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That’ll do icily: A brief look at pagophagia

In a previous blog on five ‘weird addictions’ I briefly mentioned pagophagia, a craving and compulsion for chewing ice. Pagophagia is a type of pica (which I also covered in a previous blog). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Although the incidence of pagophagia appears to have increased over the last 30 years in westernized cultures, Dr. B. Parry-Jones (in a 1992 issue of Psychological Medicine) carried out some historical research and pointed out that both Hippocrates and Aristotle wrote about the dangers of excessive intake of iced water. Parry-Jones also noted that references to disordered eating of ice and snow were also recorded in medical textbooks from the sixteenth century. However, the first contemporary reference to pagophagia appears to have been a 1969 paper by Dr. Charles Coltman in the Journal of the American Medical Association entitled ‘Pagophagia and iron lack’.

Pagophagia is closely associated with iron deficiency anemia but can also be caused by other factors (biochemical, developmental, psychological, and/or cultural disorders). If pagophagia is due to iron deficiency (such as case studies of those with sickle cell anemia), it may sometimes be accompanied by fatigue (e.g., being tired even when performing normally easy tasks). Dr. Youssef Osman and his colleagues published a number of case reports of pagophagia in a 2005 issue of the journal Pediatric Haematology and Oncology including the case of a child with sickle cell anemia and rectal polyps (that caused a lot of bleeding and made the anemia worse):

“An 8-year-old Omani boy, a known case of sickle cell anemia…presented with history of craving for ice. The child was noticed over the last 4 months to like drinking very cold water and to open the deep freezer and scratch the ice and eat it. The parents tried to stop him from doing so, but they failed…The child was started on oral iron therapy…and his craving for ice was completely stopped. Meanwhile, the rectal polyp was removed surgically”.

Other potential health side effects include constant headaches (a ‘brain freeze’ similar to ‘ice cream headache’) and teeth damage although this is thought to be relatively rare. However, a recent paper by Dr. Yasir Khan and Dr. Glen Tisman in the Journal of Medical Case Reports highlighted the case of a 62-year-old Caucasian man who presented with bleeding from colonic polyps associated with drinking partially frozen bottled water.

Khan and Tisman also suggested that some people who are deficient in iron experience tongue pain and glossal inflammation (glossitis). Others claim that chewing ice may help those with stomatitis (i.e., inflammation of the mucous lining inside the mouth). A recent 2009 case study published by Dr. Tsuyoshi Hata and his colleagues in the Kawasaki Medical Journal, reported the case of a 37-year old Japanese women who ate copious amounts of ice to relieve the pain of temporomandibular joint disorder (i.e., chronic pain in the joint that connects the jaw to the skull). Khan and Tisman also claim that the classical symptoms of pagophagia have changed in the last 40 years since Dr. Coltman’s initial paper in the Journal of the American Medical Association.

“This may probably be the result of advances in technology and changes in culture. When initially described [by Coltman], pagophagia was defined as the excessive ingestion of ice cubes from ice trays and the ingestion of ice scraped from the wall of the freezer. With the advent of ice cube makers and auto defrosters, the presentation of pagophagia has changed in a subtle manner as described in…our patients. Now we observe a subtler ingestion and/or sucking of ice cubes from large super-sized McDonalds-like cups and from the use of popular bottled water containers that have been frozen”.

There have been few epidemiological studies examining the prevalence of pagophagia. Such estimates vary widely within particular populations but (according to Dr. Youssef Osman and his colleagues) have been shown to be more common in low socioeconomic and underdeveloped areas. Pagophagia is thought to be relatively harmless in itself or to one’s health, although there are some claims in the literature that pagophagia can be addictive. However, empirical reviews suggest that pagophagia (and pica more generally) is part of the obsessive-compulsive disorder spectrum of diseases. As a consequence, some case studies even suggest that ice chewing compromises their ability to maintain jobs or personal relationships.

Treatment for pagophagia can often be overcome with iron therapy and Vitamin C supplements (to supplement iron deficiency if that is the cause). For instance, Dr. Mark Marinella in a 2008 issue of the Mayo Clinic Proceedings successfully treated a 33-year old woman with pagophagia following complications with gastric bypass surgery:

“The patient received red blood cells, iron sucrose, and levofloxacin. On further questioning, the patient denied taking vitamin, mineral, or iron supplements since surgery and reported prolonged, heavy menstrual cycles. She consumed large amounts of ice daily for several months. The patient’s husband frequently observed her in the middle of the night with her head in the freezer eating the frost off the icemaker. The patient admitted to awakening several times nightly for months with an uncontrollable compulsion to eat the frost on the icemaker. This craving resolved after transfusion and iron administration”

However, if the condition is psychologically or culturally based, iron and vitamin supplements are unlikely to work, and other psychological treatments (such as cognitive-behavioural therapy) are likely to be employed.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Coltman, C.A. (1969). Pagophagia and iron lack. Journal of the American Medical Association, 207, 513-516.

de Los Angeles, L., de Tournemire, R. & Alvin, P. (2005). Pagophagia: pica caused by iron deficiency in an adolescent. Archives of Pediatrics, 12, 215-217.

Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemadej, U.J., Cole, O.J., Westney, O.E., Jones, S. Laryea, H. & Westney, L.S. (1994). Pica in an urban environment. Journal of Nutrition (Supplement), 124, 954-962.

Hata, T., Mandai, T., Ishida, K., Ito, S., Deguchi, H. & Hosoda, M. (2009). A rapid recovery from pagophagia following treatment for iron deficiency anemia and TMJ disorder accompanied by masked depression. Kawasaki Medical Journal, 35, 329-332.

Khan, Y. & Tisman, G. (2010). Pica in iron deficiency: A case series. Journal of Medical Case Reports, 4, 86. Located: http://www.jmedicalcasereports.com/content/4/1/86

Kirchner, J.T (2001). Management of pica: A medical enigma. American Family Physician, 63, 1177-1178.

Marinella, M. (2008). Nocturnal pagophagia complicating gastric bypass. Mayo Clinic Proceedings, 83, 961

Osman, Y.M., Wali, Y.A. & Osman, O.M. (2005). craving for ice and iron-deficiency anemia: a case series. Pediatric Hematology and Oncology, 22, 127-131.

Parry-Jones, B. (1992). Pagophagia, or compulsive ice consumption: A historical perspective. Psychological Medicine, 22, 561-571.

Dhat’s life: A beginner’s guide to semen loss syndrome

In previous blogs I have examined various culture bound syndromes (CBSs) such as koro and berserkers. CBSs comprise a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies and are often unknown outside of their own local regions. One of the more unusual CBSs is dhat syndrome, typically located in the Indian sub-continent (India, Sri Lanka, Bangladash). Dhat is one of the CBSs listed in the World Health Organization’s International Classification of Diseases.

The term ‘Dhat syndrome’ was first described by Dr. N.N. Wig in a 1960 issue of the (Indian) Journal of Clinical and Social Psychiatry, and then by Dr. J.S. Neki in the British Journal of Psychiatry (1973). A 1975 paper by Dr. H.K. Malhotra and Dr. N.N. Wig in the Archives of Sexual Behavior called dhat “the exotic neurosis of the Orient”. According to a short paper by Dr. Om Prakash in the Indian Journal of Psychiatry, dhat syndrome comprises various psychological, somatic and sexual symptoms attributed by the patient to the passing of whitish fluid, believed to be semen in urine (i.e., psychological distress and anxiety related to semen-loss). Prakash says that the word ‘dhat’ is derived from the Sanskrit word ‘dhatu’ (which has multiple meanings including ‘metal’, ‘elixir’ and ‘constituent part of the body’). He also noted that:

 “This notion of seminal loss frightens the individual into developing a sense of doom if a single drop of semen is lost, thereby producing a series of somatic symptoms…fear of semen loss and resulting problems [in India] is so strong that cures are advertised by vaids and hakims everywhere – on walls, on television, in newspapers and on roadside hoardings”.

The anxiety surrounding the semen loss can also relate to the releasing of semen via nocturnal emissions (i.e., ‘wet dreams’) and masturbation. The symptoms include fatigue, listlessness, appetite loss, lack of physical strength, poor concentration, forgetfulness, guilt, and (in some cases) sexual dysfunction. Given the syndrome relates to psychological anxiety surrounding semen loss, the disorder is (necessarily) found among men, but interestingly, the dhat syndrome has also been applied to women who experience similar symptoms relating to white vaginal discharge). According to an online article on CBSs, it claims that:

“The anxiety related to semen loss can be traced back thousands of years to Ayurvedic texts, where the loss of a single drop of semen, the most precious body fluid, could destabilize the entire body”

A 2004 literature review on dhat syndrome by Dr. A. Sumathipala and colleagues in the British Journal of Psychiatry speculated that the disorder was a “hypochondriacal preoccupation”. This may have some validity as a 1990 paper by Dr. R.K. Chadha and Dr. N. Ahuja (also in the British Journal of Psychiatry) reported a study of 52 dhat patients. Three-quarters of their sample were reported as having hypochondriacal symptoms.

