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Anna Hofmann

5/10/19

Pd 3

Uncovering the Secrets: Culture-Bound Syndromes

Abstract:

In the 1960s, world-renowned psychiatrist Pow Ming Yap first coined the term

culture-bound psychogenic psychosis after his research done in various Asian societies and

tribes. He noted that people living in these populations described their personal behavioral

syndromes different than those typically categorized in mainstream, Western psychiatry

(Rebhun, 2004). This initial discovery paved way for the worldwide recognition and

development of culture-bound syndromes (CBS). In this paper, three different CBS’s are

described, along with each region's cultural norms and expectations, in order to draw a potential

conclusion. This is also done through meta-analysis. To conclude this paper, three potential

causes of CBS’s are noted, with information to support each.

Introduction:

Nature vs. nurture: is behavior inherited through genes or acquired through experiences?

If one is focusing on universal mental illnesses found coherently across the world, the answer is

most likely both. But, this may change when discussing a culture-bound syndrome, which is a

condition that only occurs within one specific culture, region, or society. These disorders can be
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either categorized as a mental illness or a disease without tissue abnormalities, where the

complication is centered around the brain (Burton, 2012). ​Upon further analysis, culture-bound

syndromes and their effects are labeled as such because of how they differentiate themselves

from Western disorders, and can be attributed to one’s definitive upbringing and homelife​. In

addition to supporting this, the purpose of this paper is to define culture-bound syndromes and

what they entail for the person and the society, identify specific examples of these to help

explain, analyze cultural-norms in various societies and their relationship with culture-bound

syndromes, and to compare possible explanations for this phenomena.

Pow Ming Yap, a world-renowned psychiatrist, first defined the term culture-bound

psychogenic psychosis after his research done in Asian, Pacific, and tribal societies during the

1960s. He noted that people living in these types of populations described their personal

behavioral syndromes different than those typically categorized in mainstream, Western

psychiatry (Rebhun, 2004). Yap’s findings were documented both in 1962 and 1969 in the Acta

Psychiatrica Scandinavica, a Scandinavian peer-reviewed medical journal (Reuters, 2015). He

modified the term to culture-bound syndrome 7 years later, which ultimately led to a greater

recognition and increased popularity within the psychiatric community (Ventriglio et al., 2015).

With the technological advancements of the later 20th century, including the

development of the home computer and the internet, a greater global awareness followed. Said

devices allowed for mass, worldwide communication to become more readily available to those

who may not have had access in the past. With this, doctors and researchers from around the

world were able to share their information and findings more easily (Watters, 2010). Although
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Yap first coined the name culture-bound syndrome over 50 years ago, these technological

advancements helped make the term more universal.

Review of Literature:

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a handbook

written by American professionals that resulted from many years of psychological research and

defines mental illnesses and conditions (Henderson, 2010). In the 5th edition, there are 23

culture-bound syndromes recognized within their own chapter (Nasser, 2012). An example of

one culture-bound syndrome described is ataque de nervios, which is directly translated into

English from Spanish as “attack of the nerves”. Ataque de nervios is a mental disorder where a

person experiences uncontrollable screaming or crying, inability to move due to fear, trembling,

fainting, seizures, heart palpitations, and other similar symptoms. These symptoms can occur at

random or when the person affected becomes triggered due to a shocking situation, which

oftentimes is a family member’s death (Fritscher, 2018). Fritscher’s evidence has suggested that

this disorder only occurs within the culture of Latino persons living in and originating from the

Caribbean Islands. Studies also point to ataque de nervios being observed in mostly women over

the age of 45 (Fritscher, 2018). A potential reason for this age assumption is because of the

adaptation to the culture and customs. If this disorder does occur due to a theme of nurture in the

nature vs. nurture schema, this could be a possibility. This syndrome is oftentimes compared to a

person having a panic attack, which can be seen globally as a somewhat frequent occurrence.

However, in a panic attack, a person's strong emotional and physical states are in response to
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their anxiety and/or fear in a certain situation (Lopez & Guarnaccia, 2000). For more about

ataque de nervios and other culture-bound syndromes, see figure 1.

