Culture bound syndromes

Culture bound syndrome, culture related specific disorders, culture specific disorders/ syndromes, exotic psychiatric syndromes or Rare atypical unclassifiable disorders.

1. CULTURE BOUND SYNDROMES Presenter – DR. SUBHENDU SEKHAR DHAR

2. OVERVIEW Introduction Evolution of concept Historical aspect Nosology Subdividing CBS Common culture bound syndromes Course & Prognosis Treatment Critique

3. INTRODUCTION ‘CULTURE’ : Defined as :- Comprising the ideas, values, habits & other patterns of behaviour which a human group transmits from one generation to another , OR The whole complex of traditional experiences, concepts, system of values & behavioural rules in a society Cultures are open, dynamic systems that undergo continuous change over time.

4. INTRODUCTION RACE is defined as ‘A culturally constructed category of identity that divides humanity into groups based on a variety of superficial physical traits attributed to some hypothetical intrinsic, biological characteristics. ETHNICITY is a culturally constructed group identity use to define peoples & communities.

5. INTRODUCTION Culture bound syndrome also known as culture related specific disorders, culture specific disorders/ syndromes. In the American handbook of psychiatry, Exotic psychiatric syndromes or Rare atypical unclassifiable disorders. They all refer to certain illnesses or disorders which occur exclusively in certain cultures and not found in others.

6. DEFINITION In medicine and medical anthropology, a  culture - bound syndrome ,  culture -specific  syndrome , or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or  culture . 1980s - Raymond Prince and co-workers Proposed a definition of these phenomena as a “ collection of signs and symptoms (excluding notions of cause), which is restricted to a limited number of cultures primarily by reason of certain of their psychosocial features .”

7. HISTORICAL PERSPECTIVES In 1904 Emil Kraepelin initiated the field of comparative psychiatry ( Vergleichende Psychiatrie ) through investigation of dementia praecox in Java, and he later documented psychiatric presentations among Native Americans, African Americans and Latin Americans. It was first described in Kraepelin textbook of psychiatry, the 8 th edition (1909)

8. HISTORICAL PERSPECTIVES Pow Meng Yap, a pioneer in cultural psychiatry (1962) introduced ‘atypical cultural bound psychogenic psychosis’ which he later abbreviated to ‘culture bound syndrome’ In 1985 in the book “ The Culture Bound Syndromes ”, Ronald Simons & Charles Hughes used the taxonomic principle to group the syndromes based on their phenomenological similarity across diverse cultural settings.

9. HISTORICAL PERSPECTIVES Ruth Levine and Albert Gaw suggested the term ‘folk diagnostic categories’ They proposed a criteria for culture specific syndromes – Must be a discreet, well defined syndrome Recognized as a specific illness in the culture Disorder must be recognized, and sanctioned as a response to certain precipitants in the culture. Higher incidence or prevalence in the society where it is culturally recognized.

10. HISTORICAL REPORTS 1893,1897 – W.G.Ellis  Amok,Latah (Malays) 1908 – W Fletcher Elaboration on Latah 1910-Musgrave,Sison Mali- mali (Philippines) 1913 –Brill – Pibloktoq (Arctic Hysteria) 1933 - John Cooper – Windigo psychosis- Algonquian Indians 1934 - Wulfften Palthe  koro 1936 - Winiarz and Wielawski  imu 1940 – Still  Dhat syndrome(India)

11. HISTORICAL REPORTS 1948- Gillin  magical fright 1957-Cannon  ‘voodoo’ death 1959- Fernández -Marian  ataques de nervios (Puerto Rica) 1960- Raymond Prince  ‘brain fag’ syndrome among Nigerian students 1962- T. A. Lambo  malignant anxiety (Africa) 1964- Rubel  susto (Hispanic Americans) 1966- Hsien Rin  frigophobia (excessive fear of catching cold) observed in Taiwan.