Another study in the British Journal of Psychiatry a year later by Dr. M.S. Bhatia and Dr. S.C. Malik reported that 93 (out of 144) consecutive patients attending a sexual dysfunction clinic had dhat syndrome. A number of papers published on the dhat syndrome in the 1980s and 1990s all report that depressive, anxiety and/or somatoform disorders are prevalent in the majority of dhat sufferers. A small 1989 Sri Lankan study by Dr. P. De Silva and Dr. S. Dissanayake in the Sexual and Marital Therapy journal on 38 men with sexual dysfunction, reported that ‘semen loss’ was seen by most of the men as the main reason for their sexual dysfunction. The same study reported that 40% of the sample had hypochondriasis. Similar findings have been reported among Bangladeshi men. (It should also be noted that there are various reports of similar syndromes in other countries. For instance, Prakash’s paper also mentions ‘shen-k’uei’ in Taiwan and China which from the symptoms listed appear almost identical to dhat)

Based on papers published in the British Journal of Psychiatry and Indian Journal of Psychiatry (mainly from the 1980s and 1990s), Prakash presents a profile of those affected with dhat and claims that most are young males, recently married, from rural areas, low to average socioeconomic status (farmers, labourers, farmers), and from families with conservative attitudes towards sex. He also claims (seemingly based on a 2001 book chapter by by Dr. A. Avasthi and Dr. R. Nehra) that there are three types of dhat patients:

  • Dhat alone (where their symptoms are attributed to semen loss, and with presenting symptoms that are hypochondriacal, depressive or anxiety-related in nature)
  • Dhat with comorbid depression and anxiety (where dhat is seen as a symptom accompanying another disorder)
  • Dhat with sexual dysfunction

The duration of the symptoms can be relatively short-lived (e.g., 3-12 months) but some papers report people suffering for up to 20 years. Prakash lists the most common co-morbid disorders and sexual dysfunctions associated with dhat. This included depressive neurosis (40%-42%), anxiety neurosis (21%-38%), somatoform and hypochondriasis (32%-40%), erectile dysfunction (22%-62%), and premature ejaculation (22%-44%). Prakash also reports that the majority (i.e., two-thirds) of dhat sufferers recover (66%), with the remainder either improved (22%) or unchanged (12%). Finally, the most recently published paper on dhat syndrome by Dr. Neena Sanjiv Sawant and Dr. Anand Nath in a 2012 issue of the Sri Lankan Journal of Psychiatry noted that dhat beliefs are often based on misconception and myths:

“These myths and misconceptions which are deeply rooted in Indian culture are passed from generation to generation. Due to the lack of proper information and lack of open communication between parents and children, the only source of knowledge for many remain their peers, who are equally ignorant about the subject, and this leads to widespread misconceptions. Many people consult unqualified practitioners who reinforce their ignorance”

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Avasthi, A. & Nehra, R. (2001). Sexual disorders: A review of Indian Research. In: Murthy, R.S. (Ed.), Mental Health in India (1995-2000) (pp.42-53). Bangalore: People’s Action for Mental Health.

Behere, P.B., Natraj, G.S. (1984). Dhat syndrome: The phenomenology of a culture-bound sex neurosis of the orient. Indian Journal of Psychiatry, 26, 76-78.

Bhatia, M.S. & Malik, S.C. (1991). Dhat Syndrome – A useful diagnosis entity in Indian Culture. British Journal of Psychiatry, 159, 69-75.

Chadda, R.K. & Ahuja, N. (1990). Dhat syndrome: A sex neurosis of the Indian subcontinent. British Journal of Psychiatry, 156, 577-579.

De Silva, P. & Dissanayake, S.A.W. (1989) The loss of semen syndrome in Sri Lanka. A clinical study. Sexual and Marital Therapy, 4, 195-204.

Malhotra, H.K. & Wig, N.N. (1975). A culture bound sex neurosis in the Orient. Archives of Sexual Behaviour, 4, 519-528.

Neki, J.S. (1973). Psychiatry in South East Asia. British Journal of Psychiatry, 123, 257-269.

Prakash, O. (2007). Lessons for postgraduate trainees about Dhat syndrome. Indian Journal of Psychiatry, 49, 208–210.

Sawant, N.S. & Nath, A. (2012). Cultural misconceptions and associated depression in Dhat syndrome. Sri Lankan Journal of Psychiatry, 3, 17-20.

Sumathipala, A. Siribaddana, S.H. & Bhugra, D. (2004). Culture-bound syndromes: The story of dhat syndrome. British Journal of Psychiatry, 184, 200-209.

Wig, N.N. (1960). Problems of mental health in India. Journal of Clinical and Social Psychiatry (India), 17, 48-53.

Flesh start: A beginner’s guide to Windigo Psychosis

In previous blogs I have examined various culture bound syndromes (i.e., a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies). Arguably, one of the most interesting culture bound syndromes is (the much disputed) ‘Windigo psychosis’ that was said to have been reported among Algonquian native tribes (which are among the biggest and most widespread of North American natives and who lived around the Great Lakes of Canada and America). The disorder allegedly comprised individuals who intensely craved human flesh and who believed they would turn into cannibals.

The windigo was a cannibalistic spirit forest creature that appeared in Algonquian legends, and was known by lots of other names and variants (including – among 37 others identified by John Columbo in his 1982 book Windigo – wendigo, weendigo, windiga, waindigo, windago, wihtikow, and witiko). For instance, the Ojibwa tribe (a Native American people originally located north of Lake Huron before moving westward in the 17th and 18th centuries into Michigan, Wisconsin, Minnesota, western Ontario, and Manitoba) believed the windigo was a ferocious ogre that took children away if they did not behave themselves.  More generally, it was believed that the windigo could possess and infect human beings and transform them into cannibalistic creatures. Such cannibalistic practices were said to have begun in times of extreme winter famine when families were isolated and confined to their cabins because of heavy snowfall. Legend also has it that the infected sufferer would have their heart turned to ice.

However, windigo is a disorder that has been continually challenged across many decades as a myth (for instance, Dr. R.H. Prince in a 1992 issue of Transcultural Psychiatric Research Review; Dr. R.C. Simons and Dr. C. Hughes in a 1993 book chapter on culture bound syndrome; Dr. P.M. Yap in a 1967 issue of the Australia New Zealand Journal of Psychiatry). Whether the condition genuinely existed or not, no-one disputes that the number of cases reported over the last hundred years are minimal.

According to John Columbo, the first derivation of the word ‘windigo’ (i.e., the word ‘onaouientagos’ meaning both ‘cannibal’ and ‘evil spirit’) first appeared in print as long ago as 1722 in an account by Bacqueville de la Potherie, a French traveler. Windigo psychosis was said to occur when an individual became highly anxious that they were transforming into a windigo and believed that other humans that they lived among them were edible. Symptoms of the psychosis were said to include nausea, vomiting, poor appetite and anti-social behaviour. In extreme cases, the psychosis was said to produce suicidal tendencies (as a way of preventing possession by the windigo) and/or homicidal tendencies (to eat the human flesh of others). A book (The Lost Valley and Other Stories) written by Algernon Blackwood in 1910 featured a horror story (called ‘The Wendigo’), and was widely believed to be based on the Algonquian windigo legends.

In the 1982 book Windigo: An Anthology of Facts and Fantastic Fiction edited by John Columbo, he noted that:

“Windigo has been described as the phantom of hunger which stalks the forests of the north in search of lone Indians, halfbreeds, or white men to consume. It may take the form of a cannibalistic Indian who breathes flames. Or it may assume the guise of a supernatural spirit with a heart of ice that flies through the night skies in search of a victim to satisfy its craving for human flesh. Like the vampire, it feasts on flesh and blood. Like the werewolf, it shape-changes at will”.

In an online article about ‘culture specific diseases’, Denis O’Neil claims that modern medical diagnoses might label windigo as a form of paranoia because “of the irrational perceptions of being persecuted”. Here, O’Neil argues that it is the windigo monsters who are the persecutors (i.e., the windigo monsters are trying to turn people into monsters like themselves).  O’Neil also argues that in contemporary North American culture “the perceived persecutors of paranoids are more likely to be other people or, perhaps, extra terrestrial visitors”. 

Writing in a 2006 issue of the journal Transcultural Psychiatry, Dr. Wen-Shing Tseng said that it’s important to re-examine the sources of knowledge for each culture-related specific syndrome (including windigo which she also examined). She acknowledged that literature relating to windigo dated back to the 17th century, she made a lot of reference to the work of J.E. Saindon and the Reverend J.M. Cooper who both worked among an Algonquian community in the 1930s. She argued that the reports of both Saindon and Cooper “were based on second-hand information provided by non-clinical observers”. She then noted that the pioneering cultural psychiatrists of the 1950s and 1960s dealt with these early accounts “as though they were well-defined clinical entities with the diagnostic term witiko psychosis”.

