03 - 3.3 Culture Bound Syndromes

3.3 Culture-Bound Syndromes

developed on English-speaking Western subjects and may not be appropriate for use among ethnic minority patients or non–English-speaking individuals due to lack of cultural equivalence. Translating items is insufficient to achieve linguistic equivalence, as the meaning and connotation changes and idioms of expression differ between languages. In addition, norms also may differ between ethnic groups, and tests need to be standardized with representative patients. The complexity of translating an instrument varies depending on how much the construct being measured differs between the two cultures. There are four different approaches to translation. An ethnocentric approach is one in which the researcher assumes that the concepts completely overlap in the two cultures. The instrument is used with individuals who differ from the population in which the instrument was originally developed and normed. The pragmatic approach assumes that there is some overlap between the two cultures and attempts are made to measure the overlapping aspects of the construct, emic aspects. An emic plus etic approach goes one step further and also attempts to measure culture-specific aspects of the construct. Lastly, sometimes translation is not possible when the concepts do not overlap at all within the two cultures. REFERENCES Aggarwal NK. The psychiatric cultural formulation: Translating medical anthropology into clinical practice. J Psychiatr Pract. 2012;18(2):73. Biag BJ. Social and transcultural aspects of psychiatry. In: Johnstone EC, Owens DC, Lawrie SM, Mcintosh AM, Sharpe S, eds. Companion to Psychiatric Studies. 8th ed. New York: Elsevier; 2010:109. Breslau J, Aguiler-Gaxiola S, Borges G, Kendler KS, Su M. Risk for psychiatric disorder among immigrants and their USborn descendants: Evidence from the National Comorbidity Survey Replication. J Nerv Ment Dis. 2007;195:189. Bolton SL, Elias B, Enns MW, Sareen J, Beals J, Novins DK. A comparison of the prevalence and risk factors of suicidal ideation and suicide attempts in two American Indian population samples and in a general population sample. Transcult Psychiatry. 2014;51:3–22. Chao RC, Green KE. Multiculturally Sensitive Mental Health Scale (MSMHS): Development, factor analysis, reliability, and validity. Psychol Assess. 2011; 23(4):876. De La Rosa M, Babino R, Rosario A, Martinez NV, Aijaz L. Challenges and strategies in recruiting, interviewing, and retaining recent Latino immigrants in substance abuse and HIV epidemiologic studies. Am J Addict. 2012;21(1):11. Kagawa-Singer M. Impact of culture on health outcomes. J Pediatr Hematol Oncol. 2011;33 Suppl 2:S90. Kohn R, Wintrob RM, Alarcón RD. Transcultural psychiatry. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:734. Kortmann F. Transcultural psychiatry: From practice to theory. Transcultural Psychiatry. 2010:47(2):203. Ruiz P. A look at cultural psychiatry in the 21st century. J Nerv Ment Dis. 2011;199(8):553. Ton H, Lim RF. The assessment of culturally diverse individuals. In: Lim RF, ed. Clinical Manual of Cultural Psychiatry. Washington, DC: American Psychiatric Publishing; 2006:3–31. 3.3 Culture-Bound Syndromes

Cross-cultural mental health professionals have introduced a number of terms to refer to and describe culture-specific forms of expressing and diagnosing emotional distress. The term culture bound was used in the past to describe patterned behaviors of distress or illness whose phenomenology appeared distinct from psychiatric categories and were considered unique to particular cultural settings. The clear implication was that Western psychiatric categories were not culture bound, but rather universal, and that proper characterization would disclose a simple translation key for non-Western syndromes. The dichotomy between syndromes that are “culture free,” emerging from EuroAmerican and European societies, and those that are “culture bound,” emerging from everywhere else, is of course patently false. Culture suffuses all forms of psychological distress, the familiar as well as the unfamiliar. CULTURE-BOUND SYNDROMES AND THEIR RELATIONSHIP TO PSYCHIATRIC DIAGNOSES Only a few of the many cultural forms of expressing distress have received sustained research attention with integration of cultural and psychiatric research methods. This chapter focuses on some of those syndromes from diverse cultural regions, which have received the most intensive research and have been shown to be associated with psychiatric categories: Amok, ataques de nervios, possession syndrome, and shenjing shuairuo. Amok Amok is a dissociative episode that is characterized by a period of depression followed by an outburst of violent, aggressive, or homicidal behavior. Episodes tend to be caused by a perceived insult and are often accompanied by persecutory ideas, automation, amnesia, and exhaustion. Patients return to premorbid states following the episode. Amok seems to be prevalent only among males. The term originated in Malaysia, but similar behavior patterns can be found in Laos, Philippines, Polynesia (cafard or cathard), Papua New Guinea, and Puerto Rico (mal de pelea), and among the Navajo (iich’aa). Phenomenology. A prototypical episode is composed of the following elements:

