Introduction and History
Culture-specific diagnoses, also referred to as culture-bound syndromes, ethnic psychoses, and atypical culture-bound reactive syndromes, have been studied since the early eighteenth century. Culture-specific diagnoses encompass a diverse group of illnesses whose syndrome constellations are unique to certain cultural groups. While general medical conditions which localize to certain geographic regions or genetic groups have been historically included with the culture-specific diagnoses, the term is now primarily used to refer to mental health conditions. Culture-specific diagnoses are distinct from idioms of distress. Idioms of distress are a culturally unique presentation of coping with and expressing negative experiences and emotions (Kirmayer & Young, 1998). Idioms of distress are most commonly manifested as somatization with the body system and form of physical manifestation of the emotional distress varying by culture. Knowledge of both culture-specific diagnoses and idioms of distress is important in order to recognize treatment needs in immigrant populations whose culture-based illness presentations may vary from the native population.
A review of the terms race, ethnicity, and culture is helpful in the study of culture-specific diagnoses. The United States Department of Health and Human Services defines culture broadly as a common heritage or set of shared beliefs, norms, and values. Culture can be defined anthropologically as a system of shared understanding or meaning. Cultural beliefs are not static over time, but shift with changing moods and attitudes (Mental Health: Culture, Race, and Ethnicity A Supplement to Mental Health: A Report to the Surgeon General. Department of Health and Human Services, 1999). Additionally, one’s own cultural identification can also change over time. Immigrants to a new country can slowly alter their own cultural identity to reflect their new home. The term race is defined in a report to the United States Surgeon General not as a biological or genetic category, but rather a social categorization that is defined by the culture itself. Ethnicity, on the other hand, is a common set of historical experiences, rites, and shared language. While individuals of the same racial or ethnic group may consider themselves a part of the same culture, this is not always the case and should not be assumed.
As early as the eighteenth century scientists were identifying differences in illnesses based on the geographic origin of the sufferer. In 1733, George Cheyne, a Scottish physician practicing in England, wrote of disorders which he felt were more common amongst the English in The English Malady (Cheyne, 1733). He attributed these disorders of low spirit, nervous distempers, melancholy, and hypochondria to the cultural factors of poor diet, “manner of living,” and geographic factors including weather. By the late nineteenth century, the now famous Malaysian-specific disorders of amok and latah were identified by W. Gilmore Ellis (Prince & Tcheng-Laroche, 1987). In the 1950s and 1960s, P.M. Yap, a psychiatrist based at the Hong Kong University, wrote several papers examining these phenomenon commonly referred to at the time as “peculiar” (Tseng, 2006). He went through several descriptive terms for these illnesses and finally settled on the now commonly used term culture-bound syndrome in 1967. New disorders continued to be reported as mental health practitioners traveled to other lands, finding what they perceived to be unusual symptom constellations and “folk remedies.” In the 1970s and 1980s, there was an emphasis on the subgrouping of disorders and ways to conduct empirical studies comparing and contrasting disorders across cultures. By the 1990s, culture-specific diagnoses began to decrease somewhat in relevance as more emphasis was placed on cultural sensitivity and consideration in all facets of psychiatric diagnosis and treatment.
Classifications of Disorders
Because of the clinical similarities between certain culture-specific disorders, there has been a push to classify these diseases by their constituent behaviors (Simons & Hughes, 1993). A grouping of symptomatically similar culture-specific diagnoses was first referred to as a taxon by Ronald C. Simons, and the concept quickly spread (Simons, 1985). Sorting the culture-specific diagnoses into sets was meant to facilitate an appreciation of the similarities of distinct disorders. These groupings also served to facilitate easier study of the disorders with less distraction by the confounding influence of the foreignness of the given culture. Taxa (plural of taxon) allow for reconciliation of what are referred to as “orphan cases,” in which typical presentations of culture-specific diagnoses occur in other cultures. Simons suggested the following taxa: genital retraction, sudden mass assault, running, fright, startle matching, sleep paralysis, and cannibal compulsion. By arranging the culture-specific diagnoses in this manner, scientists can better study etiology and underlying psychological processes in related disorders. In the future, this may also allow for the study of genetic or neuro-imaging data.
The World Health Organization’s International Classification of Diseases 10th edition (ICD-10)’s Classification of Mental and Behavioural Disorders (World Health Organization, 1992), used by most European countries, does not include culture-specific diagnoses as diagnostic criteria. The authors instead cite the dwindling interest in a separate category for such diseases and the lack of “sound descriptive studies, preferably with an epidemiological basis.” The authors go on to suggest that these disorders can be considered local variants of existing mental disorders within the ICD-10 and, therefore, should be coded accordingly with additional notation as to the nature of the culture-specific disorder involved and any feigning of symptoms or attention-seeking behaviors observed.
The Diagnostic and Statistical Manual – 4th Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) includes a glossary of culture-bound syndromes. In the introduction, the authors define culture-bound syndromes as “recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV-TR diagnostic category.” The manual goes on to explain that culture-bound syndromes are localized to a specific society or culture and “frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences.” The DSM-IV-TR lists 25 of the most commonly encountered culture-bound syndromes in North American mental health practice.
Review of Culture-Specific Diagnoses
Over 200 disorders have been identified as being culturally specific. Many syndromes have multiple names in different languages, and there is a great degree of overlap between certain disorders (Simons & Hughes, 1993). Some disorders have fallen out of favor over the years. The following represents the most common and most studied culture-specific diagnoses arranged by geographic area.
Dr. Anitta Juntunen wrote in 2005 about the baridi syndrome among the Bena people of Tanzania (Juntunen, 2005). Through interviews with the local people, she was able to identify the signs and symptoms of this disorder as consisting of feelings of restlessness, fatigue, drowsiness, lack of appetite, and general feelings of illness. Advanced baridi was identified by joint deformity, extremity weakness, and mental disturbances. The Bena consider baridi to be caused by acting against the interests and norms of the tribe, being disobedient or critical of elders, neglectful in familial duties, using slanderous or insulting language, or breaking sexual taboos. Treatment is in the form of a return to cultural norms by apologies, gifts, and herbal remedies under the direction of a healer.
The DSM-IV-TR defines boufée délirante as a French term used to refer to a sudden outburst of agitation seen in West Africa and Haiti (American Psychiatric Association, 2000). There is typically irritable behavior, confusion, and psychomotor agitation. Hallucinations and paranoia may be present, causing a presentation similar to the DSM-IV-TR’s Brief Psychotic Disorder (American Psychiatric Association).
