In the fall of 2011, a mysterious illness came over the pupils of Le Roy Junior/Senior High School east of Buffalo, N.Y.
Student after student and one single adult – 20 individuals in total – inexplicably began stuttering, twitching and exhibiting other involuntary movements. The alarming spread of the bizarre symptoms captured national and international media attention, as environmental activists, including the famous Erin Brockovich, hypothesized that toxic contaminants were to blame.
Yet, all tests conducted by school and state officials ruled out potential physical causes, including pollutants, side effects from drugs and vaccines, trauma and genetic factors, according to a Reuters report of the episode.
The diagnosis? Mass psychogenic illness, also known as mass hysteria.
Mass psychogenic illness is a curious socially transmitted phenomenon, in which multiple individuals come down with physical symptoms in what's believed to be a reaction to a psychological stressor, such as fear. Far from imaginary, the symptoms are – and to the sufferers, feel – very real. It's a stark example of the powerful connection between the body and the mind.
What if you could contract an illness just by being in a place where people believe in it?
What if you could cure what ails you by relocating to a place where people don't believe your malady exists?
These are some of the titillating, if controversial, ideas that U.S. writer Frank Bures explores in his wonderfully weird new book, The Geography of Madness: Penis Thieves, Voodoo Death and the Search for the Meaning of the World's Strangest Syndromes.
As the title suggests, Bures leads his readers around the globe, looking for insights into what are known as "culture-bound syndromes" or "cultural syndromes." These include voodoo death, also known as psychogenic death, where people seem to die when they believe their own death is imminent, and amok, a Malaysian term for when individuals go on a wild killing spree with no recollection of having done so afterward. Similar to mass psychogenic illness, they're influenced by a social group or collective mindset.
It may all sound like the stuff of magic and make-believe. But Bures makes the case that our cultural beliefs also play a significant role in many of the common conditions we experience in the Western world, including premenstrual syndrome, gluten intolerance and depression. Science, education and a skeptical attitude toward voodoo and spirits do not make us immune to our own cultural syndromes, he argues.
The main focus of Bures's adventures, however, revolves around finding answers to one particularly peculiar phenomenon called koro, where men perceive their penises shrinking, vanishing or being "stolen" from them. As unbelievable as koro may sound to North Americans, Bures tracks down sufferers, healers and psychiatrists from Nigeria to China, where incidents of koro not only occur, but sometimes occur in epidemics.
I reached Bures at his office in Minneapolis, Minn., to ask him to explain.
What is koro?
It's a condition where a person feels his, and sometimes her, genitals are being pulled into their body, and there's a fear that they'll die if that happens. It's sometimes called genital retraction syndrome. You'll find different versions of it in different countries around the world. In some countries, it'll be kind of contagious and spread among people in a mass-panic way.
It is partly a mass psychogenic illness when it spreads through a population, but it's also a body dysmorphic disorder, too, and it's related to the cultural narrative that people believe in.
How does koro in Nigeria differ from koro in Hong Kong or koro in the southern Chinese island province of Hainan?
It differs in the world that it comes out of. So people in Nigeria will believe that different forces are behind it than in China. In China, Singapore, Hong Kong, it's sometimes related to the traditional Chinese medicine idea of balancing hot and cold energies and the fear of losing too much heat. In Hainan, it's sometimes seen as a spirit or a fox ghost who wants to collect penises or heat, or yang energy, so it can go into the next world. There are different versions. In Nigeria, the perceived root cause would be magic, or invisible forces that other people can control for good or ill on a personal level.
What is it about the cultures of these places that explains why koro occurs there?
In any culture, what makes something like this possible is if enough people believe it and if enough people hear stories about it. When you hear stories about something happening to someone like this, or anything really, at first, there's a process of it becoming familiar, then possible and, ultimately, if enough people believe it strongly enough, it becomes real for everybody. So that's kind of how this works.
In some places in Nigeria, you won't find people doubting this is a possibility. So the environment is such that it can run through a population like that. In Nigeria, there's also a lot of insecurity and in a place like Lagos, it's chaotic, or at least it was when I was there. You always feel like you've got to watch your back. But that wouldn't explain all of it. A lot of these things are just down to really the shared narrative that people have. I mean, you'll read in the paper about penis thefts happening.
What separates cultural syndromes from mere superstitions?
When you say superstition, that implies that it's just something made up or something not real, or imaginary. That goes back to this view that there's a correct view of the world, which is ours in the West, which doesn't have superstitions and is purely rational and factual and empirical, and that there are other people who have not risen to our level of civilization who don't have this correct view yet. That's an old understanding of cultural evolution.
