Cultural Concepts of Distress and Culture Bound Syndromes

All forms of distress are locally shaped, including the DSM disorders.

– DSM-5 (APA, 2013, p. 758) 

Note: Directly taken from: DSM-5 on Culture: A Significant Advance
Posted on June 27, 2013 by Constance A. Cummings
http://thefprorg.wordpress.com/2013/06/27/dsm-5-on-culture-a-significant-advance/

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5
APA, 2013) was finally presented on May 18th at the American Psychiatric Association’s annual
meeting in San Francisco. Much ink has been spilled into the media about the ten-year process
leading up to last month’s unveiling. But there has been virtually no mention of the fact the
DSM-5 is a vast improvement in its treatment of culture. It reflects a much more inclusive
description of the range of psychopathology across the globe, not just the particular constructs or
exemplars most commonly encountered in the US, Western Europe, and Canada. I think the
cultural component of DSM-5 has the makings of a model on which subsequent versions of the
manual should be based.

According to cultural psychiatrist Roberto Lewis – Fernandez (Columbia University),

“including information on cultural concepts of distress in DSM-5 will enhance the validity and
clinical usefulness of diagnostic practice” across the board. Lewis-Fernández began his talk by
briefly describing the limitations of DSM-IV-TR, which listed twenty-five “culture-bound
syndromes” in an appendix. The use of the term “culture-bound” made these conditions appear
highly localized and confined, a cabinet of curiosities. The list was also heterogeneous, Lewis-
Fernández continued, some “syndromes,” including nervios, seemed to represent specific
situational predicaments, or variations in the way people express their distress, rather than
coherent collections of symptoms. Other expressions, such as ataque de nervios, are syndromic,
but do not always represent psychopathology. Still others (like shenjing shuairuo or
‘neurasthenia’) appeared to be a cover term for several common, but seemingly unrelated, human
ailments (e.g., fatigue, dizziness, headache, GI problems, sexual dysfunction, excitability);
another group of conditions simply defied DSM categorization, such as mal de ojo (‘evil eye’).

Under the direction of Kimberly Yonkers and Lewis-Fernández, chair and co-chair respectively
of the Gender and Cross-Cultural Issues Study Group, DSM-5 is a vast improvement. The
new volume is divided into three sections – Section 1: Introduction (“DSM-5 Basics”); Section
II: “Diagnostic Criteria and Codes”; Section III: “Emerging Measures and Models” – and an
Appendix, which includes a “Glossary of Cultural Concepts of Distress.” Section III includes a
chapter on cultural formulation, featuring an updated version of the outline introduced in DSM-
IV as well as an approach to assessment, using the Cultural Formulation Interview (CFI). The
chapter also includes a section discussing “Cultural Concepts of Distress” (pp. 758–759).

As Lewis-Fernández explained, the notion of “culture-bound syndromes” has been replaced by

three concepts: (1) cultural syndromes: “clusters of symptoms and attributions that tend to co-
occur among individuals in specific cultural groups, communities, or contexts . . . that are
recognized locally as coherent patterns of experience” (p. 758); (2) cultural idioms of distress:
“ways of expressing distress that may not involve specific symptoms or syndromes, but that
provide collective, shared ways of experiencing and talking about personal or social concerns”
(p. 758); and (3) cultural explanations of distress or perceived causes: “labels, attributions, or
features of an explanatory model that indicate culturally recognized meaning or etiology for
symptoms, illness, or distress” (p. 758).

Lewis-Fernández used depression as an example of a cultural concept. For western

clinicians, major depressive disorder (MDD) can be considered a “syndrome,” or cluster of
symptoms that appear to “hang together.” But depression can also be considered an “idiom of
distress,” in the sense that westerners commonly talk of feeling depressed in everyday life.
Finally, the label depression can imbue a set of behaviors with a particular meaning. No single
concept maps onto a specific psychiatric disorder, and, conversely, no single psychiatric disorder
(e.g., MDD) maps onto a cultural concept (e.g., nervios). In all, the glossary lists nine of  “the
best-studied concepts of distress around the world” – ataque de nervios (‘attack of nerves’), dhat
syndrome (‘semen loss’), khyâl cap (‘wind attack’), kufingisisa (‘thinking too much’), maladi
moun (lit. ‘human caused illness’), nervios (‘nerves’), shenjing shuairuo (re-glossed as
‘weakness of the nervous system’), susto (‘fright’), and taijin kyofusho (‘interpersonal fear
disorder’).