In a paper by Dr. Lou Marano in a 1982 issue of Current Anthropology, it was noted that aspects of the Windigo belief complex may have had components in some individual’s psychological dysfunction. However, he concluded that after (i) five years’ field experience among Northern Algonquians, (ii) extensive archival research, and (iii) a critical examination of the literature:

“There probably never were any windigo psychotics in an etic/behavioral sense. When the windigo phenomenon is considered from the point of view of group sociodynamics rather than from that of individual psychodynamics, the crucial question is not what causes a person to become a cannibalistic maniac, but under what circumstances a Northern Algonquian is likely to be accused of having become a cannibalistic maniac and thus run the risk of being executed as such”.

In essence, Marano’s conclusion was that windigo psychosis was simply an artifact of research that was conducted without sufficient knowledge of the indigenous experience.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Colombo, J.R. (1982). Windigo: An Anthology of Facts and Fantastic Fiction. Lincoln: University of Nebraska Press.

Marano, Lou (1982). Windigo psychosis: The anatomy of an emic-etic Confusion. Current Anthropology, 23, 385-412.

O’Neil, D. (2010). Culture specific diseases. October 7. Located at: http://anthro.palomar.edu/medical/med_4.htm

Prince, R. H. (1992). Koro and the Fox Spirit on Hainan Island (China). Transcultural Psychiatric Research Review, 29(2), 119-132.

Simons, R. C., & Hughes, C. (1993). The culture bound syndrome. In A. Gaw (Ed.). Culture, Ethnicity and Mental Illness (pp. 75–99). Washington, DC: APA.

Tseng, W-S. (2006). From peculiar psychiatric disorders through culture-bound syndromes to culture-related specific syndromes. Transcultural Psychiatry, 43; 554-576.

Wikipedia (2012). Wendigo. Located at: http://en.wikipedia.org/wiki/Wendigo

Yap P. M. (1967). Classification of the culture-bound reactive syndromes. Australia New Zealand Journal of Psychiatry, 1, 172-179.

Yap, P. M. (1969). The culture bound syndromes. In W. Cahil., & T. Y. Lin. (Eds.). Mental Health Research in Asia and the Pacific (pp. 33-53). Honolulu: East West Centre Press.

Fuddy study: A brief overview of Brain Fag Syndrome

Over the last year I have examined a number of culture-bound syndromes that comprise a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies. One of the more interesting types is Brain Fag Syndrome (BFS). The first cases of BFS were described in 1960 by Dr. Raymond Prince in the British Journal of Psychiatry. He reported on a very common psychoneurotic syndrome occurring among the students of southern Nigeria” that is typically initiated after intensive periods of intellectual activity. More specifically he wrote that:

“The symptoms are such as to prevent the student from carrying on with his work and include various unpleasant head symptoms accompanied by inability to grasp what he reads or what he hears in a lecture, memory loss, visual difficulties, inability to concentrate, inability to write, etc.”

Other researchers (such as a team led by Dr. Bolanie Ola – writing in a 2009 issue of the African Journal of Psychiatry) have noted that BFS comprises a wide range of somatic complaints (as noted by Dr. Prince) but can also include cognitive and sleep-related impairments, as well as localized pain in the head and neck. BFS is seen as an interesting phenomenon in the field of transcultural psychiatry. For some researchers, BFS was controversially included (for the first time) in the fourth edition of American Psychiatric Association’s 1994 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), and included as a culture bound syndrome such as the Koro (the genital retraction syndrome that I reviewed in two previous blogs examining male Koro and female Koro).

Since the publication of Prince’s seminal paper over 50 years ago, BFS has been documented among non-Caucasians in various African countries (Ethiopia, Liberia, Ivory Coast, South Africa, and Uganda), and a few countries outside of Africa (Brazil, India, Malaysia, China). However, the number of cases from those countries outside of Africa are exceedingly rare. There also appear to be similar syndromes such as the Trinidadian illness ‘studiation madness’ that has similar symptoms to BFS.

The term ‘brain fag’ was the name of the disorder that the students themselves called it (and appears to be a shortened version of ‘brain fatigue’). Based in his early research, Dr. Prince believed that BFS was not caused and/or associated to genetic predisposition, general intelligence, parental literacy, study habits or family responsibilities. He believed that BFS was related to:

“The imposition of European learning techniques upon the Nigerian personality [and that] European learning techniques emphasize isolated endeavour, individual responsibility and orderliness – activities and traits which are foreign to the Nigerian by reason of the collectivistic society from which he derives, with its heightened ‘orality’ and permissiveness”.

Dr. Ola and his colleagues questioned the extent to which BFS is an objective or subjective phenomenon. They asked a number of pertinent questions: Is BFS one phenomenon or a variant of other known disorders? Is BFS a mental illness? Ola and colleagues described the case of a young male student from Yoruba. 

“When studying for an exam [he] began to have sharp pains in his head and could not grasp what he was reading. He slept more than usual, and had difficulty forcing himself to go to school in the morning. When writing the examinations, he felt he knew the answers, but was unable to recall them; his mind was blank. His right hand was weak and shook so that he couldn’t write. Because of these symptoms, he was forced to postpone the writing examinations for several years. His symptoms improved greatly with Largactil (an antipsychotic medication) and reassurance”.

Much like the early findings of Prince, Ola and his colleagues suggest that BFS may in sufferers be “the somatic manifestation of the rather sudden Westernization of African education”. The authors also claimed that between 6% and 54% of Nigerian university students may experience brain fag symptoms although those with the “full-blown syndrome” appear to be significantly lower. However, a more recent paper in the ASEAN Journal of Psychology claimed that among secondary school students, BFS is prevalent in 20-40% of students.

A more recent paper by Bolanie Ola and David Igbokwe in a 2011 issue of Africa Health Sciences, cites some work carried out on the etiology of BFS by Guinness in 1992 (although no reference is provided for the study itself). Guinness reported five independent factors associated with the syndrome: (a) the financial implications of education which represented the change from subsistence to cash economy; (b) fear of envy and bewitchment which represented the intense cultural response to education; (c) parenting in the pre-school years which was the independent family variable; (d) academic ability; (e) attributes of the school.

In a paper examining the factorial validation and reliability analysis of the Brain Fag Syndrome Scale (BFSS) by Ola and Igbokwe, it was argued by the authors that there was a lack of consistent findings relating to the etiology, pathophysiology and risk factors of BFS. This, they argued, reflected the “lack of standardized reproducible diagnostic criteria” for the syndrome. In short, they asserted that different studies had used different instruments to assess BFS and that only a few followed the description first formulated by Prince. They claimed that 60% of the BFS studies they reviewed simply reported the rates of BF symptoms rather than BFS. Following psychometric evaluation on 234 participants (aged 11- to 20-years), Ola and Igbokwe claimed that the BFSS is a valid and reliable two-dimensional instrument to assess BFS and can therefore be used in future studies. At least there is now an instrument that can be used to carry out empirical research more systematically.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Fatoye, F.O. (2004). Brain fag syndrome among Nigerian undergraduates: present status and association with personality and psychosocial factors. Ife Psychologia, 12, 74-85.

Fatoye, F.O. & Morakinyo, O. (2003). Study difficulty and the ‘Brain Fag’ syndrome in south western Nigeria. Journal of Psychology in Africa, 13, 70-80.

Igbokwe, D.O. & Ola, B.A. (2011). Development and validation of the Brain Fag Propensity Scale. ASEAN Journal of Psychiatry, 12, 1-13.

Morakinyo, O. (1980). Psychophysiological theory of a psychiatric illness (the Brain Fag syndrome) associated with study among Africans. Journal of Nervous and Mental Disease, 168, 84-89.

Morakinyo, O. & Peltzer, K. (2002). Brain Fag symptoms in apprentices in Nigeria. Psychopathology, 35, 362-366.

Ola, B.A. & Igbokwe, D.O. (2011). Factorial validation and reliability analysis of the brain fag syndrome scale. African Health Sciences, 11, 334-339.

Ola, B.A., Morakinyo, O. & Adewuya, O. (2009). Brain Fag Syndrome – a myth or a reality. African Journal of Psychiatry, 12,135-43.

Peltzer, K. & Woldu, S. (1990). The brain fag syndrome in female Nigerian students: intercultural analysis and intervention of gender change. Curare, 13, 141-146.

Prince, Raymond (1960). The “Brain Fag” Syndrome in Nigerian students. British Journal of Psychiatry, 106, 559-570.

