What are culture-bound syndromes?

Introduction

In the late 1960s, the fields of psychology and psychiatry developed a particular interest in how cultural factors shape the manifestation of mental disorders. Before that time, some believed that mental disorders were largely universal in their underlying causes and expression. Several decades of cross-cultural research highlighted the limitations of this view by uncovering potentially important differences in the prevalence and expression of certain psychological conditions across the world.

Models

There are two major models of psychological disorders that are limited to certain cultures. The first, a pathogenic-pathoplastic model, presumes that mental disorders across the world are identical in their underlying causes (pathogenic effects) but are expressed differently depending on cultural factors (pathoplastic effects). According to this model, cultural influences do not create distinctly different disorders but merely shape the outward expression of existing disorders in culturally specific ways.

Harvard University’s Arthur Kleinman and some other cultural anthropologists contended that this model underestimates the cultural relativity of mental disorders. In its place, Kleinman proposed the new cross-cultural psychiatry model, which maintains that many culture-bound syndromes are causally distinct conditions that bear no underlying commonalities to those in Western culture. According to this alternative model, non-Western disorders are not merely culturally specific variations of Western disorders.

In some ways, these competing models parallel the etic-emic distinction in cross-cultural psychology. As noted by University of Minnesota psychiatrist Joseph Westermeyer and others, the term “etic” refers to universal, cross-cultural phenomena that can occur in any cultural group. Conversely, the term “emic” refers to socially unique, intracultural perspectives that occur only within certain cultural groups. There is probably some validity to both perspectives. Some culture-bound syndromes may be similar to conditions in Western culture, whereas others may be largely or entirely distinct from these conditions.

Examples

Some culture-bound conditions appear to fit a pathogenic-pathoplastic model. For example, seal hunters in Greenland sometimes experience kayak angst, a condition marked by feelings of panic while alone at sea, along with an intense desire to return to land. Kayak angst appears to bear many similarities to the Western condition of panic disorder with agoraphobia and may be a culturally specific variant of this condition.

A culture-bound syndrome widespread among the Japanese is taijin-kyofusho, an anxiety disorder characterized by a fear of offending others, typically by one’s appearance or body odor. Some authors have suggested that taijin-kyofusho is a culturally specific variant of the Western disorder of social phobia, a condition marked by a fear of placing oneself in situations that are potentially embarrassing or humiliating, such as speaking or performing in public. Interestingly, Japan tends to be more collectivist than most Western countries, meaning its citizens view themselves more as group members than individuals. In contrast, most Western countries tend to be more individualistic than Japan, meaning their citizens view themselves more as individuals than as group members. As a consequence, taijin-kyofusho may reflect the manifestation of social phobia in a culture that is highly sensitive to the feelings of others.

In contrast, other culture-bound conditions may be largely distinct from Western disorders and therefore difficult to accommodate within a pathogenic-pathoplastic model. In koro (genital retraction syndrome), a condition found primarily in southeast Asia and Africa, individuals believe their sexual organs (for example, the penis in men and breasts in women) are retracting, shrinking, or disappearing. Koro is associated with extreme anxiety and occasionally spreads in contagious epidemics marked by mass societal panic. Although koro bears some superficial similarities to the Western diagnosis of hypochondriasis, it is sufficiently different from any Western condition that it may be a distinctive disorder in its own right.

Another potential example is the Malaysian condition of amok. In amok, individuals, almost always men, react to a perceived insult by engaging in social withdrawal and intense brooding, followed by frenzied and uncontrolled violent behavior. Afflicted individuals, known as "pengamoks," often fall into a stupor after the episode and report memory loss for their aggressive actions. Although amok may be comparable in some ways to the sudden mass shootings occasionally observed in Western countries, such shootings are rarely triggered by only one perceived insult or associated with stupor following the episode. Amok, incidentally, is the origin of the colloquial phrase “running amok.”

Psychiatric Classification

The fourth edition of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) provided a list of twenty-five culture-bound syndromes, including taijin-kyofusho, koro, and amok. Appearing in an appendix of the fourth edition, this list was the first official attempt by the mental health community to recognize culture-bound syndromes as worthy of research and clinical attention. The 2000 text revision of the DSM-IV (the DSM-IV-TR) added an outline of issues and factors that clinicians should consider when making diagnoses for culturally diverse patients.

Nevertheless, some researchers criticized the DSM-IV’s list of culture-bound syndromes. Some, like McGill University psychiatrists Lawrence J. Kirmayer and Eric Jarvis, argued that some of these “syndromes” are not genuine mental disorders but rather culturally specific explanations for psychological problems familiar to Western society. They cited the example of dhat, a culture-bound condition in the DSM-IV appendix that is prevalent in India, Pakistan, and neighboring countries. Dhat is commonly associated with anxiety, fatigue, and hypochondriacal worries about loss of semen. As Kirmayer and Jarvis observe, many or most individuals with dhat appear to suffer from depression, so dhat may merely be a culturally specific interpretation of depressive feelings.

Other critics charged that DSM-IV’s list of culture-bound syndromes was marked by Western bias and that some well-established psychological conditions in Western culture are in fact culture bound. For example, based on a comprehensive review of the literature, Harvard University psychologist PamelaKeel and Michigan State University psychologist Kelly Klump argued persuasively that bulimia nervosa (often known simply as bulimia), an eating disorder often characterized by repeated cycles of binging and purging, is a culture-bound syndrome limited largely to Western culture. Indeed, the few non-Western countries in which bulimia has emerged, such as Japan, have been exposed widely to Western ideals of thinness in recent decades. In contrast, as Keel and Klump noted, anorexia nervosa (often known simply as anorexia) appears to be about equally prevalent in Western and non-Western countries.

For the fifth edition of the DSM (DSM-5), published in 2013, American Psychiatric Association sought to address some of these concerns. While the DSM-5 retains the list of culture-bound syndromes, along with their "idioms of distress" and explanations, in an appendix, it also integrate their symptoms throughout the manual as additions to existing classifications. For example, "offending others," a symptom of taijin-kyofusho, was listed under the diagnostic criteria for social anxiety disorder. Another modification was the addition of an interview guide with questions about the patient's cultural, racial, ethnic, and religious heritage, which is intended to afford patients an opportunity to describe their condition in their own terms and help clinicians better interpret this information.

Mental health professionals are increasingly recognizing that psychological conditions are sometimes influenced by sociocultural context and that such context must be taken into account in their diagnoses. More research is needed to ascertain how best to classify culture-bound syndromes and integrate cultural influences into diagnostic practices.

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