COMMENTARY

Culture-Specific Psychiatric Syndromes: A Review

Christoph U. Correll, MD; Bret S. Stetka, MD; Ariel Harsinay

Disclosures

August 24, 2018

Part 1 of Medscape's Rare and Unusual Psychiatric Conditions series looked at rare psychiatric syndromes that, although seldom encountered in practice, should be identifiable and treatable by clinicians. Similarly, Part 2 looks at syndromes that have been described or tend to manifest in certain cultures or regions of the world.

In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),[1] these conditions were termed "culture-bound syndromes"; the fifth edition of the DSM (DSM-5)[2] includes them under "Cultural Concepts of Distress." This updated approach is intended to more accurately characterize cultural influences on the expression and experience of mental disorders that can manifest in anybody, increasing relevance to clinical practice. Some previously included conditions have been removed in the new manual, whereas others have been added or maintained as examples of culturally colored conditions. Although DSM-5 deemphasizes specific conditions in favor of a broader approach to cultural concepts, both those examples included and not included in the manual remain relevant to practice, given that they're still reported in many cultures around the world.

Amok ('Running Amok')/Berserker

Loosely translated as "rampage" in Malay, amok is a dissociative condition characterized by an unpremeditated violent, disorderly, or homicidal rage directed against other objects or persons. This diagnosis is found in Southeast Asia and Scandinavia. The condition, which is often accompanied by amnesia and exhaustion, is typically incited by a perceived or actual insult and can occur as part of a brief psychotic episode or as an exacerbation of a chronic psychotic illness. A similar term, "berserker," is used in Old Norse literature to describe a frenzied rage in Viking warriors.[1,3,4] Such conditions as intermittent explosive disorder; catatonic excitement; agitation and aggression under the influence of substances; and aggression associated with psychotic, mood, or personality disorders share features with amok.

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Khyâl Cap (Wind Attacks)

Found in Cambodians and Cambodian immigrants, and new to DSM-5, is khyâl cap, or "wind attacks"—characterized by dizziness, shortness of breath, palpitations, and other symptoms of anxiety and autonomic arousal. The episodes often meet the criteria for panic attacks and can be related to other anxiety or trauma-related disorders. The name comes from the theory that symptoms are due to a wind-like substance rising up in the body. Clinicians should rule out physical causes of anxiety symptoms and explore potential trauma etiology. Treatment approaches should focus on anxiety symptoms and, if present, trauma.[2]

Latah/Jumping Frenchmen of Maine

Latah describes an exaggerated startle response to frightening stimuli, diagnosed in Southeast Asia and Japan. Patients can experience a trance-like dissociation as well as echolalia and echopraxia. A similar condition, termed "jumping Frenchmen of Maine" syndrome, has been described in Franco-Canadian lumberjack communities.[1,4] This condition has features of dissociative or conversion disorders or catatonia, and it could also be a severe form of shock in response to a sudden or severe traumatic event.

Kufungisisa (Thinking Too Much)

Also new to DSM-5 is kufungisisa, or "thinking too much," a disorder of distress reported by the Shona people of Zimbabwe. The term represents both a cause of conditions akin to anxiety and depression (eg, "my heart is painful because I think too much") as well as an idiom of psychosocial stressors, such as financial or marital problems. Symptoms can overlap with several DSM diagnoses, including anxiety, panic disorders, and depression. Ruminations and somatic symptoms may be addressed with cognitive-behavioral psychotherapeutic approaches; otherwise, standard treatments for anxiety or depression can be tried.[2]

Recent research of kufungisisa has been primarily centered around patients with HIV. It has been observed that patients living with HIV are at a high risk of developing depression. In Zimbabwe, the diagnosis of depression among adolescents with HIV was characterized as a manifestation of kufungisisa, which included stress, pain, a lack of hope, and suicidal thoughts.[5]

Piblokto/Pibloktoq

Piblokto, also known as "arctic hysteria," describes a dissociative episode in which patients experience prolonged, extreme excitement sometimes followed by seizures and coma. This diagnosis is found in Arctic and Subarctic Inuit. A prodrome of irritability can occur, and during the episode, patients frequently exhibit dangerous, irrational behavior (eg, property destruction, stripping naked). It has been hypothesized by at least one researcher that the condition could result from vitamin A toxicity; organ meat from Arctic food sources, such as polar bears, seals, and walruses, contains extremely high levels of the vitamin.[1,6,7] Other potential causes of this syndrome include forms of malnutrition (eg, vitamin D or calcium deficiency) and the conditions associated with amok, including delirium and severe psychotic, mood, or personality disorders.

