CULTURE-SPECIFIC DISORDERS

“A man is part DNA, Part unknown and part what he sees and
goes through as a child.”
Evolution of the concept.
At the time colonialisation, western missionaries and physicians came in contact with
various cultures foreign to their own. Under these circumstances they encountered unique
behaviors and psychiatric conditions occurred in the specific native populations, had local
explanations for the symptom manifestations and required interventions and these were
labeled differently. This was first described Krapelin text book of psychiatry, 8th
edition(1906)

In 1962, a Chinese psychiatrist Yap, introduced in to the psychiatric literature, first made an
attempt to put in to a diagnostic classification scheme. Hughes compiled a list of 168
culture-bound syndromes in a glossary, and DSM-IV contains a glossary with 25 entries.
These listings include colloquial names for some well-known conditions.

The ICD-10 Diagnostic Criteria for Research briefly describes 12 examples of ‘culture-
specific disorders' and suggests diagnostic codes, while mentioning that these conditions
cannot be easily accommodated in established psychiatric classifications

DEFINITIONS

Culture

Culture is that complex whole which includes knowledge, beliefs, arts, morals, law, custom
and any other capabilities and habits acquired by a human as a member of society. (F.B.
Taylor). Culture is the way of life. According to National Institute of Mental Health and
Diagnosis Group Culture is defined as, the meaning, values and behavioral norms that
are learned and transmitted in the dominant society and within in its social groups.

Clture plays a decisive role in coloring the psycho pathology of various psychiatric
disorders.
However some psychiatric syndromes are limited to certain specific cultures. These
disorders are called culture specific syndromes.

Culture Specific Syndromes

Culture specific syndromes or Culture Bound Syndromes are a combination or
constellation of psychiatric and somatic symptoms that is considered to be a recognizable
decease only within a specific society or culture. There is no objective biochemical or
structural alterations of body organs or functions, and the decease is not recognized in
other cultures.

According to Hughes et. al (1997), culture bound syndromes describe a certain number
of psychiatric disorders whose phenomenology made them distinct from the Western
categories and that theoretically could be singled out as unique to a particular cultural
setting

The term culture-bound syndrome denotes, specific arrays of behavioral and experiential
phenomena that tend to present themselves preferentially in particular socio-cultural
contexts and that are readily recognized as illness behavior by most participants in that
culture.

Relevance of the assessment.

Cultural concepts are important to avoid misdiagnosis, obtain useful clinical information,
improve clinical rapport and engagement, improve therapeutic efficacy, guide clinical
research, and clarify the cultural epidemiology (APA, 2013).
Cultural and religious teachings often influence beliefs about the origins and nature of
mental illness, and shape attitudes towards the mentally ill.
Culture influences the epidemiology, phenomenology, outcome, and treatment of mental
illness (Viswanath and Chaturvedi, 2012).
Different cultures have their own beliefs to find the aetiology of mental illness, as well as
treatment and intervention processes (Jimenez, et al.,2012).
Understanding individual and cultural beliefs about mental illness is essential for the
implementation of effective approaches to mental health care.
Siewert et al. (1999) have argued that mental illness cannot be separated from the
individual’s social and cultural context and culture plays an important role in the perception
of mental illness.
Marsella and Yamada (2000) have mentioned that mental illness is closely rooted in one’s
culture, poverty, helplessness, and backed by powerful socio-political and economic
structures.

Assessment of culture-bound syndromes must start with the understanding that, each
human society has its own indigenous body of beliefs and practices which aim to explain
and treat diseases and disorders, and patients internalize that view of the world during
enculturation (Process by which people learn the dynamics of their surrounding culture and
acquire values and norms appropriate or necessary in that culture and worldviews)

They share their experiences, and deal with distress through commonly understood
symbols and meanings, and it is imperative that the phenomenological experience of the
patient be attributed importance (Sadock & Sadock, 2007)

However, the need for a separate category for disorders such as latah, amok, koro, and a
variety of other possible culture-specific disorders has not been expressed often in recent
years

Descriptions of these disorders currently available in the literature suggest that they may
be regarded as local variants of anxiety, depression, somatoform disorder, or adjustment
disorder

Also, sound descriptive studies with solid epidemiological basis that would strengthen the
case for these inclusions as separate disorders have not been identified, and hence, they
have not been separately classified (WHO, 1992)

In spite of all this, it is imperative that the clinician try to understand the patient’s symptoms
of distress by entering the patient's world

Although it is not possible to become an anthropological expert about each and every
possible cultural group, the clinician can try to learn by asking patients to share their
cultural norms as they understand those. (Sadock & Sadock, 2007)

Cultural concepts are important for several reasons (APA, 2013):

1. To avoid misdiagnosis
2. To obtain useful clinical information
3. To improve clinical rapport and engagement
4. To improve therapeutic efficacy
5. To guide clinical research
6. To clarify the cultural epidemiology

