Ruth C. Engs, Richard N. McKaig, and Bruce Jacobs, A Case Study of Mass Hysteria or Toxic Fumes ?: Considerations for University Administrators. NASPA Journal, 33(3):192-201, Spring 1996.
A case of Mass hysteria or toxic fumes ?: Considerations for University Administrators
Ruth C. Engs, Professor, Applied Health Science
HPER rm. 116
Indiana University Bloomington, IN 47405
Richard N. McKaig, Dean of
Students Indiana University
Bruce Jacobs, Director, Residence Life and Assistant Dean of
Students Indiana University
Background information concerning mass collective behavior and psychogenic illness is presented, followed by a case study and implications for staff training.
Psychogenic phenomena are rarely discussed at student affairs, residential life, campus police or health center personnel training. They also may not be recognized by first response teams or university staff when a large group of students suddenly become ill. Lack of recognition of such a phenomena can lead to overextension of medical personnel, costly investigations, increased campus stress and even potential litigation. The purpose of this article is to describe general information and symptomology concerning mass hysteria and psychogenic illness, discuss a case study which occurred in the dining facilities of a women's residential unit at a large mid- western university, and present implications for training of student affairs administrators and staff.
Information Concerning Mass Collective Behavior and Psychogenic Illness
Kerckhoff and Back (1968) suggest that there are collective human behaviors which produce different kinds of activities and phenomena. These include crowd or mob behaviors, panics, movements, crazes and fads. These types of behaviors often occur under stress or when the ordered reality of a culture or group is disrupted (Conner, 1989). Some examples of these behaviors include mob actions such as lynching a prisoner or beating bystanders during a riot. Other forms include longer term crazes, panics or movements such as Nazism and the Mcarthy era's hunt for "communists" (Lemkau 1973), the cyclical anti-alcohol and "clean living" movements (Engs 1990), or current investigation of supposed "satanic cults" practicing "ritual child abuse"(Victor 1992). Fads include such behaviors as clothing styles and youth culture activities.
Another type of collective behavior according to Kerckhoff and Back(1968) is a "hysterical contagion". It consists of the quick dissemination within a collection of people of a symptom, or a set of symptoms, for which no physical explanation can be found. Typical cases today include illness caused by alleged food poisoning, insects bites, toxic fumes, or environmental pollutants for which no pathogenic agent can be found. In this type of collective behavior something happens to affected individuals and they view themselves as victims. This type of behavior is typically referred to as " mass hysteria" or "mass psychogenic illness". Mass hysteria is defined as the occurrence in a group of people of a constellation of physical symptoms suggesting an organic illness but resulting from psychological cause (Small and Borus 1983:632). Likewise "mass psychogenic illness" or "contagious psychogenic illness" is defined as the collective occurrence of a set of physical symptoms and related beliefs among several individuals without an identifiable pathogen (Colligan and Murphy 1982:33).
Mass hysteria illnesses have been found throughout history (Sirois 1982; Colligan, Pennebaker and Murphy 1982). Hippocrates, circa 400 BC introduced the term "hysteria" meaning illness caused by a wondering womb. Symptoms included convulsions, twitching, muscle spasms, abdominal cramps nausea,and headaches in unmarried Greek women. Symptoms typically spread quickly to other women in the vicinity of the victim(Sirois 1982; Colligan, Pennebaker and Murphy 1982).
During the Middle Ages, outbreaks of mass psychogenic episodes called the St. Vitus Dance were common. The twitching accompanying this illness was considered a curse due to sinfulness. Later in early colonial
Americaillness among young girls in were attributed to witches curses(Sirois 1982; Colligan, Pennebaker and Murphy 1982). Twentieth century examples of this phenomena have been generally found in factories, the workplace, and in schools. However, about 60 percent of cases reported in English language literature in the past three decades have occurred in schools (Small and Borus, 1983). Today they are most often blamed on "toxic fumes, gasses or chemicals" or "environmental pollutants". There are numerous examples of this behavior in contemporary society. Salem, MA
Kerckhoff and Back (1968) give a detailed case history in their text, The June Bug. In this classic example, a garment manufacturing plant was shut down because of a mysterious sickness caused by a "bug bite" which affected mostly female workers. The epidemic ran its course in five days. After extensive investigation it was concluded that the illness was psychogenic in nature. In Colligan, Pennebaker and Murphy's edited volume Mass Psychogenic Illness (1982), many examples of these behaviors, particularly among female factory workers are described. In most cases the victims thought they smelled a "toxic gas or fumes". Upon investigation, no evidence of toxic gasses was found. During the beginning of the Gulf War, 17 young adolescents and four teachers became sick from "toxic fumes" in their classrooms. However, no toxic gas or pathogen was found (Rockney and Lemke,1992). This lack of a pathogen, upon investigation of the illness, is a primary characteristic of all of mass hysteria episodes.
