Culture bound syndromes.pptx for postgra

Culture bound syndrome ppt for post graduates in psychiatry

1. CULTURE BOUND SYNDROMES CHAIRPERSON : DR.K.NARASIMHA REDDI (PROF & HOD) PRESENTER: DR.NITYA (2 ND YEAR PG)

2. SCHEME OF PRESENTATION Introduction History Definition Classification Characteristics Types Treatment References

3. INTRODUCTION Also known as culture related specific disorders/culture specific disorders or syndromes. In American handbook of psychiatry, exotic psychiatric syndromes or rare atypical unclassifiable disorders They all refer to certain illness or disorders which occur exclusively in certain cultures and not found in others. If particular cultural conditions are necessary for the occurrence of a syndrome, then it is called culture bound syndrome

4. HISTORY 1770, Captain Cook described Malaysian syndrome ‘amok’. Late 19th century, W. Gilmore Ellis described ‘amok’ and ‘ latah ’ 1895, Blonk described ‘ koro ’, in South China. In 1904 Emile Kraepelin initiated the field of comparative psychiatry through investigation of dementia praecox in Java, and he later documented psychiatric presentations among Native Americans, African Americans and Latin Americans

5. HISTORY CBS were first described in Kraepelin Textbook of Psychiatry, the 8th edition in 1909. It was the Chinese psychiatrist Yap who first introduced the term Culture Bound Syndrome in 1969. CBS were first described outside the west and so were thought to be only non-western conditions Culture-bound syndromes : The story of Dhat Syndrome.D.Bhugra et alBJP (2004)

6. WHAT IS CULTURE It refers to ideas , values, habits and other patterns of behavior which a human group transmit from one generation to other.

7. CULTURE BOUND SYNDROME Definition given by Prince in 1985. Collection of signs and symptoms which is restricted to a limited number of cultures primarily by reasons of certain of their psychosocial features. Denotes specific arrays of behavioral and experiential phenomena that tend to present themselves preferentially in particular socio-cultural contexts and that are readily recognized as illness behavior by most participants in that culture.

8. DSM -V Cultural concepts of distress refers to ways that cultural groups experience understood and communicate suffering, behavioral problems or troubling thoughts or emotions. Three concepts Syndromes Idioms Explanations

9. SYNDROMES Cluster 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 Ways of experiencing distress that may not involve specific symptoms/ syndromes but that provide collective, shared ways of experiencing and talking about personal / social concerns

10. EXPLANATIONS Labels, attributions or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness or distress.

11. CLASSIFICATION OF CBS

12. CLASSIFICATION BASED ON ILLNESS ATTRIBUTION INDUCED BY ANGER BILLS, COLERA OR MUINA & HWA-BYUNG INDUCED BY FRIGHT SUSTO & KESAMBET INDUCED BY WITCHCRAFT GHOST SICKNESS & ROOTWORK OR VOODOO INDUCED BY EVIL EYE MAL DE OJO INDUCED BY PERCIEVED ORGANIC DISTURBANCE DHAT & SANGUE DORMIDA INDUCED BY POSSESSION IDIOMS OF DISTRESS: 1. NERVOIS 2. LOCURA

13. COMMON CBS IN INDIA Possession syndrome Dhat syndrome Koro Bhanmati Gilhari syndrome Compulsive spitting Suchibhai syndrome Culture bound suicide ( sati,santhra ) Jhinjhinia Ascetic syndrome

14. QUESTIONNAIRES 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. The CFI is a brief semi structured interview Follows a person-centered approach The CFI is formatted as two text columns.

15. 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).

16. Malaya Indonesian cultural region Seems to occur only among Males. Dissociative episode. Period of brooding  outburst of aggressive, violent, homicidal behavior Precipitated by a perceived slight insult Persecutory idea, automatism, amnesia, exhaustion  return to pre-morbid level. AMOK

17. LATAH Malaysian / Indonesian origin Women Dissociative episode Hypersensitivity to sudden fright Exaggerated startle response following a traumatic episode Screaming , cursing, dancing and hysterical laughter lasting a half hour or more Imitate the people around them

18. DHAT Dhat derives from the Sanskrit word ‘ Dhatu ’ meaning ‘metal’ and also ‘elixir’ or ‘constituent part of the body’. First described in western texts by Wig (1960) South Asia Young males , low socioeconomic status

19. DHAT 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 and masturbation Anxiety & distress in the absence of any identifiable physiological dysfunction. Identified as a white discharge noted during defecation and urination Variant seen in women, with whitish vaginal discharge and similar psychosomatic symptom

20. KORO Malaysia Genitals shrinking into the body Characterized by 3 features Anxiety from a subjective experience of shrinking of their penis/breasts/labia Anticipate not only impotence , but also death. Mass hysteria

21. BRAIN FAG West Africa After an intensive period of intellectual activity Associated with college or high school students Watering or dry eyes, dizziness, difficulty in concentrating , pain, fatigue, difficulty sleeping, shaking hands, rapid heart beat.