1. Exposure to a stressful stimulus or subacute conflict, eliciting in the subject feelings of anger, loss, shame, and lowered self-esteem. The stressor usually appears minor in proportion to the resulting behavior (e.g., argument with a coworker, verbal insult), but may occasionally be severe (i.e., death of a loved one).
2. A period of social withdrawal and brooding over the precipitating conflict, often involving aimless wandering, and sometimes accompanied by visual perceptual alterations.
3. Transition, usually sudden, to frenzied and extremely violent homicidality, with or without a brief prodromal stage of preparation (e.g., subject may locate preferred

weapon or reach suddenly for whatever implement is available). 4. Indiscriminate selection of victims who may or may not symbolically represent the original actors in the conflict (e.g., subject attacks only Chinese people who are strangers to him, after a conflict with a Chinese coworker). Occasionally, the subject also attacks animals or objects in his path, or wounds himself, sometimes severely. The subject perseveres at these violent activities despite external attempts to bring him under control. 5. Verbalizations, when present, may be frenzied and guttural, or express internal conflict (e.g., ask forgiveness of a relative before killing him) or split consciousness (e.g., subject admits to a positive relationship with the victim, but denies this for his “spear”). 6. Cessation may be spontaneous, but usually results from being overpowered or killed. It is typically abrupt and leads to change in consciousness, usually stupor or sleep. 7. Subsequent partial or total amnesia and report of “unconsciousness” or description of “darkened vision” (mata gelap) during the acute episode. 8. Perceptual disturbances or affective decompensations may occur for days or weeks after the acute attack. Psychosis or depression sometimes ensues. Epidemiology. Epidemiological rates of amok in Malaysia and Indonesia are unknown and may vary regionally and over time. From the available data, amok appears to follow an endemic pattern in Malayo-Indonesia with some epidemic increases, the reverse of which has been found for amok-like attacks in Laos. Amok is essentially unknown in women (only one case was found in the literature, and it was considered atypical in that no deaths occurred). It is thought to occur more frequently in men of Malay extraction, Muslim religion, low education, and rural origin, who are between the ages of 20 and 45 years. Precipitants. Precipitants of amok in Malaysia and Indonesia typically consisted of experiences eliciting in the subject marked feelings of loss, shame, anger, or lowered self-esteem. Although specific triggers were very diverse in nature and presentation, including sudden and gradual stressors, most consisted of interpersonal or social conflicts superficially appearing to generate only mild to moderate stress. These include arguments with coworkers, nonspecific family tensions, feelings of social humiliation, bouts of possessive jealousy, gambling debts, and job loss. Rarely, however, amok was precipitated by a severe stressor, such as the simultaneous death of the spouse and child of the subject. Additional Clinical Features. It is unclear whether amok episodes are associated with indirect suicidal intent on the part of the subject. Anecdotes and cultural views supporting a connection are available, but interviews with surviving subjects have tended to refute the association. Rates of relapse are unknown. It is considered very likely in the popular view, leading

