CULTURE BOUND

SYNDROME

P R E S E N TAT I O N B Y- D r S H A N T H E R I PA I R
M O D E R AT O R - D r S WA P N A S
26/06/2020
 OVERVIEW
• INTRODUCTION
• CULTURE AND PSYCHIATRY
• DEFINITION
• HISTORY
• SUBGROUPS
• MANAGEMENT
• NEWER CONCEPTS
• FUTURE DIRECTIONS
• SUMMARY
• REFERENCES

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 INTRODUCTION
• A culture comprises all of the beliefs, laws, customs, morals, capabilities, and habits of people
who cooperatively work or live in an identified social unit (tribes, cities, nations etc.) or in
institutions (armed forces, religious orders, hospital staffs etc)
• Culture has six essential characteristics
– Learned
– Passed on to generations
– Set of words, behaviours, events, symbols
– Template to shape and orient future behaviour
– Exists and evolves in a constant stage of change
– Includes pattern of both subjective and objective component
• Race is a concept that entails people being grouped primarily by physiognomy
• Ethnicity refers to subjective sense of belonging to a group of people with common national or
religional origin and shared belief, values and practices

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 CULTURE AND PSYCHIATRY
• Culture shapes how and what psychiatric symptoms are expressed and also influences
meanings that are given to symptoms
• Consideration of social and cultural contexts of the patients life and of clinical encounter is
essential for accurate psychiatric diagnosis
• Judgement that a symptom or a behaviour is abnormal requires clinical attention depending
on cultural norms that are internalised by the individual or applied by others around them
• The boundaries between normality and pathology vary across cultures for specific types of
symptoms and behaviour
• Thresholds of tolerance for specific types of symptoms and behaviours differ also across
culture and social settings

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CULTURAL CONSIDERATION IN CLINICAL PRATICE
• Culture, race and ethnicity are of crucial importance in the clinical assessment of every patient
• Culture influences process of diagnosis in many ways
– Experience and expression of symptoms and signs
– Behaviour that are criteria for diagnosis
– Configuration of symptoms into culturally distinctive syndromes
– Stigma attached to specific symptoms and syndromes that may prevent their clinical
reporting
– Influence on course of illness
– Conduct of clinical encounter through which diagnosis is made

• Diagnostic assessment must consider the degree to which the patient’s experience and
behaviour differ from relevant, social and cultural norms and generate conflict or difficulties in
adaptation within his/ her culture of origin and current social context
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 CULTURAL FORMULATION
• Cultural assessment should be a component part of every complete psychiatric assessment
• DSM-5 determined to give culture a more prominent place by position in it in introductory
chapters and revision of cultural formulation in section III – Cultural Formulation Interview
• Outline for Cultural Formulation consists of five areas of assessment
– Cultural identity of the individual
– Cultural conceptualisation of distress
– Psychosocial stressors and cultural features of vulnerability and resilience
– Cultural features of the relationship between the individual and the clinician
– Overall cultural assessment

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• Cultural identity refers to characteristics shared by a person’s cultural group.
– allows self definition
– race, ethnicity, country of origin, language use, religious and tradition – nourished beliefs,
socio- economic status, sexual orientation, migration history, experience of acculturation,
degree of affiliation with individual’s group of origin
• Conceptualization of distress represent ways in which the individual patient “experiences,
understands and communicates his or her symptoms to others”
• Explanatory models of illness- important for treatment
– Moral model
– Religious model
– Magical or supernatural explanatory model
– Medical model
– Psychosocial stress model

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 DEFINITION
• Culture-related specific psychiatric syndromes, also called as culture bound syndromes or
culture – specific disorders, refer to mental condition or psychiatric syndromes whose
occurrence or manifestations are closely related to cultural factors and thus warrant
understanding and management primarily from a cultural perspective. (OTP)

• The term “culture-bound” is used to describe a certain number of psychiatric disorders where
phenomenologies make them distinct from “western” psychiatric categories and that occur
with unusual frequency in certain cultural settings (Vyas Ahuja)

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 HISTORY
• Emil Kraepelin may be credited for first focusing on the sociocultural foundations of mental
illness
• In 1904, coined the term “vergleichende psychiatrie” or “comparative psychiatry” to stress the
study of cultural variations of psychopathology
• Early research was done by Western physicians serving in colonial outposts
• Diagnostic terms used were:
– Exotic disorders
– Ethnic psychosis
– Atypical psychosis
– Jungle psychosis

