This document discusses culture-bound syndromes from various perspectives. It provides an overview of concepts related to culture-bound syndromes and how their nosological classification has changed over time. Specific culture-bound syndromes are described such as Dhat syndrome, Koro, Amok, Arctic Hysteria, and Paris Syndrome. The document also discusses the evolution of views on semen loss from different cultural and historical lenses including Ayurveda, Islam, Buddhism, and Christianity. It highlights the need for an integrated approach in managing Dhat syndrome.

1. Culture
Bound
Syndromes
Paris
Syndrome
Stendhal
Syndrome

4. Concepts
• Pfeiffer suggested about
• Culture – specific stress
• Culture - specific shaping of conduct
• Culture – specific interpretation
• Culture-specific intervention

5. Nosological Shifts
Culture bound psychogenic psychoses
(Yap, 1962)
Culture Bound Syndromes (Yap, 1969)
Culture Specific Disorders (ICD-10)
Cultural Concepts of Distress (DSM-5)

6. Psychiatric
disorder
Diagnostic category Associated CBS
Neurosis Anxiety
Depersonalization
Personality disorder
Koro, Dhat, Brain fag
Amok, Latah
Ataque de Nervios
Psychosis Affective
Schizophrenia
Brain fag, Koro
Amok, Susto
Others Eating disorders Anorexia Nervosa, Bulimia

7. ICD-10 (12
syndromes)
DSM-IV-TR
(25
syndromes)
DSM-5 (9
syndromes)
ICD-11 (??)

8. • Initially descriptions about culture bound
syndrome – East Asia
• Western Perspectives
– Type A personality (behaviour patterns): Salience
of goal pursuance, Working against time pressure
and frustration experienced at not achieving these
goals
– Bulimia Nervosa

9. • Initially descriptions about culture bound
syndrome – East Asia
• Western Perspectives
– Type A personality (behaviour patterns): Salience
of goal pursuance, Working against time pressure
and frustration experienced at not achieving
these goals
– Bulimia Nervosa

11. A culture bound syndrome
The term was coined by – Dr.N N Wig in1960
Wig explained Dhat syndrome
The symptoms of Dhat syndrome
Fatiguability
Weakness
Decreased appetite
Sexual dysfunction
Anxiety
Feeling of guilt
The symptoms attribute to “semen loss”
Wig N. Problems of mental health in India. J Clin Soc Psychiatry. 1960;17:48–53.

12. • In Sri Lanka – Prameha
• In China – Shen K’uei
• In Malayesia & Indonesia – Latah
• In Japan - Imu
• Other parts of South East Asia – Jiryan
Mehta V, De A, Balachandran C. Dhat Syndrome: A Reappraisal. Indian J Dermatol.
2009 Jan-Mar; 54(1): 89–90.
Simons RC, Hughes CC. Dordrecht: D Reidel; 1985. The Culture-bound Syndromes:

13. Concept of culture bound
syndrome
Lipsedge M, Littlewood R. Transcultural psychiatry. In: Granville-Grosman, editor. Recent
advances in clinical psychiatry. 3rd ed. Edinburgh: Churchill Livingstone; 1985.
Mehta V, De A, Balachandran C. Dhat Syndrome: A Reappraisal. Indian J Dermatol.
2009 Jan-Mar; 54(1): 89–90.
•1969 – Yap coined the term “Culture
Bound Syndrome”
•Littlewood and Lipsedge defined
Culture Bound Syndrome as “episodic
and dramatic reactions specific to a
particular community”

14. Another debate……..
• Simons and Hughes emphasized that
– Different names has been assigned to the
same entity across different cultures.
– Phenomenologically, they are similar.
Simons RC, Hughes CC. Dordrecht: D Reidel; 1985. The Culture-bound Syndromes:
Folk Illnesses of Psychiatric and Anthropological Interest.

16. • The term “Dhat” is
derived from the
Sanskrit word “Dhatus”
• Susruta Samhita
explains “Dhatus” as
elixir of life.

17. • Ayurveda - Describes
about seven essential
elements of body
(Dhatus)
– Rasa : Fluid extract from
digested food
– Rakta : Blood
– Meda : Fat
– Mamsa : Muscle
– Asthi : Bone
– Majja : Marrow
– Sukra : Semen
Jadhav S. Dhat syndrome: A re-
evaluation. Psychiatry. 2004;3:14–6.

18. • 40 drops of rasa (food extract) = 1 drop of rakta
(blood)
• 40 drops of rakta (blood)= 1 drop of majja (marrow)
• 40 drops of majja (marrow)=1 drop of sukra (Semen)
– Some believe it to be 100 drops
• One drop of semen is
formed from 64000 drops
of food extract
Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes: The story of
dhat syndrome. Br J Psychiatry. 2004;184:200–9.
Chadda RK, Ahuja N. Dhat syndrome. A sex neurosis of the Indian subcontinent. Br J
Psychiatry. 1990;156:577–9.
El Hamad I, Scarcella C, Pezzoli MC, Bergamaschi V, Castelli F. Forty meals for a
drop of blood. J Travel Med. 2009;16:64–5.
Painuly N, Chakrabarty S. The continuing story of dhat syndrome. Br J
Psychiatry. 2004;185:260.

