A female patient who has been diagnosed with conversion disorder on the female ward at Herat Regional Hospital's Psychiatric Department in Herat Province, Afghanistan. ALL VISUALS BY LYNZY BILLING

In Afghanistan, a Quiet Epidemic of Mass Psychogenic Illness

In April 2021, Anita was lying on a stained bed in the women’s room of the psychiatric ward in Herat Regional Hospital, a government-run facility in western Afghanistan. Stiff and covered in sweat, the 20-year-old was unresponsive. It was 8 a.m. and all eight beds in the ward were occupied. Unconscious patients, shrouded in cloth, lay in the dappled morning sunlight, tended to by anxious relatives.

The night before, government forces had clashed with Taliban fighters. The hospital’s neighboring wards showed the cost of the violence: They were flooded with crashes and shouting as staff hurried down narrow corridors, pushing gurneys. But in the women’s room of the psychiatric ward, there was silence. No one moved.

Before Anita was admitted to the hospital, she had gotten into a fight with her brother. After the fight, she fell unconscious. “It was like she lost her balance,” her mother, Saeeda, said. (Saeeda opted to only disclose her and her daughter’s first names.) Then Anita started seizing. When she arrived at the hospital, though, doctors did not see any sign of a neurological condition or other physical cause that could explain the sudden collapse.

Anita’s case was far from unique. According to hospital records, the women’s ward in Herat saw 900 such cases that April. In 2021, the facility recorded 12,678 cases, up from 10,800 cases in 2020.

These mysterious ailments — often entailing loss of consciousness, convulsions, paralysis — have plagued girls and women in Afghanistan for more than a decade. Government officials, local media, and, often, the women themselves have described these events as poisonings, usually attributed to attacks by the Taliban or other militant groups. Doctors who review the cases have come to a different diagnosis: conversion disorder, also known as functional neurological symptom disorder, part of a class of conditions called somatic symptom and related disorders.

Patients with somatic symptom and related disorders experience bodily symptoms with no apparent physical cause — or an excessive response to a medical disorder. Conversion disorder is a specific form in which a patient’s physical symptoms mimic a neurological disorder. The symptoms often follow a period of significant emotional or physical distress, and they are outside of the individual’s conscious control.

Early morning on the female ward at Herat Regional Hospital’s Psychiatric Department in Herat Province, Afghanistan.

Sometimes, conversion disorders strike many people at once. During an outbreak of mass psychogenic illness — also called mass sociogenic illness, mass psychogenic disorder, epidemic hysteria, or mass hysteria — symptoms spread through a population or group, with no obvious pathogen, toxin, or other physical cause. Often, experts say, mass psychogenic illness occurs when there’s a credible threat, such as a noxious odor in a school where students are already fearful of chemical warfare.

Despite an extensive record of occurrences around the world, and decades of study, little is known about the specific causes of mass psychogenic illness, or why the condition reportedly affects women and girls most. Less still is known about mass psychogenic illness in Afghanistan, where women and girls, particularly in rural areas, have little presence in public spaces, and limited, if any, access to mental health care. Scientific research — particularly clinical research, looking directly at patients within Afghanistan — is difficult due to lack of access to patients and social structures — it is, therefore, extremely rare.

But interviews with physicians, sociologists, and people experiencing diagnosed conversion disorders indicate that the condition is widespread in Afghanistan — a quiet epidemic that, since at least 2004, has affected many women and girls in the war-torn country.

“Being a girl in Afghanistan,” Noorzad said, “comes with pressures that no one who isn’t a girl in Afghanistan would understand.”

Herat province alone has seen tens of thousands of cases over the past decade, with girls flooding into the city’s hospitals with severe dizziness, weakness, hyperventilation, headache, fever, nausea, and abdominal pain. Others are unconscious and unresponsive. In each case, doctors could not detect a physical cause and sent the girls to the province’s psychiatric ward at Herat Regional Hospital, one of only six psychiatric wards in the country. There, the girls receive IV fluids, diazepam — a generic version of the anti-anxiety drug Valium — and, at times, sedatives. Sometimes, the hospital administers electroconvulsive therapy. After 24 hours, the majority of the girls reawaken, and the hospital sends them home.

