This document provides an overview of culture bound syndromes. It begins with definitions of culture and culture bound syndromes. It then discusses the historical evolution of the concept from early documentation by explorers to inclusion in the ICD-10 and DSM-5. The document subdivides culture bound syndromes and discusses several common syndromes like Dhat Syndrome, possession syndrome, and koro. It also provides cultural explanations and approaches to management. Overall, the document examines culture bound syndromes from multiple perspectives including historical, diagnostic, and cultural frameworks.

1. CULTURE BOUND
SYNDROMES
PRESENTER – UTKARSH MODI

2. OVERVIEW
 Introduction
 Evolution of concept
• Historical aspect
• ICD 10
• DSM IV
• DSM 5
 Subdividing CBS
 Common Culture concepts of distress
 Critique

3. INTRODUCTION
 Cambridge English Dictionary states that culture is, "the
way of life, especially the general customs and beliefs, of
a particular group of people at a particular time.“[1]
 National Institute of Mental Health's Culture and
Diagnosis Group:
Culture refers to meanings, values and behavioral
norms that are learned and transmitted in the dominant
society and within its social groups.
 Culture has a significant role in coloring the
psychopathology of various disorders.

4.  Culture-specific syndrome or Culture-bound
syndrome - combination of psychiatric and
somatic symptoms that are considered to be a
recognizable disease only within a specific
society or culture. [1]
 ‘Episodic and dramatic reactions specific to a
particular community – locally defined as
discreet patterns of behavior’ (Littlewood & Lipsedge,
1985) [1]

5.  Documentation dates back to early explorers.
 1770, Captain Cook described Malaysian
syndrome ‘amok’.
 Late 19th century, W. Gilmore Ellis described
‘amok’ and ‘latah’
 1895, Blonk described ‘koro’, in South China.

6.  In 1904 Emile 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. [1]
 These syndromes were considered to be rare
and exotic, consisted of unpredictable and
chaotic behavior and the sufferers were seen as
uncivilized. [2]

7.  Pow Meng Yap (1962) recommended that the
variety of terms used to describe these
syndromes be replaced by the description
‘atypical cultural bound psychogenic psychosis’
which he later abbreviated to ‘culture bound
syndrome’ [1]
 Hughes (1985) observed that the labels ‘atypical
psychosis’ and ‘exotic syndrome’ imply
deviance from the standard diagnostic base,
making it difficult to place the diagnosis in the
appropriate cultural context. [1]

8.  Obeyesekere (1985) argues that western concepts of
depression may be seen as culture bound.[1]
 Littlewood (1996) argues reasons for abandoning
culture-bound syndromes – [1]
• As culture itself has become a recognized element within
psychiatry theory thus CBS will be come an afterthought
• Distinction between identifiable and discrete CBS is far
from clear
• Phenomenological and epidemiological data is lacking
• In the face of globalization these syndromes are likely to
disappear in increasingly homogenous world culture.

9.  The use of the suffix ‘bound’ to illustrate the
restriction of these syndromes to individual cultures
was fraught with difficulties. Hence Mezzich et al
(1996) suggested the importance of using an
anthropological framework in diagnosis. [1]
 Prince & Tcheng-Laroche (1987) emphasize 4 facets
[1]
• These are accidents of geography
• Designation
• Epidemiological differences
• Symptom differences do not add to the differentiation
of diagnosis

10.  Levine and Gaw suggested the term ‘folk
diagnostic categories’ [1]
 They proposed a criteria for culture specific
syndromes – [1]
• 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.

11.  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

12.  Criticism of DSM IV –
• Although it acknowledges the CBS, listing in the
glossary leads to confusion that they are rare and
exotic psychological curiosities.
• It fails to illuminate that the term culture bound
describes a heterogeneous group of
phenomena, some of which are true syndromes.

13. 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.

14. 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.

15.  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.

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

17.  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

18. CULTUTRAL FORMULATION &
CFI
 Culture refers to systems of knowledge, concepts,
rules, and practices that are learned and
transmitted across generations.
 Race is 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.

19.  Ethnicity is a culturally constructed group identity
used to define peoples and communities.
 The revised Outline for Cultural Formulation:
• Cultural identity of the individual
• Cultural conceptualizations of distress
• Psychosocial stressors and cultural features of
vulnerability and resilience
• Cultural features of the relationship between the
individual and the clinician
• Overall cultural assessment

20.  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 is a brief semi structured interview
• Follows a person-centered approach
• The CFI is formatted as two text columns.

