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Culture bound syndrome

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Various culture bound syndromes in psychiatry like dhat , koro , amok etc. Also description of management guidelines for culture bound syndromes.

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Culture bound syndrome

  1. 1. Culture bound syndromes Dr. Cijo Alex PG Trainee in Psychiatry, SMVMCH , Puducherry.
  2. 2. 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 in others.
  3. 3. The term culture-bound syndrome denotes a set of behavioral and experiential phenomena that is present in a particular socio cultural context and are readily recognized as illness behavior by most participants in that culture. The syndromes are commonly assigned culturally sanctioned explanations ,that, in turn, generate culturally congruent remedies, usually in the form of healing rituals. Kaplan & Sadocks Synopsis of Psychiatry ; tenth edition Pg:521
  4. 4. Culture Culture is a vast, complex concept. Culture consists of shared symbols, artifacts, beliefs, values, and attitudes. It is manifested in rituals, customs, and laws. Culture is learned through contact with family, friends, classmates, teachers, significant persons, and the media; the term for this process is enculturation. Kaplan & Sadocks Synopsis of Psychiatry ; tenth edition Pg:168
  5. 5. Acculturation and Assimilation Adults, such as migrants or refugees, who only in part adopt the culture of a host society are said to be assimilated, whereas those who assume a new cultural identity consonant with the host culture are said to be acculturated. Persons who abandon their native culture but fail to be assimilated or acculturated usually lose their sense of identity or purpose in life and are at high risk for suicide, substance abuse, and alcoholism. Kaplan & Sadocks Synopsis of Psychiatry ; tenth edition Pg:168
  6. 6. The concept of culture bound syndromes. The DSM & ICD are not universally applicable; psychopathological syndromes exist, especially in non-Western cultures that do not fit the scientific nomenclature unless they are placed into the atypical •category. These syndromes are perceived to be more influenced by culture and, therefore, have been labeled culture-bound. Some syndromes are found in distinct cultural groups, whereas others are found in large cultural regions.
  7. 7. History Conditions now been referred to as CBS were first described in Kraepelin textbook of psychiatry, the 8th edition in 1909. It was the Chinese psychiatrist Yap who first introduced the term Culture Bound Syndrome in 1969. CBS were first described outside the west and so were thought to be only non-western conditions Culture-bound syndromes:the story of dhat syndrome.D.Bhugra et alBJP(2004)
  8. 8. Nosological approach towards culture bound syndromes. • ICD 10 • DSM - IV TR • DSM - 5
  9. 9. ICD 10 Neurotic, stress-related and somatoform disorders F.48.8 - Other specified neurotic disorders This category includes mixed disorders of behavior, beliefs, and emotions which are of uncertain etiology and nosological status and which occur with particular frequency in certain cultures; The strong association of these syndromes with locally accepted cultural beliefs and patterns of behavior indicates that they are probably best regarded as not delusional. ICD 10 by WHO , page 110
  10. 10. DSM 5 The DSM 5 includes them in the Appendix under the heading “ Glossary of Cultural Concepts of Distress”
  11. 11. Examples of culture bound syndromes Dhat Amok Brain fag Koro Latah Locura Piblokoto Spell Zar
  12. 12. Dhat A folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns associated with discharge of semen , whitish discoloration of urine and feelings of weakness and exhaustion. Also called Jiryan , Sukra prameha(Sri Lanka) and Shen-K’uei(China).
  13. 13. The term Dhat is derived from the Sanskrit word Dhatu which means elixir or metal. It was first described in western psychiatric literature and the term DHAT coined by Wig in 1960s , with vague psychosomatic symptoms of fatigue, weakness, anxiety, loss of appetite, guilt and sexual dysfunction, attributed by the patient to loss of semen in nocturnal emission, through urine or masturbation. DHAT SYNDROME: A REAPPRAISAL ;Indian Journal of Dermatology Wig NN. Problem of mental health in India. J Clin Social Psychiatry. 1960;17:48–53.
