Culture bound syndrome

Culture bound syndromes
Dr. Cijo Alex
PG Trainee in Psychiatry, SMVMCH , Puducherry.

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.

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

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.

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.

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.

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)

Nosological approach towards
culture bound syndromes.
• ICD 10
• DSM - IV TR
• DSM - 5

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

DSM 5
The DSM 5 includes them in the Appendix under
the heading “ Glossary of Cultural Concepts of
Distress”

Examples of culture bound syndromes
Dhat
Amok
Brain fag
Koro
Latah
Locura
Piblokoto
Spell
Zar

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).

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.

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 .

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).

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

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

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.

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

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

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.

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)

Historical perspective and development of
beliefs related to ‘semen loss’

Comorbid diagnosis of Dhat
• Anxiety
• Depression

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.

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.

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.

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.

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.

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)

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

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” .

Latah
-Common in Malayan woman.
Response to frightening stimuli characterized by
- Increased sturtle response
- Echolalia and echopraxia
- Automatic obediance and trance states

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.

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.

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.

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.

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.

Windigo
The fear of going cannabilistic.

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.

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

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.

Cognitive and cognitive behavior therapies may
achieve some modicum of freedom from
cultural bias.

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.

Culture bound syndrome

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