Culture bound syndromes

CULTURE BOUND
SYNDROMES
PRESENTER – DR. SUBHENDU SEKHAR DHAR

OVERVIEW
 Introduction
 Evolution of concept
• Historical aspect
• Nosology
 Subdividing CBS
 Common culture bound syndromes
 Course & Prognosis
 Treatment
 Critique

INTRODUCTION
‘CULTURE’ : Defined as :-
 Comprising the ideas, values, habits & other patterns of
behaviour which a human group transmits from one generation
to another, OR
 The whole complex of traditional experiences, concepts,
system of values & behavioural rules in a society
 Cultures are open, dynamic systems that undergo continuous
change over time.

INTRODUCTION
 RACE is defined as ‘A culturally constructed category
of identity that divides humanity into groups based on
a variety of superficial physical traits attributed to
some hypothetical intrinsic, biological characteristics.
 ETHNICITY is a culturally constructed group identity
use to define peoples & communities.

INTRODUCTION
 Culture bound syndrome also known as culture related specific
disorders, culture specific disorders/ syndromes.
 In the American handbook of psychiatry, Exotic psychiatric
syndromes or Rare atypical unclassifiable disorders.
 They all refer to certain illnesses or disorders which occur
exclusively in certain cultures and not found in others.

DEFINITION
 In medicine and medical anthropology, a culture-bound
syndrome, culture-specific syndrome, or folk illness is a
combination of psychiatric and somatic symptoms that are
considered to be a recognizable disease only within a specific
society or culture.
 1980s - Raymond Prince and co-workers Proposed a
definition of these phenomena as a “collection of signs and
symptoms (excluding notions of cause), which is restricted
to a limited number of cultures primarily by reason of
certain of their psychosocial features.”

HISTORICAL PERSPECTIVES
 In 1904 Emil Kraepelin initiated the field of comparative
psychiatry (Vergleichende Psychiatrie) through investigation of
dementia praecox in Java, and he later documented
psychiatric presentations among Native Americans, African
Americans and Latin Americans.
 It was first described in Kraepelin textbook of psychiatry, the 8th
edition (1909)

 Pow Meng Yap, a pioneer in cultural psychiatry (1962)
introduced ‘atypical cultural bound psychogenic psychosis’
which he later abbreviated to ‘culture bound syndrome’
 In 1985 in the book “The Culture Bound Syndromes”,
Ronald Simons & Charles Hughes used the taxonomic
principle to group the syndromes based on their
phenomenological similarity across diverse cultural
settings.

 Ruth Levine and Albert Gaw suggested the term ‘folk diagnostic
categories’
 They proposed a criteria for culture specific syndromes –
• Must be a discreet, well defined syndrome
• Recognized as a specific illness in the culture
• Disorder must be recognized, and sanctioned as a response to certain
precipitants in the culture.
• Higher incidence or prevalence in the society where it is culturally
recognized.

HISTORICAL REPORTS
 1893,1897 – W.G.Ellis Amok,Latah(Malays)
 1908 – W Fletcher Elaboration on Latah
 1910-Musgrave,Sison Mali-mali(Philippines)
 1913 –Brill – Pibloktoq(Arctic Hysteria)
 1933 - John Cooper – Windigo psychosis- Algonquian Indians
 1934 - Wulfften Palthe  koro
 1936 - Winiarz and Wielawskiimu
 1940 – Still  Dhat syndrome(India)

HISTORICAL REPORTS
 1948- Gillin magical fright
 1957-Cannon ‘voodoo’ death
 1959- Fernández-Marian ataques de nervios(Puerto Rica)
 1960- Raymond Prince ‘brain fag’ syndrome among Nigerian
students
 1962- T. A. Lambo malignant anxiety (Africa)
 1964- Rubel susto (Hispanic Americans)
 1966- Hsien Rinfrigophobia(excessive fear of catching cold)
observed in Taiwan.

RELATIONSHIP WITH
PSYCHOPATHOLOGY
 The growing cultural pluralism in society requires clinicians to
examine the impact of cultural factors on psychiatric illness,
including on symptom presentation and help-seeking behavior.
 In order to render an accurate diagnosis across cultural
boundaries and formulate treatment plans acceptable to the
patient, clinicians need a systematic method for eliciting and
evaluating cultural information in the clinical encounter.

