Mass Psychogenic Illness and Trigger Warnings

Though a psychogenic outbreak usually resolves on its own, its victims may be unable to return to regular life without proof from a doctor that their disease was only temporary and that they are again healthy.

Many college students now demand the censorship of ideas they find objectionable, which goes against the history of open inquiry. Many people complain that such beliefs traumatize them, as if to raise the stakes by changing the concerns at hand into medical ones. The term "trauma," as used by detractors of free inquiry, implies that objectionable content not only offends decorum or pollutes the public domain, but also scars the psyche of individuals who are exposed to it. What do we make of the claim that students are so fragile that the curriculum of a lit course should include a "trigger warning" that their psyches may be harmed just as a consequence of the reading?

A medical argument necessitates a medical response.

Assume that in a small town, rumors spread that the insulation crammed into local walls and attics contains a dangerous chemical. Residents begin to report symptoms such as nausea, headache, dizziness, and poor concentration as they are literally surrounded by toxins, with each new instance causing others in a cascade effect. The Emergency Room is at capacity. However, no harmful source can be located after further analysis. According to medical literature, we are dealing with a case of mass psychogenic illness (or mass hysteria): a social phenomenon in which people become ill and inspire others to do the same in the mistaken belief that they have been exposed to a toxic agent, when in fact the belief is the cause of their illness. An epidemic of this magnitude creates a fictitious emergency.

So too, I argue, does the trigger-warning movement. A mass reaction to an imaginary toxin and an over-reaction to the perceived dangers of toxic ideas represent parallel events (except that the threat allegedly posed by toxic ideas lacks the local and limited character of a classical psychogenic incident). Just as the former has the suddenness of a panic, the latter flares up instantly on the slightest provocation, as documented recently by Greg Lukianoff and Jonathan Haidt in their critique of the trigger-warning movement, The Coddling of the American Mind. In both cases an incident can become an immediate cause célèbre, with ambulances, fire trucks, investigators, and reporters hastening to the scene of a psychogenic outbreak, and the news media, social networks, student populations, and university authorities swept up in a comprehensive reaction to students’ claims of injury.

Schools tend to be the most typical site for psychogenic breakouts, maybe because a large group of people in a small space makes for an excellent conductor. In a case reported in the New England Journal of Medicine in January 20001, a teacher in a Tennessee high school became ill after smelling a mysterious petroleum-like odor, and the illness quickly spread throughout the school, with 100 people being taken to the ER on the first day alone, some by ambulance. No harmful source was ever located, despite thorough inquiry. The disease in issue was classified as psychogenic by the authors of the NEJM article, since it was characterized by clusters of symptoms "suggestive of organic illness but without a recognized cause in a group of persons with common views regarding the etiology of the symptoms.” A similar dynamic is at work in the trigger-warning movement, which also creates a state of emergency, draws its power from shared beliefs, and blames injurious effects on phantom causes (such as words on the page).

It’s because of the recognized fallacies of hunting for the deep-seated “cause” of our mental ills that the makers of the diagnostic system used to classify psychiatric disorders in the United States—a taxonomy introduced in the Diagnostic and Statistical Manual of Mental Disorders in 1980—specifically refrained from making causal attributions. For the diagnosis of Post-Traumatic Stress Disorder (also introduced in 1980) they made an exception, however. By definition, PTSD is caused by a trauma or “stressor.” Over time, and contrary to the intent of the original designers of the diagnosis, the lowering of the diagnostic threshold made it possible to claim that events well within the scope of common experience set off PTSD.

As Nancy Andreasen, the chair of the group that developed the original PTSD criteria, noted in 2010, the concept of PTSD was "steadily broadened by clinicians to include milder stressors that were not intended for inclusion.... The diagnosis, assumed to be relatively rare in peacetime, became much more common." Could those who created the PTSD diagnosis with Vietnam veterans in mind have predicted the day in 2014 when students at the University of California, Santa Barbara passed a resolution requiring professors to notify them in advance of material "that may trigger the onset of Post-Traumatic Stress Disorder symptoms"? The term "trigger," a provocative synonym for "cause," as employed here and elsewhere by the movement that adopted it, demonstrates the causality assumptions that drive a psychogenic epidemic.

Much as illness raced through the Tennessee high school not as a result of a toxic exposure but because those affected got swept up in a frenzy of imitation, demands for trigger warnings raced from coast to coast in recent years in a kind of epidemic manner. As noted by the New York Times in 2014, “Colleges across the country this spring have been wrestling with student requests for what are known as ‘trigger warnings,’ explicit alerts that the material they are about to read or see in a classroom might upset them or, as some students assert, cause symptoms of post-traumatic stress disorder.” As the spread of the phenomenon suggests, we confront here a movement that reproduces its own exaggerations virally. The Times itself illustrates the mechanism of exaggeration in the smooth shift from the statement that material “might upset” some students to the statement that it might clinically traumatize them.