Johnson-Sabine and his colleagues reviewed discharge diagnoses of all patients discharged over a 4-year period in a Paris psychiatric hospital (Johnson-Sabine et al., 1983). They found that boufée délirante represented between 2% and 12% of all diagnoses in the 30 cases which they reviewed. When they compared the individuals who had been diagnosed with boufée délirante with those diagnosed with affective psychosis or schizophrenia, they found that the boufée délirante group was more likely to have been born outside of France and of foreign parentage, and that 40% had lived in France for less than 5 years.
Brain fag is listed in the DSM-IV-TR as a West African disorder typically affecting high school and university students (American Psychiatric Association, 2000). In response to academic pressures, students or others who work in academic fields experience an inability to concentrate, comprehend, read, or recall information, physical sensations of numbness or tingling, emotional presentations of sadness, irritability, or anxiety, or impaired sleep (Jegede, 1983). Individuals can have other somatic symptoms which focus on the head and neck and include muscle tension, pressure, pain, burning sensations, and blurry vision (American Psychiatric Association, 2000) or physiological disturbances of palpitations, tremor, weight loss, or breathing difficulties (Jegede, 1983).
Jegede studied 382 secondary school students in Ibadan, Nigeria, to see how common symptoms of brain fag were (Jegede, 1983). He found that the prevalence of symptoms ranged from 48.9% of boys and 45.6% of girls experiencing “heat in body” to 96.4% of boys experiencing headache and sleeping difficulties, and 98.9% of girls experiencing “crawling in body.” In 231 third year university students, he found frequencies ranging from 7.36% of students experiencing headaches to 65.37% experiencing “crawling feeling in the body” and 67.53% experiencing “heat in the head.” Jegede concluded that the symptoms commonly thought of as brain fag actually constitute not one disease entity, but multiple, with different etiological factors.
The DSM-IV-TR states that zar is a term used in several North African and Middle Eastern societies to refer to the possession of an individual by spirits (American Psychiatric Association, 2000). According to Grisaru, the word zar is Amharic and is a derivation of a pagan deity (Grisaru, Budowski, & Witztum, 1997). Women are particularly at risk for this condition which can be precipitated by physical ailments, infertility, or boredom. Individuals who have been affected typically present in a dissociative state. They may cry out, sing, laugh, shout or bang their heads. Longer possessions can be marked by withdrawal, and refusal to eat, drink, or carry out daily responsibilities (American Psychiatric Association). The village gathers in support of the afflicted and feasts and gifts are given to the possessing spirit to appease it. Many cultures do not see such behavior as abnormal. Grisaru found that some people experiencing zar actually find the experiences pleasurable and desirable (Grisaru et al., 1997).
Psychotic episodes of genital theft and retraction, similar to the Asian culture-bound syndrome koro, have been reported in Africa. Charles Mather (Mather, 2005) describes the case of an individual in Ghana who accused a stranger of genital theft. Cameroon, Nigeria, Gambia, and the Ivory Coast have all experienced mob lynchings of those suspected of removing men’s genitalia. In some parts of West Africa, the victims have been females with perceived shrinkage of breasts and changing or sealing off of the vagina. There have been several mass hysteria-like episodes in which several people in the same village or town are affected and frequently take justice into their own hands through violence. Some explain these experiences as the impact of juju or witchcraft (Dzokoto & Adams, 2005).
Amok is a dissociative episode characterized by a period of brooding, followed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects, according to the DSM-IV-TR (American Psychiatric Association, 2000). Episodes are also often accompanied by persecutory ideas, automatism, and amnesia. The violent acts are usually followed by exhaustion and a return to one’s premorbid level of functioning. This disorder appears to come from Malaysia, but similar behaviors have also been observed throughout Southeast Asia. Countries including Indonesia, Laos, Philippines, Polynesia, Papua New Guinea, Singapore, Sumatra, and Thailand, all have documented cases of amok. The first documented case came from Captain Cook in 1770 when he toured the Malaysian archipelagos (Haque, 2008).
The term amok is a Malaysian word meaning to engage furiously in battle and is also known amongst the Malay as matagelap, which literally means black before the eyes (Gaw & Bernstein, 1992). It is also the origin of the English phrase “running amok” (“Culture-Bound Syndromes,” n.d.). Some historians believe that amok dates back to ancient Indian warriors entering into a trance before battle. This hypnotic state allowed them to engage in combat without trepidation. These early warriors likely passed on their knowledge to the Malay people. Early Malay fighters would scream “amok” on the battlefield and with the knowledge of their predecessors they would fight without registering fear or pain. Malay fighters were instructed to engage in “fanatical charges, indiscriminant slaughter, and refusal to surrender” (Carr, 1978). Once Islam arrived to the islands, cases of amok were blamed on acts of religious fanaticism. Speculation exists that episodes were actually suicide attempts disguised as violence towards others. However, doubters argue that the Islamic faith opposes suicide and Malaysia is known to have one of the lowest suicide rates in the world. Nevertheless, one psychodynamic approach views amok as a projection of rage or an act against society instead of against oneself. Some of the folklore of Malaysia attributes cases of amok to evil spirits possessing an individual’s body and forcing him or her to engage in violent acts. Other tales portray amok as a culturally sanctioned means of expression. It is a vehicle for aggression in a society that encourages social responsibility and repression of anger.
Currently, the typical sufferer of amok is a male who has suffered a loss or has undergone a perceived insult. He is young to middle aged, isolated from his family and home, poorly educated, and from a low socioeconomic class. Others often describe the afflicted as quiet and withdrawn, but not uncommonly there exists a history of behavior problems, including immaturity, impulsivity, mood lability, and lack of accountability. Although isolated cases exist, most cases occur following exposure to similar behavior in others. Some theorists describe amok as a “transmittable” illness and argue in favor of a social learning process as the necessary ingredient for manifestation. Epidemic patterns usually emerge during times of political, economic, or sociocultural discord. Previously, the Malay people viewed amok as a mental illness, and the pengamok, or perpetrator, was felt not to be responsible for his acts of violence. However, amok episodes are now considered crimes and carry the potential for punishment by death. Interestingly, when the Malay culture shifted political views and amok became a crime as opposed to a mental illness, the number of cases declined. Now amok is considered to be a rare phenomenon, even though documented cases do still exist.