RELATIONSHIP WITH
PSYCHOPATHOLOGY
 Thus , A systematic approach for accomplishing this
information is the cultural formulation :
1. Cultural identity of the individual
2. Cultural explanations of the individual’s illness
3. Cultural factors related to psychosocial environment
and levels of functioning
4. Cultural elements of the relationship between the
individual and the clinician
5. Overall cultural assessment for diagnosis and care

NOSOLOGY
 The term culture-bound syndrome was included in DSM IV
(1994) and ICD 10 (1992).
 According to DSM IV culture-bound syndrome denotes
• recurrent,
• locality-specific patterns of aberrant behavior and troubling experience,
that may or may not be linked to a particular DSM-IV diagnostic
category.
• indigenously considered to be "illnesses," or at least afflictions.
• Generally limited to specific societies or culture areas.

DSM IV describes about 25
CBS amok
 ataques de nervios
 bilis and colera
 boufe delirante
 brain fag
 dhat
 falling out or blacking out
 ghost sickness
 hwa-byung
 koro
 latah
 locura
 mal de ojo
 nervios
 pibloktoq
 qi-gong psychotic reaction
 rootwork
 sangue dormido
 shenjing shuairuo
 shenjing shenkui
 shin-byung
 spell
 susto
 taijin kyofusho
 zar

ICD 10
 ICD 10 categorizes culture bound syndromes in the
Annex 2 and lists 12 culture bound syndromes.
 It lacks any diagnostic and cultural explanatory
guidelines.

ICD 10 describes about 12 CBS
 Amok
 Dhat
 Koro
 Latah
 Nervios
 Frigophobia
 Pibloktoq
 Susto
 Taijin Kyofoshu
 Ufufuyane
 Uqamairineq
 Windigo

DSM 5
 Cultural concepts of distress - refers to ways that
cultural groups experience, understand, and
communicate suffering, behavioral problems, or
troubling thoughts and emotions.
 Three concepts—syndromes, idioms, and
explanations.

 Syndromes - clusters of symptoms and attributions
that tend to co-occur among individuals in specific
cultural groups, communities, or contexts and that
are recognized locally as coherent patterns of
experience.
 Idioms - are ways of expressing distress that may
not involve specific symptoms or syndromes, but that
provide collective, shared ways of experiencing and
talking about personal or social concerns.

 Explanations - are labels, attributions, or features of
an explanatory model that indicate culturally
recognized meaning or etiology for symptoms,
illness, or distress.

 Importance of cultural concepts –
• To avoid misdiagnosis
• To obtain useful clinical information
• To improve clinical rapport and engagement
• To improve therapeutic efficacy
• To guide clinical research
• To clarify the cultural epidemiology

CULTUTRAL FORMULATION
INTERVIEW
 The Cultural Formulation Interview (CFI) is a set of 16
questions that clinicians may use to obtain information about
the impact of culture on key aspects of an individual's clinical
presentation and care.

 The CFI emphasizes four domains of assessment:
1. Cultural Definition of the Problem (questions 1-3)
2. Cultural Perceptions of Cause, Context, and Support
(questions 4-10)
3. Cultural Factors Affecting Self-Coping and Past Help
Seeking (questions 11-13)
4. Cultural Factors Affecting Current Help Seeking
(questions 14-16).

SUBGROUPINGS/CLASSIFICATION
 Subgrouping by cardinal symptoms: Yap (1967).
 Based on the cardinal symptoms of prototypical case :
• Primary fear reactions (malignant anxiety, latah, psychogenic /
magical death)
• Morbid rage reaction (amok).
• Specific culture-imposed nosophobia (koro).
• Trance dissociation (windigo psychosis).

 1985 –Simons,Hughes : suggested categorizing culture-
related syndromes by ‘taxon,’ i.e. group defined by a
common factor
1) Startle-matching taxon(latah, imu)
2) Sleep-paralysis taxon
3) Genital-retraction taxon (koro)
4) Sudden-mass-assault taxon (amok)
5) Running taxon(pibloktoq,grisi siknis, Arctic hysteria)
6) Fright-illness taxon (susto)
7) Cannibal-compulsion taxon (windigo psychosis).

