Abstract
Communicable diseases are transmissible diseases which result from infection, presence and growth of pathogenic biological agents in an individual human being who may become a carrier and further spread the disease to others. Pathogens may be viral, bacterial, parasitic or fungal and are capable of being spread through air, water, food, blood or other bodily fluids. A large number of infections or communicable diseases have been identified, including influenza, hepatitis, polio, HIV/AIDS, malaria, tuberculosis, typhoid, paratyphoid, among many others. In every communicable condition, the infectious agent affects the susceptible host through a specific mode of transmission. The susceptibility of the host is paramount in our understanding of the spread of communicable diseases. Communicable disease is differentiated from contagious disease, which is communicated through bodily discharge. Communicable disease, however, is an infectious disease transmissible from person to person through direct contact with an affected individual or through a vector.
The communicability of symptoms in psychiatry is often not explored. In this editorial, we highlight some psychiatric conditions which show clear patterns of communicability. Common three conditions in psychiatry are as follows: mass hysteria, folie à deux or folie à famille and epidemics of koro. We expand on mass hysteria.
Mass hysteria. It is often reported from schools, prisons and institutions where a large group of individuals suffer the same or similar hysterical symptoms, resulting from a phantom illness or an inexplicable event. It is generally accompanied by severe anxiety, excitement, panic, hyperventilation, abnormal beliefs and odd behaviours. Bartholomew and Goode (2000) list a large number of social shared delusions and hysterias from the past millennium. They define collective delusions as spontaneous, rapid spread of false or exaggerated beliefs within a population at large temporarily affecting a particular region, culture or country. They point out that mass hysteria is characterised by rapid spread of conversion disorders – a condition affecting the body but without an underlying organic basis. One recent epidemic occurred in a Malaysian school in April 2016 (‘Malaysia School Shuts’, 2016). Students complained of feeling a heavy presence and ‘seeing’ a figure. Similar reports had been reported in many other settings.
Such mass hysteria may also be seen after the death of a popular leader. Many such episodes have been reported from India where many people commit suicide after the death of a political leader. Morley (2015) reported an outbreak in Colombia affecting 240 pre-teen and teenage girls who were all hospitalised with perplexing symptoms such as fainting spells, shortness of breath, severe headaches, numb hands, nausea and convulsions. The individuals thus affected believe genuinely that they are ill, and triggers are often environmental. More often this is seen among girls, who appear to be more susceptible than boys. The key question is whether this should be seen as a collective response to stress or whether it should be seen and treated as mental illness. It is apparent that social and group influences play an important role. Thus akin to the public health model, a contagion affects the most vulnerable individuals. This vulnerability may be psychological or related to some form of strain.
The communicability of psychiatric symptoms therefore depends upon individual vulnerability, social pressures and the social environment within which these symptoms appear. Gruenberg (1957) hypothesised that social integration may play a role in developing social shared psychopathology. Wessely (1987) suggested that mass hysteria can be sub-divided into two varieties: mass anxiety hysteria and mass motor hysteria. Mass anxiety hysteria consists of episodes of acute anxiety seen generally in schoolchildren. In such cases, prior tension is absent and the rapid spread is related to visual contact. On the contrary, mass motor hysteria shows abnormalities in motor systems which can be seen across all ages. Wessely (1987) points out that such type of motor hysteria may have a gradual spread. Whereas abnormality is confined to group interaction in mass anxiety hysteria, in mass motor hysteria abnormal personalities and environments are implicated. There is little doubt that whether such events are anxiety or motor abnormalities, vulnerability at the individual level, social interactions and actual environment all play a role and deserve to be explored.
Social disintegration and subsequent integration may contribute to precipitating factors. Social networks enable us to understand individual behaviour. Across cultures, dimensions of cultures may play a significant role in the development of mass responses and also the actual types of responses. In socio-centric societies, any communication between groups of vulnerable individuals may well be very different from that of ego-centric individuals in ego-centric societies. Social networks are related to social relationships in social settings (Barnes, 1954). Mitchell (1974) points out that social networks may allow researchers to study corporate behaviours and observes that the data concerning all the links in a social network related to some event or series of events in which the analyst is interested must be inclusive. Thus the clinician dealing with people who experience hysteria or other shared psychopathology may well need to understand the actual social network and its significance to the individual.
The common features in these conditions are a vulnerable individual or a vulnerable group of individuals who are susceptible to the suggestion or pathology. The communication of pathology may well vary according to the condition. Often no vector is identified, but there may be clear direct contact with ‘affected primary’ individual. The vulnerability of other individuals makes them susceptible and they ‘catch’ these symptoms.
A major reason for our interest in the communicability of psychiatric symptoms has to be in developing a public (mental) health programme in place which can help identify vulnerable individuals and ‘inoculate’ them. Epidemics of mass anxiety whether they are anxiety hysteria or koro may well be self-limiting, but the spread of anxiety widely may not always respond to simple public education. It requires clear identification of vulnerable individuals with specific targeted intervention. In folie à deux and folie à famille, it is the strong individual who develops pathology first, and then this is taken up by others around them. Thus, the communicability of psychiatric symptoms depends upon having a strong initiator and a group of vulnerable individuals who get affected.
Thus, the challenge for clinicians, public health physicians and social psychiatrists is to understand and develop public health models which can allow the identification of vulnerability stressors and help develop ‘inoculations’ which can stop the spread of these communicable symptoms.