According to the DSM-IV-TR, latah is a hypersensitivity to sudden fright (American Psychiatric Association, 2000). It is a trance-like syndrome characterized by an extreme response to startling stimuli which is often accompanied with echopraxia, echolalia, command obedience, and dissociative behavior. Latah usually affects middle-aged women of Malaysian descent. Although it is thought to have originated in Malaysia, this disorder has actually been identified in many parts of the world. A symptomatic individual will typically demonstrate hyperfocused attention, defensive posturing, coprolalia, mimicry, and an extreme suggestibility that generally absolves them of any responsibility for their actions. Any attempts to control them are usually met with resistance. When startled, these individuals will drop or throw objects held in the hand and often will start to utter obscenities. Onlookers frequently find the behaviors amusing and victims may be intentionally startled for the enjoyment of others. Many scholars do not consider latah to be an illness, but instead view it as a culture-specific reaction to the innate startle reflex.
The DSM-IV-TR (American Psychiatric Association, 2000) defines koro as an episode of sudden and intense fear that the penis (in females, the vulva or nipples) will retract into the body and possibly cause death. This syndrome is typically found in south and east Asia and is identified by a number of local terms. Despite the majority of cases being grouped in the East, there are documented cases in non-Asian patients as well, leading to controversy over the true nature of the disorder. Popular belief states that the word koro is derived from the Malay word for tortoise, kuro, since the tortoise can retract its head into its shell. Koro consists of perceptual, cognitive, and emotional disturbances (Buckle, Chuah, Fones, & Wong, 2007). The misperception that the body part is receding into the body and subsequent cognitive distortion that this will cause death, ultimately leads to intense feelings of anxiety and panic. Koro exists in both epidemic proportions and, more rarely, as isolated occurrences. One researcher compiled a list of cases and only uncovered 19 individual episodes in 15 years (Bernstein & Gaw, 1990). Nevertheless, given the ease of immigration and the ability to travel worldwide, solitary episodes and pockets of illness may occur more often in Western society.
Epidemics of koro are believed to stem from the cultural attitudes of the people living in any given region. Chinese mythology holds that ghosts of the dead have no male reproductive organs and will disguise themselves in order to steal penises from the living. The hysterical response to this folk belief has facilitated an epidemic of koro on more than one occasion. Traditional Chinese medicine views koro as an imbalance of Yin and Yang. Good health derives from the dual power of these two forces, and, in cases of koro, the equilibrium is upset by sexual indulgence. Excessive sexual activity is thought to deplete the sperm, cause retraction of the genitals, eventually resulting in death.
Early psychoanalysts postulated that koro represents a version of Freud’s castration anxiety and that koro’s clinical features stem from underlying sexual conflicts. The biomedical approach frequently describes koro as a symptom of a medical condition as opposed to being its own illness. Koro-like symptoms have been reported in individuals experiencing heroin withdrawal, brain tumors, epilepsy, strokes, and HIV. Psychiatry has classified koro as a body image disturbance, a sexual neurosis, an acute panic reaction, a hypochondriacal stress response, a somatoform disorder, a psychotic disorder, a depersonalization disorder and a conversion reaction. Some feel the belief in retraction is an overvalued idea while others consider it to be a delusion (Bark, 1991).
Research has actually shown that a perception of penile shrinkage may be associated with a reduction in penile circumference, suggesting that some cases of koro may have a physical basis. Given the multitude of potential diagnostic categories, Albert C. Gaw proposed a decision tree to help classify this disorder. Initially, a treating physician must determine whether the genital retraction is a primary psychiatric disorder or is due to a preexisting medical condition. Then a provider would need to frame the disorder in its specific cultural context, and determine whether the koro episode is an isolated case or is occurring in the context of an epidemic. Finally, a diagnosis of Genital Retraction Disorder, Culture-Specific single case versus epidemic or Genital Retraction Disorder, Not Culture-Specific may be rendered.
According to the DSM-IV-TR (American Psychiatric Association, 2000), dhat is a folk diagnostic term used in India to refer to anxiety and hypochondriacal concerns associated with the discharge of semen. In colloquial terms, dhat is identified as a “neurosis of the Orient” (Sumathipala, Siribaddana, & Bhugra, 2004). Sufferers become severely preoccupied with the idea that they are losing semen in their urine and often present with associated feelings of fatigue and other vague somatic complaints. Open discussion about sexual issues is considered inappropriate in polite society, and those prone to overreaction may not have the necessary outlet in which to discuss misconceptions (Perme, Ranjith, Mohan, & Chandrasekaran, 2005). Innocent symptoms like fatigue may seem catastrophic when an individual simultaneously perceives his urine to be turbid or white in color. Cultural beliefs indicate semen loss is harmful to the body and, in a somatically preoccupied individual, any discoloration of the urine can lead to extreme health-related anxiety. The anxiety over semen loss traces back thousands of years to ancient Ayurvedic texts (“Culture-Bound Syndromes,” n.d.). According to the writings, semen is the most precious body fluid, and the loss of even a single drop might completely destabilize a person.
According to the DSM-IV-TR (American Psychiatric Association, 2000), hwa-byung is a Korean folk syndrome that translates into “anger syndrome.” Symptoms are thought to result from anger suppression and include indigestion, anorexia, dyspnea, insomnia, fatigue, and generalized aches and pains. Perhaps the most classic symptom is the sensation of a mass in the epigastric area, “the upper abdomen-lower chest is consistently identified as the primary site of the pathology by the patients” (Lin, 1983). Inner conflicts develop into a “blood-muscle lump” known as Hwa, and its presence is felt in the abdomen, although no evidence of its presence is found on physical examination (Pang, 1990). Unfortunately, all of the somatic complaints are rather resistant to medical treatment, and the epigastric mass sensation has driven patients to surgical interventions with little relief. Hwa-byung is considered to be chronic; one study suggested the duration was, on average, 10 years from the onset of symptoms. The causative stress is frequently identified as an extramarital affair or strained in-law relationships, although financial hardship and separation from family and social supports also qualify as stressors. These domestic situations provoke anger which the victim suppresses. Eventually, the anger manifests itself as an epigastric mass sensation along with a myriad of other somatic complaints. Prevailing theories suggest hwa-byung is a “means of expressing misery and despair without stigma” (Park, Kim, Kang, & Kim, 2001). Many sufferers consider the illness to be their destiny and suppress their anger according to cultural norms, knowing their symptoms will be recognized by others as socially acceptable. The suppressed anger is projected onto a body organ or system, and the patient deals with the resulting symptoms with resignation and acceptance, although many will still try to alleviate some of their discomfort with medical treatments. Korean culture emphasizes restraint and temperance, and it is considered a virtue to endure life’s misfortunes silently and without aggression, confrontation, or disobedience (Pang, 1990). Thus, sufferers view their illness as fate and translate their ire into physical problems that are culturally sanctioned.
