The9CulturalConceptsofDistressintheDSM5

Ataquedenervios(attackofnerves:Latinogroup)
Dhatsyndrome(semen:SouthAsians)
Khylcap(windattacks:Cambodianspeakers)
Kufungisisa(thinkingtoomuch:Shonaspeakersin
Zimbabwe)
Maladimoun(sentsickness:Haitianpopulations)
Nervios(nerves:LatinosintheUnitedStatesandLatin
America)
Shenjingshuairuo(weaknessofthenervoussystem:
MandarinChinese)
Susto:(fright:Latinogroup)
Taijinkyofusho(taijinbetweenpeople,kyofufear,
shodisorder:Japan)

DSM5GlossaryEntryforKhylCap
Khylcap.Khylattacks(khylcap),orwindattacks,isasyndromefound
amongCambodiansintheUnitedStatesandCambodia.Commonsymptomsinclude
thoseofpanicattacks,suchasdizziness,palpitations,shortnessofbreath,andcold
extremities,aswellasothersymptomsofanxietyandautonomicarousal(e.g.,tinnitus
andnecksoreness).Khylattacksincludecatastrophiccognitionscenteredontheconcern
thatkhyl(awindlikesubstance)mayriseinthebodyalongwithbloodandcausea
rangeofseriouseffects(e.g.,compressingthelungstocauseshortnessofbreathand
asphyxia;enteringthecraniumtocausetinnitus,dizziness,blurryvision,andafatal
syncope).Khylattacksmayoccurwithoutwarning,butarefrequentlybroughtaboutby
triggerssuchasworrisomethoughts,standingup(i.e.,orthostasis),specificodorswith
negativeassociations,andagoraphobictypecueslikegoingtocrowdedspacesorriding
inacar.Khylattacksusuallymeetpanicattackcriteriaandmayshapetheexperienceof
otheranxietyandtraumaandstressorrelateddisorders.Khylattacksmaybeassociated
withconsiderabledisability.
Relatedconditionsinotherculturalcontexts:Laos(penlom),Tibet(srog
rlungginad),SriLanka(vata),andKorea(hwabyung).
RelatedconditionsinDSM5:panicattacks,panicdisorder,generalizedanxiety
disorder,agoraphobia,posttraumaticstressdisorder,illnessanxietydisorder.
DiagnosticandStatisticalManualofMentalDisorders,FifthEdition,(Copyright
2013).AmericanPsychiatricAssociation.Allrightsreserved.

TypicalTriggersofaKhylAttack
Worry
Fear(e.g.,owingtonightmare,startle,traumarecall)
Anxiety
Standingupfromalyingorsittingposition
Goingintocrowdedareas(Peoplesickness,orpulmeunuh)
Ridinginacar(Carsickness,orpullaan)
Odors
OutoftheBlue

SymptomsConsideredtobeTypicalof
aKhylAttack
MostCommonsymptom:Dizziness
Typicalsymptomsofanattack:
DSMpanicattacksymptoms:fear,dizziness,palpitations,
shortnessofbreath
OtherANStypesymptoms:sorenessinthejoints,neck
soreness,tinnitus
Other:headache,outofenergy

KhylAttacksandCulturallySpecificPanicSymptoms
AmongCambodianpatients,tinnitus,necksoreness,and
headachecommonlyoccurinkhylattacks,withkhyl
attacksbeingacommonpaniclikepresentationinthat
group.

Panicattackandothersymptomsduringakhylattack(N=100)

Tinnitus

Necksoreness

Headaches

Hinton et al., 2010

KhylAttackandAnxiety
KhylattacksfreqeuntlymeetDSM5panicattackcriteria
Generalizedanxietysymptomsoranyanxietysymptomwill
usuallybelabeledasakhylattackorthepossiblestartofone
Amongtraumatizedpopulations,negativeemotionsoften
quicklyinducesomaticsymptomsthatthenmayquickly
escalatetopanic(reactivityhypothesis)
Amongtraumatizedpopulations,negativeemotionsand
somaticsymptomswilloftentriggernegativememoriesof
past,suchasofthePolPotperiod,whichthenbecomepartof
thekhylattack

HowaKhylAttackisThougthtoOccur:
TheCambodianPathophysiology
Normallykhylandbloodflowthroughconduitsinthebody
downthelimbsandintestinaltractandouttheporesofthebody
Inakhylattack,thevesselsbecomeblockedandtheporesclose,
causinganupsurgeinthebodyofkhyalandbloodtocausebodily
disasters

AKhylAttack(an

upsurgeofkhyl and blood in

the body): Associated
symptoms, ethnophysiology,
and catastrophic cognitions

Head
headachefromkhylenteringthecranium(khylmaycausesyncope)
dizzinessfromkhylenteringthecranium(khylmaycausesyncope)

tinnitusfromkhylexitingthroughtheears(khylmaycausedeafness
andsyncope)
blurryvisionfromkhylexitingthroughtheeyes(khylmaycause
blindnessandsyncope)

Neck
necksorenessfromkhyldistendingtheneckvessels(khylmaycauseneck
vesselrupture)

HeartandLungs
palpitationsfromkhylhittingtheheart(khylmaycauseheartarrest)
chestdiscomfortfromkhylenteringthechestcavity(khylmaycauseasphyxia)
shortnessofbreathfromkhylcompressingthelungs(khylmaycauseasphyxia)

HandsandArms
coldhandsfromalackofflowofkhylandblood
tothehands(thislackofflowmaycausedeathof
thehands,i.e.,stroke,andanupsurgeofkhyl
andbloodinthebody)
sorearmsfromblockageofbloodandkhylflow
owingtocoagulationlikeplugs(thislackofflow
maycausedeathofthehands,i.e.,stroke,and
anupsurgeofkhylandbloodinthebody)

Stomach
stomachdiscomfortandbloatingfromexcessivekhyl(khylmaymoveup
fromthestomachintothetrunkofthebodytocausethedisasterslistedabove)

FeetandLegs
coldfeetfromalackofflowofkhylandbloodtothefeet(thislackof
flowmaycausedeathofthelegs,i.e.,stroke,andanupsurgeofkhyl
andbloodinthebody)
sorelegsfromblockageofbloodandkhylflowowingtocoagulation
likeplugs(thislackofflowmaycausedeathofthelegs,i.e.,stroke,
andanupsurgeofkhylandbloodinthebody)

ALocalNosologyofAnxietyandPanic
Severity:
Aspectrumofkhylseverity
Mild
khyl

Moderate
khyl

Severekhyl
(calledripe
khylorbroken
khyl)

Khyl
overload

Coining(stratchingkhyl):
ItsRoleinHealingandNosology
Akeywayofdeterminingtheseverityofkhylby
assessingthecolorandbumpinessrevealedby
coining
Akeywayofremovingblockagesandrestoring
flow
Akeywaytowarmthebody
Akeywaytoremovekhylfromthebody

Coining, or gaoh
khyl, literally
scratching khyl

ImageCredit:
GregoryJuckett,
MD,MPH

ALocalNosologyofAnxietyandPanic
Severity:
Aspectrumofkhylseverity
Mild
khyl

Moderate
khyl

Severekhyl
(calledripe
khylorbroken
khyl)

Khyl
overload