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1. Introduction: Development Of The Concept And Deﬁnition
The concept of ‘culture-bound syndromes’ has been the focus of an ongoing debate in the ﬁeld of transcultural or comparative cultural psychiatry between psychiatric universalists who interpret these conditions as cultural elaborations of universal neuropsychological or psychopathological phenomena, and cultural relativists who see them as generated and expressive of distinctive features of a particular culture. The 8th edition of Kraepelin’s textbook of psychiatry in 1909 was the ﬁrst handbook describing clinical pictures which were later labeled ‘culturebound syndromes,’ namely latah, koro, and amok. In the past the term ‘exotic’ was used to emphasize the non-Western character of culture-related conditions. It was not anticipated then that a disorder such as anorexia ner osa in young women would become common due to sociocultural factors operant in modern Western society, so that it has now been recognized as a Western culture-reactive syndrome (DiNicola 1990). The concept of culture-speciﬁc psychiatric disorders was originally introduced into psychiatric literature in the 1950s and 60s by Yap, who also made the ﬁrst attempt to order what he called ‘culture-bound reactive syndromes,’ known under a great variety of folk names, in a diagnostic classiﬁcation schema (Yap 1967).
A list of 168 so-called culture-bound syndromes was compiled in a glossary by Hughes (1985), while the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition, contains a glossary with 25 entries. These listings also include colloquial and local names for some well-known ubiquitous conditions. The Diagnostic Criteria for Research of the 10th Revision of the WHO International Classiﬁcation of Diseases list 12 examples of ‘culture-speciﬁc disorders’ and suggest diagnostic codes while also stating that these conditions cannot be easily accomodated in established psychiatric classiﬁcations. Indeed, attempts at a nosological classiﬁcation of culturally related syndromes have never been quite satisfactory due to (a) the overlap of diagnostically relevant symptoms, and (b) the fact that the various indigenous terms for similar syndromes are charged with diﬀerent culture-speciﬁc meanings and traditional interpretations that codetermine the illness behavior of the patient and the reaction of the human environment.
On the basis of the data to be presented in this research paper, culture-speciﬁc psychiatric disorders are deﬁned as clusters of symptoms and behaviors that can be plausibly related to speciﬁc cultural emphases, or to speciﬁc sociocultural stress situations, which are typical of a particular population.
2. Local Folk Idioms Of Distress
Local folk idioms of distress for psychologically stressful situations that can occur in any culture are not signiﬁers of culturally speciﬁc disorders although the manifestations are inﬂuenced by the local culture. Susto, espanto, miedo are colloquially equivalent Spanish terms implying an experience of fright or scare, widely used among Hispanic populations of the Western hemisphere for a great variety of symptoms (Rubel et al. 1985). The conditions so labeled frequently resemble neurotic or somatoform syndromes but may also be caused by other kinds of disorders, including organic pathology. The Spanish word nervios is often used among Hispano-American and Caribbean populations, as is the English term nerves among rural Anglo-American groups, to denote chronic dysphoric mood states with various somatic manifestations especially in postmenopausal women under psychosocial stress, as is commonly encountered also in other cultures. The Spanish term ataque de nervios is, among Hispanic populations of Central and North America and the Caribbean, applied in reference to women showing a brief episode of behavioral discontrol as immediate reaction to any emotionally traumatizing experience (Oquendo 1994). Middleaged Korean women, like those in other cultures, may react to stressful life situations and ongoing marital or family problems, with depressed mood, feelings of anger, and somatizing complaints, typically of a sensation of an epigastric mass. This chronic dysthymia is known among Koreans and Korean–Americans as hwa-byung, ‘ﬁre disease,’ and traditionally treated by female shamans (Lin 1983).
3. Culturally Stereotyped Reactions To Extreme Environmental Conditions
Certain behavioral reactions to extreme environmental conditions are culturally stereotyped although they are not truly culture-speciﬁc. This is the case with conditions generally subsumed under the heading ‘arctic hysteria,’ a term used by outside observers for the often dramatic behavioral reactions shown by indigenous inhabitants of arctic and subarctic areas in stress situations in which the person aﬀected experiences a temporary state of dissociated consciousness induced by acute anxiety (Foulks 1972). Physical deprivation, mineral and vitamin deﬁciencies, as well as the psychological stresses of surviving in an extreme climate, were adduced to explain these phenomena which have practically disappeared as the traditional Eskimo way of life has largely been abandoned.