Taijin kyofusho is a Japanese culture-bound syndrome that directly translates to the

disorder of fear of interpersonal relations (Ruble, 2014). This is where a person is constantly

fearful that their body’s appearance may be offensive or unpleasant to others, which includes a

false assumption of their unpleasant face, body odor, specific actions, or looks in general

(Fritscher, 2018). Because of this overall fear of guilt, one may go into social isolation,

ultimately causing a decrease in a social life and activities. There are generally two main forms

that taijin kyofusho takes in an individual. The first is when someone has more biological

symptoms as a result of a social situation, which includes insulting others with someone's own

blushing, sweating, body odor, etc. But, the most common scenario is the fear of being stared at

or being caught staring at others, which is due to the shame that follows in accordance to the

syndrome. The other form that taijin kyofusho can take is more localized to the human body.

This includes the person being ashamed of a certain physical feature, such as their eyes, mouth,

knees, or presence in general (Ruble, 2014). It is common to compare taijin kyofusho to a social

anxiety or disorder. However, the two can be differentiated because the tables have essentially

turned; their descriptions are based on the feelings of the individual person vs the group around

them. In taijin kyofusho, the focus is about avoiding potential embarrassment or harm to others

rather than within oneself (Fritscher, 2018). With a social disorder, a person may be afraid that

their actions could embarrass themself rather than others. Because of this difference, taijin

kyofusho is commonly known as the Japanese people's ‘personal’ disorder, due to the fact that is
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is not found anywhere else in the world (Vriends, Pfaltz, Novianti & Hadiyono, 2013). For more

about taijin kyofusho and other culture-bound syndromes, see figure 1.

The term “running amok” is known across Western cultures as another way to say that

someone may be going crazy or wild. But, in other regions, the term has a much more solemn

meaning. Amok is a culture-bound syndrome found mostly in Malaysia, Puerto Rico, and the

Philippines, with very rare cases found in more modernized cultures (Ceccarelli, 2012). “Amok”

derives from the Malay word ​mengamok​, which means to make a furious or desparate charge.

While exploring in the 18th century, Captain Cook became the first person to recognize and

record a specific tribe that displayed the same symptoms as someone who has amok in modern

day shows. He described the affected tribesmen as violent and reckless in their actions, without

apparent cause for human life. As observed, they would randomly kill or maim other villagers or

animals without conscious awareness (Saint Martin, 1999). While the symptoms of a

modern-day case of amok are much less severe, one could say that some of the violent

tendencies are still present . Usually, temporary fits of rage are followed by a period of peaceful

amnesia. Amok is primarily seen in men living and being raised in Southeast Asian cultures. No

one currently knows exactly how or why this occurs, but there are some broad theories (Divale,

2014). According to Michigan State University, amok is a result of a biological general mental

disorder, personality pathology, and psychosocial stressor. While it has been attempted to get a

more indepth look at the process of someone having an “attack”, it is nearly impossible due to

the potential risk of injury or death for the investigator due to the erratic behavior of the affected

person(s) (Ceccarelli, 2012). For more about amok and other culture-bound syndromes, see

figure 1.
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Submission 2:

Each of the regions affected by culture-bound syndromes have unique cultural practices.

These differences can lead to a variance in response and acceptance to those struggling with a

mental illness in those areas. This leads to the thought that if these customs are truly,

unconsciously implemented into a child's life growing up, then it would be considered more

nurture rather than nature, when studying the effects of culture-bound syndromes. The social

norms in Eastern and Southeastern Asia are considered uncommon when in comparison with the

psychologically well-documented Western world. However, it is not unusual for individuals to

deviate from practiced behaviors (Carteret, 2010). For example, behavior in group settings

differs from culture to culture. People who live or are raised in a Western society tend to be

considered more individualistic in manner; this can be seen as selfish to others across the world

Westerners think of their own circumstances and objectives, and are generally less likely to reach

out to others for advice or support. On the other hand, people who identify as part of an Eastern

or Southeastern Asian culture feel more comfortable being in a group and are more likely to

actively seek assistance from others when it comes to personal and business issues (Differences

in social customs between Asia and the West, 2015). It is believed that extremely independent

behavior may disrupt the harmony of an Asian family; familial bonds are taken very seriously

(Carteret, 2010). Another example of a social norm difference between Eastern and Western

cultures are the communication devices commonly used in the two. Westerners are more likely

to speak directly about issues to others in a very straightforward manner (Differences in social

customs between Asia and the West, 2015). This is why the English language generally lacks the
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“fluff” found in other dialects. In comparison, these conversational norms may seem abrupt to

someone looking in with a more Eastern background. In these cultures, the people tend to

converse in an indirect manner, where there is emphasis on the conceptual portion of the topic

(Carteret, 2010).