19. 1500 BC
• Ayurveda
• Charaka Samhita
– Semen loss : Sukrameha –
Passage of semen in urine

20. Charaka Samhita says… Decline in
sexual performance occurs due to
Excessive indulgence in sexual
activities
Obstructing ejaculation of
semen
Sexual intercourse with
impassionate women
Black magic
Overpowering sexual urges

21. Charaka Samhita & Susruta Samhita
describes normal semen as –
Crystal like Oily
Slimy
Thick
Non – corrosive
Sweet
Honey like smell

22. • Shiva Samhita
– Sperm (Virya) is
compared with “seed”
– Loss of semen is
progress towards
death (Falling of seed
leads towards death)
– Hence emphasis was
given in preserving
the semen (seed).
Jadhav S. Dhat syndrome: A re-evaluation. Psychiatry. 2004;3:14–6.
Deb KS, Balhara YPS. Dhat Syndrome: A Review of the World Literature. Indian J Psychol
Med. 2013 Oct-Dec; 35(4): 326–331.

23. Out of the seven essential elements described,
semen is believed to be most precious one,
hence –
• It is the source of strength and stamina
• It needs to be preserved
• Its loss adversely affects the health
Behere PB, Natraj GS. Dhat syndrome: The phenomenology of a culture
bound sex neurosis of the orient. Indian J Psychiatry. 1984;26:76–8.
Singh G. Dhat syndrome revisited. Indian J Psychiatry. 1985;27:119–22.

26. • Tissot's paper in 18th century stating
that even an adequate diet could waste
away through seminal emission gained
popularity amongst the emerging
middle class and led Western Europe to
an era of masturbating insanity.
Mehta V, De A, Balachandran C. Dhat Syndrome: A Reappraisal. Indian J Dermatol.
2009 Jan-Mar; 54(1): 89–90.

27. Islamic concept
Formation of semen
continues after puberty
(Bulugh) and the excess
amount of semen formed
comes out as nocturnal
emission
Prakash O, Kar SK, Sathyanarayana Rao T S. Indian story on semen loss and related
Dhat syndrome. Indian J Psychiatry 2014;56:377-82

28. Islamic concept
• Semen loss due to
masturbation is more
harmful is unlike sexual
intercourse, because there
occurs minimal use of
tactile, visual, olfactory, or
auditory senses for arousal
and it is the psychic
stimulation that produces
excitement
• Psychic excitement results
in emotional disturbancesPrakash O, Kar SK, Sathyanarayana Rao T S. Indian story on semen loss and related
Dhat syndrome. Indian J Psychiatry 2014;56:377-82

29. Buddhist views
• Loss of semen : Sinful
offence
• Nocturnal emission is
considered as an
obstacle in the path of
spiritual progress of
monks
• Semen is the source of
energy and is formed
from purification of food
Faure B. The Red Thread: Buddhist Approaches to Sexuality. Princeton: Princeton
University Press; 1998. p. 86.
Prakash O, Kar SK, Sathyanarayana Rao T S. Indian story on semen loss and related

30. Christianity concepts
• Semen loss through
masturbation is
abnormal and sinful.
• It hampers the normal
procreation by the
process of sexual
intercourse
• Nocturnal emission is
unhygienic & impure
(Holy Bible)Hirsh A. Post-coital sperm retrieval could lead to the wider approval of assisted
conception by some religions. Hum Reprod 1996;11:245-7
Prakash O, Kar SK, Sathyanarayana Rao T S. Indian story on semen loss and related
Dhat syndrome. Indian J Psychiatry 2014;56:377-82.

31. Current
understandings

32. Dhat syndrome: In classificatory system
• Dhat syndrome as a diagnostic entity,
introduced in
– The International Classification of Diseases
(ICD-10)
– 4th edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR)
[Udina et al, 2013]
DSM-5 : Glossary section describing cultural
concepts of distress

33. Search in “Pubmed” using the keyword
“Dhat Syndrome”
• Only 65 articles, even after more than 50 years
– 45 articles were published in last 10 years
• One systematic review
Udina M, Foulon H, Valdés M, Bhattacharyya S, Martín-Santos R.
Dhat syndrome: a systematic review. Psychosomatics. 2013 May-
Jun;54(3):212-8.
• One large multi-centric study
Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, Lakdawala
B, Tripathi A, Chakraborty K, Sinha V, Bhatia MS, Pattojoshi A,
Rao TS, Rozatkar A. Comorbidity in Patients with Dhat Syndrome:
A Nationwide Multicentric Study. J Sex Med. 2015 Apr 22.
– Dhat syndrome is poorly studied, though currently it is
gaining interest of researchers

34. Management of Dhat Syndrome
• Dhat syndrome, commonly improves with anti-
anxiety or antidepressant medications as well as
psychological interventions like psycho-
education, counseling and cognitive behavior
therapy [Mehta et al, 2009].
• Anti-anxiety medications to be more effective
than any other medications in the management
of Dhat syndrome [Bhatia et al, 1998].