Frequently cited in the ethnological literature are pibloktoq (Inuit, ‘crazy’) among Eskimo in Greenland, arctic Canada, Alaska, and Siberia, and kayaks immel (Danish, ‘kayak dizziness’) also called kayakangst, among seal-hunting Greenlanders. Pibloktoqtype attacks usually aﬀected younger women who after a prodromal phase of anxious and irritated behavior started imitating animal calls, then suddenly became agitated and, screaming loudly, rushed into the snow or even into icy water, albeit not too far oﬀ so that they were easily rescued. The motor excitation ended with collapse or sometimes with convulsive movements, followed by deep sleep. There was only a vague recollection of the event which, in traditional culture, was attributed to possession by evil spirits.
Attacks of kayak-s immel occurred among seal hunters experiencing extreme isolation and sensory deprivation when sitting lonely and motionless in the kayak, surrounded by the monotonous whiteness of the arctic sea, waiting for a seal to appear. In this situation the hunters might suddenly fear the kayak was ﬁlling with icy water when they had a sensation of coldness in the legs. In a state of mounting anxiety they felt dizzy and unbalanced; were trembling and sweating, paralyzed with panic anxiety and subject to illusional perceptions. With help coming in time they could reach shore safely but more intense attacks followed on other trips so that they had to give up kayak hunting.
In the past, frequently referred to as a culturespeciﬁc condition of the Algonquin Indian tribes of northern Canada, was the ‘windigo (witiko) psychosis,’ described as an obsessive murderous desire for human ﬂesh under the delusion of being possessed by, or turning into, the mythical cannibalistic Windigo monster with a heart of ice, said to appear during severe subarctic winters. The struggle for survival in the harsh northern climate may have led to isolated instances of famine cannibalism but a critical examination of the many reports of ‘windigo psychosis’ could not conﬁrm a single case of cannibalistic compulsion (Marano 1982). The term windigo is today used among the northern Ojibwa to denote a state of deep depression, without implication of cannibalistic impulses.
4. Syndromes Related To Speciﬁc Cultural Emphases Or Speciﬁc Socio-Cultural Stress Situations
4.1 Syndromes Related To A Cultural Emphasis On Fertility And Procreation
4.1.1 ‘Genital Shrinking’ Syndrome. The MalayoIndonesian term koro and the Mandarin Chinese term suo-yang (Cantonese suk-yang) denote ‘shrinking of the penis.’ These terms refer to an acute state of panic anxiety prompted by the belief of the affected male person that his penis is shrinking and will disappear, and of the aﬀected female person that her breasts and/or labia are shrinking. The ‘genital shrinking’ is believed not only to lead to impotence and/or sterility but to death once the organs are completely retracted. This syndrome came to the attention of European psychiatry in the late nineteenth century through reports by colonial physicians working in South East Asia and through the growing interest in traditional Chinese medicine. Chinese traditional medicine interprets suo-yang as yin–yang imbalance due to deﬁciency of the ‘warm’ male principle yang and excess of the ‘cold’ female principle yin, so that vitalizing yang remedies are indicated.
For the theorists of psychoanalysis, koro served as the concrete example of Oedipal castration anxiety, while some Chinese authors like Yap saw in suo-yang the paradigm of a true culture-bound syndrome, assuming that the disorder itself was generated by the suggestive eﬀect of traditional Chinese concepts. However, it has since been ascertained that the typical ‘genital shrinking’ syndrome also occurs not infrequently among Asian and African populations without Chinese cultural inﬂuence. Complaints of genital shrinking are also occasionally verbalized by Western patients but these cases are diﬀerent from the culturally related ‘genital shrinking’ syndrome as they are associated with other, usually chronic, neurotic, psychotic, or organic conditions; and the patient’s ethnic– cultural group in Western society does not share the belief in the reality of genital disappearance and ensuing death. Koro suo-yang is the only culturally related syndrome that has occured in major epidemic outbreaks. Epidemics of ‘genital shrinking’ have been repeatedly reported in recent decades (Jilek 1986). Outbreaks in Singapore, Thailand, North East India, and South China were precipitated by collective anxieties over perceived threats to the security or even survival of the aﬄicted population; in Nigeria by fears of magic robbing of the genitals.
