News review I Culture-bound syndromes

Are culture-bound syndromes on the verge of extinction?

Mark Greener Exotic and enigmatic they may ‘bad spirits’ enter the body through Idioms of distress be, but culture-bound the toes and feet. A sudden intense Exotic though koro seems, culture-­ syndromes could be grips patients that their gen- bound syndromes are essentially disappearing from the medical italia – including the in case idioms of distress – and every lexicon, partly as a result of of females with koro – will disappear culture has its own idioms. People into their body.3 Ghosts tradition- worldwide commonly express emo- cultural boundaries becoming ally do not possess genitals.5 So, tional problems through physical blurred by the march of the some sufferers worry that koro might symptoms – so-called somatisation.6 internet and mass media. Mark prove fatal.3,5 A West Indian immi- Dhat’s somatic symptoms include Greener explores some grant who presented with koro to a weakness, fatigue, appetite loss, guilt fascinating examples of culture- London hospital worried the retrac- and sexual dysfunction.1,2 Koro’s bound syndromes and reasons tion would end in him becoming somatic symptoms include palpita- why the terms might be falling female.5 Not surprisingly, koro suf- tions, sweating, breathlessness, chest into disuse. ferers also worry about genital dys- discomfort and restlessness.­ Of function, impotency and the effect course, these are reminiscent of anx- ulture-bound syndromes are on their sex life.3 iety’s somatic symptoms. Indeed, Camong the most evocative, The typical koro patient is a some authors regard koro as a exotic and enigmatic conditions in young male. Of the 70 patients stud- culturally-bound­ form of panic dis- . Dhat, for example, ied during an outbreak of koro in order, hysteria or sexual somatisa- describes extreme anxiety sur- Assam in North East , for tion disorder and patients usually rounding loss.1,2 People with example, 97% were male, 70% were respond to anxiolytics and koro fear that their genitals are dis- unmarried and 62% were aged antidepressants.3 appearing into their abdomen.3 between 21 and 30 years. Medical anthropologist Andrew Yoruba people in experi- The episodes lasted from 10 min- Russell notes that certain organs encing ode ori – literally ‘hunter of utes to five hours, with an average ‘may become the focus of anxiety’, the head’ – report feeling as if an of 30 minutes. Koro usually occurs in which differ depending on the cul- organism is crawling through their epidemics, often fuelled by ture. In China, for example, somati- head and other parts of the body. media reports.3 sation may focus on the , They may hear boiling, hissing, Koro patients go to great – and spleen, or heart. In Iran and humming or buzzing in their ears often painful – lengths to stop the Punjab, the heart is a common and experience dizziness, darken- the retraction. Some tie strings focus for somatisation. People in ing or blurring of vision, headache, around their genitalia. Others the Anglophone world often focus bodily pains and peppery sensa- hold them tightly in their hands. on their bowels. ‘The expression of tions.4 However, some of these Others ask family members and physical complaints in these organs intriguing conditions may be on the friends to grasp their genitalia is often a metaphorical and more verge of extinction. firmly. Not surprisingly, injuries socially acceptable way of indicating are common. During the Assam emotional distress,’ he comments.6 The disappearing outbreak, some patients attended Similarly, when Japanese women Culture-bound syndromes have emergency departments sitting in reach the menopause they rarely long fascinated psychiatrists. Koro, a tub of water or with a wet cloth experience the hot flushes and night for example, begins with tingling in draped over their genitals. The sweats that are often associated with the feet and legs that spreads into traditional belief is that body heat the end of menstruation in Western the abdomen and other parts of the causes the symptoms. So, they countries. Japanese does not even body. The traditional belief is that believe, keeping the genitals cool have a word for hot flush. According the symptoms arise as ‘bad air’ or prevents retraction.3 to medical anthropologist Margaret