22. ATAQUE DE NERVIOS Attack of nerves’ - Latino descent Symptoms of intense emotional upset  anxiety  physical & verbal aggression. Dissociative experiences , Sense of being out of control , seizure like or fainting episodes ,suicidal gestures are seen. Following a stressful event. Total or partial amnesia for the episode. Females , low Se status, disrupted marital status.

23. PIBLOKTOQ Arctic hysteria – in Arctic and subarctic Eskimos Abrupt dissociative episode Following the loss or perceived loss of a valued person or object Brooding, depressive silence, LOC, wandering, echolalia, tearing of clothes. Extreme excitement upto 30 min, followed by convulsive seizures upto 12 hours

24. WINDIGO PSYCHOSIS Mythical monster’ Reported among eskimos Supernatural being possess the individual  cannabalistic urges During times of starvation, symptoms concerning the alimentary tract, such as loss of appetite or nausea from trivial causes, may sometimes cause the patient to become greatly excited by the fear of being transformed into a windigo .

25. POSSESSION STATES Women, 15-35 years ,f:m ratio 2:1 India, Sri Lanka Following a sub-acute conflict or stress Nonspecific somatic complaints Altered behavior –stereotyped and culturally determined behaviors dramatic, Aggressive or violent actions, full or partial amnesia Possession is episodic Variable outcome Can be voluntary or Involuntary ,causing distress ,not a part of religious / cultural rituals

26. ‘Weakness of the nervous system’ – Mandarin Chinese. Syndrome composed of 3 out of 5 non hierarchial symptom clusters : weakness, emotions, excitement, nervous pain, sleep. Physical & mental fatigue with gradual onset. Social & interpersonal stressors  dysregulation of bodily channels conveying vital forces. Weakness and health imbalance due to depletion of vital energy. SHENJIN SHUAIRUO

27. FAMILY SUICIDE Seen in Japan when encountering severe difficulties like financial ruin or disgrace, Japanese parents may decide to commit suicide together with their young children. Based on the belief that it would be disgraceful to live after a shameful event has happened and that the shame would be relieved by taking one’s own lives. Also, coupled with the belief that young children, if left orphaned, would be mistreated by others

28. CARGO – CULT SYNDROMES There have been occurrences of crisis cults in many different Countries – The Taiping (Great Peace) Rebellion in China, Kikuyu maumau in Kenya, and The Ghost Dance of the Plains Indians of North America. Central to all these cultures are marked feelings of inferiority, conflict, and anxiety among the participants and an attempt to renovate their self-images for a new and better way of life .

29. One kind of crisis cult is the cargo cult ( melanesia ) as a means of obtaining the manufactured articles possessed by european invaders. Believed they were given to the white people by their powerful ancestors in return for performing rituals Accordingly, the local people tried to perform the white people’s rituals, in the hopes that their ancestors would send them a lot of cargo and their lives would eventually be full of wealth .

30. Presentation: Group of followers that gave up their normal lives to perform religious rituals, waiting for the arrival of the cargo, not only for several months, but for many years. Collectively deluded and led by a cult leader

31. TAIJIN KYOFUSHO (ANTHROPOPHOBIA) "Interpersonal fear disorder" in Japanese Characterized by anxiety about and avoidance of interpersonal situations due to the thought, feeling, or conviction that one's appearance and actions in social interactions are inadequate or offensive to others. Tend to focus on the impact of their symptoms and behaviors on others.

32. Onset- between 15-25 years of age Males > Females Characteristic: fear is manifested in the presence of people of intermediate familiarity such as classmates or colleagues This is different from social phobia described in western societies, where patients have fear of socializing with strangers.

33. Variants: Fear of facial flushing ( erythrophobia ), Fear of having an offensive body odor (olfactory reference syndrome), Fear of maintaining an inappropriate gaze (too much or too little eye contact), Fear of showing stiff or awkward facial expression or bodily movements Two types: Sensitive type: concern about how others might be viewing him Offensive type: concern about how he might be affecting others

34. GHOST SICKNESS Navajo – in American Indian tribes. Weakness ,bad dreams, feelings of danger, confusion. LOC, suffocation, fainting, dizziness, hallucinations. Preoccupied with death or with someone who died. Cause is considered to be ghosts / witches. May have hallucinations.

