BRITISH JOURNAL OF (2004), 184, 200^209 REVIEW ARTICLE

Culture-bound syndromes: functioning (Murphy, 1976). These syn- dromes were considered to be rare and the story of dhatdhat syndrome exotic: they consisted of unpredictable and chaotic behaviours, and the sufferers were seen as uncivilised. By placing such syn- A. SUMATHIPALA, S. H. SIRIBADDANA and D. BHUGRA dromes in the context of Western diagnos- tic systems any links between cultural beliefs, environmental stressors and symp- toms were often ignored (Bhugra & Jacob, 1997).1997). In an interesting overview, Hughes & Wintrob (1995) recommended that the Background Culture-bound Culture-bound syndromes have been dis- conceptual frame of reference needs to be syndrome is a term used to describe the cussed under a variety of names and are expanded if the clinical significance of defined as ‘episodic and dramatic reactions culture-bound syndromes is to be under- uniqueness of some syndromes in specific specific to a particular community – stood. As these syndromes often cut across cultures.cultures. Dhat (-loss ) has locally defined as discrete patterns of diagnostic categories, it is possible that they been considered to be an exotic‘neurosis behaviour’ (Littlewood & Lipsedge, offer another way of assessment so that of the Orient’. 1985). However, Hughes (1996) proposed clinicians can attempt to understand alter- that these form a unique and distinctive native explanatory and folk models of heal- Aims ToToascertainthe ascertain the presence of class of generic phenomena, and that such ing and caring. Furthermore, by placing similar symptoms and syndromes in syndromes exist among and afflict only the these conditions in the context of the whole different cultures and historical settings. ‘others’ – people who by some criterion spectrum of disease and normality, these are outside the ‘mainstream’ population conditions may be dealt with in a more MethodMethod Electronic and manual (however defined). These syndromes have appropriate – perhaps medical – manner. sometimes been included in discussions of Yap (1962) recommended that the vari- literature searches were used to gather cultural psychiatry (Haldipur, 1980; Mur- ety of terms used to describe these syn- information on the existence and phy, 1977), and the latter authors both dromes be replaced by the description description of semen-loss anxiety in argue that this approach is a relic of an ‘atypical cultural bound psychogenic psy- different cultures and settings. imperialist Eurocentric heritage in which chosis’, which he subsequently abbreviated these syndromes have become institution- to ‘culture-bound syndrome’ (Yap, 1969). ResultsResults Most of the empirical studies alised in the classificatory systems. More than 30 years later, the time has come onon dhatdhat syndrome have emerged from Hughes (1996) raises the point that in to re-evaluate this condition. Asia, whereaswhereasits its concepts have been order to establish the ontological status of culture-bound syndromes, phenomenolo- described historicallyin other cultures, gists need to go beyond the semantic diffi- Western culture-bound syndromes including Britain, the USA and Australia. culties of ‘label grip’ – the paralysis of Interestingly, although for a long time Wes- The different sourcesindicate the analytic acumen often created by powerful tern psychiatry viewed culture-bound syn- universalityuniversalityof of symptoms and global diagnostic labels. In his opinion, the generic dromes as essentially Eastern, attention differences between culture-bound and has now been drawn to the culture-bound prevalence of this condition, despite its non-culture-bound syndromes need to be syndromes of the West. Hughes (1996) image as a‘neurosis of the Orient’. explored. Case data are helpful for this pur- identifies the type A behaviour pattern as pose, as are historical analyses of how these one such syndrome, characterised by feel- Conclusions It appears that dhatdhat symptoms came to be recognised as patho- ings of chronically struggling against time, (semen-loss anxiety) is not as culture- logical. In this paper we aim to provide a frustration at failing to achieve goals, bound as previously thought.We propose review of both historical and empirical data. hyperaggression and ambition, and impa- that the concept of culture-bound Psychiatry, too, has suffered from the tience in interpersonal relationships; simi- syndromes should be modified in line with impact of both imperialism and colonial- larly, Littlewood (1996) has described ism, not only through the suppression of bulimia nervosa as a Western culture- DSM ^ IVrecommendations. indigenous systems of , but also bound syndrome. However, both type A Declaration of interest None. through the imposition of new clinical cate- personality and variants of bulimia nervosa gories and diagnoses, thus medicalising have been reported from other parts of the Funding detailed in Acknowledgements. many forms of stress. world. Culture-bound syndromes have also been equated with ethnic psychosis and ethnic neurosis (Devereux, 1956), hysterical Definitions psychosis (Yap, 1969), and rare, unclassifi- Culture-bound syndromes were seen as able collective and exotic syndromes (Arieti causing little damage to humanity, & Meth, 1959). The myriad of titles given although they might cast light on important suggests that from the beginning the but little-understood aspects of human nosology of these syndromes has been