  14. 14. The symptoms of semen-loss anxiety are well known in Indian historical writing. In Ayurvedic texts semen production is described thus: food converts to blood, which converts to flesh, which converts to marrow, and the marrow is eventually converted into semen. It is said that it takes 40 days for 40 drops of food to be converted to one drop of blood, 40 drops of blood to one drop of flesh, and so on. In the individual susceptible , semen starts to take on an overwhelming importance. These notions frighten the individual into developing a sense of doom if a single drop of semen is lost, thereby producing a series of somatic symptoms .
  15. 15. A prototype patient is likely to be a married or recently married male, of average socioeconomic status, coming from a rural area and belonging to a family with a conservative attitude towards sex Patient's knowledge and attitude towards sexual processes which is colored by information from friends, colleagues or relatives and lay magazines is a major etiological factor behind manifestation of this syndrome. (Bhatia & Malik,1991; Akhtar, 1988; Behera & Natraj, 1984).
  16. 16. These ideas of semen loss and consequent anxiety are not confined to India; they have been reported from Sri Lanka and other parts of the subcontinent as well. Fear of semen loss and resulting problems is so strong that cures are advertised by vaids and hakims everywhere – on walls, on television, in newspapers and on roadside hoardings. DHAT SYNDROME IN A FEMALE- A CASE REPORT ;Indian Journal of Psychiatry, 2001, 43(4),345-348
  17. 17. Semen-loss anxiety in China A healthy exchange of yin and yang in sexual intercourse maintains a balance. Following masturbation, nocturnal emission or homosexual intercourse, yang would be lost but without corresponding gain of yin and the resulting imbalance leads to disease. This has been associated with epidemics of koro
  18. 18. Semen-loss anxiety in Western cultures From the times of Hippocrates and Aristotle, semen has been considered extremely important . Greeks in ancient times saw masturbation as a natural outlet for men lacking opportunity for sex. In many Western European cultures masturbation has been prohibited on religious grounds.
  19. 19. Patients having Dhat syndrome can be further divided into three categories. Dhat alone - Patients attributed their symptoms to semen loss; presenting symptoms - hypochondriacal, depressive or anxiety symptoms Dhat with comorbid depression and anxiety - Dhat was seen as an accompanying symptom Dhat with sexual dysfunction- Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry 2007;49:208-10
  20. 20. Dhat syndrome in women. • a 23 year old matriculate housewife from middle socio economic, Sikh nuclear family of urban background presented with complaints of weakness and vaginal discharge for the last 3 years and "fear" of sex of 6 months duration. • Before marriage, patient hailed from a conservative joint family of rural background where open discussions about sexual topics were discouraged. She never masturbated and had no history of premarital sexual contact. She regarded sexual intercourse as a shameful and painful activity. DHAT SYNDROME IN A FEMALE- A CASE REPORT ;Indian Journal of Psychiatry, 2001, 43(4),345-348
  21. 21. At about 20 years of age, she started feeling 'wetness' in the vagina whenever she thought of the act of sexual intercourse or on occasions spontaneously too. She did not report any foul smelling discharge or local itching. She started thinking that she was losing something vital. She also complained of weakness and "swelling" of the body, for 1-2 days after such experience. Within the next 1-2 months, she developed aches and pains throughout the body, headaches and poor concentration. She would attribute these symptoms to the 'wetness'. She started remaining constantly preoccupied with these symptoms and hence anxious.