Since the Taliban took control of the country last August, case rates have only climbed, according to psychiatrist Wahid Noorzad, who has led the Herat hospital’s psychiatric ward for more than a decade. “Being a girl in Afghanistan,” Noorzad said, “comes with pressures that no one who isn’t a girl in Afghanistan would understand.”

Thousands of cases in Afghanistan have followed a pattern: A mass illness, a media frenzy, and accusations by the former Afghan government that the Taliban was to blame. In 2011, for instance, it happened at Talaba-e Aulya, a girls’ school in the sleepy village of Abul Walid about a 45-minute drive outside of Herat city center. There, 30 young girls fell ill and were admitted to the psychiatric ward in the city center — an incident that was initially claimed as a Taliban poisoning. In 2012 in Takhar province, more than 170 women and schoolgirls fell ill after consuming water from the school’s well. Local health officials said terrorists opposed to girls’ education were to blame. A NATO laboratory in Kabul found no traces of poison in the water. The following month, 160 schoolgirls were allegedly poisoned by the Taliban again. This time, the classrooms were thought to have been sprayed with a toxic material before the girls entered, police officials said. According to CNN, “the Taliban denied responsibility, instead blaming U.S. and NATO forces for the poisonings in an attempt to ‘defame’ the insurgent group.” More incidents followed in Jowzjan province in 2012 and Farah province in 2016.

In one high-profile case in Herat in 2015, local police suspected that air freshener triggered an event that affected 208 girls and teachers. That same week, 115 students fell ill at another school in Herat. Media claimed both were poisonings even before any investigation was conducted.

As the alleged poisonings mounted at Afghan schools, physicians repeatedly reported finding no signs that toxins were responsible for the students’ illnesses. There have been no reported deaths and all the girls have made a quick recovery. One 2012 World Health Organization report counted mass poisonings at 22 girls’ schools. And according to investigations by Newsweek, the WHO, the United Nations, and NATO’s International Security Assistance Force, no evidence of toxins or poisoning were found in at least 200 samples of water, urine, and blood. Instead, the investigators concluded that the girls were suffering from mass psychogenic illness.

“I only remember that I was put in the ambulance,” Mohammadi recalled. When she woke up, she added, “the doctor told me that I went unconscious due to the bad smell in the school.”

No matter the cause, for those in the classrooms, the events were harrowing. Zarmina Mohammadi, 17, described to Undark what it was like to experience one of the events. “When I came to the school, some of the students were inside the classroom and some were walking in the yard,” said Mohammadi, who attended Talaba-e Aulya in 2011, when she was about 7 years old. “There was a smell that I did not recognize,” she said, and “then, suddenly, all the girls around me fell down.”

Mohammadi collapsed too. “I only remember that I was put in the ambulance,” she recalled. When she woke up, she added, “the doctor told me that I went unconscious due to the bad smell in the school.”

After the attack, her family blamed the Taliban. Whoever it was, she said, “we all believe that it was poisoning.”

To this day, Mohammadi does not know what was responsible for the incident. “Some people just didn’t believe us. They thought we made it up, or it was all in our head,” she said. Still, she believes they were intentionally poisoned. “There were many groups against the government, so maybe they were responsible for that,” she said, adding that they were attending a government school.

The head of Herat Regional Hospital’s Psychiatric Department, psychiatrist Wahid Noorzad, attends to a patient on the female ward.

Homaira Rahmani was in the same class as Mohammadi and also remembers a smell, describing it as metallic, a bit like the smell from an “injury, medicinal, or something like gas,” she said. (Mohammadi, Rahmani, and other classmates spoke to Undark through a translator.)

“Suddenly we felt that toxic air spreading among us,” she said. And then they were told to “hurry up and get out of the classes.” The doctors at the hospital told her she had been poisoned.

After the incident, Rahmani convinced her father to let her return to school. But, she added, “I was still very terrified for months.”

