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Culture-Bound Syndromes Culture-bound syndromes (CBSs) comprise a heterogeneous set of illness phenomena of particular interest to medical anthropologists and to psychiatrists. The eclectic nature of the category makes it hard to define precisely, and has invited much dispute over the best name and definition for it. DSM-IV (844) defines a culture-bound syndrome: recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be "illnesses", or at least afflictions, and most have local names. More generally, culture-bound syndromes comprise several kinds of illness or affliction, all of which are defined as culture-bound (and therefore have been of interest to medical anthropologists and ethnopsychiatrists) in that they do not have a one-to-one correspondence with a disorder recognized by Western, allopathic nosologies. Most CBSs were initially reported as confined to a particular culture or set of related or geographically proximal cultures. At least seven broad categories can be differentiated among phenomena often described as culture-bound syndromes: 1. an apparent psychiatric illness, not attributable to an identifiable organic cause, which is locally recognized as an illness and which does not correspond to a recognized Western disease category, e.g. amok. 2. an apparent psychiatric illness, not attributable to an identifiable organic cause, which is locally recognized as an illness and which resembles a Western disease category, but which has locally salient features different from the Western disease, and which may be lacking some symptoms seen as salient in the West. One example is shenjing shaijo or neurasthenia in China, which resembles major depressive disorder but has more salient somatic features and often lacks thedepressed mood which defines depression in the West. Another is taijin kyufusho which is widely regarded as being a peculiarly Japanese form of social phobia. 3. a discrete disease entity not yet recognized by Western medicine. The most famous example of this is kuru, a progressive psychosis and dementia indigenous to cannibalistic tribes in New Guinea. Kuru was eventually classified as a "slow-virus" disease, and is now believed to result from an aberrant protein or "prion" which is capable of replicating itself by deforming other proteins in the brain. (A 1997 Nobel prize was awarded for the elucidation of prions.) Kuru has been identified with a form of Creuzfeldt-Jakob disease, and may be equivalent or related to scrapie, a disease of sheep, and bovine spongiform encephalopathy (BSE) or "mad cow disease". 4. an illness which may or may not have an organic cause, and may correspond to a subset of a Western disease category or may elaborate symptoms not recognized as constituting a Western disease into an illness category. In other words, this is a phenomenon which occurs in many cultural settings, but which is only elaborated as an illness in one or a few. A possible example is koro, the fear of retracting genitalia, which may sometimes have a physiologicalanatomical reality, and which appears to occur independently in a non-culturallyelaborated way as a delusion or phobia in numerous cultural settings. 5. culturally accepted explanatory mechanisms or idioms of illness which do not match allopathic mechanisms or Western idioms, and which, in a Western setting, might indicate culturally inappropriate thinking and perhaps delusions or

hallucinations. Examples of this include witchcraft, rootwork (Caribbean) or the evil eye (Mediterranean and Latin America).

6. a state or set of behaviors, often including trance or possession states; hearing, seeing, and/or communicating with the dead or spirits; or feeling that one has "lost one's soul" from grief or fright; which may or may not be seen as pathological within their native cultural framework, but which if not recognized as culturally appropriate could indicate psychosis, delusions, or hallucinations in a Western setting. 7. a syndrome allegedly occuring in a given cultural setting which does not in fact exist, but which may be reported to the anthropologist or psychiatrist. A possible example is windigo (Algonkian Indians), a syndrome of cannibal obsessions whose reality has been challenged (Marano, in Simons & Hughes, 1985) but may in fact be used to justify the expulsion or execution of an outcast in a manner similar to witchcraft allegations. Debates over culture-bound syndromes often revolve around confusions or conflations among these different categories. Many so-called culture-bound syndromes actually occur in many unrelated cultures, or appear to be merely locally flavored varieties of illnesses found elsewhere. Some are not so much actual illnesses as explanatory mechanisms, like witchcraft or humoral imbalances. Beliefs in witchcraft and humoral imbalances can lead to behaviors which would seem to indicate disordered thought processes outside their cultural context, such as avoidance of cold and drafts in Chinese pa-feng and pa-leng, but which actually make sense in context. The concept of culture-bound syndromes is therefore useful insofar as it brings culture to the attention of psychiatrists trained in a different cultural tradition. Awareness of CBSs allow psychiatrists and physicians to make culturally appropriate diagnoses. The concept is also interesting to medical and psychiatric anthropologists, in that culture-bound syndromes provide examples of how culturally salient symptoms can be elaborated into illness experiences. The concept is problematic, however, in that it is not a homogeneous category, and the designation of "culture-bound" can imply that the illness is somehow "not real", or that a patient's experience can be dismissed as merely exotic. One of the best available compilations on culture-bound syndromes is: Simons, Ronald C.; and Hughes, Charles C. (eds.) (1985) The Culture-Bound Syndromes: folk illnesses of psychiatric and anthropological interest. Dordrecht, The Netherlands: D. Reidel Publishing Company. Useful information is also found commonly in the journals Culture, Medicine, and Psychiatry, and Transcultural Psychiatry. Several references are given in the bibliography.

