Responding to mass psychogenic illness

Stop that! It's not Tourette's but a new type of mass sociogenic illness

We report the first outbreak of a new type of mass sociogenic illness that in contrast to all previously reported episodes is spread solely via social media. Accordingly, we suggest the more specific term ‘mass social media-induced illness’.

In Germany, the current outbreak of mass social media-induced illness is initiated by a ‘virtual’ index case, who is the second most successful YouTube creator in Germany and enjoys enormous popularity among young people. Affected teenagers present with similar or identical functional ‘Tourette-like’ behaviours, which can be clearly differentiated from tics in Tourette syndrome.

Functional ‘Tourette-like’ symptoms can be regarded as the ‘modern’ form of the well-known motor variant of mass sociogenic illness. Moreover, they can be viewed as the 21st century expression of a culture-bound stress reaction of our post-modern society emphasizing the uniqueness of individuals and valuing their alleged exceptionality, thus promoting attention-seeking behaviours and aggravating the permanent identity crisis of modern man. We wish to raise awareness of the current global Tourette-like mass social media-induced illness outbreak. A large number of young people across different countries are affected, with considerable impact on health care systems and society as a whole, since spread via social media is no longer restricted to specific locations such as local communities or school environments spread via social media is no longer restricted to specific locations such as schools or towns.

The Unintended Consequences of Adverse Event Information on Medicines' Risks and Label Content

Patients and prescribers need to be aware of adverse drug events to minimize the risk of their occurrence and the severity with which they appear. However, numerous studies show that being informed about adverse events can increase the possibility of suffering from them. Patients tend to overestimate the likelihood of experiencing the adverse events included in the label, and this can contribute to worsening the negative expectations which are at the root of the nocebo effect. In fact, patients can become anxious after reading the undesirable effects section of the leaflet and, in addition to suffering from the nocebo effect, might not take a drug they could benefit from due to the fear of experiencing adverse events. In addition, patients' attention can focus towards non-specific symptoms of daily living that can be misattributed to the drug and included in the labelling. This article proposes a number of suggestions to reduce the abovementioned unintended effects associated with labelling, namely, an increased focus on the excess risk of experiencing adverse events rather than crude incidence, using attribute framing to help patients to better understand the risk of experiencing adverse events, dividing the undesirable effect section of the leaflet into subsections according to the level of evidence supporting causal relationships and, finally, restricting the addition of non-specific adverse events that are also symptoms of daily living to only those where there is enough evidence to show they have been caused by the drug. More studies on how to minimize the nocebo effect induced by adverse event information should be performed, and these should be done in collaboration with health authorities, to reach a shared consensus on how to better present adverse event information in the label.

Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association

One in 4 Americans >40 years of age takes a statin to reduce the risk of myocardial infarction, ischemic stroke, and other complications of atherosclerotic disease. The most effective statins produce a mean reduction in low-density lipoprotein cholesterol of 55% to 60% at the maximum dosage, and 6 of the 7 marketed statins are available in generic form, which makes them affordable for most patients. Primarily using data from randomized controlled trials, supplemented with observational data where necessary, this scientific statement provides a comprehensive review of statin safety and tolerability. The review covers the general patient population, as well as demographic subgroups, including the elderly, children, pregnant women, East Asians, and patients with specific conditions such as chronic disease of the kidney and liver, human immunodeficiency viral infection, and organ transplants. The risk of statin-induced serious muscle injury, including rhabdomyolysis, is <0.1%, and the risk of serious hepatotoxicity is ≈0.001%. The risk of statin-induced newly diagnosed diabetes mellitus is ≈0.2% per year of treatment, depending on the underlying risk of diabetes mellitus in the population studied. In patients with cerebrovascular disease, statins possibly increase the risk of hemorrhagic stroke; however, they clearly produce a greater reduction in the risk of atherothrombotic stroke and thus total stroke, as well as other cardiovascular events. There is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendonitis. In US clinical practices, roughly 10% of patients stop taking a statin because of subjective complaints, most commonly muscle symptoms without raised creatine kinase. In contrast, in randomized clinical trials, the difference in the incidence of muscle symptoms without significantly raised creatinine kinase in statin-treated compared with placebo-treated participants is <1%, and it is even smaller (0.1%) for patients who discontinued treatment because of such muscle symptoms. This suggests that muscle symptoms are usually not caused by pharmacological effects of the statin. Restarting statin therapy in these patients can be challenging, but it is important, especially in patients at high risk of cardiovascular events, for whom prevention of these events is a priority. Overall, in patients for whom statin treatment is recommended by current guidelines, the benefits greatly outweigh the risks.