200

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. THE STORY OF

problematic. The use of the suffix ‘bound’ to Association, 1994) have been amended to paper we present some historical and phe- illustrate the restriction of these syndromes incorporate culture as a factor in the diag- nomenological data from Western and to individual cultures is itself fraught with nosis of psychiatric conditions. These Eastern countries and some epidemiological difficulties. Therefore, the suggestion by formulations are explicitly committed to data from the Indian subcontinent to illus- MezzichMezzich et aletal (1996) that culture-bound taking a theoretically neutral position with trate both the universality of the symptoms, syndromes illustrate the importance of regard to aetiology as well as an explicitly and the cultural context. We then argue using an anthropological framework in descriptive approach regarding symptoms, that the reasons for abandoning culture- diagnosis becomes an important one. and may well confound reliability (Hughes, bound syndromes as a category are many. Hughes (1985) observed that the labels 1985).1985). Wintrob (1996) feels that Hughes ‘atypical psychosis’ and ‘exotic syndrome’ Wig (1994) makes a persuasive case (1996) is justified in pointing out the psy- imply deviance from a standard diagnostic that in international diagnostic systems chiatric profession’s wish to avoid compre- base; ‘exotic’ becomes foreign, exciting, de- even conditions prevalent within the Euro- hensive assessment and classification of the viant or different, strengthening the notion pean context, such as bouffebouffee´ede delirante´lirante numerous strange-sounding, difficult-to- of the ‘other’ in the pattern of diagnosis. (chronic interpretative delusional psycho- comprehend conditions known as culture- This has meant that the ‘observed devi- sis) in France, are not generally recognised. bound syndromes. The very diversity of ant’ – the patient – not only is exotic but He cautions that separately categorising these syndromes requires consideration of is also the ‘other’, making it difficult to culture-bound syndromes will not necessa- the perennial issue of defining normality. place the diagnosis in the appropriate rily improve the management of these cases cultural context. It is important to reiterate in the country’s health services. Littlewood Study objectives that patterns of psychiatric diagnosis (1996) argues that reasons for abandoning The purpose of this overview is to assert that are not just ethnocentric but are also culture-bound syndrome as an entity it is the traditional models of distress and the androcentric. include the option that all psychiatric cultural context that are important. The loss Prince & Tcheng-Laroche (1987) em- patterns are culture-bound, and as culture of semen is wrapped up in men’s perception phasise that four facets of culture-bound itself has become a recognised element of their masculinity, thus the hypochon- syndromes must be taken into account within general psychiatric theory, culture- driacal, anxiety and depressive symptoms when studying them: these are accidents bound patterns will become an after- become subsumed in the major visible of geography (i.e. a disorder may be pre- thought. Other reasons he puts forward ‘’ of semen loss. Our argument in sent in some cultures but not in others for abandoning the concept are that a dis- this paper is that cultural context colours for geographical rather than social rea- tinction between identifiable and discrete these symptoms and that such a context has sons); designation (some illnesses are con- culture-bound syndromes is far from clear; been reported in the historical documents sidered culture-bound simply because they phenomenological and epidemiological as well. Our study had two objectives: to happen to have local names); epidemiolo- data are lacking; and that patterns of gather information on studies (clinical and gical differences (global prevalence rates, Western behaviour (which may be culture- empirical) of dhatdhat syndrome and review the variations in gender ratios and age at onset bound) have been included in DSM–IV literature, and to extract information on his- may be used in assigning culture-bound categories. He points out that in the face torical data in different countries at different status); and lastly that symptom differences of globalisation (and industrialisation) periods. The hypothesis was that symptoms themselves do not add to the differentia- these syndromes are likely to disappear in of semen loss and accompanying anxiety tion of diagnosis. They illustrate this by an increasingly homogeneous world culture. would be reported in a variety of cultures. using somatisation disorder as an example; BotteBottero´ro (1991) illustrated the ethno- clusters of illnesses across cultures have si- centricity of the culture-bound syndrome milar symptoms but are called by different as described by Obeyesekere (1985), who METHOD names. In this review we aim to use some argued that Western concepts of depression of these facets to illustrate the inherent may be seen as culture-bound, and that An electronic search was made using the problems of culture-bound syndromes. traditional doctors from the Indian sub- terms SEMEN LOSS ANXIETY, DHATDHAT,, Simons (1987), commenting on the continent may relate weight loss in depres- CULTURE BOUND SYNDROMES of paper by Prince & Tcheng-Laroche (1987), sion to and diagnose Medline, Psycinfo and EMBASE with the remarked: ‘ ‘‘folk illness’’ may be a pre- dhatdhat or ‘semen-loss anxiety’, a diagnosis aim of identifying peer-reviewed papers. ferred term compared with ‘‘culture-bound that would appear alien to Western clini- This was followed by hand searching of syndrome’’ but to our mind this would still cians. Obeyesekere (1985) obviously in- the books and papers referenced in the data- give it a second-class status differentiating tended to show that Western clinical based literature. The original papers were it from a ‘‘professional illness’’ ’. Our con- concepts of depression are an example of then obtained for analysis. The data were tention is that symptoms, syndromes and culture-bound diagnosis. BotteBottero´ro (1991) ar- collected and analysed using a standardised their management must be embedded in gued that this type of explanation, often pro forma. Not all information is available local cultures in order to help clinicians. used to support an anthropological critique for every study, reflecting the heterogeneity of psychiatry (Weiss, 1986; Kleinman, of the sample and the methods. 1988), relates more to a ‘pleasant sophism’ Culture-bound syndromes than a rigorous demonstration. BotteBottero´ro RESULTSRESULTS and diagnostic classifications (1991) emphasised that semen-loss anxiety Both ICD–10 (World Health Organization, is as universal as depression but the presen- The studies listed in Table 1 are those 1992) and DSM–IV (American Psychiatric tations and symptoms do differ. In this that collected information from clinical

201201

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. SUMATHIPALA ET AL No Yes No Other NR Yes (continued) (continued) 11 NR Yes Yes NR Homosexual sex Other Yes Yes NR 11 No Unclear Yes Yes No Unclear Yes Heterosexual sex Homosexual sex Yes Mode of loss (one or more) Mode of loss (one or more) 11 NR Yes NR Heterosexual sex Yes Yes Yes NR With urine Masturbation Yes Yes 11 Yes NR Yes In Yes NR Yes Yes YesYes Yes NR NRNR NR In sleep With urine otst6otsto 6 months to6months 20 years20years NRNR esta Ls than 3 to Less than 3Less months tomonths more than 1 year ee osee loss Duration of semen losssemen more than 1 year 1^12 months NR Duration of TheThe presenting complaintcomplaint Unclear. No reported attributionattribution No, this was thethe presenting symptomsymptom itself Yes to all ee ossmnloss? Attributed to semen loss?semen Yes Yes Yes Yes presenting Unclear. No reported No, this was presenting itself Yes to all 1^12 months Attributed to Yes Yes Yes Yes inin dhatdhat discharge;discharge; groups Primary complaint of loss of semen but accompanied by mental, physicalphysical symptomssymptoms DhatDhat associatedassociated symptoms,symptoms, impotence, marital problems, weakness,weakness, premature , etc. asg fasg of Passage ofPassage urine was presenting feature but has elicited somatic symptoms Presenting symptomsymptom 1. Excessive loss of semensemen 2. Specific sexual dysfunctiondysfunction 3. Anxiety about present or future sexual function 4. Multiple physical/physical/ psychological symptomssymptoms Four different groups Primary complaint of loss of semen but accompanied by mental, impotence, marital problems, , etc. urine was presenting feature but has elicited somatic symptoms Presenting 1. Excessive loss of 2. Specific sexual 3. Anxiety about present or future sexual function 4. Multiple psychological dhatdhat 30) 30) discharge discharge ¼ nn (( dhatdhat patients with male potency disorders and complaints of dhatdhat referrals with main complaint ofof in urine Inclusion criteria See next column Four different 50 consecutive patients with male potency disorders and complaints of Consecutive referrals with main complaint in urine Inclusion criteria Passage of )) nn 38 52 50 50 52 Passage of 38 See next column 50 50 consecutive 50 Consecutive (( Sample University clinic, patient clinic, Ptia, India Psychiatric out- patient clinic, Institute of Medical Science, Varanasi, India Setting University psychiatric clinic in Delhi, India University clinic, Sri Lanka Psychiatric out- patient clinic, Ptia, India Psychiatric out- patient clinic, Institute of Medical Science, Varanasi, India Setting Sample University psychiatric clinic in Delhi, India Findings of studies conducted in settings clinical Findings of studies conducted in settings clinical eSla&eSilva & De Silva &De Dissanayake (1989)(1989) Singh (1985) eee&eee& Behere &Behere Nataraj (1984) able 1a l e 1 Ta b l e 1Tab Study DescriptiveDescriptive studystudy Chadha & Ahuja (1990)(1990) DescriptiveDescriptive studystudy Dissanayake Singh (1985) out- Psychiatric Nataraj (1984) Study Chadha & Ahuja

