IJCRR - 10(11), June, 2018
Date of Publication: 11-Jun-2018
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Cultural Specific Syndromes in India - An Overview
Author: Anuja Kapoor, Rashi Juneja, Dweep Chand Singh
Abstract:The term culture-bound syndrome denotes locality-specific, recurrent patterns of variant behavior and disturbing experience that could conceivably be connected to a specific DSM-IV-TR diagnostic category. A large number of these examples are indigenously thought to be \"illness\", or at least afflictions, and most have local names. Culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations. Present overview paper has focused on various syndromes/disorders that are specific to India or Indian culture.
Keywords: Culture bound syndrome, Disorders, India
Culture assumes to play a definitive part in shading the psychopathology of different psychiatric disorders and mental health problems. However, certain psychiatric disorders are restricted to particular cultures. These disorders are known as culture bound or culture specific syndrome. For a couple of decades, there has been an expanded interest for the culturally diverse investigation of psychiatric disorders. Culture-specific syndrome is a mixture of symptoms including psychiatric and somatic manifestations that are thought to be a recognizable ailment just inside a particular society or culture. There is no specific biochemical or structural alterations of body organs or capacities, and the same condition is not perceived in different societies.
The term Culture bound syndrome was first introduced in Diagnostic and Statistical Manual of Mental disorders fourth edition. Despite the fact that no obvious diagnostic criteria have been conceived as of now, greater part of culture specific syndrome share the characteristics like categorized as a disease in that culture, widespread recognition in that culture, unknown in different societies, no equitably obvious biochemical or organ abnormality and treated by drug/conventional healers. The beginning and propagation of culture-bound disorders are considered to be connected with the moral, educational, social, mythological and psychodynamic foundation of a given populace group, and they from time to time expand past the limits of such specific culture.
In India, common culture bound syndromes are Possession Syndrome, Dhat Syndrome, Koro, Bhanmati, Gilhari syndrome, Compulsive spitting, Suchibai syndrome, culture-bound suicide (sati, santhra), Jhinjhinia, ascetic syndrome etc.The present paper has discussed about the Sociodemographic, clinical profile and nosological status of different culture bound disorders in the Indian subcontinent.
Possession Syndrome: Diagnosable under Dissociative disorders
Person is possessed usually by ‘soul/spirit’ of dead relative or a local deity.Changed tone, even gender changes at times if the possessing soul is of opposite sex. Usually seen in people from rural areas and most often this is found in females as they found to have more piled up emotions and lesser outlets to express themselves.[1,5] Treatment incorporates cautious investigation of hidden anxiety which encouraged the possession attack. Likewise, to diminish any secondary gains that the individual might get from this conduct. These individuals are looked upon as exceptional by their families and towns which fortify the secondary gains, included in ICD-10  under Dissociative disorders.
Dhat disorder is a clinical condition in which night time discharges severe anxiety, uneasiness and hypochondriasis, frequently related with sexual ineptitude. Presentation of the disorder usually includes various psychological, somatic and sexual symptoms. Patient attributes it to the releasing of whitish discharge which he believed to be semen (Dhat), in his urine. Susruta Samhita (ancient Indian text book of surgery) has portrayed seven Dhatus (fine fluids) in the body. Aggravations of Dhat may cause mental and physical problems. Semen is the most valuablefinal seventh product of the process. Charak Samhita depicts Dhat Disorder by the name 'Shukrameha'. Shukranu is the term used for sperms in Sanskrit. Semen is also known as with another name in Sanskrit which is ‘Veerya’ which means bravery. Forty drops of bone marrow are said to be equivalent to one drop of semen. This gave rise to the belief that loss of semen in any form will lead to physical weakness and ultimately sexual impotency. On the other hand, semen preservation will prompt vigour, wellbeing and long life span. Therefore, the faith in valuable and life-saving properties of semen is profoundly imbued in Indian culture. The conviction is additionally strengthened by conventional healers what's more, sustained by companions and seniors who had experienced this ‘disorder’.Whitish discharge is faulted by patient to be the in charge of the mental and physical issues which sufferer goes through. However, there is no target confirmation of such a release. Often patients report of bad smelling semen, body pains, loss of appetite, fatigue and weight reduction, loss of consideration, worrying excessively, low mood and panic attacks. Sexual grievances are that of premature discharge and erectile dysfunction. In majority of cases, there is absence of any physical diseases like diabetes, nearby genital abnormalities and sexually transmitted illnesses. The disorder is seen mostly in individuals from lower strata that look for assistance from customary healers and it’s seen throughout the nation.Comorbid psychiatric conditions like depression, anxiety, somatoform disorder may be present. Treatment comprises of bursting myths by psychoeducation, consoling the patient, treating comorbid psychiatric condition (if any present), even symptomatic alleviation (of extreme tension that these patients endure) with the assistance of medicines in introductory phases of treatment is required to gain patient's trust.