Mass fainting in garment factories in Cambodia

This paper reports an ethnographic study of mass fainting among garment factory workers in Cambodia. Research was undertaken in 2010-2015 in 48 factories in Phnom Penh and 8 provinces. Data were collected in Khmer using nonprobability sampling. In participant observation with monks, factory managers, health workers, and affected women, cultural understandings were explored. One or more episodes of mass fainting occurred at 34 factories, of which 9 were triggered by spirit possession. Informants viewed the causes in the domains of ill-health/toxins and supernatural activities. These included "haunting" ghosts at factory sites in the wake of Khmer Rouge atrocities or recent fatal accidents and retaliating guardian spirits at sites violated by foreign owners. Prefigurative dreams, industrial accidents, or possession of a coworker heralded the episodes. Workers witnessing a coworker fainting felt afraid and fainted. When taken to clinics, some showed signs of continued spirit influence. Afterwards, monks performed ritual ceremonies to appease spirits, extinguish bonds with ghosts, and prevent recurrence. Decoded through its cultural motifs of fear and protest, contagion, forebodings, the bloody Khmer Rouge legacy, and trespass, mass fainting in Cambodia becomes less enigmatic.

Outbreak of mass sociogenic illness in a school feeding program in northwest Bangladesh, 2010

BACKGROUND

In 2010, an acute illness outbreak was reported in school students eating high-energy biscuits supplied by the school feeding programme in northwest Bangladesh. We investigated this outbreak to describe the illness in terms of person, place and time, develop the timeline of events, and determine the cause and community perceptions regarding the outbreak.

METHODS

We defined case-patients as students from affected schools reporting any two symptoms including abdominal pain, heartburn, bitter taste, and headache after eating biscuits on the day of illness. We conducted in-depth interviews and group discussions with students, teachers, parents and community members to explore symptoms, exposures, and community perceptions. We conducted a questionnaire survey among case-patients to determine the symptoms and ascertain food items eaten 12 hours before illness onset, and microbiological and environmental investigations.

RESULTS

Among 142 students seeking hospital care, 44 students from four schools qualified as case-patients. Of these, we surveyed 30 who had a mean age of 9 years; 70% (21/30) were females. Predominant symptoms included abdominal pain (93%), heartburn (90%), and bitter taste (57%). All students recovered within a few hours. No pathogenic Vibrio cholerae, Shigella or Salmonella spp. were isolated from collected stool samples. We found no rancid biscuits in schools and storage sites. The female index case perceived the unusually darker packet label as a "devil's deed" that made the biscuits poisonous. Many students, parents and community members reported concerns about rumors of students dying from biscuit poisoning.

CONCLUSIONS

Rapid onset, followed by rapid recovery of symptoms; female preponderance; inconsistent physical, microbiological and environmental findings suggested mass sociogenic illness rather than a foodborne or toxic cause. Rumours of student deaths heightening community anxiety apparently propagated this outbreak. Sharing investigation results and reassuring students and parents through health communication campaigns could limit similar future outbreaks and help retain beneficiaries' trust on nutrition supplementation initiatives.

How Should Mental Health Professionals Respond to Outbreaks of Mass Psychogenic Illness?

The management of episodes of mass psychogenic illness poses a challenge for mental health professionals who have a history of inadvertently exacerbating episodes. This article identifies the two major presentation types (anxiety vs. motor), discusses their significance as a public health issue, and offers guidelines for responding to outbreaks and addressing the media.

The mirror neuron system may play a role in the pathogenesis of mass hysteria

Mass hysteria or collective hysteria usually begins when an individual shows a hysteric manifestation in front of others in the same group who later contagiously acquire the same symptoms. The underlying pathogenesis of mass hysteria is still unknown. It has been demonstrated that the mirror neuron system (MNS) provides an important neural substrate for humans' ability to imitate and there is an inhibitive component of MNS keeping us from imitating everything we see. We proposed that the inhibitive component for MNS automatic imitation may not function well in individuals of the group that results in the outbreaks of mass hysteria. We also provide evidences from emotional contagion, gender difference and treatment in mass hysteria to support this hypothesis.