202

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. THE STORY OF DHAT SYNDROME NRNR No Other Yes No 11 NR NR YesYes Homosexual sex Other NR NR Yes 11 NRNR YesYes YesYes Heterosexual sex Homosexual sex Mode of loss (one or more) Mode of loss (one or more) 11 11 Masturbation Heterosexual sex Yes Yes NoNo Yes With urine Masturbation Yes Yes 11 Yes In sleep NR Yes Yes In sleep With urine NR NRNR NRNR Yes Yes NR Duration of semen loss NR NR Duration of semen loss NR NR Yes ee ossmnloss? Attributed to semen loss?semen Apparently yes for the index group but notbutnot reported for the controls Majority yes Yes Attributed to Apparently yes for the index group reported for the controls Majority yes NR inin dhatdhat -related fears (fears about sexual performance), somatic symptoms Presenting symptomsymptom Passage of urine in the study groupgroup Neurotic and depressive symptomssymptoms 93 had loss of semen as major symptom, but investigators identified physical, sexual and psychological symptomssymptoms Marriage-related fears (fears about sexual performance), somatic symptoms Presenting Passage of urine in the study Neurotic and depressive 93 had loss of semen as major symptom, but investigators identified physical, sexual and psychological (continued)(continued) .. complaints self- attributed to semen loss but withoutwithout substantiating evidenceevidence Inclusion criteria 0 wt 5wt a 50 with a50with presenting complaint of dhatdhat of Control group of 50 with50with diagnoses ofdiagnoses neurotic and depressive disorders but without sex- relatedrelated complaintscomplaints male patients with sexual problems Presenting complaints self- attributed to semen loss but substantiating Inclusion criteria Index group of presenting complaint of Control group of neurotic and depressive disorders but without sex- Consecutive male patients with sexual problems )) nn 3535 Presenting (( 144 100 144 Consecutive 100 Index group of Sample Referrals to a university psychiatric clinic in Colombo, Sri Lanka Setting Psychiatric out- patient clinic of ateaching hospital, India University psychiatric clinic in New Delhi, India Referrals to a university psychiatric clinic in Colombo, Sri Lanka Setting Sample Psychiatric out- patient clinic of a teaching hospital, India University psychiatric clinic in New Delhi, India Findings of studies conducted in clinical settings Findings of studies conducted in clinical settings Dewaraja & The Sasaki (1991). DescriptiveDescriptive study. Thestudy. authorsauthors attempted to replicate this study in Japan but were unable to recruit patientspatients able 1a l e 1 Ta b l e 1Tab Study NR, not repor1. ted. Seen in majority/common. Chadha (1995). Case^control design nested within a cross- sectional survey of attendersofattenders Bhatia & Malik (1991).(1991). DescriptiveDescriptive studystudy Dewaraja & Sasaki (1991). attempted to replicate this study in Japan but were unable to recruit NR, not repor ted.1. Seen in majority/common. Study Chadha (1995). Case^control design nested within a cross- sectional survey Bhatia & Malik

203

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. SUMATHIPALA ET AL

populations. Some of the studies reported centurycentury ADAD the process of semen production and its causation and management. A sig- whether the patients attributed their symp- is described thus: food converts to blood, nificant proportion of the respondents toms to semen loss, whereas in others it was which converts to flesh, which converts to agreed that semen loss was harmful and the presenting symptom itself. Common marrow, and the marrow is eventually con- their reasons varied. Interestingly, 30% presenting problems were hypochondriacal, verted into semen. It is said that it takes 40 favoured no intervention. Almost a quarter depressive or anxiety symptoms. In some days for 40 drops of food to be converted to (22.5%) advocated psychological and studies patients presented with depression one drop of blood, 40 drops of blood to one behavioural persuasion by relatives and and anxiety, and dhatdhat was seen as an drop of flesh, and so on (Bhugra & friends, such as avoiding bad company, accompanying symptom. Buchanan, 1989). In the individual psyche, masturbation and erotic literature. A small The historical perspectives and develop- therefore, semen starts to take on an over- proportion suggested dietary intervention, ment of beliefs about semen loss in some whelming importance. These notions and 6% recommended marriage as the cultures are set out in Table 2. frighten the individual into developing a treatment. The study demonstrated that sense of doom if a single drop of semen is respondents belonging to social class I lost, thereby producing a series of somatic discussed sex freely when compared with Semen-loss anxiety in the Indian symptoms (Chadha & Ahuja, 1990). lower social classes, and were less likely subcontinent These ideas of semen loss and conse- to see physical causes for semen loss. People DhatDhat derives from the word dhatudhatu quent anxiety are not confined to India; they in social class IV were more likely than any meaning ‘metal’, and also ‘elixir’ or ‘consti- have been reported from Sri Lanka and other other group to see nocturnal emission as tuent part of the body’. First described in parts of the subcontinent as well. Fear of se- abnormal and least likely to see psychologi- Western psychiatric texts by Wig (1960), men loss and resulting problems is so strong cal persuasion as a mode of treatment. dhatdhat comprises vague somatic symptoms that cures are advertised by vaidsvaids andand hakimshakims They concluded that susceptible individuals of fatigue, weakness, anxiety, loss of appe- everywhere – on walls, on television, in react to the belief system of semen loss. tite, guilt and attributed newspapers and on roadside hoardings. This seeking of medical intervention and by the patient to loss of semen in nocturnal Malhotra & Wig (1975) called dhatdhat aa the number of practitioners providing it emissions, through urine and masturbation. ‘sex neurosis of the Orient’. In an intriguing confirm the individual’s belief that there The symptoms of semen-loss anxiety are and unusual study from urban Chandigarh, are physical reasons for the complaint, well known in Indian historical writing. In they selected a random sample of 175 males which need to be addressed. Ayurvedic texts which are dated be- aged 30–50 years and used a case vignette Most of the rest of the studies from the tween the 5th millennium BCBC and the 7th to explore attitudes towards semen loss, Indian subcontinent related to clinical

Ta b l e 2 Historical perspective and development of beliefs related to ‘semen loss’

AuthorityAuthority PeriodComments

Agnivesa ?1500?1500 BCBC : An IndianTreatise on Medicine (see below)below)(see Susruta ?S? SusrutausrutaS Samhita:amhita:An IndianTreatise on . The traditional Ayurvedic knowledge of Agnivesa and Susruta was systematised and edited into these two texts between 600 BCBC andand AD 100 (samhitasamhita means ‘collection’). Semen is the most concentrated, perfect and powerful bodily substance. Its preservation guarantees health and longevity Hippocrates?460^377 BC Diseases IIIIDiseases : semen supplies the form to the human body Aristotle384^322 BC ‘Sperms are the excretion of our food, or to put it more clearly, as the most perfect component of our food’ Galen AD 130^201Involuntary loss was termed ‘gonorrhoea’: ‘it robs the body of its vital breath’; ‘losing sperm amounts to losing the vital spirits’; exhaustion, weakness, dryness of the whole body, thinness, eyes growing hollow, are the resulting symptoms Celsus caca AD 5050‘It results in death due to consumption’ Esquirol 1772^1840‘One of the most common cases of melancholia and dementia and also commonly suicide’ Tissot 1728^1797‘Losing one ounce of sperm is more debilitating than losing forty ounces of blood’, in Treatise on the Diseases Produced by OnanismOnanismby . His tenet was that debility, disease and death are the outcome of semen loss Maudsley 1835^1918Semen loss, especially if it occurs through masturbation, results in serious mental illness Beard 1839^1883‘One of the commonest explanations of neurasthenia is wastage of sexual energy, often in the form of nocturnal emissions (involuntary emissions)’, in A Practical Treatise on Nervous Exhaustion Freud 1856^1939‘Neurasthenia in males is acquired at and becomes manifest in the patient’s twenties. Its source is masturbation, the frequency of which parallels that of male neurasthenia’. Freud opposes Steckel’s view that semen loss has no pernicious effect on brain functioning The LancetLancetThe 1840^1843Editorial and articles by G. Dangerfield and W. H. Ranking: ‘On physical disability, mental impairment and moral degeneration caused by seminal loss’ ‘The symptoms, pathology, causes and treatment of spermatorrhoea’ ‘Spermatorrhoea, or the involuntary discharge of the seminal fluid’

