This document discusses cultural concepts of distress and how they have been assessed and categorized over time. It provides examples of early studies of cultural variations in psychopathology from the early 1900s. It describes the evolution of terms used to describe culture-specific forms of distress from "culture-bound syndromes" to more recent terms like "cultural concepts of distress". The document also discusses different proposed systems for categorizing cultural concepts, including by cardinal symptoms, taxons, and relationship to cultural factors. It provides examples of specific cultural concepts and their proposed relationships to culture and corresponding DSM-5 disorders.

1. Cultural Concepts of Distress
and Assessment

2. • Cultural assessments in psychiatry have evolved in tandem with
changing definitions of culture throughout time, especially within
anthropology.
• In 1904, Emil Kraepelin sailed to Java, Indonesia, and investigated
symptom manifestations in 100 European, 100 indigenous, and 25
Chinese patients at the Buitenzorg mental hospital.

3. • Kraepelin found that psychotic Javanese patients experienced fewer
visual and auditory hallucinations and crystallized delusions than
European patients, leading him to conclude that the Javanese mind
was more primitive than the European mind

4. • Cultural psychiatry has documented wide variations in the experience
and expression of mental distress around the world.
• Historically, these variations were often characterized in terms of
“culture-bound syndromes”—distinctive patterns of co-occurring
symptoms and signs that were assumed to be rooted in or “bound” to
local features of culture and context.

5. • The clear implication was that Western psychiatric categories were
not culture-bound, but rather universal, and that proper
characterization would disclose a simple mapping of non Western
syndromes onto the categories of international nosology

6. • The attribution of “boundedness” emerged early in the history of
cultural psychiatry in colonialist contexts in which observers had
limited understanding of local cultures. Hence, there was a strong
tendency to exaggerate difference, generate stereotypes, and
“exoticize” the Other.

7. • The foreign observers believed that the communities had been
socially isolated and, therefore, saw the patterns of distress as unique
and locality bound.
• Considering the massive migrations and cultural diffusions that have
occurred throughout human history, this assumption of boundedness
has rarely been tenable.

8. • For example, in the 1950s, Raymond Prince described a Nigerian
culture-bound syndrome of “brain fag” characterized by feelings of
mental fatigue, difficulty concentrating, heat in the head, and other
somatic symptoms. Brain fag was found among students who were
the first in their families.

9. • However, recent historical evidence shows that “brain fag” was
commonly described in England in the late 1800s and, presumably,
traveled to Nigeria as part of the colonial system to be adopted as a
local mode of expressing distress.

10. • Cross-cultural mental health researchers have introduced several
terms to refer to and describe culture-specific forms of expressing
and diagnosing emotional distress, including cultural syndromes,
popular or folk illness categories, idioms of distress, and illness
explanations or attributions.
• The need for multiple terms reflects the complexity of the ways in
which people experience, understand, and communicate distress.

11. • Anthropologists use the term folk illness to refer to local illness
categories that are based on particular systems of medicine or
broader cultural ontologies, independently of whether they are
organized as discrete syndromes or not.
• A related term is popular illness category, which simply reflects the
fact that these are labels or constructs used by lay people.

12. • However the term “folk” tends to connote less affluent and formally
educated sectors of society and ignores the fact that these categories
are used in complex medical systems.
• Hence DSM-5 uses the more general term cultural concepts of
distress to encompass folk illnesses, cultural syndromes, idioms of
distress and causal explanations.

14. YEAR EVENTS
1893 W. Gilmore Ellis - reported amok which was observed among the Malays. 7
1897 W. Gilmore Ellis - reported latah and described it as a mental malady of the Malays. 8
1908 William Fletcher - further elaborated on latah and described its relation to crime. 9
1910 Musgrave and Sison – reported the phenomenon of ‘mimic psychosis’ which was similar to
latah. It was called mali-mali by the local people of Philippines where it was observed. 10
1913 A. A. Brill - reported piblokto (Arctic hysteria), observed among the Inuit community of
Greenland, during Robert E. Peary’s visits. 11
1933 Rev. John M. Cooper - reported ‘witiko psychosis’. He claimed that it ‘typically’ existed
among the Cree, who were members of the Algonquian Indians, living in northern Canada. 12
1934 van Wulfften Palthe - reported koro as an unusual form of anxiety neurosis.13