Wikipedia (2012). Brain fag. Located at: http://en.wikipedia.org/wiki/Brain_fag

Doggy day care: An overview of Puppy Pregnancy Syndrome

In my previous blogs, I have looked separately at pregnancy delusions (i.e., women and men who think and claim they are pregnant but are not – including Couvade Syndrome) and culture bound syndromes (i.e., a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies). Since writing those blogs I unearthed a fascinating academic paper examining one of the strangest culture bound syndromes I have ever come across. While idly looking for some inspiration for a new blog, I happened (by chance) to come across a blog written in November 2011 by Jesse Bering on the Scientific American website which began with this opening paragraph.

Are you suffering abdominal pain or discomfort, fatigue, nausea, flatulence, heartburn, and acid reflux? Have you been having difficulty urinating, or experiencing pain while doing so? Oh, and one other question – have you been spontaneously expelling microscopic bits of disintegrated dog fetuses through your urethra? If you answered “yes” to all of the above, then you may be suffering from “Puppy Pregnancy Syndrome”.

Bering’s report was based on a 2003 paper published in the International Journal of Social Psychiatry, entitled Puppy pregnancy in humans: A culture-bound disorder in rural West Bengal, India”. The paper described a phenomenon that has only ever been reported in this one Indian area (near Kolkata) where both and women are convinced that it is possible to become pregnant and carrying a canine foetus if they are bitten by dogs – particularly if the dog is sexually aroused and because the dog’s saliva contains dog gametes. The phenomenon is a fairly recent one as there are few reports of ‘puppy pregnancy’ prior to 2000.

The paper, by Dr. Arabinda N. Chowdhury (Professor of the Institute of Psychiatry, Kolkata, India) and colleagues featured seven cases of people suffering from puppy pregnancy (six males and one female). The men claim to give birth to the puppies via their penis (in a similar excruciating fashion to the way that men have to pass kidney stones). At night, the female case claimed she could hear the puppies barking in her abdomen.

They also interviewed a further 42 adult villagers to see how prevalent the belief in puppy pregnancy was. They reported that three-quarters of the villagers interviewed believed with “definite certainty” that puppy pregnancy existed (73%), while only 9% had no belief in the phenomenon. In fact, it was reported that almost all the villagers could name someone whose unexplained death they believed was the direct consequence of a toxic puppy pregnancy (including those who were among the most well educated). The authors noted that in relation to the cases they outlined that:

“Psychiatric status showed that there was a clear association of obsessive-compulsive disorder in two cases, anxiety-phobic locus in one and three showed no other mental symptom except this solitary false belief and preoccupation about the puppy pregnancy…One case (11-year-old child) exemplified how the social imposition of this cultural belief made him a case that allegedly vomited out an embryo of a dog foetus… the cases presented a mix of somatic and psychological complaints and their help-seeking behaviour was marked”.

Due to the widespread belief in the existence of puppy pregnancy fact, the village community has their own “medical” specialists who “treat” the condition called bara ojhas. These so-called specialists provide remedies and/or perform abortion-inducing rituals. During the early stages of “pregnancy”, the use of herbal medicines by bara ojhas are said to help dissolve the puppy foetuses so that they are naturally expelled through the person’s genitals in an unobtrusive way. In Jesse Bering’s account of puppy pregnancy, he describes the case of a male:

“After one 24-year-old college graduate had an encounter with a stray dog that scratched him on the leg six months earlier, he became extremely wary of dogs because he was deathly afraid that one might knock him up. He was so preoccupied with dogs that even in the interview room he was apprehensive that a dog may come out from under the table. To address his unending circular ruminations about puppy pregnancy, his dog anxiety, and his obsessive-compulsive need to search for microscopic fetal canine parts in his urine, he was prescribed Clomipramine (an antidepressant) and Thioridazine (an antipsychotic). Importantly, he also underwent a month of behavioral reconditioning with a dog while being treated as an inpatient”.

Obviously, the condition may have no medical basis, but on a psychological level, the people in the Indian community experiencing a puppy pregnancy believe it is real. Dr. Chowdhury and colleagues believe that the crux of the condition is “the absence of any realistic consideration about the absurdity of asexual animal pregnancy and pregnancy in males (to the degree of delusional conviction).”

Dr. Chowdhury and colleagues believe that Puppy Pregnancy Syndrome meets the criteria for a genuine Culture-Bound Disorder because the mass delusional belief occurs as a consequence of “emotionally fuelled social transmission” only found in a very particular community (in this case, rural West Bengal), and that the disorder needs “proper cultural understanding for its effective management”.

Jesse Bering’s blog also made reference to another culture where giving birth to animals is a widely held belief. Bering cited the anthropologist E.E. Evans-Pritchard’s account of the Azande people in Africa who believe that some women can give birth to cats. I actually managed to get hold of Evans-Pritchard 1976 book Witchcraft, Oracles, and Magic among the Azande. The Azande believe that many animals are witches or dead witches inhabiting the animals. The most feared animal by the Azande are wildcats (called the adandara) that they believe have sex with female villagers. These women then allegedly give birth to kittens who are then said to breastfeed them like human children. The appendices in Evans-Pritchard’s book (based on his interviews with the Azande) reported:

The male cats have sexual relations with women who give birth to kittens and suckle them like human infants. Everyone agrees that these cats exist and that it is fatal to see them…There are not many women who give birth to cats, only a few. An ordinary woman cannot bear cats but only a woman whose mother has borne cats can bear them after the manner of her mother”.

When interviewing Azande people, Evans-Pritchard said that his personal contacts included only two cases of people who had actually seen adandara. He then went on to note:

“Azande often refer to lesbian practices between women as adandara…This comparison is based upon the like inauspiciousness of both phenomena and on the fact that both are female actions which may cause the death of any man who witnesses them…Homosexual women are the sort who may well give birth to cats and be witches also. In giving birth to cats and in lesbianism the evil is associated with the sexual functions of women”.

Given that so little information was given in Evans-Pritchard’s book, I have no idea if the belief in adandara could be classed as a culture-bound syndrome, but there do seem to be similarities with Puppy Pregnancy Syndrome.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bering, J. (2011). Puppy pregnancy syndrome: Men who think they are pregnant with dogs. Scientific American, November 15. Located at: http://blogs.scientificamerican.com/bering-in-mind/2011/11/15/puppy-pregnancy-syndrome-men-who-are-pregnant-with-dogs/

Chowdhury, A., Mukherjee, H., Ghosh, H.K. & Chowdhury, S. (2009). Puppy pregnancy in humans: A culture-bound disorder in rural West Bengal, India. International Journal of Social Psychiatry, 49, 35-42.

E.E. Evans-Pritchard (1976). Witchcraft, Oracles, and Magic among the Azande. Oxford: Clarendon Press.

Voice of America (2012). Bizarre medical myth persists in rural India.Located at: http://www.voanews.com/content/bizarre-medical-myth-persists-in-rural-india-143818636/179310.html

Shrink rap: A beginner’s guide to Koro in females

In a previous blog, I examined Koro (the so-called genital retraction syndrome). This is a culture-bound syndromes found primarily in Asian regions (e.g., China, Singapore, Thailand, India). Koro refers to a kind of “genital hysteria” with “terror stricken” individuals (typically male) believing that that their genitals are shriveling, shrinking up, retracting into the abdomen and/or disappearing, and that this ultimately leads to death. Writing in a 1997 issue of the Journal of Psychology and Human Sexuality, Dr. J.T. Cheng noted of Koro that it:

“Is best perceived as a social malady supported by cultural myths which tend to affect young people who are deprived of proper sex information to explain their physical development”.

Koro is rarely described in women but published case studies in the academic literature do exist. All of these female cases report that the affected women reported the shrinking of the vulval labia, nipples, and/or the breasts. The interesting thing about Koro is that all the body parts affected (penis in males; breasts, nipples and labia in women) are those that naturally swell and shrink in response not only in relation to sexual arousal but also in response to temperature and climate changes, depression, anxiety, stress, fear, illness, and/or psychoactive drug ingestion.

Most Koro epidemics while primarily comprising males always appear to involve a small minority of females. For instance, Dr. Robert Bartholomew’s book Exotic Deviance reports the Koro epidemic that occurred in northeast Thailand at the end of 1976 that affected approximately 2,000 people (primarily rural Thai residents in the border provinces of Maha Sarakham, Nakhon Phanom, Nong Khai and Udon Thani). As with most Koro epidemics, the symptoms included the perception of genital shrinkage and impotence among males, whereas females typically reported sexual frigidity, with breast and vulva shrinkage. The origins of the epidemics can vary and include the supernatural. For instance, in a 1986 issue of the journal Curare, Dr. W.G. Jilek described an atmosphere of collective fear of ghosts during a Koro epidemic in Zhanjiang town (Guangdong in China). Those affected believed that ghosts would make the genitals of men and breast of women shrink and disappear into the abdomen and chest. To end the Koro epidemic, the villagers’ drove the ghosts out of their village used drum-beating, bell ringing and bursting of firecrackers.