204

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. THE STORY OF DHAT SYNDROME

populations. Often dhatdhat was described and In an interesting study from Sri Lanka, produces weakness. Similar symptoms diagnosed as a separate entity and many De Silva & Dissanayake (1989) observed were reported among Chinese populations authors did not give the associated psychi- that in their cohort of 38 men recruited in the UK (Haslam, 1980) and in Malay- atric diagnosis. Thus, sometimes the syn- from a clinic where they had presented with sia (Tan, 1969). drome is seen and recognised as a culture- sexual dysfunction semen loss was given as In China, there are beliefs that women bound syndrome. Our contention is that a major causative factor by the men them- have the ability to steal vital fluid from this reflects a historical approach; looking at selves. These men believed that excessive men and this loss of semen can lead to dis- some of the detailed data, it appears that the loss of semen led to sexual dysfunction ease (Botte(Bottero,´ro, 1991). Weakness in Chinese syndrome is accompanied by easily and clini- and physical symptoms and thus was harm- people connotes loss of vital energy (qiqi oror cally recognisable common mental disorders, ful. A majority of individuals reported con- ch’ich’i), and excessive loss of semen through and that its descriptions abound in other tinuing loss of semen over a period ranging or masturbation creates cultures (European and Western) as well. from 6 months to 20 years. More than half anxiety because semen is said to contain Chadha & Ahuja (1990) reported on 52 were found to have somatic symptoms; jingjing (the essence of qiqi), which when lost patients who had volunteered passage of 53% received a diagnosis of anxiety, 40% produces weakness (Kleinman, 1988). Yap dhatdhat in the urine as their presenting com- of hypochondriasis and 5% of stress reac- (1965) posits that a healthy exchange of plaint; more than three-quarters were said tion. The sample size is small but it yinyin andand yangyang in sexual intercourse main- to have accompanying hypochondriacal indicates the presence of psychological tains a balance. Following masturbation, symptoms, although the descriptions do and somatic symptoms to be significant. nocturnal emission or homosexual inter- not make clear whether the diagnosis of hy- Similar findings have been reported among course,course, yangyang would be lost but without cor- pochondriasis was made by the patient or Bangladeshi men in the UK (Clyne, 1964). responding gain of yinyin and the resulting the clinician, or what specific criteria were Dewaraja & Sasaki (1991) too col- imbalance leads to disease. This has been used to define such hypochondriasis. Inter- lected data from the same clinic in Sri Lan- associated with epidemics of korokoro – an-–an- estingly, they reported that seven patients ka, and of 35 patients attributing their other culture-bound syndrome in which (who did not have hypochondriasis) had symptoms to loss of semen half had somatic the individual holds the belief that his penis ‘pure’‘pure’ dhatdhat syndrome. Our contention is symptoms and a third had sexual deficien- is shrinking into his body and disappearing that it is possible that this concern with cies. These authors attempted to replicate (Yap, 1965; Rin, 1966; Tseng et aletal, 1988).,1988). dhatdhat itself is a hypochondriacal preoccupa- the findings in Japan but were not able to Kleinman (1982) reported that more tion. Bhatia & Malik (1991) from the same do so. They also conducted a survey of than three-quarters of patients presenting centre in North India reported that of 144 beliefs of undergraduates in Sri Lanka and with neurasthenia in Taiwan attributed consecutive patients attending a sexual dys- Japan. Using an 18-item questionnaire they their symptoms wholly or partially to or- function clinic, 93 presented with passing found that Sri Lankan students were more ganic causes. His earlier notion of explana- dhatdhat. When these 93 patients were assessed likely to believe in semen loss. tory models (Kleinman, 1980) in with Hamilton Rating Scales and assigned understanding the patient’s perspective of to ICD–9 diagnostic categories, a signifi- Semen-loss anxiety in China aetiology, course, management and out- cant number had one or more somatic Wen & Wang (1980) define shen-k’ueishen-k’uei asas come is a useful one. symptoms, of which weakness was the most vital or kidney deficiency. In classical The Chinese concept of shanjing shuair- common. A third reported sexual problems, Chinese medicine shenshen (kidney) is the reser- uouo (neurasthenia) is said to have erectile and half scored above 7 on the Hamilton voir of vital essence in semen (chingching) and)and impotence as one of its key symptoms Rating Scale for Depression. Nearly a third k’ueik’uei signifies deficiency. A form of sexual (Lee & Wong, 1995), but it is not clear received no psychiatric diagnosis. These neurosis is associated with excessive semen what the direction of causal effect is. Lee authors reported ‘pure’ dhatdhat syndrome in loss due to frequent intercourse, masturba- (1999(1999aa) argues that the imbalance of vital 60 patients (42%). tion, nocturnal emission or passing of white energyenergy qiqi leads to the symptoms, which Chadha (1995), in a case–control design turbid urine which is believed to contain se- represents an epistemological counterin- study, compared those presenting with dhat men. Young people who think they might stance to the Western ontological model with controls who had neurotic disorders. be suffering from it become anxious and of disease. Lee (1999bb) points out that, as He defined dhatdhat in the urine as dhat syn- panicky, and complain of somatic symp- a result of social upheavals, the concept of drome, although not all sufferers from dhat toms (with no organic cause) such as dizzi- shanjing shuiairuo is changing and being syndrome acknowledge loss through urine. ness, backache, fatiguability, weakness, contested, and clinicians are reconstituting Nearly half were reported to have depressive , frequent and physical it as the popular Western diagnosis of disorder, 18% had anxiety disorder and thinness. All these signs and symptoms have depression, which may reflect a modernist 32% had somatoform disorders – the figures been acknowledged by individuals deemed view.view. forforcontrolswere54%,30%and16% controls were 54%, 30% and 16% to be suffering from dhatdhat syndrome.syndrome. Taoist techniques in ancient China were respectively, which reflect the source of data Described historically by Ku-Wu Chen based on the principle that seminal essence collection for the controls. Thus, the validity (1939) the Chinese concept of semen-loss was located in the lower part of the male of diagnosis and associated psychiatric diag- anxiety is also related to korokoro (see be-(seebe- abdomen, and they aimed to increase the nosis can be questioned. Similar findings of low), and impotence. Yap amount of life-giving seminal essence depression in 52% and anxiety disorders in (1965) reported similar symptoms among ((chingching) by sexual stimulus while at the same 16% of cases had been previously reported Cantonese patients in Hong Kong. Tseng time avoiding possible loss (Bullough, by Singh (1985) from another part of (1973) suggested that as semen is seen 1976). It was essential that the woman northern India. as the essence of energy its excretion reach in intercourse so that the