15. 1948 Gillin - elaborated on magical fright. 17
1957 Cannon - reported on ‘voodoo’ death. 18
1959 Fernández-Marian - reported a Puerto Rican syndrome. It was later described as ataques de
nervios by Guarnaccia, Rubio-Stipec, & Canino in 1989. 19
1960 Raymond Prince - reported the ‘brain fag’ syndrome among Nigerian students. 20
1962 T. A. Lambo - described the phenomenon of malignant anxiety in Africa. 21
1964 Rubel - reported the phenomenon of susto which was observed among Hispanic Americans.
22
1966 Hsien Rin – presented a case of frigophobia. It was an excessive fear of catching cold seen in
Taiwan. 23
1974 Kasahara described ‘anthrophobia’ in Japan. 24
1975 Burton-Bradley in Papua New Guinea reported ‘cargo cult’. 25
1976 Suwanlert reported a variety of spirit possession named phii pob in Thailand. 26
1976 In Australia, among aborigines John Cawte reported malgri (territorial anxiety). 27
1977 Lee reported an anger syndrome named hwabyung prevalent among Koreans. 28

16. • atypical, culture bound, psychogenic psychosis’(Yap, 1962)
• culture-bound, reactive syndromes’(Yap, 1967)
• culture-bound syndromes’(Yap, 1969)
• culture-related specific psychiatric syndromes’ (Tseng & McDermott,
1981)
• culture-related specific syndromes’ (Tseng, 2001)
• culture specific disorders’ (ICD-10, WHO, 1992)
• culture-related syndromes’ (Jilek, 2000)
• cultural concepts of distress’ (DSM-5, APA, 2013)

17. Four key features of cultural concepts were
described in DSM -5:
i) The correspondence between any cultural concept and a diagnostic
entity is more probably one-to-many and in either direction.
ii) The severity denoted by cultural concepts may range from symptoms
that do not meet DSM criteria of any disorder to conditions fulfilling
diagnostic criteria.
iii) The same cultural term may denote multiple cultural concepts.
iv) As a response to global and local influences, they may change over
time.

18. CULTURAL
CONCEPTS
TYPE RELATED CONDITIONS IN DSM-5
1. Ataque de nervios Syndrome
or
Idiom of
distress
Panic disorder, panic attack, conversion disorder, other
specified or unspecified dissociative disorder, intermittent
explosive disorder, other specified or unspecified trauma and stressor-
related disorder other specified or unspecified anxiety disorder,
2. Dhat syndrome Cultural
Explanation
Persistent depressive disorder (dysthymia), major depressive
disorder, generalized anxiety disorder, illness anxiety disorder, somatic
symptom disorder, early (premature) ejaculation, erectile disorder,
other specified or unspecified sexual dysfunction, academic problem.
3. Khyal cap Syndrome Panic disorder, panic attack, generalized anxiety disorder,
agoraphobia, illness anxiety disorder, posttraumatic stress disorder.

19. 4. Kufungisisa Idiom of
distress
&
Cultural
explanation
Persistent depressive disorder (dysthymia), major depressive
disorder, generalized anxiety disorder, obsessive-compulsive
disorder, posttraumatic stress disorder, persistent complex
bereavement disorder.
5. Maladi moun Cultural
explanation
Schizophrenia with paranoid features; Delusional disorder,
persecutory type.
6. Nervios Idiom of
distress
Persistent depressive disorder (dysthymia), major depressive
disorder, social anxiety disorder, generalized anxiety disorder,
somatic symptom disorder, other specified or unspecified
dissociative disorder, schizophrenia.

20. 7. Shenjing
shuairuo
Syndrome Persistent depressive disorder (dysthymia), major
depressive
disorder, generalized anxiety disorder, social anxiety
disorder, somatic symptom disorder, posttraumatic stress
disorder, specific phobia.
8. Susto Cultural
explanation
Major depressive disorder, somatic
symptom disorders,
posttraumatic stress disorder, other specified
or unspecified
trauma and stressor-related disorder.
9. Taijin kyofusho Syndrome Social anxiety disorder, delusional disorder, body
dysmorphic
disorder, obsessive-compulsive disorder, olfactory
reference syndrome.