 Tseng (2001) divided specific syndromes into several groups:
• Culture-related beliefs as causes for the occurrence (koro /dhat) :
PATHOGENETIC
• Culture-patterned specific stress-coping reactions (amok / family
suicide) : PATHOSELECTIVE
• Culture-shaped variations of psychopathology (taijinkyofusho
/brain fag syndrome) : PATHOPLASTIC

• Culturally elaborated unique behavior reactions (latah) :
PATHOELABORATING
• Culture-provoked frequent occurrences of pathological
conditions (mass hysteria / substance abuse) :
PATHOFACILITATING
• Cultural interpretations and reactions to certain mental
conditions (hwabyung / susto) : PATHOREACTIVE

In India, common culture bound
syndromes are
 Dhat Syndrome,
 Possession Syndrome,
 Koro,
 Gilhari syndrome,
 Bhanmati sorcery,
 Compulsive spitting,
 Culture-bound suicide (sati, santhra),
 Ascetic syndrome,
 Suudu,
 Jhin jhinia etc.

POSSESSION SYNDROME
 Osterreich (1966) defined possession as 'a state in
which the organism appears to be invaded by a new
personality and governed by a strange soul'.
 Introduced into modern
scientific literature
by P. M. Yap in 1960,
and was called as
‘possession syndrome'.

 Cognate experiences have been reported in extremely diverse cultural
settings, including India, Sri Lanka, Hong Kong, China, Japan, Malaysia,
Niger, Uganda, Southern Africa, Haiti, Puerto Rico and Brazil.
 AKA Zar in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African
and Middle Eastern societies.
 More common in women, with a female to male ratio of 2 or 3 to 1.
 Age of onset is usually between 15 and 35 years, but many cases
reportedly begin in childhood.
 Attacks may persist well into middle age, and geriatric cases have also
been reported.
 The syndrome has been identified in all Hindu castes, as well as in
Muslims, Christians, and tribal peoples.
 However, it is more commonly described among Hindus.

 In DSM IV TR, this class of presentations is subsumed in
appendix B under the proposed category of “dissociative
trance disorder,”
 A single or episodic alteration in the state of consciousness
characterized by the replacement of customary sense of
personal identity by a new identity. This is attributed to the
influence of a spirit, power, deity, or other person, as
evidenced by one (or more) of the following:
• a) stereotyped and culturally determined behaviors or
movements that are experienced as being controlled by the
possessing agent.
• b) full or partial amnesia for the event.

 Phenomenology:
• Onset occurs typically due to subacute conflict or stress.
Onset may also vary by geographical region.
• Dramatic, semi-purposeful movements, aggressive or
violent actions directed at self or at others.
• Verbalizations, derogatory comments or threats of
violence directed against significant others.
• Specific gestures, comments or requests denoting the
appearance of a known possessing personality
• Emergence of one or several secondary personalities
distinct from that of the subject.
• Specific identities of possessing personalities remain
undisclosed for some time
• Outcome is variable

 Possession can occur sporadically involving one
individual or can occur simultaneously as an
epidemic involving many people.
 It can be voluntary and involuntary
 Possession can be beneficial to the individual by
giving him a special status in the society.

 Precipitants:
- Marked social/ family conflicts
- Stressful life transitions
- Hysterical, histrionic & immature defense mechanisms
 Relationship to psychiatric diagnosis:
- Schizophrenia: 40 – 59%
- Manic depressive illness: 11 – 13%
- Dissociative disorders: 9.5%
- Relapse rates - unknown
 Psychiatric treatment typically avoided.
 Indigenous treatments – neutralization of conflicts or
stress.

DHAT SYNDROME
 Dhat derives from the Sanskrit word ‘Dhatu’ meaning
‘metal’ and also ‘elixir’ or ‘constituent part of the
body’.
 AKA dhatu, jiryan, shen-k'uei(Chinese & Taiwan)
 First described in western texts by N.N.Wig (1960)
 Comprises vague somatic symptoms of fatigue,
weakness, anxiety, loss of appetite, guilt and sexual
dysfunction attributed by the patient to loss of semen
in nocturnal emissions, through urine or
masturbation.

