1. Introduction
During the period 14 -25 February, 2000, about 1430 learners at various schools in Mangaung and Heidedal townships in Bloemfontein, experienced some itching. The Grades that were mostly affected were Grade 8, 9 and 10. A small group of Primary school children were affected as well. It was, however, difficult to get the actual numbers that were affected, as no reliable statistics was kept.

The itching lasted an average of six days Entomologists, in their analysis of dust samples collected at the schools, found a number of book lice. These, however, did not pose any threat to human health. The entomologists also suspected that some of the children could have been infected by itch mite but this was based purely on the presenting symptoms. No organic cause was found. A few teachers mainly female reported experiencing some itching also.

2. Aim of the Study:

For this study, only thirteen schools in the Mangaung and Heidedal area were included. The aim of this study was:

3. Method:

Learners at the affected schools were grouped by the teachers into those who were affected and those who were not affected. A representative sample was then selected randomly from each group. Three psychologists interviewed the learners in English, Sesotho, Xhosa and Afrikaans using a questionnaire guide that had been designed to elicit; symptoms, thoughts and feelings about the itching, what made the itching feel better and what seemed to exacerbate it. The learners were also asked how they got to know about the itching, what else happened when they were itching. Questions aimed at eliciting the presence of verbal and/or visual hallucinations were also asked.

A total of 192 learners were interviewed in group settings, using tape recorders. Groups averaged fifteen learners, twelve from those who were affected and three from the group that was not affected. Individual interviews with three of the affected teachers were conducted.

4. Results:

The tapes were transcribed and the information gathered during the interviews grouped into four themes, physical symptoms, social impact, psychological effects and interventions.

4.1 Incidence of Itching:

The incidence of itching in the schools differed. The learners seemed to be aware of which school was the first to be affected in the Mangaung area. The itching was experienced as soon as the learners entered the school premises. Very few reported itching and scratching at home. Learners who first reported the itching were taken to the principal’s office or the staff room. The other learners went to observe what was happening and then their own itching started. Others reported that the itching started when they watched others scratching themselves at assembly, in the classroom, at the clinics or at the hospital.
 
 

4.2. Physical Symptoms:

The itching started after they felt a gush of hot air, then hyperventilation, headache, pins and needles, dizziness, chest tightness were amongst the symptoms reported. Oxygen had to be administered to some.

Itching was reportedly worse when any liquid was applied. This, they agreed was due to the open sores that had formed as a result of the scratching. The learners used items such as stones, walls, scrubbing brushes, rulers and pens for scratching

4.3. Social Impact:

The itching was perceived to be contagious; this resulted in rejection by family and society. Taxi drivers would not stop for them, some parents refused to let them play with the other siblings or friends. Some of the learners who were not affected thought that although there were some who really were affected, there were others who were shamming.

4.4 Psychological Effects:

Fear of being affected was reported by most who had not experienced any itching and this caused some anxiety. The rejection that those who were itching experienced angered them. They felt they were not responsible for their condition. Rumours abounded as to what the cause of the itching was. Satanism was blamed for the itching, others said there were two boys who were seen sprinkling some white powder in the girls’ toilets.

There were rumours that two learners had died but this was never verified. It appears that the source of some of the rumours, were members of the public who phoned the local radio station chat shows to discuss the itching.

4.5. Intervention Strategy:

The itching was mostly treated with Calamine lotion (an anti histamine), after a bath in a Jeyes Fluid solution (an antiseptic). Some reported drinking the Jeyes Fluid mixture while others reported applying several lotions that had been prepared by their grandmothers "iirati" (home remedies), even petrol

When the principals set limits after schools reopened after the fumigation; that if there were any who were still itching they should go home and come back when healed, no further reports of itching were received.

5. Discussion
Commonly in sudden and dramatic situations such as these where there is widespread illness whose causes are obscure or unknown, chemicals that are present in the environment in minute concentrations are summarily and misguidedly targeted as likely culprits Once mass anxiety hysteria is in progress participants seize on any suitable excuse, be it gas or food poisoning, for rumour is rife when an air of uneasiness pervades any collectivity ¹. A white powder was identified as the source of the itching in this study, but this fact was never verified. It could also not be explained why it only affected learners when they entered the school premises and why it affected girls mostly.

Hysteria remains a controversial term. Modern authors tend to view it in its narrower psychiatric sense. Central to this is the implication that hysteria should involve the adoption of symptoms that are not explained by physical disease, but corresponding to a notion of physiological or psychological dysfunction. Secondary gain may occur but it is indistinguishable from the advantages of the sick role² Illness behaviour can be learned³. This social learning theory could explain why the learners developed itching after watching their friends scratch.