In practice, according to Lewis-Fernández, “each illness has to be assessed in its own

right” and both the practitioner’s expertise and epistemological assumptions and the individual’s
understanding of the illness should apply. That is, the clinician must not only draw from
diagnostic experience, available categories of illness, and the various dimensions along which
aspects of the illness may range, but also recognize and try to understand each individual’s
anomalous experience. Furthermore, he said that nosology “has to be constantly evolving” due to
“cultural variation over time in the way that psychopathological experiences are constructed.”
But the information provided throughout DSM-5, and particularly in the cultural formulation
chapter should help practitioners avoid misdiagnosis, obtain clinically useful information,
improve clinical rapport and therapeutic efficacy, guide research, and clarify cultural
epidemiology.

Lewis-Fernández sketched the structure of the Cultural Formulation Interview (CFI),

which is also included in Section III. The CFI is a semi-structured interview composed of 16
questions that focuses on individual experience and social context (the objective is to assess
cultural factors using a person-centered approach). The text is divided into two columns, with
questions on the right and instructions on the left. Two versions are available, one for the
individual and one for an informant, such as a family member or caregiver. (The interviews are
available online at psychiatry.org/dsm5.) There are also 12 Supplementary Modules to the CFI,
which provide additional questions to flesh out domains assessed briefly in the 16-item CFI (e.g.,
cultural identity) as well as questions that can be used during the cultural assessment of
particular groups, such as children and adolescents, older adults, immigrants and refugees, and
caregivers.

Lewis-Fernández also described how the glossary works using ataque de nervios as an
example. Briefly, ataque is a syndrome characterized by “intense emotional upset, including
acute anxiety, anger, or grief; screaming and shouting uncontrollably; attacks of crying;
trembling; heat in the chest rising into the head; and becoming verbally and physically
aggressive,” or otherwise feeling out of control (p. 833). (Ataque, like depression, also qualifies
as an idiom of distress and an explanation.) The entry in the glossary cross-references related
conditions in other cultural contexts and in the main text of DSM-5 (e.g., panic disorder).
Conversely, a section in the entry under “panic disorder” in Section II of the volume (“Culture-
Related Diagnostic Issues,” pp. 211–212) describes ataque and refers the reader to the glossary.
In this way, clinicians are alerted to culture-related features of DSM prototypes in the main text
and in more detail in the glossary. The cross-referencing, absent in DSM-IV, should enhance the
ability of the clinician to diagnose syndromes in an appropriate cultural context.

In closing, Lewis-Fernández said that further research must continue to improve the
international applicability of DSM by exploring the range of cultural variation (such as the nine
examples provided in the glossary) and making revisions. The objective is that DSM-5 and
subsequent versions reflect a more inclusive description of the range of psychopathology across
the globe, not just the particular constructs or exemplars most commonly encountered in the US,
Western Europe, and Canada.

20 More Rare and Unusual Psychiatric Syndromes

Note: Taken directly from: 20 More Rare and Unusual Psychiatric Syndromes
Christoph U. Correll, MD; Bret S. Stetka, MD
July 10, 2014
http://www.medscape.com/features/slideshow/culture-synd#1

Correll and Stetka (2014), reported in Medscape, the top list rare and unusual psychiatric
syndromes. Similarly, they have reported the syndromes that have been described or tend to
manifest in certain cultures or regions of the world.

In DSM-IV (APA, 2000), these conditions was termed "culture-bound syndromes";

DSM-5 (APA, 2013) includes them under "Cultural Concepts of Distress." This updated
approach is intended to more accurately characterize cultural influences on the expression and
experience of mental disorders that can manifest in anybody, increasing relevance to clinical
practice. Some previously included conditions have been removed in the new manual, whereas
others have been added or maintained as examples of culturally-colored conditions. Although
DSM-5 deemphasizes specific conditions in favor a broader conceptual approach to cultural
concepts, both those examples included and not included in the manual remain relevant to
practice, given that they're still reported in many cultures from around the world.

