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The globetrotter’s guide to psychiatric culture-bound syndromes

By Dr Ruairi McNicholas and Dr Stephen McWilliams - 22nd Oct 2023

psychiatric

A fascinating journey through lesser known psychiatric conditions usually only seen in specific local cultures

Culture is everything in psychiatry. In a world where our outpatient clinics are becoming ever more diverse, we need to be attuned to the subtleties of varied personal experiences and perspectives. We all take the International classification of diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) for granted, but sometimes avoid straying too far beyond the common Western diagnoses of depression, bipolar disorder, schizophrenia, anxiety, attention deficit disorder, and so forth. But what if we were to take a journey around the world to explore some illnesses that are thoroughly ingrained in specific local cultures? Illnesses we do not commonly see in your average Western mental health service. What might we find?

We could begin our journey deep inside the Arctic Circle, where a condition known as Piblokto has fascinated explorers and psychiatrists since the late 1800s. Seen among Inuit populations across the arctic region, most commonly in Northern Greenland, Piblokto usually affects females during the darkness of the long winter months, often in response to sexual or emotional trauma. Regarded as a dissociative neurosis, Piblokto typically occurs in four stages, namely a period of social withdrawal, followed by a period of excitement with displays of irrational, out-of-character or even dangerous behaviours. Tearing off one’s clothes and running around in the freezing conditions is not unusual. This is typically followed by a convulsive state, and then by a period of stupor. Those who recover will often have total amnesia for the episode. The disorder is traditionally believed to be a possession by evil spirits, and traditional treatment by faith healers includes the induction of trance-like states.

Travelling south, to the Great Plains and Great Lakes region of North America, one might encounter a condition called Wendigo. Seen in the Algonquin-speaking indigenous population, Wendigo psychosis involves a person developing a delusional belief that they are possessed by a malevolent cannibalistic spirit. Like Piblokto, this condition often begins with social withdrawal and brooding, with the subsequent emergence of depressive symptoms, obsessional thoughts about the Wendigo ‘creature’, the fear of becoming a cannibal (felt to be morally incomprehensible in their culture), and finally the development of a craving for human flesh. There have been cases of Wendigo psychosis leading to murder and actual cannibalism and its use as a diagnosis has been criticised by some as a spurious means to rationalise homicide. The incidence of Wendigo psychosis has decreased significantly since the indigenous population came into contact with Western culture and is now quite a rare phenomenon.

Susto is a condition found in certain indigenous populations in Mexico and Central America. In their culture, there is a widely-held belief that when a person is exposed to a traumatic event, they lose some of their ‘vital essence’, causing them to become ill. Someone experiencing Susto may display a wide range of physical and psychological symptoms with a clinical picture that shares similarities with post-traumatic stress disorder, depressive disorder, and somatisation disorder.


‘Wendigo psychosis’ involves a person developing a delusional belief that they are possessed by a malevolent cannibalistic spirit

Like Susto (and indeed many of the culture bound syndromes), Ataque de Nervios (ADN) typically occurs in response to an acutely stressful event, such as a divorce or the death of a close family member. Also known as Puerto Rican syndrome, ADN is seen throughout the Spanish speaking Caribbean and Central American nations. Literally translating to “attack of the nerves”, a person with the condition might be seen to scream and cry uncontrollably. They can display verbal and physical aggression, dissociative phenomena, suicidal behaviour, fainting episodes and non-epileptic seizures. There have been some comparisons with the Western diagnosis of panic disorder, and indeed it is thought that 36 per cent of Puerto Ricans with ADN also meet the criteria for panic disorder. That said, unlike panic disorder, ‘fear’ is not typically a central feature.

Around the world, mental illness continues to be viewed with varying degrees of stigma. In cultures that retain strong links with folklore and superstition, one might believe that a psychotic or depressive illness has been ‘sent’ to a person by another out of envy or hatred. In Haiti, this is known as Maladi Moun. Factors such as stigma, lower educational attainment, low levels of mental healthcare, and underlying traditional beliefs are thought to create the cultural context necessary for Maladi Moun to take hold as a reasonable explanation for the experience of mental ill-health. Treatments tend to focus on spiritual rituals and herbal remedies, and there is an acceptance of the need for increased family support and rest as vital components in the healing process.

