1. CULTURE BOUND
SYNDROMES
- DR DEEPIKA SINGH,
2ND YR RESIDENT,
DEPT OF PSYCHIATRY,
GSMC & KEMH

2. INTRODUCTION
• 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.

3. DEFINITION
• Culture refers to a way of life of a group of
people.
• Culture in this context refers to the ideas,
values, habits and other patterns of behaviour
which a human group transmits from one
generation to another.

4. • Various definitions for CBS have been
proposed by Cassidy 1962; Tseng &
Mcdermont 1981; Littlewood
&Lipsedge 1986.
• However, the most widely accepted is
that proposed by Prince 1985 which
states that
“CBS is a collection of signs and
symptoms which is restricted to a
limited number of cultures primarily
by reasons of certain of their
psychosocial features.”

5. HISTORY
• Conditions now been referred to as CBS was first
described in Kraepelin textbook of psychiatry, the
8th edition (1909)
• It was Yap, a Chinese psychiatrist in 1962 that
introduced it (although they were described as folk
names) into the psychiatric literature first made an
attempt to put into a diagnostic classification
scheme.
• CBS were first described outside the west and so
were thought to be only non-western conditions

6. • ICD-10 Diagnostic criteria of research
describes about 12 though they are
not in any distinct class of their own
because they have no sound
descriptions or epidemiological basis
that separates them from those
already classified
• DSM IV describes about 25.
• Some say the are just cultural
manifestations of already described
neuropathology.

7. CLASSIFICATION
• Cultural emphasis on fertility and procreation
-genital shrinking (koro /suo-yang),
-semen loss (dhat) syndromes
• Cultural emphasis on learnt dissociation
-latah type and
-amok type reactions
• Syndromes related to acculturative stress
-Brain fag,
-Bouffee-delirante type reactions

8. • Idioms of distress –
-susto/ espanto,
-nervios,
-hwa-byung,
-ataque de nervios
• Syndromes related to physical
appearance (taijin-kyofu reactions)
• Reactions to extreme environmental
conditions (arctic hysteria)
- pibloktoq,
- Windigo psychosis

9. • Amok (Malaysia)Cafard or Cathard (Laos,
Polynesia, the Phillipines)
• Mal de pelea (Puerto Rico)
• Iich'aa (Navajo)

10. 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.
-It seems to occur only among males,
and is often precipitated
by a perceived slight or insult.

11. -It is often accompanied by persecutory
ideas, automatism, amnesia or
exhaustion, following which the
individual returns to their premorbid
state.
- The victim, has often experienced a
loss of social status or a major life
change.

12. Early travelers in Asia sometimes 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.

13. •
•
•
•
Dhat (India) Jiryan (India)
Sukra Prameha (Sri Lanka)
Shen-k'uei (China, Taiwan)
Shenkui (China)
-Dhat (semen-loss anxiety) is a disorder found,
obviously, among men only... except, not always.
-Although it is rare, women have experienced
similar symptoms related to whitish vaginal
discharge. The general psychosomatic symptoms
are very similar.

14. • dhat is defined as "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 and
masturbation."
• The anxiety related to semen loss
can be traced back thousands of
years to Ayurvedic texts, where the
loss of a single drop of semen, the
most precious body fluid, could
destabilize the entire body.

15. • Shen-k'uei, a Chinese syndrome, is described as "A
form of sexual neurosis associated with excessive
semen loss due to frequent intercourse, masturbation,
nocturnal emission or passing of white turbid urine
which is believed to contain semen.
• Young people who think they might be suffering from it
become anxious and panicky, and complain of somatic
symptoms (with no organic cause) such as dizziness,
backache, fatigue, weakness, insomnia, frequent
dreams and physical thinness," essentially the same set
of symptoms as dhat.
• Women may be seen as stealing vital energy through
sexual intercourse, and any form of semen loss could
lead to an imbalance in chi.

16. • Koro (Malaysia)Shuk yang or shook
yong or suo yang (China)
• Jinjinia bemar (Assam)
• Rok-joo (Thailand)
• Suudu (Tamil, India)

17. • Koro is probably one of the better
known of the culture-bound
disorders. The primary symptoms is
that the penis (in males) or the vulva
and breasts (in women) are receding
into the body, possibly causing death.

