Mae Ling Catayong

Culture-Bound Syndromesㅤㅤㅤ HON 440-1007

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Introduction

What is a culture-bound syndrome?

A combination of somatic and psychiatric symptoms that can be considered a recognizable disorder within a specific society or culture (Worthy et al. 2020)

First described by Pow Ming Yap as “culture-bound psychogenic psychoses,” who later modified the term to culture-bound syndromes or culture-specific disorders (Ventriglio et al. 2016)

International Classification of Diseases, 10th Revision (ICD-10) Framework (Worthy et al. 2020):

Categorization as a disease within the culture

Widespread familiarity within the culture

Lack of familiarity or misunderstanding of the condition from people in other cultures

No objectively demonstrable biochemical or tissue abnormalities

Usually recognized and treated by the folk medicine of the culture

Aims:

To investigate the different types of culture-bound syndromes in order to try to get a better understanding of how culture can influence manifestations of health-related issues

Is any syndrome or condition truly culture-bound or culture-specific?

Removal of some syndromes between the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to the DSM-5

Changing definitions of the culture-bound concept and the syndromes themselves

Rationale:

Thought it would be interesting to find out how researchers of this topic differentiated culture-bound syndromes from similar existing diagnostic criteria, specifically in the psychiatric realm

In diverse communities, culture-bound syndromes are possibly an important concept in how ethnic minorities view health

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Amok

(Imai et al. 2019)

Amok can be defined as “a culture-bound syndrome related to sudden mass homicide”

This study aimed to clarify and explain the changing ideas about amok

Conducted a historical review of 88 articles in English (found through PubMed) and discovered that the meanings and believed causes of amok have changed over time

Before 1800s, the concept of amok was “frequently associated with war or honor during this period”

Between the 11th and 13th centuries, the introduction of Islam was accelerated; amok was now used in relation to Islam

Some believed that amok was performed exclusively by people who practiced the religion and it was considered a negative behavior

Around the 16th century, European colonization was established

Amok was seen as “madness or behavior that led to punishment under European law”

For the first time, amok was mentioned in courts of law, “with the purpose of suppressing native people’s tendency to regard amok as heroic”

1800-1850

A patient with amok was described in a medical context for the first time

The patient insisted that he suffering from possession by the devil, but the doctor concluded that his symptoms were caused by gastritis or the exacerbation of a gastric ulcer

1850-1900

Chronic dementia, monomania, and psychosis were regarded as psychiatric causes of amok

Emergence of psychodynamic psychiatry

Alcohol and opium were also considered causes of amok 

1900-1950

Defense mechanisms, personality, and heredity were introduced as potential causes of amok

Turbulent period; 2 world wars, followed by national independence movements in Indonesia, India, and the Federation of Malaya

Concept of psychobiology emerged

After 1950

Psychodynamic concepts of amok were replaced by “sociocultural explanations focusing on cultural norms, background, and ways of thinking”

Political explanations, proposing that amok was politically motivated

Psychiatry more associated with external and social issues

Changes in the frequency and concept of amok were seemingly affected by “social events, medical discoveries, knowledge of descriptors, and sometimes the benefit to users”

Concepts of amok change “depending on the history of society, as well as the knowledge and intention of people at the time”

from http://criticalpsychiatry.blogspot.com/2018/09/running-amok-in-american-society.html

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short video going over amok and how it became part of an idiom

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Hwa-byung

(Chung Pang 1990)

Hwa-byung is a condition in which suppressed anger causes a variety of somatic symptoms (when emotions associated with the specifically Korean way of perceiving and reacting to intolerable and tragic life situations cause bodily symptoms)

“...lasting anger, disappointments, sadness, miseries, hostility, grudges, and unfulfilled dreams and expectations”

Hwa means "fire" and "anger," and Byung means "illness"

This study aimed to explore the cultural construction of hwa-byung among elderly Korean immigrants in the United States

Participants included 20 elderly (age 64-80) Korean immigrant women

Participant observation (taking part in the activities of Korean elderly immigrants in church, at association meetings, picnics, small social gatherings, parties, and wedding ceremonies)

Semi-structured interview guide was used to examine illness beliefs and practices

All interviews and explanations were conducted in Korean

Gastro-intestinal, vascular circulatory, sensory neurological, cardiac, musculoskeletal, respiratory, genitourinary, and endocrinological symptoms; chronic and related to past troubled life experiences