4.1.2 ‘Semen Loss’ Syndrome. Known in the traditional medicine of China as shen-k’uei, ‘weakness of the kidneys,’ in the Ayurvedic medicine of India as dhat (from Sanskrit dhatu, essential body substance) or jiryan, in Sri Lanka as sukra prameha, the complaint of ‘semen loss’ is not uncommon among young men of these countries in which a high premium is placed on reproductive capability and semen is considered a precious elixir of life. The presented symptoms have a hypochondriac quality; they are associated with an anxious and dysphoric mood state and typically attributed to the imagined loss of sperm in urine or to natural nocturnal emissions (Paris 1992). Sperm loss is assumed to cause the symptoms of general weakness, loss of energy, exhaustion, difﬁculty concentrating, sexual dysfunction, and rather vague somatic complaints. Many of these patients consult practitioners of traditional medicine as well as medical doctors; as immigrants they are also increasingly seen in European and North American clinics.
4.2 Syndromes Related To A Cultural Emphasis On Learnt Dissociation
4.2.1 Latah-Type Reactions. The peculiar latah reactions have been cited by cultural relativists as a paradigm of culturally generated behavior (Kenny 1978), and by biopsychological universalists as cultural elaborations of the neurophysiological startle reﬂex (Simons 1996). Latah reactions were interpreted by Gilles de la Tourette as a variant of his neurological syndrome, and by Kretschmer as a phylogenetic mechanism. The complete latah syndrome consists of an initial startle response provoked by a person of certain social status and triggered by a visual, acoustic, or tactile stimulus, the sensitivity to which is both individual and culture-speciﬁc. The startle response induces an altered state of consciousness, associated with repeated impulsive utterance of sounds or inarticulate words, often also swearing with sexual or obscene words (‘coprolalia’). Characteristic are echopraxia, echomimia, and echolalia, namely the exact imitation of the provoking person’s movements, facial and oral expression; even of words and sentences spoken in foreign languages. Automatic obedience to commands may occur in hypnoid trance and serve the amusement of onlookers. The latah syndrome can sometimes culminate in a brief state of cataleptic rigidity. Because of the typical echo symptoms, latah reactions are known in French psychiatry as ne roses d’imitation.
Automatic imitation behavior has also repeatedly been observed in normal indigenous people during ﬁrst contact with Europeans, as already reported by Charles Darwin from Tierra del Fuego and more recently from remote areas of Melanesia (Gajdusek 1970) and East Africa (Jilek-Aall 1979). The typical latah syndrome occurs mostly in females over two geographic zones (Winzeler 1995): the South East Asian zone, encompassing Malaysia, Indonesia (latah, ‘nervous, ticklish’), Thailand (bah-tshi, ‘tickle-crazy’), Burma-Myanmar (yaun, ‘ticklish’), the Philippines (mali-mali); the North Eurasian zone, encompassing the Ainu people of Hokkaido and Sakhalin (imu, ‘startle’), aboriginal peoples in Mongolia and Siberia (Russian, miryachit), and the Sami of northernmost Europe (‘Lapp panic’). The varied ethnic groups of these two latah zones have no culture traits in common other than (a) learnt dissociation which is practiced from early youth on in religious, social, and therapeutic ceremonies, trance rituals, and shamanic seances; (b) learning by imitation and coping by copying the behavior of persons who appear to be more powerful. Sporadic occurence of latah symptoms has been reported among some males in ArabicIslamic populations of North Africa and Yemen, and among South African Bantu people. While European cases are rarely encountered elsewhere, the endemic and familiar incidence of so-called ‘jumping,’ a reaction similar to latah, among males of French Canadian background in certain rural areas of Maine, New Hampshire, and Quebec, has attracted scientiﬁc interest since the 1870s.