Glossary of Culture-Bound Syndromes: This glossary lists most of the culture-bound syndromes found in the literature, although it is by no means exhaustive. Syndromes are listed alphabetically in two sections: actual culture-bound syndromes vs. culture-specific idioms of disease (see the introductory essay for a brief description of the differences.) The major geographical or cultural locale for each syndrome is given, along with a brief description and a listing of synonyms or similar syndromes in other cultural regions. For syndromes (e.g., koro) which have a similar presentation in many cultures, only one or two of the best-documented variants have a description. The following list is adapted in part from lists of culture-bound syndromes given in DSMIV (pp. 845-849) and in Kaplan and Sadock's Synopsis of Psychiatry (pp. 190-191, 493494). Simons & Hughes (1985: 475-505) give a much more extensive listing of culturebound syndromes; however, their descriptors are not always specific enough for inclusion here.

The author of the glossary list added several syndromes, expanded or condensed descriptors, and divided the categories into actual culture-bound syndromes vs. culturespecific idioms of disease.

At present, descriptions in this list are more complete for syndromes of East Asia, Southeast Asia, and South Asia, which are my areas of interest. Psychiatric syndromes which are endemic to particular cultures: •

amok or mata elap: (Malaysia) a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects. The episode tends to be precipitated by a perceived insult or slight and seems to be prevalent only among males. The episode is often accompanied by persecutory ideas, automatism, amnesia for the period of the episode, exhaustion, and a return to premorbid state following the episode. Some instances of amok may occur during a brief psychotic episode or constitute the onset or exacerbation of a chronic psychotic process. Similar to cafard or cathard (Polynesia), mal de pelea (Puerto Rico), iich'aa (Navaho), and syndromes found in Laos, Papua New Guinea, and the Philippines. Similar also to the nascent American folk-category of going postal.

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anorexia mirabilis or holy anorexia: (medieval Europe): severe restriction of food intake, associated with experience of religious devotion. Often not considered pathological within the culture. The terms are used by historians, and are not emic.

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anorexia nervosa (North America, Western Europe): severe restriction of food intake, associated with morbid fear of obesity. Other methods may also be used to lose weight, including excessive exercise. May overlap with symptoms of bulimia nervosa.

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boufée deliriante: (West Africa and Haiti) sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. It may sometimes be accompanied by visual and auditory hallucinations or paranoid ideation. Similar to DSM-IV brief psychotic disorder.

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brain fag or brain fog: (West Africa) a condition experience by primarily male high school or university students. Symptoms include difficulties in concentrating, remembering, and thinking. Students often state that their brains are "fatigued". Additional symptoms center around the head and neck and include pain, pressure, tightness, blurring of vision, heat, or burning. "Brain tiredness" or fatigue from "too much thinking" is an idiom of distress in many cultures. May resemble anxiety, depressive, or somatoform disorders in DSM-IV.

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bulimia nervosa (North America, Western Europe): binge eating followed by purging through self-induced vomiting, laxatives, or diuretics; and morbid fear of obesity. May overlap with symptoms of anorexia nervosa.