currently in Malaysia to permanent psychiatric hospitalization of surviving subjects, and, in the past, to banishment or execution. Treatment. Afflicted individuals in 20th-century Malaysia have been exempted from legal or moral responsibility for acts committed while in a state of amok by means of a kind of “insanity defense,” which characterizes the attack as “unconscious” and beyond the subject’s control. They were subsequently hospitalized, sometimes permanently, and frequently received diagnoses of schizophrenia and were treated with antipsychotic medication. Alternatively, trials have sometimes resulted in criminal verdicts and prolonged imprisonment. Ataque de Nervios Ataque de nervios is an idiom of distress principally reported among Latinos from the Caribbean, but recognized among many Latin American and Latin Mediterranean groups. Commonly reported symptoms include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, and verbal or physical aggression. Dissociative experiences, seizure-like or fainting episodes, and suicidal gestures are prominent in some attacks but absent in others. A general feature of an ataque de nervios is a sense of being out of control. Ataques de nervios frequently occur as a direct result of a stressful event relating to the family (e.g., news of a death of a close relative, a separation or divorce from a spouse, conflicts with a spouse or children, or witnessing an accident involving a family member). People may experience amnesia for what occurred during the ataque de nervios, but they otherwise return rapidly to their usual level of functioning. Ataque de nervios (attack of nerves, in Spanish) is a syndrome indigenous to various Latin American cultures, notably those of the Hispanic Caribbean (Puerto Rico, Cuba, and the Dominican Republic). It has received considerable attention in the psychiatric and anthropological literature since the mid-1950s, mostly in Puerto Rican communities on the island and in populations within the United States. Phenomenology. An ataque de nervios can be described as prototypically composed of the following elements:

1. Exposure to a frequently sudden, stressful stimulus, typically eliciting feelings of fear, grief, or anger, and involving a person close to the subject, such as a spouse, child, family member, or friend. Severity of the trigger ranges from mild-moderate (i.e., marital argument, disclosure of migration plans) to extreme (i.e., physical or sexual abuse, acute bereavement).
2. Initiation of the episode is immediate upon exposure to the stimulus, or after a period of brooding or emotional “shock.”
3. Once the acute attack begins, rapid evolution of an intense affective storm follows, characterized by a primary affect usually congruent with the stimulus (such as anger,

fear, grief) and a sense of loss of control (emotional expressions). 4. These are accompanied by all or some of the following: A. bodily sensations: Trembling, chest tightness, headache, difficulty breathing, heart palpitations, heat in the chest, paresthesias of diverse location, difficulty moving limbs, faintness, blurred vision, or dizziness (mareos). B. Behaviors (action dimension): Shouting, crying, swearing, moaning, breaking objects, striking out at others or at self, attempting to harm self with nearest implement, falling to the ground, shaking with convulsive movements, or lying “as if dead.” 5. Cessation may be abrupt or gradual, but it is usually rapid, and often results from the ministration of others, involving expressions of concern, prayers, or use of rubbing alcohol (alcoholado). There is return of ordinary consciousness and reported exhaustion. 6. The attack is frequently followed by partial or total amnesia for the events of the episode, and descriptions such as the following for the acute attack: Loss of consciousness, depersonalization, mind going blank, and/or general unawareness of surroundings (alterations in consciousness). However, some ataques appear to exhibit no alterations in consciousness. Epidemiology. Risk factors for ataque de nervios span a range of social and demographic characteristics. The strongest predictors of ataque are female gender, lower formal education, and disrupted marital status (i.e., divorced, widowed, or separated). Ataque sufferers also reported less satisfaction in their social interactions generally and specifically with their spouses. In addition, people who experienced an ataque de nervios were more likely to describe their health as only fair or poor, to seek help for an emotional problem, and to take medications for this purpose. Persons with ataque also reported deriving less satisfaction from leisure time activities and feeling overwhelmed more often. Precipitants. Prototypically, ataque de nervios was linked by sufferers to an acute precipitating event or to the summation of many life episodes of suffering brought to a head by a trigger that overwhelmed the person’s coping ability. In 92 percent of cases, the ataque was directly provoked by a distressing situation, and 73 percent of the time it began within minutes or hours of the event. A majority of first ataques (81 percent) occurred in the presence of others, as opposed to when the sufferer was alone, and led to a the person receiving help (67 percent). Unlike the typical experience of persons with panic disorder, most patients reported feeling better (71 percent) or feeling relieved (81 percent) after their first ataque. The first episodes of ataque de nervios are closely tied to the interpersonal world of the sufferer and they result in an unburdening (desahogarse) of one’s life problems, at least temporarily. Additional Clinical Features. The association between ataque de nervios and a