Another student there that day, Nazila Yusufi, confirmed details of Mohammadi and Rahmani’s accounts and said that some of her classmates suffered recurring symptoms for years. “They thought that a gas leak caused the incident,” she said, and decided that all the windows of the classrooms should be opened at the beginning of every school day to prevent future episodes.

The girls had reason to be fearful. During their first rule, the Taliban barred women from attending school between 1996 and 2001. After they fell from power, girls’ education became a target; over the years, school attacks have killed hundreds of girls, and wounded hundreds more. In May last year, a car bombing, followed by two blasts outside Sayed al-Shuhada school in Dasht-e-Barchi, a predominantly Shia Hazara area in western Kabul, killed at least 85 people, most of them schoolgirls, and left 147 people injured. The Taliban has denied being behind the blasts.

In popular media, mass psychogenic illness outbreaks have been reported in dozens of countries across the world, and the illness is sometimes presented as a relatively harmless anomaly. In one well-known 2011 case, a group of teen girls in Le Roy, New York, began twitching and developing vocal tics. Images of the girls’ involuntary movements were shared, setting off speculation about environmental toxins and a flood of national media attention. Neurologists diagnosed the girls with mass psychogenic illness and said the images should be removed from media as part of the cure.

Researchers say the condition is often connected to experiences of extreme stress. Indeed, there is a small but detailed literature documenting cases in conflict zones, including one outbreak in Soviet Georgia in 1989 that affected hundreds with blurred vision, dizziness, and fainting. In another case in Kosovo in 1990, a mysterious illness spread suddenly among thousands of ethnic Albanian high school students. The New York Times documented an outbreak of mass fainting and dizziness in the Israeli-occupied West Bank in 1983, affecting 943 residents, most of whom were teenage girls. Investigators concluded that the wave of complaints were mostly psychosomatic — a case of mass psychogenic illness.

Mass psychogenic illness is “a collective stress response,” Bartholomew said, and “everyone is potentially susceptible because it's based on a belief” — in many cases, of a perceived threat.

Residents in all of these locations have had prolonged exposure to extreme anxiety, where political conflict or ethnic and religious tensions are a fact of life. Intense media coverage seemed to exacerbate outbreaks.

After decades of war, Afghanistan is also a fertile environment for mass psychogenic illness, according to the few sociologists who have studied the phenomenon. The affliction “is a social barometer of the times and prevailing fears,” said Robert E. Bartholomew, a medical sociologist and honorary senior lecturer at the University of Auckland who has published research on the condition in Afghanistan. He’s looked at about 3,500 cases going back to the 1500s.

“Stress triggers these outbreaks,” he said. “Particularly exposure to prolonged stress. The nerves and neurons that send messages to the brain get garbled and you get twitching and shaking.”

The result, he said, is a “trancelike and dopey” state, which can come and go. “What’s interesting is, if the stress dissipates, just gradually over time, it tends to go away,” he added. “But if it doesn’t, it keeps going on in a waxing and waning fashion and can go on for years.”

A psychiatrist meets with a patient who has been diagnosed with conversion disorder on the female ward at Herat Regional Hospital’s Psychiatric Department in Herat Province, Afghanistan.

Mass psychogenic illness is “a collective stress response,” he said, and “everyone is potentially susceptible because it’s based on a belief” — in many cases, of a perceived threat. When the perceived threat is believable, it can manifest itself as psychogenic illness, he added, which is often met with skepticism or controversy.

The Afghan incidents come amid a larger social panic about Taliban insurgents and their religious views. It’s an atmosphere ripe for terror — both real and imagined — and psychosomatic responses, experts say, may not be that different from other ways our bodies respond to stress. “In psychology, we are very aware of how our emotional state can cause physical symptoms,” Kate MacKrill, a psychologist at the University of Auckland who has collaborated with Bartholomew, wrote via email. “For example, when we are nervous we experience a whole range of symptoms, such as sweating, shaking, nausea, and headaches. These are real symptoms that have been caused by our mind.” Similarly, according to MacKrill and other experts, the mind can channel emotional distress into the kinds of symptoms that characterize conversion disorder.