Hwa-byung is a mode in which Korean elderly women construct illness, as a personal, social, and cultural adaptive response

It is considered a virtue to bear misfortunes, miseries, and unfair treatment silently and patiently amongst Koreans

Physical complaints are readily accepted, but psychological or mental complaints are often ignored or resisted

Hwa-byung provides a way of conceptualizing and resolving emotional distress through somatization

Hwa-byung is treated holistically with “psychosocial support from family, spiritual comfort, home and popular remedies, traditional Korean medicine, and biomedical treatments”

This article and this blog post goes over hwa-byung in relation to the concept of “han”

from https://eportfolios.macaulay.cuny.edu/reisf16/posts/

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really nice podcast episode on hwa-byung from Korean individuals

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Hikikomori

(Kato et al. 2011)

Hikikomori can be defined as “complete withdrawal from society for 6 months or longer”

This study aimed to investigate whether hikikomori exists in other countries

If so, how are patients with hikikomori diagnosed and treated in these other countries?

Approximately half of participants were psychiatrists recruited from Japan and the rest were from Korea, Australia, Taiwan, Bangladesh, Iran, India, Thailand, and the USA

Asked to rate various factors related to hikikomori in their respective countries

Given two case vignettes and a self-administered questionnaire about the cases’ diagnosis, frequency, cause, suicide risk, and treatment plan

The vignettes described social, psychiatric, family, drug, and present illness history

Results indicated that hikikomori is present in countries outside of Japan and more often in urban areas

In most countries, hikikomori was also more frequently seen amongst teenagers than adults

Psychiatrists from other countries offered diagnoses of “adjustment disorder, anxiety disorder, autism spectrum disorders, conduct disorder, dysthymia, impulse control disorder, prodromal schizophrenia, schizoid personality disorder, simple schizophrenia, and social phobia”

Some psychiatrists from Japan, Korea, Taiwan, Thailand, and the USA appointed hikikomori as a diagnosis

Some Japanese psychiatrists did not believe that people with hikikomori required psychiatric treatment, while most psychiatrists from other countries proposed hospitalization as a preferred treatment

This may be due to hikikomori having been prevalent in Japan for so long that it has become a somewhat acceptable behavior within their society

These results beg the question of whether hikikomori is truly bound to one specific culture and suggest more research should be done on the epidemiology of the syndrome in international settings

It may be important to note that psychiatric education and training may vary in each country and that can influence diagnosis and treatment strategy

from https://www.bbc.com/future/article/20190129-the-plight-of-japans-modern-hermits

This article goes over how COVID-19 can increase prevalence of hikikomori globally

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an interesting video depicting several cases of hikikomori and how people try to help

A YouTube comment under this video:

Let's not fool ourselves thinking this is only a Japanese phenomenon. Sure Japanese culture may make the problem more pronounced, but there are plenty of people all over the world who do not fit into society. Society can be harsh, especially if you cannot conform to what is considered normal.

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a way in which some try to help hikikomori

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Taijin Kyofusho

(Essau et al. 2012)

Taijin kyofusho can be defined as a “culture-bound form of social phobia that is characterized by an intense fear that one’s body parts or functions displease, embarrass, or are offensive to others”

This study aimed to compare social phobia and taijin kyofusho symptoms of young adults in England and Japan and assess the role played by their family environment in the manifestation of the two conditions

They administered questionnaires to 927 participants, 462 from England and 465 from Japan

The questionnaire measured social phobia & taijin kyofusho symptoms and evaluated the family environment in which participants grew up in

A bilingual translator translated the questionnaire from English (the original language) to Japanese, then another bilingual translator translated it back to English; then they both discussed and resolved any differences between the original and the back-translated versions

Results indicated that Japanese young adults experienced higher levels of social phobia and taijin kyofusho symptoms compared to British young adults

Also indicated that family sociability consistently affected social phobia and taijin kyofusho symptoms in participants of both countries

Japanese child-rearing emphasizes accommodation to social expectations, which may increase their sensitivity to disapproval

British child-rearing instead emphasizes individualism, autonomy, independence, and freedom

These results suggest that cross-cultural models should consider familial factors, which may be predictors for certain culturally specific conditions

The authors also proposed taijin kyofusho as a variant of social interaction anxiety

Something to note is that there is a possible dissimilarity in Japanese and British participants’ willingness to report on mental health symptoms and family environment