Nosological classification -icd-10

F48 Other neurotic disorders

F48.0 Neurasthenia

F48.8 Other specified neurotic disorders

Includes: Briquet's disorder, Dhat syndrome, Koro, Latah, occupational neurosis, including
writer's cramp, psychasthenia, psychasthenic neurosis, psychogenic syncope

DSM-5

DSM-5 replaces the construct of the culture-bound syndrome in DSM-IV-TR with 3

concepts:

Cultural syndrome: A cluster of invariant symptoms in a specific cultural group

Cultural idiom of distress: A way of talking about suffering among people in a cultural
group

Cultural explanation or perceived cause for symptoms, illness, or distress

Section III (Emerging Measures and Models) contains a Cultural Formulation

Cultural Formulation Interview: A 16-item semi-structured interview

The Appendix contains a Glossary of Cultural Concepts of Distress

In addition to the CFI, DSM-5 contains the following tools and information that may be
useful when integrating cultural information in clinical practice:

Data in DSM-V criteria and text for specific disorders: Information on cultural variations in
prevalence, symptomatology, associated cultural concepts, and other clinical aspects
Other conditions that may be a focus of clinical attention: Some of the clinical concerns
identified by the CFI may correspond to V codes or Z codes

Glossary of cultural concepts of distress

Various Culture-Bound Syndromes

Koro

Koro is a psychological disorder characterized by delusions of penis shrinkage and

retraction into the body, accompanied by panic and fear of dying. This delusion is
rooted in Chinese metaphysics and cultural practices. The disorder is associated with the
belief that unhealthy or abnormal sexual acts (such as sex with prostitutes, masturbation,
or even nocturnal emissions). Koro is thought to be transmitted through food.

Windigo

Wendigo Psychosis is a mental disorder in which a person intensely craves human flesh
and thinks they are turning into a cannibal (despite an abundance of healthy food
available).

The Windigo sufferer either to threaten those around them or to act violently or anti-
socially, they were then generally executed. While some have denied the existence of this
disorder, there are a number of credible eyewitness accounts, both by aboriginal
communities and by Westerners, that prove that Windigo psychosis is a factual historical
phenomenon.

Gururumba

Gururumba is a “wild man” episode in which the suffer (typically a married male) begins by
burglarizing neighboring homes – taking objects that he thinks are valuable but which
seldom are. He then runs to the forest for a number of days returning without the objects
and with a case of amnesia. The sufferer appears hyperactive and clumsy with slurred
speech.
This disorder is specific to New Guinea.

Saora Disorder

In this disorder, young men and women sometimes exhibit abnormal behavior patterns.
They cry and laugh at inappropriate times, have memory loss, pass out, and claim to
experience the sensation of being repeatedly bitten by ants when no ants are present.

These individuals are usually teenagers or young adults who are not attracted to the
ordinary life of a subsistence farmer. They are under considerable psychological stress
from social pressure placed on them by their relatives and friends. It is seen among the
Saora tribe of Orissa State in India.

Shenkui
A sufferer of shenkui shows marked anxiety or panic symptoms with accompanying
somatic complaints for which no physical cause can be demonstrated. Symptoms include
dizziness, backache, fatigability, general weakness, insomnia, frequent dreams, and
complaints of sexual dysfunction (such as premature ejaculation and impotence).
Symptoms are attributed to excessive semen loss from frequent intercourse, masturbation,
nocturnal emission, or passing of “white turbid urine” believed to contain semen. Excessive
semen loss is feared because it represents the loss of one’s vital essence and can thereby
is life threatening.

It is seen as a Chinese culture-bound syndrome, and in Taiwan it is called as Shen-k'uei

Ghost Sickness
It was a disorder in which some Native American tribes believe to be caused by association
with the dead or dying. It is associated with witchcraft. Symptoms are general weakness,
loss of appetite, a feeling of suffocation, recurring nightmares, and a pervasive feeling of
terror. If you were buried alive with a loved one or friend below ground, you may feel as if
you were suffocating. The sickness is attributed to ghosts (chindi) or, occasionally, to
witches.

It is considered to be a psychotic disorder of Navajo origin of America.

Couvade Syndrome
Couvade syndrome involves a father experiencing some of the behavior of his wife at near
the time of childbirth, including her birth pains, postpartum seclusion, food restrictions, and
sex taboos”. The term originally referred to the medieval Basque custom in which the
father, during or immediately after the birth of a child, took to bed, complained of having
labour pains, and was accorded the treatment usually shown women during pregnancy or
after childbirth.

In some extreme cases, fathers can grow a belly similar to a 7-month pregnant woman and
gain approximately 25 to 30 pounds (“phantom pregnancy”). Other symptoms include and
are not limited to developed cravings, suffered nausea, breast augmentation, and insomnia

Homosexual Panic

Homosexual panic is a term, first coined by psychiatrist Edward J. Kempf in 1920,

describing an acute, brief reactive psychosis involving delusions and hallucinations
accusing a person of various homosexual activities. The condition most often occurs in
people who suffer schizoid personality disorders who have insulated themselves from
physical intimacy. Breakdowns often occur in situations that involve enforced intimacy with
the same sex, such as dormitories or military barracks.