Approximately 75% of hwa-byung cases are women. One survey found that the majority of female hwa-byung sufferers were of low socioeconomic status, lived in rural areas, used tobacco and alcohol, and were either divorced or separated from their spouse (Park et al., 2001). Many of those who were afflicted were aware that their illness was not necessarily physical, but were reluctant to view themselves as psychiatric patients. Sufferers retain insight as to the nature of their symptoms, but may prefer to utilize medical treatment alternatives rather than focusing on the emotional aspects of the illness.
The DSM-IV-TR (American Psychiatric Association, 2000) defines Taijin kyofusho as a culturally distinct phobia in Japan that parallels the symptoms of Social Phobia in the West. Taijin means interpersonal, and kyofusho means fear. Taijin kyofusho together refers to an individual’s intense fear that his or her body will somehow offend other people through appearance, odor, facial expression, or movement (Gaw, 2001). The dread of hurting or offending others typically takes one of four forms. Sekimen-kyofu is a phobia of blushing, shubo-kyofu is a phobia of a deformed body, jikoshisen-kyofu is a phobia of eye-to-eye contact, and jikoshu-kyofu is a phobia of foul body odor (“Culture-Bound Syndromes,” n.d.). The syndrome typically afflicts young people, and symptoms are most salient during interpersonal situations. Included in the official Japanese diagnostic system for mental disorders, taijin kyofusho is likely fueled by a cultural emphasis on proper behavior in all social interactions. Due to the conviction that they are repulsing others, sufferers will take showers, brush their teeth, and change their clothes on a frequent basis, and may ultimately avoid public appearances (Suzuki et al., 2004).
Given the variability of its presentation, taijin kyofusho likely exists on a continuum from transient adolescent social anxiety to fixed delusions. Currently the most common form is a fear of blushing, which affects young males who are in the adolescent stage of self-consciousness and feelings of insecurity (Suzuki et al., 2004). Prognosis is uncertain, but generally symptoms will attenuate in the fourth decade of life (Russell, 1989). However, some cases progress and take on the characteristics of more debilitating illnesses such as schizophrenia. More mild cases of taijin kyofusho typically result in symptoms only when in the physical presence of others and are limited to encounters with “intermediate-level persons” such as classmates, coworkers, and neighbors. Complete strangers would not induce high levels of anxiety, nor would family or intimate friendships. Serious cases involve individuals not actually present and take on more of a delusional quality such as the belief that one is polluting the entire neighborhood and offending everyone within its borders. Strangers and intimates alike create fear and the victim may become housebound. Mild sufferers seek psychiatric help for their affliction; serious sufferers often lack insight into their condition and opt for more radical measures such as surgery to remove their offending physical flaws. Ultimately, individuals with taijin kyofusho pursue treatment out of concern that they are offending their fellow man. Theorists argue that this “altruistic” attempt to correct a weakness mirrors the Japanese values of maintaining quality interpersonal relationships.
The DSM-IV-TR (American Psychiatric Association, 2000) describes shenjing shuairuo as a Chinese condition characterized by mental and physical fatigue, dizziness, headaches, and impairments of sleep, concentration, and memory. Made famous by Arthur Kleinman, the symptoms are often synonymous with Western diagnoses of Mood or Anxiety Disorders (Hall, 2006). China recognizes shenjing shuairuo in the Chinese Classification of Mental Disorders, Second Edition, and the syndrome is also identified by the term Neurasthenia. Neurasthenia is a designation that was once recognized by the DSM as a part of Western medicine, but the disorder has been omitted in recent revisions. However, it is still recognized by the World Health Organization’s ICD-10 (World Health Organization, 1992) classification system.
In translation, the term shenjing means “nervous system” and shuairuo means “weakness” (Gaw, 2001). It includes elements of depression and anxiety, and is frequently accompanied by gastrointestinal problems, sexual dysfunction, irritability, excitability, and other signs of autonomic dysfunction. At one time, it was the second most common diagnosis in Chinese psychiatric hospitals and one of the most common diagnoses overall. Neurasthenia, or “exhaustion of the nerves,” (Parker, Gladstone, & Chee, 2001) once served as a mark of status since the upper class were considered more susceptible to these health problems in the same way that ulcers or high blood pressure might indicate a person of important occupational status today (Hall, 2006). Since neurasthenia was considered to be a diagnosis of the elite, members of upper-class society were treated by the most respected physicians, and these patients were not stigmatized as “mentally ill.” Many neurasthenia patients are survivors of China’s Cultural Revolution, a violent mass movement that began in 1966 and ended officially with Mao’s death in 1976. The Cultural Revolution brought about widespread social, political, and economic upheaval. Many people developed symptoms of shenjing shuairuo in response to the economic chaos and massive social and political changes. Currently, the Chinese view the disturbance as a depletion of “qi,” which translates into “energy flow” and is believed to constitute a fundamental part of every living thing. Symptoms of various illnesses are often believed to be the result of interrupted or blocked qi movement through the body’s meridians, as well as deficiencies or imbalances of qi in multiple organ systems. The symptoms of shenjing shuairuo are not unique to China, and many societies across the globe have grouped similar symptoms together and label them according to their own cultural beliefs.
Bilis and Colera
The DSM-IV-TR defines bilis and colera as a group of syndromes in which extreme anger results in disturbances between the spiritual and physical aspects of an individual (American Psychiatric Association, 2000). These disorders, which can also be referred to as muni, demonstrate the belief by many Latino cultures that anger is a strong and dangerous emotion. Individuals who have been afflicted by bilis or colera can present with nervous tension, headache, trembling, yelling out, GI disturbances, or fainting (American Psychiatric Association, 2000).