12. RELATIONSHIP WITH PSYCHOPATHOLOGY The growing cultural pluralism in society requires clinicians to examine the impact of cultural factors on psychiatric illness, including on symptom presentation and help-seeking behavior. In order to render an accurate diagnosis across cultural boundaries and formulate treatment plans acceptable to the patient, clinicians need a systematic method for eliciting and evaluating cultural information in the clinical encounter.

13. RELATIONSHIP WITH PSYCHOPATHOLOGY Thus , A systematic approach for accomplishing this information is the cultural formulation : Cultural identity of the individual Cultural explanations of the individual’s illness Cultural factors related to psychosocial environment and levels of functioning Cultural elements of the relationship between the individual and the clinician Overall cultural assessment for diagnosis and care

14. NOSOLOGY The term culture-bound syndrome was included in DSM IV (1994) and ICD 10 (1992). According to DSM IV culture-bound syndrome denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience, that may or may not be linked to a particular DSM-IV diagnostic category. indigenously considered to be "illnesses," or at least afflictions. Generally limited to specific societies or culture areas.

15. DSM IV describes about 25 CBS amok ataques de nervios bilis and colera boufe delirante brain fag dhat falling out or blacking out ghost sickness hwa-byung koro latah locura mal de ojo nervios pibloktoq qi -gong psychotic reaction rootwork sangue dormido shenjing shuairuo shenjing shenkui shin- byung spell susto taijin kyofusho zar

16. ICD 10 ICD 10 categorizes culture bound syndromes in the Annex 2 and lists 12 culture bound syndromes. It lacks any diagnostic and cultural explanatory guidelines.

17. ICD 10 describes about 12 CBS Amok Dhat Koro Latah Nervios Frigophobia Pibloktoq Susto Taijin Kyofoshu Ufufuyane Uqamairineq Windigo

18. DSM 5 Cultural concepts of distress - refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions. Three concepts— syndromes , idioms , and explanations .

19. Syndromes - clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience. Idioms - are ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns.

20. Explanations - are labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress.

21. Importance of cultural concepts – To avoid misdiagnosis To obtain useful clinical information To improve clinical rapport and engagement To improve therapeutic efficacy To guide clinical research To clarify the cultural epidemiology

22. CULTUTRAL FORMULATION INTERVIEW The Cultural Formulation Interview (CFI) is a set of 16 questions that clinicians may use to obtain information about the impact of culture on key aspects of an individual's clinical presentation and care.

23. The CFI emphasizes four domains of assessment: Cultural Definition of the Problem (questions 1-3) Cultural Perceptions of Cause, Context, and Support (questions 4-10) Cultural Factors Affecting Self-Coping and Past Help Seeking (questions 11-13) Cultural Factors Affecting Current Help Seeking (questions 14-16).

24. SUBGROUPINGS/CLASSIFICATION Subgrouping by cardinal symptoms: Yap (1967). Based on the cardinal symptoms of prototypical case : Primary fear reactions (malignant anxiety, latah , psychogenic / magical death) Morbid rage reaction (amok). Specific culture-imposed nosophobia ( koro ). Trance dissociation ( windigo psychosis ).

25. SUBGROUPINGS/CLASSIFICATION 1985 – Simons,Hughes : suggested categorizing culture-related syndromes by ‘ taxon ,’ i.e. group defined by a common factor Startle-matching taxon ( latah , imu ) Sleep-paralysis taxon Genital-retraction taxon ( koro ) Sudden-mass-assault taxon (amok) Running taxon ( pibloktoq,grisi siknis , Arctic hysteria) Fright-illness taxon ( susto ) Cannibal-compulsion taxon ( windigo psychosis).