In 2005, Vivian Dzokoto and Glenn Adams published a paper in Culture, Medicine and Psychiatry examining genital shrinking epidemics in West Africa. More specifically, they examined all media reports of genital shrinking in six West African nations between January 1997 and October 2003 (comprising a total of 56 media reports). Most of the reports were of males but Dzokoto and Adams noted that three Ghanaian news reports included females. All three women reported experiencing shrinking breasts and/or changes to their genitalia. They also noted that:

“One report described a woman whose ‘private parts sealed.’ Another report described a woman who reported that her genital organ (unspecified) was vanishing. Again, it is unclear whether references to sealing and vanishing of female genitalia represent different ways of describing the same experience or represent qualitatively distinct forms of subjective experience.In all reported cases, experience of symptoms tended to be brief and acute. There were no reported cases of recurrence”.

The earliest report of Koro in a female was arguably be in a 1936 book chapter entitled ‘Psychiatry and Neurology in the Tropics’ by Wulfften Palthe. Since then there have been sporadic reports of female Koro in the literature. One of the more notable cases reported was by Kovács and Osváth in a 1998 issue of the journal Psychpathology. This case was unusual because it was a case of genital retraction syndrome in Hungary (although the woman reported was a Korean woman by background).

In a 1982 issue of the Indian Journal of Psychiatry, Dr. D. Dutta and colleagues reported on the (then) recent epidemic of Koro that occurred in four districts of Assam (June 1982 to September, 1982). The 83 cases they reported included 19 females. Interestingly, all the female Koro cases in this particular sample believed it was their breasts that were affected in some way. More specifically, Dr. Dutta and his team reported that:

“9 out of 19 female cases (47.3%) suffered from genital symptoms in form of shrinkage or pull of the breast. Not a single female complained of labial shrinkage. 12 out of 19 cases (69.1%) reported retrosternal pain and other anxiety symptoms subsequently leading to dissociation of varying degree and duration”.

In 1994, Dr. Arabinda Chowdhury (who has written lots of papers on the topic of Koro) published a paper in the journal Transcultural Psychiatry comprising an analysis of 48 cases of female Koro (based on a population of women that claimed to have Koro in an Indian epidemic in the North Bengal region). In females, Dr. Chowdhury noted that “the cardinal symptom is the perception of retraction or shrinkage of nipple or breast mass into the chest cavity or of labia into the abdomen with acute fear of either imminent death or sexual invalidism”. This was the first paper in the world literature to explore the detailed clinical characteristics of Koro in females. Before examining the individual cases, Dr. Chowdhury examined the gender distribution in seven Koro epidemics. The following statistics were reported: Singapore (1969; 469 cases, 15 female), Thailand (1978; 350 cases, 12 female), Indonesia (1978; 13 cases, 2 female), India (1982; 83 cases, 19 female), India (1985; 31 cases, 13 female), India (1988; 405 cases, 48 female) and China (1988; 232 cases, 37 female).

Dr. Chowdhury reported that of the 48 female cases (aged 8 to 54 years), the mean age was nearly 24 years. In relation to Koro, 56% reported retracting nipples (both breasts in all but two cases), 13% reported a flattening of their breasts, 8% reported a retraction in both breasts, 8% reported a pricking sensation in both breasts, 8% reported retraction of the labia, and 5% reported vaginal pain.

It appears that in the same that penis size seems to be a near-universal concern and/or obsession of men, women also share a similar fear, but with different sexual body parts (i.e., vulvas, breasts, and nipples). All of these body parts in males and females (i.e., penis, scrotum, breasts, nipples) are physiologically capable of changing size not only in relation to sexual arousal but also from other non-sexual factors (temperature and climate change, anxiety, depression, stress, fear, illness, and/or psychoactive drug ingestion/intoxication).

One literature review of 84 case reports of Koro (and Koro-like disorders) published in a 2008 issue of the German Journal of Psychiatry by Dr. Petra Garlipp (Hannover Medical School Germany) concluded that there were two unifying features of the case reports cited in the clinical literature. These were (i) the diversity in relation to the clinical picture, the underlying mental disorder, the treatment approach and their classification and nomenclature chosen, and (ii) the symptom of fear.

In response to Dr. Garlipp’s paper, Dr. Arabinda Chowdhury noted that by only using published case studies, female Koro was hardly discussed (because most data about female Koro comes from data collected during Koro epidemics rather than case study interview data). why the review had been so biased towards males. Based on his own research, Dr. Chowdhury wrote that there were at least 146 female Koro case reports from seven epidemics in the years 1969 to 1988. He believed the large number of cases involving women offered many interesting clinical issues in the female expression of Koro, which should have been included in Garlipp’s review. His view was that the differences between male and female Koro in relation to psychodynamics, presentation and associated clinical features of Koro would have made Garlipp’s paper “more interesting”. However, Dr. Chowdhury’s paper didn’t mention what these differences were. Maybe there is not the data to do this. Although it is known that episodes of female Koro can endure for weeks or months, the origin of female anxiety over the absorption of their sex organs is at present unclear.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bartholomew, R. (2000). Exotic Deviance: Medicalizing Cultural Idioms from Strangeness to Illness. Boulder: University of Colorado Press.

Bartholomew, R. (2008). Penis panics. In R. Heiner (Ed.), Deviance across cultures (pp. 79–85). New York: Oxford University Press.

Chowdhury, A.N. (1994). Koro in females: An analysis of 48 cases. Transcultural Psychiatry, 31, 369-380.

Chowdhury, A.N. (2008). Ethnomedical concept of heat and cold in Koro: study from Indian patients. World Cultural Psychiatry Research Review, July, 146-158.

Chowdhury, A.N. (2008). Cultural Koro and Koro-Like Symptom (KLS). German Journal of Psychiatry, 11, 81-82

Cheng, S.T. (1997). Epidemic Genital Retraction Syndrome: Environmental and personal risk factors in Southern China. Journal of Psychology and Human Sexuality, 9, 57-70.

Dutta, D., Phookan, H.R. & Das, P.D. (1982). The Koro epidemic in Lower Assam. Indian Journal of Psychiatry, 24, 370-374.

Dzokoto, V.A. & Adams, G. (2005). Understanding genital-shrinking epidemics in West Africa: Koro, Juju, or mass psychogenic illness? Culture, Medicine and Psychiatry, 29,53-78.

Garlipp, P. (2008). Koro – A culture-bound phenomenon intercultural psychiatric implications. German Journal of Psychiatry, 11, 21-28.

Jilek, W.G. (1986). Epidemic of “Genital Shrinking” (Koro): Historical review and report of a recent outbreak in south China. Curare, 9, 269-282.

Kar, N. (2005). Chronic koro-like symptoms – two case reports. BMC Psychiatry, 5, 34 (doi:10.1186/1471-244X-5-34).

Kovács, A. & Osváth P. (1988). Genital retraction syndrome in a Korean woman. A case of Koro in Hungary. Psychopathology, 31, 220-224.

Lehman, H. E. (1980). Unusual Psychiatric disorders. In: A.M. Freedman, H.I. Kaplan & B.J. Sadock (Eds.). Comprehensive Textbook of Psychiatry (Third Edition, Vol. II). Baltimore: Williams and Wilkins.

Palthe, P.M. (1936). Psychiatry and Neurology in the Tropics. In: C.D. de Langen and A. Lichtenstein (Eds.), A Clinical Textbook of Tropical Medicine (pp. 525-547). Batavia: G. Kolff and Company.

Phillips, K. (2004). Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 3, 12-17.

Genital on my mind: A beginner’s guide to Koro

Koro is a culture-bound syndrome found primarily in Asian regions (e.g., China, Singapore, Thailand, India) and has been documented for thousands of years in those particular cultures. In essence, Koro refers to a kind of “genital hysteria” with “terror stricken” males believing that that their genitals are shriveling, shrinking up, retracting into the abdomen and/or disappearing, and that this ultimately leads to death (a so-called ‘genital retraction syndrome). The word ‘Koro’ is of Malayan-Indonesian origin and means ‘tortoise’ (presumably used to highlight the similarity between the retracting head and wrinkled neck of a tortoise and the belief that the male penis is retracting inside the body). Writing in a 1997 issue of the Journal of Psychology and Human Sexuality, Dr. J.T. Cheng noted of Koro that it:

“Is best perceived as a social malady supported by cultural myths which tend to affect young people who are deprived of proper sex information to explain their physical development”.

Various academic papers and book chapters (such as one by Dr. R. Bartholomew in 2008) claim that affected individuals take extreme measures to suspend the condition (e.g., placing clamps, clothes pegs, rubber bands, and/or tying string around their penis to stop it retracting. In some cases, men had family members physically hold onto their penis until they receive “treatment” from local healers). According to Dr. Bartholomew episodes of Koro can last for weeks or months and affect thousands of men. The condition has been recorded in Chinese academic texts going back to the 1800s. There also appear to be different cultural variants of Koro-like syndromes. For instance, in West Africa, some Nigerian men actually believe that their penises have been stolen.