35. Voodoo Death and Sorcery Fear (Magic-Fear-Induced-Death Seen mostly in African-Americans and Hispanics. The typical voodoo ceremony includes short-lasting, voluntary, ritual-induced hysterical or psychotic states, trance-like states, convulsions, excitement and twilight states. The belief in the possibility of being involuntarily possessed by evil spirits induces chronic hysterical and psychosomatic symptoms.

36. There are the voodoo deaths or fatal consequences of the patient’s belief that he is the victim of black magic and of evil spell cast upon him. The underlying cause of death may be a state of shock produced by over stimulation of the sympathetic or parasympathetic systems. Many deaths may be due to poison, organic illness, or the victim's refusal of food and water.

37. FRIGOPHOBIA A rare type of chronic anxiety state characterized by fear of cold and fear of wind. Seen in China and Chinese immigrants in Australia and some parts of Central and South America Underlying belief: that cold and wind will misalign the delicate balance between yin and yang and that will lead to mental illness

38. Characterized by: Compulsive dressing in heavy or excessive clothes Avoidance of going out or to buildings with air conditioning Multiple somatic complaints following any exposure like headache, dizziness, chest pain, stomach ache, etc.

39. MALGRI SYNDROME Seen in some aboriginal tribes of Australia Associated with intense anxiety about being attacked by spirits called Malgri - which would occur if a person enters the sea without washing his hands after handling that land food. Symptoms: headache, abdominal pain, bloating, pain in the lower extremities and vomiting Believed to be cured only by washing themselves in freshwater or sea water depending on the case.

40. MALADI MOUN Humanly caused illness / sent sickness Haitian communities Interpersonal envy and malice harming their enemies by sending illness such as : Psychosis, depression, social/academic failure, inability to perform daily activities Young healthy children at risk Evil eye

41. ROOT WORK Southern US, Caribbean Mal puesto or brujeria Conviction that illnesses are brought about by supernatural means – witchcraft or evil influence Symptoms include anxiety, GI complaints and fear of being poisoned or killed.

42. ZAR North African and Middle Eastern society Possessed by a spirit  dissociative episodes Apathetic , withdrawn , unable to carry out daily tasks

43. China Sexual neurosis associated with excessive semen loss due to frequent intercourse, masturbation, nocturnal emission or passing of white turbid urine. Anxious, panic attacks & somatic symptoms Symptoms attributed to increased semen loss Women may be seen as stealing vital energy through sexual intercourse SHENKUEI

44. KUFUNGISISA Zimbabwe – idiom of distress – ‘thinking too much’ Causative of anxiety , depression, somatic problems Involves ruminating on upsetting thoughts Indicative of interpersonal and social difficulties

45. NERVIOS Idiom of distress Latinos in the US and Latin America State of vulnerability to stressful life experiences Emotional distress , Somatic disturbance , Inability to function Headache -‘brain aches, nervousness, stomach disturbances, sleep difficulties Irritability ,inability to concentrate, trembling, tingling

46. HWA BYUNG Korea – ‘fire illness’ Middle aged women , Lower socioeconomic status, rural families with H/O domestic trouble. Build up of unresolved anger Strong psychosomatic component – Anger experienced as heavy mass pushed up from abdomen into the chest Sleeplessness , dizziness, headaches, indigestion, sexual dysfunction etc.

47. BOUFFEE DELIRANTE West Africa ,Haiti Under age 30 Sudden outburst of agitated , aggressive behavior, marked confusion ,psychomotor excitement Acute ,non affective ,non schizophrenic psychosis Visual/auditory hallucinations + Complete remission

48. KHYAL CAP Panic attack like condition seen in Cambodia. Characterized by “ Khyal attacks” or “Wind attacks” Symptoms : Panic attacks, Dizziness, Palpitations, SOB, Cold extremities, Anxiety, Autonomic arousal Eg : tinnitus and neck soreness. Triggers: Worrisome thoughts; orthostasis ; specific odors with negative association ; agoraphobic type cues (crowded spaces or riding in a car)

49. LOCURA Latin America Chronic state of severe psychosis Multiple life stressors , inherited vulnerability or both Agitation , incoherence, unpredictability Auditory /visual hallucinations Inability to follow rules of social interaction and possible violence

50. SUSTO US , Mexico, Central America , South America Frightening event  unhappiness and sickness Low mood , low self worth ,lack of motivation, feeling of sadness, appetite disturbances and inadequate sleep Social and functional impairment Vegetative function impairment Somatic complaints –aches, pains, diarrhoea , pallor, cold extremities 3 syndromic types – MDD , PTSD, Somatic symptom disorder

51. TAIJIN KYOFUSHO Japanese - Interpersonal fear disorder Anxiety centered around the dread of hurting or offending others Tend to focus on the impact of their symptoms and behaviors on others 2 culture related forms – ‘sensitive type’ & ‘offensive type’ Concerns may have delusional quality

52. GILHARI SYNDROME Squirrel/lizard syndrome West Rajasthan Experiences a blood filled swelling on the body changing its position eventually reaching the neck blocks the airway Trusts the condition to be intense and lethal unless it has been removed. Medically due to contraction of particular group of muscles following serious tension & stress.