26. SUBGROUPINGS/CLASSIFICATION Tseng (2001) divided specific syndromes into several groups: Culture-related beliefs as causes for the occurrence ( koro / dhat ) : PATHOGENETIC Culture-patterned specific stress-coping reactions (amok / family suicide) : PATHOSELECTIVE Culture-shaped variations of psychopathology ( taijinkyofusho /brain fag syndrome) : PATHOPLASTIC

27. SUBGROUPINGS/CLASSIFICATION Culturally elaborated unique behavior reactions ( latah ) : PATHOELABORATING Culture-provoked frequent occurrences of pathological conditions (mass hysteria / substance abuse) : PATHOFACILITATING Cultural interpretations and reactions to certain mental conditions ( hwabyung / susto ) : PATHOREACTIVE

28. In India, common culture bound syndromes are Dhat Syndrome, Possession Syndrome, Koro , Gilhari syndrome, Bhanmati sorcery, Compulsive spitting, Culture-bound suicide (sati, santhra ), Ascetic syndrome, Suudu , Jhin jhinia etc.

29. POSSESSION SYNDROME Osterreich (1966) defined possession as 'a state in which the organism appears to be invaded by a new personality and governed by a strange soul'. Introduced into modern scientific literature by P. M. Yap in 1960, and was called as ‘possession syndrome'.

30. Cognate experiences have been reported in extremely diverse cultural settings, including India, Sri Lanka, Hong Kong, China, Japan, Malaysia, Niger, Uganda, Southern Africa, Haiti, Puerto Rico and Brazil. AKA Zar in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies. More common in women, with a female to male ratio of 2 or 3 to 1. Age of onset is usually between 15 and 35 years, but many cases reportedly begin in childhood. Attacks may persist well into middle age, and geriatric cases have also been reported. The syndrome has been identified in all Hindu castes, as well as in Muslims, Christians, and tribal peoples. However, it is more commonly described among Hindus.

31. In DSM IV TR, this class of presentations is subsumed in appendix B under the proposed category of “dissociative trance disorder,” A single or episodic alteration in the state of consciousness characterized by the replacement of customary sense of personal identity by a new identity. This is attributed to the influence of a spirit, power, deity, or other person, as evidenced by one (or more) of the following: a) stereotyped and culturally determined behaviors or movements that are experienced as being controlled by the possessing agent. b) full or partial amnesia for the event.

32. Phenomenology : Onset occurs typically due to subacute conflict or stress. Onset may also vary by geographical region. Dramatic , semi-purposeful movements, aggressive or violent actions directed at self or at others. Verbalizations , derogatory comments or threats of violence directed against significant others. Specific gestures , comments or requests denoting the appearance of a known possessing personality Emergence of one or several secondary personalities distinct from that of the subject. Specific identities of possessing personalities remain undisclosed for some time Outcome is variable

33. Possession can occur sporadically involving one individual or can occur simultaneously as an epidemic involving many people. It can be voluntary and involuntary Possession can be beneficial to the individual by giving him a special status in the society.

34. Precipitants: Marked social/ family conflicts Stressful life transitions Hysterical, histrionic & immature defense mechanisms Relationship to psychiatric diagnosis: Schizophrenia: 40 – 59% Manic depressive illness: 11 – 13% Dissociative disorders: 9.5% Relapse rates - unknown Psychiatric treatment typically avoided. Indigenous treatments – neutralization of conflicts or stress.

35. DHAT SYNDROME Dhat derives from the Sanskrit word ‘Dhatu’ meaning ‘metal’ and also ‘elixir’ or ‘constituent part of the body’. AKA dhatu , jiryan , shen-k'uei (Chinese & Taiwan) First described in western texts by N.N.Wig (1960) Comprises vague somatic symptoms of fatigue, weakness, anxiety, loss of appetite, guilt and sexual dysfunction attributed by the patient to loss of semen in nocturnal emissions, through urine or masturbation.

36. CLINICAL FEATURES

37. Semen loss anxiety in India The patient presenting with Dhat syndrome is typically more likely to be recently married of average or low socio-economic status (perhaps a student, laborer or farmer by occupation) comes from a rural area belongs to a family with conservative attitudes towards sex

38. The symptoms of semen loss anxiety have been well known in Indian historical writing. It is not only confines to India, and has been reported from Sri Lanka (shukra prameha) and China. Often described as a separate entity and many authors did not give associated psychiatric diagnosis, thus it is seen and recognized as a culture bound syndrome.