While a trigger warning in theory guards against trauma, it has the actual effect of multiplying claims of trauma by students who are primed to expect it and have a ready-made lexicon to describe both its effects and the outrages that bring it on. Elsewhere I’ve discussed the process of “disease-mongering” by which normal experiences like transient depression come to be defined, diagnosed, treated, popularized, and perhaps even suffered as disorders. (See, for example, The Nocebo Effect: Overdiagnosis and Its Costs [Palgrave Macmillan, 2015].)  The trigger-warning movement brands and propagates “trauma” in the same way, making it possible to portray even a work as non-inflammatory as The Great Gatsby as dangerous to the psyche of the reader. While the distress of the aggrieved students is real, so was the distress of the Tennesseans who found themselves in the ER as a result of exposure to an agent that didn’t exist.

How can words on the page come to be amplified into an existential menace if they have as little potential to create deep and enduring harm as an imagined toxin? Perhaps the trigger-warning movement gives them a virulence they don't have otherwise. As more students join the movement and imitate one another's actions, the bandwagon as a whole gains strength, which in turn fuels the rhetoric of those who ride it. The trigger-warning movement feeds on itself in the sense that its strength inflates its claims, which in turn mobilizes its followers. In the same way, a psychogenic epidemic does. The sight and story of so many individuals becoming unwell at the school in question motivated others to become ill as well. So much duplication of behavior took place that, in the words of the NEJM authors, symptoms seemed to spread by “contagion”—sociological contagion, that is. For what it’s worth, the medical literature refers to the event inciting such an outbreak as a trigger.

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The trigger-warning movement isn't limited to a specific location or moment, unlike the Tennessee instance, which appears to have been rendered all the more acute by its confinement. Nonetheless, mimesis is at the root of it. Participants in the movement shout the same grievances and distress formulae as those who produce identical complaints in reaction to the same imagined poison, with all of this identification working to unite the soldiers and recruit additional believers. Members of the trigger-warning movement have strong opinions about what constitutes a trauma in the first place, much as the Tennessee incident occurred among people "with shared beliefs about the etiology of the symptoms." One of such views is that belief-systems such as racism constitute a fatal threat, which is why they wish to police opinion, which is in direct opposition to the heritage of open inquiry.

While doctors on hand during psychogenic outbreaks tell “war stories” about them and count the costs of the “disruption to the community” (as the NEJM authors put it), the proponents of trigger warnings seek to disrupt the community, just as they aim to impose their own sort of martial law, in which ordinary liberties like respect for the beliefs of others are suspended. In response to the psychogenic outbreak, the Tennessee school shut down temporarily. The study of a literary work can readily be shut down if all students need to do to shut it down is claim to be wounded by it.

Notwithstanding the over-reactions of those caught up in the psychogenic episode on the one hand and those traumatized by their reading on the other, the disturbances that set off their fears are not especially unusual. Among the Tennesseans who thought they had been exposed to toxic fumes the most common symptoms reported were headache, dizziness, nausea and drowsiness—the sort of nonspecific ills that show up in any number of disorders or in no disorder at all, being part of the human lot. The entire list of reported symptoms, including such generic ones as “nervousness,” reads like an anthology of human complaints. To be offended or even disgusted by something you read is also a common event.

However, in both circumstances, an inflammatory interpretation permits the individual experiencing the events to view them as a crisis. With so many people around you becoming unwell as a result of inhaling pollutants (and who can resist breathing? ), little ailments like headaches and anxiousness take on a new significance and become crises. The fire alarm was indeed triggered in the middle of the panic in the school in question. Members of the trigger-warning movement are experts in alarmist hyperbole, criticizing not just "unsafe environments," but also those who reject their "right to exist." The regular emotion of being bothered or offended by words on the page might balloon into the ominous experience of being threatened in the atmosphere of exaggeration provided by their own voices. As a result, a movement designed to provide a sense of security in pupils has instead exacerbated their worries.

As the psychogenic incident played out in the Tennessee high school, at some point it became clear to doctors that no toxic source existed and that the complaints they were seeing—compounded of quite ordinary symptoms—had no cause beyond the anxieties of the sufferers, just as in other incidents of this kind. Neither air samples nor the school’s ventilation and plumbing systems nor an aerial survey of the region nor even an investigation of some caves in the vicinity of the school yielded any suspect finding. Blood tests of everyone evaluated in the ER proved normal.

Despite this, the physicians decided it was better to let the scenario play out rather than bring out to people who had been unwell that they had caused their own disease. The authors of the NEJM wrote, "Physicians and others are naturally hesitant to proclaim that an epidemic of sickness is psychogenic, because the diagnosis tends to arouse guilt and wrath." Students who claim to be traumatized by the written word may react angrily to any counselor or therapist who even suggests that their suffering is their own fault. Professors, for their part, are hesitant to challenge students' claims to authority over what may and cannot be stated in the world.

Though a psychogenic outbreak usually resolves on its own, its victims may be unable to return to regular life without proof from a doctor that their disease was only temporary and that they are again healthy. Another potential parallel to the trigger-warning movement may be found here. If Lukianoff and Haidt are correct, the false emergencies that the movement creates (and the restrictions on liberty that such crises bring) will continue until young people who have been raised believing that they are delicate beings are reassured about their ability to withstand the stress and strain of intellectual conflict. Of course, the fact that students seeking the suppression of harmful ideas have the strongest psychological justification for their intolerance—that they are merely acting out their upbringing—doesn't excuse them at all.

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