Culture-bound syndromes

Oyedeji Ayonrinde¹ and Dinesh Bhugra²

¹ Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust, London, UK

² Professor of Mental Health and Cultural Diversity, Institute of Psychiatry, King’s College London, London, UK

Introduction

Mental disorders and mental illness have been reported from across cultures even though rates of different illnesses vary due to a number of factors. Cultures influence the way distress is expressed and thus notions of culture-bound emerged, arguing that certain conditions were confined to certain specific cultures only. As a consequence of colonialism, psychiatrists as well as anthropologists from Europe and America have had a significant influence on the early descriptions of unfamiliar presentations of mental distress in other cultures. Their research interests led to the dissemination of descriptions of exotic manifestations of mental disorders in indigenous or native groups around the world. Descriptions of these indigenous health systems, idioms of distress and therapeutic interventions were found appealing and led to the emergence of “cultural” diagnoses. Over the years, the medicalisation of social expression of distress has led to the evolution of “new syndromes” and disorders in scientific literature.

Yap [1] described culture-bound psychogenic psychoses as a way of harmonising a wide range of disorders with a complex socio-cultural influence on their presentation. In 1969 he subsequently abbreviated this terminology to culture-bound syndromes [2].

Elaborating on this, Bhugra and Jacob [3] observed that these syndromes described “rare, exotic unpredictable and chaotic behaviours at their core among uncivilised people.” These authors asserted that these behaviours were described in the context and against a backdrop of Western diagnostic systems with little appreciation of socio-environmental influences and the tolerance of symptoms within the culture. This Western medicalisation was felt to lead to Eurocentric labelling of culturally acceptable behaviour in non-Western populations.

In a similar vein, Hughes and Wintrob [4] emphasised the need for a contextual frame of reference for the full appreciation of unfamiliar clinical presentations.

Initial descriptions of these syndromes were predominantly from Far East Asia; however, Western culture-bound syndromes such as Type A behaviour patterns and bulimia have been suggested by Hughes [5] and Littlewood [6] respectively. Type A personality is based on the cultural salience of goal pursuance, working against time pressure, and the frustration experienced at not achieving these goals. Explored in cultural context, this may reflect the “individualistic” or egocentric nature of the society with a greater emphasis on “I-ness.” In such societies kinship or family links may be weaker, compared with collectivist or “sociocentric” societies, which promote group relationships and kinship sharing of resources [7]. Such societal values may influence individuals and the normalisation of behaviours.

This chapter reviews the historical and current status of culture bound syndromes in contemporary clinical practice by exploring the development of two well documented syndromes and their current relevance. Focusing on brain fag syndrome and on dhat highlights historical evolution and questions the nosological, diagnostic and therapeutic relevance of these concepts.

Society and illness

Societal differences in economic, political, and social functioning influence healthcare, and the rates and distribution of common mental disorders in the population [8]. Culture within each society also determines what counts as aberrant behavior, such as a crime or mental disorder, as well as what is acceptable. The interplay between culture and mental wellbeing can be observed in all spheres of life, such as attitudes to diet, body image, relationships, vocation, and study.

Over the last half century, there has been an evolution in the names used to describe unfamiliar or unique cultural phenomena (see Figure 17.1):

Ethnic or exotic psychosis
Culture-reactive (ICD 10) [9]
Culture-Bound Syndromes
Culture Specific Disorders (ICD-10)
Cultural Concepts of Distress (DSM-5)

c17-fig-0001 — **Figure 17.1** Nosological timeline.

Nosological definitions of culture-bound syndromes have not been static over the decades. The core features, syndrome features, and labels have been inconsistent.

Bound: The concept of boundedness has been a controversial one, as it is uncommon for a particular set of symptoms within a syndrome to be bound to a specific culture. This presents a further challenge in that cultures seldom have clearly defined boundaries of their own. Hughes [12] observed that labels suggesting exotic syndromes and atypical psychoses are grounded on the premise that these disorders deviate from recognised and perhaps standard Western diagnoses.

Exotic indicates something unusual, foreign, not indigenous, alien, and different. However, differences do not imply psychopathology and would require an awareness from within the culture before considering labelling with a diagnosis. Failure of the clinician to put an unfamiliar behaviour in the true cultural context may lead to the pathologisation of normal or acceptable behaviour.