39. Semen loss anxiety in China Wen and Wang (1980) define shen-k’uei as vital or kidney deficiency. Sexual neurosis associated with excessive semen loss due to frequent intercourse, masturbation, nocturnal emission or passing of white turbid urine. Patient becomes anxious, panicky with symptoms like dizziness, backache, fatigability, weakness, insomnia, frequent dreams and physical thinness.

40. Weakness in Chinese people connotes loss of vital energy (qi or chi) Yap also posits that a healthy exchange or yin and yang occurs in sexual intercourse. Whereas following nocturnal emission, masturbation or loss in urine only yang is lost without gain of yin. In a study of 87 patients in a urology clinic in China 23 were found to have sexual neurosis with shen-k’uei syndrome and 64 patients blames their problems on masturbation.

41. Semen loss anxiety in Western cultures Galen has described similar syndrome as Dhat in his writings. Jewish writers too acknowledge that depositing of semen anywhere else than the vagina was debilitating to health. Tissot’s writing in the 18 th century which was embraced by the middle classes and sexual purity became a way of distinguishing themselves from promiscuity of the noble and lower social classes.

42. DHAT SYNDROME Benjamin Rush believed that all diseases could be caused by debility of the nervous system and propounded that careless indulgence in sex would cause multiple illnesses. In France, Lallemand was concerned that involuntary loss of semen would lead to insanity. William Acton, an English physician advised people to engage in infrequent sex .

43. Management of Dhat syndrome Wig suggested emphatic listening, a non confrontational approach, reassurance and correction of wrong beliefs, along with use of placebo, anti-anxiety and antidepressant drugs whenever required. Depressive symptoms of this syndrome showed effective response to SSRI along with regular counselling,

44. DHAT SYNDROME Other intervention studies for Dhat suggest sex education, relaxation therapy and medications. Sex education focuses primarily on anatomy and physiology of sexual organs.

45. In a study of 5 cases in NIMHANS, an attempt was made to develop a structured module for management of Dhat. Intake and assessment Socializing the patient to CBT Basic sex education Cognitive restructuring and other techniques Cognitive restructuring Relaxation Imaginal desensitization Masturbation as homework Kegel’s exercises and other specific techniques Termination

46. KORO Refers to an episode of sudden and intense anxiety that the penis (or, in women, the vulva and nipples) will recede into the body and possibly cause death. The syndrome is reported in south and east Asia. Also known as – shuk yang, shook yong , and suo yang (Chinese); jinjinia bemar (Assam); or rok-joo (Thailand)

47. Expect consequences to be fatal. More common in males. Inappropriate sex, such as masturbation or sex outside of marriage, illness, exposure to cold Koro like symptoms – UK, Canada, Israel Clamps, ties, pegs or hooks may be used Onset is rapid, intense, unexpected Therapy : Assurance, educational counselling .

48. GILHARI SYNDROME This population believed that it starts as feeling of Gilhari running on back of body associated with intense pain and anxiety and finally Gilhari reaching the throat causing stoppage of breathing. Gilhari syndrome is prevalent in Bikaner region People believed that Gilhari must be crushed to death or it will kill patients and the treatment is mainly received from local expert or faith healers.

49. ASCETIC SYNDROME First described by Neki in 1972 Appears in adolescents and young adults Characterized by social withdrawal, severe sexual abstinence, practice of religious austerities, lack of concern with physical appearance and considerable loss of weight.