Clinical Lycanthropy

Lycanthropy is a rare condition in which sufferers experience the delusion of transforming into an animal. Affected people may also behave like the animal they believe they have turned into. "Lycanthropy" derives from the Greek myth in which King Lycaon is transformed into a wolf as punishment for serving human flesh to Zeus at dinner,[8] and perhaps the folk belief in werewolves has its origin in the condition. Wolf and dog transformations are most commonly described, but transformations into other animals, including birds and insects, have also been reported. In that sense, the syndrome may be shaped by personal, cultural, and regional influences. Effectively a specific form of a delusional misidentification syndrome, it is not surprising that lycanthropy typically occurs in the context of schizophrenia, psychotic mood disorders, or substance-induced psychoses.

Wendigo Psychosis

The term "wendigo psychosis" describes an insatiable craving for human flesh even when other food is available. It was first described in Algonquin Indians who felt that tribe members engaging in cannibalism then turned into, or were occupied by, a feared, flesh-eating creature or spirit called the wendigo. If attempts at a cure by traditional native healers or Western doctors failed and the person went on to threaten others or act violently, execution of the sufferer often followed. Although some have denied the validity of this disorder, there have been several credible eyewitness accounts by both aboriginal and nonaboriginal peoples. A psychotic origin of these behaviors cannot be excluded.[9]

Maladi Moun (Humanly Caused Illness)

Maladi moun ("humanly caused illness"), found in Haitian communities, is seen as an explanation for many medical and psychiatric symptoms. It is thought that illness is literally "sent" by others out of envy and hatred and can describe psychosis, depressive symptoms, and even academic or social problems. The condition often overlaps with delusional disorder and schizophrenia with paranoid features. In approaching this condition, it is important to differentiate extreme forms of rationalization mixed with magical beliefs, overvalued ideas, and explanations shared by a cultural subgroup from emerging or manifest psychotic symptoms. Potentially emerging psychosis may require close observation and treatment of frequently present comorbid conditions, including depression and substance use disorders, whereas manifest psychotic disorders probably require antipsychotic treatment.[2]

Taijin Kyofusho

Taijin kyofusho is a diagnosis found in Japan. Patients with taijin kyofusho (literally "the disorder of fear") experience extreme self-consciousness regarding their appearance. Patients suffer from intense, disabling fear that their bodies are embarrassing or offensive to others.[1,10] This culture-bound condition has overlapping features with social phobia and body dysmorphic disorder.

Saora

Young men and women in India's Saora tribe will occasionally exhibit memory loss, fainting, and inappropriate crying or laughing. Sufferers often claim to experience the sensation of being repeatedly bitten by insects when none are present. This behavior has been claimed to occur in response to social pressure to lead a certain way of life expected by one's family and/or community (ie, farming), whereas tribe members often attribute the behavior to the actions of supernatural beings who want to marry the afflicted persons.[11] This syndrome has features of a dissociative or conversion disorder.

Koro

Koro is intense anxiety related to the belief that one's own genitalia are shrinking or receding, resulting in possible death. This diagnosis is found in Asia, specifically Southeast Asia. Rooted in Chinese metaphysics and cultural practices, Koro is included in the Chinese Classification of Mental Disorders, Second Edition.[1,12] The disorder has also been associated with the belief that perceived inappropriate sexual acts (eg, extramarital sex, sex with prostitutes, or masturbation) disrupt the yin/yang equilibrium, thought to be achieved during marital sex. Koro has also been thought to be transmitted through food. One could also hypothesize that excessive guilt and shame about fantasized or executed sexual acts might play a role in the delusional belief.

Shenkui/Dhat Syndrome

Dhat derives from the Sanskrit for "elixir that constitutes the body." Dhat is an Indian folk diagnosis in which patients experience severe anxiety and hypochondria related to the loss of semen through urine, nocturnal emission, or masturbation. A similar condition, shenkui, has been described in China.[1,13] In shenkui, marked anxiety or panic symptoms are accompanied by somatic symptoms, such as dizziness, backache, fatigue, and sexual dysfunction. The excessive loss of semen is feared because it is seen as the loss of one's vital essence. Similar to koro, one could hypothesize that the intense fear present in dhat and shenkui could be related to fantasized or performed sexual acts that the person feels are forbidden or unacceptable to the self or others. However, the description could also be related to an unrecognized depressive disorder or somatization disorder.