Bartholomew began analyzing data on the schoolgirl cases in 2015 at the request of the former Afghan government, which provided him and two other researchers with statistical data. Bartholomew also scoured thousands of articles about the alleged poisonings in Afghanistan. “I remember going through the [global terrorism database] at the time, and it was school attack after school attack,” he said. “No deaths. No serious injuries. It’s so striking. And then they quickly recover. And, it’s so typical of mass psychogenic illness.”

But the newspapers, he added, repeatedly treated the cases “as poisoning, and after a while it just became this taken for granted reality that people accept. And that’s really unfortunate.”

One of the few scholars to have studied Afghan women and their psychosocial needs on the ground is Patricia Omidian, a medical anthropologist at Focusing Initiatives International, a mental health and wellness nonprofit. Trained at University of California, Berkeley, Omidian has spent 17 years working in Afghanistan and Pakistan, developing wellness programs designed to address trauma and psychosocial wellness.

In Afghanistan, she worked with the University of Massachusetts Center for International Education and Catholic Charities to address the psychosocial needs of Afghan women. The psychosomatic conditions she witnessed, she said, should be understood as part of a broader mental health crisis in a country stricken by war since the 1970s. While working with hundreds of women in the refugee community, Omidian said she saw many cases of mental illness and psychosomatic disorders, and she heard stories of subsequent suicide attempts.

Schools would be a common site for mass psychogenic illness outbreaks, according to Omidian, particularly in Afghanistan, where girls and women are largely segregated both in the public sphere and at home. And she said women and girls with psychosomatic disorders and mental illness were often experiencing exhaustion from the housework and a lack of food — things that can bring about psychosis. “And then you add it into, ‘well my best friend has it so, here you go, I do too now,’” Omidian said.

There are few settings and occasions where women are given attention, she added, except when they are taken to the hospital: “In Afghanistan, if you don’t do it in the culturally recognized way, nobody knows you’re in distress.”

In Undark’s interviews with women who had experienced alleged poisoning attacks, none had heard of mass psychogenic illness. But some found it plausible. After hearing details of the phenomenon, Rahmani said that her 2011 experience in Herat “could be some kind of a psychological disease.”

“We all believe that many groups, including the Taliban, do not want women to study, and I think that affected us,” she added. “We are under pressure and fear. This mental stress is fixed in every female student’s mind, so when we see any student tensed, we might think she is poisoned, and that affects us too.” She paused. “But it doesn’t matter what I say anyway — why speak up, no one believes us,” she said, “just because we are girls.”

Asefa Rashiq, the head teacher at the girls’ school in Herat, who witnessed the outbreak in Talaba-e Aulya school in 2011, agreed, noting that rumors of previous poisonings were widespread. This could produce real impacts in their minds, Rashiq said, adding through a translator that when the girls see any student tense or unconscious, their mentality awakens that fear and that leads to them also falling unconscious. “We see it in other cases also, when a girl has some pressure or tension, she can spread that to other girls in her classroom,” Rashiq added.

It’s difficult to overstate the tension felt by many people in Afghanistan, which has now been at war for four decades.

It’s difficult to overstate the tension felt by many people in Afghanistan, which has now been at war for four decades. Reliable statistics on anything are hard to come by in Afghanistan, but Human Rights Watch estimates that depression, anxiety, and post-traumatic stress affect half of Afghanistan’s population. In 2017, the World Health Organization estimated that 1 million Afghans were suffering from depressive disorders and 1.2 million from anxiety. The numbers may be higher, given the social stigma still attached to mental illness. And yet, psychology, counseling, psychiatry, psychotherapy, and psychotraumatology are almost completely unrecognized professions in a country where many are left traumatized by years of war and in desperate need of experts and specialists in the field.