In addition to cultural norms, there are also other traditional practices that differ between

societies. These customs are considered common etiology; magic and other mandic art are

oftentimes prevalent in areas where culture-bound syndromes are seen (Henderson, 2010). For

example, in East Asia, magic within cultural practices was first discovered to have an origin in

about 403 BCE. In these countries, magic was used to provide a means to accomplish specific

ends through gestures, spells, smulets, etc. It was important for people to have strong ancestral

connections, which led to an association with spirit dealings. This ideology from premodern

sources has continued into the 21st century, especially within Buddhism and Daoism practices

(Magic: Magic in East Asia, 2005). Traditionally, children in these communities are raised with

viewpoints and exposure to mandic art, therefore being considered a part of their upbringing and

seen as normal (Henderson, 2010). There are common spells to summon deities to drive off

demons, cure illnesses, rid nights of terrors, obtain objects of desire, and many more. Oftentimes,

many methods are used to conduct these spells, including but not limited to amulets, unique cuts

and species, silk strips, and ashes (Magic: Magic in East Asia, 2005). These specific uses of

magic and spells are entirely unique to the East Asian culture and communities, where a majority

of culture-bound syndromes are observed. Because of this connection, it is plausible that the

raising of children who are exposed to these practices are more likely to be diagnosed with a
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culture-bound syndrome specific to those regions. This would be considered nurture rather than

nature, when comparing origin.

Because of these norms found within different societies and cultures, one could conclude

that the way someone is raised could be a potential cause of a culture-bound syndrome and that

all mental illness and syndrome cases are caused by an equal amount of both nature and nurture

during ones childhood. These diagnoses cannot be focused on the specific genes, but rather more

on the human psychology that states that that is how a person acts based on their parents

genealogy (Murphy, 2019). But, it is necessary for researchers to have access to an extensive

amount of resources in order to make a complete conclusion. A better identification and

classification of environmental factors can be used to compare with existing information

regarding genetic influences (Cooper, 2018). However, general human beliefs develop

differently around the world, according to University of Sydney professor Dominic Murphy,

2019. This allows for data to fluctuate, depending on the tests being done, mental illnesses being

tested, traditions and norms within the societies, and other factors. Therefore, it may be very

difficult to directly compare the two across the world.

Another theory is that one can use cultural norms and traditions to attribute culture bound

illnesses to the definitive upbringing of a child, which was previously stated as the general

hypothesis. Between societies, there are specific ways of conducting a normal life, formally

discussed as norms. Essentially, these morals are never taught, they are simply picked up when

being raised in a certain environment. For example, a wedding dance analogy: most likely, no

one is taught how to dance at a wedding , but they will know how to do it anyway when the time

comes. Because there are cultural differences when it comes to these dances, this would be
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considered something that is picked up unconsciously and naturally. Another example is the way

parents or guardians cope with stress. Growing up, if a child sees their mother put a cold towel

on her forehead when stressed, that child is going to reach adulthood with the same image in

their mind. They will most likely reciprocate it, if not exposed to other methods (Murphy, 2019).

This theory can be used to associate culture-bound syndromes with how someone is raised with

different traditions and values present.

A final theory is that one can attribute brain wiring and genealogy to pass culture-bound

syndromes down through familial ancestry. In general, some types of mental disorders can be

considered solely hereditary. For example, bipolar disorder, schizophrenia, and major depression

all have a genealogical tie. In 2013, a study was done to scan thousands of genetic markers to

search for tiny variations that are more likely to show up in those who have had a particular

condition than those who haven’t. It was found that a variation was located in the gene that

allows calcium to flow into neurons. Basing this variation on those that it affected, it has a tie to

a patient diagnosis of bipolar disorder, schizophrenia, and major depression (National Institutes

of Health, 2013). Because of this study, doctors and scientists were able to draw the conclusion

that it is possible for a mental disorder to be considered directly genetic. But, when it comes to

culture-bound syndromes and their cause, the varying diagnoses and ample regions make it

difficult to make such an assumption. There can be things in common with how the brain works

universally, but it will take different forms in different cultures (Murphy, 2019).

