block with 2:1 conduction, predominantly sinus arrhythmia 14/F Jerking, eyes back, Syncope, possible Not done CT normal ECG: left axis deviation unresponsive, epilepsy, for age shortness of breath, hyperventilation numbness and tingling 14/F Fearful, increased tone, Panic attacks Not done Not done Not done breathed rapidly, shortness of breath, numbness and tingling, no loss of consciousness 16/F Numbness and tingling, Atypical epilepsy, EEG normal Not done ECG normal jaw and extremities anxiety jerk, shortness of breath, legs stiffen, eyes twitch 15/F Generalized weakness, “Spells” and headaches EEG 1 and EEG 2: MRI normal; CT normal Not done dizziness, numbness normal; video-EEG except for sinus and tingling, indicated opacity unresponsive but can pseudoseizures hear 16/F Unresponsive, Syncope, depression Not done Not done Not done shortness of breath, numbness and tingling, jerking of limbs (at other times) 14/F Dizziness, fell, jerking, Stress, anxiety attack, EEG normal; video-EEG MRI normal Not done starring episodes depression, indicated hyperventilation pseudoseizures 14/F Vertigo, collapse, Epilepsy EEG 1: normal; EEG 2: MRI normal ECG normal; 24-h ECG generalized jerking, read as abnormal 1 and ECG 2: rare eyes roll, numbness, owing to isolated premature atrial unresponsive but can nonlocalized spikes contractions hear during drowsiness; video-EEG indicated pseudoseizures ~15/F Unresponsive, Did not see physician Not done Not done Not done shortness of breath, jerking, eyes back, arms numb 15/F Face drawn, numbness Epilepsy EEG 1 and EEG 2: CT: small ECG 1 and ECG 2: and tingling, normal; video-EEG retrocerebellar normal; weakness, shortness indicated arachnoid cyst echocardiogram: of breath, pseudoseizures mitral valve prolapse unresponsive

Abbreviations: CT, computed cranial tomography; EEG, electroencephalogram; ECG, electrocardiogram; MRI, magnetic resonance imaging; MRV, magnetic resonance venography. *Not all of the listed symptoms occurred with each episode.

Bartholomew and Wessely4,5 divide mass hysteria into acterized by dissociation, motor changes (eg, twitching, 2 major categories: mass anxiety hysteria and mass mo- shaking, or contractions), and histrionic behavior. Mass tor hysteria. As in our group, mass motor hysteria tends anxiety hysteria, in contrast, typically arises from the per- to last for weeks or months and is often precipitated by ception of a false threat and has a short duration, often a stress or social situations. This type of hysteria is char- day or less. These individuals exhibit anxiety and so-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 matic complaints.4,5 As in our group, separation of the Accepted for Publication: February 26, 2004. affected individuals often stops the episodes. Correspondence: E. Steve Roach, MD, Department of Neu- These attacks caused a considerable burden on the stu- rology, Wake Forest University School of Medicine, Medi- dents and their families. Eight of the students reported cal Center Boulevard, Winston-Salem, NC 27157. some type of adverse social or psychological conse- Author Contributions: Study concept and design: Roach. quence to their attacks, such as ridicule from other stu- Acquisition of data: Roach and Langley. Analysis and in- dents, inability to drive, and strained family and inter- terpretation of data: Roach and Langley. Drafting of the personal relationships. In at least 1 family, anger generated manuscript: Roach. Critical revision of the manuscript for by differing interpretations of the daughter’s attacks con- important intellectual content: Roach and Langley. Admin- tributed to the parents’ separation and pending divorce. istrative, technical, and material support: Roach and Additionally, the frequent occurrence of the episodes dur- Langley. Study supervision: Roach. ing school placed a strain on school personnel and dis- Acknowledgment: We thank Beth Lovette, RN, and rupted the education of the other students. Charlotte Shoemaker, RN, for their help compiling Delayed recognition of mass hysteria in these stu- information about the nature and frequency of the epi- dents led several individuals to have diagnostic proce- sodes. We thank Christine Dean, MD, for providing video- dures and receive treatment that could have been electroencephalography results for 3 of the students. avoided had the similarities between these individuals been noted earlier. Fragmentation of the students’ REFERENCES medical care probably contributed to the delayed recognition. Another factor may have been the reluctance 1. Mkize DL, Ndabeni RT. Mass hysteria with pseudoseizures at a South African high school. S Afr Med J. 2002;92:697-699. of some families to consider psychological explana- 2. Taylor BW, Werbicki JE. Pseudodisaster: a case of mass hysteria involving 19 tions for the episodes when suggested by their physi- schoolchildren. Pediatr Emerg Care. 1993;9:216-217. cian. Although the underlying dynamics that initiate 3. Modan B, Swartz TA, Tirosh M, et al. The Arjenyattah epidemic: a mass phenom- and perpetuate mass hysteria are poorly understood, enon: spread and triggering. Lancet. 1983;2:1472-1475. 4. Bartholomew RE, Wessely S. Protean nature of mass sciogenic illness: from pos- its prompt recognition allows physicians to avoid sessed nuns to chemical and biological terrorism fears. Br J Psychiatry. 2002; unnecessary tests and treatments and to reassure both 180:300-306. the affected individuals and the public. 5. Wessely S. Mass hysteria: two syndromes? Psychol Med. 1987;17:109-120.

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