Elizabeth Cartwright, Ph.D., identified coraje, a disorder similar to bilis and colera, during her time living among the Amuzgo Indians of Oaxaca, Mexico (Bender, 2003). While coraje has been translated as anger, this is an oversimplified Westernization of the disorder. The Amuzgo see coraje as a result of negative interactions and events in one’s life. When coraje befalls an individual, it is believed to settle on a specific body region which will present symptoms of the illness (Bender, 2003). For example, if it settles on one’s head, the victim may have headaches, or if it settles in the limbs, it may cause pain or weakness. Coraje can move about the body. Extra care, including the wearing of special belts, is taken by the Amuzgo to prevent the migration of the disorder to the heart which they believe can result in death. One of the cardinal features of coraje is the fact that it can be contagious. The weak, elderly, and young are at particular risk. As a result the community is very careful to not become angry with one another or yell which could spread the disease (Bender, 2003). Curing this ailment is undertaken by a “curandera” who combines elements of traditional tribal beliefs with Roman Catholicism.
Nervios and Ataque De Nervios
Nervios translates as “nerves” and ataque de nervios as an “attack of nerves (American Psychiatric Association, 2000).” These disorders seen in people of Hispanic background have been described in the literature for over 40 years. Nervios is a more general chronic condition in which an individual suffers a constellation of somatic symptoms in response to ongoing stress. These symptoms can range from insomnia and headaches to heart palpitations, body aches, and chest pain. It is generally associated with overwhelming worry. Interpersonal stressors such as family and relationship difficulties are a frequent cause of nervios. Ataque de nervios is a more acute disorder with an abrupt onset in reaction to an intense stressor such as the death of a loved one, accident, war, or learning extremely bad news. The manifestations of such an attack can include dizziness, faintness, shaking or seizure-like activity, and palpitations. Aggression can also occur, frequently in the form of verbal threats, swearing, striking out at others, or harming oneself (American Psychiatric Association, 2000). Such episodes can serve an adaptive role within the community of bringing together an individual’s family and friends for support in their time of need. Such brief and culturally accepted forms of ataque de nervios rarely necessitate the intervention of traditional or modern medical practitioners. It is only when the illness is long-lasting or atypical that help is typically sought.
Guarnaccia, Good, and Kleinman (1990) reviewed data suggesting that these nervous disorders presented with more numerous and more clinically significant symptoms amongst Puerto Ricans in New York City than other Hispanic groups. They found deficiencies in several of the prior studies, including the ways in which methodological differences and a lack of clear and consistent measures may have skewed results. Guarnaccia and his colleagues identified confounding factors that could increase the rate at which people of certain cultural backgrounds report mental and somatic symptoms, including the stigma associated with a given illness in the culture and the type of health care system an individual has been raised in (Guarnaccia et al., 1990). They also found that the immigrant role and its associated stresses may play a large part in the elevated rate of mental illness and severity of symptoms seen in Puerto Ricans in New York compared to native New Yorkers and Puerto Ricans who did not emigrate (Guarnaccia et al., 1990).
One of the major criticisms of the inclusion of nervios and ataque de nervios as distinct culture-specific diagnoses has always been their similarity to panic attacks and panic disorders. Meghan Keough and colleagues conducted a study in which more than 300 undergraduate students of different cultural and ethnic backgrounds were asked about their experiences of symptoms of panic attacks, ataque de nervios, and, as a test of reliability, koro (Keough, Timpano, & Schmidt, 2009). The names of the disorders were withheld to ensure the results were not confounded by an individual’s familiarity with the diseases. Twenty-five percent of the sample reported a lifetime experience of at least one episode consistent with ataque de nervios, while only 17% endorsed symptoms of a panic attack, and none reported a history of koro symptoms. They found that only 9% of respondents reported a history of both ataque de nervios and panic attacks. Such a low co-occurrence rate supports a clinical distinction between these two disorders. They found that neither self-identification as Hispanic, nor rate of acculturation as measured by the Multigroup Ethnic Identity Measure (MEIM) or Psychological Acculturation Scale (PAS) correlated with the rate of ataque de nervios. This finding suggests that ataque de nervios may be more universal than previously believed.
In contrast to the low co-occurrence rate found by Keough, Ester Salmán and her colleagues found high rates of panic disorders in Hispanic individuals with a history of ataque de nervios (Salmám et al., 1998). Salmán and her colleagues developed the Ataque de Nervios Questionnaire-Revised (ANQ-R) and administered it to 156 Hispanic individuals who had presented to a nonprofit anxiety disorder clinic in New York. Of those studied, 69.9% reported at least one episode of ataque de nervios. Of those who had a history of ataques, 41.3% also met criteria for panic disorder (with or without agoraphobia), 8.3% for generalized anxiety disorder, 4.6% for social phobia, and 8.3% for anxiety disorder not otherwise specified. They found no statistically significant difference in the specific ataque de nervios symptoms or coexisting psychiatric disorders between those respondents from Puerto Rico, Dominican Republic, or “other” Hispanic nationalities. The differences in co-occurrence rates in these two studies may be a function of the populations studied as Keough at al. interviewed a nonclinical sample of undergraduate students and Salmán et al. utilized individuals who had specifically presented for treatment at an anxiety clinic. Since individuals with “typical” ataque de nervios symptoms do not usually seek treatment, it would make sense that Salmán’s sample had more coexisting pathology based on the fact that they had sought out treatment at an anxiety clinic.
Falling Out/Blacking Out
The DSM-IV-TR (American Psychiatric Association, 2000) defines episodes of falling out or blacking out as “a sudden collapse, which sometimes occurs without warning,” but can be preceded by feelings of light headedness, dizziness, or a “swimming” feeling in the head. The person typically falls to the ground and feels unable to move. While their eyes are frequently open, they claim a lack of sight, though they can hear what is going on around them. Such episodes primarily occur in the southern United States and the Caribbean. The DSM-IV-TR comments that such episodes may correspond to a diagnosis of Conversion Disorder or Dissociative Disorder (American Psychiatric Association, 2000).
Weidman reviewed data collected from approximately 100 households comprised of various ethnic groups as part of a comparative study of health conditions, beliefs, and practices in inner-city Miami (Weidman, 1979). She found that 23% of the Bahamian sample reported instances of “blacking out,” while 10% of the Southern African American sample reported “falling out.” Weidman’s colleague, Lefley, reviewed Miami Fire Department’s “run reports” describing their emergency calls over an 8-month period (Lefley, 1979). She found that 12% of the 3,700 reports were for possible cases of falling-out. Of the possible falling-out cases African Americans represented over 49%, Latinos represented 21%, and non-Latin Caucasians represented 30%. They attributed the relatively low percentage of Latinos to their overall underrepresentation in total numbers of emergency service runs.