It was most common during the mass mobilization of World War II when barracks typically
provided little privacy with communal showers and often without doors or even cubicles
around toilets. Treatment usually involves hospitalization, firstly to remove the person from
the situation and also because the condition may lead to suicidal or homicidal acts. Usually
members of the opposite sex are selected to treat those suffering from the disorder, and
invasive procedures such as injections with needles or suppositories are avoided.

Amok
A dissociative episode characterized by a period of brooding followed by an outburst of
violent, aggressive, or homicidal behavior directed at persons and objects; precipitated by
a perceived slight or insult. Seems to be prevalent only among men;

This disorder is seen especially in Malaysia. Also seen in some other parts of the world like
Laos, Philippines, Polynesia (cafard or cathard), Papua New Guinea, and Puerto Rico (mal
de pelea), and among the Navajo (iich'aa),

Ataque de Nervios
Uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head,
and verbal or physical aggression, dissociative experiences, seizure like or fainting
episodes, and suicidal gestures, a sense of being out of control

An idiom of distress principally reported among Latinos from the Caribbean, but recognized
among many Latin American and Latin Mediterranean groups.

Some other important CBS are tabulated below with the major symptoms and the region
they were seen most commonly.

Acute nervous tension, headache,

trembling, screaming, stomach
BILIS AND disturbances, and, in more severe cases,
Latinos
COLERA (MUINA) loss of consciousness; underlying cause is
thought to be strongly experienced anger or
rage
Sudden outburst of agitated and aggressive
behavior, marked confusion, and
BOUFFEE
psychomotor excitement, sometimes West Africa and Haiti
DELIRANTE
accompanied by visual and auditory
hallucinations or paranoid ideation
Difficulties in concentrating, remembering,
West African high
and thinking, ‘brain fatigue’; Additional
school or university
somatic symptoms are usually centered
BRAIN FAG students in response to
around the head and neck and include
the challenges of
pain, pressure or tightness, blurring of
schooling
vision, heat, or burning
A sudden collapse, which is sometimes
preceded by feelings of dizziness or
swimming in the head; eyes are usually
FALLING-OUT OR Southern U.S. &
open, but the person claims an inability to
BLACKOUT Caribbean groups
see; usually hear and understand what is
occurring around them but feel powerless
to move
A preoccupation with death and the Frequently observed
GHOST
deceased (sometimes associated with among members of
SICKNESS
witchcraft), bad dreams, weakness, feeling many American Indian
 of danger, loss of appetite, fainting, tribes
dizziness, fear, anxiety, hallucinations, loss
of consciousness, confusion, feelings of
futility, and a sense of suffocation
Insomnia, fatigue, panic, fear of impending
HWA-BYUNG death, dysphoric affect, indigestion,
(WOOL-HWA- anorexia, dyspnea, palpitations, A Korean folk
BYUNG, ANGER generalized aches and pains, and a feeling syndrome
SYNDROME) of a mass in the epigastrium; Attributed to
the suppression of anger
Hypersensitivity to sudden fright, often with
echopraxia, echolalia, command
obedience, and dissociative or trancelike
behavior.