53. JHIN-JHINIA West Bengal It means Tingling and numbness Spreads all over the body astounded and unmoving crash on the ground Vanishes in a couple of hours Epidemic

54. MALIGNANT ANXIETY Seen in culturally marginal Africans Could be sporadic or endemic. Usually precipitated by new and stressful life situations Symptoms : Intense anxiety; Severe irritability that could sometimes lead to homicidal behavior; restlessness ; intense fear; subjective feeling of a change in his sense of self and reality though there is no personality deterioration or disintegration.

55. ASCETIC SYNDROME Depicted by Neki Adolescents and young adults Social withdrawal, sexual abstinence, practice of religious routines, lack of concern with physical appearance and considerable weight loss.

56. SUUDU South India – Tamil Males and females Excruciating pain in urination and pelvic heat Extreme abdominal torment, dark yellow urine, painful & burning micturition , headaches, fatigue, constipation, dry mouth. It is due to increase in inner heat of body often due to dehydration. Relieved by applying sesame oil or castor oil in navel / pelvic area, oil massage f/b warm water shower, intake of fenugreek seeds doused overnight in water.

57. SUCHI – BHAI SYNDROME Bengali term which means Obsessional neurosis. Widows Washing too often , washing of money , bathing for 4 hours twice a day, changing of street clothes, hanging clothes outside on a tree and enters house naked, hopping while walking, not eating anywhere outside, sprinkling cow dung water on all visitors, remaining immersed in holy river for most part of the day.

58. MASS HYSTERIA Mass hysteria is where hundreds to thousands of individuals apparently was accepting and carrying on in a way that they usually don’t. Atypical hysteria epidemic ( reported by choudhary et al.) in a tribal village of Tripura, India where 4 males and 8 females affected within a span of 10 days. It is self-limiting and the individual shows improvement in symptoms in the course of 1-3 days

59. The central feature of the episode is a trance state of 5 – 15 minutes with restlessness Attempts of self injury Running away Inappropriate behaviour Inablity to identify family members Refusal of food Intermittent mimicking of animal sounds.

60. CULTURE BOUND SUICIDE SATI: It is an act of self-immolation by a dowager on her spouse’s fire – bed. Seen in Brahmins & Kshatriyas . Prohibited in India since 19 th century. JAUHAR IN RAJASTHAN: It is a suicide conferred by ladies even before the passing of her husband when looked by prospect of shame from another man (normally an over coming lord)

61. SANTHARA / SALLEKHANA : In this people, deliberately surrender life by fasting unto demise over some undefined time frame for religious motivations to attain Moksha (salvation). Seen as a part of Jain community. It is believed that the individual (performing the act) will get rid of anger, ego, attachment, greed, old age and terminal illnesses.

62. GAS SYNDROME Most common complaints that are being heard from individuals coming to medical set up is ‘Gas’ or ‘ Vayu ’ etc. Individuals come up with a number of symptoms like abdominal discomfort, headache, chest pain, joint pains, somatic complaints, back pain attributing to gas.

63. Determining whether the symptomatology represents a culturally appropriate adaptive response to a situation Clinicians are well advised to Know or search out the demographics of the local population or catchment area being served Recognize that always a local pattern exists naming conceptualization, naming, vocabulary, explanation and treatment of pattern of distress that afflict a community, including mental disorders Talk with the family and learn about local customs or search out other modes of documentation TREATMENT

64. Persons within the culture almost always recognize that one of their own acting in deviant manner, their input can be extremely valuable in making an assessment of mental disorder. Treatment of possession syndrome It includes careful exploration of underlying stress which precipitated the possession attack Also to decrease any secondary gains patient may be getting from this behavior

65. Treatment of Dhat syndrome Wig suggested emphatic listening ,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 Sex education, relaxation therapy and medications. Sex education focuses primarily on anatomy and physiology of sexual organs. Treatment of KORO includes assurance and educational counselling

66. IMPORTANCE OF CULTURAL CONCEPTS To avoid mis -diagnosis. To obtain useful clinical information. To improve clinical rapport and engagement. To improve therapeutic efficacy. To guide clinical research. To clarify cultural epidemiology.

67. REFERENCES Kaplan and Sadocks Comprehensive Textbook of Psychiatry 10 th Edition Diagnostic and statistical manual of mental disorders 5 th edition International Journal of Current Research and Review ( Anuja kapoor -et -al) June 2018 (Cultural Specific Syndromes in India)