Similarly, in pockets of the Islamic world, Evil Eye refers to a constellation of distressing mental state abnormalities, which are believed to have been sent by another person, or ‘jinn’ (evil spirits).

Travelling east to Africa’s most populous country, Nigeria, Brain Fag syndrome (BFS) is a well-described disorder that typically affects young students in high school or college. Symptoms include somatic complaints such as headaches and eye-pains, sleep disturbance, and cognitive complaints such as difficulty concentrating. BFS is thought to emerge as a result of high levels of family expectation placed upon young people to be successful. Prevalence rates are thought to be as high as 25 per cent amongst Nigerian students and there is a high crossover with symptoms of depressive disorder and anxiety disorders, as well as the more recently described phenomenon of ‘burnout’. Treatment success has been seen with antidepressants, benzodiazepines, and relaxation exercises.

Further east to Southern Asia (India, Pakistan, Nepal, Bangladesh, and Sri Lanka), one might encounter Dhat syndrome, a disorder in which men believe that they are passing semen in their urine. Certain Hindu cultures believe that semen is a ‘vital fluid’, and its loss can provide an explanation for a whole constellation of mental and physical symptoms. Persons suffering with premature ejaculation and erectile dysfunction may attribute their symptoms to Dhat, often leading to a self-perpetuating cycle of guilt (eg, about inappropriate sexual desire and masturbation) and rumination which further exacerbates psychosexual difficulties. Although semen loss is felt by the person to be the causative factor, it is not necessarily associated with sexual problems. Dhat is often thought of as a culture-bound manifestation of depression and can present with symptoms such as low mood, anhedonia, appetite loss, tiredness, anxiety, and somatic symptoms. Dhat is seen more often in those of lower socioeconomic status and with lower educational attainment, and has been successfully treated with antidepressants and cognitive behavioural therapy.

Latah, a sort of ‘startle disorder’ seen in Malaysia and Indonesia, can be quite dramatic when encountered. It typically occurs following a sudden shock (such as a loud noise) and can result in symptoms such as echolalia, echopraxia, coprolalia, mimicry, command obedience, uncontrollable laughing or crying, and dissociative and trance-like states. During an episode of Latah, the individual might obey commands that are completely against cultural norms, or they might blurt out expletives of a sexually inappropriate nature. One hypothesis is that Latah represents a manifestation of repressed emotional expression in a stifling cultural environment. It is most commonly seen in middle-aged women, and may be exploited to provoke amusement in others. It is associated with high levels of physiological arousal and was previously interpreted by Gilles de la Tourette as a variant of his eponymous neurological syndrome.

Also seen in Malaysia, Amok is a dissociative disorder of which there are reports dating back many centuries. The phrase “to run amok” has been utilised in the English language to signify a person behaving in a chaotic or destructive manner. In Malay culture, there is a belief that Amok is caused by an evil tiger spirit entering a person. The traditional picture of Amok involves the individual (almost always male) acquiring a weapon, perhaps a sword or dagger, and then proceeding on a murderous rampage. The victims are typically unknown to the assailant who typically keeps going until subdued by lethal means. Assailants who survive often claim total amnesia for the event. There are recent theories linking Amok with psychopathy, and as with Wendigo psychosis, perpetrators may manipulate culturally-held beliefs to justify heinous crimes. Other theories link Amok with the concept of ‘male honour’, with the perpetrator subsequently considered a person to be feared and respected.

In Cambodia, Khyâl Cap centres on the belief that Khyâl – or ‘wind’ – rises within the body as an explanation for various different complaints such as acute anxiety, panic, psychosis, and somatic symptoms. For example, dizziness and tinnitus may be attributed to wind entering the skull, while breathlessness and chest pain may be seen to represent wind entering the chest to press against the heart, lungs, and so forth. Khyâl attacks are similar to panic attacks and generalised anxiety and can be triggered by archetypal anxiety-inducing scenarios such as open spaces or stressful situations. They often occur without warning and, like anxiety disorders, can be self-perpetuating with ruminative worrying about future Khyâl attacks.