It’s not likely to get better. In August 2021, the Taliban took control of Afghanistan and the U.S. departed. Speaking with Undark last fall, Noozad, the department head of the psychiatric ward in Herat, said the ward is seeing more somatoform disorder cases than ever before. The Taliban had taken a hardline approach to women’s place in society in the past, and now, almost a year into their latest rule, they are bringing in increased restrictions for women. Teenage girls have still not been allowed back to school in much of the country, women often struggle to travel without a male guardian, and parks and universities are increasingly gender segregated. While women are working in some sectors, such as health care and education, men and women no longer share office spaces. Other women have been told not to come back to work, or have chosen not to return out of fear for their safety. At a press conference in Kabul on May 7, 2022, the Ministry for the Propagation of Virtue and the Prevention of Vice announced that women would have to cover their faces in public, except for their eyes, and laid out an escalating set of punishments for anyone refusing to comply.

In April 2021, at the hospital in Herat, Anita waited for hours, tended to by her mother. Eventually Noorzad, diagnosed her with conversion disorder.

The ward often sees cases of depression, PTSD, personality disorders, and bipolar, but many of the cases are conversion disorder, Noorzad said. “Sometimes there may be a combination of disorders,” he added. “We had a patient who had a conversion disorder, but she also had depression.”

The patients display neurological symptoms, Noorzad said, and go into trancelike states. Symptoms of conversion disorder may overlap with those of other mental health issues, especially because people who have mental health conditions can be more likely to develop conversion disorder, Noorzad said.

Richard Kanaan, a psychiatrist at the University of Melbourne who specializes in conversion disorder, said he agreed with Noorzad.

“In Afghanistan, if you don’t do it in the culturally recognized way, nobody knows you’re in distress,” Omidian said.

“What we would call ‘co-morbidity’, meaning you have more than one illness (physical or mental) at once, is extremely common in conversion disorder, both with physical and mental health issues,” Kanaan wrote in an email to Undark. “Probably the most common mental health problems that we see co-occurring are anxiety and depression, though panic disorder and other trauma reactions also regularly co-occur, as do other somatoform disorders.”

Since Noorzad began treating the cases in 2011, he said he has observed a correlation between the increase in violence and the increase in cases flooding into the ward. During the U.S. troop withdrawal in the first eight months of 2021, there was a spike in somatoform disorder cases on the ward, Noorzad told Undark in a follow-up phone call in October 2021. Domestic violence and economic strain drive cases too, he said.

Stronger counseling and psychology resources — largely unrecognized professions in Afghanistan — could help, Noorzad said.

During his examination of Anita, Noorzad noted that she had no abnormal physical conditions and appeared to be healthy. Her paralysis, and the slight twitching of her eyes, indicated conversion disorder, he said, based on his years of experience treating women and girls with the condition. “Conversion disorder is the mind shutting the physical movements of the body,” he said. “The symptoms we see include false paralysis, selective dullness, fainting, imbalance, resistance to speech, and reawakening without drug intervention.”

He asked Anita’s mother to wait while he determined what stage of the disorder she was in.

Anita’s body was rigid, showing “defense mechanisms,” said Noorzad. He tried to bring her to consciousness by flicking her forehead and trailing a rolled up piece of tissue along her inner eyelids to test her response. Then he pulled car keys from his pocket and dragged them up the bottom of her foot.

When she felt the key against her foot, Anita awakened. Noorzad declared her fit to return home. But Anita wasn’t ready to leave. “Not yet,” she said slowly, turning to Noorzad. “I want to stay here a little longer.”

Lynzy Billing is a freelance writer and photographer based in Afghanistan and Iraq.

UPDATE: The latest revision of the The Diagnostic and Statistical Manual of Mental Disorders (DSM) notes that the preferred name for conversion disorder is now functional neurological symptom disorder. The piece has been updated to include this terminology, although both names continued to be widely used in the medical community. The piece has also been updated to note that the condition falls under a category called somatic symptom and related disorders. The category was previously called somatoform disorder. Finally, the piece has been updated to note that Robert E. Bartholomew is an honorary senior lecturer, rather than a lecturer, at the University of Auckland.