It looks like we can file this one under “here we go again.” A small town in Colombia, El Carmen de Bolivar, has seen more than 200 girls hospitalized with a mysterious illness since May of this year. The symptoms include dizziness, headaches, and fainting. So far, all of the girls hospitalized have been found to be healthy and were quickly released from the hospital without discovering any specific disease or pathology.
Unfortunately I have to depend on news outlets to provide information about this case, and most are skimpy on details. However, taking what is being reported, the case has all the features of mass psychogenic illness. Specifically, the cases are clustering in a small community, which is typical for typical for episodes of mass delusions. The symptoms being reported are all subjective and the kinds of symptoms that can result entirely from psychological stress. I have seen no reports of objective clinical findings, such as fever, rash, abnormal laboratory findings, strange lesions, or objective findings on exam.
Doctors who have examined the patient feel that the presentation is consistent with psychogenic illness. I have discussed this at length previously. A psychogenic illness results from the physical manifestation of psychological stress. This is always partly a diagnosis of exclusion, meaning that other causes of the presenting symptoms need to be ruled out. However, it is more than just a diagnosis of exclusion, as there are sometimes clinical features that can be positively demonstrated to be psychological rather than physical. The ultimate test of the psychogenic diagnosis is that patients should improve with support and encouragement.
From a practical clinical point of view, once a specific treatable illness has been ruled out (it may not be possible to prove a negative, that no biological illness is present, but it is possible to rule out any known and treatable condition), then it makes sense to focus on symptom management and quality of life. Further, all chronic illnesses can have a psychological component. Being chronically ill can cause stress, anxiety, and depression which in turn can disrupt sleep, cause muscle tension, and result in further physical symptoms.
Therefore, once demonstrable, treatable pathology has been ruled out, a physician can remain agnostic toward the true underlying cause of the symptoms, and shift focus to managing quality of life, including stress management, treating anxiety and depression, and improving sleep and other lifestyle factors.
There are a few pitfalls that can happen along the way, however. Patients or their family may be frustrated at the lack of a specific pathophysiological diagnosis and will therefore continue to seek a specific diagnosis and treatment. There are certainly cases where a specific diagnosis was missed and only later properly diagnosed. Therefore it is reasonable to seek a second or even third opinion regarding an unusual illness. Also it’s important to make sure you have seen an appropriate specialist. However, this can turn into an endless and counterproductive adventure in doctor-shopping, with endless “million-dollar workups.”
Even worse, desperate patients seeking an acceptable diagnosis may run afoul of a fringe or alternative practitioner who will happily provide a dubious diagnosis and offer to treat.
In some cases, patients may find themselves the focus of media attention. Journalists looking for a “dog bites man” narrative are likely not to put the story into a reasonable perspective, but rather spin a tale of a desperate patient being dismissed by an uncaring medical establishment, perhaps with a brave maverick doctor willing to step in and save the day. An alternate narrative can turn the case into a “mystery illness” and then stoke fears of a possible environmental cause that can be putting the entire community at risk.
These are the cases that may catch fire and turn into a mass psychogenic illness. Now, with social media, mainstream media is no longer necessary. Posting one video on YouTube or Facebook may be enough to fan the flames. Of course, in a local and tight-knit community, no media is necessary, as fears can spread the old-fashioned way, by word of mouth.
The Colombia case seems to one of the local spread variety. This is case often described as a “community panic” – in this case there is widespread fear among the community that the Gardisil vaccine is to blame. All of the patients with symptoms are girls, and it is reported that they all recently received the Gardisil vaccine (however, I find it unlikely that 100% did, and we are given no authoritative information that this claim is true). Some parents are already convinced it is the vaccine, and the claim is being irresponsibly spread by some media outlets.
There has already been an investigation (at least preliminary), and there does not appear to be any connection to the vaccine. It is reported that 2.9 million women in Colombia alone have been given the Gardisil vaccine, and there is no indication of any similar reaction.
The story is very similar to the LeRoy New York story from 2012. In that case 20 children (all but one girls) came down with a “mystery illness” characterized by twitching. Activists came out of the woodwork to exploit the case to promote their pet ideology. Anti-vaxxers, as with this case, immediately blamed Gardisil. Some environmentalists (most famously, Erin Brockovich) blamed toxins in the soil. Brockovich argued it was from a chemical spill from 1970. Alternative practitioners were happy to offer their fake diagnoses – one patient being diagnosed and treated for chronic Lyme disease.
Now, two years later, the dust has settled on the LeRoy case. No toxins or environmental factors have been identified. No doctor has been able to document any previously-missed pathology. The neurologist who treated 15 of the patients also reports that they are completely or mostly better with nothing but reassurance. It’s possible that the initial case was a genuine case of Tourette’s syndrome, but then triggered a psychogenic reaction in the other cases.
Conclusion
We will have to wait for more details to emerge regarding the Colombia case, but as of now it seems like a classic case of mass psychogenic illness. There hasn’t been as much of a media feeding frenzy so far as there was with the LeRoy case, but now that the story is getting some international attention that may change.
Media attention in such cases is largely counterproductive – helping to spread symptoms, spread unfounded fears, and promote fringe theories. I am not saying it is wrong to report such stories at all, but care should be taken to put them into a proper context and to avoid spreading unnecessary fear. Media reporting so far has at least contained some skepticism. Most reports include the following:
Meanwhile, Health Minister Alejandro Gaviria is criticizing hyped coverage by the media for stirring panic, saying concerns about their vaccine, which has been applied to 2.9 million women in Colombia, are baseless.
“On one side we have the weight of scientific evidence and on the other are opinions and moral prejudices,” he told W Radio on Wednesday, adding the cervical cancer claims the lives of more than 3,000 women every year in Colombia.
I do think it’s important to properly report such cases, and to do appropriate follow up. There hasn’t been nearly as much reporting about the follow up of LeRoy, for example, as there was for the initial occurrence. It would be good for the public to know that in that case, the experts were correct and the psychogenic illness hypothesis was largely demonstrated to be correct. Further, speculations about environmental toxins and vaccine fears proved baseless.