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• Prof. PM Yap of Hong Kong – great contribution to concept of culture- bound syndrome
– 1962- suggested the term “atypical culture- bound psychogenic psychosis”
– Later – “culture bound, reactive syndrome” then, “culture- bound syndrome”

• Pfieffer postulated more elaborately for dimensions of cultural influences in shaping CBS
– Culture specific areas of stress
– Culture specific shaping of conduct
– Culture specific interpretation
– Culture specific intervention

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• Culture- bound syndromes section of DSM-5 consists of three concepts
• Cultural Syndrome defined as cluster or group of co-occurring symptoms found in specific
cultural group, community or context
– May or may not be recognized as an illness within the culture but recognized by an
outside observer
– Nine cultural syndromes – Ataque de Nervious, Dhat syndrome, Khyal cap, Kufungisisa,
Maladi moun, Nervious, Shenjing shuairuo, Susto, Tajin kyofusho
• Cultural idiom of distress is linguistic term, phrase or way of talking about suffering, shared
with other people from same culture and used to express, communicate or comment on
distress in general
• Causal attribution is a label, attempt at explaining or ascertaining causes of the symtpoms,
illness or distress.

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• However it is recently realized that such psychiatric manifestations are not necessarily
confined to particular group.
– Koro occurs among Thai and Indian people not only among South Chinese
– Amok attacks other than in Malaysia occurs sporadically in Philippines, Thailand, United
States
• Therefore the term culture- bound does not seem to apply, has been suggested that “culture-
related specific psychiatric syndrome”(Tseng and McDermott) would be more accurate.

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 GLOBALIZATION
• Globalization means crossing borders.
• Key features of globalization are:
– Instant communication
– Fast, efficient means of travel
– Deregulation of commerce
– Widened access to technology
– Supranational political bodies
– Cross- border cultural interaction
• Migration is known to have significant effects on health, with migrants showing higher rates
of both physical and mental illness

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 SUBGROUPS OF CULTURE RELATED SPECIFIC
SYNDROMES
• Various subgroup system has been proposed
– According to symptoms
– Common factor (taxon)
– Contribution of culture to psychopathology
• Yap (1967) attempted to classify the culture-bound syndromes on basis of symptoms:
– Primary fear reaction (malignant anxiety, latah)
– Morbid rage reaction (amok)
– Nosophobia (koro)
– Trance dissociation (windigo psychosis)

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• Simons (1985) attempted a classification of CBS on basis of taxon: SEVEN
– Startle matching (latah)
– Sleep paralysis (Old hag)
– Genital retration (koro)
– Sudden mass assault (amok)
– Running
– Fright illness
– Cannibal compulsion

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 DIFFERENT WAYS BY WHICH CULTURE CONTRIBUTES TO PSYCHOPATHOLOGY

PROPOSED BY TSENG IN 2001,

• Pathogenetic effect – culture has causative effect
• Pathoselective effect – culture selects the nature and type of psychopathology
• Pathoplastic effect – culture contributes to manifestation of psychopathology
• Pathoelaborating effect – culture elaborates and reinforces certain types of manifestations
• Pathofacilitating effect – culture contributes to the frequent occurrence of particular
psychopathologies
• Pathoreactive effect – culture determines the reaction to psychopathology
• Pathodiscriminating effect – socio- cultural labelling of behaviour as normal or abnormal

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 CULTURE-BOUND SYNDROMES IN INDIA
• Dhat Syndrome
• Koro
• Possession Syndrome
• Bhanmati
• Gilhari syndrome
• Suchibai syndrome
• Culture bound suicide
• Jhinjhinia
• Ascetic syndrome
• Suudu