But I don't think that's an accurate way of looking at it because we can see the same effects in our medicine and in our culture, where our beliefs are an active part of things and it's more of an interaction between the beliefs and the biology than just either the beliefs or the biology.
Some of the people you interviewed in the book suggested education will eliminate some of these syndromes, like koro. What do you think?
I think it might, but I don't think that means there won't be cultural syndromes. I think what will be happening, and what is happening, is maybe what we used call cultural syndromes are still around, but they're not as frequent or they appear in slightly different forms. But also you have Western cultural syndromes creeping in, like anorexia.
This idea that anorexia or some of the other examples you offer, such as premenstrual syndrome, gluten intolerance and depression, may be cultural, it sounds like an invitation for a fight.
Well, yeah, it might be. Not a fight, but a conversation I'd like to start.
So can you explain what is it about these conditions that may be culture-bound?
What I mean by that is our model of the body is a biomedical model in the West. And, generally, that means viewing it as a machine. When something is wrong, we feel like you should be able to find a biological cause and fix that the way a mechanic fixes a car. But the body is just not that simple.
There's a [Canadian] philosopher named Ian Hacking who came up with this idea of "bioloop," where the mind and the body contribute to each other in this sort of looping effect; your beliefs alter your biology and your biology has an effect on your mental state. So that would mean our ideas of what we expect from the world and our life would be factors in our health and illness as well. So, like, a factor in depression would be this expectation in the United States, and Canada too I'm sure, of happiness and the feeling that if you're not happy, something is wrong. Other cultures don't really have that expectation. That could be not necessarily a cause of depression, but a factor.
In Kelly McGonigal's book The Upside of Stress, she talks about when you view stress as dangerous, your body has what's called a threat response. You produce different hormones, you have a different blood flow, a different heart rate compared to what's called a challenge response, when you don't view stress as dangerous. In the short term, it's not really a big deal, but over the long term, the threat response can have a lot of negative affects that we associate with stress, but the challenge response doesn't.
So, let's say, for example, if you're viewing your unhappiness as damaging, does that contribute to a threat response that is more damaging and contributes to poorer overall well-being? These are the questions we're asking. It's more complex than the biomedical model, but it's also more real.
How do the placebo effect and the nocebo effect fit into all this?
The placebo effect is experiencing the health benefits of positive expectations from a treatment. Nocebo effect is the opposite. It's experiencing negative effects from a perceived harm. They work by different mechanisms, but the way they work is the same. The expectation is created and this kind of experience happens in the body.
There's an experiment in the 1960s where people were given sugar water and told, "This is going to make you vomit," and it does. Or they're told, "This mild electrical current is going to cause you pain in your head," and there's no current, some people will experience pain anyway. These are not imagined side effects. People actually feel nauseous, they actually feel pain, not imagined pain.
So what did you find out about the treatment or cure for koro?
Some patients get better when they go to the doctor, and the doctor tells them: "It will be fine. You won't die from this." So some people will modify their belief so that it's not a dangerous thing. Some people will modify their belief so that they don't believe it's a real thing any more. And a few people will keep experiencing symptoms because our culture has a power over us. It can be changed, but it's hard.
Diseases you can get if you believe in them
In his book The Geography of Madness, author Frank Bures explores the phenomena of cultural syndromes, conditions that seem to occur only in specific areas of the world and among specific cultures. Here are a few examples.
Hikikomori: This form of severe social withdrawal affects mainly young Japanese men. Sufferers can confine themselves to their rooms for years, and as Bures observes, some even develop necrosis, or tissue death commonly associated with bed sores.
Amok: Although the term "amok" comes from Malaysia, the phenomenon – the act of going on a killing rampage with no recollection afterward – is recognized in other places around the world. Amok, for example, is called "mal de pelea" in Puerto Rico. Bures suggests mass shootings in the United States, which tend to occur with far less frequency in other countries, may also be considered a variation of amok.
Fugue: A Frenchman named Albert Dadas is believed to have been the first case of fugue, documented in the late 1880s. Dadas was known to possess an uncontrollable compulsion to wander off and reappear elsewhere without any recollection of how he got there. Although fugue had its heyday and the term still appears in casual use, Bures says people are no longer diagnosed with fugue.
Premenstrual syndrome: This is among the more controversial examples he raises, and Bures emphasizes this is not primarily his own argument, but a case others make: PMS doesn't seem to exist in the same way in other places in the world. Women in Hong Kong, for instance, experience some of the physical symptoms, such as bloating, before the onset of menstruation, he says. But they do not tend to experience many of the other symptoms associated with the syndrome, such as anxiety, moodiness, sadness and food cravings. "I'm not saying it's not real," Bures emphasizes. Rather, he suggests people's expectations of PMS could impact women's experience of it. Wency Leung