205205

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. SUMATHIPALA ET AL

man would receive her yinyin essence; the however, after its expulsion, people who are in disorder. Again, this is not dissimilar to moremore yinyin essence he received without giving this state experience a languor at the stomach the symptoms and concerns of patients out his precious male substance the greater orifice, exhaustion, weakness, and dryness of who present with dhatdhat. Tissot gave scienti- the whole body.They become thin, their eyes his strength would become, and this could fic credibility to the Western hostility to grow shallow’ (Galen,1963 reprint). be achieved through coitus reservatus – sex. The similarities between the hostility keeping the penis in the but avoiding This description is not dissimilar from that to sex then prevalent in the West and that orgasm. Another technique was to practise of the modern dhatdhat syndrome. Before the now current in India are uncanny. Formerly huan ching pu nao (making the chingching returnreturn Christian era, Jewish writers too acknowl- a society with a positive view of sex, Hindu to nourish the brain), suggesting that this edged that the depositing of semen any- culture has now become obsessed with the method and positive thinking would cause where else than the vagina was idea that the main purpose of sex is pro- seminal essence to ascend and rejuvenate debilitating and that to become ritually creation rather than pleasure. other parts of the body. Masturbation for pure after such emission a short period of The emerging middle classes of the 18th men was seen as leading to a loss of vital continence was normally required. Mastur- century embraced Tissot’s ideas with great essence. Manipulation of genitals without bation was regarded as a crime deserving enthusiasm, and sexual purity became a orgasm was encouraged, but involuntary the death penalty, according to one Talmu- way of distinguishing themselves from the emissions were viewed with concern; these dic writer. A fear of loss of semen was well sexual of the nobility and the were thought to be caused by fox spirits known, but why this loss was so feared is lower social classes. Tissot (1766) led the and to lead to weakness in men. not entirely clear (Bullough, 1976). Bul- Western world into an age of masturbatory Wen & Wang (1980) studied 87 pa- lough suggested that a loss might imply (or, shall we say, dhatdhat) insanity. Alhough tients attending a clinic in Taiwan, the failure of men’s duty to procreate and Tissot’s work did not reach the USA until and found that 23 had sexual neurosis with replenish the earth; unexpected or inap- 1832, his influence was apparent in the shen-k’ueishen-k’uei syndrome and four-fifths of the propriate loss of semen might lead to reduc- writings of Benjamin Rush, who is often remaining 64 patients blamed their prob- tion in the size of the tribe, thereby making credited as the father of American psy- lems on masturbation. More than 23 cases it more vulnerable. chiatry. Rush believed that all diseases ofof shen-k’ueishen-k’uei came from the lower socio- In many Western European cultures could be caused by debility of the nervous economic classes and all reported mastur- masturbation has been prohibited on reli- system and propounded that careless indul- bation or nocturnal emission and were gious grounds. Even nocturnal emissions gence in sex would lead to seminal weak- anxious, depressed and hypochondriacal. were seen as sinful and required three ness, impotence, , tabes dorsalis, These authors compared shen-k’ueishen-k’uei withwith nights of an hour-long standing vigil for ex- pulmonary consumption, dyspepsia, dim- pramehaprameha reported from Sri Lanka by piation if the sinner had been receiving an ness of sight, vertigo, epilepsy, hypochon- Obeyesekere (1976), and acknowledged adequate diet of beer and meat. Those on driasis, loss of memory, myalgia, fatuity that the similarities between the two condi- poor diets were merely required to sing and death (Rush, 1812). An American phy- tions were great. They point out that these psalms or undertake extra work. Appar- sician, Sylvester Graham, advocated Gra- conditions are universally occurring dis- ently it was assumed that a person who ham flour (unbolted wheat) and ‘Graham eases for which illness behaviours, experi- had been fasting would have less control crackers’ as a cure for debility, skin and ences and beliefs are culture-specific. Tan over his bodily processes, hence an involun- lung disease, headaches, nervousness, and (1980) too related these symptoms to tary nocturnal emission would be less sinful. weakness of the brain – much of which he hypochondriasis. These symptoms and European attitudes to non-heterosexual blamed on sexual excess (Graham, 1834). their explanations are culturally embedded behaviour and loss of semen varied in the The cause was orgasm due to abuse or mis- and have been reported widely from the Middle Ages: see Bullough (1976) for a use of sexual organs; overindulgence in sex continent of Asia. Engelhardt (1974) sug- further discussion. However, for our pur- caused languor, lassitude, muscular relaxa- gested that medicine culturally constructs poses, Tissot’s writings in the 18th century tion, general debility and heaviness, depres- categories of behaviour that fit previous provide an interesting overview. He be- sion of spirits, loss of appetite, indigestion, moral or legal categories: thus, the creation lieved that even with an adequate diet the faintness and sinking at the pit of the sto- ofof dhatdhat and other culture-bound syndromes body could waste away through diarrhoea, mach, increased susceptibility of skin and has to be seen in the historical and legal blood loss and seminal emission. Semen lungs, feebleness of circulation, chilliness, constructs of the time. caused the beard to grow and muscles to headache, melancholy, hypochondria, hys- thicken, and its involuntary loss weakened terics, feebleness of senses, impaired vision, Semen-loss anxiety men. Frequent intercourse was dangerous loss of memory, epilepsy, insanity and apo- in Western cultures in itself, but the most dangerous loss of se- plexy. Like the Hindu perceptions, Graham From the times of Hippocrates and Aristo- men occurred when the individual lost it believed that the loss of an ounce of semen tle, semen has been considered extremely through unnatural means, of which mastur- was equivalent to the loss of several ounces important for the healthy functioning of bation was the most debilitating. Such of blood; therefore every time a man ejacu- the individual. Greeks in ancient times waste of semen could lead to cloudiness of lated he lowered his life force and exposed saw masturbation as a natural outlet for ideas and madness, decay of bodily powers, his system to diseases. These attitudes are men lacking opportunity for sexual inter- acute pains in the head, pimples on the face, not dissimilar to attitudes held by patients course. Galen (c. 130–201), following the eventual weakness of the power of genera- presenting with dhatdhat syndrome and example of Aristotle, stated: tion (as indicated by impotence, premature mentioned in Ayurvedic texts. ‘Certain people have an abundant warm sperm ejaculation, gonorrhoea, priapism and In France, Lallemand (1839) too was which incessantly arouses the need of excretion: tumours of the bladder) and intestinal concerned with involuntary loss of semen,

206

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. THE STORY OF DHAT SYNDROME