 Semen loss anxiety in India
 The patient presenting with Dhat syndrome is typically
more likely to be
• recently married
• of average or low socio-economic status (perhaps a
student, laborer or farmer by occupation)
• comes from a rural area
• belongs to a family with conservative attitudes towards
sex

 The symptoms of semen loss anxiety have been well
known in Indian historical writing.
 It is not only confines to India, and has been reported
from Sri Lanka (shukra prameha) and China.
 Often described as a separate entity and many
authors did not give associated psychiatric diagnosis,
thus it is seen and recognized as a culture bound
syndrome.

 Semen loss anxiety in China
• Wen and Wang (1980) define shen-k’uei as vital or
kidney deficiency.
• Sexual neurosis associated with excessive semen loss
due to frequent intercourse, masturbation, nocturnal
emission or passing of white turbid urine.
• Patient becomes anxious, panicky with symptoms like
dizziness, backache, fatigability, weakness, insomnia,
frequent dreams and physical thinness.

 Weakness in Chinese people connotes loss of vital
energy (qi or chi)
 Yap also posits that a healthy exchange or yin and
yang occurs in sexual intercourse. Whereas following
nocturnal emission, masturbation or loss in urine only
yang is lost without gain of yin.
 In a study of 87 patients in a urology clinic in China
23 were found to have sexual neurosis with shen-
k’uei syndrome and 64 patients blames their
problems on masturbation.

 Semen loss anxiety in Western cultures
• Galen has described similar syndrome as Dhat in his
writings.
• Jewish writers too acknowledge that depositing of
semen anywhere else than the vagina was debilitating
to health.
• Tissot’s writing in the 18th century which was
embraced by the middle classes and sexual purity
became a way of distinguishing themselves from
promiscuity of the noble and lower social classes.

DHAT SYNDROME
 Benjamin Rush believed that all diseases could be caused by
debility of the nervous system and propounded that careless
indulgence in sex would cause multiple illnesses.
 In France, Lallemand was concerned that involuntary loss of
semen would lead to insanity.
 William Acton, an English physician advised people to engage in
infrequent sex.

 Management of Dhat syndrome
• Wig suggested emphatic listening, a non
confrontational approach, reassurance and correction
of wrong beliefs, along with use of placebo, anti-
anxiety and antidepressant drugs whenever required.
• Depressive symptoms of this syndrome showed
effective response to SSRI along with regular
counselling,

DHAT SYNDROME
• Other intervention studies for Dhat suggest sex education,
relaxation therapy and medications.
• Sex education focuses primarily on anatomy and physiology of
sexual organs.

 In a study of 5 cases in NIMHANS, an attempt was made
to develop a structured module for management of Dhat.
• Intake and assessment
• Socializing the patient to CBT
• Basic sex education
• Cognitive restructuring and other techniques
1. Cognitive restructuring
2. Relaxation
3. Imaginal desensitization
4. Masturbation as homework
5. Kegel’s exercises and other specific techniques
• Termination

KORO
 Refers to an episode of sudden and intense anxiety that the
penis (or, in women, the vulva and nipples) will recede into the
body and possibly cause death.
 The syndrome is reported in south and east Asia.
 Also known as –
• shuk yang, shook yong, and suo yang (Chinese);
• jinjinia bemar (Assam);
• or rok-joo (Thailand)

 Expect consequences to be fatal.
 More common in males.
 Inappropriate sex, such as masturbation or sex outside of
marriage, illness, exposure to cold
 Koro like symptoms – UK, Canada, Israel
 Clamps, ties, pegs or hooks may be used
 Onset is rapid, intense, unexpected
 Therapy : Assurance, educational counselling.

GILHARI SYNDROME
 This population believed that it starts as feeling of Gilhari
running on back of body associated with intense pain and
anxiety and finally Gilhari reaching the throat causing
stoppage of breathing.
 Gilhari syndrome is prevalent in Bikaner region
 People believed that Gilhari must be crushed to death or
it will kill patients and the treatment is mainly received
from local expert or faith healers.

ASCETIC SYNDROME
 First described by Neki in 1972
 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.