Correll and Stetka (2014), mentioned that in reconsidering the diagnosis of cultural-
related psychiatric conditions, DSM-5 addresses the idea that the prior label, "culture-bound
syndromes", overemphasizes locality and ignores the fact that "clinically important cultural
differences often involve explanation or experience of distress, rather than culturally distinctive
configurations of symptoms." The new approach acknowledges that all mental health conditions,
including DSM disorders, are "locally shaped" and describes 4 key nosologic features of cultural
concepts: (1) rarely do they have a one-to-one correspondence with DSM diagnoses; (2) they
may apply to presentations with a wide range of severity, including conditions that do not meet
any DSM criteria; (3) a cultural term is often applied to multiple cultural concepts; and (4) like
culture and DSM itself, cultural concepts may evolve over time owing to local and global
influences added by Correll and Stetka (2014).

Amok (running amok)/Berserker

Region/Culture: Southeast Asia, Scandinavia

Loosely translated as "rampage" in Malay, amok is a dissociative condition

characterized by a non-premeditated violent, disorderly, or homicidal rage directed
against other objects or persons. The condition, which is often accompanied by amnesia
and exhaustion, is typically incited by a perceived or actual insult and can occur as part of
a brief psychotic episode or as an exacerbation of a chronic psychotic illness. A similar
state, Berserker, is used in Old Norse literature to describe a frenzied rage in Viking
warriors. Conditions such as intermittent explosive disorder; catatonic excitement;
agitation and aggression under the influence of substances; and aggression associated
with psychotic, mood, or personality disorders share features with amok.

Khyâl Cap (Wind Attacks)

Region/Culture: Cambodia and Cambodian immigrant communities

Found in Cambodians and Cambodian immigrants, and new to DSM-5, is khyâl

cap -- or, "wind attacks" -- characterized by dizziness, shortness of breath, palpitations,
and other symptoms of anxiety and autonomic arousal. The episodes often meet the
criteria for panic attacks and can be related to other anxiety or trauma-related disorders.
The name comes from the theory that the symptoms are due to a wind-like substance
rising up in the body. Clinicians should rule out physical causes of anxiety symptoms and
explore the potential trauma etiology. Treatment approaches should focus on anxiety
symptoms and, if present, trauma.

Latah/Imu/Mali-mali/Jumping Frenchmen of Maine

Region/Culture: Southeast Asia, Japan

Latah describes an exaggerated startle response to frightening stimuli. Patients

can experience a trance-like dissociation as well as echolalia and echopraxia. A similar
condition, termed "jumping Frenchmen of Maine" syndrome, has been described in
Franco-Canadian lumberjack communities. This condition has features of dissociative or
conversion disorders or catatonia, or could also be a severe form of shock in response to a
sudden or severe traumatic event.

Kufungisisa (Thinking Too Much)

Region/Culture: Zimbabwe
 Also new to DSM-5 is kufungisisa, or "thinking too much," a disorder of distress
reported by the Shona people of Zimbabwe. The term represents both a cause of
conditions akin to anxiety and depression (eg, "my heart is painful because I think too
much") as well as an idiom of psychosocial stressors, such as financial or marital
problems. Symptoms can overlap with several DSM diagnoses, including anxiety, panic
disorders, and depression. Ruminations and somatic symptoms may be addressed with
cognitive-behavioral psychotherapeutic approaches; otherwise, standard treatments for
anxiety or depression can be tried

Piblokto/Pibloktoq

Region/Culture: Arctic and Subarctic Eskimos

Piblokto, also known as "arctic hysteria," describes a dissociative episode in

which patients experience prolonged, extreme excitement sometimes followed by
seizures and coma. A prodrome of irritability can occur, and during the episode, patients
frequently exhibit dangerous, irrational behavior (ie, property destruction, stripping
naked). It has been hypothesized by at least one researcher that the condition could result
from vitamin A toxicity; organ meat from Arctic food sources such as polar bears, seals,
and walruses contains extremely high levels of the vitamin. Other potential causes of this
syndrome include forms of malnutrition (eg, vitamin D or calcium deficiency) and the
conditions associated with amok, including delirium and severe psychotic, mood, or
personality disorders.

Clinical Lycanthropy

Region/Culture: Various

Lycanthropy is a rare condition in which sufferers experience the delusion of

transforming into an animal. Affected people may also behave like the animal they
believe they have turned into. "Lycanthropy" derives from the Greek myth in which King
Lycaon is transformed into a wolf as punishment for serving human flesh to Zeus at
dinner,[7] and perhaps the folk belief in werewolves has its origin in the condition. Wolf
and dog transformations are most commonly described, but transformations into other
animals, including birds and insects, have also been reported. In that sense, the syndrome
may be shaped by personal, cultural, and regional influences. Effectively a specific form
of a delusional misidentification syndrome, it is not surprising that lycanthropy typically
occurs in the context of schizophrenia, psychotic mood disorders, or substance-induced
psychoses.