which would lead to insanity. William Ac- seminal loss weakened the system led to de- the Orient. The scientific backing of morality ton, an English , encouraged men mands by the colonists for treatments for and the prohibition of sexual activity contin- to engage in sex infrequently so that they semen loss. Darby (2001) cautions that it is ued unabated in the 19th and early 20th cen- could not lose their energy through pro- not possible to draw a hard and fast line turies; their impact on ‘patients’ is uncertain, longed sexual activity; he maintained that between regular doctors and quacks: the but there is little doubt thatmuch of the the worst kind of seminal emission was by former exhibited plenty of evidence of ignor- writings of Graham, Kellogg and others were masturbation (Acton, 1871). Another ant faddism and eccentricity, whereas the directed at the general population. There American, Kellogg (of breakfast cereal latter frequently offered more humane and must have been a demand for such advice, fame), believed that the nervous shock less damaging treatments. George Beaney, because most of these monographs went into accompanying the exercise of the sexual who graduated from Edinburgh and settled several editions and were translated into sev- organs was the most profound to which in Melbourne in 1857, published exten- eral European languages. The similarities the nervous system was subject, and sively on the damaging effects of sperma- between their writings and the present-day produced a long list of symptoms, both torrhoea, suggesting that semen was more descriptions of dhatdhat are remarkable. physical and psychological: precious than blood, and that treatments ‘the dangers were terrible to behold, senile geni- for spermatorrhoea were effective if victims tal excitement produced intense congestion and avoided the ‘quacks’. Spermatorrhoea was DISCUSSION led to cultural irritation, priapism, piles and pro- defined as an abnormal emission of seminal lapsus of , atrophy of the testes, varico- fluid:fluid: There are problems with the data we have coele, nocturnal emissions and general presented. Empirical and clinical findings exhaustion’ (Kellogg,1882). ‘of allthe diseases to which manisliable there are few others which induce so much mental anxiety are reported for south Asia, where dhatdhat isis His cereals were developed as a panacea for as this and it embitters all the victim’s [sicsic]social seen as a significant clinical problem, the ills of masturbation. Every loss of se- relations and subjects him to the harrowing re- although we have described some historical men was regarded as equivalent to the loss flection that he is the object of the taunts and and cultural contexts. For Western coun- of 4 ounces of blood, and although the jeers ofthose about him’ (Beaney,1870). tries and Australia, the data we have body could eventually replace the loss it Masturbation was both a specific form of presented are historical. took time for it to recuperate (Hunter, spermatorrhoea and its cause, and it ruined Our contention is that with industriali- 1900).1900). the nervous equilibrium of the sexual system. sation and urbanisation, the anxiety about In Britain in the 1840s, articles on the According to Beaney, the consequences of semen loss in the West diminished, and involuntary discharge of seminal fluid masturbation and spermatorrhoea included the same is likely to happen in southern dominateddominated The Lancet. Dangerfield sug- inflammation of the urethra, bladder irrita- Asia as well. If we understand dhatdhat as aasa gested that, as a result of involuntary tion, disturbed sleep, erotic dreams, confu- culture-bound syndrome, the historical discharge,discharge, sion of mind, vertigo, wakefulness, evidence indicates that it was prevalent in ‘the patient complains of weakness, restlessness depression, tuberculosis, epilepsy and Europe, USA and Australia in the 19th cen- andlistlessness, his manners are shy and nervous impotence. Darby (2001) suggested that tury. In those countries it might have disap- with a remarkable timidity and indisposition to Beaney’s views were religious tub-thumping peared in response to changes in social and answer questions, his complexion is generally and were not scientific. However, it is poss- economic factors, whereas it is still preva- pale,pale,slightlyemaciated,hegraduallylosesmem- slightly emaciated, he gradually loses mem- ible that Beaney merely reflected the preva- lent in southern Asia. We believe that the ory, has dull pain, and feeling of weakness espe- cially in the lower extremities along with fatigue. lent public view of spermatorrhoea and universality of symptoms of anxiety (in this On further investigations, the physician will find semen-loss anxiety. In making his views case secondary to feared or actual loss of that he has been afflicted for some time with more culturally specific to Australian man- semen) has to be acknowledged. Our initial seminal emissions during sleep accompanied by hood, Beaney makes the point that the rela- hypothesis has been partially proved. libidinous dreams’ (Dangerfield,1843). tively free and easy life of the Antipodes Although we found that symptoms of In a comprehensive review, Darby (2001) and the more relaxed social structure lead semen-loss anxiety were reported from a suggested that male circumcision was advo- to increasing sexual precocity among chil- range of cultures, we also found that in cated as a cure for spermatorrhoea (as well dren, thus magnifying the threat to Austra- the West these symptoms were mainly as masturbation) and this was the testing lian manhood. Recommended treatments reported during the 19th century. We be- ground on which regular medical practi- included sitz baths, alcohol and chemical lieve that although there are discrepancies tioners sought to establish their credentials compounds such as potassium bromide in the data from modern-day India, and and to demarcate themselves from quacks. and phosphorus, and application of electri- only descriptions exist of the symptoms in He argued that William Acton in Britain city to the nervous system. Gradually cir- 18th- and 19th-century Western societies, and George Beaney in Australia were repre- cumcision came to be seen as a treatment it proves that dhatdhat syndrome is not sentatives of the battle for professional turf for these sexual urges. culture-bound and it is certainly not an and the medical right to manage all the Thus it seems that in the 19th century exclusive exotic neurosis of the Orient. functions of the body. Unfortunately for about semen loss were widespread Furthermore, it is our contention that dhatdhat the regular doctors, until circumcision be- even in what was then a remote outpost of andand dhatdhat syndrome as described in research came an option the treatments they offered the British Empire. Whether the clinicians from the Indian subcontinent is not always differed little from those of their rivals. were reflecting their own anxieties or those a homogeneous entity, and although syn- Colonialism imposed this 19th-century of their patients remains a moot point. dromes by definition are heterogeneous medical orthodoxy in Australia (Walker, What is clear is that semen-loss anxiety is the symptoms described are more likely to 1985, 1987, 1994); the theory that any neither a new condition nor confined to be psychological or psychosomatic even

207

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. SUMATHIPALA ET AL

though their attribution to dhatdhat may bemaybe and human – that are allocated. Tseng Advanced Life Considered inTheir Physiological, Social and culturally influenced. (2001) proposes that culture-bound syn- Moral Relations. London: Churchill. We welcome the amendments to DSM– dromes be sub-grouped according to the American Psychiatric Association (1994) Diagnostic IV in that it now offers an outline for cul- six impacts of culture mentioned above; and Statistical Manual of Mental Disorders (4th edn)edn)(4th (DSM^IV).Washington, DC: APA. tural formulation in which multiaxial diag- but we maintain that the time has come Arieti,Arieti,S.&Meth,J.(1959) S. & Meth, J. (1959) Rare, unclassifiable, nostic assessments are supplemented by a to abandon this category altogether and fo- collective and exotic syndromes. In American Handbook systematic review of the individual’s cultur- cus on multi-axial systems that include cul- of Psychiatry (ed. S. Arieti), pp. 546^563. New York: al background and the role of the cultural tural factors in aetiology and management. Basic Books. context in the expression and evaluation DhatDhat provides an illustration that, when Beaney, G. J. (1870) Spermatorrhoea in its Physiological, of symptoms and dysfunction, together looked at carefully, these conditions trans- Medical and Legal Aspects.Melbourne:Walker. with the effect that cultural differences cend cultural boundaries, and such varia- Beard, G. M. (1905) A Practical Treatise on Nervous might have on the relationship between tions should be seen in the cultural context. ExhaustionExhaustion. New York: E. B. Treat. the individual and the clinician. Cultural We believe that attribution patterns and Behere, P. B. & Nataraj, G. S. (1984) Dhat syndrome: identity of the individual and cultural ex- explanatory models need to be studied the phenomenology of a culture bound sex neurosis of the Orient. Indian Journal of Psychiatry,, 2626,76^78., 76^78. planations of the individual’s distress – as regarding semen-loss anxiety in different well as factors related to psychosocial en- cultures to confirm our hypothesis. We Beiser, M. (1987) Commentary. Culture Medicine and PsychiatryPsychiatry,, 1111, 29^34.,29^34. vironment, levels of functioning and the accept that loss of semen is a shared belief Bhatia, M. S. & Malik, S. C. (1991) Dhat syndrome. A relationship between the individual and reported from certain societies; it may be useful diagnostic entity in Indian culture. British Journal of clinician – are important. If all these factors that this is reported because the clinicians PsychiatryPsychiatry,, 159, 691^695.

are taken into account and used seriously in and the researchers are aware of it and Bhugra, D. & Buchanan, A. (1989) Impotence in diagnoses then the scope for culture-bound therefore willing to ask questions regarding ancient Indian texts. Sexual and Marital ,, 44,, syndromes becomes even more limited, even such an attribution. Beiser (1987) cautions 87^92.87^92. though this category is retained in DSM–IV. that the general thrust of the argument for Bhugra, D. & Jacob, K. S. (1997) Culture bound Prince & Tcheng-Laroche (1987) the closure of the concept of culture-bound syndromes. InTroublesome Disguises (eds D. Bhugra & A. Munro), pp. 296^334. Oxford: Blackwell. pleaded that culture-bound syndrome sta- syndrome is premature. We disagree, and tus should not be assigned on the basis believe that the time is right to look at the BotteBottero,¤ro, A. (1991) Consumption by semen loss in India and elsewhere. Culture, Medicine and Psychiatry,, 1515,, of the geographic distribution of the ill- classificatory systems, their purpose, their 321^359.321^359. ness, nor on the basis of a local ‘label’, isolationist tendencies and their emphasis Bullough,V.L. (1976) Sexual Variance.Chicago,IL: notions of cause or epidemiological fea- on disease rather than illness. Wig’s University of Chicago Press.