Symptomology and Characteristics of Mass Psychogenic Illnesses
There is a remarkable similarity between the symptomology of the mass psychogenic illnesses no matter what the triggering event. Some of the major characteristics common to psychogenic illness include:
1. Sudden onset with dramatic symptoms, rapid spread and rapid recovery. All studies reporting psychogenic illness discuss the rapidity of the onset of the illness. Most of these epidemics are gone in a few hours or days. The most effective way to curb the spread of the symptoms is to separate the victim from the group. The attack rate is generally about "8 to 10% in large groups and from 30 to 50% in small groups"(Sirois 1982:225; Sirois 1974).
2. Predominantly young female populations. From 60 to 90% of victims of psychogenic illnesses have "historically been young females" (Colligan and Murphy,1982:41). Groups of females working, living or eating together are most at risk for this behavior. Even if males are present females comprise most of the victims as is illustrated in some of the most recent examples from the literature (Small, Propper, Randolph, Spencer, 1991; Rockney and Lemke, 1992)
3. Victims often know each other or are in the same friendship circles. Observing a friend become sick is the best predictor of the development of symptoms (Small,et al 1991; Colligan, Pennebaker, Murphy 1982;Stahl and Lebedun, 1974)
4. A triggering stimulant. An auditory or visual triggering stimulus is generally found. Victims interpret this stimulus as a toxic fume or gas, tainted food, bug bites or toxic pollutant. Upon investigation, when an odor can even be detected, cleaning solvent, painting, machinery or repair liquids, unfamiliar construction or fumigation odors have sometimes been found (Rockney and Lemke, 1992; Colligan, Pennebaker, Murphy 1982).
5. Apparent transmission by sight, sound or both. Seeing a victim collapse is a predictor of others getting the symptoms (Colligan, Pennebaker, Murphy 1982; Rockney and Lemke 1992; Small and Borus 1983).
6. Negative laboratory or physical findings confirming a specific organic cause or pathogen. The illnesses are "real," however, there is an absence of any chemical toxin or biological pathogen. The diagnosis of psychogenic illness is generally made after all possible factors have been ruled out. However, it must be kept in mind that victims are often reluctant to accept a diagnosis of mass hysteria or "mass hyperventilation" and sometimes accuse the institution of a "coverup." In some cases there may be unexpected laboratory results which cause confusion and promote controversy about suspected etiologies (Rockney and Lemke, 1992).
7. Underlying psychological or physical stress. Individual stress from an unfamiliar environment or performance anxiety; social stress including war, rapid technological change, or epidemic diseases; and school and work related stress including the beginning of the school year are common (Sirois 1982;Rockney and Lemke 1992; Colligan, Pennebaker, Murphy, 1992).
8. Boredom, or perceived boredom. Worker boredom with routine tasks has been found in many cases of illness (Kerckhoff and Back 1968).
9. A felt lack of emotional or social support. This is more likely to occur among new members in a collection of people (Kerckhoff and Back, 1968).
10. Unrelated symptoms among a group of individuals affected: hyperventilation or fainting the most common. Other symptoms discussed in the literature include: dizziness, nausea and vomiting, headaches, chest pains, chills, eye or mouth stinging, flushing, hives, convulsions, stinging or paralysis in extremities, swollen and bloody lips, skin disorders, asthma attacks, and disorientation in time/space.
11. Relapse of illness. Relapse of the illnesses among victims in the same setting have sometimes been found to occur (Colligan and Murphy, 1982).
Mass psychogenic illnesses can be a great concern for student affairs administrators and others working with students. The reason is the potential for long term effects resulting from this type of event. If no physical or chemical etiology for the illness can be found and if episodes reoccur, the illness remains a mystery. This unsolved mystery can lead to anxiety, fear, spread of rumor and even possible litigation (Brodsky 1988). Therefore, it is important that individuals working a university environment understand the potential consequences of this psychogenic phenomena. Following is a case study and discussion of case management and staff training issues.
Facility and Staff Responsibilities
The residence center in which the incident occurred is located on a large state-supported midwestern university. The building houses 880 female residents; 70% first year, 15% sophomores, and 15% juniors/seniors. This living unit is comprised of three buildings: two ten story highrises which contain student living space and a center building which houses two dining rooms, a snack bar, a library, a small convenience store, classrooms, meeting rooms, administrative offices and a service desk. The building is 30 years old and has been well maintained. One of the dining rooms had been closed for nine months for renovations.