Sometimes the condition occurs en masse such as the “penis panics” that have been documented in countries such as China, India and Singapore. For instance, a well documented Koro panic occurred in Singapore during the Autumn of 1967. The regional hospitals were inundated with hundreds of men demanding penile treatment (and thinking they would die without treatment). During this particular Koro epidemic, it was thought that the cause was eating pork (from pigs that had been inoculated for swine fever).

In Northeast Thailand in November/December 1976, around 2,000 men thought that their penises were shrinking. Another ‘penis panic’ was reported more recently in the Guangdong province of China. For over a year in 1984-1985 around 5,000 people living in the region believed they had Koro. Other Chinese Koro epidemics have occurred frequently on Hainan Island in the China Sea and also in the nearby Leizhou Peninsula in Southern China. These Koro epidemics suggest that various socio-cultural factors are influencing people’s beliefs about the condition. However, on a socio-demographic level, the psychological literature on Koro suggests that individuals that are most likely to be affected are those living in rural regions where there is poor education.

Most Koro epidemics are among adult males but isolated “collective occurrences” of Koro among children have also been reported in the Chinese Sichuang Province in a 1993 issue of the Chinese Journal of Mental Health. More recently, in a December 2010 issue of World Cultural Psychiatry Research Review, Dr. Li Jie (Guangzhou Psychiatric Hospital, China) reported a Koro endemic among 64 schoolboys in the Fuhu village of Guangdong. The contributing factors for the mass occurrence were reported as being (i) the familiarity with koro in the community, (ii) stress due to their studies, and (iii) a misleading warning and instruction from the school principal.

The interesting thing about Koro is that the penis is a body part that naturally swells and shrinks in response not only in relation to sexual arousal but also in response to temperature and climate changes, depression, anxiety, stress, fear, illness, and/or psychoactive drug ingestion. These real reasons for penile shrinkage when combined within cultures that accept and to some extent ‘authenticate’ the existence of Koro, can lead (in some instances and circumstances) to the psychosocial panics documented in particular regions or countries. Koro has also been is associated with various and specific cultural beliefs. One such set of beliefs is that unhealthy or abnormal sexual behaviours (e.g., masturbation, wet dreams, sex with prostitutes, etc.) disturb the “yin/yang equilibrium” that allegedly exists within a husband and wife’s sex life and causes Koro.

Some psychologists have also speculated that Koro may be psychologically related to body dysmorphic disorder. However, Dr Katharine Phillips (Warren Alpert Medical School of Brown University, USA), an expert in BDD and writing in a 2004 issue of World Psychiatry notes that although Koro has similarities to BDD, Koro differs from BDD by (i) its normally brief duration of a few weeks or months rather than years, (ii) different associated features (e.g., the belief by the sufferer that they are going to die), (iii) response to reassurance, and (iv) occasional epidemic occurrences (something that never happens with more traditional BDD occurrences).

However, there were a couple of case reports published by Dr. Nilamadhab Kar (Wolverhampton Primary Care Trust, UK) in BMC Psychiatry arguing that Koro is not always an acute, brief lasting illness. Dr. Kar’s paper reported two cases of males with with koro-like symptoms from East India (characterized by excessive anxiety and a belief that their genitals were shrinking) had lasted over ten years and concluded that in some cases, there is the possibility of a chronic form of Koro syndrome.

One literature review of 84 case reports of Koro (and Koro-like disorders) published in a 2008 issue of the German Journal of Psychiatry by Dr. Petra Garlipp (Hannover Medical School Germany) concluded that there were two unifying features of the case reports cited in the clinical literature. These were (i) the diversity in relation to the clinical picture, the underlying mental disorder, the treatment approach and their classification and nomenclature chosen, and (ii) the symptom of fear. Based on her comprehensive review, Dr. Garlipp collated all known etiological and predisposing factors. The two main sets of factors implicated in Koro and Koro-like disorders were (i) psychosexual conflicts, (ii) personality factors, (iii) cultural beliefs, (iv) sexual conflicts, and (v) guilt feelings, often caused by religious background. She also reported that factors implicated with commonly shared beliefs included (i) geographic seclusion, (ii) mostly young poorly educated men susceptible to superstitious beliefs, (iii) suggestion, (iv) belief in the concept of Koro, (v) immature personality and lack of sexual confidence, (vi) previous knowledge of Koro, (vii) poor body image, (viii) history of venereal disease, and (ix) preoccupation with genitals.

Dr Garlipp also concluded that treatment with antidepressants and antipsychotics has – in the main – been successful. She also concluded that:

“Koro in its original sense is an Asian socio-cultural phenomenon. Its clinical picture has been controversially discussed in psychiatric literature but could be best described as a kind of panic disorder with the leading symptom of fear projected to the genitals. Yet, it is questionable whether this phenomenon can be put into a Western dominated classification of psychiatric diseases, as the socio-cultural roots are not adequately appreciated…All clinical phenomena presenting themselves in a wider sense as genital retraction syndromes with the leading symptom of fear should be named as such: genital retraction syndromes. All other nomenclatures, especially Koro- like syndrome, secondary Koro etc., should be dismissed as misleading”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Adeniran, R.A. & Jones, J.R. (1994). Koro: Culture-bound disorder or universal symptom? British Journal of Psychiatry, 164, 559- 561.

Bartholomew, R. (2008). Penis panics. In R. Heiner (Ed.), Deviance across cultures (pp. 79–85). New York: Oxford University Press.

Cheng, S.T. (1997). Epidemic Genital Retraction Syndrome: Environmental and personal risk factors in Southern China. Journal of Psychology and Human Sexuality, 9, 57-70.

Garlipp, P. (2008). Koro – A culture-bound phenomenon intercultural psychiatric implications. German Journal of Psychiatry, 11, 21-28.

Jie, L. (2010). Koro endemic among school children in Guangdong, China. World Cultural Psychiatry Research Review, December, 102-105.

Kar, N. (2005). Chronic koro-like symptoms – two case reports. BMC Psychiatry, 5, 34 (doi:10.1186/1471-244X-5-34).

Phillips, K. (2004). Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 3, 12-17.

Tseng, W.S., Kan-Ming, M., Hsu, J., Li-Shuen, L., Li-Wah. O., Guo-Qian, C., & Da-Wie J. (1988). A sociocultural study of Koro epidemics in Guangdong, China. American Journal of Psychiatry, 145, 1538-1543.

Tseng, W.S., Kan-Ming, M., Li-Shuen, L., Guo-Qian, C., Li- Wah, O., & Hong-Bo, Z. (1992). Koro epidemics in Guangdong, China. A questionnaire survey. Journal of Nervous and Mental Diseases, 180, 117-123.

Zhang, J.K. & Zhu, M.X. (1993). Three cases report of children Koro. [Chinese] Chinese Journal of Mental Health, 7, 40-41.

Region airs disease: A brief overview of culture bound syndromes

In a previous blog on coprophagia, I made a brief reference to Pibloktoq. Also known as Piblokto and Arctic Hysteria, the condition only manifests itself in winter among Inuhuit societies living (unsurprisingly) within the Arctic Circle. The condition is characterized by “an abrupt dissociative episode of intense hysteria, frequently followed by convulsive seizures and coma lasting up to 12 hours. Symptoms can include intense screaming, uncontrolled wild behaviour, depression, coprophagia, and insensitivity to extreme cold”.

Culture bound syndromes comprise a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies. They are often unknown outside of their own local regions. Even though the concept of culture-bound syndrome is highly controversial, the term was included in the American Psychiatric Association’s 1994 Diagnostic and Statistical Manual of Mental Disorders. Culture-specific syndromes are characterized by:

  • Categorization as a disease in the culture (i.e., not a voluntary behaviour or false claim);
  • Widespread familiarity in the culture;
  • Complete lack of familiarity of the condition to people in other cultures;
  • No objectively demonstrable biochemical or tissue abnormalities (symptoms);
  • The condition is usually recognized and treated by the folk medicine of the culture.

Today’s blog is a brief look at some of the different culture bound syndromes that exist around the world. In later blogs I am going to look at some of these in much greater detail, but for this article, I am just going to take a brief look at a few of the ones that I find psychologically interesting.