sense of loss of control and of being overwhelmed highlight the importance of the association between the cultural syndrome and other behaviors associated with acute emotional dysregulation. Most concerning among these is the strong relationship between ataques and suicidal ideation and attempts. Other related behaviors include loss of aggression control, expressed as attacks on people or property, and dissociative experiences, both of which are related to the acute ataque experience. Specific Cultural Factors. The complex relationship between ataque de nervios and psychiatric diagnosis may be clarified in reference to its broader popular nosology. In the Hispanic Caribbean and other areas of Latin America, ataque is part of a popular nosology of nervios (nerves), composed of other related categories. Experiences of adversity are linked in this nosology to ensuing “alterations” of the nervous system, which result in its impaired functioning, including the peripheral nerves. This quasianatomical damage is evidenced in emotional symptoms, including interpersonal susceptibility, anxiety, and irritability, as well as in physically mediated symptoms, such as trembling, palpitations, and decreased concentration. Treatment. No treatment studies of ataque de nervios have ever been conducted. Typical treatment involves, first, ensuring the safety of the person and those around him or her, given the association between ataque, suicidality, and uncontrolled aggressivity. “Talking the person down” is usually helpful, accompanied by expressions of support from relatives and other loved ones; the use of rubbing alcohol (alcoholado) to help calm the person is a culturally prescribed way of expressing this support. “Telling the story” of what led to the ataque usually constitutes the principal therapeutic approach in subsequent stages of treatment. Because one of the main functions of the attack is to communicate a feeling of being overwhelmed, indicating receipt of the message and the desire to offer support are usually perceived as therapeutic. The person should be allowed to set the pace of disclosure and to give enough details and circumstances to feel “unburdened” (desahogado[a]). In the case of single or occasional ataques in the absence of a psychiatric diagnosis, brief follow-up is usually sufficient. This may be discussed with the patient and the family as a way of ensuring a full return to the previous healthy state. For recurrent ataques, treatment depends on the associated psychopathology, the nature of the precipitants (including traumatic exposure), the degree of family conflict or support, the social context, the previous treatment experiences, and the patient’s and family’s expectations, among other factors. Psychotherapy is typically the mainstay of treatment, given the usual source of the overwhelmed behavior in the interpersonal milieu. Pharmacotherapy may also be useful in the treatment of ataque-related psychopathology; primary emphasis should be placed on treating the underlying disorder. Given the slow crescendo of many ataques, judicious use of short-acting benzodiazepines also has a role in helping abort an impending episode. However, this should not be the main form of treatment for recurrent ataques, since it only forestalls the principal function of the syndrome as a mode of

communication. Instead, psychotherapy and a social activism stance by the therapist that acknowledges the origins of adversity among low-income Latinos in socioeconomic disenfranchisement and ethnic/racial discrimination are usually required to address the interpersonal and sociocultural roots of ataque de nervios. Possession Syndrome Involuntary possession trance states are very common presentations of emotional distress around the world. Cognate experiences have been reported in extremely diverse cultural settings, including India, Sri Lanka, Hong Kong, China, Japan, Malaysia, Niger, Uganda, Southern Africa, Haiti, Puerto Rico, and Brazil, among others. Possession syndrome is an umbrella English-language term used to describe South Asian presentations of involuntary possession trance that encompasses multiple names in regional languages and dialects of India and Sri Lanka. These presentations are seen as a form of illness by the person’s cultural group because they are involuntary, they cause distress, and they do not occur as a normal part of a collective cultural or religious ritual or performance. Phenomenology. It is important to distinguish at the outset between possession syndrome, as an instance of possession trance, and the broader category of possession. The latter refers to a general ideology describing the full range of direct spirit influences on human affairs including effects on physical, psychological, spiritual, social, and ecological realms. By contrast, as a subset of general possession experience, possession trance refers to specific alterations in consciousness, memory, behavior, and identity attributed to direct spirit influence. In addition to pathological possession trance states, South Asian cultures authorize multiple examples of normal possession and possession trance. When voluntary and normative, these states are typically seen as instances of religious devotion, mystical ecstasy, social commentary, asceticism, interpersonal relations, existential reflection, and the study of consciousness. This chapter discusses possession syndrome as a pathological entity with an established phenomenology, that is, as a special case in the general continuum of etiological ideas regarding possession illnesses. A prototypical episode is composed of the following elements:

