EagleTribune.com, North Andover, MA

January 30, 2013

Unexplained hiccups may be related to stress or strep strain

By Ethan Forman
Staff writer

---- — DANVERS — With more than a dozen students reportedly exhibiting unexplained vocal tics or hiccups at Essex Agricultural and Technical High School, some look to a psychiatric cause called mass psychogenic illness that can be related to stress. Others say it could be a rare case of a strep infection leading to an autoimmune reaction.

Local and state health officials have declined to speculate but are investigating. School officials are cooperating with experts in trying to find a cause, and Danvers Public Health Director Peter Mirandi has said he has no confirmed cases.

Dr. Edward Hart, a pediatric neurologist at North Shore Medical Center, has not examined any of the students at the approximately 450-student agricultural and vocational school, but said it appears that “mass hysteria or conversion disorder” may be at work.

It was the same diagnosis of the doctor who examined a group of high school girls at Le Roy High School in upstate New York last year who came down with debilitating tics. As in that case, there seems to be a line drawn among those who see the issue as a psychiatric disorder, not easily explained or treated, and those who see the matter in light of a rare condition in which a strep infection leads to an autoimmune reaction in the brain, resulting in tics or other behaviors.

“Subconscious mechanisms can take over in the absence of a biological or organic cause and propagate it,” Hart said. He thinks clusters of students coming down with the same symptoms are examples of conversion disorders, rather than the cause of a bacteria or a virus.

Hiccuping, the involuntary contraction of the diaphragm followed by a “hic” sound, is also called singultus. Hart said anyone can make a hiccup sound voluntarily.

However, in the case of more than a dozen students coming down with bouts of hiccups, “in no way are they malingering, they are not doing it on purpose,” Hart said.

What is at work is subconscious, he said.

“It was once hypothesized that these mechanisms were in response to underlying conflicts,” Hart said in an email, “which the subconscious mind somehow ‘converted’ into these behaviors. As the conscious mind rejects some inner thoughts, it was believed, they then emerged in other ways, as, for example, in a hiccup. That theory is not now universally accepted, by any means, and the exact subconscious mechanisms are not truly understood. What is accepted, however, is that these behaviors do not have a biological basis, and thus they are not ‘catching’ or contagious, despite the appearance of spreading from one student to another.”

Hiccups are not contagious and usually stop after a short period of time, and the odds are unlikely that more than one student, much less more than a dozen, would develop bouts of hiccups at the same time, Hart said.

What may be at play is that one student comes down with the hiccups, perhaps a leader among students. It’s possible that subconsciously students want to be like that other student, so others catch the same anxiety and the disorder takes on a life of its own.

“For whatever reason, it spreads,” Hart said. Girls are more susceptible, he said.

One parent who knows a thing or two about dealing with such an issue is Lynn Johnson, a Virginia mom whose daughter, Lauren, was featured in the national news for sneezing up to 25,000 times a day in 2009.

Johnson said her daughter was eventually diagnosed with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or PANDAS. It’s as if one’s autoimmune system is “going defunct,” she said. A series of illnesses, Lyme disease, a vaccination and a severe cold might have triggered her daughter’s condition. Lauren was eventually treated with antibiotics and antibodies, and the sneezing stopped. She’s now a freshman in high school and an aspiring marine biologist.

Johnson cautioned that one should not draw conclusions, and that any number of things, from environmental to infectious triggers, could be at play. Each child needs individualized screening to see what is at work.

“Keep an open mind,” said Johnson, who founded The PANDAS Resource Network to provide information to parents, physicians and health care providers with information. “No one should be telling you without a thorough examination you have conversion disorder or PANDAS.”

Dr. Lazlo Mechtler, the medical director of the neuro-oncology department at Dent Neurologic Institute in Amherst, N.Y., treated the girls at Le Roy High School who suffered from debilitating tics.

His diagnosis of conversion disorder, rather than PANDAS, came under intense scrutiny.

Mechtler said yesterday that he wants to be cautious and does not want to make a diagnosis from afar, but students should be seen by a physician and a neurologist who specializes in such disorders, and a long list of possibilities need to be ruled out before a diagnosis can be made.

In a case of conversion disorders, Mechtler said, when a group of people start exhibiting the same symptoms, it’s called a mass psychogenic illness.

In treating such a case among students, the kids need to be kept from one another, kept away from social media, and kept off TV and out of the mainstream media, to avoid making their conditions worse, he said. There should be minimal media exposure, and only reputable doctors should see them.

In the Le Roy case, Mechtler found that when other doctors came up with other theories, and the networks and cable shows descended on the families, some of those being treated lost faith in the original diagnosis. Some were treated for PANDAS and got better. Others eventually came back to Mechtler’s team for treatment.

Staff writer Ethan Forman can be reached at 978-338-2673, by email at eforman@salemnews.com or on Twitter at @DanverSalemNews.