Locura is a “term used by Latinos in the United States and Latin America to refer to a severe form of chronic psychosis,” according to the DSM-IV-TR (American Psychiatric Association, 2000). Individuals who are believed to be suffering from locura typically present with symptoms of incoherence, inability to function in society, hallucinations, aggression, impulsivity, and bizarre behavior that is outside of socially acceptable norms (American Psychiatric Association, 2000). Locura is believed to be caused by repeated stressors in life, a familial vulnerability to the disorder, or a combination of the two. Individuals who have been identified by family and friends as having locura would benefit from an evaluation for schizophrenia or other psychotic disorders.
Pinaeros and his colleagues reviewed an “outbreak” of nine cases locura in an indigenous Columbian population in their 1998 article (Pinaeros, Rosselli, & Calderon, 1998). They presented with bizarre behavior, headaches, convulsions, and visions. Trials of antipsychotic medications, religious healers, and herbal remedies were unsuccessful and individuals only responded to shamans of the same ethnic origin. They concluded that the presentation was a reaction to the psychosocial stress of culture changes in their community.
Rootwork, according to the DSM-IV-TR, is a belief in the ability of an individual to influence another’s physical well-being with hexes, witchcraft, or sorcery (American Psychiatric Association, 2000). Physical symptoms can vary greatly and are believed to be the direct result of the type of supposed magic at work. Treatment is typically sought from a special healer or “root doctor.” While rootwork is primarily seen in the Southern United States and the Carribean, similar versions referred to as mal puesto or brujeria are present in Latin cultures. This condition is also very similar to mal de ojo, a Mediterranean belief in the ability of those who wish someone ill to effectuate that wish through the use of magic, referred to as “the evil eye” (American Psychiatric Association, 2000). Those who have been affected may exhibit crying, fever, poor sleep, or gastrointestinal distress.
Mathews wrote extensively of the traditional medical practice of African Americans which he identified as having roots in the “slave culture of the antebellum South” (Mathews, 1987). She identified illnesses which are conceptualized as “natural” under this framework, including hypertension, anemia, and diabetes, in contrast to those thought of as “unnatural,” including magical possession, fading, and magical poisoning. Natural illnesses are believed to be caused by blood imbalances that can be cured by natural substances, including food and herbs, while unnatural illnesses have their roots in magic and require treatment by a root doctor who can undo the harmful spells. She concludes by emphasizing that rootwork serves psychological and social needs which cannot be met by the general medical community and the importance of physicians to communicate with their patients in a culturally respectful manner.
According to Nicholas, DeSilva, and Grey (2006), séizisman or “seized-up-ness” is a disorder of Haitians in which an extreme emotion or unexpected event or situation brings on a physical reaction (Nicholas et al., 2006). The extreme emotion can be in the form of anger or joy and can be precipitated by learning of injury or death of a loved one or witnessing a fight. The physical consequences are believed to be a result of blood rushing to the head. This can result in difficulty breathing, weeping, confusion, or a state of paralysis. The effects can last from hours to days. Treatment is typically in the form of a rallying of social supports, massages, and herbal remedies. A particularly concerning form of Séizisman involves pregnant women and those who have recently delivered. In this group, an episode of Séizisman is believed to carry the risk of miscarriage, maternal death, premature delivery, deformations in the fetus, or tainted breast milk. As a result, it is common in this culture to delay the giving of bad news until after delivery, in an attempt to shield pregnant women from exposure to stress; special accommodations may be made if bad news or stress cannot be avoided.
The DSM-IV-TR states that susto is a disorder in which an extreme fright causes the soul to leave the body (American Psychiatric Association, 2000). Susto goes by many names, including espanto, pasmo, tripa ida, perdida del alma, and chibih, and is believed to affect Latinos in the Americas. The symptoms of susto are various and include sleep and appetite disturbances, pain, gastrointestinal disturbances, sadness, difficulty with social roles, or even death. There can be a delay between exposure to the stressor and the appearance of symptoms, and the illness can last for months or years. Treatment is often sought from indigenous healers who work to return the soul to the body and restore the balance between body and spirit.
Weller and her colleagues interviewed 200 subjects in a family medicine clinic in Guadalajara, Mexico, to determine if there was an association between a history of susto and current depressive symptoms (Weller, Baer, Garcia, & Rocha, 2008). Over 69% of the sample reported a past history of susto. They found that a history of susto was not significantly associated with age, marital status, educational level, income, or a rural background. Individuals who reported a history of susto had significantly higher levels of current stress and depressive symptoms than those who did not. Individuals with a prior episode of susto were twice as likely as those without it to have a high current likelihood of depression.
First identified by Abraham Brill in 1913, pibloktoq has also been referred to as Arctic hysteria (Dick, 1995). Pibloktoq was first observed in the Inuit people of Greenland and later in other arctic and subarctic Eskimo communities. The DSM-IV-TR defines pibloktoq as “an abrupt dissociative episode accompanied by extreme excitement of up to 30 min duration” (American Psychiatric Association, 2000). During the episode, the afflicted individual may shout obscenities, remove clothing, become aggressive, or eat feces. An episode may be preceded by social withdrawal or irritability. Following an attack, the individual may display convulsions and “coma” lasting up to 12 h. Seizure disorders should be ruled out in individuals who present with symptoms of pibloktoq as should excessive levels of vitamin A which can be found in high amounts in arctic marine life and mammals and which comprises a large part of many Eskimos’ diet and can cause similar symptoms (Landy, 1985).
