Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (24 page)

Ultimately, however, Charcot’s sweeping power (if not his reputation) was limited to his lifetime. The Viennese psychoanalyst Wilhelm Stekel is quoted as saying, “Twenty years after Charcot’s death one could not find a single case of hysteria in any of the Paris hospitals.”

•   •   •

T
o learn more about somatoform disorders that might previously have been classified as hysterical, I shadowed Dr. LaFrance one day in his neuropsychiatry and behavioral-neurology clinic. I watched him evaluate Gloria, a nineteen-year-old woman who had developed an incapacitating movement disorder over the past year. Before Gloria’s appointment had even begun, I was aware of her symptoms. Sitting in the waiting area with her father, she was occasionally besieged by a violent jerk of one arm, accompanied by a forward thrust of her neck and a throaty, guttural honk. As she walked down the hall toward the exam room, the jerking and honking happened twice more. Passersby turned toward the noise and openly gaped at her.

In the exam room, with the door closed behind her, Gloria immediately started crying. Dr. LaFrance had simply asked her to talk about what brought her to see him. Her body, so recently overtaken by dramatic spasms, sank into the more familiar convulsions of sobs as she described the gradual onset of her “tics.” At first, about a year earlier, she had noticed her hand jerking occasionally, “nothing that anyone would notice,” she said. However, as weeks went by, the movements became more frequent and more pronounced.

“Suddenly my whole arm would jump across my body,” she explained through her tears, “and then my neck started straining with it.” The movements weren’t occasional anymore; they were happening many times in an hour, sometimes even every minute or so. They also weren’t subtle anymore, and people began to turn to look at her.

“I used to go out with my friends,” Gloria said, “but I stopped because I was so embarrassed.” The less she went out, the worse the movements became when she did leave the house. When the noise started in conjunction with the movement, Gloria and her family became distraught.

“Kids started pointing at me in the grocery store. People stared at me wherever I went. Sometimes I think I scared them. I’d be walking down a sidewalk or through a mall, and people would veer away from me. Or they’d put their arms around their kids and pull them quickly in the opposite direction, like I was contagious, or a crazy person or something.” Gloria had been working as a clerk at a rental-car company but left the job. “They didn’t fire me or anything, but they were worried about how customers would feel, whether it would turn people away. Once the noise started, I knew I didn’t really have a choice. I couldn’t stay.”

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.

•   •   •

O
ne 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.