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 Pathogenetic effect

Culture- related belief as cause of occurrence

 DHAT SYNDROME
• Synonyms – sukrameha, Semen- loss anxiety, semen- leaking anxiety disorder, spermatorrhea
• ‘dhatu’ means precious fluid – Semen (veerya) is considered to be most precious elixir
• Coined by Prof. NN Wig in 1960
• Dhat syndrome refers to clinical condition in which patient is morbidly preoccupied with
excessive loss of semen from an improper form of leaking, such as nocturnal emissions,
masturbation, urination.
• Belief – 40 drops of bone marrow equal to one drop of semen
• Underlying anxiety is based on cultural belief that excessive semen loss will result in illness
• Predominantly young males – vague, multiple somatic complaints- fatigue, weakness, anxiety,
loss of appetite, feelings of guilt
• Some complain of sexual dysfunction and some complain of opaque urine
• Syndrome is also widespread in SriLanka (sukra prameha), Bangladesh, Pakistan, China
(shenkui)
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 • Khan (2005) studied treatment seeking pattern of
subjects with Dhat syndrome in Lahore:
– 50% of subjects sought help from Hakims
– 1.6%consulted psychiatrist
• Singh et al in 2003 reported that the concept of Dhat
syndrome has also been extended to women presenting
with somatic symptoms a/w leukorrhoea and
explained as due to loss of a ‘vital fluid’
• Symptoms disapper if misconceptions about semen
loss are effectively dealt with and by increasing
knowledge about sex.
Professor N N Wig

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 KORO
• Synonym- genital- retraction anxiety disorder, suoyang
• Koro – Malay word means “head of the turtle” symbolising the male sexual organ which can
“shrink”
• Clinically refers to psychiatric condition in which patient is morbidly concerned that his
penis is shrinking excessively and subsequently dangerous consequences might occur
• Originally koro was considered to be syndrome related to Chinese
• First known reference – northern China in 7000BC
• First well developed concept based on Yin-Yang was described between 476 and 221BC – in
first textbook of Chinese medicine, the Yellow Emperor’s Classic Text of Internal Medicine
• Majority of cases are young males who fear that their penis are shrinking
• Other organ concerned are- nose, ear, nipples or labia

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• Further occurrence of disease in Malaysia and Indonesia due to Chinese migrants – Cultural-
diffusion view
• Above view is doubted due to occurrence of such cases in India, Israel, UK
• Koro may present as symptom, syndrome or epidemic
• Classified either into- hypochondriacal disorder, anxiety disorder or body dismorphic
disorder depending on the presentation
• koro- like symptoms: patient with primary psychiatric disorder such as affective disorder,
schizophrenia, anxiety disorder, substance use presenting with koro symptom
• Usually benign in an individual, but may occasionally grow into an epidemic
• Epidemic koro has been observed in several areas- Guangdong area of China, Singapore,
Thailand and India (jhinjhini bhimari) – manifest as panic state
• Therapy- Assurance, providing adequate psychosexual knowledge, clearing misconceptions
• Treat any underlying psychiatric disorder

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• The methodologies can be partitioned into four primary roads:
(1) preventive measures as endorsed by the culturally embedded myths
(2) manipulatory techniques (pulling the penis outward, affixing of cinches and strings to the
penis) performed by the patient himself, relatives or companions
(3) people mending proposals to battle the confusion, including unique weight control plans
containing yang substances (e.g., bamboo, deer horn, dark pepper powder, ginger) and
execution of ceremonies to pursue away the insidious soul (striking gongs, setting off
fireworks)
(4) Medical management

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 SORCERY FEAR AND VOODOO DEATH
• Synonym- Magic-fear-induced-death, Thanatomania
• Refers to sudden occurrence of death associated with taboo-
breaking or curse fear
• Based on belief in witchcraft – the putative power to bring
about misfortune, disability and even death through spiritual
mechanism
• A severe reaction may result from such belief leading to death
– psychogenically induced death – eg of culture induced
morbid fear reaction
• Deaths are scientifically due to overstimulation of autonomic
nervous system, poison, organic illness, refusal to take food
and water
• Voodoo culture is practised in Africa and among native West
Indians
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 Pathoselective effect

Culture-patterned specific coping reactions

 AMOK
• Amok is a Malay term that means to engage furiously in battle
• Amok refer to an acute outburst of unrestrained violence a/w indiscriminate homicidal
attacks, preceded by period of brooding, and ending with exhaustion and amnesia
• Possible explaination of its occurrence in Malay society is due to religious background of
people where suicide is considered most heinous act in Mohammedan religion
• In past this reaction has been influenced due to infections and epilepsy
• Psychological point of view- extraordinary sensitivity to hurt and tendency to blame others
for ones own difficulties are considered possible causes of employment
• Amok behavior is seen in other areas such as – Phillipines, United States
• Communicability and transmission from one generation to other

