Culture Bound Syndromes

Culture refers to ‘way of life’ or the way groups of people do things. It includes customs, traditions, values, concepts, rules, practices and set of knowledge that are acquired over a period of time and transmitted across generations through learning. Culture is significant from psychiatric point of view because it influences psychopathology of various psychiatric disorders, how symptoms are perceived, explained and from where help is sought. Some psychiatric syndromes are thought to be limited to certain specific cultures. These disorders are called culture specific or culture bound syndrome, that is, ailments that are generally confined to a certain cultural group or geographic region with similar cultural groups.

Yap first defined culture-bound psychogenic psychoses in 1962. This term was modified by him 7 years later to culture-bound syndromes. In 1992, the ICD-10 used the term ‘culture-specific disorders’. In the DSM-IV-TR, culture-bound syndromes were seen as recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category.

The following characteristics were seen as crucial for culture-bound syndromes as per DSM-IV-TR (2000):

1. Indigenously considered illnesses or afflictions– considered as a deviation from normal or healthy presentation.
2. Local names – the experience of mental distress is given a specific local name, often in the indigenous or key language of communication.
3. Symptoms, course and social response are often influenced by local cultural factors.
4. Limited to specific societies or cultural areas – this may be a geographical region, areas with shared ethnic history or identity.
5. Localized – experiences that are not globally recognized or span different regions.

The DSM-5 discarded the concept of culture bound syndromes with a preference for the term ‘cultural concepts of distress’. The ways by which cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions are referred to as cultural concepts of distress. So, rather than culturally distinctive configuration of symptoms, culture bound syndromes are in reality, clinically important cultural differences in explanations or experience of distress.

S.No. Name Region Clinical features Related conditions in other cultural contexts

1. 1. Ataque de nervios Latino descent • Sense of being out of control.
      • Intense emotional upset,
      • Screaming and shouting uncontrollably, crying spells, trembling,
      • Heat in chest rising into head,
      • Becoming verbally and physically aggressive.

Usually occurs after some stressful event relating family, e.g. news of death of close relative, conflicts with spouse or children, witnessing an accident involving a family member. Indisposition (Haiti), blacking out (Southern United States), falling out (West Indies)

1. 1. Dhat syndrome South Asia Term first used by Dr. N.N. Wig.

Nocturnal emissions lead to severe anxiety and hypochondriasis. Patients often present with:

1. 1. • generalized weakness,
      • aches and pains all over body,
      • tingling and numbness in various parts of body especially peripheries,
      • easy fatigue,
      • lassitude,
      • loss of appetite, weight loss,
      • loss of attention and concentration, excessive worrying,
      • panic attacks,
      • sadness of mood,
      • forgetfulness,
      • feelings of guilt (especially towards masturbation during adolescence),
      • sexual complaints (premature ejaculation and erectile dysfunction).

Patient attributes it to the passing of whitish discharge, believed to be semen (Dhat), in urine.

The mainstay of treatment is counseling along with sex education, to remove misconceptions regarding semen loss, fears regarding masturbation and nocturnal emission. Koro (South east Asia), shen-k´uei or kidney deficiency (China)

1. 1. Khyâl cap Cambodia
      • Symptoms of panic attacks (dizziness, palpitations, shortness of breath, cold extremities);
      • symptoms of autonomic arousal (tinnitus, neck soreness) Pem lom (Laos), srong rlung gi nad (Tibet), vata (Srilanka), hwa byung (Korea)
   2. Kufungisisa Zimbabwe ‘Thinking too much’
      • Anxiety symptoms
      • Panic attacks
      • Depressive symptoms
      • Irritability Brain fag (Nigeria)
   3. Maladi moun Haitian community ‘Sent sickness’

Interpersonal envy and malice cause people to harm their enemies by sending illnesses like psychosis, depression, social and academic failure, and inability to perform daily activities. Mal de oj (Spanish), mal’occhiu (Italian) (Evil Eye)

1. 1. Nervios Latinos Refers to a general state of vulnerability to stressful and difficult life experiences. Symptoms include:
      • Headaches and ‘brain aches’ occipital neck tension)
      • Irritability
      • Stomach disturbances
      • Sleep difficulties
      • Nervousness
      • Easy tearfulness
      • Inability to concentrate
      • Trembling
      • Tingling sensation Nerva (Greeks in North America), nierbi (Sicilians in North America), nerves (whites in Appalachia & Newfoundland)
   2. Shenjing shuairuo China ‘Weakness of the nervous system’

In traditional interpretation, it results when bodily channels (jing) conveying vital forces (shen) become dysregulated due to social and interpersonal stressors.