Culture-bound syndromes in the diagnostic manuals (DSM and ICD)

ICD-10

The International Classification of Diseases (ICD-10) [9] recognises a number of culturally uncommon symptom patterns and presentations referred to as culture-specific disorders. While they were felt to have diverse characteristics, they shared two key features:

Not being easily accommodated in established and international diagnostic categories
Initial description in a particular population or cultural area and subsequent association with this community or culture

Systematic study of culture specific disorders faces additional challenges of the frequently acute and transient as well as rare.

The ICD-10 indicates the status of culture specific disorders is controversial in that researchers argue the differences of cultural disorders are in degree from existing familiar disorders, thus suggesting cultural disorders are only local variations of established disorders such as depression. In light of this, only tentative associations were made by the ICD-10 between cultural syndromes and recognised psychiatric categories pending a stronger evidence base. Given the large membership of the WHO, resource differences, research, and health priorities of member countries, it is no surprise caution is being exercised with endorsing specific symptom clusters. It is anticipated that the salience given to cultural issues and specific syndromes will shift in the ICD-11, as has been the case with the DSM classificatory system.

DSM-IV-TR [10]

The term culture-bound syndrome “denotes recurrent, locality-specific patterns of aberrant behaviour and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category.” This definition was based on the premise that culture-bound syndromes had the following characteristics:

Characteristics of culture-bound syndromes [10]

Indigenously considered illness or afflictions, therefore a recognition within the society as a deviation from normal or healthy presentation
Local names: the ascription of a specific local name to the experience of mental distress; often in the indigenous or key language of communication and may be components of folk diagnostic categories
Symptoms, course, and social response often influenced by local cultural factors; for instance, the folk healing systems for the symptoms based on the explanatory model of the experiences
Limited to specific societies or cultural areas: may be a geographical region, areas with shared ethnic history or identity; for instance, some cultural practice and artefacts of the Yoruba culture of western Nigeria may also be found in Brazil
Localised: therefore experiences that are not globally recognised or span different regions

DSM-5 changes, 2013

The DSM-5 [11] discarded the concept of culture-bound syndromes with a preference for the term cultural concepts of distress. This was defined as “ways cultural groups experience, understand, and communicate suffering, behavioural problems, or troubling thoughts and emotions.”

Introducing this change, DSM-5 elaborates on three cultural concepts:

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

Controversy regarding the concept of culture-bound syndromes has received wide recognition. The DSM-5 contends that the terminology ignores the influence of culture on more specific experience and expression of distress. This questions the validity of culturally circumscribed collections of symptoms as had been the case previously. Reinforcing this view, the DSM-5 stresses all mental distress is culturally framed and different populations have culturally determined ways of communicating distress, explanations of causality, coping methods, and help-seeking behaviour.

These World Health Organisation and American Psychiatric Association diagnostic classificatory systems have had continuous reviews and amendments to incorporate new anthropological, psychiatric, and social research findings, and recognise societal changes in idioms of distress, illness awareness, and explanatory models.

These views highlight the nosological challenges of using a term when it can be argued that all psychiatric disorders are culture bound.

Culture bound syndromes in the diagnostic manuals (DSM and ICD)

While a large number of culture-bound syndromes have been described over the years, the enduring nature of each varies. For instance, the DSM-IV-TR described 25 syndromes; however, the DSM-5, published in 2013, reduced the number of detailed cultural concepts of distress (culture-bound syndromes) to 9 in light of the current research evidence base (see Tables 17.1 and 17.2).

Table 17.1 Various culture-bound syndromes.

x indicates description of the syndrome in the different diagnostic manuals.