Human brain evolution and the "Neuroevolutionary Time-depth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder

The DSM-III, DSM-IV, DSM-IV-TR and ICD-10 have judiciously minimized discussion of etiologies to distance clinical psychiatry from Freudian psychoanalysis. With this goal mostly achieved, discussion of etiological factors should be reintroduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). A research agenda for the DSM-V advocated the "development of a pathophysiologically based classification system". The author critically reviews the neuroevolutionary literature on stress-induced and fear circuitry disorders and related amygdala-driven, species-atypical fear behaviors of clinical severity in adult humans. Over 30 empirically testable/falsifiable predictions are presented. It is noted that in DSM-IV-TR and ICD-10, the classification of stress and fear circuitry disorders is neither mode-of-acquisition-based nor brain-evolution-based. For example, snake phobia (innate) and dog phobia (overconsolidational) are clustered together. Similarly, research on blood-injection-injury-type-specific phobia clusters two fears different in their innateness: 1) an arguably ontogenetic memory-trace-overconsolidation-based fear (hospital phobia) and 2) a hardwired (innate) fear of the sight of one's blood or a sharp object penetrating one's skin. Genetic architecture-charting of fear-circuitry-related traits has been challenging. Various, non-phenotype-based architectures can serve as targets for research. In this article, the author will propose one such alternative genetic architecture. This article was inspired by the following: A) Nesse's "Smoke-Detector Principle", B) the increasing suspicion that the "smooth" rather than "lumpy" distribution of complex psychiatric phenotypes (including fear-circuitry disorders) may in some cases be accounted for by oligogenic (and not necessarily polygenic) transmission, and C) insights from the initial sequence of the chimpanzee genome and comparison with the human genome by the Chimpanzee Sequencing and Analysis Consortium published in late 2005. Neuroevolutionary insights relevant to fear circuitry symptoms that primarily emerge overconsolidationally (especially Combat related Posttraumatic Stress Disorder) are presented. Also introduced is a human-evolution-based principle for clustering innate fear traits. The "Neuroevolutionary Time-depth Principle" of innate fears proposed in this article may be useful in the development of a neuroevolution-based taxonomic re-clustering of stress-triggered and fear-circuitry disorders in DSM-V. Four broad clusters of evolved fear circuits are proposed based on their time-depths: 1) Mesozoic (mammalian-wide) circuits hardwired by wild-type alleles driven to fixation by Mesozoic selective sweeps; 2) Cenozoic (simian-wide) circuits relevant to many specific phobias; 3) mid Paleolithic and upper Paleolithic (Homo sapiens-specific) circuits (arguably resulting mostly from mate-choice-driven stabilizing selection); 4) Neolithic circuits (arguably mostly related to stabilizing selection driven by gene-culture co-evolution). More importantly, the author presents evolutionary perspectives on warzone-related PTSD, Combat-Stress Reaction, Combat-related Stress, Operational-Stress, and other deployment-stress-induced symptoms. The Neuroevolutionary Time-depth Principle presented in this article may help explain the dissimilar stress-resilience levels following different types of acute threat to survival of oneself or one's progency (aka DSM-III and DSM-V PTSD Criterion-A events). PTSD rates following exposure to lethal inter-group violence (combat, warzone exposure or intentionally caused disasters such as terrorism) are usually 5-10 times higher than rates following large-scale natural disasters such as forest fires, floods, hurricanes, volcanic eruptions, and earthquakes. The author predicts that both intentionally-caused large-scale bioevent-disasters, as well as natural bioevents such as SARS and avian flu pandemics will be an exception and are likely to be followed by PTSD rates approaching those that follow warzone exposure. During bioevents, Amygdala-driven and locus-coeruleus-driven epidemic pseudosomatic symptoms may be an order of magnitude more common than infection-caused cytokine-driven symptoms. Implications for the red cross and FEMA are discussed. It is also argued that hospital phobia as well as dog phobia, bird phobia and bat phobia require re-taxonomization in DSM-V in a new "overconsolidational disorders" category anchored around PTSD. The overconsolidational spectrum category may be conceptualized as straddling the fear circuitry spectrum disorders and the affective spectrum disorders categories, and may be a category for which Pitman's secondary prevention propranolol regimen may be specifically indicated as a "morning after pill" intervention. Predictions are presented regarding obsessive-compulsive disorder (OCD) (e.g., female-pattern hoarding vs. male-pattern hoarding) and "culture-bound" acute anxiety symptoms (taijin-kyofusho, koro, shuk yang, shook yong, suo yang, rok-joo, jinjinia-bemar, karoshi, gwarosa, Voodoo death). Also discussed are insights relevant to pseudoneurological symptoms and to the forthcoming Dissociative-Conversive disorders category in DSM-V, including what the author terms fright-triggered acute pseudo-localized symptoms (i.e., pseudoparalysis, pseudocerebellar imbalance, psychogenic blindness, pseudoseizures, and epidemic sociogenic illness). Speculations based on studies of the human abnormal-spindle-like, microcephaly-associated (ASPM) gene, the microcephaly primary autosomal recessive (MCPH) gene, and the forkhead box p2 (FOXP2) gene are made and incorporated into what is termed "The pre-FOXP2 Hypothesis of Blood-Injection-Injury Phobia." Finally, the author argues for a non-reductionistic fusion of "distal (evolutionary) neurobiology" with clinical "proximal neurobiology," utilizing neurological heuristics. It is noted that the value of re-clustering fear traits based on behavioral ethology, human-phylogenomics-derived endophenotypes and on ontogenomics (gene-environment interactions) can be confirmed or disconfirmed using epidemiological or twin studies and psychiatric genomics.