BHANMATI SORCERY
 This is seen in South India. Belief in magical spells that produce evil spirits to
cause psychiatric illness like conversion disorders, somatization disorders,
anxiety disorder, dysthymia, schizophrenia etc.
 Nosological status unclear
JHIN JHINIA
 Occurs in epidemic form in India
 Characterised by bizarre and seemingly involuntary contractions and spasms
 Nosological status unclear

SUUDU
 It is a 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.
CULTURE BOUND SUICIDE
 Sati : self-immolation by a widow on her husband’s pyre.
 According to Hindu mythology, Sati the wife of Dakhsha was so overcome at the
demise of her husband that she immolated herself on his funeral pyre and burnt
herself to ashes. Since then her name ‘Sati’ has come to be symptomatic of self-
immolation by a widow.
 Was seen mostly in Upper Castes notably Brahmins and Kshatriyas.
 Banned in India since 19th century.

AMOK/ RUN AMOK
 Amok (Malaysia) /Cafard or Cathard (Laos, Polynesia,
Phillipines) /Mal de pelea (Puerto Rico) /Iich'aa (Navajo)
 Amok (to attack furiously, in Malay) is a syndrome indigenous
to the Malayo-Indonesian cultural region.
 This is a dissociative episode featuring a period of brooding
followed by an outburst of aggressive, violent or homicidal
behavior aimed at people and objects.
 Men of Malay extraction, Muslim religion, low education and
rural origin, Between the ages of 20 and 45.

AMOK/ RUN AMOK
 Early travelers in Asia describe a kind of military amok, in
which soldiers facing apparently inevitable defeat suddenly
burst into a frenzy of violence which so startled their enemies
that it either delivered victory or at least ensured what the
soldier in that culture considered an honourable death.
 In 1634, the eldest son of the Raja of Jodhpur ran amok at the
court of Shah Jahan, failing in his attack on the emperor, but
killing five of his officials.

 Precipitants - include arguments with coworkers, nonspecific
family tensions, feelings of social humiliation, bouts of
possessive jealousy, gambling debts, and job loss.
 The victim, known as a pengamok, suddenly withdraws from
family and friends, then bursts into a murderous rage,
attacking the people around him with whatever weapon is
available.
 He does not stop until he is overpowered or killed; if the
former, he falls into a sleep or stupor, often awakening with no
knowledge of his violent acts.

 Prototypical episodes:
1. Exposure to a stressful stimulus or subacute conflict, eliciting
in the subject feelings of anger, loss, shame, and lowered
self-esteem.
2. A period of social withdrawal.
3. Transition.
4. Indiscriminate selection of victims.
5. Verbalizations.
6. Cessation.
7. Subsequent partial or total amnesia.
8. Perceptual disturbances or affective decompensations.

 Treatment –
• Afflicted individuals in 20th-century Malaysia have been
exempted from legal or moral responsibility for acts
committed while in a state of amok by means of a kind of
“insanity defense,” which characterizes the attack as
“unconscious” and beyond the subject’s control.
• Subsequently hospitalized, frequently received diagnoses of
schizophrenia and were treated with antipsychotic
medication.

ATAQUE DE NERVIOS
 Idiom of distress
 Latinos, Carribean, Latin American Cuba, Puerto Rico and the
Dominican Republic.
 Epidemiology:
• Lifetime prevalence: 13.8% (Puerto Ricans)(1987)
• F: M = 1.8 – 2.5 : 1
• Above age of 45
• Less than high school education
• Divorced/ widowed/ separated
• Not employed

 Characterized by symptoms of –
• Intense emotional upset
• Acute anxiety, anger or grief
• Screaming or shouting uncontrollably
• Attacks of crying
• Trembling, palpitations, chest tightness
• Heat in chest rising into the head
• Verbally or physically aggressive
• Feelings of imminent fainting
• A general feature is a sense of being out of control.
 Attacks can occur due to –
• Stressful event relating to family
• It can also occur without a clear precipitant

 Prototypical episode:
1. Exposure to a sudden stressful stimulus
2. Initiation of the episode
3. Rapid evolution of an intense affective storm
4. Sense of loss of control.
5. These are accompanied by:
1. Bodily sensations
2. Behaviours
6. Cessation
7. Return to ordinary consciousness and exhaustion.
8. Partial/ total amnesia may follow

 Relation to Psychiatric diagnosis:
• Most common: Panic disorder
• Others: Mood & anxiety disorders
• Intense fearfulness, feelings of asphyxia, and chest tightness
suggestive of panic disorder
• emotion of anger & aggressive behaviour suggestive of mood
disorder.