	Culture bound syndrome	Country/region	ICD-10 (12 syndromes) – described	DSM IV-TR (25 syndromes) – described	DSM 5 (9 syndromes) – described
1.	Amok	Malaysia	x	x
2.	Ataque de nervios	Latin America/ Latino Caribbean		x	x
3.	Bilis and colera	Latino		x
4.	Boufee delirante	West Africa, Haiti		x
5.	Brain fag	West Africa		x
6.	Dhat	India	x	x	x
7.	Falling-out (blacking out)	South USA, Caribbean		x
8.	Ghost sickness	American Indian (Native American)		x
9.	Hwa-byung	Korea		x
10.	Koro	Malaysia	x	x
11.	Khyâl cap	Cambodia			x
12.	Kufungisisa	Zimbabwe			x
13.	Latah	Malaysia, Indonesia	x	x
14.	Locura	Latino, USA, Latin America		x
15.	Mal de ojo	Mediterranean		x
16.	Maladi moun	Haiti			x
17.	Nervios	Latino, Latin America	x	x	x
18.	Pibloktoq	Artic Circle	x	x
19.	Qi-gong psychotic reaction	China		x
20.	Rootwork	Southern USA, Caribbean		x
21.	Sangue dormido	Portuguese Cape Verde		x
22.	Shenjing shuairuo	China		x	x
23.	Shen-k’uei	China	x	x
24.	Shin-byung	Korea		x
25.	Spell	Southern USA		x
26.	Susto	Latino/ South America	x	x	x
27.	Taijin kyofusho	Japan	x	x	x
28.	Zar	Ethiopia, Somalia, Egypt, Sudan. North Africa, Middle East		x
29.	Others Pa-leng Ufufuyane, saka Uqamairineq Windigo	China Southern Africa Arctic Circle N.E. North America	x x x x

Interested readers are referred to Simon and Hughes [12, 13] and the DSM (DSM-IV and DSM-5 glossaries [10, 11] for more detail on different culture-bound syndromes and concepts of distress.

Table 17.2 Nosological interplay between psychiatric disorders and culture-bound syndromes [14].

Textbook of Cultural Psychiatry, edited by Dinesh Bhugra and Kamaldeep Bhui, Cambridge University Press, 2007.

Psychiatric disorder	Diagnostic category	Associated culture-bound syndrome
“Neurosis”	Anxiety Depersonalisation Personality disorder	Koro Dhat Brain fag Amok Latah Ataque de nervios
Psychosis	Affective Schizophrenia	Brain fag Koro Amok Susto
Others	Eating disorders	Anorexia nervosa Bulimia

Specific culture-bound syndromes

Brain fag syndrome: A case study of the stability of a culture-bound syndrome [15]

Brain fag syndrome has been embedded in anthropological, social science and psychiatric literature as a West African culture-bound syndrome for many years. In 1960, Raymond Prince, a Canadian psychiatrist and anthropologist working in Nigeria, published some observations made during his clinical practice in the country. He described a cluster of symptoms unfamiliar to him as the brain fag syndrome, characterised by somatic, affective, anxiety, and cognitive complaints in African individuals engaged in educational pursuit [16].

Ever since his original report, descriptions of brain fag syndrome have achieved wide acclaim in peer-reviewed psychiatric journals, textbooks, and classificatory volumes such as the ICD-10 and DSM-IV-TR.

It is not uncommon to read flamboyant descriptions in contemporary textbooks of this exotic “African syndrome” and the need to give careful consideration when presented with an African student manifesting somatic, affective, or anxiety symptoms. This is usually illustrated by accounts of African immigrant students presenting to college or university health centres with burning or crawling sensations, difficulty with recall, and anxiety. The texts reinforce the notion that these students from an unfamiliar culture may be particularly vulnerable when studying and may also apply faulty study techniques with detrimental effects on their mental wellbeing.

In these contemporary texts, brain fag syndrome was initially coined and described in Nigeria and the etymology of the phrase “brain fag” rooted in a form of pidgin Nigerian-English, colloquially referring to forms of mental exhaustion.

Interestingly, this version of the history of “brain fag” has been a source of pride in some quarters as a unique manifestation of a specific mental disorder discovered in West Africa, hence putting the region on the nosological map of psychiatric literature. There remain some serious questions. For example, was the phrase “brain fag” coined in West Africa? Are some West African individuals particularly vulnerable to education and study? Is this presentation unique or do similar presentations exist in other regions of the world? In essence, is the brain fag syndrome truly culture bound?

An etymological exploration of the term “brain fag”

Contrary to the popular belief that its origins were in 1960s Africa, the concept of brain fag was initially described in Britain in the early 1800s and subsequently disseminated around the British Empire with the colonial spread of the English language in the same way semen-loss anxiety was used and treated both in Britain and the U.S. [17].

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May 29, 2017 | Posted by admin in PSYCHIATRY | Comments Off

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Culture-bound syndromes

Introduction

Society and illness