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dhat: (India) semen-loss syndrome, characterized by severe anxiety and hypochondriacal concerns with the discharge of semen, whitish discoloration of the urine, and feelings of weakness and exhaustion. Similar to jiryan (India), sukra prameha (Sri Lanka), and shenkui (China).

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falling out or blacking out: (Southern U.S. and Caribbean) episodes characterized by sudden collapse, either without warning or preceded by feelings of dizziness or "swimming" in the head. The individual's eyes are usually open, but the person claims inability to see. The person usually hears and understands what is occurring around him or her, but feels powerless to move. May correspond to DSM-IV conversion disorder or dissociative disorder

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ghost sickness: (American Indian groups) preoccupation with death and the deceased, sometimes associated with witchcraft. Symptoms may include bad dreams, weakness, feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of consciousness, confusion, feelings of futility, amd a sense of suffocation.

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grisi siknis: (Miskito Indians, Nicaragua) symptoms include headache, anxiety, anger, aimless running. Some similarities to pibloktoq.

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Hi-Wa itck: (Mohave American Indians) insomnia, depression, loss of appetite, and sometimes suicide associated with unwanted separation from a loved one.

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hsieh-ping: (Taiwan) a brief trance state during which one is possessed by an ancestral ghost, who often attempts to communicate to other family members. Symptoms include tremor, disorientation and delirium, and visual or auditory hallucinations.

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hwa-byung or wool-hwa-bung: (Korea) "anger syndrome". Symptoms are attributed to suppression of anger and include insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, anorexia, dyspnea, palpitations, generalized aches and pains, and a feeling of a mass in the epigastrium. See also bilis and colera, below.

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involutional paraphrenia: (Spain, Germany) paranoid disorder occurring in midlife.

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koro: (Malaysia) an episode of sudden and intense anxiety that the penis (or in the rare female cases, the vulva and nipples) will recede into the body and possibly cause death. The syndrome occasionally occurs in local epidemics. This syndrome occurs throughout south and east Asia under different names: suo yang (China); jinjinia bemar (Assam); and rok-joo (Thailand). It has been identified in isolated cases in the United States and Europe, as well as among diasporic ethnic Chinese or Southeast Asians.

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latah: (Malaysia and Indonesia) hypersensitivity to sudden fright, often with echopraxia, echolalia, command obedience, and dissociative or trancelike behavior. The Malaysian syndrome is more frequent in middle-aged women. Similar syndromes include: amurakh, irkunii, ikota, olan, myriachit, and menkeiti (Siberian groups); bah-tschi, bah-tsi, and baah-ji (Thailand); imu (Ainu & Sakhalin, Japan); and mali-mali and silok (Philippines).

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locura: (Latin America) a severe form of chronic psychosis, attributed to an inherited vulnerability, the effect of multiple life difficulties, or a combination of the two. Symptoms include incoherence, agitation, auditory and visual hallucinations, inability to follow rules of social interaction, unpredictability, and possible violence.

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pibloktoq or Arctic hysteria: (Greenland Eskimos) an abrupt dissociative episode accompanied by extreme excitement of up to 30 minutes' duration and frequently followed by convulsive seizures and coma lasting up to 12 hours. The individual may be withdrawn or mildly irritable for a period of hours or days before the attack and will typically report complete amnesia for the attack. During the attack, the individual may tear off his or her clothing, break furniture, shout obscenities, eat feces, flee from protective shelters, or perform other irrational or dangerous acts. The syndrome is found throughout the arctic with local names.

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qi-gong psychotic reaction: (China) an acute, time-limited episode characterized by dissociative, paranoid, or other psychotic or nonpsychotic symptoms that occur after participating in the Chinese folk health-enhancing practice of qi-gong. Especially vulnerable are individuals who become overly involved in the practice.

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sangue dormido: (Portuguese Cape Verdeans) Literally "sleeping blood". Symptoms include pain, numbness, tremor, paralysis, convulsions, stroke, blindness, heart attack, infection, and miscarriage.