Psychosocial responses to environmental incidents: a review and a proposed typology

OBJECTIVE

The objective of this review was to propose a typology for understanding the diversity of psychosocial reactions to environmental incidents.

METHODOLOGY

The first section provides an introduction and background to the topic; we then attempt to provide a typology of psychosocial responses to environmental incidents.

RESULTS

Response to an environmental incident can be usefully considered in terms of the exposure, the response of the individual, the action of professionals, the response of the community, and the influence of the society in which the incident occurs. We reviewed each of these factors.

CONCLUSIONS

By examining incidents in an ordered framework, we suggest that a more comprehensive understanding is possible. We also suggest some basic ways in which the psychosocial management of such difficult and diverse incidents could be improved.

Mass hysteria revisited

PURPOSE OF REVIEW

Instances of mass psychogenic response have occurred throughout history, and across population groups; however, the present-day threat of terrorism and biological warfare is expected to enhance societal vulnerability to epidemics of such events. This paper provides a brief review of the current state of knowledge regarding the conceptualization, diagnosis, and management of mass psychogenic response.

RECENT FINDINGS

Various terms are nowadays used to denote mass hysteria, such as 'mass psychogenic illness' and 'mass sociogenic illness'. Recent studies investigating personality types predisposed to mass hysteric reactions are inconclusive with a range of results found. Cognitive models of this condition have been effective in promoting empowerment and adaptation among vulnerable individuals. The actions of governments, medical communities, and the media are pivotal in the management of mass hysteria.

SUMMARY

The diagnosis of mass hysteria remains contentious, and the mechanisms underlying its perpetuation are similarly ambiguous. The prevalence of 'threat' within the modern sociocultural climate is likely to increase the incidence of the condition, and this could result in serious implications for health services. A holistic approach entailing the collaboration of various public sectors performing a range of preventive activities will be required to contain future mass psychogenic reactions.

Exploratory study on psychosocial impact of the severe acute respiratory syndrome (SARS) outbreak on Chinese students living in Japan

The aim of this study is to explore the impact of the 2003 SARS outbreak on Chinese students living in Japan. A cross-sectional study was conducted using a semi-structured questionnaire. The participants were recruited at multiple locations at the University of Tokyo, Japan. The results showed approximately 60% (96/161) of the respondents felt an impact of SARS on college life; they had experienced SARS-related fear, worry, depression as well as social discrimination and had taken SARS prevention measures for daily protection in Japan during the epidemic. The magnitude of the impact was associated with socio-demographic factors, including their age, specialty, area of previous residence in China and length of stay in Japan. The findings suggest that the SARS outbreak had a psychosocial impact on the Chinese students living in Japan, even though none of them had SARS. Social support tailored for these foreign students should be provided during such a disease outbreak.