(Iwata et al. 2011)

Sekimen-kyofu: phobia of blushing Shubo-kyofu: phobia of a deformed face/body Jikoshu-kyofu: phobia of having foul body odor Jikoshisen-kyofu: phobia of eye contact or one’s own glance or gaze

They believe their gaze “assumes an offensive nature and is uncontrollably directed at persons near them”

People with jikoshisen-kyofu feel “deeply ashamed, demeaned, and unaccepted, and many eventually avoid social situations”

Not many cases have clearly demonstrated jikoshisen-kyofu in the West to date

from https://www.tofugu.com/japan/taijin-kyofusho/, also a short article worth reading

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mentions that this is more common in men rather than women, which is different from Western social anxiety/phobia

briefly goes over some treatments for taijin kyofusho towards the end (3:20)

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Ataque de Nervios

(Keough et al. 2009)

Ataque de nervios translates into “attack of nerves”

Characterized by episodes of intense emotional distress expressed through symptoms such as “uncontrollable shouting, attacks of crying, trembling, and heat in the chest rising into the head” and are often triggered by “interpersonal conflict or the death of a loved one”

The aim of this study was to examine the cultural and symptomatic distinctiveness of ataques de nervios

342 undergraduate participants (200 Caucasian, 58 African American, 50 Hispanic, 8 Asian, 25 multi-ethnic, and 1 unreported)

Participants completed measures that assessed their level of acculturation, panic attack and ataque de nervios experience, and anxiety risk factors

Results of the study demonstrated that prevalence rates of ataques de nervios were not significantly different amongst the three main groups evaluated (Caucasian, African American, and Hispanic participants)

Unlike ataques de nervios, panic attacks were associated with fear and apprehension

Unlike panic attacks, ataques de nervios are described and experienced as more acceptable expressions of distress

Ataques de nervios do not seem to be entirely unique to Hispanic culture; however, there does seem to be a differentiation between the experience of panic attacks and ataques de nervios

It is important to consider that the sample contained significantly more Caucasian participants compared to all other ethnic groups, which makes the plausibility of this study questionable when it comes to comparing ataques de nervios prevalence between ethnic groups

Some people who are Hispanic also identify as Caucasian

This article refers to the syndrome as “Puerto Rico syndrome”

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Culture-Bound Syndromes to Cultural Concepts of Distress

(Ventriglio et al. 2016)

DSM-IV Framework

Recognized within the society as a deviation from normal or healthy presentation

Local names (often in the culture’s native language)

Symptoms are often influenced by local cultural factors

Limited to specific societies or cultural areas (this can be a geographical region or areas with shared ethnic history or identity)

Localized (experiences not globally recognized)

DSM-5 discarded “culture-bound syndromes” for “cultural concepts of distress”

Cultural concepts of distress are defined as “ways cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts or emotions”

syndromes: clusters of symptoms and attributions occurring among individuals in specific cultures

idioms of distress: shared ways of communicating, expressing or sharing distress

explanations: labels, attributions suggesting causation of symptoms or distress

Listed 16 fewer syndromes than the DSM-IV (25 to 9)

“...emphasizes that all mental distress is culturally framed and acknowledges that different populations carry varying and culturally determined ways of communicating distress along with explanations of causality, coping methods and help-seeking behaviors”

It is suggested that cultures are evolving as a result of globalization, which can amalgamate cultures and alter how we view certain syndromes or who develops them

This article discusses the debate over whether eating disorders can be considered culturally-specific

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Conclusion

Our perspectives on culturally related and influenced health issues are subjective and change over time

Why do our views on disorders change? 

Several societal, medical, and beneficial ideas change as we gain knowledge or experience certain events or discoveries

“Socio-geographical context and observers’ knowledge and positions [could] affect the conceptualization and observation of disorders” (Imai et al. 2019)

I believe that globalization and the Internet play a part in spreading certain concepts to other cultures--the vast media coverage of hikikomori compared to other cultural concepts

Should culture-bound syndromes be medicalized?