SHENJING SHUAIRUO
 Mandarin/ Chinese: Weakness of the nervous system
 China, Japan, Hong Kong & Taiwan
 Chinese classification of mental disorders 2-R
• 3 symptoms out of 5
• For at least 3 months
• Weakness, emotional, excitement, nervous symptoms & sleep
disturbances
• Included in ICD 10 as “neurasthenia”

 Prototypical episode:
1. Gradual onset
2. Sense of powerlessness
3. Various symptoms
4. Sufferer seeks the sick role
5. Amelioration of precipitating stress improves outcome

 Epidemiology:
• 5.9 % unspecified neurasthenia
• 5.1% college population
• 6.4% 12 month prevalence
 Precipitants:
• Work related stress
• Study related stress
• Interpersonal/ family related stress
• Loss of face

 Relationship with psychiatric diagnosis:
• Depression: 30 – 70 %
• Somatoform pain disorder: 47%
• Undifferentiated somatoform: 35%
 Treatment:
• Self help remedies
• Preference for non psychiatric settings
• Traditional Chinese medicines
• Polypharmacy

LATAH (Malaysia,Indonesia)
 AKA yaun(Burma), mali-mali(Philippines), bah-tsche(Thai),
myriachit(Russia),I mu(Japan), Jumping
Frenchmen(French-Canadian)
 Highly exaggerated responses to a fright or trauma: “startle”
 Screaming, cursing, dancing and hysterical laughter ,
involuntary echolalia, echopraxia, or trance-like states.
 More frequent in middle-aged women.
 Subjects are often in great demand at social occasions –will
provide comic relief by uttering obscenities when provoked.

PIBLOKTOQ
 AKA Arctic hysteria
 Follows loss / perceived loss of a valued person or object
 Symptoms : Last for few minutes
• brooding,
• depressive silences
• loss / disturbances of consciousness
• seizure-like episodes
• tearing off clothes
• fleeing or wandering
• rolling in snow
• speaking in tongues(glossolalia) or echolalia

BILIS (cólera or muina)
 Underlying cause : strongly experienced anger or rage
 Latino groups view anger as a particularly powerful emotion that can have
direct effects on the body and exacerbate existing symptoms
 Major effect : disturb core body balances (ie. balance between hot & cold
valences in the body & between material and spiritual aspects of the
body)
 Symptoms :
• Headache
• trembling, screaming,
• stomach disturbances, loss of consciousness.
 Acute episode : chronic fatigue

Boufée delirante
 Sudden outburst
 Acute, nonaffective and non-schizophrenic psychosis
 Complete remission after an acute episode.
 Under age 30
 Strikes "like a thunderbolt."
 West Africa and Haiti, Caribbean
 Sometimes accompanied by visual , auditory hallucinations or
paranoid ideation.
 Episodes may resemble brief psychotic disorder.

BRAIN FAG/ BRAIN FOG
 College or high school students.
 Symptoms : difficulties in concentrating, remembering, thinking
 Students often state that their brains are fatigued.
 Additional somatic symptoms are usually centered around the head and neck
pain, pressure or tightness, blurring of vision, heat, burning sensation
 United States : among the elderly
 West Africa
• In sub saharan area : most common among young men pursuing a western-style
education.
 An idiom of distress in many cultures, and resulting syndromes can resemble
certain anxiety, depressive, and somatoform disorders.

WINDIGO(NE US)
 AKA witiko, witigo (Algonkian name-mythical monster)
 Rare, historic accounts of cannibalistic obsession. Traditionally
, ascribed to possession, with victims(usually male) turning into
cannibal monsters.
 Symptoms : depression, homicidal or suicidal thoughts,
delusional, compulsive wish to eat human flesh.
 Most victims were socially ostracized or put to death.
 Earlier , episodes described as hysterical psychosis,
precipitated by chronic food shortages and cultural myths
about starvation and windigo monsters.

FALLING-OUT / BLACKOUT
 Primarily in southern US and Caribbean groups.
 Characterized by a sudden collapse, which sometimes occurs
without warning but is sometimes preceded by feelings of
dizziness or a “swimming” in the head.
 Eyes are usually open, but the person claims an inability to
see.
 They usually hear and understand what is occurring around
them but
feel powerless to move.

