BRITISH JOURNAL OF PSYCHIATRY (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 (semen-loss anxiety) 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 medicine, 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 DHAT SYNDROME 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 ‘pathology’ 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