  • Beserkers is a culture-bound condition historically affecting Norsemen. The condition manifested itself among males only as an intense fury and rage (“berserkergang”) and mostly occurred in battle situations (but could also occur when they were engaged in labour-intensive work). When suffering the condition, it was alleged that the men affected were able to perform almost seemingly impossible super-human feats of strength. Those with beserkers were also said to experience a specific set of symptoms prior to the rage (i.e., beginning with shivering and chattering of their teeth, followed by a swelling and changing of colour in the face as they literally became ‘hot-headed’. The final stage was full-blown rage and fury accompanied by noisy grunts and howls. They would then just indiscriminately injure, maim and kill anything in their path. This would be followed by one or two days of feebleness, along with a dulling of the mind.
  • Koro is found primarily in Asian regions (e.g., China, Singapore, Thailand, India) and has been documented for thousands of years in those particular cultures. In essence, Koro refers to a kind of “genital hysteria” with “terror stricken” males believing that that their genitals are shriveling, shrinking up, retracting into the abdomen and/or disappearing, and that this ultimately leads to death (a so-called ‘genital retraction syndrome). The word ‘Koro’ is of Malayan-Indonesian origin and means ‘tortoise’ (presumably used to highlight the similarity between the retracting head and wrinkled neck of a tortoise and the belief that the male penis is retracting inside the body). Some psychologists have also speculated that Koro may be psychologically related to body dysmorphic disorder.
  • Wendigo is a psychotic mental disorder found primarily among Algonquian Native cultures in North America, but the frequency of Wendigo cases has declined rapidly in recent times because of Native American urbanization. It is also known by many variant names (including Windigo, Weendigo, Windago, Waindigo, Windiga, Witiko, and Wihtikow) and is part of a traditional belief system among the Oiibwe and Salteaux, the Cree, the Naskapi, and the Innu tribes. In essence, Individuals with Windigo believe that they are turning into cannibals and as a consequence have intense cravings for human flesh. Those with Wedigo were often executed as they typically threatened those they came into contact with. Although many have disputed whether the disorder exists, there are a significant number of substantiated eyewitness accounts (including Western anthrolopologists and ethnographers that demonstrate Wendigo is a factual phenomenon.
  • Gururumba is a culture-bound disorder found only in New Guinea and sometimes referred to as ‘Wild Pig Syndrome’. Affected individuals are typically married men who become “wild men” (i.e., engage in involuntary anti-social behaviour) and engage in stealing items from houses in their neighbourhood. The items stolen are usually of little value but those with Gururumba believe the objects stolen have value. Once stolen, the person decamps to local forests, lives there for a number of days and then returns empty handed, slurring their speech, and suffering from amnesia, hyperactivity, and clumsiness. Those from Gururumba believe that the illness is transmitted through being bitten by ghosts of recently deceased tribe members. There are also a number of reports from Papua New Guinea that eating various parts of plants and/or fungi can initiate the syndrome.
  • Saora Disorder is found only among the Saora tribe of Orissa State in India and is sometimes termed a ‘Shamanic initiatory illness’. Affected individuals can be male or female (and are typically teenagers or young adults) who display abnormal behaviour that Western health practitioners may define as a mental disorder. Those suffering often experience social stress from friends and relatives pressuring them to take on the life of a farmer against their wishes. Symptoms of Saora Disorder include inappropriate laughing and crying, amnesic episodes, fainting and passing out, and the experience of being constantly bitten by ants. Interestingly, the Saoran people blame the disorder on supernatural spirits who they claim want to marry the affected individual.
  • Shenkui (sometimes translated as ‘kidney weakness’) is a Chinese culture-bound syndrome in which male men suffer acute anxiety and/or panic symptoms accompanied by a range of physical symptoms but have no discernible underlying physical complaint. Shenkui symptoms can include intense tiredness, bouts of dizziness, intense aching and body weakness  (e.g., backache), insomnia, and sexual dysfunction (e.g., impotence, premature ejaculation). Chinese men attribute the effects of Shenkui to excessive loss of semen (via too much masturbation, frequent sexual intercourse, and wet dreams). Chinese men believe the condition to be life threatening because excessive semen loss is thought to represent the loss of life’s vital essence (a result from a deficiency in yang). A similar condition exists in India and other South Asian cultures, where it is known as dhat.
  • Ghost Sickness is a culture-bound psychotic disorder found among Navajo Native Americans. Members of these tribes think the disorder is highly associated with death. For instance, those afflicted are often mildly obsessed with a deceased person whom they believe to be the source of their problem. One of the major symptoms of the condition is an intense feeling of suffocation and terror because the affected person feels as though they are being buried alive with a friend or loved one. Other reported symptoms include general weakness and apathy, a loss of appetite, and recurring nightmares. The Navajo primarly attribute the condition to ‘chindi’ (ghosts), although sometimes it is attributed to witchcraft. Dr. Robert Putsch writing in a 2007 issue of the journal Drumlummon Views says that: “spirits or ‘ghosts’ may be viewed as being directly or indirectly linked to the cause of an event, accident, or illness”.
  • Grisi Siknis (which roughly translates as “crazy sickness” and is also known as ‘grisi munaia’, ‘Chipil siknis’ and ‘Nil siknis’) is a culture-bound disorder that is primarily found among the Miskito People of eastern Central America. Most affected individuals are young women (typically 15 to 18 years of age) and the disorder is considered contagious. According to Dr. Phil Dennis in a 1981 issue of Medical Anthropology, grisi siknis is typically characterized by long periods of anxiety, nausea, dizziness, irrational anger and fear, interlaced with short periods of rapid frenzy. When a Gris Siknis sufferer has an attack they completely lose consciousness. They then fall to the floor and after regaining consciousness they become (like berserkers above) almost super-human. They feel no pain, feel invincible, may speak in tongues, and will attack anyone near them believing that they are ‘devils’. Alleged eyewitness accounts have claimed that some affected individuals will vomit up strange things (coins, hair, and even spiders). Once the attack is over, they have no memory of anything that has happened. According to Dr. Dennis, the Meskito people believe grisi siknis is caused by possession by evil spirits

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bartholomew, R. (2008). Penis panics. In R. Heiner (Ed.), Deviance across cultures (pp. 79–85). New York: Oxford University Press.

Dennis, P.A. (1981). Part three: Grisi Siknis Among the Miskito. Medical Anthropology, 5, 445–505.

Garlipp, P. (2008). Koro – A culture-bound phenomenon intercultural psychiatric implications. German Journal of Psychiatry, 11, 21-28.

Newman, P. (1964). ‘Wild Man’ behavior in a New Guinea Highlands community. American Anthropologist, 66, 1-19.

Newman, Philip L. (1981). Sexual politics and witchcraft in two New Guinea societies. In G.D. Berremen (Ed.), Social Inequality: Comparative and Developmental Approaches, (pp.103-121). New York: Academic Press.

Phillips, K. (2004). Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry, 3, 12-17.

Putsch, R.W. (2007). Ghost illness: A cross-cultural experience with the expression of a non-Western tradition in clinical practice. Drumlummon Views, Winter, 126-145.

Sumathipala, A., Siribaddana, S.H. & Bhugra, D. (2004). Culture-bound syndromes: The story of dhat syndrome. British Journal of Psychiatry, 184, 200-209.

Wikipedia (2012). Culture-bound syndrome. Located at: http://en.wikipedia.org/wiki/Culture-bound_syndrome

Wikipedia (2012). Ghost sickness. Located at: http://en.wikipedia.org/wiki/Ghost_sickness

Waste not, want not: A brief overview of coprophagia

One of the most stomach churning behaviours among humans is coprophagia (i.e., the eating of faeces), and has the capacity to generate intense emotional reactions among those witnessing such behaviour. I don’t know about you, but my first visual exposure to human copraphagia was in the 1972 John Waters film Pink Flamingos when the leading “actress” Divine (a transvestite male) ate the freshly produced (and real) excrement from a dog that had just defecated on the pavement. As the narrator states immediately this as happened, Divine is “not only the filthiest person in the world, but is also the world’s filthiest actress”. The arts world is littered with coprophagic references and acts ranging from the detailed descriptions in the Marquis de Sade’s infamous novel The 120 Days of Sodom through to recent films such as The Human Centipede.

Hundreds of years ago, medical doctors used to taste their patients’ faeces as a way to assess their patients health and condition. Such historical actions, while seemingly gross, at least had a functional goal. In contemporary society, coprophagia often occurs among individuals with severe developmental disabilities although for a very small minority, coprophagic acts may occur as part of the sexual paraphilia coprophilia (i.e., sexual arousal and pleasure from faeces).

Copraphagia is a complex behavioural disorder and is commonly regarded as a variant form of pica (i.e., the eating of non-nutritive items or substances), even though there are many health risks associated with it (e.g., intestinal parasites, diarrhea, blood-borne pathogens). Other problems include poor oral hygiene, chronic gingival infection, and salivary gland infections.

A number of medical disorders have been identified that are associated with coprophagia including seizure disorders, cerebral atrophy, and tumours. There are also many psychological and psychiatric disorders associated with coprophagia including mental retardation, alcoholism, severe depression, autism, obsessive-compulsive disorder, Klüver-Bucy syndrome, schizophrenia, fetishes, delirium, and dementia. The psychopathological roots and etiology of coprophagia still remain little known, and much of what has been published academically involves case studies. Furthermore, the prevalence of copraphagia is also unknown but thought to be very rare.