GHOST SICKNESS
 A preoccupation with death and the deceased (sometimes
associated with witchcraft)
 Observed among members of many American Indian tribes.
 Symptoms attributed :
• bad dreams, weakness
• feeling of danger, loss of appetite
• fainting, dizziness, fear, anxiety
• hallucinations, loss of consciousness, confusion
• feelings of futility, & a sense of suffocation.

HWA-BYUNG
 AKA wool-hwa-byung
 Korean folk syndrome : ”fire sickness”
 “anger syndrome”
 Attributed to suppression of anger
 Symptoms include
• insomnia, fatigue, panic,
• fear of impending death,
• dysphoric affect, indigestion, anorexia,
• dyspnea, palpitations, generalized aches & pains, feeling of mass in epigastrium.
 >75% in women

LOCURA
 Latinos in U.S. and Latin America
 Severe form of chronic psychosis.
 Attributed to an inherited vulnerability, to the effect of multiple
life difficulties, or to a combination of both factors.
 Symptoms include
• incoherence, agitation
• auditory and visual hallucinations
• inability to follow rules of social interaction
• Unpredictability & possibly violence.

MAL DE OJO
 Widely found in Mediterranean cultures
 Spanish phrase : “evil eye”
 Children & infants are especially at risk
 Symptoms include :
• fitful sleep, crying without apparent cause,
• diarrhea, vomiting and fever .
• Sometimes adults (especially women) have the condition.

QI-GONG PSYCHOTIC
REACTIONS
 Acute, time-limited episodes characterized by dissociative,
paranoid, or other psychotic or nonpsychotic symptoms
 May occur after participation in the Chinese folk health-
enhancing practice of qi-gong (exercise of vital energy)
 Especially vulnerable are persons who become overly involved
in the practice
 Included in CCMD-2.

ROOTWORK
 A set of cultural interpretations that ascribe illness to
hexing, witchcraft, sorcery, or evil influence of another
person
 Symptoms : generalized anxiety , G.I. complaints (e.g.,
nausea, vomiting, diarrhea), weakness, dizziness, the fear of
being poisoned, and fear of being killed (voodoo death)
 Roots, spells, or hexes can be put or placed on other person,
causing a variety of emotional and psychological problems

ROOTWORK
 Hexed person may even fear death until the root has been
taken off (eliminated), usually through the work of a root
doctor (a healer in this tradition), who can also be called on
to bewitch an enemy.
 Found in the southern U.S. among both African-American
and European-American populations and in Caribbean
societies.
 AKA mal puesto / brujeria in
Latino societies

SANGUE DORMIDO
 “sleeping blood”
 Portuguese Cape Verde Islanders & immigrants to the United
States
 Symptoms :
• pain, numbness, tremor, paralysis,
• convulsions, stroke, blindness
• heart attack, infection, and miscarriages

SHIN-BYUNG
 A Korean folk label
 Initial phases characterized by anxiety and somatic complaints
• general weakness, dizziness, fear, anorexia, insomnia, gastrointestinal
problems
 Subsequent dissociation and possession by ancestral spirits.

SPELL
 A trance state in which persons “communicate” with deceased
relatives or spirits
 Associated with brief periods of personality change
 Seen among African-Americans and European-Americans
from the southern United States
 Spells are not considered to be medical events in the folk
tradition but may be misconstrued as psychotic episodes in
clinical settings.

SUSTO
 “soul loss”
 Folk illness: Latinos (US) & people in Mexico, Central America, and
South America.
 AKA espanto, pasmo, tripa ida, perdida del alma, chibih, lanti, mogo
laya, el miedo.
 Attributed to a frightening event that causes the soul to leave the body
and results in unhappiness and sickness.
 Experience significant strains in key social roles
 Symptoms may appear any time from days to years after the fright is
experienced
 Extreme cases can result in death.

TAIJIN KYOFUSHO(Japan)
 AKA shinkeishitsu, anthropophobia
 Culturally distinctive phobia which Resembles social phobia
 Fear of social contact(especially friends)
 Extreme self-consciousness (concern about physical appearance, body
odour, blushing)
 Fear of contracting disease.
 Somatic symptoms: head, body & stomach aches, fatigue, and insomnia
 Included in Japanese diagnostic system for mental disorders.