LATAH The term is of Malaysian or Indonesian

but found in many parts
origin, Other terms are amurakh, irkunil,
of the world.
ikota, olan, myriachit, and menkeiti
(Siberian groups); bah tschi, bah-tsi, baah-ji
(Thailand); imu (Ainu, Sakhalin, Japan);
and mali-mali and silok (Philippines); In
Malaysia, it is more frequent in middle-aged
women
A severe form of chronic psychosis;
Incoherence, agitation, auditory and visual
A term used by Latinos
hallucinations, inability to follow rules of
LOCURA in the United States
social interaction, unpredictability, and
and Latin America
possibly violence; attributed to an inherited
vulnerability and multiple life difficulties
Widely found in
Mediterranean cultures
and elsewhere in the
Fitful sleep, crying without apparent cause,
world; Children are
MAL DE OJO diarrhea, vomiting and fever in a child or
especially at risk;
infant
Sometimes adults
(especially women)
have the condition
state of vulnerability to stressful life A common idiom of
NERVIOS experiences and to a syndrome brought on distress among Latinos
by difficult life circumstances; headaches in the United States
 and brain aches, irritability, stomach and Latin America
disturbances, sleep difficulties,
nervousness, easy tearfulness, inability to
concentrate, trembling, tingling sensations,
and mareos (dizziness with occasional
vertigo-like exacerbations)
An abrupt dissociative episode
accompanied by extreme excitement of up
to 30 minutes' duration and frequently It is observed primarily
followed by convulsive seizures and coma in Arctic and subarctic
PIBLOKTOQ lasting up to 12 hours; Eskimo communities,
person may be withdrawn or mildly irritable although regional
for hours or days before the attack and variations in name exist
typically reports complete amnesia for the
attack.
Occur after
participation in the
Chinese folk health-
QI-GONG Acute, time-limited episodes characterized enhancing practice of
PSYCHOTIC by dissociative, paranoid, or other qi-gong (exercise of
REACTIONS psychotic or nonpsychotic symptoms vital energy);
Especially those who
become overly involved
in the practice
Generalized anxiety and gastrointestinal
complaints (e.g., nausea, vomiting,
Southern United States
diarrhea), weakness, dizziness, the fear of
among both African-
ROOTWORK being poisoned, and sometimes fear of
American and
(MAL PUESTO being killed (voodoo death); ascribe illness
European-American
OR BRUJERIA) to hexing, witchcraft, sorcery, or evil
populations and in
influence of another person; root has to be
Caribbean societies
eliminated, usually through the work of a
root doctor (a healer in this tradition)
Among Portuguese
SANGUE
Pain, numbness, tremor, paralysis, Cape Verde Islanders
DORMIDO
convulsions, stroke, blindness, heart attack, (and immigrants from
(SLEEPING
infection, and miscarriages there to the United
BLOOD)
States)
SHENJING A condition characterized by physical and
China
SHUARIUO mental fatigue, dizziness, headaches, other
 (NEURASTHENIA) pains, concentration difficulties, sleep
disturbance, memory loss, gastrointestinal
problems, sexual dysfunction, irritability,
excitability, and various signs suggesting
disturbance of the autonomic nervous
system

CULTURE SPECIFIC DISORDERS IN INDIA

 Dhat Syndrome
 Possession Syndrome
 Koro
 Gilhari syndrome
 Ascetic syndrome
 Jhinjhinia
 Bhanmati
 Culture-bound suicide (sati, santhara)
 Mass hysteria
 Compulsive spitting
 Culture-bound trichotillomania

DHAT SYNDROME

Dhat syndrome is a clinical entity recognized both by general public as well as medical
practitioners in which nocturnal emissions lead to severe anxiety and hypochondriasis,
often associated with sexual impotence (Chhabra et. Al, 2008). The term was first used by
Wig in 1960 . Patient usually presents with various somatic, psychological, and sexual
symptoms (Chadda & Ahuja, 1990; Singh, 1985; Nakra et. Al, 1977). Patient attributes it to
the passing of whitish discharge, believed to be semen (Dhat), in urine. However, there is
no objective evidence of such a discharge. Sometimes, patient also reports of foul smelling
semen and less viscous semen (Chhabra et. Al, 2008)

Symptoms include

 Generalised 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
 Sad mood
 Forgetfulness (Singh et. Al., 2001; Chhabra et. Al., 2008; Pundhir et. Al., 2015):
 Feelings of guilt (especially towards masturbation during adolescence)
 Sexual complaints are that of premature ejaculation and erectile dysfunction

In majority of cases, there is absence of any physical illness like diabetes, local genital
abnormalities, or sexually transmitted diseases.These must be ruled out before labeling
Dhat syndrome (Bhatia & Malik, 1991)

Background
The word Dhat is derived from Sanskrit word ‘Dhatu’ meaning precious fluid. In Susruta
Samhita (ancient Indian text of surgery) has described 7 Dhatus in the body and
disturbances of any of it can cause physical and mental weakness of that person. Out of
all these seven, Semen is considered to be the most precious fluid in the body. It is
believed that, one drop of blood is derived from 40 meals, 40 drop of blood is equal to one
drop of bone marrow and 40 drop of is equals to one drop of semen.

Charak Samhita describes a disorder resembling Dhat Syndrome by the name

‘Shukrameha’ (Chhabra et. Al., 2008; Chadda & Ahuja, 1990; Kulhara & Avasthi, 1995)

This gives rise to belief that loss of excessive semen in any form (masturbation, nocturnal
emissions) is harmful. On the other hand, its preservation will lead to health and long life.
Thus, the belief in precious and life-preserving properties of semen is deeply ingrained in
Indian culture. The belief is further reinforced by traditional healers and perpetuated by
friends and elders who suffered from this syndrome (Tripathi & Sridevi, 2014; Pundhir et.
Al., 2015)

Epidemiology

This illness is present all over the country. In India, prevalence rate varies between 40-66%
(Sinha & Singh, 2013; Tripathi & Sridevi, 2014). Also seen in surrounding countries like Sri
Lanka (Sukra Prameha), Pakistan, and China (Sen-k’uri) (Jadhav, 2004). The concept of
Dhat syndrome or semen-loss syndrome was prevalent among Western cultures with
different names at some point of time (Kallivayalil et. Al., 2010). Most of the empirical
studies on Dhat syndrome have emerged from Asia, whereas its concepts have been
described historically in other cultures, including Britain, the USA and Australia
(Sumathipala et. Al, 2004)

These studies emphasized that different sources indicate the universality of symptoms and
global prevalence of this condition, despite its image as a 'neurosis of the Orient’ (Pundhir
et. Al, 2015; Malhotra & Wig, 1975). The syndrome is seen usually in people from lower
socioeconomic strata who seek help from traditional healers before reaching hospitals
(Chhabra et. Al, 2008). The studies except one (Singh et. Al, 2001) reported so far pertain
almost exclusively to male patients.