18. • Means head of tortoise in Japanese, shrinking
of the penis in Chinese. It is characterised by
3features:
-The individual feels an acute state of
anxiety from a subjective experience of
shrinking of their penis / breasts/ labia.
-They anticipate not only impotence
/sterility but also death!
-They are also able to convince people in
their immediate environment and so “life
saving” measures are taken!

19. • In other parts of the world, the belief may be that,
rather than the genitals shrinking into the body, they
are being stolen by supernatural methods.
• In the Guangdong region in China, it is believed that a
fox spirit can steal penises, while it is more likely to be
ascribed to sorcerers or black magic in regions of
Africa. The theft is carried out when the sorcerer
touches the affected person. The person may believe
that, although his penis has been returned, it is smaller,
malformed or the property of another person entirely

20. • Koro sometimes seems to be spread socially and
may be a kind of mass hysteria, causing widespread
panics and concern, as well as a disorder of
individuals. Afflicted persons may resort to clamps,
ties, pegs or hooks to keep the genitals from fully
receding, sometimes resulting in damage to the
organs.

21. Brain fag or brain fog (West Africa)
Studiation Madness (Trinidad)
• This disorder
typically begins
after an
intensive period
of intellectual
activity, and is
usually
associated with
college or high
school students.

22. Symptoms may include
-watering or dry eyes, dizziness,
blurring of vision,
-difficulty concentrating or
remembering,
-pain or feelings of pressure in the
head or neck, fatigue and difficulty
sleeping, shaking hands, rapid
heartbeat,
-crawling sensations under the skin,
feelings of weakness and
depression.

23. • The term "brain fag" has been used in the United States
in the past to describe an overtaxed mind, especially
among the elderly. However, usage declined to nonexistent by the 1950s. It began in its current form in
Africa in the 1960s.
• The term 'fag' is
believed to have
been derived from
'fatigue'

24. We still refer to
having a foggy mind
when we feel
confused, have
difficulty
remembering and
can't concentrate.

25. • Although DSM-IV specifies West
Africa as the cultural origin, the term
and syndrome occur in many subSaharan areas, and appears to be
most common among young men
pursuing a western-style education.

26. Boufée delirante (West Africa, Haiti)
A sudden outburst of agitated and
aggressive behavior, marked
confusion and psychomotor
excitement. It is an acute,
nonaffective and non-schizophrenic
psychosis, accompanied by visual and
auditory hallucinations and/or
paranoid ideation. A distinctive
feature is a complete remission after
an acute episode.

27. • Patients are typically under age 30, and do not
have previous diagnoses of psychological or
neurological disorders. It strikes "like a
thunderbolt." Duration is typically brief, and
the patient may never have another episode.
• This term was used in French psychology for
some time, but is now declining. Although the
DSM-IV lists West Africa and Haiti as locations,
it appears to be more widespread across the
Caribbean and areas that have traditionally
been associated with French occupation, and
within France itself.

28. • Hwa-byung or ul-hwa-byeong or wool-hwabyung (Korea)
• Literally translates to "fire illness", and most
often occurs in middle-aged women in their 40s
and 50s who are less educated, come from a
lower socio-economic level and live in rural
areas. The individuals typically live in
traditional families, which stress the value of
males while devaluing women. A woman's
virtue is to quietly bear misfortune and
unhappiness while maintaining harmony.

29. • Hwa-byung is believed to be caused by a
build-up of unresolved anger.
• The triggering cause is external events,
particularly intra-familiar stressors such
as spousal infidelity and conflict with inlaws. Because of the cultural emphasis
on familial harmony and peace,
expressing anger is not acceptable, so the
anger is suppressed, and builds on itself
over time. The supressed anger, hate and
despair is known as haan, or "everlasting
woe".

30. • This syndrome has a strong
psychosomatic component. Anger is
often experiences as a heavy mass
which pushed up from the abdomen
into the chest.
• Sufferers complain of sleeplessness,
dizziness, headaches, indigestion,
sexual dysfunction, intolerance to
heat, dry mouth, hot and cold
flushes, weakness, heart palpitations,
and blurred vision.