35. Grover S, Avasthi A,
Gupta S, Dan A, Neogi R,
Behere PB, Lakdawala B,
Tripathi A, Chakraborty
K, Sinha V, Bhatia MS,
Pattojoshi A, Rao TS,
Rozatkar A.
Comorbidity in
Patients with
Dhat
Syndrome: A
Nationwide
Multicentric
Study.J Sex Med.
2015 Apr 22.
32.8% - No comorbidity
20.5% - Depressive disorders
20.5% - Neurotic, stress-related
and somatoform disorders
Half (51.3%) of the study sample
had comorbid sexual dysfunction.

36. Dhat syndrome do occur in females…
• Chaturvedi SK. Psychaesthenic
syndrome related to leukorrhoea in
Indian women. 1988; 8 (1):67-72.
• Chaturvedi SK, Chandra PS, Issac MK,
Sudarshan CY. Somatization
misattributed to non-pathological
vaginal discharge. J Psychosom Res.
1993 Sep;37(6):575-9.
• Singh G, Avasthi A, Pravin D.
Dhat syndrome in a female- a case
report. Indian J Psychiatry. 2001
Oct;43(4):345-8.

37. Dhat Syndrome:
Need of an integrated approach

38. •Why should we
integrate?
•With whom should we
integrate?

39. Why should we integrate?
• Integrate
–To understand
–To build a therapeutic
relationship
–To treat
–To work as a team
–To grow

40. With whom should we integrate?
• Integration of psychiatry and allied
disciplines (Collaborative approach of
Psychiatrists, Psychologists, Psychiatry
Social Workers, Psychiatric Nurse etc)
• Integration of other medical disciplines
with psychiatry (Collaborative approach with
other medical disciplines like – General
Medicine, Dermatology & Venerology,
Urology, Neurology)
• Integration with alternative systems of
medicine (Collaboration with Ayurvedic,
Homeopathic, Unnani, Siddh practitioners)
• Integrations of Cultural concepts with

42. Visit our website at - iisb.org

43. Amok
• Seen in Indonesia & Malaya
• Starts with period of threatening followed by
violent behavior, sometimes use of dangerous
weapons
• Afterwards amnesia is reported

44. Arctic Hysteria
• Syn: Pibloktoq
• Seen in Eskimos
• Common in Women
• C/Fs: Episodes of cry & screaming followed by
tearing of cloths, running wildly and
sometimes jumping into cold water
• Violent behavior may be reported

45. Koro
• Genital retraction syndrome
• Acute anxiety experience
related to perception of
progressive decrease in size
of penis
• May have fear of death
• Common in South East Asia,
China
• Epidemic in North East India
- 1982

46. Windigo
• A form of psychosis
• Seen in Algonkian
Indians
• Fear of becoming a
cannibal through
possession by
“Windigo”

47. Lizzard syndrome

48. Suchi bai
• Syn: Purity mania
• Commonly seen in Bengali Widows
• Fear of contamination, excessive cleanliness
are seen

49. Others
• ? Trans – possession episodes
• ? Anorexia nervosa

50. History enables us to understand the
conceptual evolution of a belief.
Culture bound syndrome is a classic
example, how an illness behavior was
nurtured over centuries by different
cultures

51. Paris Syndrome
• Paris Syndrome
– A transient psychological disorder
– Seen in some individuals visiting Paris or Western
Europe
– Clinical features
• Delusions - persecutory
• Hallucinations
• Derealization
• Depersonalization
• Anxiety
• Psychosomatic symptoms

52. Paris Syndrome
• Commonly seen as a culture shock
• First reported in 2004
• Japanese are more susceptible (approx – 12/Year)
• Contributing factors
– Language barrier
– Cultural difference
– Idealized image of Paris
– Exhaustion – Jet lag also attributes
– Contradiction – Contrary to expectation about
facilities

53. Stendhal syndrome
• Syn: Stendhal’s Syndrome / Hyperkulturemia/ Florence
Syndrome
• A psychosomatic disorder
• Named after - French author Stendhal (pseudonym of
Marie-Henri Beyle), who described his experience with the
phenomenon during his 1817 visit to Florence in his
book Naples and Florence: A Journey from Milan to Reggio
• Clinical features
– Dizziness
– Palpitation
– Tachycardia
– Hallucinations

54. • Cause
– Exposure to experiences of great personal
significance (Viewing art)
– Confrontation with immense beauty of natural
world
Stendhal syndrome

55. • There are many descriptions of people becoming
dizzy and fainting while taking in Florentine art,
especially at the aforementioned Uffizi in
Florence, dating from the early 19th century on.
• The syndrome was only named in 1979, when it
was described by Italian psychiatrist Graziella
Magherini, who observed and described more
than 100 similar cases among tourists and
visitors in Florence.
Stendhal syndrome

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57. CultureBoundSyndrome
Culture
ContextPsychiatric
disorder