Stress, High School, Tics and Secondary Stress Response

by James Porter March 19, 2012

I've been following the story of the high school girls in LeRoy, NY, a town outside of Rochester, where as many as 18 students, all at the same school, have developed tics (in this case, involuntary arm movements) that are so severe some of the girls have been out of school for months. I've resisted commenting on this story until now because 1. It's already a media circus and 2. It was so obvious to me that these kids were suffering from a stress-related condition and not some mysterious underground toxin.

But now that it's been written up as the cover story for this week's Sunday New York Times Magazine, I'm drawn in by its many, many references to stress, the amygdala, conversion disorder and even mirror neurons (aspects of stress I've written about extensively in other blogs). The handling of the case, the publicity, the diagnosis, and the aspect of secondary stress (which I'll explain in a moment) all say a lot about what it means to have a stress-related illness in this day and age, and how that could impact the welfare of an entire town!

The two girls who appeared on The Today Show, and as it turns out, many of the other girls, are all clearly dealing with a fair amount of stress. You don't have to dig too deep to find out that one of the girls had been assaulted by her father and another girl's father committed suicide in front of her. Another girl is under the sole care of an older sibling and one of the common threads amongst all the girls is that they all seem to be estranged from their fathers.

Dr. Lazlo Mechtler, a leading neurologist in the area, who has been treating them, diagnosed the problem as a "conversion disorder" which is when the mind converts emotional disturbances (i.e., stress) into physical symptoms like tics. "These girls in this case are under an enormous amount of stress...the attention, the cameras, all the social media, it has made things much worse."

Even the real life Erin Brockovich (famously played in a movie by Julia Roberts) sent a team to LeRoy to take a soil sample.

One of the first issues for anyone facing a stress-related disorder is the simple reality that's there's no quick fix to the problem. It takes awareness, observation, effort and willpower to overcome a stress-related health problem. Generally people don't want to hear this diagnosis nor do they want to do the work required to fix it. In addition, a stress-related diagnosis seems to suggest to people, that the problem isn't real: that it's all in their heads. The second issue, that nobody recognizes in this case, is that there is often a secondary stress reaction to a stress-related disorder: People tend to get stressed about being stressed. More about this in a minute.

When one doctor, Rosario Trifiletti came along and suggested that the problem was a rare strep-based illness (that somehow only affected girls) and thus could be treated with antibiotics, there was great rejoicing amongst the parents and their children who felt like they finally had an illness they could be proud of - rather than some psychological disorder they had to apologize for. (That took away the secondary stress reaction - because with this diagnosis the primary cause was NOT stress.)

"But when the subject of the girls' personal backgrounds came up...Dr. Trifiletti said he had not had the time to ask them about those kinds of things. The abuse, the troubling family circumstances - much of it came as news to him. 'Jeez, I didn't realize the extent,' Trifiletti said. 'These aren't things people want to talk about. I don't know, maybe I'm wrong. It's hard to distinguish between the drug and the placebo effect.'" (From the NY Times article.)

I think it's so telling here, that the doctor didn't have time to ask these girls about their background (i.e., their stress levels) and thus, like most doctors, treated the element of stress as if it was a non-starter. Given the time constraints most doctors are under these days, it's not surprising that this doctor would try to find a cure for these girls without taking enough time to find out what was really wrong with them in the first place.

Also worth noting here is the doctor's comment that he's not sure how to distinguish between the drug and the placebo effect. The placebo effect is a force to be reckoned with, and a lot of the medicines used to treat these kind of problems, including anti-depressants get much of their impact from the power of the placebo effect. To this effect, the American Journal of Medicine published a controversial article last year stating that anti-depressants were no better than a placebo when used to treat mild to moderate depression.

Of course, what all doctors realize is, without a real pill, YOU HAVE NO PLACEBO EFFECT. In other words, since a doctor can't ethically prescribe a sugar pill, even a drug with lots of side effects, will have a long shelf-life if it can even just slightly beat the placebo effect in terms of helping people get over depression, anxiety, or any other stress-related disorder for that matter.

18 girls at Le Roy High School have developed uncontrollable tics.

Another interesting aspect of this case is the belief that it was a mass psychogenic illness (AKA mass hysteria) that led to so many other girls coming down with the same symptoms. Apparently these cases of mass hysteria, which are not exactly common, aren't incredibly rare either:

"Simon Wessely, an epidemiologist at King's College in London and chairman of the department of psychological medicine, estimates that hundreds of outbreaks occur every year in the United States - just this past November, 22 students fell ill with stomach complaints at a football game in Houston, and no one so much as noticed outside the local news. Motor mass hysterias - twitching, fainting, stuttering - are more rare and draw more attention." (NY Times)

And what's driving the explanation for this "motor mass hysteria" is none other than the mirror neurons (see Blog entitled Neuroplasticity, Mindsight and Dr. Daniel Seigel.) inside our head that cause us to feel exactly what another human being is feeling.

Mirror neurons, were discovered at a lab in Italy where scientists were monitoring specific neurons in a monkey's brain. When one of the researchers happened to bring in a bag of peanuts and eat them in front of the monkey, the researchers noticed that the monkey's neurons lit up as if the monkey was eating the peanuts. This led to more research which revealed that the way we are able to empathize with another human being is through the existence of these mirror neurons which allow us to feel what another person is feeling. However, in the case of the high school girls in LeRoy, NY, their mirror neurons apparently caused motor mass hysteria.