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Lock these differences in vasomotor mean that the remaining manifesta- consultants. If the trends continue symptoms may reflect, at least in tions should be labelled a cul- the authors predict the ‘decline part, the fact that female ageing is ture-bound syndrome. ‘Better and possible extinction in the use of not associated with reduced status control of the infectious diseases in this diagnosis among Nigerian psy- and worth in Japan, as it is in the western world would not mean chiatrists, critically within the soci- North America.7 relabelling … common infections ety in which this culture-bound in the Asian/African cultures as syndrome was originally described’.9 Changing patterns culture-bound,’­ they note.2 The reasons for a fall in brain Culture-bound syndromes may fag’s diagnostic popularity – such as reflect the dominance of western On the way out? any contribution made by the diagnostic and nosological clas­ Over the last few years, barriers change from postcolonial to con- sifications and, Ventriglio and between cultures have become temporary medical training – are colleagues comment, the ‘long-­ more porous, encouraged by the not clear. But the decline parallels standing impact of colonialism’.1 For internet and other media,1 which wider cultural changes. Brain fag instance, dhat-like syndromes might change the patterns of was ‘a familiar idiom of distress’ ascribed to semen loss though noc- many so-called culture-bound syn- when some senior clinicians were turnal emissions or dromes. For instance, brain fag syn- being educated. In today’s Nigerian have been experienced by men in drome has several distinctive society, brain fag is ‘no longer com- the Americas, China, and emotional and somatic symptoms, mon cultural parlance’. Indeed, the Russia at different points in history.2 including: intellectual and sensory authors of the paper, who are of In the west, the syndrome became a (usually visual) impairment; pain or Nigerian ancestry and work in men- medical curiosity. In other parts of a sensation of burning in the head tal health services in the country, the world, it became a cul- and neck; sad and tense facial ‘have rarely’ heard the term used ture-bound syndrome. expressions, and ‘a characteristic ‘outside academic circles’.9 This At one point, for instance, the gesture of passing the hand over raises the prospect that cultural- leading Victorian psychiatrist Henry the surface of the scalp or rubbing ly-bound diagnostic categories Maudsley suggested that semen the vertex of the skull’.9 Typically, could perpetuate culture-­bound loss, especially through masturba- brain fag emerges at times of inten- syndromes after the term and syn- tion, caused serious psychiatric sive study, such as just before exams. drome has fallen into disuse else- illnesses. In editorials and articles Patients typically ascribe the symp- where in society. published between 1840 and 1843, toms to mental exhaustion follow- The Lancet argued that seminal loss ing excessive ‘brain work’.9 Two-way traffic caused physical and mental impair- Against this background, a Cultural influences, however, go ment as well as moral degenera- recent survey of 102 psychiatrists in both ways. Migration can contribute tion.8 Similarly, brain fag’s Nigeria found that 98% recognised to the spread of some culture-bound­ ‘idiomatic and syndromic use’ (see the term ‘brain fag syndrome’. But syndromes. Initially, psychiatrists below) became extinct in Britain in only 22% diagnosed brain fag syn- believed koro was confined to people the 19th and 20th century, before a drome in their practice. Most pre- of South China and valley, resurgence in Nigerian students, ferred diagnoses of anxiety, affective where it is called suo-yang. Koro also captured in a 1960 paper, and then and somatic disorders.9 They treated emerged in migrant Chinese work- in some other African countries.9 brain fag using psychological thera- ers in South-East . Later studies In such cases, poor health liter- pies (46.5%), pharmacotherapy identified koro in India, Western acy combined with local beliefs and (42.8%) and lifestyle changes such , America and Britain.3 Cases attitudes transform a ‘universal con- as changing study methods and of koro in the UK have been reported dition’ into a culture-bound syn- sleep hygiene (4.8%). Interestingly, in, for instance, European Cauca- drome, such as turning the once psychiatrists who had practised for sians and West Indian immigrants. widespread anxiety about semen more than five years diagnosed In some cases, koro can be a manifes- loss into dhat. However, Balhara and brain fag significantly more often tation of affective or schizophrenic Goel point out, just because a syn- than those practising for five years psychosis. In other words, koro – in drome disappears because of or less (59% and 41%). Registrars many ways the archetypal culture-­ improved treatment and literacy in were 90% (odds ratio 0.1) less likely bound syndrome – may not be a one part of the world, that does not to diagnosis brain fag than the specific diagnosis.5 www.progressnp.com Progress in Neurology and Psychiatry I Vol. 21 Iss. 1 2017 I 31 News review I Culture-bound syndromes