Religious Experiences and Culture-Specific Diagnoses
Historically, certain religious beliefs have been considered culture-specific diagnoses. While these beliefs can impact presentation and treatment of mental illnesses, they should not be confused with culture-specific diagnoses. The belief in spirit possession is one such example that can be seen in many different religions, including the Caribbean religion of Santería (Alonso & Jeffrey, 1988). Santería is a combination of African and Catholic rituals and beliefs. One aspect of Santería involves festivals during which participants try to be possessed by spirits of saints. In 1988, Drs. Alonso and Jeffrey discussed clinical cases in which four individuals’ psychiatric presentation was confounded by their belief and practice of Santería. An important point made in their article is that while these beliefs are associated with culturally based religious practice, they are distinct from culture-specific diagnoses. Beliefs in ideas such as spirit possession and communication with the dead can represent a culturally and religiously accepted norm (Alonso & Jeffrey, 1988). The authors report that an examination of an individual’s adaptive functioning can help distinguish those whose beliefs cross the threshold of accepted cultural belief into delusion. They suggest a review of the person’s ability to carry out usual activities, to use good judgment, and to appreciate the limitations of their beliefs to aid in the assessment (Alonso & Jeffrey, 1988).
Erika Bourguignon’s 1976 article, “Possession and Trance in Cross-Cultural Studies of Mental Health,” further elaborates on the prominent role of trances in many cultures (Bourguignon, 1976). Dr. Bourguignon points out that, when reviewing trance states, it is important to look at not just the state of consciousness the person is in, but also the cultural significance of the experience and the beliefs and practices that surround attaining and interpreting it. She emphasizes that the dissociative state that is typical of both trances and possession is not pathological in itself, just as the dissociation induced by hypnosis or suggestion is not by itself a sign of psychopathology (Bourguignon, 1976). The cultural significance given to this dissociative state is frequently religious or sacred, and can deal with soul loss, spiritual possession, or spirit quests among other culturally significant concepts. Dr. Bourguignon defines a nonpossession trance as an intrapersonal event frequently involving hallucinations, which is knowable to others in the community only through the self-report of the individual. In contrast, a possession trance is a group event in which the possessed takes on the characteristics of the possessing animal or spirit and the audience or observers serve an important role (Bourguignon, 1976). In her 1972 review of 488 societies, she found that 90% recognized some form of trance or possession state within their culture (Bourguignon).
The DMS-IV-TR is also careful to point out that not all of the culture-bound syndromes it describes actually represent an illness; they can, instead, be a normal part of religious, spiritual, and cultural life (American Psychiatric Association, 2000). The authors point out that while “spells” or trance states in which individuals communicate with deceased relatives or other spirits may be misconstrued as a psychotic episode, they are not to be considered as medical events. The authors also point out that zar, which presents with spirit possession, is not considered pathological within the African culture. As a result, these states can only be understood within the context of the role they play within a given culture. These experiences warrant treatment only if they vary widely from the culturally accepted parameters of the experience or if they cause the individual some form of distress or impaired functioning.
Criticisms of Culture-Specific Diagnoses
During the past 3 decades, numerous criticisms have been leveled at the field of culture-specific diagnoses. Many of these began as there was a move toward greater respect and acceptance of the cultural practices of non-Westernized societies and an improved understanding of the impact that cultural differences have on all aspects of health care. These criticisms have grown so strong that many practitioners and even the World Health Organization have moved away from utilizing this category of diagnosis, instead applying mainstream or “typical” psychiatric diagnoses when clinically indicated, accompanied by a notation about cultural factors that are present.
One major criticism of culture-specific diagnoses is the fact that many of the beliefs and symptom clusters that make up these “disorders” are considered normal within their given culture. For example, many cultures have a strong belief in the supernatural and believe that spirits and witchcraft play a prominent role in the etiology of disease. Some Haitians have been found to believe that supernaturally induced illnesses are real and can result from a variety of sources including strained relationships with God, curses from angered individuals whether living or deceased, or retaliation from an offended lwa or spirit (Nicholas et al., 2006). These religious and supernatural issues are believed to cause illnesses directly or to be indirectly responsible for weakening the person and allowing illness to occur. These beliefs can serve as a lens through which genuine physical ailments are understood in this culture and can serve a useful role in rallying social and spiritual support as an individual battles illness. While some of these ideas may seem odd to Westerners, so too may the religious beliefs of Christianity or Judaism seem strange to other cultures. Respect must be given to cultural and religious practices. Acceptance of these beliefs and behaviors as normal for a given culture or religion can be undermined by naming them as syndromes or diseases.
Another key criticism of culture-specific diagnoses has been the overlap between many of these disorders and other DSM-IV-TR and ICD-10 diagnoses. Even the architects of the DSM-IV-TR note several likely overlaps between certain culture-bound syndromes and other diagnoses (American Psychiatric Association, 2000). They suggest that such falling-out spells may represent a form of dissociative disorder or conversion disorder and boufée delirante may represent brief psychotic disorders. One theory of why new culture-specific diagnoses were created when already existing psychiatric diagnoses could have been used to account for behaviors is a sort of “culture-shock” on the part of the clinicians visiting these foreign countries. It is possible that the differences of these newly studied societies in which culture-specific disorders were identified were so striking to the scientists that they were unable to appreciate the even more significant similarities, and, thus, “new” disorders were discovered (Hughes, 1993).
It is not surprising then that the vast majority of the culture-specific diagnoses are found within non-Western cultures or aboriginal groups that may reside within the borders of Westernized countries but whose cultural practices are nonetheless alien from the majority. Ronald Simons and Charles Hughes point out that Western diagnoses are also “bound” within the culture in which they were created, but are not distinguished as such because the cultural factors were not as visible to Western clinicians as were the cultural factors of “exotic” societies (Simons & Hughes, 1993). While knowledge of the impact of culture on a patient’s presentation and illness course is important, so too is an accurate diagnosis and unnecessarily distinguishing disorders that could appropriately be grouped together can have negative consequences on patient care. With improvements in genetic studies of illness, brain imaging, and medications approved for specific diseases, accurately identifying the illness has become even more essential. It is important to keep in mind that even if a more traditional psychiatric illness can be diagnosed, there is always a need to appreciate and understand the individual’s cultural background. Cultural awareness is essential in framing and explaining the diagnosis to the patient and his or her family and understanding reactions to treatment recommendations. Additionally, in some cases, it may also be useful to enlist the aid of cultural guides or indigenous healers and remedies just as one might enlist the assistance of a clergy member in the treatment of a patient with strong religious convictions (Guthrie & Szanton, 1976).