1. Onset occurs typically due to subacute conflict or stress and shows considerable variation. It may be gradual and nonspecific (e.g., diverse somatic complaints, such as dizziness, headaches, abdominal discomfort, hot-cold flashes, listlessness, or difficulty breathing) or sudden and specific, in the form of an abrupt transition to an altered state of consciousness.
2. Behavior during the altered state consists of some or all of the following: A. Dramatic, semi-purposeful movements, such as head bobbing, bodily shaking, thrashing, gyrating, or falling to the ground, accompanied by guttural, incoherent verbalizations, such as mumbling, moaning, or shrieking. B. Aggressive or violent actions directed at self or at others, including spitting, striking, and impulsive suicidal or homicidal gestures. Verbalizations may be

coherent and consist of derogatory comments or threats of violence directed against significant others or against the subject (in the third person) and typically considered by observers to be uncharacteristic of the subject’s usual behavior. C. Specific gestures, comments or requests denoting the appearance of a known possessing personality by (1) reference to standard attributes of culturally recognizable figures or (2) the name and degree of relation of deceased family members or acquaintances. 3. In all cases, this state is marked by the emergence of one or several secondary personalities distinct from that of the subject. Their specific identities, which may remain undisclosed for some time, adhere to cultural norms regulating permissible agents of possession, which vary by religion, region, and caste. Acceptable agents include spirits of deceased family members, in-law relations, or known village acquaintances who died under specific conditions of distress, and minor supernatural figures of the Hindu pantheon (rarely major deities) and the Islamic spiritual world. 4. Possession by the secondary personality(ies) is episodic, resulting in alternation between the usual personality of the subject and the altered state. The subject in his or her usual identity appears in a daze, exhausted, distressed, or confused about the situation and may report visual or auditory perceptual disturbances regarding the possessing agent, as well as “unconsciousness” and partial or total amnesia for the altered state. 5. Frequently, the specific identities of possessing personalities remain undisclosed for some time, requiring the active ministrations of family members and the intervention of specialized indigenous practitioners. The process of disclosure is conceived as a struggle between the family members and the beneficent agents possessing the healer on the one side, and the troublesome possessing personalities on the other. It is characterized by remarkable reactivity on the part of the subject to environmental cues, including direct questioning, strategic neglect, and aggressive manipulation. 6. Outcome is variable. Total recovery is often reported at the cessation of a single acute episode, which may be of several weeks’ duration. Alternatively, prolonged morbidity may result, or even, rarely, death. Data on the epidemiology, precipitants, and associated psychopathology of subjects with possession syndrome in South Asia is limited by methodological considerations. These include lack of representative community samples and nonsystematic definitions of the syndrome, which shows considerable regional variation. Epidemiology. Possession syndrome is more common in women, with a female-tomale ratio of approximately 3 to 1 in both community and psychiatric cohorts. Age of onset is usually between 15 and 35 years, but many cases reportedly begin in childhood. Attacks may persist well into middle age, and geriatric cases have also been reported. Precipitants. Precipitants of possession syndrome are varied but typically consist

of marked social or family conflicts, or stressful life transitions, of subacute duration, eliciting strong feelings of vulnerability in persons without firm emotional support. Examples encountered in the literature included marital conflict, abuse, and neglect, at times associated with alcoholism; arrival of a new bride to the home of her husband’s family; delay in arranging marriage, or in consummating it; forced marriage; widowhood; postpartum status; loss of family social standing; death of a family member; difficulty finding employment and financial difficulties; alienation from family support; and subordination to other family members and in-laws. Specific Cultural Factors. Possession syndrome constitutes a normative cultural category throughout India and Sri Lanka. It may present initially in a variety of forms, linked by the attribution of spirit etiology. When it presents in a nonspecific fashion, indigenous diagnosis is confirmed by the appearance of the altered state during the therapeutic ritual. It is considered an affliction by its painful, involuntary nature and attributed to the intervention of specific spiritual agencies acting independently or at the behest of a witch. Certain castes and persons in transitional states (e.g., puerperium) are considered most vulnerable to spirit attack, especially when deprived of emotional and material support. Treatment. Specialized indigenous practitioners and ritual therapies are generally available and widely utilized, but psychiatric treatment is typically avoided. Indigenous treatments include neutralization of the conflict or stress via the communal rituals involved in exorcism, as well as the reformulation of the suffering into beneficent individual and communal practice via initiation into a spirit devotion cult, such as the Siri cult of South India, or education into the roles of oracle (diviner), exorcist, or, rarely, avatar (divine incarnation). Shenjing Shuairuo Shenjing shuairuo (“weakness of the nervous system” in Mandarin Chinese) is a translation and cultural adaptation of the term “neurasthenia,” which was transmitted into China from the West and from Japan in the 1920s and 1930s. Revived in its modern form by the American neurologist George Beard since 1868, his formulation of neurasthenia (Greek for “lack of nerve strength”) originally denoted a heterogeneous syndrome of lassitude, pain, poor concentration, headache, irritability, dizziness, insomnia, and over 50 other symptoms. It was considered at first an “American disease,” resulting from the “pressures” of a rapidly modernizing society, but was later adopted by European diagnosticians. Its pathophysiology was thought to derive from a lowering of nervous system function on a physical rather than emotional basis, due to excessive demand on its use, especially among the educated and wealthier classes. In Soviet psychiatry, buttressed by Pavlovian research, it was a central component of mental health nosology, which became especially influential in Chinese psychiatry after the communist revolution of 1949.