21. In an attempt to organize and classify the various culture -bound
syndromes, several systems were proposed by different authors. The
important among them are enlisted below:
1. Subgrouping by cardinal systems
2. Subgrouping by taxons
3. Subgrouping by relationship to culture

22. • 1. SUBGROUPING BY CARDINAL SYSTEMS
•
• Pow Meng Yap (1967) was of the view that these syndromes are
regional variations of universal psychiatric disorders, produced by the
influence of local beliefs, social structure and values in the clinical
presentation. He believed that all attempts to classify illnesses should
be based on etiology, but there was insufficient knowledge to give an
aetiological classification of the culture-bound syndromes. So he
attempted to do the categorization by identifying the cardinal
symptom of the prototypical case or primary emotional state.

23. i) Primary fear reactions – included latah, malignant anxiety,
psychogenic or magical death.
ii) Morbid rage reaction – amok.
iii) Specific culture-imposed nosophobia - koro
iv) Trance dissociation - windigo psychosis

24. • 2. SUBGROUPING BY TAXONS
This was proposed by Ronald C. Simons and Charles C. Hughes in 1985.
They were having the opinion that phenomenological similarity was
present between various culture related syndromes across diverse
cultural settings.
The concept of ‘taxon’ was borrowed from biology to refer to a
category that arranges a group of objects based on a common factor.
Thus categorization of these syndromes into various subgroups was
done with each subgroup defined by a common factor.

25. i) The startle-matching taxon - included latah and imu. ii) The sleep-
paralysis taxon
iii) The genital-retraction taxon - koro.
iv) The sudden-mass-assault taxon – amok.
v) The running taxon - grisi siknis, pibloktoq and arctic hysteria. vi) The fright-
illness taxon – susto.
vii) The cannibal-compulsion taxon - windigo psychosis.

26. 3. SUBGROUPING BY RELATIONSHIP TO CULTURE
• Tseng and McDermott in 1981. The subgrouping of culture related
syndromes was done according to how they might be affected by
various cultural factors. As the cultural perspective was taken into
consideration, this appeared to be a more meaningful approach.

27. i) Pathogenic effect – cultural factors having causative effect.
ii) Pathoselective effect – cultural factors selects the type and nature of
psychopathology.
iii) Pathoplastic effect – cultural beliefs contribute to the manifestation of
psychopathology.
iv) Pathoelaborating effect - certain types of manifestations are elaborated and
reinforced by cultural factors.
v) Pathofacilitating effect – cultural factors contribute to the frequent occurrence
of certain psychopathologies.
vi) Pathoreactive effect - the reaction to psychopathology is determined by
culture.

28. SYNDROMES IN WHICH CULTURAL FACTORS HAVE
PATHOGENIC EFFECTS
• KORO (Genital-retraction anxiety disorder)
Koro was initially considered to be a culture bound syndrome occurring
only in the Chinese population, but later in many South and East Asian
countries like Singapore, Thailand, Indonesia and India.
Koro refers to an episode of intense and sudden anxiety that the penis
(in males) or nipples and vulva (in females) will recede into the body,
which may possibly lead to death.

29. • Dhat syndrome (Semen-loss anxiety)
Mostly described in India, this condition was later found to be widely
prevalent in Pakistan, Bangladesh, Nepal, China, Sri Lanka (known as
prameha disease) and Taiwan.
The patients usually present with vague symptoms such as weakness,
fatigue, anxiety, loss of appetite, weight loss, guilt, impotence or
premature ejaculation , depressive mood etc. They attribute the
symptoms to the excessive loss of semen.

30. • The chief complaint by the patient is whitish discoloration or turbidity
of the urine which he considers as result of passage of semen in
urine. It is most commonly observed in young men from lower socio -
economic strata. A variant of this can also be found in women, as an
excessive concern regarding white vaginal discharge.

31. • Frigophobia :
This condition is typically found in China, Taiwan and south -east Asia,
characterized by ‘morbid fear of catching cold’.
• Sorcery fear and Voodoo death :
‘Voodoo’ Death was first described by Walter B. Cannon as unexplained
and sudden death resulting from a voodoo curse.

32. • Malgri (Territorial Anxiety Syndrome) :
The term malgri is the name of aborigines inhabiting the Wellesley Islands
of the Gulf of Carpentaria in Australia among whom this condition was
originally described. First reported by John Cawte in 1976. In this area it is
folk belief that if a person enters the sea without washing hands after
handling the land food, the spirit guarding that littoral will enter his belly
like a bullet and will make that person sick.