50. BHANMATI SORCERY This is seen in South India. Belief in magical spells that produce evil spirits to cause psychiatric illness like conversion disorders, somatization disorders, anxiety disorder, dysthymia , schizophrenia etc. Nosological status unclear JHIN JHINIA Occurs in epidemic form in India Characterised by bizarre and seemingly involuntary contractions and spasms Nosological status unclear

51. SUUDU It is a culture specific syndrome of painful urination and pelvic “heat” familiar in south India, especially in the Tamil culture. It occurs in males and females. It is popularly attributed to an increase in the “inner heat” of the body often due to dehydration. CULTURE BOUND SUICIDE Sati : self-immolation by a widow on her husband’s pyre. According to Hindu mythology, Sati the wife of Dakhsha was so overcome at the demise of her husband that she immolated herself on his funeral pyre and burnt herself to ashes. Since then her name ‘Sati’ has come to be symptomatic of self-immolation by a widow. Was seen mostly in Upper Castes notably Brahmins and Kshatriyas . Banned in India since 19th century.

52. AMOK/ RUN AMOK Amok (Malaysia) / Cafard or Cathard (Laos, Polynesia, Phillipines ) /Mal de pelea (Puerto Rico) / Iich'aa (Navajo) Amok (to attack furiously, in Malay) is a syndrome indigenous to the Malayo -Indonesian cultural region. This is a dissociative episode featuring a period of brooding followed by an outburst of aggressive, violent or homicidal behavior aimed at people and objects. Men of Malay extraction, Muslim religion, low education and rural origin, Between the ages of 20 and 45.

53. AMOK/ RUN AMOK Early travelers in Asia describe a kind of military amok, in which soldiers facing apparently inevitable defeat suddenly burst into a frenzy of violence which so startled their enemies that it either delivered victory or at least ensured what the soldier in that culture considered an honourable death. In 1634, the eldest son of the Raja of Jodhpur ran amok at the court of Shah Jahan , failing in his attack on the emperor, but killing five of his officials.

54. Precipitants - include arguments with coworkers, nonspecific family tensions, feelings of social humiliation, bouts of possessive jealousy, gambling debts, and job loss. The victim, known as a pengamok , suddenly withdraws from family and friends, then bursts into a murderous rage, attacking the people around him with whatever weapon is available. He does not stop until he is overpowered or killed; if the former, he falls into a sleep or stupor, often awakening with no knowledge of his violent acts.

55. Prototypical episodes: Exposure to a stressful stimulus or subacute conflict, eliciting in the subject feelings of anger, loss, shame, and lowered self-esteem. A period of social withdrawal. Transition. Indiscriminate selection of victims. Verbalizations. Cessation. Subsequent partial or total amnesia. Perceptual disturbances or affective decompensations .

56. Treatment – Afflicted individuals in 20th-century Malaysia have been exempted from legal or moral responsibility for acts committed while in a state of amok by means of a kind of “ insanity defense ,” which characterizes the attack as “ unconscious ” and beyond the subject’s control. Subsequently hospitalized, frequently received diagnoses of schizophrenia and were treated with antipsychotic medication.

57. ATAQUE DE NERVIOS Idiom of distress Latinos, Carribean , Latin American Cuba, Puerto Rico and the Dominican Republic. Epidemiology: Lifetime prevalence: 13.8% (Puerto Ricans)(1987) F: M = 1.8 – 2.5 : 1 Above age of 45 Less than high school education Divorced/ widowed/ separated Not employed

58. Characterized by symptoms of – Intense emotional upset Acute anxiety, anger or grief Screaming or shouting uncontrollably Attacks of crying Trembling, palpitations, chest tightness Heat in chest rising into the head Verbally or physically aggressive Feelings of imminent fainting A general feature is a sense of being out of control. Attacks can occur due to – Stressful event relating to family It can also occur without a clear precipitant

59. Prototypical episode : Exposure to a sudden stressful stimulus Initiation of the episode Rapid evolution of an intense affective storm Sense of loss of control. These are accompanied by : Bodily sensations Behaviours Cessation Return to ordinary consciousness and exhaustion. Partial/ total amnesia may follow

60. Relation to Psychiatric diagnosis: Most common: Panic disorder Others: Mood & anxiety disorders Intense fearfulness, feelings of asphyxia, and chest tightness suggestive of panic disorder emotion of anger & aggressive behaviour suggestive of mood disorder.