Research Methods and Data Collection:

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In order to draw adequate conclusions, it was determined that cross-analyzing five

different culture-bound syndromes would potentially yield the most useful results. The research

hypothesis discusses the possible “cause” for these syndromes, and therefore using a chart to

compare and contrast aspects of each could help make connections between them. Five academic

journals of five different culture-bound syndromes were used in the data collection. Those

syndromes included were: Ataque de nervios, dhat, taijin kyofusho, koro, and amok. Each

journal highlighted the area/culture derived from, common symptoms, potential cause, etc. The

chart is included below.

Figure 1

Article #1: Article #2: Article #3 Article #4 Article #5

Ataque de Taijin Amok Dhat Koro
Nervios Kyofusho

Country/area Note: Hispanic Occurs mostly Captain Cook Seen in men in Seen in men
derived from Americans in Japan and was the first to various Asian and (few)
represent Korea, record amok; cultures/countr women
greatest however, very this was done ies, including originating
majority of few similar in 1770 and India and from and/or
people studied cases have seen in Malay China. India residing in
for conclusion been seen in tribesmen. was the focus China. There
purposes. other areas of After his initial of the study. have been
the world experience, many
researchers “epidemics”
discovered that that have
amok was seen occurred there,
in many where a
isolated percentage of
primitive the population
tribes. Due to in infected.
the lack of The first
isolated living, recorded case
cases of amok of koro was
are extremely over two
rare in present thousand years
 11

day. ago found in

Chinese
medical
records. The
first recorded
epidemic was
in 1865 in
Southern
China.

Symptoms Uncontrollable Giving offense An individual Fatigue, The fear that

shouting, to others in acting anxiety, guilt, the penis,
attacks of social irrationally: loss of nipples, vulva,
crying, situations causes general appetite, and or other sexual
trembling, and through one’s havoc, rage sexual organs are
heat in chest physical followed by dysfunction retracting into
rising into characteristics. attack, and due to loss of the body. The
head. Incl: blushing, extreme semen. In the patient feels as
Dissociative gaze, body violent psyche, a if the organ
symptoms odor, or tendencies single “waste” does retract, it
include improper facial towards of a drop of will result in
suicidal expressions in oneself and semen leads to death. This
gestures, general. others. a series of fear leads to
seizures, or somatic extreme
fainting symptoms. anxiety in the
episodes. patient, and
going to
extreme
measures to
prevent it.

Potential Usually (Face-to-face The people Ayurvedic Traditionally,

cause/source following a contact) affected were texts, dated koro is
distressing usually between the attributed to
event, such as considered odd 5th millennium the female fox
death of a or angry in BC and the 7th fairy, as it is
loved one or general, with century AD, believed that
an no driving describe semen she takes away
interpersonal force in production as a human energy
conflict. actions part of an (potential lack
(completely almost of reproductive
random). religious organs).
concept. In
summarization
, food converts
to blood,
which converts
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to flesh, which
converts to
marrow, which
converts to
semen. This
ancient
mindset is a
possibility in
detecting the
origin of the
feelings felt by
someone who
has dhat.

What sets it 1- Hispanic 1- Focused on 1- Was only 1- Nowhere 1- Unusual

apart? participants doing seen in else in the feeling that is
exhibit a something primitive, world is there easily
higher rate embarrassing isolated a fear as distinguished.
than for another communities unusual and Retracting
non-Hispanic rather than to (ex: specific as genitalia is
counterparts oneself Philippines, semen loss most
(according to 2- Oftentimes, Papua New 2- Its roots are prominent
only study the people Guinea, Laos, recorded symptom; this
done affected are Puerto Rico, thousands of is very
correlating the obsessed with etc.). years ago, straightforwar
two). avoiding the 2- Extreme unlike some d.
2- Hispanic idea of shame violence other mental 2- Out of all
people with without illnesses previously
lower rates of apparent described
acculturation cause; culture-bound
report higher including syndromes,
rates. killing (others koro is the
3- a history of or oneself), most localized;
trauma is more rioting, erratic it is only seen
strongly behavior, etc. in China, and
associated, 3- Seemed to mostly in the
rather than just “infect” certain southern
anxiety tribes more portion.
sensitivity in than others,
general. with cases
differing in
severity.