33. SYNDROMES IN WHICH CULTURAL FACTORS HAVE
PATHOSELECTIVE EFFECTS
• AMOK :
Amok refers to a dissociative episode characterized by an outburst of
aggressive, violent or homicidal behaviour directed against people and
objects preceded by a period of brooding.
Malay mythology describes amok as an involuntary behaviour which is
caused by the evil spirit “hantu belian”, entering a person's body
and making him or her to have violent behaviour without conscious
awareness.

34. • CARGO CULT SYNDROMES (MILLENNIARY DELUSIONS) :
Historically there have been occurrences of ‘crisis cults’ in different
countries like Kikuyu maumau in Kenya and the Taiping rebellion in
China. They were characterized by many non -logical, magicoreligious
endeavors by the members of a native culture taking place when they
are exposed to some superior cultures.

35. SYNDROMES IN WHICH CULTURAL FACTORS HAVE
PATHOPLASTIC EFFECTS
TAIJIN KYOFUSHO OR ANTHROPOPHOBIA :
Taijin kyofusho is a cultural syndrome characterized by anxiety about
interpersonal situations occurring due to the feeling, though t or
conviction that the appearance and actions of someone in social
interactions are offensive or inadequate to others which leads to the
avoidance of such situations

36. • BRAIN FAG SYNDROME
• ARCTIC HYSTERIA or PIBLOKTOQ :
Unique hysterical attack occurring in the Eskimo people, characterized
by a sudden dissociative episode accompanied by marked excitement
which may last as long as 30 minutes.

37. SYNDROMES IN WHICH CULTURAL FACTORS
HAVE PATHO ELABORATING EFFECTS
• LATAH :
This term is used to denote the state of highly exaggerated response
occurring when an individual is startled or being subjected to a sudden
fright. The response is comprised of altered consciousness and a
transient dissociated state showing abnormal behaviors.
Echolalia, echopraxia, automatic obedience, euphoric mood and verbal
outbursts involving erotic words are observed. Following the cessation
of the attack subject usually will have amnesia regarding the incident.

38. SYNDROMES IN WHICH CULTURAL FACTORS
HAVE PATHO FACILITATING EFFECTS
• This category is comprised of several psychiatric disorders in which
cultural factors have strong influence in determining the prevalence.
They do not constitute unique or specific disorders or clinical
manifestations.
• Substance use, alcohol related problems, group suicide and mass
hysteria are some examples of this category.

39. SYNDROMES IN WHICH CULTURAL FACTORS HAVE
PATHO REACTIVE EFFECTS
• ATAQUE DE NERVIOS :
This condition is observed typically among the various Latin American
cultures, especially in the Hispanic people of Cuba, Puerto Rica and the
Dominican Republic.
Attacks occur following a stressful event such as death of a relative or
marital conflicts. The characteristic symptoms are uncontrollable
shouting, trembling, attacks of crying, numbness, heat in chest raising
into head and physical or verbal aggression. The attacks usually end
rapidly, mostly when others intervene. This condition predominantly
affects females.

40. • HWABYUNG :
• Hwabyung is an ‘illness of attribution’. It’s attributed to suppression of
anger and observed in women. In male dominated Korean society,
women are often mistreated and they are compelled to suppress
their emotions. The accumulated resentment is considered as the
core dynamics in development of Hwabyung.
• The symptoms include fatigue, insomnia, panic, dysphoric affect, fear
of impending death, anorexia, indigestion, palpitations, dyspnea,
feeling of a mass in the epigastrium and generalized pains and aches.

41. • SUSTO :
Susto is prevalent among Latinos in United States and people of Mexi
co, South America and Central America.
The word susto in Spanish means ‘fright’. This term is used to describe
chronic complaints which are attributed to the loss of soul caused by a
frightening event, including anorexia, agitation, decreased or excessive
sleep, mental confusion, lack of motivation, and emotional symptoms
such as depression, irritability and anxiety.