More recently, the hikikomori syn- symptoms will become culturally of culture-bound syndromes will drome is recognised increasingly influenced rather than bound:1 a help uncover the multitude of fac- outside Japan. A person with the trend that, as we have seen, already tors that contribute to idioms of hikikomori syndrome – typically an seems to be underway. distress from Tokyo to Tallahassee adolescent male – completely with- In addition, diagnostic criteria to Tewksbury, and thereby aid man- draws from society for at least six may need to expand as studies agement. Perhaps the extinction of months. The lifetime prevalence in suggest that constellations of symp- culture-­bound syndromes might young adults in Japan is around 1%. toms once regarded as culture-­ not be before time. Typical hikikomori cases and hikiko- bound are found outside the region mori-like phenomena have also in which they were identified first. Mark Greener is a freelance medical occurred in, for example, Oman, For instance, further epidemiologi- writer. Spain, India, Iran, Korea, Bangla- cal and psychopathological­ studies desh, Australia and the USA. The need to characterise ‘primary’ (not References hikikomori syndrome appears to be an expression of another psychiat- 1. Ventriglio A, Ayonrinde O, Bhugra D. Relevance of culture-bound syndromes in especially common in urban ric disorder) and ‘secondary’ hikiko- the 21st century. Psychiatry Clin Neurosci settings.10 mori (caused by an established 2016;70:3–6. While psychiatrists from diverse disorder such as Asperger’s syn- 2. Balhara YPS, Goel R. Culture bound syndromes: Need to relook, relabel and cultures recognise the hikikomori drome, personality disorder or include? Asian J Psychiatr 2011;4:75. syndrome, management differs and social phobia). If primary hikikomori 3. Kumar R, Phookun HR, Datta A. Epidemic there is little agreement about the exists, Kato et al. believe that the of Koro in North East India: An observational underlying aetiology. Hikikomori-­ condition should be added to the cross-sectional study. Asian J Psychiatr 2014; 12:113–7. like phenomena are ‘somewhat Diagnostic and Statistical Manual of 4. Makanjuola RO. ‘Ode Ori’: a culture-bound accepted’ in Japanese society and Mental Disorders (DSM) and the disorder with prominent somatic features in psychiatrists tend to suggest psycho- International Statistical Classifica- Yoruba Nigerian patients. Acta Psychiatr Scand 1987;75:231–6. therapy, especially for teenage tion of Diseases and Related Health 5. Ang PC, Weller MP. Koro and psychosis. Br J patients. Psychiatrists in Bangla- Problems (ICD).10 Psychiatry 1984;145:335. desh, Iran and Korea tend to sug- On the other hand, the Chinese 6. Russell A. The social basis of medicine. 10 Chichester: Wiley-Blackwell, 2009. gest pharmacotherapy. The extent and some other countries may move 7. Harrington A. The cure within: a history of to which the variations in manage- to a more culture-specific­ classifica- mind-body medicine. New York: WW Norton, ment are ‘true’ cultural differences tion of mental health.1 Ventriglio 2008. 8. Sumathipala A, Siribaddana S H, Bhugra D. rather than reflecting, for and colleagues suggest that psychia- Culture-bound syndromes: The story of Dhat instance, access to services awaits trists need to urgently debate the syndrome. Br J Psychiatry 2004; 184:200–9. further study. merits of a universalist versus relativ- 9. Ayonrinde OA, Obuaya C, Adeyemi SO. Brain Against this background, the istic classification. Potentially, how­ fag syndrome: a culture-bound syndrome that may be approaching extinction. BJPsych Bull future of the culture-bound syn- ever, they suggest that ‘better 2015;39:156–61. dromes as a diagnostic category understanding across cultures will 10. Kato TA, Tateno M, Shinfuku N, et al. seems uncertain. On the one hand, lead to more balanced and nuanced Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan? A preliminary the lowering of cultural barriers approaches to diagnostic catego- international investigation. Soc Psychiatry means that constellations of ries’.1 Indeed, better understanding Psychiatr Epidemiol 2012; 47:1061–75.

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