tures. More importantly, they felt that concept of simple, bias-free and clinically Chadha, R. K. (1995) Dhat syndrome: is it a distinct the meaning of illness for both individuals useful classification (Wig, 1994) remains a clinical entity? Acta Psychiatrica Scandinavica,, 9191,136^139.

and their culture should not be confused distant . Kapur (1987) introduces Chadha,Chadha,C. C. & Ahuja, N. (1990) Dhat syndrome. A sex with syndrome descriptions or used as cri- the Eastern spiritual tradition to emphasise neurosis of the Indian subcontinent. British Journal of teria for international classification. Beiser that nature cannot be reduced to discrete PsychiatryPsychiatry,, 156,577^579.,577^579. (1987) considers that some conditions will building blocks or categories, but is rather Clyne, M. B. (1964) Indian patients. Practitioner,, 193,, never fit into the illness discourse and a web of interconnecting relationships. 195^199.195^199. must remain exotic or unclassifiable. We Kapur’s view is that a classification system Dangerfield, G. N. (1843) The symptoms, pathology, feel that it is possible to categorise these based only on symptoms and signs would causes and treatment of spermatorrhoea. Lancet,, ii,, 211^216.211^216. conditions, provided the emphasis is on be useful if there were a one-to-one re- Darby, R. (2001) Asourceofseriousmischief.In lationship between the syndrome, the pro- pathology in its true biopsychosocial con- Understanding Circumcision (eds G. C. Denniston, text, allowing the diagnostic flexibility. cesses at various levels and management F.M. Hodges & M. F.Milos), pp.153^197.Newpp. 153^197.New York: Kleinman’s caution of category fallacy be- strategies. This is not so, however, and it is Kluwer Academic. came much more relevant in this context not possible to trigger in our minds the De Silva, P. & Dissanayake, S. A.W. (1989) The loss ofofTheloss (Kleinman, 1980). appropriate meaning at whatever level we semen syndrome in Sri Lanka. A clinical study. Sexual and Marital Therapy,, 44,195^204.,195^204. We acknowledge the assertion by Tseng wish to operate. We agree with Kapur’s asser- (2001) that cultures do influence psycho- tion that the classification of psychiatric dis- Devereux, G. (1956) Normal and abnormal. In Some Uses of Anthropology (eds J.J.B.Casgrande B. Casgrande & T.Gladwin). pathology – through pathogenic, patho- order should allow itself to be open to all Washington, DC: Anthropological Society. selective, pathoplastic, pathoelaborating, experiences, expressions and meanings, and Dewaraja, R. & Sasaki,Y. (1991) Semen losslossSemen pathofacilitating and pathoreactive effects – users should remain open to the realisation syndrome. A comparison between Sri Lanka and Japan. but we believe that the interaction between that there is no absolute truth to any of these. American Journal of Psychotherapy,, 4545,14^20.,14^20. the individual and the culture is extremely Engelhardt, H.T.H. T. (1974) The diseases of masturbation: complex. Even if the culture is pathofacilita- ACKNOWLEDGEMENTS values and concepts of disease. Bulletin of the History of tory or pathoreactive, the individual’s disor- MedicineMedicine,, 4848, 234^248.,234^248. der can be and will be influenced by other A.S. is funded by the Wellcome Trust. D.B. has Galen (1963 reprint) OnThe Passion and Error of The factors such as personality traits, peer and fa- accepted hospitality and lecture fees from Eli Lilly, SoulSoul (trans. P.W.Hawkins).Columbus,OH:P.W.Hawkins). Columbus, OH: Ohio State Janssen-Cilag, Lundbeck and Sanofi-Synthelabo. University. mily support available to the individual, and Graham, S. (1834) A Lecture toYoung Men on Chastity.. alternative explanations of the experience. REFERENCES Boston, MA: Pierce. Society and culture will no doubt dic- Haldipur, C. V. (198(1980) 0) Theideaofculturalpsychiatry:aThe idea of cultural psychiatry: a tate pathways into help-seeking and care, Acton, W. (1871) The Functions and Disorders of the comment on the foundations of cultural psychiatry. and the resources – economic, political Reproductive Organs in Childhood,Youth,Childhood, Youth, Adult Age, and Comprehensive Psychiatry,, 2121,,206^211. 206^211.

208

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use. THE STORY OF DHAT SYNDROME

Haslam, M. T. (1980) Medicine and the Orient: Shen-k’uei syndrome. British Journal of ,, 77,,31^36. 31^36. CLINICAL IMPLICATIONS Hughes, C. C. (1985) Glossary.InGlossary.In Culture Bound Syndromes (eds R. C. Simons & C. C. Hughes), && Clinicians should embed psychiatric symptoms in their cultural context. pp.465^505. Dordrecht: Reidel. && Culture-bound syndromes are neither exotic nor rare, and often span different Hughes, C. C. (1996) The culture bound syndromes and psychiatric diagnosis. In Culture and Psychiatric cultures. Diagnosis: A DSM ^^IV IV Perspective (eds J. Mezzich, A. Kleinman,H.Fabrega,Kleinman, H. Fabrega, et aletal), pp.pp.298^308.Washington, 298^308.Washington, && Researchers should not rely only on epidemiological data. DC: APA.DC:APA.

Hughes, C. C. & Wintrob, R. M. (1995) Culture bound LIMITATIONS syndromes and the cultural context of clinical psychiatry. InIn Review of Psychiatry (eds J. M.M.Oldham Oldham & M. Riba), && Historical data may be scanty and biased. pp. 565^597.Washington, DC: APA. && Culture-bound syndromes such as dhat do not explain somatisation disorders. Hunter,W.J.Hunter, W. J. (1900)(19 0 0) Manhood: Wrecked and Rescued.. New York: Health Culture. && Culture-bound syndromes may reflect a culturally specific idiom of distress. Kapur, R. L. (1987) Commentary. Culture, Medicine and Psychiatry,, 1111,43^48., 43^48.

Kellogg, J. H. (18 82) Plain Facts for Old and Young.. Burlington,VT: Senger. A. SUMATHIPALA, MD,MRCPsych, Section of Epidemiology,Institute of Psychiatry,London,UK; Kleinman, A. (1980) Patients and their Healers in the S. H. SIRIBADDANA, MD, Sri Jayawerdenpura General Hospital, Nugegoda, Sri Lanka; DINESH BHUGRA, Context of Culture. Berkeley,CA:Berkeley, CA: University of California PhD,FRCPsych, MPhil, Section of Cultural Psychiatry,Institute of Psychiatry,London,UKPsychiatry,London,UK Press. Correspondence: Professor Dinesh Bhugra,Bhugra, Section of Cultural PsychPsychiatry,PO25,Instituteiatry,PO25,Institute of Psychiatry, Kleinman, A. (1982) Neurasthenia and depression. Culture, Medicine and Psychiatry,, 66,117^190.,117^190. London SE5 8AF,UK

Kleinman, A. (1988) The Illness Narratives,p.23.New (First received1Aprilreceived 1 April 2003, final revision 21July21 July 2003, accepted 31July31 July 2003) Yo r k : B a si c B o o k s .