In the 1980s and 1990s, a backlash against the ethnocentric focus of the culture-specific diagnoses and an increased understanding and appreciation of the role of culture in diseases led to the characterization of several diseases in industrialized nations as culture-bound. One of the first diseases to be conceptualized in this way was anorexia nervosa, a mental illness that is, in part, defined by fears of gaining or maintaining an appropriate weight and distortions in the way one’s body shape and size are perceived (Swartz, 1985). This disorder was first seen almost exclusively in countries in which food was abundant and there was a social preference for thinness (American Psychiatric Association, 2000). Cases of anorexia nervosa became increasingly more common in less affluent nations as exposure to this Westernized ideal of beauty became more widespread (Sing, 1996). The geographic creep of this illness demonstrates that as cultural norms shift, disorders thought to be culturally tied can become embedded in new regions.
In 1982, Cheryl Ritenbaugh took this argument one step further, demonstrating how even obesity could be thought of as a culture-bound syndrome within the United States (Ritenbaugh, 1982). In her article, “Obesity as a Culture-Bound Syndrome,” she traces the history of cultural ideas about weight from positive associations with fertility to religious denouncements of gluttony, to the prominence of a more adolescent-appearing female figure in media. Around the same time that popular notions of beauty began favoring slim, athletic figures, the general public was becoming more aware of the negative health impacts of obesity. She finds support for her theory of obesity as a culture-bound disease in the prominence within the culture of the United States of diet-aids and health spas, and the amount of funds spent on treatment and research of obesity and obesity-related illnesses (Ritenbaugh, 1982). Several other conditions were briefly considered as Western culture-specific diagnoses, including premenstrual syndrome (PMS) (Johnson, 1987) and dissociative amnesia (Pope, Poliankoff, Parker, Boynes, & Hudson, 2007), before this movement was replaced by a more general understanding of the role that culture plays in all disorders.
Another major criticism of the field is the lack of consistency in the identification of diseases that constitute culture-specific diseases. Prince and Tcheng-Laroche delineated several potential pitfalls in assigning a constellation of symptoms the status of culture-specific disease or culture-bound syndrome (Prince & Tcheng-Laroche, 1987). These include the use of different names to refer to the same constellation of symptoms in different regions; the impact of different geographic factors on physiology, such as low iodine in the soil leading to similar disease manifestations; epidemiological differences such as gender distributions, age of onset, and frequency; and subtle differences in presentation between different cultural groups that do not inherently change the disease nature, duration, or course. All of these factors make it difficult to establish which conditions should be considered culture-specific diseases. Claire Cassidy (Cassidy, 1982) and her colleague Cheryl Ritenbaug (Ritenbaugh, 1982) sought to create a clear definition of culture-bound syndromes. They identified a culture-bound syndrome as “a constellation of symptoms which has been categorized as a dysfunction or disease,” characterized by one or more of four factors: an inexorable connection to the associated culture or subculture, an etiology which reflects behavioral norms of the culture, a reliance on culture-specific ideology and technology to diagnose the illness, and the inability of a cultural outsider to accomplish successful treatment. While this is helpful in understanding how they conceptualize these disorders, it is not a concise definition and has not gained wide usage.
The lack of solid studies and empirical data on culture-specific diagnoses has been another criticism of the field. In 1990, Guarnaccia suggested that a major limitation of cross-cultural psychiatry was that studies were typically undertaken with Western diagnostic scales (Guarnaccia et al., 1990). They suggested that instruments should be developed to assess symptoms of local illnesses. The use of standardized instruments would allow more empirical studies which could help to differentiate culture-specific diagnoses from other DSM-IV-TR and ICD-10 recognized mental illness or provide firm data that no such difference actually exists. Guarnaccia and his colleagues further encouraged the inclusion of individuals who are knowledgeable about the local culture and are able to act as ethnographical interpreters in the design and implementation of such studies (Guarnaccia et al.).
Implications of Culture-Specific Diagnoses on Immigrants
Over the last several decades, countries outside the United States have been plagued by armed conflict, dictatorships, gender oppression, poverty, famine, and a myriad of other hardships. Their struggles have led to an increase in migrations worldwide. In 2000, the United Nations considered one out of every 135 living individuals to be a “refugee” (Pumariega, Rothe, & Pumariega, 2005). In the United States, “first and second generation immigrant children are the most rapidly growing segment of the American population, with the great majority of this population being of non-European origin” (Pumariega et al., 2005). Given the diversity of cultural backgrounds among immigrants to the United States and other countries, physician familiarity with identifying and treating culture-bound illnesses is essential. Older immigrants are especially likely to express distress in a pattern that is consistent with their own traditions and practices. However, older immigrants are less likely to seek medical care, in large part due to Western psychiatrists being unable to properly recognize and manage their symptoms. One study looked at Korean American immigrants and found that their mental health needs were not being addressed due to an underutilization of psychiatric services in the United States. Access to treatment barriers include “failure of mental health services to provide culturally relevant interventions,” “an inadequate number of trained mental health workers, especially psychiatrists who are culturally sensitive,” and a “belief in ethnic traditional medicine” (Lee, Hanner, Cho, Han, & Kim, 2008). Language barriers and the stigma many ethnic groups place on mental health conditions further reduce the chances of an immigrant population receiving appropriate psychiatric care.
In addition, immigrants remain a high-risk group given the complexity of their social situation. Many of them face separation from their families, detention in refugee camps, and discrimination once they arrive in their new country. They inhabit crime-filled inner-city neighborhoods and cannot afford health insurance, a quality education, or job security. Mental health treatment becomes a low priority, and those that seek care are faced with physicians who are ill-equipped to recognize their presenting symptoms. Given the growing ethnic and cultural diversity of the world, the challenges mental health care workers face in providing culturally competent care will continue to grow. Health care systems across the globe need to develop comprehensive research programs that will help address the complexity of culture-bound syndromes and allow psychiatrists to understand and treat foreign born populations who present with symptoms unique to their background (Guarnaccia & Rogler, 1999).
In summary, while the study of culture-specific diagnoses has helped to broaden mental health practitioners’ understanding of some unique conditions, it has also been criticized for its apparent assumption that behaviors that differ from those that are common in one’s own culture are a disease or disorder. In the last 20 years, there has been an improved effort to view all mental and physical disorders through the lens of culture awareness. This has led to an improved understanding of what is considered normal behavior within a given culture. Knowledge of culture-specific diagnoses is beneficial as it expands practitioners’ familiarity with unique cultural experiences and symptom presentations. It is only through our understanding of culturally acceptable behavior that we will be able to identify and help those individuals whose presentation differs from the acceptable and treads into the pathological.