The patient presenting with Dhat syndrome is typically more likely to be recently married; of
average or low socio-economic status, comes from a rural area and belongs to a family
with conservative attitudes towards sex (Bhatia & Malik, 1991; Chadda & Ahuja, 1990;
Behere & Natraj, 1984)

Comorbid Conditions
Concomitant psychiatric morbidity like depression, somatoform disorder, anxiety disorder
may be present; also associated with koro (Grover et. Al., 2015; Tripathi & Sridevi, 2014;
Patil et. Al, 1996; Kishore et. Al., 1996; Chadda & Ahuja, 1990; Bhatia et. Al., 1989; Singh,
1985; Nakra et. Al, 1977). Neurotic depression followed by generalized anxiety disorder is
the commonest psychiatric disorders seen in patients with Dhat syndrome (Patil et. Al,
1996; Bhatia et. Al., 1989; Singh, 1985)

Dhat: Syndrome or Symptom?

Chadha & Ahuja (1990) reported that among their research subjects, more than three-
quarters had accompanying hypochondriacal symptoms, although it was not clear what
specific criteria were used to define such hypochondriasis. They also reported that seven
patients (who did not have hypochondriasis) had ‘pure’ dhat syndrome, which implies that
this concern with dhat itself is a hypochondriacal preoccupation. Chadha (1995) found that
those presenting with dhat had complaints similar to the controls who had neurotic
disorders
The most reported conditions were depressive disorder, anxiety disorder, and somatoform
disorders. Thus, the validity of diagnosis and associated psychiatric diagnosis can be
questioned. Mumford (1996) found that the dhat complaint was strongly associated with a
DSM-III-R diagnosis of depression. It is suggested that dhat could be a culturally
determined symptom associated with depression rather than a Cultural Bound Syndrome.

Similarly, Perme et. Al. (2005) found that patients with dhat syndrome have similarities with
other functional somatic syndromes. This study suggests inclusion of dhat syndrome as a
functional somatic disorder rather than restricting it to a CBS

Treatment
The role of knowledge and locally prevalent beliefs has been emphasized as explanation of
the condition in several studies (Perme at. Al, 2005; Dewaraja & Sasaki, 1991; Bhatia et.
Al, 1989). Treatment mainly consists of dispelling of myths by psychoeducation, reassuring
the patient, treating any underlying psychiatric disorder. Even symptomatic relief (of severe
anxiety that these patients suffer) with the help of medications in initial stages of treatment
is required to gain confidence of the patient (Pundhir et. Al, 2015)

A recent study reveals that CBT, supportive psychotherapy, reassurance, and family
intervention could be helpful in reducing the distress level (Salam et. al., 2012; Salman et.
al., 2012; Mohar & Beutler, 1990; Munjack et al. 1984)

Rapid improvement in the depressive symptoms over a period of two weeks was also
found, which suggests that the depression was reactionary or secondary (Tripathi &
Sridevi, 2014; Sinha & Singh, 2013)

Possession syndrome
Diagnosable under Dissociative disorders (Chhabra et. Al, 2008). Patient is possessed
usually by ‘spirit/soul’ of deceased relative or a local deity. Clouding of consciousness,
changed demeanor, and tone of voice and subsequent amnesia (Khalifa & Hardie, 2005)

Among many other changes, gender ‘changes’ at times if the possessing soul is of
opposite sex. Possession-form dissociative identity disorder can be distinguished from
culturally- accepted possession states in that the former (APA, 2013). It is involuntary,
distressing, uncontrollable, and often recurrent or persistent, Involves conflict between the
individual and his/her surroundings, family, social, and work milieu. It is manifested at times
and in places that violate the norms of the culture and religion.
Background
Many religious shrines hold special annual festivals where hundreds of people get
possessed simultaneously. These people are looked upon as special by their families and
villages which reinforce the secondary gains (Chhabra et. Al, 2008). However, in certain
areas, it is attributed to sin (Khalifa & Hardie, 2005; Kroll & Bachrach, 1984; Zilboorg, 1941)

Epidemiology
Possession syndrome is usually seen in rural areas or in migrants from rural areas.
Majority of these patients are females who otherwise don’t have any outlet to express their
emotions (Chhabra et. Al, 2008). Chaturvedi et. Al. (2010) found that dissociative disorders
are still commonly diagnosed in both inpatient and outpatient settings. Unlike in the West,
dissociative identity disorders were rarely diagnosed. Instead, possession states were
commonly seen in the Indian population, indicating cross-cultural disparity. Nowadays the
incidence seems to be decreasing in India.