4.2.2 Amok-Type Reactions. The term amok is originally derived from the Portuguese–Indian amuco, referring to heroic warriors ready to die in battle who are immortalized in Malayan epics, similar to the berserkr in ancient Norse sagas. Today, ‘running amok’—likewise ‘going berserk’—has become a colloquial label for any episode of apparently unprovoked randomly aggressive and homicidal behavior, usually engaged in by attention-craving angry young men in modern Western society. Although such behavior has certain features in common with the amok reaction observed among Asian amok-runners, it does not represent the speciﬁc dissociative syndrome described under this term (Pfeiﬀer 1994). Typical amok reactions are preceded by a dysphorictense mood state in the context of perceived or imagined social adversity or slight, loss of prestige or status, interpersonal or socioeconomic problems. A sometimes trivial event then triggers the actual amok reaction. After a phase of meditative brooding an alteration of the state of consciousness ensues in which visual perception changes: the outside world turns into darkness or becomes red, threatening visions may appear, causing feelings of fear or rage. The aﬀected person is suddenly seized by hypermotility and embarks on the amok run, a discharge of aggression leading to random destruction and killing, and eventually to suicide or suicide attempt. In case of survival, the attack is terminated by stuporous sleep; afterwards amnesia is claimed for actions committed.
Amok reactions have been presented as speciﬁc to the male ethos of Malayo-Indonesian culture. Such reactions also occur among related ethnic–cultural groups in the Philippines and in Laos. However, there are also typical amok cases in Papua New Guinea (Burton-Bradley 1975), besides the common nonviolent pseudo-amok, the psychodramatic ‘wild man behavior’ of New Guinea highlanders. In historical analysis, amok in Southeast Asia appears to have changed from a gloriﬁed warrior ethos and means of social protest of the precolonial era, to a dissociative reaction, which in more recent times is mainly found in marginal ﬁgures or as an episode during the course of a chronic mental disorder (Murphy 1973).
4.3 Syndromes Related To A Cultural Emphasis On Presenting A Pleasing Physical Appearance: Taijinkyofu Reactions
In contrast to the condition commonly diagnosed in Western psychiatry as social phobia, the Japanese form of anthropophobia, taijin-kyofu (‘fear in relation to others’), is not a phobic avoidance of social contacts in order to avoid unpleasant feelings for oneself; rather it is the fear that one’s external appearance may be disturbing or oﬀending to the other who as a rule is neither a stranger nor a close relation but a respected acquaintance. Symptoms of taijin-kyofu were already mentioned in the eleventh century Genji saga by Lady Murasaki Shikibu, and detailed clinical descriptions suggest this condition to be typical of Japanese culture (Kimura 1995). However, this type of anthropophobia is also not uncommon in Korea (Lee et al. 1994). The clinical syndrome taijin-kyofu was introduced into psychiatric literature in the 1920s by Shoma Morita as a subtype of the nervous temperament (shinkeishitsu) that he considered to be the main indication for his ‘Morita Psychotherapy.’ The syndrome is not uniform but occurs as one of several phobic anxiety manifestations: as erythrophobia (i.e., fear of blushing in front of others); as eye contact phobia (i.e., fear that others feel bothered when looked at); as body odour phobia (i.e., fear that one’s own assumedly oﬀensive body odour will bother others); as dysmorphophobia (i.e., fear of having an extremely unattractive, repulsive face or defective physique); or as fear that one will grimace or otherwise behave embarrassingly. The suﬀerers tend to be convinced of their imagined defects to a degree that their phobias appear delusional, and the presence of other psychotic symptoms has to be ruled out in order to delimit taijin-kyofu from a schizophrenic disorder. However, the anthropophobic patient’s relation to the human environment is fundamentally diﬀerent from that seen in chronic schizophrenic psychoses. Taijin-kyofu patients are neither autistic nor paranoid; they suﬀer from a fear of presenting themselves.