Although neurasthenia declined in importance in Western classification systems during the 20th century, Shenjing shuairuo underwent marked popular and professional development in mainland China, Taiwan, Hong Kong, in Chinese migrant communities, and in Japan, where a similar syndrome is labeled shinkei suijaku. From a peak in about 1980, when it may have constituted up to 80 percent of all “neurotic” diagnoses in Chinese societies, Shenjing shuairuo has undergone intense psychiatric and anthropological re-examination. Currently, it features prominently in the second edition revised Chinese Classification of Mental Disorders (CCMD-2-R), under the section on “other neuroses.” The CCMD-2-R diagnosis requires three symptoms out of five nonhierarchical symptom clusters, organized as weakness, emotional, excitement, and nervous symptoms, as well as a fifth category of sleep disturbances. Like other neurotic disorders in the Chinese manual, the condition must last at least 3 months, and should (1) lower the efficiency of work, study, or social function; (2) cause mental distress; or (3) precipitate treatment seeking. Phenomenology. Given the evolution of diagnostic practice regarding shenjing shuairuo in Chinese societies over the last decades, which may be labeled the professional approximation of the condition, or its “disease” aspect, phenomenological description in this chapter is based instead on clinical histories of self-identified sufferers, or the “illness” aspect of the syndrome. The following elements are prototypical:

1. Onset is usually gradual, sometimes spanning several years, and typically emerges out of a conflictive, frustrating, or worrying situation that involves work, family, and other social settings, or their combination. A sense of powerlessness in changing the precipitating situation appears central to most illness accounts of the syndrome.
2. Symptoms show substantial individual variation, but usually involve at least some of the following spontaneous complaints: Insomnia, affective dysphoria, headache, bodily pains and distortions (e.g., “swelling” of the head), dizziness, difficulty concentrating, tension and anxiety, worry, fatigue, weakness, gastrointestinal problems, and “troubled vexation” (,fan nao). This last emotion has been described as a form of irritability mixed with worry and distress over “conflicting thoughts and unfulfilled desires,” that may be partially concealed for the sake of preserving social harmony.
3. The sufferer frequently seeks the sick role, attributing his or her difficulties in meeting work, school, or other social expectations to the syndrome. Sources of treatment vary substantially across Chinese communities, depending on the availability of formal and traditional service sectors.
4. Course is variable and may respond closely to changing interpersonal and social circumstances. Amelioration of the precipitating stressor(s) typically brings about substantial improvement, although residual symptoms appear common.
5. Response to treatment may be strongly mediated by the illness role and its