There exists no satisfactory definition of mass hysteria. Some ⁴ believe that mass hysteria is a form of abreaction to resolve conflicting situations. This explanation is, however, not valid for group behaviour. A wide variety of crazes, panics and abnormal group beliefs etc. have all been labelled as mass hysteria. The boundaries of collective behaviour and mass hysteria have yet to be drawn. Mass Hysteria has been defined as a constellation of symptoms that are suggestive of an organic illness, but do not have an identified cause, in a group of people with shared beliefs about the cause of the symptom⁵ .

Episodes of mass hysteria can be taxomised into these broad categories ⁴:

Mass hysteria is a social phenomenon often occurring among otherwise healthy people who suddenly believe they have been made ill by some external factor. These people often have shared beliefs about the cause of the symptom⁶. In another study, conducted in South Africa¹⁴, it appears that common beliefs in witchcraft as the cause of the mass hysteria were what held the group together. In societies where there are two or more medical systems that are used to explain disease, it is possible that illness that cannot be explained can be attributed to witchcraft and sorcery. In our study, however, beliefs in witchcraft and sorcery did not come up, as the main cause of the itching was said to be some white powder.

Mass hysteria spreads by sight and or sound. It also occurs most often among adolescents or preadolescents. In groups of students, its incidence is reportedly, higher among girls than boys^6,7,9,. In most cases "victims" return to a normal state of health soon after being convinced that the illness is over or never existed¹⁵. Individuals continually engage in reality testing by comparing their perceptions with those of others round them. Since individuals are more dependent upon others and less on themselves in their construction of social reality, an opinion, attitude or conviction is correct, valid and proper to the extent that it is anchored in a group of people with similar beliefs, opinions and attitudes¹⁶.

Information on the diagnosis of mass hysteria is incomplete. Whether such psychosocial factors as school morale affect the likelihood of it developing is unknown. The Bronx school where the mass hysteria developed in 1999 is reportedly in a poor neighbourhood. The same could be said of the neighbourhoods in which the incidents of itching were reported, in the Free State. None of the surburban schools were affected.

Mass hysteria, should be regarded as a phenomenon with certain characteristics⁷:
 

Although the methodology used in this study differs from that used in the other studies^7,9,14, the authors do note, however, that symptoms such as headaches, anxiety, hyperventilation, chest tightness, and nausea were also reported by the learners in their study. It is significant that few reports of mass anxiety hysteria contain any reference to external stress or tension. The occurrence of collective behaviour cannot itself be taken as proof of pre- existing tension, it can be inferred if emotional difficulties or stresses are identified prior to the outbreak⁷.

What is communicated in mass anxiety hysteria is not any single behaviour or a fantasy idea but a collective feeling - anxiety. It is not the idea of anxiety that is contagious, but anxiety itself ⁷. Mass hysteria can be divided into two syndromes⁷ thus:
 

The learners in our study reported symptoms, such as fear of being affected. These could be associated with anxiety. The illness was sudden, dramatic and explosive. The learners were mostly affected at school. The spread appears to have been definitely by line of sight - they developed symptoms when they saw others scratching. There is no evidence of any preexisting tension and the majority of the learners were female, under the age of eighteen. When the principals set limits, no further outbreaks were reported. It seems evident; therefore that although the DSM IV nosology does not include collective or mass hysteria, the diagnosis of Mass Anxiety Hysteria be adopted to explain the itching that was experienced in these schools.

Recommended Intervention:
Researchers on Mass Hysteria ^6,7,9, seem to agree that, cases of Mass Hysteria should be handled thus:

1. Time should not be wasted in a fruitless search for environmental precipitants, which by reinforcing behaviour may serve to prolong  the episode. Mass hysteria should not be a diagnosis of exclusion, after all the physical , chemical and biological factors have been ruled out then it should be made.

2. Group anxiety should be reduced.

3. Statements denying the role of the presumed agent should be made by those in authority. Public health statements can help terminate these epidemics. A temporary school closure may be necessary Separating learners and minimising contact among those affected and those not affected may be successful. This strategy was adopted by one of the headmasters in the affected schools and no further reports of itching were received.

4. Setting of limits. Some headmasters in our study, set limits to the itching
and told those who were still itching to stay at home until it stopped.

5. No further reports of itching were received from the learners in their schools.It seems clear that because of the psychological nature of this epidemic, only psychological interventions will be effective. Trying to find an organic cause for the epidemic will not only waste valuable time but scarce resources as well.