Perceived poisons

Perceived poisoning may manifest in numerous ways; however, all cases share certain characteristics. All are fostered by the wide availability of unreliable information about chemical safety, poor understanding of scientific principles, and ineffective risk communication. Although this problem is still incompletely understood, some approaches have been demonstrated to be useful, such as education about risk, appropriate reassurance, and empathy on the part of the practitioner. Successful management may curtail the spread or exacerbation of symptoms, whereas unsuccessful treatment may cause the problems to escalate, with detrimental effects on both society and patient.

Evaluating the human response to chemicals: odor, irritation and non-sensory factors

Although airborne chemicals can directly elicit adverse reactions via stimulation of the olfactory and trigeminal nerves, such as sensory irritation of the mucous membranes of the eyes, nose and throat, an individual's subjective experience is often the result of a complex sequence of events involving those sensory, physiological signals and psychological processes involved in perception, memory and judgment. To evaluate the contribution of these processes, an information-processing model of chemosensory perception is introduced. The model incorporates (1) the perception of odor and trigeminal irritation, and accompanying physiological and somatic changes that follow directly from the encounter with volatile organic compounds (VOCs) in the environment (bottom-up processing), and (2) any physiological/ somatic changes and subjective experiences of irritancy that are influenced by cognitive processes that have been primed by the perception of odor (top-down processing). The model is illustrated with data from our laboratory, and its utility in the context of setting occupational exposure limits is discussed.

Biochemical terrorism: too awful to contemplate, too serious to ignore: subjective literature review

BACKGROUND

It is important not to foster unnecessary public anxiety with regard to the risk of a biochemical terrorist incident, but the authorities need to consider their response strategy, particularly with regard to mental health issues.

AIMS

To describe the likely effects of a terrorist incident involving biochemical agents and to identify important response issues.

METHOD

Literature survey.

RESULTS

Observations following conventional terrorist incidents and other major trauma, including biochemical and nuclear accidents, suggest that a biochemical terrorist incident would have widespread public effects. The mental health services should play a major role in designing an effective multi-disciplinary response, particularly with regard to the reduction of public anxiety, identifying at-risk individuals and collaborating with medical and emergency services, as well as providing care for those who develop post-traumatic psychopathology.

CONCLUSIONS

We should not feel helpless in the face of a biochemical threat; there is considerable knowledge and experience to be tapped. A well-designed, well-coordinated and rehearsed strategy based on empirical evidence will do much to reduce public anxiety and increase professional confidence.

Mass psychogenic illness after vaccination

When vaccines are administered to groups, the physical reactions of the recipients may be similar, causing a form of mass reaction, the mechanism for which is the same as that for mass reactions from other causes. These phenomena have been categorised as mass psychogenic illness (MPI), and have been defined as the collective occurrence of a constellation of symptoms suggestive of organic illness but without an identified cause in a group of people with shared beliefs about the cause of the symptom(s). A review of the literature shows that such outbreaks have been reported in differing cultural and environmental settings including developing and industrialised countries, in the work place, on public transport, in schools, and the military. The perceived threats have been against agents such as food poisoning, fire and toxic gases. Whatever the place or perceived threat, the response seems to be similar. The symptoms generally included headache, dizziness, weakness, and loss of consciousness. Once under way, MPIs are not easy to stop. Incidents reported in the literature show that they can quickly gather momentum and can be amplified by the press who disseminate information rapidly, escalating the events. Management of such mass events can be extremely difficult. Should the public health official in charge continue to try and determine the cause, or should this person call off the entire investigation? It is suggested here that once vaccines are identified as a probable cause of the phenomenon, a dismissive approach may actually be harmful. Unless the spokesperson has already earned a high level of trust, the public are not likely to be convinced easily that nothing was wrong with the vaccine until it has been tested. An increased awareness of MPIs on the part of organisers of future mass vaccination campaigns seems appropriate. Immunisation managers should be aware that mass immunisation campaigns could generate such mass reactions. It is therefore essential that surveillance/reporting systems for reporting adverse events be improved before such campaigns. A mass campaign using a smallpox vaccine should be accompanied by a surveillance system capable of distinguishing between multiple cases of conventionally understood vaccine reactions and outbreaks of mass psychogenic illness.