The center has residence life, housing, and food service staffs. The residence life staff consists of one full-time professional, four graduate assistants, 20 resident assistants, and six diversity advocates. The housing staff is made up of two professionals and seven custodial staff. The food service staff has one manager, one production coordinator, one service coordinator, 15 full-time employees, and 12 hourly workers.
The residence life staff has primary responsibility for intervening in crisis situations. To support the staff's work in this area, the department offers a comprehensive training program. The program consists of a two-credit hour course and an intensive workshop just prior to the opening of school. Topics covered in the class and the workshop cover a range of issues related to crisis intervention. Among the topics the staff in residence life discusses are: fire safety; tornado evacuation; psychological emergencies; working with assault victims; and intervention by the University Police Department. In all of these instances, the staff members are to support the students involved, assist them as necessary, and seek support of their supervisors as soon as possible.
Description of the Event
The event occurred around 6:00 p.m. during the first week of school(7) when students begin to form support networks(9). (Note: the number(s) that appear in parenthesis in this description of the event are references to the symptomatology and characteristics of mass psychogenic illness detailed in the first section). Students were waiting in the snack bar serving line. The weather during the week had been extremely hot and very humid and most of this all-female (2) residence facility does not have air conditioning. The event began when one individual in the serving area reported to another that she had seen some dusty substance in the air (4,5). Then one of the individuals reported feeling very ill and reported this information to the food manager. Almost immediately other individuals reported similar symptoms (1) and smelling a stench (4). The reported symptoms were: shortness of breath, feeling sick, and eye and skin irritation (10). As students reported feeling sick, they were asked to leave the snack bar area as well as the adjoining dining hall area by food staff members. In order to speed up an evacuation, the students were asked to leave their belongings (i.e. backpacks and books) and to return immediately to their rooms.
A number of the residence life staff were in the immediate area and became involved in the evacuation procedure. They guided students back to their rooms, calmed people and dispensed information. As soon as practical, members of the residence life and dining hall staffs informed their supervisors of the incident. Emergency medical personnel, police, emergency repair crews, and various university administrative staff reported to the scene. The first people to arrive found a large number of students and workers reporting symptoms (the final total was 69 people - approximately 8% (1) of the population).
Although the two residence towers are not connected to the central dining area, the decision was made to evacuate the residence areas. This was accomplished by activating the fire alarm. The entire building was cleared by 6:20 pm. Students who reported being ill were taken by ambulance or bus to the hospital. The other students were directed to the lounge areas of the two nearby residence centers. By 7:30 pm, the emergency crews had investigated all possible sources of toxic leaks and determined that there were no leaks nor were any toxic materials found. Based on this information, and the fact that each residence living space had its own air circulation system, a decision was made that students be allowed to return to their rooms. Before allowing students to return to their rooms, however, a meeting was held at 8:00 p.m. with the Residence Life staff at which the police, university administrators, hospital personnel and emergency personnel updated information and answered questions. The resident assistants were instructed to hold floor meetings, to assess the mood and emotional status of their residents and report their findings at a 10:00 pm meeting. Personnel present at the 8:00 p.m. meeting were also present at this 10:00 p.m.meeting. The residence assistants reported the status of student residents, the staff was given updated information, and questions were addressed.
The dining hall area remained closed the next day to enable a full and thorough investigation. The university risk management staff met with all the students who were hospitalized. This office handles liability exposures and investigates any potential claims that might be filed against the university. They paid the medical expenses for these students. Of the students hospitalized, all but three were treated for hyperventilation (10). An exact cause of their aliments was not determined and two were kept for observation overnight. The full investigation of the physical facility did not identify a toxic substance leak (6). Some construction material and cleaning solutions were found, but were not considered to be toxic. The construction material may have produced a dusty substance in the air and the cleaning solutions may have produced a stench (4). The smell also may have come from cooking equipment.
The local newspaper reported this event on the front page the next day. There were several other reports all mentioning that the university was investigating the source of this problem and that there was no evidence of any toxic chemicals or substances in this unit.
When confronted with this type of illness, calm responsive leadership from staff is essential for monitoring the situation. Protocols for contacting emergency personnel need to be implemented immediately, and as soon as possible those stricken should be separated from those showing no symptoms of the illness. A precautionary evacuation of the area and relocation of members of the group to comfortable areas can help avoid panic reactions. It is important that staff be available, both on site where the illness occurred and in the area where the group is relocated so that communication can be maintained and rumors can be held to a minimum. As the number of those stricken increases, facilities for transporting those who are feeling ill will be severely stretched. If possible, those only moderately affected should be transported to the health care facility using buses or other forms of public conveyance which are quickly available. Those experiencing the most acute symptoms will require the attention of emergency medical personnel for transport.