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shenjian shuairuo: (Chinese) equivalent to now-defunct diagnosis of "neurasthenia". Symptoms include physical and mental fatigue, dizziness, headaches and other pains, difficulty concentrating, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and various signs suggesting disturbances of the autonomic nervous system. Many cases would be DSM-IV criteria for major depressive disorder or an anxiety disorder.

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Shenkui (Chinese): marked anxiety or panic symptoms with accompanying somatic complaints for which no physical cause can be demonstrated. Symptoms

include dizziness, backache, fatiguability, general weakness, insomnia, frequent dreams, and complaints of sexual dysfunction (such as premature ejaculation and impotence). Symptoms are attributed to excessive semen loss from frequent intercourse, masturbation, nocturnal emission, or passing of "white turbid urine"

believed to contain semen. Excessive semen loss is feared because it represents the loss of one's vital essence and can thereby be life threatening. Similar to dhat and jiryan (India); and sukra prameha (Sri Lanka). •

shin-byung: (Korea) syndrome characterized by anxiety and somatic complaints (general weakness, dizziness, fear, loss of appetite, insomnia, and gastrointestinal problems), followed by dissociation and possession by ancestral spirits.

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shinkeishitsu: (Japan) syndrome marked by obsessions, perfectionism, ambivalence, social withdrawal, neurasthenia, and hypochondriasis.

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spell: (southern U.S.) a trance state in which individuals "communicate" with deceased relatives or with spirits. At times this is associated with brief periods of personality change. Spells are not considered medical events in the folk tradition, but may be misconstrued as psychotic episodes in a clinical setting.

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tabanka: (Trinidad) depression associated with a high rate of suicide; seen in men abandoned by their wives.

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taijin kyofusho: (Japan) a syndrome of intense fear that one's body, body parts, or bodily functions are displeasing, embarrassing, or offensive to other people in appearance, odor, facial expressions, or movements. Similar in some respects to DSM-IV social phobia, and included in the official Japanese classification of mental disorders.

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windigo or witiko: (Algonkian Indians, NE US and Eastern Canada) Not in DSMIV. Famous syndrome of obsessive cannibalism, now somewhat discredited. Wendigo was supposedly brought about by consuming human flesh in famine situations. Afterwards, the cannibal was supposed to be haunted by cravings for human flesh and thoughts of killing and eating humans. Excellent review of the windigo literature in Lou Marano. "Windigo psychosis: the anatomy of an emicetic confusion." In The Culture-Bound Syndromes. Ronald Simons and Charles Hughes. (eds.) Boston, MA: D. Reidel Publishing Company. 1985.

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zar: (Ethiopia, Somalia, Egypt, Sudan, Iran, and elsewhere in North Africa and the Middle East) experience of spirit possession. Symptoms may include dissociative episodes with laughing, shouting, hitting the head against a wall, singing, or weeping. Individuals may show apathy and withdrawal, refusing to eat or carry out daily tasks, or may develop a long-term relationship with the possessing spirit. Such behavior is not necessarily considered pathological locally. For an ethnographic description of similar possession, see Vincent Crapanzano, Tuhami: portrait of a Moroccan.

Culture-specific idioms of distress and disease: •

ataque de nervios: an idiom of distress principally reported among Latinos from the Caribbean, but also among many Latin American and Latin Mediterranean groups. Symptoms include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising to the head, and verbal or physical aggression. Ataques de nervios frequently occur as a result of a stressful family event, especially the death of a relative, but also a divorce or fight with a family member.

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bilis and colera: part of a general Latin American idiom of distress and explanation of physical or mental illness as a result of extreme emotion, which upsets the humors (described in terms of hot and cold.) Bilis and colera specifically implicate anger in the cause of illness.

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mal de ojo: (Spain and Latin America) the Spanish term for the evil eye. Evil eye occurs as a common idiom of disease, misfortune, and social disruption throughout the Mediterranean, Latin American, and Muslim worlds.

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nervios: (Latin America) Idiom of distress, refers to a general state of vulnerability to stressful life experiences and to a syndrome brought on by such

stresses. Symptoms may be very broad, but commonly include emotional distress, headaches, irritability, stomach disturbances, sleep disturbances, nervousness, easy tearfulness, inability to concentrate, tingli...