Koro, seen in Southern China and in other South East Asian cultures (generally in persons of Chinese decent), involves an overpowering belief that the genitals are shrinking or retracting in spite of overwhelming objective evidence to the contrary. This is associated with perceived loss of sexual power. During an episode, a person may believe that this process is irreversible and will ultimately lead to their death. Individuals and their families may resort to preventative measures such as applying opposing traction, and there have been cases of injuries resulting from such behaviours. Traditional Chinese medicine refers to penile shrinkage and abdominal distension as a precursor to death, and Koro is felt to result from disturbances of ‘Qi’ or ‘vital energy’. It has been linked with body dysmorphic disorder and has also been described in Western medical literature as ‘genital retraction disorder’. There have been multiple documented cases of Koro ‘outbreaks’, including epidemics in China in the mid-1980s affecting over 3,000 people and providing evidence for the concept of mass hysteria.

Another culture-bound syndrome seen in China and Taiwan (and thought to be linked to Koro in its origins) is a disorder known as Pa Leng or ‘frigophobia’. This disorder is traditionally felt to occur as a consequence of an imbalance in a person’s yin and yang, with affected males perceived to have too much yin (the female element). The physical manifestation of Pa Leng is an unwarranted fear of coldness, which can present as a person wearing excessive amounts of clothing in inappropriate weather conditions despite reassurances that there is no danger. It has been linked with hypochondriasis and obsessive compulsive disorder (OCD).

Travelling northeast across the South China Sea to Japan, one might encounter a disorder known as Taijin Kyofusho, which is roughly translated to “the fear of interpersonal relations”. Although similar to the Western concept of social anxiety, where a person might harbour a fear of embarrassing themselves or being judged because of social ineptness, a person with Taijin Kyofusho often report feelings of shame and embarrassment about themselves, resulting in a fear of displeasing others. It is relatively common in Japan, with a lifetime prevalence of 3-to-13 per cent. It often presents with excessive rumination and typical somatic anxiety symptoms and is further reinforced by avoidance behaviours. Examples of subtypes of Taijin Kyofusho include phobias of blushing, eye-contact, body odour, and displeasing physical features (earning it comparisons with body dysmorphic disorder and hypochondriasis). Cases vary in severity, from a transient short-lived illness, to a chronic delusional state which may be seen in conjunction with schizophrenia.

Knowledge is power

The ICD-11 has sought to distance itself somewhat from the specific culture-bound syndromes described in previous versions, shifting toward a more culturally-informed, data-driven approach to descriptors. Certain diagnostic criteria and guidelines have been modified, with new culturally-relevant categories added and greater credence given to culture-related features of specific disorders.

Learning about other cultures can help us increase our knowledge around mental health concepts and expand the vocabulary we use to describe mental illness. After all, what are diagnostic handbooks other than a means of assigning language to a consistently-observed pattern of symptoms or behaviours? The origins and manifestations of distress and mental turmoil have always been difficult to understand and, throughout history, folk beliefs and traditional teachings have sought to explain the unexplainable where there is a dearth of available knowledge. In clinics we find ourselves trying to ‘explain the unexplainable’, with diagnoses such as non-epileptic seizures, irritable bowel syndrome, and functional neurological disorder continuing to pose challenges to the clinician and patient alike.

According to the recent Census of April 2022, there are currently around 703,700 non-Irish nationals living in Ireland, accounting for 13.8 per cent of the total population. Although the likelihood is low of an Irish psychiatrist or GP encountering a textbook example of one of the disorders described above, the odds are shortening. For every well-documented disorder, there are many more unique cultural beliefs that may be encountered over the course of a doctor’s career. We should aim to ascertain a clear picture of the patient’s personal belief system before we reconcile it with our own, as a successful treatment plan will need a successful buy-in from the patient after a two-way negotiation based on common ground. Sometimes it is our own understanding that needs to expand, in order to accommodate healing in those that we strive to treat.

DR RUAIRI MCNICHOLAS, Registrar in Psychiatry, St Vincent’s University Hospital, Elm Park, Dublin; and DR STEPHEN MCWILLIAMS, Associate Clinical Professor of Psychiatry, School of Medicine, University College Dublin, and Consultant Psychiatrist, St John of God Hospital, Stillorgan, Co Dublin

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