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 FAMILY SUICIDE
• When adults encounter severe difficulties there are many ways to deal with it.
• As one of the ways to cope up they committ suicide with their young children
• This is based on belief that it would be disgraceful to live after a shameful thing had
happened, shame would be relieved by ending ones life
• “blood is thicker than water” – family ties are strong, hence children are not alone to live as
they would be mistreated after death of parents
• Seen in Japan

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 CULTURE-BOUND SUICIDE
• Sati: an act of self-immolation by a dowager on her spouse’s fire-bed
– Hindu mythology
– Brahmins and kshatriya
• Jauhar : suicide conferred by ladies even before the passing of her husband when looked by
prospect of shame from another man
• Santhra: deliberately surrender life by fasting unto demise over some undefined time frame
for religious motivations to attain Moksha

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 PATHOPLASTIC EFFECT
• Culture- shaped variations of psychopathology
• Clinical picture that is considerably different from the ordinal symptomatology of identified
disorders described in current psychiatric classification
• Uniqueness of symptomatology is culturally attributed

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 ANTHROPOPHOBIA
• Synonyms- interpersonal relation phobia, taijin-kyofu-shio
• Prevalent among Japanese – culturally it is situation oriented society
• Onset of illness between 15- 25 years, males> females
• Cardinal symptoms are- fear of one’s bodily odours, fear of flushing, fear of showing odd
attitudes towards others, fear of eye contact with others, concern about others attitude
towards oneself, fear of body dysmorphia
• Characterisitic fear is induced in the presence of classmates, colleagues and friends – those
who are neither particularly close nor strangers
• Subjects are concerned with how to relate to people with intermediate familiarity, as these
are the people with whom subjects exercise delicate etiquette

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 BRAIN FAG SYNDROME
• Common minor psychiatric disorder occurring among students in South Nigeria
• Characterized by subjective complaints of intellectual impairment, sensory impairment,
somatic complaints (pain and burning sensation in head and neck)
• Students used the term “brain fag” to complain that they were no longer able to read, grasp
whatever they were reading or recall whatever they had just read
• In Nigeria, education was a family affair where brighter child was supported financially for
education and was inturn expected to take responsibility when the need arose

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 ARCTIC HYSTERIA
• Synonym – Pibloktoq, polar hysteria
• Observed among Eskimo people
• Characterized by sudden onset of loss or disturbance of consciousness
• Patient may show abnormal behaviours such as – tearing of his or her clothing, glossolalia,
fleeing, rolling in the snow, throwing anything handy around, performing mimetic acts or
convulsion, or other bizarre behavior
• Predominantly in women occasionally among men
• No specific precipitating causes are noted
• Prevalent in winter
• Suspected that disorder is due to anxiety triggered by severe culturally typical stresses – fear
of certain impending situations, fear of loss, fear of losing emotional support, including
sense of being on safe , solid familiar ground

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 Pathoelaborating effect

Culturally elaborated unique behavior

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 LATAH
• Synonym – startle-induced dissociative reaction
• Latah is a Malay word referring to condition in which a person, after being startled by an external
stimuli(tickle), experiences an altered consciousness and falls into transient dissociated state exhibiting
unusual behaviour
• Beyond Malaysia seen in other countries:
– Burma – yaun
– Thailand – bah-tsche
– Philippines – mali-mali
– Russia – myriachit
– Japan- it imu
• Two variants of the disorder
– Brief startle reaction with echo symptoms – utter obscenities
– Chronic disorder – over time leads to permanent automatic obedience, personality deterioration and echo
reactions

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• Predominantly among women
• Following psychological stressful event like- loss of significant other
• Once reaction is experienced it becomes habitual
• Subject usually claims amnesia or puzzled about the episode
• In traditional polygamous Malay extended family structure is male dominant where this is
accepted as female attention seeking response