An article suggests that the role of popular media could be emphasized in the decline of
reports of possession (Halliburtona, 2005)

Possession: Syndrome or Symptom?

Freud (1946) demonstrated his psychoanalytic point of view in his analysis of Christoph
Haizman’s case Jung (1966) did not address himself to the problem of demon possession
He was more interested in studying the phenomenon of glossolalia. He stated that
glossolalia had nothing to do with divine spirit, instead it is a ‘hypermnesia’ phenomenon—
a state of heightened memory of things long consciously forgotten but brought back into
mind in a dissociated or trance state.

Vivier (1968) echoed Jung’s view by saying that, ‘Glossolalia occurs either in mass
hysterical reaction associated with religious ceremony or in quiet meditation’

Treatment
Those patients affected have mostly sought religious healing (Campion & Bhugra, 1997).
Treatment includes careful exploration of underlying stress which precipitated the
possession attack. The therapist should try also to decrease any secondary gains patient
may be getting from this behavior. Antidepressants and anxiolytics are helpful in certain
cases to reduce the immediate difficulties.(Pundhir et. Al, 2015)
Koro
Koro is a psychological disorder characterized by delusions of penis shrinkage and
retraction into the body, accompanied by panic and fear of dying. This delusion is rooted in
metaphysics and cultural practices. The disorder is associated with the belief that
unhealthy or abnormal sexual acts (such as sex with prostitutes, masturbation, or even
nocturnal emissions).The symptomatology is described as short in duration (Chhabra et.
Al, 2008)

Usually accompanied by complaints of palpitations, sweating, pericardial discomfort, and

trembling. It may occur as epidemics.

Background

Personality factors, Cultural beliefs, and Sexual conflicts and guilt feelings, often caused by
religious background (Chowdhury, 2008; Cheng, 1997; Rosca-Rebaudengo et. al., 1996;
Adeniran & Jones, 1994; Ungvari & Mullen, 1994; Fishbain et. al., 1989; Modai et. al.,
1986; Yap, 1965). In a study of the Koro epidemic in Kerala, Promodu et. Al. (2012) found
that etiology was purely psychogenic factors. Previous knowledge of the koro syndrome
combined with unhealthy premorbid personality traits and life stress led to the outbreak of
this epidemic.

Individuals with histrionic and anxious personality disorder/ traits were more likely to be
affected by such conditions

In a study of the epidemic in West Bengal, several ethno medical explanatory concepts like
increased body heat, supernatural causes, sexual deficits, physical strain, fever, and fear
were elicited as causes (Chowdhury, 2008)

Epidemiology
Seen in northeastern states like Assam and West Bengal, and in both sexes Koro is rarely
described in female patients (Kovács & Osváth, 1998; Bartholomew, 1994; Sachdev, 1985;
Dutta, 1982; Koro Study Team, 1969). The syndrome mostly appears in young (Koro Study
Team, 1969), otherwise ‘mentally healthy people’ who have a knowledge of the existence
of Koro (Cheng, 1997). Most patients are illiterate/ had only primary education (Ghosh et.
Al, 2013)

Co morbid conditions
Harmful use of alcohol, alcohol dependence, and regular cannabis use was found (Ghosh
et. Al, 2013) Severe anxiety, acute stress reaction, and hypochondriacal preoccupation
with genital symptoms was seen along with associated moderate to severe depression
(Chowdhury, 2008). It can also be presented in association with Dhat syndrome (Grover et.
Al., 2015; Patil et. Al, 1996; Kishore et. Al., 1996)

Treatment
Koro presentation commonly occurs with a mixture of high anxiety and depression
(Chowdhury & Rajbhandari, 1995)

Immediate treatment calls for a symptomatic approach, usually with anxiolytic and
antidepressant medication (Hallak et. Al., 2000; Nakaya, 2002)

Strong reassurances with supportive psychotherapy, and in some cases, long-term insight-
oriented psychotherapy is helpful (Ghosh et. Al., 2013; Fishbain et. Al., 1989)

GILHARI SYNDROME

This syndrome is 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
(Bhatia et. Al., 2011; Chhabra et. Al, 2008). Patient presents with intense anxiety and
apprehension of death and with crushed-type skin injuries, which was produced either by
relatives or faith healers to kill the Gilhari (Jain et. Al., 2014).