This disorder is mostly seen in northeastern states like Assam. This condition is related with an extraordinary dread of genitalia shrinkage and withdrawing into abdomen driving eventually to death and is seen in both the sexes. If in this triad of subjective symptomatology any of the components is missing, or the syndrome appears outside the endemic areas, it is referred to as "koro-like" or "atypical koro". Individual applies outside retractors to the genitalia in type of cinches, chains and so forth to maintain a strategic distance from it withdrawing back. It is depicted as a syndrome in ICD-10 and DSM-IV. Yap portrayed Koro patients as dependent, immature and lacking confidence in their virility and being in steady sexual conflicts. In the event that reports of koro events that likewise address the issues of its premorbid personality, the traits extant surviving in the patients fit Yap's depiction.
The treatment methodologies can be partitioned into four primary roads: (1) preventive measures as endorsed by the culturally embedded myths;(2) manipulatory techniques (pulling the penis outward, affixing of cinches and strings to the penis) performed by the patient himself, relatives or companions; (3) people mending proposals to battle the confusion, including unique weight control plans containing yang substances (e.g., bamboo, deer horn, red pepper stick, dark pepper powder, ginger)  and execution of ceremonies to pursue away the insidious soul (striking gongs, setting off fireworks); (4) the modern medical origination, which mulls over the likelihood of koro superimposed on a psychiatric issue, secondary to the organic illness, evoked by a psychological trigger, or any blend of these.
This is seen in South India. It is believed to be due to presence of psychiatric illness like somatization disorders, conversion disorders, dysthymia, anxiety disorder, schizophrenia etc. Nosological status is unclear.[5,11]
Gilhari syndrome is also known as the “squirrel or lizard syndrome” and is highly prevalent among the regions of west Rajasthan. As per the individuals suffering with this describe it as a little blood filled swelling on the body changing its position now and again as though squirrel or lizard is moving in the body from back and reaches the neck prompting obstacle of airways took after by death in the event that it isn't pulverized. The individual emphatically trusts that the condition is intense and lethal. Medicinal professionals explain that the Gilhari disorder is only the strong contraction or movements of the particular group of muscles that is caused by the serious tension and stress in a person. It influences for the mostly young adults who are having the false social convictions of lizards and being under a greater amount of physical, biological and mental burdens. The physical examination uncovers no physical illness in the person. They simply address these symptoms as tactile hallucinations with delusions. The patients can be sorted as having somatoform issue related with maladaptive practices.The treatment of this disorder is essentially centered around reassuring the patient and giving supportive psychotherapy. Anti-anxiety drugs are considered to be valuable in diminishing the manifestations in couple of patients.
Culture-bound suicide (sati,jouhar,santhra)
Sati is an act of self-immolation by a dowager on her spouse's fire-bed. As indicated by Hindu mythology, Sati the aspect of Dakhsha was so overcome at the death of her husband that she immolated herself on his memorial service fire and consumed herself to ashes.From that point forwarded the name as‘Sati’which has come to be symptomatic of self-immolation by a widow. Seen for the most part in Upper Castes outstandingly Brahmins and Kshatriyas. It is prohibited in India since nineteenth century. Nevertheless, one case has been reported in Rajasthan after 1904. Another classification of culture bound suicide is Jauhar. It is a suicide conferred by ladies even before the passing of her husband when looked by prospect of shame from another man (normally an overcoming lord). Most striking case in the history is Rani Padmini of Chittor(Rajasthan) to evade the attacking armed force of Sultan from Delhi in fifteenth century.
Next critical sort is Santhara/Sallekhana. In this people, deliberately surrender life by fasting unto demise over some undefined time frame for religious motivations to attain Moksha(salvation). It is mostly seen as a part of Jain Community who commends these occasions as religious celebrations. Individual at first takes fluids, later notwithstanding declining to take them. It is believed that the individual (performing the act) will get rid of anger, ego, attachment, greed, old age and terminal illnesses.
In vernacular "Jhin-Jhini" means tingling and numbness. As tingling and numbness are the presenting symptoms of the strange disease it was called "Jhin-Jhini". As an epidemic was first reported in the village Arkhali situated in West Bengal. The disease struck an individual unexpectedly with sensation of tingling and numbness in the legs which spread upward all through the body. Inside a couple of moments, the patient is seized with the loathsomeness of looming demise and sobs for help before he ends up noticeably astounded and unmoving. Unless saved, he would crash on the ground. With the aid of local remedy offered by a "rescue squad" (made during the epidemic) improvised for the occasion, he would recover after l/2hr. to 2 hrs. "Jhin-Jhini" gives off an impression of being a functional mental disorder which harrows a man drastically and vanishes inside a couple of hours, leaving no detectable trace. The disorder spreads quickly inside a span of a couple of kilometers and its frequency drops to nil inside a couple of months. It has, without a doubt, every one of the qualities of a scourge psychogenic confusion like an epidemic psychogenic disorder like contagious hysteria or epidemic koro.