Symptoms include:

1. 1. • Weakness and mental fatigue
      • Irritability
      • Headache
      • Insomnia
      • Anxiety symptoms Ashaktapanna (India), shinkei-suijaku (Japan)
   2. 8 Susto Mexico, Central America, South America, Latinos in the United States Illness attributed to a frightening event that causes the soul to leave the body and results in unhappiness and sickness. Symptoms include:
      • Appetite disturbance
      • Inadequate or excessive sleep
      • Troubled sleep/ dreams
      • Somatic symptoms
      • Feelings of sadness, worthlessness, or dirtiness
      • Interpersonal sensitivity
      • Lack of motivation Espanto (Andean region)
   3. Taijin kyofush Japan ‘Interpersonal fear disorder’

Anxiety about and avoidance of interpersonal situations due to thought, feeling or conviction that one’s appearance and actions in social situations are inadequate or offensive to others. Tein kong po (Korea)

Other culture bound syndromes not included in DSM 5:

Amok: It is usually seen in Southeast Asia (Malaysia). It is characterized by a sudden, unprovoked episode of rage in which the affected person runs about (runs ’amok’) and injures or kills, indiscriminately, any person who is encountered on the way.

Koro: This culture bound syndrome is seen in Asia, including India. The affected male person has the belief that his penis is shrinking and may disappear into his abdominal wall and he may die. Rarely, females may be affected, with the corresponding belief that their breasts and/or vulva are shrinking. Koro is usually based on culturally believed fears regarding nocturnal emission and masturbation. It often tends to spread rapidly in other members of the community in an epidemic form.

Wihtigo (Windigo): This syndrome is seen in native American-Indians and occurs especially during periods of starvation. The affected person has the belief that he has been transformed into a wihtigo or a cannibal monster.

Piblokto (Arctic hysteria): This syndrome occurs in Eskimos, usually females. The affected person tears off her clothes, and throws herself on ice in extremely cold conditions, screams uncontrollably, shouts curses, breaks nearby items, eats excrement, or runs out naked into the cold or walks on thin ice. The episode usually lasts for 1-2 hours, followed by amnesia for the event.

Latah (Startle reaction): This syndrome has been reported from Malaysia, affecting the Malay and Iban people. It usually occurs in women. It is characterized by automatic obedience, exaggerated startle responses and involuntary vocalizations, echolalia and echopraxia.

Culture Bound Syndromes Seen in India

Apart from Dhat syndrome, koro and amok (described above), other culture bound syndromes seen in India include:

Jhin Jhinia- Characterized by bizarre and seemingly involuntary contractions and spasms.

Bhanmati Sorcery- Seen in South India., it is believed to be due to psychiatric illness i.e. conversion disorders, somatization disorders, anxiety disorder, dysthymia, schizophrenia etc.

Suudu- Characterized by painful urination and pelvic “heat” seen in south India, especially in the Tamil culture. It occurs in males and females. It is usually treated by the following:

1. Applying a few drops of sesame oil or castor oil in the navel and the pelvic region
2. Having an oil massage followed by a warm water bath
3. Intake of fenugreek seeds soaked overnight in water

Gilhari Syndrome- Characterized by patient complaining of small swelling on the body changing its position from time to time as if a gilhari (squirrel) is travelling in the body.

Ascetic Syndrome- First described by Neki in 1972. It appears in adolescents and young adults. Characterized by social withdrawal, severe sexual abstinence, practice of religious austerities, lack of concern with physical appearance and considerable loss of weight.

Mass Hysteria- Short lasting epidemics where hundreds to thousands of people are seen to believe and behave in a manner in which ordinarily they would not.

Possession Syndrome- Patient is allegedly possessed usually by ‘spirit/soul’ of deceased relative or a local deity and speaks in changed tone. Even gender changes at times if the possessing soul is of opposite sex. It is usually seen in rural areas or in migrants from rural areas. Majority of these patients are females who otherwise do not have any outlet to express their emotions.

Culture Bound Suicide

Sati : self-immolation by a widow on her husband’s pyre.

Jouhar : Suicide committed by a woman even before the death of her husband when faced by prospect of dishonor from another man (usually a conquering king).

Santhara/Sallekhana : voluntarily giving up life by fasting unto death over a period of time for religious reasons (to attain God/ Moksha).