Shenjing Shuairuo (Neurasthenia)

Shenjing shuairuo is a broad Chinese folk diagnosis characterized by fatigue, poor concentration, irritability, pain, and a variety of somatic symptoms. Traditionally, it probably included a range of mental health disorders and accompanying somatic symptoms, which would meet today's DSM-5 criteria for a mood or anxiety disorder.[1,14] Across all cultures, it is not uncommon that mood disorders are expressed as somatizing, rather than mental, symptoms, in part to avoid the stigma often associated with mental disorders. This would fit with somatoform disorders, such as conversion disorder or somatization disorder. The description of shenjing shuairuo would also fit chronic fatigue syndrome, which remains poorly understood.

Zar

Zar is a psychiatric illness diagnosed in North Africa and the Middle East. Attributed to spirit possession—and not considered a pathology locally—people experiencing zar undergo dissociative episodes, including fits of excessive laughing, yelling, crying, and hitting their head against a wall. Patients are often apathetic and report developing long-term relationships with their possessor.[1] On the basis of its phenomenology, zar could be conceptualized as a recurrent brief psychotic episode, delusional disorder, dissociative condition, or potentially a substance-induced event. Zar is an important example of how certain culture-bound syndromes can be seen as normal or as a sign of being "selected," whereas other cultures would consider such symptoms pathologic.[1]

Shin-byung (Spirit Sickness)

Shin-byung is a folk diagnosis in Korea that is characterized by anxiety and numerous somatic symptoms, such as weakness, dizziness, and gastrointestinal symptoms. Patients often dissociate and attribute their state to possession by ancestral spirits.[1] The condition can also be viewed as somatization of an underlying major depressive or anxiety disorder, or as an adjustment disorder, which is destigmatized by attributing this mental state to possession by a spirit. Shin-byung shares features of somatoform or dissociative disorders.

Ghost Sickness

Ghost sickness is characterized by a preoccupation with death and the deceased and is frequently seen in Native Americans but has also been described in Hispanic cultures. Symptoms are broad and can include weakness, dizziness, loss of appetite, feelings of danger, dizziness, fear, anxiety, hallucinations, and a sense of suffocation.[1] As evidenced by this symptom constellation, ghost sickness could also be conceptualized as protracted or pathological grief or depression, which is expressed predominantly somatically and may increase the acceptability of the disturbed mental state to afflicted people and those who know them.

Susto

From the Spanish word for "fright," susto refers to the soul leaving the body in response to a frightening experience. Susto is diagnosed in certain Latino populations. Symptoms can recur for years and are consistent with multiple DSM-5 diagnoses, including major depressive disorder, posttraumatic stress disorder, and somatic symptom and related disorders.[1]

Falling Out

Falling-out episodes are characterized by a sudden collapse, sometimes preceded by dizziness, in which patients often report temporary blindness despite their eyes remaining open. Falling out is found in the southern United States and the Caribbean. Patients are generally aware of their environment but report being unable to move.[1] This set of symptoms has overlapping features with cataplexy, a rare condition in which patients have a sudden and transient loss of muscle tone (usually in response to strong emotions) and fall to the ground. They also may experience vasovagal syncope due to a strong physical or psychological event, as well as catatonia, conversion disorder, or dissociative disorder.

Grisi Siknis

Grisi siknis is a hysterical condition reported in Nicaragua. In English, the term translates to "crazy sickness." It is highly contagious and affects mainly young girls and women, especially those 15-18 years old. The attacks start with headaches, dizziness, anxiety, nausea, irrational anger, and/or fear. During the attack, the victim "loses consciousness," falls to the ground, and subsequently runs away. Afflicted persons may view others as devils, feel no pain from bodily injuries, and have absolute amnesia regarding their physical circumstances. Some shadow-fight with unseen opponents, whereas others have been reported to have performed superhuman acts and spoken in tongues. This condition has features of dissociative or conversion disorders.[1]

Gururumba

Gururumba is a diagnosis from New Guinea that describes an episode in which the afflicted person (usually a married man) begins burglarizing neighboring homes, taking objects that he considers valuable but which seldom are. He then runs away, often for days, returning without the objects and amnestic about the episode. Sufferers have been described as hyperactive, clumsy, and with slurred speech. This syndrome has features of a dissociative or conversion disorder but also could be a substance intoxication-related condition.[8]

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