doi:10.1111/pcn.

12359

Relevance of culture-bound syndromes in the 21st century

Antonio Ventriglio, MD, PhD,1 Oyedeji Ayonrinde, FRCPsych, MBA2 and
Dinesh Bhugra, CBE, PhD, FRCP, FRCPE, FRCPsych3*
1
University of Foggia, Foggia, Italy, and 2South London and Maudsley Foundation NHS Trust and 3Institute of Psychiatry,
Psychology and Neuroscience, King’s College London, London, UK

Culture-bound syndromes were first described over
60 years ago. The underlying premise was that certain
psychiatric syndromes are confined to specific cul-
tures. There is no doubt that cultures influence how
symptoms are perceived, explained and from where
help is sought. Cultures determine what idioms of
distress are employed to express distress. Rapid glo-
balization and industrialization have made the world
a smaller place and cultures are being more influ-
enced by other cultures. This has led to social and
economic changes in parts of the world where such
syndromes were seen more frequently. In this review
we illustrate these changes using the example of dhat
syndrome (semen-loss anxiety). The number of syn-
dromes in the DSM-5 has been reduced, acknowledg-
ing that these syndromes may be changing their
presentations. Clinicians need to be aware of social
and economic changes that may affect presentation
of various psychiatric syndromes.
Key words: cultural concepts of distress, culture-
bound syndromes, culture-specific syndromes, dhat
syndrome, semen-loss anxiety.

ECENT CHANGES IN the DSM-51 may have
R abandoned the term ‘culture-bound syndromes’
but in many parts of the world its use continues. Over
60 years ago, these syndromes appeared as exotic,
alien, indigenous conditions seen in cultures that
were also seen as less psychologically developed.
Over the years, many of these syndromes have been
reported from multiple cultures using different
idioms of distress.
There is no doubt that cultures influence how
people experience emotional distress, how they
express it and in what terms and, more importantly,
from where they seek help. Historically, colonizers
saw those who were being ruled as exotic natives who
were perhaps not very psychologically sophisticated
and therefore ignorant and objects of observation.
*Correspondence: Dinesh Bhugra, CBE, PhD, FRCP, FRCPE,
FRCPsych, Institute of Psychiatry, Psychology and Neuroscience,
King’s College London, Health Service and Population Research
Department, PO 25, David Goldberg Centre, De Crespigny Park,
London SE5 8AF, UK. Email: dinesh.bhugra@kcl.ac.uk
A longer version of this paper was previously published as a chapter in the
book Troublesome Disguises.
Accepted 26 August 2015.
These psychiatrists and many anthropologist observ-
ers ignored existing indigenous health-care systems,
idioms of distress and the therapeutic interventions
used by these populations. In many health-care
systems, the approach is much more social rather
than biological and even when the body is affected,
social factors are seen as playing a major role.
BACKGROUND
Yap2 was the first to describe culture-bound psycho-
genic psychoses – a term subsequently abbreviated
to ‘culture-bound syndromes.’3 These were seen as
‘rare, exotic unpredictable and chaotic behaviors at
their core among uncivilized people.’ There is no
doubt that this was a reflection of the existing diag-
nostic systems where these systems were often diffi-
cult to classify. Bhugra and Jacob4 suggest that these
behaviors were diagnosed with somewhat limited
understanding of the cultural context. On the one
hand, this is really surprising, as psychiatry is a
medical specialty strongly influenced by cultural
and social factors; but on the other hand, psychiatry
may reflect somewhat rigid, patrician and paternal-
istic views.

