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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

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