Wendigo Psychosis

Region/Culture: Various

Wendigo psychosis describes an insatiable craving for human flesh, even when
other food is available. It was first described in Algonquin Indians who felt that tribe
 members engaging in cannibalism, then turned into, or were occupied by, a feared, flesh-
eating creature or spirit called the wendigo. If attempts at a cure by traditional native
healers or Western doctors failed and the person went on to threaten others or act
violently, execution of the sufferer often followed. While some have denied the validity
of this disorder, there are a number of credible eyewitness accounts, by both aboriginal
and nonaboriginal peoples. A psychotic origin of these behaviors cannot be excluded.

Maladi Moun (Humanly Caused Illness)

Region/Culture: Haiti and Haitian communities

Maladi moun ("humanly caused illness"), found in Haitian communities, is seen

as an explanation for a number of medical and psychiatric symptoms. It is thought that
illness is literally "sent" by others out of envy and hatred and can describe psychosis,
depressive symptoms, and even academic or social problems. The condition often
overlaps with delusional disorder and schizophrenia with paranoid features. In
approaching this condition, it is important to differentiate extreme forms of
rationalization mixed with magical beliefs, overvalued ideas, and explanations shared by
a cultural subgroup from emerging or manifest psychotic symptoms. Potentially
emerging psychosis may require close observation and treatment of frequently present
comorbid conditions, including depression and substance use disorders, whereas manifest
psychotic disorders probably require antipsychotic treatment.

Taijin Kyofusho

Region/Culture: Japan

Patients with taijin kyofusho (literally "the disorder of fear") experience extreme
self-consciousness regarding their appearance. Patients suffer from intense, disabling fear
that their bodies are embarrassing or offensive to others. This culture-bound condition
has overlapping features with social phobia and body dysmorphic disorder.

Saora

Region/Culture: Southeastern India

Young men and women in India's Saora tribe will occasionally exhibit memory
loss, fainting, and inappropriate crying or laughing. Sufferers often claim to experience
the sensation of being repeatedly bitten by insects when none are present. This behavior
has been claimed to occur in response to social pressure to lead a certain way of life
expected by one's family and/or community (ie, farming), while tribe members often
attribute the behavior to the actions of supernatural beings who want to marry the
afflicted persons. This syndrome has features of a dissociative or conversion disorder.
Koro

Region/Culture: Asia, Southeast Asia

Koro is intense anxiety related to the belief that one's own genitalia are shrinking
or receding, resulting in possible death. Localized epidemics have been reported. Koro,
rooted in Chinese metaphysics and cultural practices, is included in the Chinese
Classification of Mental Disorders, Second Edition.The disorder has also been associated
with the belief that perceived inappropriate sexual acts (eg, extramarital sex, sex with
prostitutes, or masturbation) disrupt the yin/yang equilibrium, thought to be achieved
during marital sex. Koro has also been thought to be transmitted through food. One could
also hypothesize that excessive guilt and shame about fantasized or executed sexual acts
might play a role in the delusional belief.

Dhat Syndrome

Region/Culture: India

Shenkui

Region/Culture: China

Dhat derives from the Sanskrit for "elixir that constitutes the body." Dhat is an
Indian folk diagnosis in which patients suffer from severe anxiety and hypochondria
related to the loss of semen through urine, nocturnal emission, or masturbation. A similar
condition, shenkui, has been described in China. In shenkui, marked anxiety or panic
symptoms are accompanied by somatic complaints, such as dizziness, backache, fatigue,
and complaints of sexual dysfunction. The excessive loss of semen is feared because it is
seen as the loss of one's vital essence. Similar to koro, one could hypothesize that the
intense fear present in dhat and shenkui could be related to fantasized or performed
sexual acts that the person feels are forbidden or unacceptable to the self or others.
However, the description could also be related to an unrecognized depressive disorder or
somatization disorder.