In the first place it was depicted by Neki. Disorder is seen in teenagers and youthful grown-ups. It is portrayed by social withdrawal, serious sexual restraint, routine with regards to religious austerities, and absence of worry with physical appearance and excess loss of weight. Not much literature is available.
It is a culture specific disorder of excruciating pain in urination and pelvic "heat" recognizable in south India, particularly in the Tamil culture. It happens in both male and females. It is prominently ascribed to an increase in the "inner heat" of the body frequently because of dehydration.Individuals believe that it is frequently caused by high temperature amid summers, long travel, lack of healthy foods and fluids, lack of sleep and so on. The person presents with the objections of extreme abdomen torment, dark yellow urine, painful and burning micturition, headaches, fatigue, constipation and dry mouth.It is typically treated through:
1. Applying a couple of drops of sesame oil or castor oil in the navel and the pelvic area.
2. Having an oil massage took after by a warm water shower.
3.Intake of fenugreek seeds doused overnight in water.
Short enduring scourges of Mass Hysteria where hundreds to thousands of individuals apparently was accepting and carrying on in a way in which commonly they won’t. In a report by Choudhary et al. of an atypical hysteria epidemic in a tribal village of the State of Tripura, India where four malesand eight females were affected within a span of ten days. The central feature of the episodic is a trance state of 5 to 15 minutes with restlessness, attempts at self-injury, running away, inappropriate behaviour, inability to identify family members, refusal of food and intermittent mimicking of animal sounds. The illness was self-limiting and the individual showed improvement in symptoms in the course of one to three days’ duration.
In Bengal customs influence individual conduct to a degree which verges on pathological level. A vernacular term 'suchi-bai' in Bengali dialect means a condition like obsessional neurosis. Certain group of individuals, especially widows in the days of yore had multitudinous taboos forced on them. They were relied upon to take after the standards totally, for dread of social ostracisation. Many of them often became over-stringent about pollution rules, their conduct going past the points of confinement of custom and circumscribing on the ludicrous. The people group still perceives such individuals as abnormal and the condition is referred to in the vernacular dialect as ‘suchi-bai’, truly, immaculateness insanity. The people group endures individuals with ‘suchi-bai’. They are from time to time treated; regularly a ‘specialty’ in the family is found for an influenced grandmother or an aunt. Common symptoms of these patients include washing too often; not eating anywhere outside; changing of street clothes (own and sometime compulsorily for all family members); washing of money (including currency notes); bathing for four hours twice a day; hanging out street clothes outside on a tree and entering house naked; hopping while walking (to avoid touching anything dirty in the streets); remaining immersed in the holy river for best part of the day; sprinkling of cow dung water on all visitors etc.
One of the common complaints that are being heard from individuals coming to medical set upsis ‘Gas’ or ‘vayu’ etc. Individuals come up with number of symptoms like abdominal discomfort, headache, chest pain, joint pains, somatic complaints, back pain to ‘Gas’. ‘Gas’ is reported to be the cause for the distress and the primary duty of the treating clinician is to relieve them of the gas. The problem of troubling Gas or vayu has been affecting Indian culture since a long time. We do see a good amount of patients visiting different specialists attributing all their problems to Gas. 'Gas Syndrome’ is proposed as a culture bound syndrome. Ancient Indian text Charak Samhita has also talked about vayu. To deal with such a condition it becomes really important to understand the individual’s deep rooted beliefs and understanding of the illness. Otherwise, the gap between the clinician and patient can result in dissatisfaction. If the clinician keeps himself/herself distant from understanding patient’s traditional health beliefs, then the patient may not accept the treatment or become non-compliant.
The famous cultural psychiatrist Yap suggested that although cultural beliefs play a major role in coloring psychopathology in a number of illnesses but in certain illnesses, these may exert pathoplastic effects to an extent that it makes the illness to appear significantly different from the original one. Suggesting that the type of illness is still conspicuously universal involve the view that any new clinical condition must be a variety of something already perceived and depicted. As Yap said, two problems that would come up then: First, how much do we know about the culture-bound syndromes for us to be able to fit them into standard classification; and second, whether such a standard and exhaustive classification in fact exists.
Another bunch of cultural psychiatrists have also suggested that a culture-bound syndrome may have different manifestations which may fall into different sections of conventional classificatory systems such as the DSM IV or DSM 5 which argues against a simplistic reduction of culture-bound syndromes to a category of the conventional classificatory systems. Also, the nosological status of culture-bound syndromes has been debated.
Each person’s experience with the mental health and illness is unique. It isthe bio-psycho-social processes that contribute to somatic distress or syndrome. We believe that there is a need of studying attribution patterns and explanatory models with respect to the cultures regarding the symptomology of culture bound syndromes. Therapeutic management needs to be developed and established with respect to the culture. By ensuring evidence-based treatment and therapy and developing culturally responsive services, these common yet complicated conditions can be studied more and can provide more adequate treatment options.
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