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

23. SUBDIVIDING CBS
 True CBS
 Dissociative phenomena
1. Amok (Malaysian)
2. Falling out or blacking out (Southern US and
Caribbean)
3. Latah (Malaysians)
4. Pibloktoq (Arctic and subarctic eskimos)
5. Grisi siknis (Atlantic coasts of Nicaragua & Honduras)
6. Shin-byung (Korean)

24.  Anxiety states
1. Ataque de nervios
2. Dhat
3. Koro
4. Kayak angst
5. Taijin Kyofusho
 Affective/Somatoform disorders
1. Brain fag
2. Shenjing Shuairuo
3. Anorexia Nervosa
4. Chronic Fatigue Syndrome

25.  Illness of attribution
1. Induced by anger – Bilis, Colera, or Muina & Hwa-
Byung
2. Induced by fright – Susto & Kesambet
3. Induced by Witchcraft – Ghost sickness &
Rootwork or voodoo
4. Induced by the “Evil eye” – mal de ojo
5. Induced by Percieved organic disturbance –
Dhat & Sangue Dormida
6. Induced by possession

26.  Idioms of distress
1. Nervios
2. Locura

27.  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,
• Jhinjhinia etc.

28. DHAT SYNDROME (South Asia)
 Dhat derives from the Sanskrit word ‘Dhatu’
meaning ‘metal’ and also ‘elixir’ or ‘constituent part
of the body’.
 First described in western texts by 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.

29.  Clinical features

31.  Semen loss anxiety in India
• Historical perspective [1]
• The patient presenting with Dhat syndrome is
typically more likely to be
o recently married
o of average or low socio-economic status (perhaps
a student, laborer or farmer by occupation)
o comes from a rural area
o belongs to a family with conservative attitudes
towards sex

32.  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.

33.  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.

34.  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 23
were found to have sexual neurosis with shen-
k’uei syndrome and 64 patients blames their
problems on masturbation.

35.  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.

36.  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 (1839)
 William Acton, an English physician
 Kellogg believed that the nervous shock
accompanying the exercise of sexual organs
was the most profound.

37.  Management of Dhat syndrome
• Wig suggested emphatic listening, a non
confrontational approach, reassurance and
correction of erroneous 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,

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

39.  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

40. POSSESION 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'.

41.  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.

42.  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

43.  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.
 More common in women, with a female to male
ratio of 2 or 3 to 1.

44.  No consensus has been achieved to understand
this phenomenon. Its been described as –
• A culture bound syndrome
• Hysterical dissociation or psychosis
• Synonymous to western trance state
• Expected behavior
 In a study of an area including 30 small villages a
one year prevalence rate of 3.7 was obtained
which could be attributed to the high
prevalence of belief in possession phenomena.

45. 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.

46.  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)

47.  Kraeplin(1921)- hypochondriacal delusion seen in
depressive illness
 Yap(1965)- depersonalisation syndrome manifesting
as a body image disturbance due to dissociative
mechanism
 Chowdhury- psychosexual conflicts lead to body
image disturbance
 Psychodynamic view- powerful symbol of loss of
potency and power in the male-depressive
negative self image

48. 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.

49. 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

50. HIKIKOMORI (Japan)

51.  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 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

52.  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

53. AMOK
 Syndrome indigenous to the Malayo-Indonesian
cultural region.
 Men of Malay extraction.
Muslim religion, low education, and rural origin.
Between the ages of 20 and 45
 Precipitants - include arguments with coworkers,
nonspecific family tensions, feelings of social
humiliation, bouts of possessive jealousy, gambling
debts, and job loss.

54. 1. Exposure to a stressful stimulus or subacute
conflict
2. Feelings of anger, loss, shame, and lowered self-
esteem
3. A period of social withdrawal
4. Transition
5. Indiscriminate selection of victims
6. Verbalizations
7. Cessation
8. Subsequent partial or total amnesia
9. Perceptual disturbances or affective
decompensations

55.  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.

56. ATAQUE DE NERVIOS (Latino descent)
 Idiom of distress
 Although descriptions of some ataques de
nervios most closely fit the DSM-IV-TR description
of panic attacks, the association of most
ataques with a precipitating event and the
frequent absence of the hallmark symptom of
acute fear or apprehension distinguish them
from panic disorder.

57.  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

58.  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

59. KHYÂL CAP (Cambodians)
 Common symptoms include –
• Panic attacks, such as dizziness, palpitations, shortness
of breath, and cold extremities
• Symptoms of anxiety and autonomic arousal (e.g.,
tinnitus and neck soreness).
 Typical triggers –
• Worry
• Fear, going to crowded places
• Standing up from lying or sitting position
• Odors

60.  Include catastrophic cognitions centered on the
concern that khyal (a wind like substance) may
rise in the body.
 Khyâl attacks usually meet panic attack criteria
and may shape the experience of other anxiety
and trauma- and stressor related disorders.
 Laos (pen lom), Tibet (srog rlunggi nad), Sri Lanka
(vata), and Korea (hwa byung).

61. KUFUNGISISA (Zimbabwe)
 Kufungisisa ("thinking too much" in Shona) is an
idiom of distress and a cultural explanation
among the Shona of Zimbabwe
 Indicative of interpersonal and social difficulties
 Involves ruminating on upsetting thoughts,
particularly worries.