31. • They show evidence of anxiety, pervasive
depression, obsessions and compulsions,
anorexia and feelings of hatred, shame,
paranoia, fearfulness, destructive impulses,
irritability, anxiety and absent mindedness.
• Western diagnoses range from major
depression, anxiety disorders such as phobias,
generalized anxiety and obsessive-compulsive
disorder, and somatization disorders.

32. Ataque de nervios (Latin America,
Latin Mediterranean, Caribbean)
Symptoms commonly include
uncontrollable shouting, attacks of crying,
trembling, heat in the chest rising into the
head, and verbal and physical aggression.
Some prominently feature dissociative
episodes, seizure-like or fainting
episodes, and suicidal gestures, while
others lack those features entirely.

33. • A key feature is a sense
of being out of control,
and it is usually triggered
by a stressful event.
• It is commonly thought
to be a result of a
chronic build up of anger
over time. People may
not remember what they
did during the ataque,
and usually return to
normal following the
incident.

34. Bilis or cólera or muina (Latinos)
-The cause of this disorder is seen to
be a strongly expressed anger or rage,
which disrupts the balance of both
emotional and physical humors.
-Symptoms may include acute nervous
tension, headache, trembling,
screaming, stomach disturbances such
as nausea, vomiting or diarrhea, and
even loss of consciousness.

35. -Chronic fatigue may result from an acute
episode.
-The words bilis and cólera translate into bile
and cholera, This refers to the idea of
humors, which has had a longstanding effect
on medicine, and is based on the doctrine of
Hippocrates.

36. • Latah (Malaysia)Amurakh, irkunii, olan,
myriachit or menkeiti (Siberian)
• Bah tschi, bah-tsi or baah-ji (Thailand)
• Imu (Ainu, Sakhalin, Japan)
• Mali-mali or Silok (Phillipines)
• Jumping Frenchmen(French-Canadian)

37. • Latah is an exaggerated startle
response, typically found among
women. Being surprised may result
in screaming, cursing, dancing and
hysterical laughter that might last a
half hour or more.
• They may imitate the people around
them or things they see or hear in
the media
• .Latah often occurs following a
traumatic episode. There are many
cultures which have similar
syndromes, but it is unclear how or if
they relate to each other.

38. Zar (North African and Middle Eastern societies)
• Those affected believe they are possessed by
a spirit, and may experience dissociative
episodes when they shout, laugh, weep, sing
or hit their heads on the wall. They may also
become apathetic, withdrawn and unable to
carry out daily tasks. Some develop a
relationship with the possessing spirit. It may
not be considered pathological.

39. • Falling-out or blacking out (Southern USA,
Caribbean)
-The individual experiences dizziness and a
spinning sensation before a sudden
collapse. Although the eyes may be open, the
person reports being unable to see, although
they hear and understand what is happening
around them without being able to interact.

40. • Ghost Sickness (Navajo)
• Weakness, bad dreams, feelings of
danger, confusion, feelings of futility,
loss of appetite, feelings of
suffocation, fainting, dizziness,
hallucinations and loss of
consciousness. May become
preoccupied with death or with
someone who died.
• The cause is usually considered to be
ghosts or, less often, witches. The
person may have hallucinations.

41. • Locura (Latin America, Latinos in US)
A chronic state of severe psychosis, attributed to
multiple life stressors, inherited vulnerability, or
a combination of both.
Symptoms include agitation, incoherence, audio
and visual hallucinations, inability to follow the
rules of social interaction, unpredictability and
possible violence.

42. • Mal de ojo (Mediterranean)
• "evil eye“
• Children and infants are especially at
risk. With adults, women are more likely to
be affected.
• Symptoms include fitful sleep, crying
inconsolably without apparent cause,
diarrhea, vomiting and fever. It is most
widespread in the Mediterranean and Near
East cultures.
Mal de ojo is a Spanish phrase, and the idea
is widespread in many Latino cultures.

43. • Nervios (Latino societies)
• Refers both to a sense of vulnerability to
stressful life experiences and the
symptoms produced by that
vulnerability.
• The person may experience emotional
distress, somatic complaints and inability
to function. Common symptoms are
headaches, irritability, stomach
disturbances, sleep difficulties,
nervousness, inability to concentrate,
easy tearfulness, trembling, tingling
sensations and mareos (dizziness with
vertigo-like sensations).