61. SHENJING SHUAIRUO Mandarin/ Chinese: Weakness of the nervous system China, Japan, Hong Kong & Taiwan Chinese classification of mental disorders 2-R 3 symptoms out of 5 For at least 3 months Weakness, emotional, excitement, nervous symptoms & sleep disturbances Included in ICD 10 as “neurasthenia”

62. Prototypical episode : Gradual onset Sense of powerlessness Various symptoms Sufferer seeks the sick role Amelioration of precipitating stress improves outcome

63. Epidemiology: 5.9 % unspecified neurasthenia 5.1% college population 6.4% 12 month prevalence Precipitants: Work related stress Study related stress Interpersonal/ family related stress Loss of face

64. Relationship with psychiatric diagnosis: Depression: 30 – 70 % Somatoform pain disorder: 47% Undifferentiated somatoform: 35% Treatment: Self help remedies Preference for non psychiatric settings Traditional Chinese medicines Polypharmacy

65. LATAH ( Malaysia,Indonesia ) AKA yaun (Burma), mali-mali (Philippines), bah- tsche (Thai), myriachit (Russia), I mu (Japan), Jumping Frenchmen (French-Canadian) Highly exaggerated responses to a fright or trauma : “ startle ” Screaming, cursing, dancing and hysterical laughter , involuntary echolalia, echopraxia , or trance-like states . More frequent in middle-aged women. Subjects are often in great demand at social occasions –will provide comic relief by uttering obscenities when provoked.

66. PIBLOKTOQ AKA Arctic hysteria Follows loss / perceived loss of a valued person or object Symptoms : Last for few minutes brooding, depressive silences loss / disturbances of consciousness seizure-like episodes tearing off clothes fleeing or wandering rolling in snow speaking in tongues( glossolalia ) or echolalia

67. BILIS ( cólera or muina ) Underlying cause : strongly experienced anger or rage Latino groups view anger as a particularly powerful emotion that can have direct effects on the body and exacerbate existing symptoms Major effect : disturb core body balances ( ie . balance between hot & cold valences in the body & between material and spiritual aspects of the body) Symptoms : Headache trembling, screaming, stomach disturbances, loss of consciousness. Acute episode : chronic fatigue

68. Boufée delirante Sudden outburst Acute, nonaffective and non-schizophrenic psychosis Complete remission after an acute episode. Under age 30 Strikes "like a thunderbolt."   West Africa and Haiti, Caribbean Sometimes accompanied by visual , auditory hallucinations or paranoid ideation. Episodes may resemble brief psychotic disorder.

69. BRAIN FAG/ BRAIN FOG College or high school students. Symptoms : difficulties in concentrating, remembering, thinking Students often state that their brains are fatigued. Additional somatic symptoms are usually centered around the head and neck pain, pressure or tightness, blurring of vision, heat, burning sensation United States : among the elderly West Africa In sub saharan area : m ost common among young men pursuing a western-style education. An idiom of distress in many cultures, and resulting syndromes can resemble certain anxiety, depressive, and somatoform disorders.

70. WINDIGO(NE US) AKA witiko , witigo ( Algonkian name-mythical monster) Rare, historic accounts of cannibalistic obsession. Traditionally , ascribed to possession, with victims(usually male) turning into cannibal monsters. Symptoms : depression, homicidal or suicidal thoughts, delusional, compulsive wish to eat human flesh. Most victims were socially ostracized or put to death. Earlier , episodes described as hysterical psychosis, precipitated by chronic food shortages and cultural myths about starvation and windigo monsters.

71. FALLING-OUT / BLACKOUT Primarily in southern US and Caribbean groups. Characterized by a sudden collapse, which sometimes occurs without warning but is sometimes preceded by feelings of dizziness or a “swimming” in the head. Eyes are usually open, but the person claims an inability to see. They usually hear and understand what is occurring around them but feel powerless to move.