© 2015 The Authors 3

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4 A. Ventriglio et al.
In this commentary, we review the historical and
current status of culture-bound syndromes using dhat
(a syndrome of semen-loss anxiety seen very com-
monly in the Indian sub-continent) as an illustrative
example.
Nosological timeline
Yap first defined culture-bound psychogenic psycho-
ses in 1962.2 He modified the term to culture-bound
syndromes 7 years later3 and subsequently several
such syndromes have been described and studied. In
1992, the ICD-105 used the term ‘culture-specific dis-
orders’ and 15 years later the DSM-51 abandoned the
term to replace it with cultural concepts of distress
(see the study by Ayonrinde and Bhugra for further
discussion).6
What does ‘culture-bound’ really mean? We believe
that the concept of boundedness and whether certain
illnesses are really bound to certain cultures is prob-
lematic. In particular, old traditional boundaries
across cultures are becoming more porous and, with
rapid globalization, cultural factors are becoming
perhaps more diffuse and more accessible. The rapid
increase in the use of social media and inter-
connectedness through increased and rapid access to
media, including the Internet, has added another
complicating and complex dimension.
CULTURE-BOUND SYNDROMES IN
THE DIAGNOSTIC MANUALS
(DSM AND ICD)
As mentioned earlier, the rise of culture-bound syn-
dromes may be a reflection of the rise of Western
diagnostic and classificatory systems and also the
long-standing impact of colonialism. Recent shifts in
the DSM-51 may indicate a change away from these
factors. The two major psychiatric classificatory
systems have used these syndromes in slightly differ-
ent ways. Interestingly, the ICD-10,5 which is a more
culturally sensitive system, acknowledges that these
syndromes are not easy to fit into classificatory
categories.
ICD-10 (1992)
5
The ICD-10 recognizes a number of culturally
uncommon symptom patterns and presentations
referred to as ‘culture-specific disorders.’ While
© 2015 The Authors
Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2016; 70: 3–6
acknowledging that these sydromes have diverse
characteristics, they also have two common features:
1 They are not easily accommodated in established
and international diagnostic categories.
2 Their initial description is in a particular popula-
tion or cultural area and their subsequent associa-
tion is with this community or culture.
The ICD-10 has thus made cautious and tentative
associations between cultural syndromes and recog-
nized psychiatric categories, but the problem again is
that these are culturally specific. We argue that these
are reported from other cultures too and are not
exclusive.
DSM-IV-TR (2000)
In the DSM-IV-TR,7 culture-bound syndromes were
seen as recurrent, locality-specific patterns of aber-
rant behavior and troubling experience that may or
may not be linked to a particular DSM-IV diagnostic
category.
The following characteristics were seen as crucial
for culture-bound syndromes:
1 Indigenously considered illnesses or afflictions –
therefore a recognition within the society as a
deviation from normal or healthy presentation.
2 Local names – the ascription of a specific local
name to the experience of mental distress. This is
often in the indigenous or key language of com-
munication and may be components of folk diag-
nostic categories.
3 Symptoms, course and social response often influ-
enced by local cultural factors – for instance the
folk healing systems for the symptoms based on
the explanatory model of the experiences.
4 Limited to specific societies or cultural areas – this
may be a geographical region, areas with shared
ethnic history or identity. For instance some cul-
tural practices and artifacts of the Yoruba culture of
western Nigeria may also be found in Brazil.
5 Localized – therefore experiences that are not glob-
ally recognized or span different regions.
The DSM-51 discarded the concept of culture-
bound syndromes with a preference for the term ‘cul-
tural concepts of distress.’ This has been defined as
‘ways cultural groups experience, understand, and
Psychiatry and Clinical Neurosciences 2016; 70: 3–6
communicate suffering, behavioral problems, or
troubling thoughts and emotions.’ Consequently
three cultural concepts have been identified: ‘syn-
dromes’ (clusters of symptoms and attributions
occurring among individuals in specific cultures);
‘idioms of distress’ (shared ways of communicating,
expressing or sharing distress); and ‘explanations’
(labels, attributions suggesting causation of symp-
toms or distress).
Interestingly, the DSM-5 emphasizes that all
mental distress is culturally framed and acknowl-
edges that different populations carry varying and
culturally determined ways of communicating dis-
tress along with explanations of causality, coping
methods and help-seeking behaviors.
CHANGES IN THE DIAGNOSTIC
MANUALS (DSM AND ICD)
For a time, there was an expansion in the number of