HIKIKOMORI (Japan)
 A form of severe social withdrawal characterized by
adolescents and young adults who become recluses in
their parents’ homes, unable to work or go to school for
months or years
 A national research taskforce of Japan further condensed
this definition into the following description: “the state of
avoiding social engagement (e.g., education,
employment, and friendships) with generally persistent
withdrawal into one’s residence for at least 6 months as a
result of various factors

 Proposed Criteria :
1. The person spends most of the day and nearly every day
confined to home.
2. Marked and persistent avoidance of social situations (e.g.,
attending school, working) and social relationships (e.g.,
friendships, contact with family members).
3. The social withdrawal and avoidance interferes significantly
with the person’s normal routine, occupational (or academic)
functioning, or social activities or relationships.
4. The person perceives the withdrawal as ego-syntonic.
5. In individuals aged less than 18 yr, the duration is at least 6
months.
6. The social withdrawal and avoidance are not better accounted
for by another mental disorder

COURSE & PROGNOSIS
 Limited data on the longitudinal course of patients with culture-
bound syndromes
 Suggest that some of them eventually develop clinical features
compatible with a diagnosis of schizophrenia, bipolar disorder,
cognitive disorder, or other psychotic disorders.
 Gathering information from all possible sources is crucial.
 As clinical pictures evolve over time, thorough re evaluations
should be conducted periodically to refine the diagnosis and
improve clinical care.

TREATMENT
 Determining whether the symptomatology represents a culturally appropriate
adaptive response to a situation.
 Clinicians are well advised to
 (1) know or search out the demographics of the local population or
catchment area being served.
 (2) recognize that always a local pattern exists of conceptualization, naming,
vocabulary, explanation, and treatment of patterns of distress that afflict a
community, including mental disorders.
 (3) talk with the family and learn about local customs or search out other
modes of documentation.
 Persons within the culture almost always recognize that one of their own is
acting in a deviant manner, and their input can be extremely valuable in making
an assessment of mental disorder.

TREATMENT
 Insight into the dynamics of the patient's world facilitates the
clinician's efforts to adapt his or her techniques (e.g., general
activity level, mode of verbal intervention, content of remarks,
tone of voice) to the patient's cultural background.
 Implies acceptance of, and respect for, the patient's cultural
frame of reference and opens the possibility of direct
intervention in the lives of patients, who may be willing to
cooperate when they feel understood.

CRITIQUE
 There is still ongoing debate about the status of the
syndromes with two school of thoughts –
1. Some feel it is essential to recognize these disorders as separate
entity and give the adequate importance.
2. Others believe that separate classification of these symptoms would
lead it its neglect by clinicians as they would be considered irrelevant
due to its cultural specificity. Also the underlying cultural aspect might
be lost in the process.
 One set of debates focuses on the relationship between the
culture-bound syndromes and psychiatric disorders
according to predominant symptom

CRITIQUE
 N.N.Wig (1994) cautions that separately categorizing CBS will not
necessarily improve the management of these cases in the country’s
health services.
 Littlewood (1996) argued that abandoning CBS includes an option that all
psychiatric illnesses are culture bound and recognizing the cultural
aspect will make culture bound patterns as an afterthought.
 In the face of globalization the CBS are likely to disappear in the
increasingly homogenous word culture.

CRITIQUE
 The relabeling of ‘culture bound syndromes’ as
‘cultural concepts of distress’ is a welcomed change.
 Future direction remains unclear with lack of
epidemiological studies and whether the CBS should
be classified as a separate disease entity or be
explained on the basis of predominant presenting
features and associated DSM or ICD diagnoses is up
for debate.

REFERENCES
 Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9E
 Diagnostic and Statistical Manual 4 TR by APA
 Diagnostic and Statistical Manual 5 by APA
 Cross-cultural Psychopathology FANNY M. CHEUNG
 Cultural Bound Syndromes in India: Vishal Chhabra, M.S. Bhatia, Ravi Gupta
 Culture-bound syndromes : the story of dhat syndrome A. SUMATHIPALA, S.
H. SIRIBADDANA and D. BHUGRA
 PCNA : Culture bound syndromes, Levine and Gaw,
 https://www.researchgate.net/publication/14655778_Culture-bound_syndromes
 www.google.com (images)

Culture bound syndromes

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