Shenjing Shuairuo (Neurasthenia)

Region/Culture: China

Shenjing shuairuo is a broad Chinese folk diagnosis characterized by fatigue, poor

concentration, irritability, pain, and a variety of somatic complaints. Traditionally, it
likely included a range of mental health disorders and accompanying somatic symptoms,
which would meet today's DSM-IV criteria for a mood or anxiety disorder.Across all
cultures, it is not uncommon that mood disorders are expressed as somatizing -- rather
than mental -- symptoms, partly to avoid the stigma often associated with mental
disorders. This would fit with somatoform disorders such as conversion disorder or
 somatization disorder. The description of shenjing shuairuo would also fit chronic fatigue
syndrome, which remains poorly understood.

Zar

Region/Culture: Northern Africa, Middle East

Attributed to spirit possession -- and not considered a pathology locally -- people

experiencing zar undergo dissociative episodes, including fits of excessive laughing,
yelling, crying, and hitting their head against a wall. Patients are often apathetic and
report developing long-term relationships with their possessor. On the basis of its
phenomenology, zar could be conceptualized as a recurrent brief psychotic episode,
delusional disorder, dissociative condition, or potentially a substance-induced event. Zar
is an important example of how certain culture-bound syndromes can be seen as normal,
or as a sign of being "selected," where other cultures would consider such symptoms
pathologic.

Shin-byung (Spirit Sickness)

Region/Culture: Korea

This folk diagnosis is characterized by anxiety and numerous somatic complaints,

such as weakness, dizziness, and gastrointestinal symptoms. Patients often dissociate and
attribute their state to possession by ancestral spirits. The condition can also be viewed as
somatization of an underlying major depressive or anxiety disorder -- or as an adjustment
disorder -- which is destigmatized by attributing this mental state to possession by a
spirit. Shin-byung shares features of somatoform or dissociative disorders.

Ghost Sickness

Region/Culture: Native Americans, Hispanics

Ghost sickness is characterized by a preoccupation with death and the deceased

and is frequently seen in Native Americans but has also been described in Hispanic
cultures. Symptoms are broad and can include weakness, dizziness, loss of appetite,
feelings of danger, dizziness, fear, anxiety, hallucinations, and a sense of suffocation. As
evidenced by this symptom constellation, ghost sickness could also be conceptualized as
protracted or pathological grief or depression, which is expressed predominantly
somatically and may increase the acceptability of the disturbed mental state to afflicted
people and those who know them.

Susto

Region/Culture: United States, Latin America, South America

 From the Spanish for "fright," and common in certain Latino populations, susto
refers to the soul leaving the body in response to a frightening experience. Symptoms can
recur for years and are consistent with multiple DSM-5 diagnoses, including major
depressive disorder, posttraumatic stress disorder, and somatic symptom and related
disorders.

Falling Out

Region/Culture: Southern United States, Caribbean

Falling-out episodes are characterized by a sudden collapse, sometimes preceded

by dizziness, in which patients often report temporary blindness despite their eyes
remaining open. Patients are generally aware of their environment, but report being
unable to move.This set of symptoms has overlapping features with cataplexy, a rare
condition in which patients have a sudden and transient loss of muscle tone (usually in
response to strong emotions) and fall to the ground. They also may experience vasovagal
syncope, due to a strong physical or psychological event, as well as catatonia, conversion
disorder, or dissociative disorder.

Grisi Siknis

Region/Culture: Central and South America

Grisi siknis is a hysterical condition reported in Nicaragua. In English, the term

translates to "crazy sickness." It is highly contagious and affects mainly young girls and
women, especially those 15-18 years old. The attacks start with headaches, dizziness,
anxiety, nausea, irrational anger, and/or fear. During the attack, the victim "loses
consciousness," falls to the ground, and subsequently runs away. Afflicted persons may
view others as devils, feel no pain from bodily injuries, and have absolute amnesia
regarding their physical circumstances. Some shadow-fight with unseen opponents, while
others have been reported to have performed superhuman acts and spoken in tongues.
This condition has features of dissociative or conversion disorders.

Gururumba

Region/Culture: New Guinea

Gururumba describes an episode in which the afflicted person (usually a married

man) begins burglarizing neighboring homes, taking objects that he considers valuable
but which seldom are. He then runs away, often for days, returning without the objects
and amnestic about the episode. Sufferers have been described as hyperactive, clumsy,
and with slurred speech. This syndrome has features of a dissociative or conversion
disorder but also could be a substance intoxication-related condition.