72. GHOST SICKNESS A preoccupation with death and the deceased (sometimes associated with witchcraft) Observed among members of many American Indian tribes. Symptoms attributed : bad dreams, weakness feeling of danger, loss of appetite fainting, dizziness, fear, anxiety hallucinations, loss of consciousness, confusion feelings of futility, & a sense of suffocation.

73. HWA-BYUNG AKA wool- hwa - byung Korean folk syndrome : ” fire sickness” “anger syndrome” Attributed to suppression of anger Symptoms include insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, anorexia, dyspnea , palpitations, generalized aches & pains, feeling of mass in epigastrium . >75% in women

74. LOCURA Latinos in U.S. and Latin America Severe form of chronic psychosis. Attributed to an inherited vulnerability, to the effect of multiple life difficulties, or to a combination of both factors. Symptoms include incoherence, agitation auditory and visual hallucinations inability to follow rules of social interaction Unpredictability & possibly violence.

75. MAL DE OJO Widely found in Mediterranean cultures Spanish phrase : “ evil eye” Children & infants are especially at risk Symptoms include : fitful sleep, crying without apparent cause, diarrhea , vomiting and fever . Sometimes adults (especially women) have the condition.

76. QI-GONG PSYCHOTIC REACTIONS Acute, time-limited episodes characterized by dissociative, paranoid, or other psychotic or nonpsychotic symptoms May occur after participation in the Chinese folk health-enhancing practice of qi -gong (exercise of vital energy) Especially vulnerable are persons who become overly involved in the practice Included in CCMD-2.

77. ROOTWORK A set of cultural interpretations that ascribe illness to hexing, witchcraft, sorcery , or evil influence of another person Symptoms : generalized anxiety , G.I. complaints (e.g., nausea, vomiting, diarrhea ), weakness, dizziness, the fear of being poisoned, and fear of being killed (voodoo death) Roots, spells, or hexes can be put or placed on other person, causing a variety of emotional and psychological problems

78. ROOTWORK Hexed person may even fear death until the root has been taken off ( eliminated ), usually through the work of a root doctor (a healer in this tradition), who can also be called on to bewitch an enemy. Found in the southern U.S . among both African-American and European-American populations and in Caribbean societies. AKA mal puesto / brujeria in Latino societies

79. SANGUE DORMIDO “ sleeping blood ” Portuguese Cape Verde Islanders & immigrants to the United States Symptoms : pain, numbness, tremor, paralysis , convulsions, stroke, blindness heart attack, infection, and miscarriages

80. SHIN-BYUNG A Korean folk label Initial phases characterized by anxiety and somatic complaints general weakness, dizziness, fear, anorexia, insomnia, gastrointestinal problems Subsequent dissociation and possession by ancestral spirits.

81. SPELL A trance state in which persons “communicate” with deceased relatives or spirits Associated with brief periods of personality change Seen among African-Americans and European-Americans from the southern United States Spells are not considered to be medical events in the folk tradition but may be misconstrued as psychotic episodes in clinical settings.

82. SUSTO “soul loss” Folk illness: Latinos (US) & people in Mexico, Central America, and South America. AKA espanto , pasmo , tripa ida , perdida del alma, chibih , lanti , mogo laya , el miedo . Attributed to a frightening event that causes the soul to leave the body and results in unhappiness and sickness. Experience significant strains in key social roles Symptoms may appear any time from days to years after the fright is experienced Extreme cases can result in death.

83. TAIJIN KYOFUSHO(Japan ) AKA shinkeishitsu , anthropophobia Culturally distinctive phobia which Resembles social phobia Fear of social contact (especially friends) Extreme self-consciousness (concern about physical appearance, body odour, blushing) Fear of contracting disease. Somatic symptoms : head, body & stomach aches, fatigue, and insomnia Included in Japanese diagnostic system for mental disorders.