Ku-Wu Chen, D. (1939) A Clinical Text of Chinese MedicineMedicine..Taipei: Taipei: General Press. Obeyesekere, G. (1985) Depression, Buddhism and Walker, D. (1987) Modern nerves, nervous moderns: work of culture in Sri Lanka. In Culture and Depression notes on male neurasthenia. Australian Cultural History,, Lallemand, M. (1839) On Involuntary Seminal Discharges (eds A.Kleinman & B.Good), pp.pp.134^152. 134^152. Dordrecht: 66, 49^63.,49^63. (trans.W. Wood). Philadelphia, PA: Waldier. Reidel. Lee, S. (1999aa)) The vicissitudes of neurasthenia in Walker, D. (1994) Energy and fatigue. Australian Cultural Prince, R. & Tcheng-Laroche, F. (1987) Culture Chinese societies: where will it go from the ICD^10? History,, 13,164^178., 164^178. bound syndromes and International Disease Transcultural Psychiatry Research Review,, 3131,153^172. classifications. Culture, Medicine and Psychiatry,, 11,,3^20. 3^20. Weiss, M. (1986)(19 8 6) History of psychiatry in India: toward a Lee, S. (1999bb)) Diagnosis postponed: Shenjing Shuaruo culturally and historiographically informed study of Rin, H. (1966) Two forms of vital deficiency syndrome and the transformation of psychiatry in post Mao China. indigenous traditions. SamiksaSamiksa,, 44,,519^528. 519^528. among Chinese male mental patients. Tra n s c ult uraluralTra Culture, Medicine and Psychiatry,, 23, 349^380.,349^380. Psychiatry Research Review,, 33,19^214.,19^214. Wen,T.-K. & Wang, C.-L. (1980) Shen-k’uei syndrome: Lee, S. & Wong, K. C. (1995) Rethinking neurasthenia: a culture-specific sexual neurosis inTaiwan. In NormalNormal Rush, B. (1812) Medical Inquiries and Observations upon the illness concepts of shenjing shuaruo among Chinese and Abnormal Behaviour in Chinese Culture (eds A. the Diseases of the Mind. Philadelphia, PA: Kimber & undergraduates in China. Culture, Medicine and Kleinman & T.-Y.Lin), pp. 357^369.Dordrecht: Reidel. Richardson.Richardson. Psychiatry,, 19, 91^111.91 ^ 111. Wig, N. N. (196 0) Problems of the mental health in Simons, R. C. (1987) Commentary. Culture, Medicine Littlewood, R. (1996) Cultural comments on culture India.India. Journal of Clinical and Social Psychiatry (India),, 1717,, and Psychiatry,, 11, 21^28.,21^28. bound syndromes: 1.In Culture and Psychiatric Diagnosis: 48^53.48^53. ADSM^IVPerspectiveA DSM ^IV Perspective (eds J. Mezzich, A.Kleinman, H. Singh, G. (1985) Dhat syndrome revisited. Indian Journal Wig, N. N. (19 94) An overview of cross-cultural and Fabrega, et aletal), pp. 309^312.Washington, DC: APA. of Psychiatry,, 2727,119^221.,119^221. national issues in psychiatric classification. In Psychiatric Littlewood, R. & Lipsedge, M. (1985) Culture bound Tan, E. S. (1969) The symptomatology of anxiety in Diagnosis: A World Perspective (eds J.E.Mezzich,Y.HondaJ. E. Mezzich,Y.Honda syndromes. In Recent Advances in Clinical Psychiatry (ed. Malaysia. Australia and New Zealand Journal of Psychiatry,, & M.M.C.Kastrup),pp.3^10.NewYork:Springer. C. Kastrup), pp. 3^10. New York: Springer. K.Granville-Grossman), pp.105^142. Edinburgh: 33,,271^276. 271^276. Churchill Livingstone. Wintrob, R. M. (1996) Cultural comment on culture TaTan, n , EE. . SS. . (1(1980) 9 8 0 ) Culture bound syndromes. In NormalNormal bound syndromes. In CultureandPsychiatricDiagnosis:ACulture and Psychiatric Diagnosis: A Malhotra , H. K. & Wig, N. N. (1975) Aculturebound and Abnormal Behaviours in Chinese Culture (eds A.A.(eds DSM ^ IV Perspective (eds J. Mezzich, A.A.Kleinman, Kleinman, H. sex neurosis in the Orient. Archives of Sexual Behaviour,, Kleinman & T.-Y.Lin), pp. 371^386. Dordrecht: Reidel. Fabrega, et al), pp. 313^320.Washington, APA. 44,519^528., 519^528. Tissot, S. A. (1766) Onanism, or aTreatise on the WorldHealthOrganization(1992)InternationalInternational Mezzich, J. E., Kleinman, A., Fabrega, H., et aletal Diseases Produced by Onanism (trans. A. Hume). London: Statistical Classification of Diseases and Related Health (19 9 6) Introduction. In Culture and Psychiatric Diagnosis: Pridden. ProblemsProblems (ICD^10).Geneva:(ICD ^10). Geneva: WHO. ADSM^IVPerspectiveA DSM ^IV Perspective (eds J. E. Mezzich, A.A.Kleinman, Kleinman, H. Fabrega, et aletal), pp. xvii^ xxiii.Washington, DC: APA. Tseng,W.-S. (1973) The development of psychiatric Yap,P. M. (1962) Words and things in comparative concepts in traditional Chinese medicine. Archives of psychiatry with special reference to exotic psychosis. Murphy, H. B. M. (1976) Notes for a theory of latah. In General Psychiatry,, 2929, 569^575.,569^575. Culture Bound Syndromes (ed.W.(ed.W.Lebra), Lebra), pp.pp.3^21. 3^21. Acta Psychiatrica Scandinavica,, 3838,157^182., 157^182. Honolulu: University of Hawaii Press. Tseng,W.-S., Mo, K. M., Hsu, J., et aletal (19 8 8) AA Yap,P. M. (1965) : a culture b o undun d sociocultural study of koro epidemics in Guangdong, depersonalisation syndrome. British Journal of Psychiatry,, Murphy,Murphy,H. H. B. M. (1977) Transcultural psychiatry China. American Journal of Psychiatry,, 145145, 1538^1543. should begin at home. Psychological Medicine,, 77,369^371. 111111, 43^45.,43^45. Tseng,W.-S. (2001) Handbook of Cultural Psychiatry.San Obeyesekere, G. (1976) The impact of Ayurvedic ideas Diego,CA: Academic Press. Yap,P. M.M.Yap,P. (19 (1969) 69) The culture bound syndromes. In on the culture and the individual in Sri-Lanka. In Asian Mental Health Research in Asia and The Pacific (eds W.W.(eds Medical Systems (ed.C.(ed. C. Leslie), pp.201^226.Berkeley,pp. 201^226. Berkeley, Walker, D. (1985) Continence for a nation: seminal loss Cahil & T. Y. Lin), pp. 33^53. Honolulu: East ^ West CA: University of California Press. and national vigour. Labour History,, 48,1^14. Centre Press.

209209

Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 07:10:31, subject to the Cambridge Core terms of use.