According to a study (Jain et. Al., 2014), about 30% of their sample was male and 70%
was female.Patients were from a rural background and educated up to primary or middle
level, but majority of them were illiterate. Somatoform disorder was the most observed
comorbid condition, along with other specified neurotic disorders (F48.8)

The treatment was to cut or crush the Gilhari till it dies, mainly done by local expert and
faith healers

Ascetic syndrome
First described by Neki in 1972
This syndrome is characterized by social withdrawal, severe sexual abstinence, practice of
religious austerities, lack of concern with physical appearance, and considerable loss of
weight (Jain et. Al., 2014; Bhatia et. Al., 2011; Chhabra et. Al, 2008; Bhatia, 1999)

Appears in adolescents and young adults

JHIN JHINIA

Characterized by bizarre and seemingly involuntary contractions and spasms (Jain et. Al.,
2014; Chhabra et. Al, 2008)

Occurs in epidemic form in India (Nandi et. Al., 1992)

BHANMATI

Belief in magical spells that produce evil spirits to cause psychiatric or physical illnesses

Seen in South India (Mazumber, 2009; Chhabra et. Al, 2008; Bhatia, 1999; Keshavan et.
Al., 1989; Carstairs & Kapur, 1976)

An almost identical pattern has also been described in West Bengal (Bhattacharya, 1986)
and Bangladesh (Marks & Groves, 1989)

SUUDU

Culture specific syndrome of painful urination and pelvic “heat” Familiar in south India,
especially in the Tamil culture Occurs in males and females Popularly attributed to an
increase in the “inner heat” of the body, often due to dehydration (Chhabra et. Al, 2008)

It is usually treated by Applying a few drops of sesame or castor oil in the navel and the
pelvic region, having an oil massage followed by a warm water bath and Intake of
fenugreek seeds soaked overnight in water

This is known to exist in other parts of South India, and the methods of treatment are also
similar (Chhabra et. Al, 2008)

CULTURE- BOUND SUICIDE

Sati

This denotes the self-immolation by a widow on her husband’s pyre. This was seen mostly
in Upper Castes. This practice was banned in India since 19th century. After that only one
known case was reported since 1904 in Rajasthan (Chhabra et. Al, 2008)
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 Moksha. This practice is mostly seen in Jain Community, which celebrates these
events as religious festivals. Those person initially takes liquids, later even refusing to take
them.

Recently 4 cases reported from Rajasthan (Chhabra et. Al, 2008)

Mass Hysteria
This syndrome is characterized as a short lasting epidemics where several people behave
in a manner in which they ordinarily wont (Chhabra et. Al., 2008). Choudhary et al. (1993)
reported an atypical hysteria epidemic in a tribal village of the State of Tripura, India. In that
incident,12 people, 8 female and 4 male, were affected in a chain reaction within a span of
ten days

The cardinal feature was an episodic trance state (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

Compulsive spitting
Compulsive spitting, as a culture- bound syndrome has not been previously reported in the
literature (Bhatia, 2000; Bhatia & Shome, 1993). It occur co morbid with schizophrenia,
mania, depression, OCD, tic disorder, and epilepsy

Culture-Bound Trichotillomania
Mostly seen in persons belonging to a monastic sect of the Jain community, and those
affected will remove all their hair on the head manually, by plucking it out. This was also
called "Locha" and is done to denote detachment from physical pain (Bhatia, 2000; Shome
et. Al., 1993)
Some of other important cultural bound syndromes with their symptoms and region of the
world where they are commonly seen, are tabulated below.

Acute nervous tension,

headache, trembling,
screaming, stomach
Bilis and Colera disturbances, and, in more
Latinos
(Muina) severe cases, loss of
consciousness; underlying
cause is thought to be strongly
experienced anger or rage

Sudden outburst of agitated and

aggressive behavior, marked
confusion, and psychomotor
Bouffee
excitement, sometimes West Africa and Haiti
Delirante
accompanied by visual and
auditory hallucinations or
paranoid ideation

Difficulties in concentrating,
remembering, and thinking,
‘brain fatigue’; Additional
West African high school or
somatic symptoms are usually
Brain Fag university students in response to
centered around the head and
the challenges of schooling
neck and include pain, pressure
or tightness, blurring of vision,
heat, or burning

A sudden collapse, which is

Falling-out or Southern U.S. & Caribbean
sometimes preceded by feelings
Blackout groups
of dizziness or swimming in the
head; eyes are usually open, but
 the person claims an inability to
see; usually hear and
understand what is occurring
around them but feel powerless
to move

A preoccupation with death and

the deceased (sometimes
associated with witchcraft), bad
dreams, weakness, feeling of
Frequently observed among
danger, loss of appetite,
Ghost sickness members of many American
fainting, dizziness, fear,
Indian tribes
anxiety, hallucinations, loss of
consciousness, confusion,
feelings of futility, and a sense
of suffocation

Insomnia, fatigue, panic, fear of

impending death, dysphoric
Hwa-byung affect, indigestion, anorexia,
(wool-hwa- dyspnea, palpitations,
A Korean folk syndrome
byung, anger generalized aches and pains,
syndrome) and a feeling of a mass in the
epigastrium; Attributed to the
suppression of anger