In a 1989 study of 14 elderly coprophagic patients (average age of 71 years) in psychiatric hospitals published in the British Journal of Psychiatry, Ghaziuddin and McDonald reported that nine had senile dementia, two were severely depressed, and one had cerebral atrophy. Three of the 14 were reported has having no cognitive deficits. Although comprising only 14 patients, this is actually one of the largest studies in the area as most published papers consist of case studies.

As mentioned above, copraphagia can on occasion be seen as part of a sexual fetish where the eating of faeces is associated with sexual arousal. In a 1995 issue of the Journal of Sex and Marital Therapy, Dr. T. Wise and Dr. R. Goldberg reported the case of a non-psychotic 47-year old man of normal intelligence who had a fetish for faecal smearing that escalated into coprophagia when combined with alcohol abuse and depression.

In researching this blog, I came across a form of culture bound syndrome called Arctic Hysteria (also known as Piblokto and Pibloktoq) where one of the common symptoms is coprophagia. Culture bound syndromes comprise a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies. Arctic Hysteria only manifests itself in winter among Inuhuit societies living (unsurprisingly) within the Arctic Circle. The condition is characterized by “an abrupt dissociative episode of intense hysteria, frequently followed by convulsive seizures and coma lasting up to 12 hours. Symptoms can include intense screaming, uncontrolled wild behaviour, depression, coprophagia, and insensitivity to extreme cold”. Some scholars have cast doubt on its existence as a bona fide medical entity, but the association with copraphagia occurs repeatedly.

There is a wide variety of treatments that have been used for coprophagia including behavioural therapy, dietary changes, pharmacotherapy (e.g., tricyclic antidepressants, haloperidol, perospirone), and electro-convulsive therapy. All of these have reported at least partial success.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Beck D.A. & Frohberg, N.R. (2005). Coprophagia in an elderly man: a case report and review of the literature. International Journal of Psychiatry Medicine, 35, 417-427.

Donnellan, C.A. & Playfer, J.R. (1999). A case of coprophagia presenting with sialadenitis. Age and Ageing, 28, 233-234.

Foxx, R. M., & Martin, E. D. (1975). Treatment of scavenging behavior (coprophagy and pica) by overcorrection. Behavior Research and Therapy, 13, 153–162.

Friedin, B.D., & Johnson, H.K. (1979). Treatment of a retarded child’s feces smearing and coprophagic behavior. Journal of Mental Deficiency Research, 23, 55–61.

Ghaziuddin, N. & McDonald, C. (1989). A clinical study of adult coprophagics. British Journal of Psychiatry, 4, 53-54.

Harada, K.I., Yamamoto, K. & Saito, T. (2006). Effective treatment of coprophagia in a patient with schizophrenia with the novel atypical antipsychotic drug perospirone. Pharmacopsychiatry, 39, 113.

Ing, A.D., Roane, H.S. & Veenstra, R.A. (2011). Functional analysis and treatment of coprophagia. Journal of Applied Behavior Analysis. 44, 151–155

Pardini, M., Guida, S. & Gialloreti, L.E. (2010). Aripiprazole Treatment for Coprophagia in Autistic Disorder. Journal Neuropsychiatry and Clinical Neuroscience, 22(4), E33

Wise, T.N. & Goldberg, R.L. (1995). Escalation of a fetish: coprophagia in a nonpsychotic adult of normal intelligence. Journal of Sex and Marital Therapy, 21, 272-275.

Waste not, want not: A brief overview of coprophagia

One of the most stomach churning behaviours among humans is coprophagia (i.e., the eating of faeces), and has the capacity to generate intense emotional reactions among those witnessing such behaviour. I don’t know about you, but my first visual exposure to human copraphagia was in the 1972 John Waters film Pink Flamingos when the leading “actress” Divine (a transvestite male) ate the freshly produced (and real) excrement from a dog that had just defecated on the pavement. As the narrator states immediately this as happened, Divine is “not only the filthiest person in the world, but is also the world’s filthiest actress”. The arts world is littered with coprophagic references and acts ranging from the detailed descriptions in the Marquis de Sade’s infamous novel The 120 Days of Sodom through to recent films such as The Human Centipede.

Hundreds of years ago, medical doctors used to taste their patients’ faeces as a way to assess their patients health and condition. Such historical actions, while seemingly gross, at least had a functional goal. In contemporary society, coprophagia often occurs among individuals with severe developmental disabilities although for a very small minority, coprophagic acts may occur as part of the sexual paraphilia coprophilia (i.e., sexual arousal and pleasure from faeces).

Copraphagia is a complex behavioural disorder and is commonly regarded as a variant form of pica (i.e., the eating of non-nutritive items or substances), even though there are many health risks associated with it (e.g., intestinal parasites, diarrhea, blood-borne pathogens). Other problems include poor oral hygiene, chronic gingival infection, and salivary gland infections.

A number of medical disorders have been identified that are associated with coprophagia including seizure disorders, cerebral atrophy, and tumours. There are also many psychological and psychiatric disorders associated with coprophagia including mental retardation, alcoholism, severe depression, autism, obsessive-compulsive disorder, Klüver-Bucy syndrome, schizophrenia, fetishes, delirium, and dementia. The psychopathological roots and etiology of coprophagia still remain little known, and much of what has been published academically involves case studies. Furthermore, the prevalence of copraphagia is also unknown but thought to be very rare.

In a 1989 study of 14 elderly coprophagic patients (average age of 71 years) in psychiatric hospitals published in the British Journal of Psychiatry, Ghaziuddin and McDonald reported that nine had senile dementia, two were severely depressed, and one had cerebral atrophy. Three of the 14 were reported has having no cognitive deficits. Although comprising only 14 patients, this is actually one of the largest studies in the area as most published papers consist of case studies.

As mentioned above, copraphagia can on occasion be seen as part of a sexual fetish where the eating of faeces is associated with sexual arousal. In a 1995 issue of the Journal of Sex and Marital Therapy, Dr. T. Wise and Dr. R. Goldberg reported the case of a non-psychotic 47-year old man of normal intelligence who had a fetish for faecal smearing that escalated into coprophagia when combined with alcohol abuse and depression.

In researching this blog, I came across a form of culture bound syndrome called Arctic Hysteria (also known as Piblokto and Pibloktoq) where one of the common symptoms is coprophagia. Culture bound syndromes comprise a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies. Arctic Hysteria only manifests itself in winter among Inuhuit societies living (unsurprisingly) within the Arctic Circle. The condition is characterized by “an abrupt dissociative episode of intense hysteria, frequently followed by convulsive seizures and coma lasting up to 12 hours”. Symptoms can include intense screaming, uncontrolled wild behaviour, depression, coprophagia, and insensitivity to extreme cold”. Some scholars have cast doubt on its existence as a bona fide medical entity, but the association with copraphagia occurs repeatedly.

There is a wide variety of treatments that have been used for coprophagia including behavioural therapy, dietary changes, pharmacotherapy (e.g., tricyclic antidepressants, haloperidol, perospirone), and electro-convulsive therapy. All of these have reported at least partial success but as with research on coprophagia more generally, most treatment papers are based on case studies.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Beck D.A. & Frohberg, N.R. (2005). Coprophagia in an elderly man: a case report and review of the literature. International Journal of Psychiatry Medicine, 35, 417-427.

Donnellan, C.A. & Playfer, J.R. (1999). A case of coprophagia presenting with sialadenitis. Age and Ageing, 28, 233-234.

Foxx, R. M., & Martin, E. D. (1975). Treatment of scavenging behavior (coprophagy and pica) by overcorrection. Behavior Research and Therapy, 13, 153–162.

Friedin, B.D., & Johnson, H.K. (1979). Treatment of a retarded child’s feces smearing and coprophagic behavior. Journal of Mental Deficiency Research, 23, 55–61.

Ghaziuddin, N. & McDonald, C. (1989). A clinical study of adult coprophagics. British Journal of Psychiatry, 4, 53-54.

Harada, K.I., Yamamoto, K. & Saito, T. (2006). Effective treatment of coprophagia in a patient with schizophrenia with the novel atypical antipsychotic drug perospirone. Pharmacopsychiatry, 39, 113.

Ing, A.D., Roane, H.S. & Veenstra, R.A. (2011). Functional analysis and treatment of coprophagia. Journal of Applied Behavior Analysis. 44, 151–155

Pardini, M., Guida, S. & Gialloreti, L.E. (2010). Aripiprazole Treatment for Coprophagia in Autistic Disorder. Journal Neuropsychiatry and Clinical Neuroscience, 22(4), E33

Wise, T.N. & Goldberg, R.L. (1995). Escalation of a fetish: coprophagia in a nonpsychotic adult of normal intelligence. Journal of Sex and Marital Therapy, 21, 272-275.