I find “cultural concepts of distress” to be much more fitting than “culture-bound syndromes”

It is apparent that cultural factors do moderately affect the manifestations of health issues, even if not necessarily culture-bound or specific

Taijin kyofusho specifically does not seem to be something very prevalent in the West

Rather than separating specific cultures from the others (Japan vs. the rest of the world), I think it is okay to be more broad (collectivist culture) and it is plausible for something that was once more culture-specific to become more widespread over time

In order to improve healthcare, there should be an emphasis on attaining a better understanding of how symptoms are expressed and what things cause distress within each culture

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Glossary

Amok: a syndrome related to sudden mass homicide (Imai et al. 2019)

Ataque de nervios: “attack of nerves”; characterized by episodes of intense emotional distress (expressed through uncontrollable shouting, attacks of crying, trembling, and heat in the chest rising into the head), often triggered by interpersonal conflict or the death of a loved one (Keough et al. 2009)

Cultural concept of distress: the way in which cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts or emotions (Ventriglio et al. 2016)

Culture-bound syndrome: a combination of somatic and psychiatric symptoms that can be considered a recognizable disorder within a specific society or culture (Worthy et al. 2020)

Hikikomori: a syndrome in which an individual experiences “complete withdrawal from society for 6 months or longer” (Kato et al. 2012)

Hwa-byung: a condition in which suppressed anger causes a variety of somatic symptoms (Chung Pang 1990)

Taijin kyofusho: a syndrome akin to social phobia that is characterized by “an intense fear that one’s body parts or functions displease, embarrass, or are offensive to others” (Essau et al. 2012); subtypes:

Jikoshisen-kyofu: phobia of eye contact or one’s own glance or gaze (Iwata et al. 2011)

Jikoshu-kyofu: phobia of having foul body odor (Iwata et al. 2011)

Sekimen-kyofu: phobia of blushing (Iwata et al. 2011)

Shubo-kyofu: phobia of a deformed face/body (Iwata et al. 2011)

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References

Chung Pang, Keum Young. 1990. “Hwabyung: The Construction of a Korean Popular Illness Among Korean Elderly Immigrant Women in the United States.” Culture, Medicine, and Psychiatry 14(1):495–512. 

Essau, Cecilia A., Satoko Sasagawa, Junwen Chen, and Yuji Sakano. 2012. “Taijin Kyofusho and Social Phobia Symptoms in Young Adults in England and in Japan.” Journal of Cross-Cultural Psychology 43(2):219–32. 

Imai, Hissei, Ogawa, Yusuke, Okumiya, Kiyohito, and Kozo Matsubayashi. 2019. “Amok: A Mirror of Time and People. A Historical Review of Literature.” History of Psychiatry 30(1):38–57. 

Iwata, Yasuhide, Katsuaki Suzuki, Nori Takei, Timothea Toulopoulou, Kenji J. Tsuchiya, Kaori Matsumoto, Shu Takagai, Masaya Oshiro, Kazuhiko Nakamura, and Norio Mori. 2011. “Jiko-Shisen-Kyofu (Fear of One's Own Glance), but Not Taijin-Kyofusho (Fear of Interpersonal Relations), Is an East Asian Culture-Related Specific Syndrome.” Australian and New Zealand Journal of Psychiatry 45(2):148–52. 

Kato, Takahiro A., Masaru Tateno, Naotaka Shinfuku, Daisuke Fujisawa, Alan R. Teo, Norman Sartorius, Tsuyoshi Akiyama, Tetsuya Ishida, Tae Young Choi, Yatan Pal Singh Balhara, Ryohei Matsumoto, Wakako Umene-Nakano, Yota Fujimura, Anne Ward, Jane Pei-Chen Chang, Rita Yuan-Feng Chang, Behrang Shadloo, Helal Uddin Ahmed, Tiraya Lerthattasilp, and Shigenobu Kanba. 2011. “Does the ‘Hikikomori’ Syndrome of Social Withdrawal Exist Outside Japan? A Preliminary International Investigation.” Social Psychiatry and Psychiatric Epidemiology 47(7):1061–75. 

Keough, Meghan, Kiara Timpano, and Norman Schmidt. 2009. “Ataques De Nervios: Culturally Bound and Distinct from Panic Attacks?” Depression and Anxiety 26(1):16–21. 

Ventriglio, Antonio, Oyedeji Ayonrinde, and Dinesh Bhugra. 2016. “Relevance of Culture-Bound Syndromes in the 21st Century.” Psychiatry and Clinical Neurosciences 70(1):3-6. 

Worthy, Lisa D., Trisha Lavigne, and Fernando Romero. 2020. “Culture-Bound Disorders.” Pp. 251-252 in Culture and Psychology. Phoenix, AZ: MMOER.