62.  Associated with a range of psychopathology,
including anxiety symptoms, excessive worry,
panic attacks, depressive symptoms, and
irritability
 "Thinking too much“ may also be a key
component of cultural syndromes such as "brain
fag" in Nigeria. Where it is mainly attributed to
study.

63. MALADI MOUN (Haitian)
 Cultural explanation
 Interpersonal envy and malice cause people to
harm their enemies by sending illnesses such as
psychosis, depression, social or academic failure,
and inability to perform activities of daily living.
 Someone who is attractive, intelligent, or wealthy is
perceived as especially vulnerable, and even
young healthy children are at risk.

64.  Often expressed in the form of "evil eye" (e.g. in
Spanish, mal de ojo, in Italian, mal'occhiu).

65. Shenjing shuairuo
 “Weakness of the nervous system” in Mandarin
Chinese. Is a translation and cultural adaptation
of the term “neurasthenia”.
 CCMD-2-R diagnosis requires three symptoms
out of five nonhierarchical symptom clusters,
organized as weakness, emotional, excitement,
and nervous symptoms, as well as a fifth
category of sleep disturbances

66.  Phenomenology:
1. Onset is usually gradual
2. Insomnia, affective dysphoria, headache, bodily
pains and distortions (e.g., “swelling” of the
head), dizziness, difficulty concentrating, tension
and anxiety, worry, fatigue, weakness,
gastrointestinal problems, and “troubled
vexation”
3. The sufferer frequently seeks the sick role
4. Course is variable and may respond closely to
changing interpersonal and social
circumstances.

67.  Empirical assessment of the precipitants of
shenjing shuairuo has found high rates of work-
related stressors, which were made more
intractable by the centrally directed nature of
mainland Chinese society.

68. NERVIOS (Latinos)
 Idiom of distress
 Nervios refers to a general state of vulnerability to
stressful life experiences and to a syndrome brought
on by difficult life circumstances.
 Nervios starts with ‘a persistent idea that ‘is stuck to
one’s mind’ (‘idea pegada a la mente’), and these
‘particular ideas invade the mind and accumulate.
Affected individuals think so much about the ideas
that the ideas ‘get stuck’ to the brain’.

69.  Common symptoms include headaches and
brain aches, irritability, stomach disturbances,
sleep difficulties, nervousness, easy tearfulness,
inability to concentrate, trembling, tingling
sensations, and mareos (dizziness with
occasional vertigo-like exacerbations).
 Nervios is a broad syndrome that spans the
range from cases free of a mental disorder to
presentations resembling adjustment, anxiety,
depressive, dissociative, somatoform, or
psychotic disorders.

70. SUSTO
 Susto (“fright” or “soul loss”) is a folk illness
prevalent among some Latinos in the United
States and among people in Mexico, Central
America, and South America.
 Susto is an illness attributed to a frightening
event that causes the soul to leave the body
and results in unhappiness and sickness.

71.  Typical symptoms include :
• appetite disturbances,
• inadequate or excessive sleep,
• troubled sleep or dreams,
• a feeling of sadness,
• lack of motivation to do anything, and
• feelings of low self-worth or dirtiness.
• Somatic symptoms

72. Taijin kyofusho
 Taijin kyofusho is a culturally specific expression of
social anxiety in Japanese and Korean cultures
 People affected by this disorder are concerned
about doing something, or presenting an
appearance, that will offend or embarrass the other
person eg. A typical expression of TKS is the fear to
offend others by emitting offensive odors, blushing,
staring inappropriately, and presenting an improper
facial expression or physical deformity.

73.  This disorder is more common in males than
females (at the ratio of 3:2)
 The Japanese diagnostic system classifies taijin
kyofusho into four subtypes:
• sekimen-kyofu (the fear of blushing),
• shubo-kyofu (the fear of a deformed body),
• jikoshisen-kyofu (the fear of eye-to-eye contact),
and
• jikoshu-kyofu (the fear of one's own foul body
odor).

74. BOUF´EE DELIRANTE (West Africa and
Haiti)
 Sudden outburst of agitated and aggressive
behavior, marked confusion, and psychomotor
excitement.
 May sometimes be accompanied by visual and
auditory hallucinations or paranoid ideation.
 May resemble an episode of brief psychotic
disorder.

75. BRAIN FAG (West Africa)
 Difficulties in concentrating, remembering, and
thinking.
 Students often state that their brains are
fatigued.
 Somatic symptoms are usually centered around
the head and neck and include pain, pressure
or tightness, blurring of vision, heat, or burning.

76. LATAH (Malaysian or Indonesian origin)
 Hypersensitivity to sudden fright, often with
echopraxia, echolalia, command obedience,
and dissociative or trance-like behavior.
 More frequent in middle-aged women.
 Subjects are often in great demand at social
occasions –will provide comic relief by uttering
obscenities when provoked.

77. 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

78.  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.

79.  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.

80. THANK YOU