I grew up in Batavia, N.Y., about ten miles down the road from the small town of LeRoy. I had just gone off to Cornell a few months before the big train derailment in December, 1970, that spilled cyanide crystals and about 30,000 gallons of the solvent called tricholoroethene onto the railroad bed.
I never imagined that 40 years later, as a psychiatrist, I’d be reading about this incident in connection with one of the most mysterious mass outbreaks of neurological symptoms in recent memory. And yet, this past January, the environmental-activist-cum-movie-star, Erin Brockovich, began investigating a possible connection between that chemical spill and the bizarre outbreak among a group of LeRoy Junior-Senior High School students.
I truly don’t know what explains the strange constellation of signs and symptoms seen in this group of young people. I’m not sure anybody does. Most of the expert opinion has settled on the description of “mass psychogenic illness.”
Some clinicians have used the term “conversion disorder,” which, in the older psychiatric classification (DSM-II), was considered a type of “hysterical neurosis.” (Subsequent DSMs expunged the terms “hysteria” and “neurosis” for a variety of reasons.) From the reports I have read, the teenagers involved have had a thorough medical and neurological evaluation. Dr. Gregory Young of the N.Y. Department of Health told NBC News, “We have conclusively ruled out any form of infection or communicable disease and there’s no evidence of any environmental factor.’’
My colleague and CNN mental health expert, Dr. Charles Raison, recently reviewed this story in a thoughtful commentary. He concluded—quite reasonably—that “conversion disorder is a plausible explanation” for the tics, verbal outbursts, and apparent seizures afflicting this group of 12 or more adolescent females. (It seems that one male and a 36-year-old female are also among those now showing tic-like symptoms).
But as Dr. Raison rightly observed, “No one likes conversion disorder as an explanation for the tic epidemic. Patients feel insulted, stigmatized and dismissed. Their parents feel dismissed and terrified that something medical has been missed… And what doctor worth his or her salt would be truly satisfied with an explanation that tells us nothing about the cause of the disease or how to specifically treat it?”
Indeed, there are many difficulties with both the concept of conversion disorder and the secondary explanation of “mass contagion.” When I was in residency, one of my revered teachers used to say, “Beware of diagnosing hysteria. It’s usually the last diagnosis the patient will ever receive.” She meant that once a patient had been labeled with “conversion disorder” or “hysteria,” no doctor would ever again take the patient’s symptoms seriously. The patient could end up in the emergency room with crushing, substernal chest pain radiating to her jaw—classic symptoms of a heart attack—and still be labeled “a hysteric!”
But the problems with “conversion disorder” go much deeper. First of all, what exactly is being “converted” in this disorder? This particular diagnosis—listed among the so-called somatoform disorders– is actually an anomaly in the modern-day classification scheme. As even many non-psychiatrists know, the current DSM-IV normally uses a combination of personal history, behavioral observations, and reports from the patient as the basis for diagnosing a given disorder. The premise behind the post-DSM-II classification schemes is that the diagnostic criteria should not speculate on “hidden” or internal causes, such as the “unconscious defense mechanisms” so dear to psychoanalysts.
Indeed, with a few exceptions—for example, Adjustment Disorders, Post-traumatic Stress Disorder, and certain disorders due to medical or neurological causes—the DSM-IV steers clear of “explaining” much of anything. So again: what is being “converted” in conversion disorder? In truth, nobody knows. In psychoanalytic theory—not necessarily synonymous with the truth—it was hypothesized that a repressed idea or unconscious conflict was “converted” into a bodily (somatic) symptom, such as a paralyzed limb. In effect, the psychoanalysts argued that the body would “speak” for the mind’s dark, submerged impulses—particularly in young females. For example, a wife’s unconscious, “forbidden wish” to strike her husband might lead to sudden paralysis of her arm.
But no scientific study or experiment has ever proved this theory—nor is such proof likely, given the obvious difficulties in spotting those repressed ideas as they are mysteriously transformed into bodily impairments.
But even if the psychoanalytic theory were somehow proved, we would then have the further difficulty of explaining the “contagion” effect—how the “hysterical neurosis” leaps from the initial sufferer to other nearby individuals, as has been theorized in LeRoy. Does the original unconscious conflict get converted into some sort of electromagnetic wave that travels to the brains of susceptible victims? Or, more plausibly, do we need to invoke sociological theories, involving empathic “identification” of suggestible subjects with the initial sufferer? Perhaps so—but here, too, we are more in the realm of speculation than of science. And yet, there is no denying that history records many outbreaks of what, for lack of a better term, we call “mass psychogenic illness” –often, but not always, among young females.
In recent years, advances in neuroimaging have fostered more “brain-based” studies of so-called conversion phenomena. For example, Dr. Jon Stone and colleagues in Edinburgh, Scotland, studied patients diagnosed with conversion-related ankle weakness, and compared them with control subjects instructed to simulate the same symptom—that is, control subjects were told to “fake” ankle weakness. Using a technique called functional magnetic resonance imaging (fMRI), these researchers found a distinctive pattern of regional brain activation in the conversion subjects. The pattern overlapped with, but differed from, that seen in the “simulators.”
But it’s not yet clear whether the pattern in the conversion subjects represents a cause or a consequence of the underlying problem. And, thus far, there is still no consensus on the underlying neurobiology of conversion symptoms. Some evidence suggests that individuals (mainly females) with conversion symptoms have higher-than-expected rates of childhood trauma, including physical or sexual abuse. While this could point to “psychological” explanations of conversion, it may also suggest that early childhood trauma has long-lasting effects on brain structure or function. Indeed, the more we examine conversion phenomena, the less useful the “mind vs. brain” dichotomy appears. Calling conversion symptoms “psychogenic” – suggesting that they are mere phantasms of the mind — may greatly oversimplify their underlying nature. Many cases of apparent “hysteria” eventually prove to have underlying medical or neurological causes. Furthermore, there are documented cases in which “hysterical” symptoms have been found to co-exist with bona fide neurological disease.
Whatever the ultimate cause or causes of conversion, it seems clear that this condition does not represent “malingering” or an attempt to deceive others. Unfortunately, individuals diagnosed with conversion symptoms are often written off as “crocks” or “fakers” and denied a thorough medical evaluation. For some patients with apparent conversion symptoms, “hysteria” is indeed the last diagnosis they are likely to receive. In time, we may discover a number of distinct causes for the symptoms experienced by the LeRoy students, varying from person to person. For now, we need to keep an open mind about whatever is afflicting these young people, and treat them with respect, understanding, and patience.
Thanks to Dr. Charles Raison for his helpful comments on this piece.
Image courtesy of Wikimedia Commons.