relationship to the intractability of precipitating stressors. Precipitants. Empirical assessment of the precipitants of shenjing shuairuo has found high rates of work-related stressors, which were made more intractable by the centrally directed nature of mainland Chinese society. These included unwelcome work assignments, job postings that caused family separations, harsh criticism at work, excessive workloads, monotonous tasks, and feelings of inadequacy or incompatibility of skills and responsibilities. Students usually described less severe study-related precipitants, particularly school failure or anxiety over the mismatch between personal or family aspirations and performance. Other interpersonal and family-related stressors included romantic disappointments, marital conflict, and the death of a spouse or other relative. Chinese etiological understandings of the syndrome commonly invert the Western view of “psychosomatic” presentations, whereby social-interpersonal precipitants cause psychological distress that is displaced onto bodily experience. Additional Clinical Features. Clinical course of the syndrome may depend on the associated psychiatric comorbidity and on the degree of persistence of the precipitating stressors. One longitudinal study found complete resolution of shenjing shuairuo symptoms and good social adjustment 20 years from the index diagnosis in 83 of 89 cases. Only one case was receiving continued treatment, and no subjects reported the onset of depressive disorder subsequent to the shenjing shuairuo diagnosis. Chinese psychiatrists have carried out numerous studies of neurophysiological and cognitive function in shenjing shuairuo patients since the 1950s. Most have reported abnormalities compared to normal controls, including in tests of polysomnography, electroencephalography, psychogalvanic reflexes, gastric function, and memory function. These findings need to be replicated with well-controlled samples using contemporary diagnostic instruments. Specific Cultural Factors. The evolving definitions of shenjing shuairuo have emerged from a tradition of syncretism in Chinese medicine between indigenous illness understandings and international contributions. Nineteenth-century Western notions of a weakened nervous system due to overuse (neurasthenia) found an ancient cognate expression in Chinese concepts of bodily meridians or channels (,jing) binding vital organs in balanced networks along which forces (e.g., qi, vital energy, in yin and yang forms) could be disrupted from their normal harmonious flow. This gave rise to shenjing shuairuo, an illness whereby the jing that carry shen—spirit or vitality, the capacity of the mind to form ideas and the desire of the personality to live life—have become shuai (degenerate) and ruo (weak) following undue nervous excitement. Treatment. When accessing formal sectors of care, most patients used both Western-trained physicians and traditional Chinese doctors. Nonpsychiatric medical settings were preferred, including neurology and general medicine clinics, in concert with cultural understandings of the somatopsychic etiology of shenjing shuairuo, which

emphasize its physical mediation. The modality of treatment was usually traditional Chinese medicines, which were prescribed by both Western-trained and Chinese-style doctors. This conformed to the balanced status still ascribed to both types of training among Chinese physicians. Polypharmacy was common, combining sedatives, traditional herbs, antianxiety agents, vitamins, and other tonics. Despite active suppression of religious healing in China, almost a quarter of patients were also engaged in such treatment. REFERENCES Bhugra D, Popelyuk D, McMullen I. Paraphilias across cultures: Contexts and controversies. J Sex Res. 2010;47(2):242. Bhui K, Bhugra D, eds. Culture and Mental Health. London: Hodder Arnold; 2007. Bou Khalil R, Dahdah P, Richa S, Kahn DA. Lycanthropy as a culture-bound syndrome: A case report and review of the literature. J Psychiatr Pract. 2012;18(1):51. Crozier I. Making up koro: Multiplicity, psychiatry, culture, and penis-shrinking anxieties. J Hist Med Allied Sci. 2012;67(1):36. Donlan W, Lee J. Screening for depression among indigenous Mexican migrant farmworkers using the Patient Health Questionnaire-9. Psychol Rep. 2010;106(2):419. Guarnaccia PJ, Lewis-Fernández R, Pincay IM, Shrout P, Guo J, Torres M, Canino G, Alegria M. Ataque de nervios as a marker of social and psychiatric vulnerability: Results from the NLAAS. Int J Soc Psychiatry. 2010;56(3):298. Haque A. Mental health concepts in Southeast Asia: Diagnostic considerations and treatment implications. Psychol Health Med. 2010;15(2):127. Jefee-Bahloul H. Teaching psychiatry residents about culture-bound syndromes: implementation of a modified team-based learning program. Acad Psychiatry. 2014;1–2. Juckett G, Rudolf-Watson L. Recognizing mental illness in culture-bound syndromes. Am Fam Physician. 2010;81(2):206 Lewis-Fernández R, Guarnaccia PJ, Ruiz P. Culture-bound syndromes. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:2519. Llyod K. The history and relevance of culture-bound syndromes. In: Bhui K, Bhugra D, eds. Culture and Mental Health. London: Hodder Arnold; 2007:98. Swartz L. Dissociation and spirit possession in non-Western countries: Notes towards a common research agenda. In: Sinason V, ed. Attachment, Trauma and Multiplicity: Working With Dissociative Identity Disorder. 2nd ed. New York: Routledge; 2011:63. Teo AR, Gaw AC. Hikikomori, a Japanese culture-bound syndrome of social withdrawal?: A proposal for DSM-5. J Nerv Ment Dis. 2010;198(6):444.