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 Pathoreactive effect

Cultural interpretation of certain mental disorder

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 ATAQUES DE NERVOIS
• Literally means attack of nerves, refers to stress induced, culturally shaped unique emotional
reaction with mixed anxiety- hysterical features
• Category used frequently by Hispanic people
• Initially observed among Puerto Rican army recruits labelled as Puerto Rican syndrome
• Common symptoms are shaking, palpitaions, sense of heart rising to the head and numbness
• Individual may shout, swear and strike out at others and finally fall to ground
• Typically occurs at funerals, accidents, family conflicts
• Focusing on symptoms alone misses what is most salient and meaningful about illness
categories

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 POSSESSION
• Person is possessed usually by ‘soul/spirit’ of dead relative or a local deity.
• Changed tone, even gender changes at times if the possessing soul is of opposite sex.
• Usually seen in people from rural areas
• Most often this is found in females as they found to have more piled up emotions and lesser
outlets to express themselves.
• Treatment incorporates cautious investigation of hidden anxiety which encouraged the
possession attack.
• To diminish any secondary gains that the individual might get from this conduct.
• These individuals are looked upon as exceptional by their families and towns which fortify
the secondary gains
• Included in ICD-10 under Dissociative disorders

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 HWABYUNG
• Fire sickness in Korean language
• Imbalance among the five elements within body (metal, wood, water, fire and earth) may
cause physical disorders
• Folk idiom of distress characterized by a wide range of somatic and emotional symptoms
• Two- thirds of the patient were women with domestic problems – husband’s extramarital
relationship and strained in-law relationship
• Due to male chauvinism, female are taught to accept defeat, bear frustration for stability in
family
• Accumulated resentment becomes an issue and later through pathoreactive effect it is
expressed

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 SUSTO
• el meido (Bolivia), lanti (philippines), mogo laya (New Guinea)
• Synonym- soul loss
• Literally means fright in Spanish
• Folk belief that every individual possesses a soul, but through certain experience, such as
being startled or frightened, a person’s soul may depart from the body
• As a result soul lost person will manifest certain morbid mental conditions and illness
behaviour
• Remedy is to recapture soul through rituals
• Manifested syndrome is usually heterogeneous and symptoms are not shared in a group
• Hence here role of culture is interpretation of and reaction to the illness

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 PATHOFACILITATING EFFECTS
• Cultural influence of prevalent occurrence of disorder
• Several conditions that are commonly known as psychiatric disorder
• Includes- massive hysteria
- group suicide
- alcohol- related problems
- substance abuse

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 MASSIVE HYSTERIA
• Mass sociogenic illness, mass psychogenic disorder, epidemic hysteria, or mass hysteria
• the rapid spread of illness signs and symptoms affecting members of a cohesive group
• The central feature of the episodic is a trance state of 5 to 15 minutes with restlessness,
attempts at self-injury, running away, inappropriate behaviour, inability to identify family
members, refusal of food and intermittent mimicking of animal sounds.
• The illness was self-limiting and the individual showed improvement in symptoms in the
course of one to three days’ duration
• Various religious centres
• Case reports in Delhi, Tripura, Karnataka

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 MISCELLANEOUS
• Bhanmati sorcery:
– This is seen in South India.
– It is believed to be due to presence of psychiatric illness like somatization disorders,
conversion disorders, dysthymia, anxiety disorder, schizophrenia etc

• Suudu:
– culture-specific syndrome of painful urination and pelvic "heat" familiar in South India
– especially in the Tamil culture
– It occurs in males and females
– It is popularly attributed to an increase in the "inner heat" of the body often due to dehydration
– It is typically treated through:
1. Applying a couple of drops of sesame oil or castor oil in the navel and the pelvic area.
2. Having an oil massage took after by a warm water shower.
3. Intake of fenugreek seeds doused overnight in water.
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• Mal de ojo :
– evil eye
– Children are especially at risk
– Fitful sleep, crying without apparent cause, diarrhea, vomiting and fever

• Gas Syndrome:
– One of the common complaints that are being heard from individuals coming to medical set
ups is ‘Gas’ or ‘vayu’ (Charaka samhita)
– number of somatic symptoms
– ‘Gas’ is reported to be the cause for the distress
– primary duty of the treating clinician is to relieve them of the gas