The term is of Malaysian or

Indonesian origin, but found in
Hypersensitivity to sudden many parts of the world. Other
fright, often with echopraxia, terms are amurakh, irkunil, ikota,
Latah echolalia, command obedience, olan, myriachit, and menkeiti
and dissociative or trancelike (Siberian groups); bah tschi, bah-
behavior tsi, baah-ji (Thailand); imu (Ainu,
Sakhalin, Japan); and mali-mali
and silok (Philippines); In
Malaysia, it is more frequent in
 middle-aged women

A severe form of chronic

psychosis; Incoherence,
agitation, auditory and visual
hallucinations, inability to
follow rules of social A term used by Latinos in the
Locura
interaction, unpredictability, United States and Latin America
and possibly violence;
attributed to an inherited
vulnerability and multiple life
difficulties

Widely found in Mediterranean

Fitful sleep, crying without
apparent cause, diarrhea,
Mal de ojo
vomiting and fever in a child or
infant
cultures and elsewhere in the
world; Children are especially at
risk; Sometimes adults
(especially women) have the
condition

Refers both to a general state of

vulnerability to stressful life
experiences and to a syndrome
brought on by difficult life
circumstances; headaches and
brain aches, irritability, A common idiom of distress
Nervios stomach disturbances, sleep among Latinos in the United
difficulties, nervousness, easy States and Latin America
tearfulness, inability to
concentrate, trembling, tingling
sensations, and mareos
(dizziness with occasional
vertigo-like exacerbations)

Pibloktoq An abrupt dissociative episode It is observed primarily in Arctic

accompanied by extreme and subarctic Eskimo
 excitement of up to 30 minutes' communities, although regional
duration and frequently variations in name exist
followed by convulsive
seizures and coma lasting up to
12 hours;

person may be withdrawn or

mildly irritable for hours or
days before the attack and
typically reports complete
amnesia for the attack.

Occur after participation in the

Acute, time-limited episodes
Qi-gong
characterized by dissociative,
psychotic
paranoid, or other psychotic or
reactions
nonpsychotic symptoms
Chinese folk health-enhancing
practice of qi-gong (exercise of
vital energy); Especially those
who become overly involved in
the practice

Generalized anxiety and

gastrointestinal complaints
(e.g., nausea, vomiting,
diarrhea), weakness, dizziness,
the fear of being poisoned, and
Rootwork Southern United States among
sometimes fear of being killed
both African-American and
(voodoo death); ascribe illness
(mal puesto or European-American populations
to hexing, witchcraft, sorcery,
brujeria) and in Caribbean societies
or evil influence of another
person; root has to be
eliminated, usually through the
work of a root doctor (a healer
in this tradition)

Sangue Pain, numbness, tremor,

Among Portuguese Cape Verde
dormido paralysis, convulsions, stroke,
Islanders (and immigrants from
(sleeping blindness, heart attack,
 blood) infection, and miscarriages there to the United States)

A condition characterized by
physical and mental fatigue,
dizziness, headaches, other
pains, concentration
Shenjing difficulties, sleep disturbance,
shuariuo memory loss, gastrointestinal China
(neurasthenia) problems, sexual dysfunction,
irritability, excitability, and
various signs suggesting
disturbance of the autonomic
nervous system

A condition characterized by
physical and mental fatigue,
dizziness, headaches, other
pains, concentration
Shenjing difficulties, sleep disturbance,
shuariuo memory loss, gastrointestinal China
(neurasthenia) problems, sexual dysfunction,
irritability, excitability, and
various signs suggesting
disturbance of the autonomic
nervous system

Treatment of Culture bound syndromes.

Treatment of a culture-bound syndrome poses several diagnostic challenges, the first of
which is determining whether the symptomatology represents a culturally appropriate
adaptive response to a situation. Clinicians must:

1. know or search out the demographics of the local population 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.

Indigenous Healers

Several researchers have reported success in the use of indigenous and traditional healers
in the treatment of psychiatric patients, especially those whose psychotic conditions are
substantially connected to culture-specific beliefs (e.g., fear of voodoo death)

The World Health Organization has advocated implementation of a policy of close

collaboration between the conventional health system and traditional medicine (Sadock &
Sadock, 2007)

Psychotherapy

 Psycho-education
 Cognitive and cognitive behavior therapies
 Supportive psychotherapy (Pundhir et. Al, 2015; Tripathi & Sridevi, 2014; Sinha &
Singh, 2013; Salam et. al., 2012; Salman et. al., 2012; Sadock & Sadock, 2007)

Conclusion
Culture has a complex and multifaceted relationship with manifestations of
psychopathology. Culturally determined variations in the symptoms of major psychiatric
disorders constituting the well-recognized aspect of such interface. Relatively understudied
are the various forms of marginal social existence provided by all cultures to serve as a
readymade disguise for individual psychopathology.

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