culture-bound syndromes from 25 syndromes in the
DSM-IV-TR, but it has come down to nine in the
DSM-5. Not surprisingly, various concerns have been
raised about the diagnostic validity of culture-bound
syndromes.8,9
Culture-bound syndromes are culturally influ-
enced and, we would argue, also influenced by exist-
ing health-care systems. Semen-loss anxiety has
been reported from many parts of the world as loss
of semen due to nocturnal emissions or masturba-
tion, and the condition affects individual notions of
masculinity.
DHAT, OR SEMEN-LOSS ANXIETY
SYNDROME, IN THE INDIAN
SUB-CONTINENT
Etymology
Dhat, or semen-loss anxiety syndrome, includes
symptoms of semen-loss, which lead to complaints
of weakness and anxiety. The word dhat is derived
from the Sanskrit word dhatu, which means metal in
Sanskrit and is also used as a colloquial term for
semen. Early descriptions in 1960 by Wig and col-
leagues from north India observed that dhat syn-
drome involved many vague somatic complaints of
weakness, fatigue, anxiety, loss of appetite, guilt and
sexual dysfunction, which were seen as a direct result
of semen loss following masturbation, nocturnal
emissions or micturition.10,11
Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurology
Culture-bound syndromes in 21st century 5
Such symptoms have been noted in ancient Indian
Ayurvedic texts dating to about 5000 BC. In these
texts, semen production was described as ‘food con-
verts to blood which converts to flesh which converts
to marrow and ultimately to semen.’ Each of these
steps is supposed to take 40 days,12 thus making
semen incredibly precious. These symptoms are
widely recognized across the Indian subcontinent
and folk and traditional treatments are easily avail-
able and widely sought, even though very little evi-
dence exists for their success. We hypothesize that
these treatments may work as placebo as the practi-
tioners may be able to understand the cultural
context.
As mentioned above, there is no doubt that, for
men, semen-loss and the resulting anxiety are
incredibly important. Attitudes to masculinity, male
sex roles, procreation and fertility all play a role in
generating such anxiety. Similar values and anxieties
were seen in industrial countries, such as Britain
and the USA, in the 19th century. Dietary supple-
ments, such as corn flakes and crackers, were adver-
tised and sold as treatment for semen-loss
anxiety.3,8,9 In the Indian sub-continent, faith healers
and traditional healers continue to offer various
types of food supplements, herbs and treatment
strategies. It will be important to explore whether
such anxiety has disappeared from industrial
nations and the subsequent role globalization is
likely to play in eliminating such anxieties or
whether, on the other hand, it may further contrib-
ute to it. Urbanization is also likely to play a role as
increased access to education spreads and higher
levels of education and changes in understanding
masculinity may well lead to a further reduction of
the condition.
The future of culture-bound syndromes or culture-
specific manifestations of distress as a range of disor-
ders is uncertain, even though the DSM-5 has taken
the right steps. Recent reports of hikkikomori from
Japan (where teenagers become withdrawn socially)
raise a wider question as to whether this is a genuine
response to changing pressures related to social
media or something entirely different. There have
been case reports from other parts of the world
too.13,14
The evolution of other culturally specific diagnostic
systems, such as the Chinese Classification of Mental
Disorders,15 may indicate a shift in some cultures from
a universal classification of mental disorders to a
more culture-specific classification. We believe that
© 2015 The Authors
6 A. Ventriglio et al.
psychiatry as a profession needs an urgent debate on
universalist versus relativist classificatory systems.
CONCLUSIONS
With cultures in transition in many parts of the world
as a result of inter-connectedness and globalization,
it is critical that clinicians are aware of how local
cultures are changing. We believe that it is extremely
likely that culture-bound syndromes will no longer
be culturally bound but culturally influenced. As a
result of globalization, resulting and associated
industrialization and urbanization may well lead to
changes related to a move towards societies becom-
ing more modern and less traditional, which in itself
may change the perceptions and idioms of distress.
Consequently, it is likely that not only will the
expressions and idioms of distress change but so will
the pathways to help-seeking. We hope that, as a
result of globalization, better understanding across
cultures will lead to more balanced and nuanced
approaches to diagnostic categories.
ACKNOWLEDGMENTS
The authors have no conflicts of interest. They
received no financial or research awards for this
paper.
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