4.4 Syndromes Related To Acculturative Stress
4.4.1 Brain Fag. The term ‘brain fag,’ coined by Nigerian students, refers to a condition ﬁrst reported by Prince (1960). The brain fag syndrome has since been recognized in a high percentage of Nigerian students at home and abroad, and also in other African countries (Liberia, Ivory Coast, Uganda, Tanzania, Malawi, Swaziland) in students exposed to the acculturative stress of a Western-type education system emphasizing theoretical book knowledge, quite diﬀerent from the practical know-how and tribal lore acquired through oral traditions by older generations in Africa. It is noteworthy that subnormal intelligence, malnutrition, or physical disease do not account for the symptoms of brain fag which are also seen at educational institutions in Europe and North America among African students in good state of nutrition and general health. The brain fag syndrome is categorically diﬀerent from the general study stress and examination crises experienced by students from Western or Asian cultures with centuries of literary tradition and education systems already long-based on reading and writing and on memorizing texts for formal examinations. The brain fag syndrome is also clinically diﬀerent from the common complaints everywhere related to study stress: The mere eﬀort of reading may cause blurred vision and ﬂow of tears. There are also inability to concentrate on reading material and lectures, impairment of retention and memory, daytime fatigue and disturbed night sleep. Characteristic symptoms are the feeling of burning heat on head and body and the sensation of crawling as if caused by insects on, or by worms under, the skin.
4.4.2 Bouﬀee Delirante-Type Reactions. Clinical ﬁndings as well as research data indicate that acute transient psychotic and psychosis-like reactions occuring in African and Afro-Caribbean populations are disorders directly related to culture and culture change, and are encountered with increasing frequency in Africa (Jilek and Jilek-Aall 1970). Such reactions are characterized by intense fear of magical persecution or retribution and are usually triggered by an event or experience evoking acute anxiety in the context of beliefs in sorcery or witchcraft that persist or even increase under rapid sociocultural changes. Bouﬀee delirante-type reactions are of sudden onset and brief duration, they are associated with paranoid delusions, oneroid (i.e., dream-like) confusion, frequently also visual and auditory hallucinations, and often lead to dramatic and sometimes dangerous actingout behavior.
Anglophone psychiatrists have described transient psychotic and psychosis-like reactions in Africans under various terms while their francophone colleagues use the diagnostic label bouﬀee delirante, which was introduced into French psychiatry in the 1880s by Magnan and later redeﬁned by French-speaking authors in Africa in accordance with their clinical experience (Collomb 1965). The well-known Nigerian psychiatrist Lambo introduced the English term ‘frenzied anxiety’ and equated it with bouﬀee delirante (Lambo 1960). As repeatedly stated by Lambo and by other researchers, the main underlying causes for these states are not toxic–organic but sociocultural factors. Among these factors, of paramount importance is the stress exerted by rapid culture change which is leading to the social marginalization of many Africans in the process of ‘modernization,’ as recently also conﬁrmed in Swaziland (Guinness 1992). Under situations of urbanization and Westernizing acculturative pressures the traditional communalistic society is disintegrating and the supportive kin network is breaking down. The individual then experiences an increasing economic rivalry and social isolation which intensiﬁes the old fears of witchcraft and sorcery, never obliterated by Christianity, while the traditional protective and remedial resources are no longer readily available.
5. Culture-Speciﬁc Disorders vs. Traditional Ritual Behavior
Culture-speciﬁc psychiatric syndromes have to be diﬀerentiated from extracurricular but not pathological behavior in the traditional rituals of non-Western cultures. A Western-trained clinician who attaches pathology labels to behaviors and ideas that are considered normal in a non-Western culture, commits a ‘eurocentric fallacy.’ As a general statement it can be said that the culture-speciﬁc disorders are not part of ceremonials in which ritualized altered states of consciouness are induced and practiced for religious or therapeutic purposes. While such institutionalized trance and ‘possession’ states constitute culture-congenial behavior in certain ceremonials, the culturespeciﬁc syndromes described above are considered as abnormality or illness also by the indigenous experts of the culture and are explained in terms of a particular folk etiology which determines traditional therapeutic management.
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