As soon as all victims have been removed from the area, staff should seal off the facility and cooperate with emergency personnel as they conduct their initial investigation to determine the cause of the illness. It is also useful to have staff available to manage the many on-lookers that are likely to come to the scene as emergency vehicles collect around the facility. The manner in which the on-lookers are dealt with can assist in setting a tone of calm and control, as well as limit the number of unsubstantiated rumors that spread regarding the incident. Staff should also be assigned to go to the hospital or health care facility treating those stricken to ensure communication back to the campus and to assist students at the hospital with non-medical concerns including transportation back to campus, contact with concerned friends, and responding to questions regarding when students will be allowed to return to their residence hall rooms.
While the emergency services personnel are conducting their initial assessment of the area in which the illness occurred, access to the facility will likely be under their control. Depending upon the amount of time that a preliminary investigation takes, several alternative strategies should be considered. University staff working as a team should begin considering alternatives for responding to requests from the media for information on the incident, for providing alternative lodging or dining facilities that may be necessary, for educating support staff on the actual nature of the incident, and for informing student residents of actions that will be taken in response to the incident. It is appropriate that one media spokesperson be designated. This person should be readily available to respond to questions with as much information as possible. This is especially important in cases where physical causes for the illnesses are not identified because there will be a tendency to mistrust statements which seem to minimize the danger because of the "real" symptoms experienced by the victims.
When emergency personnel have completed their assessment of the extent and nature of the problem on site, specific decisions can be made regarding return of residents to the facility. In the case study presented, it was decided to close the dining facility for an additional 24 hours so that a more thorough investigation could be completed, although it appeared unlikely that a physical cause for the incident would be identified. The more extensive assessment, and the precautionary evacuation completed shortly after the incident began suggested a tone of thoroughness and care that helped reduce anxiety.
As plans were made to return students to the facility, it was helpful to use medical personnel, environmental hazard officers, and fire safety officers to brief staff on the results of their preliminary investigation. Staff members were assured that it was safe to return to the facility, and precautionary measures being taken in the next 24 hours were discussed. Information was provided on how to respond to questions about the condition of those stricken and what to do if additional students experienced similar symptoms during the next few hours. It was important that support staff communicated that information to residents in small groups so that individual student's questions could be answered, and residents could know who to contact if they perceived additional problems. It also proved beneficial to have the students returning to the facility contact their parents because reports of the incident were spread through the state-wide media. As soon as possible, university risk management personnel or the appropriate office for the institution, should provide information as to who will be responsible for the medical costs incurred by individuals stricken. Since medical payments and liability concerns are often handled differently from institution to institution, it is recommended that legal advice be obtained from the institution's counsel when formulating this portion of a risk management plan. Having an answer that is supported by others in the institution and can be clearly communicated to students and parents will help to diffuse some of the problems after the event.
In the days following the incident, questions will remain as to what caused of the illness, what safeguards are there to prevent a reoccurrence, and what assurances are there that the facility is now safe. Answers to these questions when no physical cause is identified, as is the case in a mass psychogenic illness, must focus on building confidence that adequate care has been taken. Inquiries can be expected from students, parents, and the media. The ease with which individuals with questions can receive a reply from an appropriate university spokesperson can affect the level of trust perceived in the answers given. It is appropriate that at the end of the professional investigation of the incident, a report be issued to all interested parties. Because indeed the symptoms experienced by the victims were real, it is important to acknowledge that. Especially in cases of mass psychogenic illness, a coordinated staff response is essential for minimizing the disruption to the student community.
IMPLICATIONS FOR STAFF TRAINING
Incidents such as that described in the case study reinforce the importance of staff training for coping with emergency situations. Most residence life programs provide training for fire emergencies, weather related emergencies, individual illness and emotional or psychological stress. The use of case studies involving mass psychogenic illness would be a worthwhile addition to those training efforts. It is important, however, that at the onset when the true cause of the symptoms is unknown that staff proceed in a similar manner as would be used with other mass illness situations which are the result of an identifiable physical cause.
Staff training should emphasize the importance of good communication during emergency situations and the importance of controlling rumors with accurate information. Periodic evaluation of the coordination of emergency response services on and off campus should also occur (For one model, see the concept of a trauma response team as discussed by Scott, Fukuyama, Dunkel, & Griffin, 1992). Residence life staff should be involved in that evaluation and review process so that there is a familiarity with response protocols. Familiarity with the phenomena of mass psychogenic illness and recognition of the symptomology and characteristics of this type of event should be discussed in training so that staff can anticipate those occasions when additional vigilance is appropriate. Adequate training and a plan for action in response to mass psychogenic events can help in their overall resolution.
While incidents such as these are relatively rare, the response of staff will set a tone that has an impact on the community well beyond the short term perceived critical nature of the illness.
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