Cultural Those who are In Japanese When the first As mentioned Han Chinese
similarities more exposed culture, the case was above, there (southern)
(traditions, to/strongly people adhere recorded in are deep have a
etc.) identify with to an implicit 1770, there ancestral roots tradition of
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the Hispanic social rule that was no for dhat. This viewing all
culture tend to all face-to-face technology for seems to be the types of
exhibit higher communicatio inhabited, leading sexuality as
rates of n should be isolated islands possible taboo.
endorsement cordial and to cultural Traditionally,
considerate. communicate correlation. koro is
Also, it is with the attributed to
important to outside world. the female fox
“save face”, There are very fairy, as it is
according to few modern believed that
traditions recorded cases, she takes away
which could human energy
lead to the (potential lack
assumption of reproductive
that this had to organs).
do with the
diagnosis

Analysis/test 1- surveyed 1- surveyed N/A Malhotra & Used

methods 342 college two groups of Wig, 1975: meta-analysis
students university 1- random to cross
(variety of students. One sample of 175 reference 131
declared college in males aged articles, mostly
ethnicities) Jogjakarta, 30-50 in India. case studies,
2- provided Indonesia and 2- used a case with the
description of the other in vignette to keyword
three mental Basel, collect their “koro”.
illnesses/disor Switzerland. ideas about
ders: Ataque 2- given semen loss, its
de nervios, questionnaire causation, and
panic attacks, consisting of management.
and koro questions
(added for having to do
reliability). with
The self-measured
descriptions self-construal,
were not social anxiety,
named. taijin
3- students kyofusho,
asked to DSM-IV social
identify which phobia, and the
(if any) of the wish for
illnesses they professional
had help for social
experienced. anxiety
symptoms.
3- The
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Indonesian
sample
recorded more
social-anxiety
symptoms in
relation to
taijin kyofusho
than the Swiss
counterpart.
The result was
similar to
studies done in
Japan.

Conclusion? None Taijin It is now It was Psychosexual

explicitly kyofusho was suspected that concluded that conflicts,
identified confirmed to an underlying while dhat still personality
be a psychological qualifies as a factors,
culture-bound condition or culture-bound cultural
syndrome. The mental illness syndrome, it beliefs, and
specific could be a does not guilt feelings
symptoms are contributor to correlate (often caused
not seen having amok. exactly. The by religious
anywhere else While there evidence background)
in the world are many points to quite could be seen
and can be treatment a large as a cause. For
contrasted in options, it is percentage of an epidemic,
comparison to not fully clear men suggestibility
regular social on why amok experiencing and prior
anxiety. was so dhat symptoms knowledge,
prevalent in before/during/ along with
the past. after potential seclusion of
semen loss. If living, are
this attributed.
experiment
represents dhat
universally, it
might not be
considered a
syndrome at
all, due to its
commonality.

Results and Data Analysis:

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After the evaluation of the five sources, no conclusions were able to be made explicitly

regarding the hypothesis. It was hoped that a connection would be made between two or more

culture-bound syndromes that alluded to the statement that culture-bound syndromes are

“nurture”-based, but this was unsuccessful. However, some other observations were made. Both

Mexico/United States (area ataque de nervios is derived from) and isolated tribespeople (area

amok is derived from) are generally considered individualistic cultures. Both of the syndromes

have symptoms that concentrate on anger and self-induced fury, which are correlational to the

characteristics of those living in more individualistic cultures. On the other hand, taijin kyofusho

originates from Japan, a collectivist culture. This syndrome has to do with the person affected

putting others before themselves, a common trait of someone living in a collectivist culture (less

self-centered).

Discussion and Conclusion:

Looking into the future, it is crucial that people have a global perspective. Based on the

mystery of the exact causes of a culture-bound syndrome and mental illnesses and the

information found through the meta-analysis, there is still a lot to learn. Americans often find

themselves living in a bubble, unexposed to the cultures and world around them. This also

applies to becoming more educated on topics related to mental health in general. If people are

aware of these potentially dangerous and sufferable illnesses, it may be easier to prevent them for

those who are susceptible.

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