The New York Times article also mentions the amygdala, which is a part of the brain that, until another NY Times writer, Dan Goleman wrote the book Emotional Intelligence, no one had ever heard of. And even though Goleman wrote that book almost 20 years ago, my Microsoft Word program still thinks I'm misspelling it - underlining it in red every time - because MS Word hasn't heard of it either. Anyway here's the passage from the article about the amygdala:

Researchers think the illness might have something to do with the amygdala, a locus of startle and fear responses in the brain, which has been shown to be overactive in patients with conversion disorder. "Ordinarily, the amygdala might create psychological distress, but instead, in these cases, it would create an involuntary movement," says Mark Hallett, a senior investigator at the National Institute of Neurological Disorders and Stroke. He added, though, that while the theory is plausible, "we're at a primitive level" in terms of understanding how it works.

I personally think the amygdala, which is now considered to be the source of the stress response, is basically just memory imprinter. And traumatic events get imprinted in this almond shaped area of the brain in bold, because the body - in its wisdom - doesn't want us to repeat the same mistakes (that bring us harm) twice. The amygdala, which stores these stressful memories in the nearby hippocampus, replays them in the form of a bodily reaction (like tics) whenever it is reminded of the original trauma, no matter how slight that original trauma might have been. We feel the replay inside our bodies in terms of low level anxiety, depression, hostility, fear, and sometimes even an "involuntary" bodily movement such as a tic.

I attended a behavioral medicine conference in 2010 where Dr. Peter Levine was giving a keynote presentation on "How the Body Releases Trauma." He talked about how he had been treating an Iraq war veteran with severe PTSD. His theory was that when faced with trauma, a person tends to freeze in place and the trauma often gets frozen in the body at the time of the traumatic event and somehow needs to be released. Dr. Levine showed film footage of the veteran from before his treatment began which showed that his tics were quite severe. The veteran's whole body convulsed every five or ten seconds as he talked, even though he was talking about something fairly innocuous. Levine's treatment for this vet included a meditation practice where the vet was instructed to hum or chant in a low voice similar to the sound of ships fog horn. When Levine interviewed him on camera after several months of therapy, his tics were almost completely gone.

We know from studies at the University of Wisconsin that meditation changes the brain. I believe Dr. Levine's therapy changes the neural wiring of the amygdala in the same way that meditation does. Thus the brain let's go of the "bold" traumatic imprint (frozen at the moment of trauma) that's causing the body to want to release this trauma in the form of tics. So when we extrapolate these finding for the girls in Le Roy, NY is there a form of meditation that might help them recover voluntary control of their bodies? Yes I believe there is. Would they agree to start meditating on a regular basis? No I don't think they would. And that goes back to my first statement about how a diagnosis of stress, requires work to fix and most patients would prefer to take a pill.

I'm also surprised in this case- or maybe not surprised - that nobody seems to realize how much stress these girls are under. Notice how Katie, one of the students who was on The Today Show, denies that she is under any kind of unusual stress in the passage below from the Sunday Times:

Katie's mother, Beth had recently had brain surgery and "in addition to her tumor, Beth suffers from trigeminal neuralgia, a nerve condition that causes excruciating pain in her face. In the weeks leading up to the surgery, she was so sick she sometimes had trouble getting out of bed. The surgery took place just a week before the onset of Katie's tics. Katie could see the line of questioning that piece of information might provoke, so she quickly clarified. "She's had, like, 13," Katie said of the surgeries. If that seems like something that might be hard on a child, Katie isn't one to dwell on it. "I'm so used to it," she said, her voice trailing off in a huge yawn. "Seriously, it was like a walk in the park."

Thera (one of the other girls affected by the tics and a friend of Katie's) was perched on the bed, biting her nail. It was not just cheerleading and clothes that bound the girls: both have gone through a lot with their families - troubles of very different natures, but troubles nonetheless."

When you read the rather long article in the New York Times it's clear to the reporter, and to you the reader that basically the whole town is under siege, not just because it's economic base is withering, but because with all the reporters and with all the speculation about what is causing the problem in all these teenage girls, even the price of real estate has been adversely affected. The whole town is suffering from a classic secondary stress reaction.

You and I have secondary stress reactions when we get stressed about being up in the middle of the night or get stressed about feeling a rapid heartbeat. In each case, the primary stressor is what causes you to wake up (like a loud noise or a bad dream) or what raises your heartbeat (like walking up a long set of stairs) and the secondary stressor is your reaction to being stressed (which can turn sleeplessness into full blown insomnia or an elevated heart rate into a panic attack).

I believe the girls got stressed out about being stressed out and the town got stressed out about the girls being stressed out. I've heard of secondary stress reactions in people, but this is the first time I've ever heard of a whole town suffering from a secondary stress reaction!

Basketball games at Le Roy High School were canceled because other teams were afraid of going there.

Everyone tries to cover up, or perhaps more accurately, ignore their stress symptoms. We all tend to soldier on and keep moving forward. Whether we take copious amounts of ibuprofen for our chronic pain, or spend money that we don't have, or eat when we are not hungry, or drink wine after a bad day, these are all escape activities that allow us to ignore our pain. So that's why we rarely attribute our suffering to stress. We don't realize how long or how deeply we've been affected by it. But keep this up long enough, and get enough school-aged children involved too, and your whole town could brought to its knees getting stressed about its own levels of stress.

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