44. • Rootwork (southern US, Caribbean)Mal
puesto or brujeria (Latino societies)
• The conviction that illnesses are brought
about by supernatural means, such as
witchcraft, voodoo, or evil
influence. Symptoms include anxiety,
gastrointestinal complaints, and fear of being
poisoned or killed.

45. • Sangue dormido (Portuguese Cape Verde
Islanders)
• "Sleeping blood," pain, numbness, tremor,
paralysis, convulsions, stroke, blindness, heart
attack, infection and miscarriage

46. Shenjing Shuairuo (Chinese)
This disorder is the equivalent of neurasthenia, a
disorder no longer recognized by the DSMIV. It includes elements of depression and
anxiety disorders, such as physical and mental
fatigue, dizziness, headaches, gastrointestinal
problems, difficulty concentrating, sleep
disturbance, memory loss, sexual dysfunction,
irritability and excitability.

47. Shin-byung (Korean)
Anxiety and somatic complaints, such as general
weakness, dizziness, fear, loss of appetite,
insomnia and gastrointestinal problems,
followed by dissociation and possession by
ancestral spirits

48. • Susto (Latino societies)
• Literally "fright", this generally falls into either
natural or supernatural origin. Natural origins
are cultural stressors, and are more likely to
affect women than men. Supernatural origins
may be thought to have been sent by a sorcerer,
and may be triggered by witnessing supernatural
phenomenon such as ghosts.
• Symptoms include nervousness, anorexia,
insomnia, listlessness, fatigue, despondency,
muscle tics and diarrhea.

49. Taijin kyofusho (Japan)
• A feeling of intense anxiety centered
around the dread of hurting or
offending others.
• Taijin kyofusho is divided into four
categories: sekimen-kyofu (phobia of
blushing), shubo-kyofu (phobia of a
deformed body), jikoshisen-kyofu
(phobia of eye-to-eye contact), and
jikoshu-kyofu (phobia of a foul body
odor)

50. • Qi-gong Psychotic Reaction (China)
• Qi-gong (exercise of vital energy) is a Chinese
method of meditation
• The DSM IV and Chinese Classification of Mental
Disorders define it as an acute, time-limited
episode characterized by dissociative, paranoid
and other psychotic and non-psychotic
symptoms that occur after participation in
Qigong. An alternate name for the syndrome is
Qigong Deviation Syndrome.

51. -According to a recent study, folk-beliefs attribute the
condition to "adverse flow in the body," "uncontrollable
behavior," "over-meditation" and "spirit possession".
-Over a third of 129 respondents described sensory
problems (32%), mood symptoms (90%) and behavioral
problems (37%). Other symptoms listed were memory
problems (24%), attention difficulties (26%), thought
disorders (18%) and disordered consciousness
(2%). Nearly all patients report "the Qi moving within the
body, and dashing or rushing into the head."

52. • Somatic symptoms may include
headaches, dizziness or disorientation,
and strange sensations in the lower
abdomen (the Dan-Tian point).
• They may demonstrate
hypochondriasis, anxiety, sadness and
feelings of being out of control.
• In addition, they may experience
visual and auditory hallucinations. The
symptoms occur after Qigong practice
and may last two weeks to a month.

53. • Pibloktoq (Inuit)
• Also known as Arctic hysteria,
this often follows the loss or
perceived loss of a valued
person or object.
• Symptoms include brooding,
depressive silences, loss or
disturbances of consciousness,
seizure-like episodes, tearing off
clothes, fleeing or wandering,
rolling in snow, speaking in
tongues or echolalia (echoing
other people's words)

54. • Windigo psychosis
• A.k.a. witiko, witigo which means
mythical monster, a supernatural being
possess the individual, causing them to
have cannabalistic urges!
• It has been reported among Eskimos.
• The term windigo is now used by
Ojibwas to mean a depressed mood of
deep sorrow and hopelessness.

55. TAKE HOME MESSAGE…
• Before diagnosing apparently unusual
behaviour or ideas in a person of
another cultural group, the psychiatrist
has to get information from others in
the same cultural group if such
behaviour or ideas are congenial or
pathological in a given situation to
prevent a misdiagnosis!

56. THANKYOU...