The Phenomenon of the Culture-Bound Syndrome

      
       There are some medical conditions that may look unusual from an outsider's perspective, but are better understood when you analyze the cultural context and social situations that brought them about. For instance, it is relatively common for Puerto Ricans to undergo panic attacks, called ataque de nervios, when subject to stress. They will shout, cry uncontrollably, become aggressive, and even become detached from their surroundings. To placid outsiders of this culture, however, this behavior would likely immediately seem strange.

       Ataque de nervios1 is an example of a culture-bound syndrome2, a largely heterogenous group of conditions that occur because of the pervasive influence of culture and environment3.

       To a medical professional, it is practical to study culture-bound syndromes in a society that is culturally diverse, or to study the unique psychology of their local culture4. For instance, the Philippines has had its fair share of mass psychogenic illness. Many of us have likely read news articles about local schoolgirls claiming mass demon possession. While mass psychogenic illness can be seen in many cultures, what people attribute it to (in this case, demons and supernatural forces) can be influenced largely by culture.


[Photo credit: Medscape website]
      
       Let us look at two examples of culture-bound syndromes, psychological conditions that are rooted in anxiety but are also shaped by cultural influence.

Koro5

       Sufferers of Koro are under the strong belief that their genitals are disappearing and retracting into their bodies, despite the lack of physical evidence to indicate this. In China, it is believed to be caused by sexual practices that are considered by traditional Chinese medicine (TCM) to be unhealthy, such as masturbation and frequent ejaculation.

       Because practitioners of TCM believe that semen is connected to one's vital energy, its depletion will lead to genital shrinkage and eventually death. Their excessive cultural guilt and shame about these sexual acts can contribute to the anxiety they experience.

       The anxiety of genital retraction is not unique to Chinese culture, however. Europeans in the 15th century believed that witches could cast malicious spells on men that would cause them to lose their penises. In the 20th century, there were epidemics of so-called 'genital theft' in West Africa, wherein practitioners of witchcraft were blamed for stealing the spiritual essence of men's genitalia, thereby causing impotence.

[Photo credit: Genius website]

       When examining complaints of genital shrinkage, physicians will try to differentiate among abnormalities that can be corrected by physical means (such as buried penis, a condition in overweight men where a normal penis is simply buried in suprapubic fat), body dysmorphic disorder and koro, so that they can assess which therapy would be ideal.

Taijin Kyofusho6,7

       Taijin kyofusho is a form of social anxiety where its sufferers are wracked constantly by guilt that other people find their presence offensive. They're deeply embarrassed by their bodies - their smell, their facial expressions, and even establishing eye contact - and exhibit the classical signs of anxiety.

       While some sufferers of social anxiety worry constantly that they will be judged by others for being socially awkward and thus be embarrassed by it, people who suffer from this condition are actually more concerned with the idea that they would embarrass someone else. This, and other forms of social anxiety may likely have been triggered by traumatizing/embarrassing events, and fearing harassment, they avoid social situations altogether.

[Photo credit: Tofugu website]

        It is also surprisingly prevalent in the Japanese population. In more individualistic cultures, it is perfectly healthy to go your own way and pursue your own goals; in more collectivist cultures, the opinion of the group matters greatly. In a study by Leung et al. (1994), it was found that American children are more likely to develop social anxiety disorder if their parents focus on how other people's opinions are important, and use shame to discipline them.

       Unlike with social anxiety disorder, however, people with taijin kyofusho believe that they have physical defects so it may also be associated with body dysmorphic disorder. However, another study conducted contrasting American and Korean patients with seasonal affective disorder (SAD) found that some features of taijin kyofusho are actually not uncommon in American SAD patients. Hence, it may not be so culturally specific.

       Cognitive behavioral therapy is usually the course of action for treatment, but Japanese therapists specifically use Morita therapy, a traditional method designed to address the condition.

       There are other examples of culture-bound syndromes that exist and are included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V)  used by psychiatrists and clinical psychologists, but the status of these as true culture-bound syndromes are still debated. For instance, when individuals (usually male) run amok, they will indiscriminately attack anyone they encounter in a murderous rage. Many cases end with the perpetrator's death. It originated with the Malay word mengamuk, and was observed in 18th century tribesmen who would go on murderous frenzies, a behavior that is strangely tolerated by the tribe.

       This is because they believed that these men were possessed by malevolent spirits that would cause them to attack others. On the other hand, others would also argue that we see equivalents of these in the West, with spree killers going on rampages and also ending up with the same fate. Thus, it is not unique to Southeast Asian culture.

       Regardless, culture and societal norms still play a great role in influencing how people think, and how these societal pressures can generate anxiety in members of society who feel like outsiders8.


REFERENCES:
1. Fernandez, et al. (2002). Dissociation, childhood trauma, and ataque de nervios among Puerto Rican psychiatric outpatients. Am J Psychiatry 159: 1603-1605.
2. Levine, R.E. & Gaw, C. (1995). Culture-bound syndromes. Psychiatr Clin North Am 18(3): 523-536.
3. Guarnaccia, P.J. & Rogler, L.H. (1999). Research on culture-bound syndromes: New directions. Am J Psychiatry 156:9.
4. Cuellar, I. & Paniagua, F. (2000). Handbook of multicultural mental health: Assessment and treatment of diverse populations. NY: Academic Press.
5. Mattelaer, J.J. & Jilek, W. (2007). Koro: The psychological disappearance of the penis. The Journal of Sexual Medicine 4(5): 1509-1515.
6. Essau, C.A. et al. (2011). A Japanese form of social anxiety (taijin kyofusho): Frequency and correlates in two generations of the same family. Int J Soc Psychiatry.
7. Choy, Y. et al. (2008). Features of the offensive subtype of Taijin Kyofu Sho in US and Korean patients with DSM IV social anxiety disorder. Depression and Anxiety 25(3): 230-240.
8. O'Neil, D. (2010). "Culture specific diseases". Retrieved from http://anthro.palomar.edu/medical/med_4.htm

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