42. CULTURE SPECIFIC DISORDERS SUGGESTED ICD -10 CODE
1. Amok F68.8 Other specified disorders of adult personality and
behaviour
2. Dhat/ Jiryan/ Dhatu/ Shen
k’uei/ Shen-kui
F48.8 Other specified neurotic disorders
F45.34 Somatoform autonomic dysfunction of the
genitourinary system
3. Koro/ Suk yeong/ Jinjin bemar/
Suo-yang
F48.8 Other specified neurotic disorders
F45.34 Somatoform autonomic dysfunction of the
genitourinary system

43. 4. Latah F48.8 Other specified neurotic disorders
F44.88 Other specified dissociative (conversion)
disorders
5. Pibloktoq/ Arctic hysteria F44.7 Mixed dissociative (conversion) disorders
F44.88 Other specified dissociative (conversion)
disorders
6. Nerfiza/ Nerves/
Nervios/
Nevra
F32.11 Moderate depressive episode with somatic
syndrome
F48.0 Neurasthenia
F45.1 Undifferentiated somatoform disorder
7. Pa-leng/ Frigophobia F40.2 Specific phobias
8. Susto/ Espanto F45.1 Undifferentiated somatoform disorder
F48.8 Other specified neurotic disorders

44. 9. Taijin kyofusho /
Anthropophobia/ Shinkeishitsu
F40.1 Social phobias
F40.8 Other phobic anxiety disorders
10. Ufufuyane/ Saka F44.3 Trance and possession disorders
F44.7 Mixed dissociative (conversion) disorders
11. Uqamairineq F44.88 Other specified dissociative (conversion) disorders
G47.4 Narcolepsy and cataplexy (Includes: sleep paralysis)
12. Windigo (?) F68.8 Other specified disorders of adult personality and
Behaviour

45. • John Carr hypothesized that all forms of psychopathology, including
the folk illnesses, represent culturally authorized final common
behavioral pathways. These are behavioral responses, part of a
limited number of behavioral repertoires that individuals use in
response to stressful conditions that are common to humanity.
• Although significantly shaped by culture, these pathways are
mediated by universal mechanisms of learning and cognition.

46. • To elucidate the relationship between amok and depression, for
example, Carr and Peter Vitaliano contended that alternate
expressions of distress are culturally determined variants of response
to comparable life stress conditions.
• Then why some respond with aggression, some with depression, and
still others cope adaptively to similar aversive events. Culture-specific
and idiosyncratic responses to stress result from complex interactions
between physiological processes, predisposing personality styles,
cognitive processes, and learned problem-solving skills.

47. • Ethnographic work reveals that cultural concepts of distress identify socially
constructed patterns of interpretation of suffering that serve pragmatic
communicative functions. Clarifying these functions requires what Good and
Delvecchio Good called a “meaning-​centered medical anthropology” that
investigates illness forms from the perspective of semantic networks, the clusters
of experiences, words, and interpretations that give rise to particular illness forms
as modes of experience and expression.
• These meaning networks are called “semantic” because they reveal the role of
interpretation and communication in shaping reality and may include “personal
trauma, life stresses, fears and expectations about the illness . . . the metaphors
associated with a disease, the ethnomedical theories, the basic values and
conceptual forms, and the care patterns that shape the experience of the illness
and the social reactions to the sufferer in a given society.” By taking this
contextual approach, the basic organizational principle underlying a particular
illness form can be established in order to assess the degree to which it is
descriptive, etiological, or expressive of particular concerns.

48. • The Explanatory Model Questions were proposed by Kleinman in
1980 as a tool to aid clinicians in interviewing patients about their
cultural understandings of their illnesses. This deceptively simple set
of eight groups of questions provides a framework for a brief clinical
interview that can identify the presence and meaning of a folk illness
category. In particular, the first five groups of questions are useful in
this regard and include:
► What do you call your problem? What name does it have? ► What
do you think has caused your problem? ► Why do you think it started
when it did? ► What does your sickness do to you? How does it work?
► How severe is the sickness? Will it have a short or long course ?

49. The DSM-IV Outline for Cultural Formulation

51. The CFI guidelines provide a definition of culture as (1) the values,
orientations, knowledge, and practices that individuals derive from
membership in diverse social groups (e.g., ethnic groups, faith
communities, occupational groups, and veterans groups); (2) aspects of
an individual’s background, developmental experiences, and current
social contexts that may affect his or her perspective, such as
geographical origin, migration, language, religion, sexual orientation, or
race/ethnicity; and (3) the influence of family, friends, and other
community members (the individual’s social network) on the
individual’s illness experience.

52. The DSM-5 Cultural Formulation Interview
(CFI)

55. Role of Cultural Identity