The Coca-Cola incident in Belgium, June 1999

The present paper describes the outbreak of health complaints that occurred in Belgium, in June 1999, among schoolchildren and members of the general public in relation to the consumption of Coca-Cola and other soft drinks. The outbreak took place in the wake of a major food crisis, caused by PCB/dioxin contamination of animal feed, that had erupted shortly before. The clinical features (absence of serious poisoning) and epidemiological characteristics of the Coca-Cola outbreak pointed to mass sociogenic illness, and no subsequent toxicological or other data have refuted this hypothesis.

The role of suggestions and personality characteristics in producing illness reports and desires for suing the responsible party

For this project, 92 students entered an abandoned theater room in an old basement of the university where sand was scattered throughout. The purpose of the study was to experimentally demonstrate that psychological suggestions could produce illness reports and to explore who is most likely to say that they would sue for personal damages. The students filled out the Trait-State Anger Scale and two subscales, Anger Temperament and Anger Reaction (C. D. Spielberger, G. A. Jacobs, S. Russell, & R. S. Crance, 1983) as well as the Costello-Comrey Anxiety Scale (G. C. Costello & A. L. Comrey, 1967), the Hardiness Inventory (S. C. Kobasa, 1982), the Pennebaker Inventory of Limbic Languidness (J. W. Pennebaker, 1982), and, embedded in the Hardiness Inventory, measures of current illness as a result of exposure to the basement room. Half the participants were met by a confederate student who claimed to be cleaning up the remains of a production of "Lawrence of Arabia," and the other half were met by a confederate construction worker who claimed that "The stuff will tear up your skin and your lungs." Those in the experimental groups who perceived danger and scored low in the hardiness dimension of challenge were more likely to report symptoms of illness. Willingness to file a law suit was predicted by a model including perceived danger and the personality characteristic of anger reactivity.

Breast implants and illness: a model of psychological factors

Studies of disease outcomes have not produced an explanation or an intervention for the symptoms and complaints that some women have attributed to breast implants. Reviews of the literature have found no increased risk of specific systemic disease, and no treatment recommendations have emerged. However, similar symptoms in fibromyalgia, chronic fatigue, and other contexts have been considered to be stress or behaviourally mediated, and a number of promising behavioural interventions have been developed. Aetiological, research, and treatment implications may follow from the consideration of such symptoms within a behavioural medicine model that allows for the interaction of physical and psychological influences. In the case of implants, a mass somatisation model may also help to discern the potential effects of litigation and other social influences.

Terrorism and the ethics of emergency medical care

The threat of domestic and international terrorism involving weapons of mass destruction-terrorism (WMD-T) has become an increasing public health concern for US citizens. WMD-T events may have a major effect on many societal sectors but particularly on the health care delivery system. Anticipated medical problems might include the need for large quantities of medical equipment and supplies, as well as capable and unaffected health care providers. In the setting of WMD-T, triage may bear little resemblance to the standard approach to civilian triage. To address these issues to the maximum benefit of our patients, we must first develop collective forethought and a broad-based consensus that these decisions must reach beyond the hospital emergency department. Critical decisions like these should not be made on an individual case-by-case basis. Physicians should never be placed in a position of individually deciding to deny treatment to patients without the guidance of a policy or protocol. Emergency physicians, however, may easily find themselves in a situation in which the demand for resources clearly exceeds supply. It is for this reason that emergency care providers, personnel, hospital administrators, religious leaders, and medical ethics committees need to engage in bioethical decision making before an acute bioterrorist event.

Defense system shortcuts and limits of scope

Defense, as a key factor of life, shares the biological tendencies of simplicity and energy saving. We propose that, like the mind, defense tends to rely on shortcuts via immune memes. Also, response repetition may induce the formation of virtual 'modules' [toolkits] to simplify and perfect performance. Engaged modules may expand by proliferating or by capturing immune components from the 'dormant' and even perhaps from active ones. With regard to recovery and/or survival, complexity of the integrated defense system (IDS) (1) requires to be inside of what we call the 'functional window'. In contrast to the physiological and common disease repair, energy is squandered when IDS perceives real danger. Our concern is the uncertain transition to conditions that do not fit into the IDS routine and, even worse, that are outside the functional window where the system is lacking.