  22. 22. The different sources indicate the universality of symptoms and global and global prevalence of this condition, despite its image as an exotic ‘neurosis of the Orient’ , challenging its diagnosis as a culture bound syndrome. Culture-bound syndromes:the story of dhat syndrome.D.Bhugra et alBJP(2004)
  23. 23. Historical perspective and development of beliefs related to ‘semen loss’
  24. 24. Comorbid diagnosis of Dhat • Anxiety • Depression
  25. 25. Management of Dhat syndrome Understanding of Dhat syndrome by Modern Medicine fails to impress most patients. Wig suggested emphatic listening, a nonconfrontational approach, reassurance and correction of erroneous beliefs, along with the use of placebo, anti-anxiety and antidepressant drugs, wherever required. Other group advocated psychoeducation and culturally informed cognitive behavioral therapy. Good response was reported with anti-anxiety and antidepressant drugs as compared to psychotherapy. Depressive symptoms of this syndrome showed effective response to selective serotonin reuptake inhibitors along with regular counseling. The available intervention studies suggest that the management of Dhat syndrome involves sex education, relaxation therapy and medications. Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry 2007;49:208-10
  26. 26. Sex education primarily focuses on anatomy and physiology of sexual organs and their functioning with reference to masturbation, semen, nocturnal emissions. It also involves functioning with genitourinary system independent of gastrointestinal tract, etc. Relaxation therapy mainly consists of Jacobson's Progressive Muscular Relaxation Technique, which can be combined with biofeedback (so as to facilitate objective evidence and mastering of anxiety by the patient). Relaxation therapy should be practiced two to three times per day regularly, especially after therapy sessions are over. Evaluation of the presence of associated anxiety or depressive symptoms that may impede the process of therapy must be performed. Anxiolytics or/and antidepressants can be added for the least possible time and in the least possible doses. Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry 2007;49:208-10
  27. 27. With industrialisation and urbanisation, the anxiety about semen loss in the West diminished, and the same is likely to happen in southernAsia as well. If we understand dhat as a culture-bound syndrome, the historical evidence indicates that it was prevalent in Europe, USA and Australia in the 19th century. In those countries it might have disappeared in response to changes in social and economic factors, whereas it is still prevalent in southern Asia.
  28. 28. Amok Indiscriminate , unprovoked episode of destructive or homicidal activity followed by amnesia. May be accompanied by persecutory idea , automatism , amnesia and exhaustion. May culminate in suicide.It seems to occur only among males, and is often precipitated by a perceived slight insult. Common in Indonesia & Malaysia. Malayan Men running Amok.
  29. 29. 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.
  30. 30. Koro -Head of Turtle. A term probably of Malaysian origin, that 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 diagnosis is included in the second edition of Chinese Classification of Mental Disorders (CCMD-2)
  31. 31. 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
  32. 32. Brain fag West African concept referring to a condition experienced by university or high school students in response to challenges of schooling. Difficulty in concentrating , remembering and thinking. “ Brain fatigue” .
  33. 33. Latah -Common in Malayan woman. Response to frightening stimuli characterized by - Increased sturtle response - Echolalia and echopraxia - Automatic obediance and trance states
  34. 34. Piblokto An abrupt dissociative episode accompanied by extreme excitement and frequently followed by convulsive seizures and coma. The person may be withdrawn or mildly irritable for a period of hours or days before the attack and typically reports complete amnesia for the attack. During the attack persons may tear off their clothing, break furniture, shout obscenities, eat feces, flee from protective shelters, or perform other irrational or dangerous acts.
  35. 35. Locura A term used in the United States and Latin America to refer to a severe form of chronic psychosis Symptoms exhibited by persons with locura include incoherence, agitation, auditory and visual hallucinations, inability to follow rules of social interaction, unpredictability, and possibly violence.
  36. 36. Boufée delirante 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.
  37. 37. spell A trance state in which persons communicate• with deceased relatives or spirits. At times the state is associated with brief periods of personality change. The culture-specific syndrome is seen among African-Americans and European-Americans from the southern United States.
  38. 38. Rootwork 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. Southern US and the Caribbean's.
  39. 39. Windigo The fear of going cannabilistic.
  40. 40. zar A general term applied in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies to the experience of spirits possessing a person. Persons possessed by a spirit may experience dissociative episodes that may include shouting, laughing, hitting the head against a wall, singing, or weeping.
  41. 41. Course and 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
  42. 42. Treatment 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. Acceptance of and respect for the patient's cultural frame is important.
  43. 43. Cognitive and cognitive behavior therapies may achieve some modicum of freedom from cultural bias.
  44. 44. One promising avenue is collaboration with indigenous healers. Several researchers have reported their success in the use of indigenous healers, especially those whose psychotic conditions are substantially connected to culture-specific beliefs. Kaplan & Sadocks Synopsis of Psychiatry ; tenth edition Pg:524
  45. 45. Thank you
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Various culture bound syndromes in psychiatry like dhat , koro , amok etc. Also description of management guidelines for culture bound syndromes.

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