Culture Bound Syndromes Cultural Variations and Psychopathology

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Freddy A. Paniagua

Department of Psychiatry and Behavioral Sciences University of Texas Medical Branch Galveston, Texas

Inaccuracies in the assessment and diagnosis of psychopathological conditions with culturally diverse groups (i.e., overdiagnosis, underdiagnosis, and misdiagnosis) might result from a lack of understanding of the presence of cultural variants leading to symptoms resembling psychopathology. These variables have generally been described in the case of culture-specific disorders known as "culture-bound syndromes" (Castillo, 1997; Dana, 1993; Dana, 1995; Ivey, Ivey, & Simek-Morgan, 1996; Paniagua, 1998; Pedersen, 1997; Pedersen, Dra-guns, Lonner, & Timble, 1996; Ponterotto, Casas, Suzuki, & Alexander, 1995; Smart & Smart, 1997). Smart and Smart (1997), for example, pointed out that the glossary (Appendix I) of culture-bound syndromes included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) "are description of 25 forms of aberrant behavior that are referred to as locality-specific troubling experiences that are limited to certain societies or cultural areas" (p. 394). These "locality-specific aberrant experiences," have been given specific names in the cross-cultural literature. Table I shows examples of culture-bound syndromes often-considered specific to a

Handbook of Multicultural Mental Health: Assessment and Treatment oj Diverse Populations Copyright © 2000 by Academic Press. All rights of reproduction in any form reserved.

TABLE I Summary of Cultural-Bound Syndromes

Name Group

Ataques de nervios Hispanics Oui

Amok, Mal de pelea Malaysia, Laos,

Philippines, Polynesia, Papua New Guinea, Puerto Rico

Brain fag African Americans

Boujée délirante Haitians

Colera Hispanics

Dhat India, China, Sri Lanka

Falling-out African Americans

Ghost sickness American Indians

Hwa-byung Asians

Description

:-of-consciousness state resulting from evil spirits. Symptoms include attacks of crying, trembling, uncontrollable shouting, physical or verbal aggression, and intense heat in the chest moving to the head. These ataques are often associated with stressful events (e.g., death of a loved one, divorce or separation, or witnessing an accident including a family member).

A dissociative disorder involving outburst of violent and aggression or homicidal behavior at people and objects. A minor insult would precipitate this condition. Amnesia, exhaustion, and persecutory ideas are often associated with this syndrome.

Problems with concentration and thinking among high school and university students experiencing the challenges of schooling. Symptoms include head and neck pain, blurring of vision, burning, and heat resembling Somatoform, Depressive, and Anxiety Disorders.

Sudden outburst of aggression, agitation associated with confusion, psychomotor excitement, and symptoms resembling Brief Psychotic Disorder (including visual and auditory hallucinations, paranoid ideation)

Anger and rage disturbing body balances leading to headache, screaming, stomach pain, loss of consciousness, and fatigue.

Extreme anxiety associated with a sense of weakness, exhaustion, and the discharge of semen

Seizurelike symptoms resulting from traumatic events such as robberies.

Weakness, dizziness, fainting, anxiety, hallucinations,'confusion, and loss of appetite resulting from the action of witches and evil forces.

Pain in the upper abdomen, fear of death, tiredness resulting from the imbalance between reality and anger

(continues)

8. Culture-Bound Syndromes TABLE I (continued)

Name Group

Koro Asians

Latah Asians

Mal de ojo Hispanics

Ode-ori Nigeria

Pibloktog Arctic, Subarctic

Eskimos

Kyofusho Asians

Mal puesto, hex, African Americans, root work, Hispanics voodoo death

Susto, espanto, Hispanics miedo, pasmo

Wacinko American Indians

Wind/cold illness Hispanics, Asians

Description

A man's desire to grasp his penis (in a woman, the vulva and nipples) resulting from the fear that it will retract into his body and cause death.

A sudden fright resulting in imitative behaviors that appears beyond control including imitation of movements and speech; the individual often follows commands to do things outside his or her wish (e.g., verbal repetition of obscenities)

Medical problems such as vomiting, fever, diarrhea, and mental problems (e.g., anxiety, depression) could result from the mal de ojo (evil eye) the individual experienced from another person. This condition is common among infants and children; adults might also experience similar symptoms resulting from this mal de ojo.

Sensations of parasites crawling in the head, feelings of heat in the head, paranoid fears of malevolent attacks by evil spirits.

Excitement, coma, and convulsive seizures resembling an abrupt dissociative episode, often associated with amnesia, withdrawal, irritability, and irrational behaviors such as breaking furniture, eating feces, and verbalization of obscenities.

Guilt about embarrassing others, timidity resulting from the feeling that the appearance, odor, and facial expressions are offensive to other people.

Unnatural diseases and death resulting from the power of people who use evil spirits

Tiredness and weakness resulting from frightening and startling experiences

Feelings of anger, withdrawal, mutism, suicide from reaction to disappointment and interpersonal problems

A fear of the cold and the wind; feeling weakness and susceptibility to illness resulting from the belief that natural and supernatural elements are not balanced given cultural context or society (Castillo, 1997; Griffith & Baker, 1993; Levine & Gaw, 1995; Price, 1993; Rubel, O'Nell, & Collado-Ardon, 1984; Simons & Hughes, 1993; Westermeyer, 1985).

The same cross-cultural literature, however, suggests that symptoms associated with a given mental disorder may be related to a particular cultural context but the disorder is not considered an example of "culture-bound syndromes" per se (e.g., Table I). In this case, clinicians are advised to consider specific cultural variants, which might explain symptoms suggesting the disorder under consideration. Although the DSM-IV did not explicitly emphasize this point, a review of the way the DSM-IV discusses cultural variants across several disorders suggests a distinction between culture-bound syndromes (e.g., Table I) and the cultural variables contributing to symptoms in a given DSM-IV disorder. For example, as noted by Lewis-Fernandez and Kleinman (1995) the Task Force on Culture and DSM-IV recommended the inclusion of Dissociative Identity Disorder and Anorexia Nervosa as examples of "culture-bound syndromes" in the Glossary (Appendix I). Apparently, this recommendation was not implemented in the DSM-IV because these disorders were not examples of "locality-specific patterns of aberrant behavior and troubling" (DSM-IV, 1994, p. 844) resembling culture-bound syndromes included in the Glossary (Appendix I). In the DSM-IV, however, cultural variations were considered as potential factors contributing to Dissociative Identity Disorder and Anorexia Nervosa.

Below are examples of disorders (in alphabetical order) which were not specifically included in the DSM-IV as examples of "culture-bound syndromes" (Table I), but in which culture-specific contexts were considered to assist clinicians with the application of "DSM-IV criteria in a multicultural environment" (DSM-IV, 1994, p. 843). It should be noted that in the case of several disorders, the DSM-IV suggests that the particular disorder may resemble one of the culture-bound syndromes in Appendix I. The term "resemble," however, suggests that in the DSM-IV that disorder is not a culture-bound syndrome per se. For example, "boufée délirante" was included as an example of culture-bound syndromes in Appendix I, and, according to the DSM-IV, episodes associated with this culture-bound syndrome "may resemble an episode of Brief Psychotic Disorder" (1994, p. 845). When applicable, this point is also noted in this chapter.

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