84. HIKIKOMORI (Japan)

85. HIKIKOMORI (Japan) A form of severe social withdrawal characterized by adolescents and young adults who become recluses in their parents’ homes, unable to work or go to school for months or years A national research taskforce of Japan further condensed this definition into the following description: “the state of avoiding social engagement (e.g., education, employment, and friendships) with generally persistent withdrawal into one’s residence for at least 6 months as a result of various factors

86. Proposed Criteria : The person spends most of the day and nearly every day confined to home. Marked and persistent avoidance of social situations (e.g., attending school, working) and social relationships (e.g., friendships, contact with family members). The social withdrawal and avoidance interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships. The person perceives the withdrawal as ego-syntonic. In individuals aged less than 18 yr, the duration is at least 6 months. The social withdrawal and avoidance are not better accounted for by another mental disorder

87. COURSE & PROGNOSIS Limited data on the longitudinal course of patients with culture-bound syndromes Suggest that some of them eventually develop clinical features compatible with a diagnosis of schizophrenia, bipolar disorder, cognitive disorder, or other psychotic disorders. Gathering information from all possible sources is crucial. As clinical pictures evolve over time, thorough re evaluations should be conducted periodically to refine the diagnosis and improve clinical care.

88. TREATMENT D etermining whether the symptomatology represents a culturally appropriate adaptive response to a situation. Clinicians are well advised to (1) know or search out the demographics of the local population or catchment area being served. (2) recognize that always a local pattern exists of conceptualization, naming, vocabulary, explanation, and treatment of patterns of distress that afflict a community, including mental disorders. (3) talk with the family and learn about local customs or search out other modes of documentation. Persons within the culture almost always recognize that one of their own is acting in a deviant manner, and their input can be extremely valuable in making an assessment of mental disorder.

89. TREATMENT Insight into the dynamics of the patient's world facilitates the clinician's efforts to adapt his or her techniques (e.g., general activity level, mode of verbal intervention, content of remarks, tone of voice) to the patient's cultural background. Implies acceptance of, and respect for, the patient's cultural frame of reference and opens the possibility of direct intervention in the lives of patients, who may be willing to cooperate when they feel understood.

90. CRITIQUE There is still ongoing debate about the status of the syndromes with two school of thoughts – Some feel it is essential to recognize these disorders as separate entity and give the adequate importance. Others believe that separate classification of these symptoms would lead it its neglect by clinicians as they would be considered irrelevant due to its cultural specificity. Also the underlying cultural aspect might be lost in the process. One set of debates focuses on the relationship between the culture-bound syndromes and psychiatric disorders according to predominant symptom

91. CRITIQUE N.N.Wig (1994) cautions that separately categorizing CBS will not necessarily improve the management of these cases in the country’s health services. Littlewood (1996) argued that abandoning CBS includes an option that all psychiatric illnesses are culture bound and recognizing the cultural aspect will make culture bound patterns as an afterthought. In the face of globalization the CBS are likely to disappear in the increasingly homogenous word culture.

92. CRITIQUE The relabeling of ‘culture bound syndromes’ as ‘cultural concepts of distress’ is a welcomed change. Future direction remains unclear with lack of epidemiological studies and whether the CBS should be classified as a separate disease entity or be explained on the basis of predominant presenting features and associated DSM or ICD diagnoses is up for debate.

93. REFERENCES Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9E Diagnostic and Statistical Manual 4 TR by APA Diagnostic and Statistical Manual 5 by APA Cross-cultural Psychopathology FANNY M. CHEUNG Cultural Bound Syndromes in India: Vishal Chhabra , M.S. Bhatia, Ravi Gupta Culture-bound syndromes : the story of dhat syndrome A. SUMATHIPALA, S. H. SIRIBADDANA and D. BHUGRA PCNA : Culture bound syndromes, Levine and Gaw , https://www.researchgate.net/publication/14655778_Culture-bound_syndromes www.google.com (images)

94. THANK YOU