• Jhinjhinia: short duration of tingling and numbness

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• Ascetic syndrome:
– In the first place it was depicted by Neki.
– Disorder is seen in teenagers and youthful grown-ups
– Social withdrawal, serious sexual restraint, routine with regards to religious austerities,
and absence of worry with physical appearance and excess loss of weight
• Suchi-bai syndrome:
– condition like obsessional neurosis
– Certain group of individuals, especially widows in the days of yore had multitudinous
taboos forced on them
– Follow stringent rules
• Khyal cap
• Gillhari syndrome
• Nervious
• Ghost sickness

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ASSESSMENT AND TREATMENT

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 CULTURAL FORMULATION INTERVIEW
• Semistructured interview that includes explicit instructions to the interviewer
• It uses person- centered aproach to conduct a cultural assessment by eliciting information
from patient about his or her views and those of others in their family and social network
thereby avoids stereotyping about the way that patients interpret their illness experience
• Comprises of four sections that together include 16 questions:
– Cultural definition of presenting problem
– Cultural perceptions of cause, context and support available
– The role of cultural identity
– Cultural factors affecting coping and health- seeking practices
• Includes informant version of sufficient information not obtained from the patient
• Eleven supplementary modules

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 CULTURAL BARRIERS TO MENTAL HEALTH
CARE
– Mistrust and fear of treatment
– Alternative ideas about what constitutes illness and health
– Language barrier and ineffective communication
– Access barriers such as inadequate insurance coverage
– Lack of diversity in mental health workforce
• Tseng proposes three levels of approach:
– Clinical level
– Research level
– Theoretical level

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 COMMUNICATION
• Be aware that a person’s culture will shape how they understand health and ill-health
• Learning about specific cultural beliefs that surround mental illness in the person’s
community
• Know what is normal and what is not in person’s culture
• Learning how mental illness is described in person’s community
• Be aware of what concepts, behaviour or language are taboo

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 TREATMENT
• Formulation of a collaborative model that is acceptable to both clinician and patient is the
sought- for end point, which would include an agreed upon set of symptoms to be treated and
an outline of treatment procedure to be used.
• Pharmacological to treat underlying primary psychiatric illness, alleviate anxiety
• Evaluate for comorbid illness
• Culture specific therapies
• Clarifying myths and misconceptions
• Psychoeducation of family members
• Relaxation therapy
• Address stressors

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 NEWER CONCEPTS

• Few syndromes are not culture bound as they are found across culture over a period of time
• Consideration of changeability of culture and phachopathology is dynamic
• Amok was considered normal in originally referred to war cry of Malay pirates, later
legislation passed by British in 1893 for all amok subjects to be tried in court
• The underlying belief of these syndromes are dimensional hence the presentation of
symptoms needs to be seen from a clinical prospective rather than viewing it as neurotic
disorder alone
• Social changes contribute to fading of such syndromes. Eg- family suicide and latah

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 FUTURE DIRECTIONS
• Need for studies that focus on cultural dimensions and impact of culture on such syndromes
involving individual cases
• Well designed questionnaire
• Survey of non-patient group where a specific syndrome tends to occur

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 SUMMARY
• Each person’s experience with the mental health and illness is unique.
• It is the bio-psycho-social processes that contribute to somatic distress or syndrome.
• There is a need of studying attribution patterns and explanatory models with respect to the
cultures regarding the symptomology of culture bound syndromes.
• Therapeutic management needs to be developed and established with respect to the culture.
• By ensuring evidence-based treatment and therapy and developing culturally responsive
services, these common yet complicated conditions can be studied more and can provide
more adequate treatment options.

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 References
• Benjamin J Sadock, Virginia Alcot Sadock, Pedro Ruiz. Kaplan and Sadock’s
Comprehensive Textbook of Psychiatry. 2017, 10th edition.
• Michael G Gelder, Nancy C Andreasen et al.New Oxford Textbook of Psychiatry.2 nd edition.
• JN Vyas, Niraj Ahuja. Textbook of Postgraduate Psychiatry. 2nd edition
• JN Vyas, Shree Ram Ghimire. Textbook of Postgraduate Psychiatry.2016, 3nd edition
• Anuja Kapoor, Rashi Juneja, Dweep Chand Singh. Cultural Specific Syndromes in India –
An Overview. Int J Cur Res Rev2018(10) 11: 2-6

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