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Ovid: Oxford Handbook of Psychiatry

Editors: Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew Title: Oxford Handbook of Psychiatry, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 20 – Transcultural psychiatry Chapter 20 Transcultural psychiatry P.834
Introduction Psychiatry is undeniably a branch of Western medicine and our conception of psychiatric illness (and how best to treat it) is undoubtedly heavily influenced by Western social and cultural factors. However, the scientific validity of these concepts can be readily tested if they can be shown to cross cultural boundaries. Emil Kraepelin recognised this argument when he visited Java in 1896, and found that the clinical symptoms of ‘dementia praecox’ could be seen in patients he met there, just as they were manifest in his own patients in Germany. It was not until the WHO International Pilot Study of Schizophrenia in 1973 that the incidence of schizophrenia (defined by narrow criteria) was found to be 0.7–1.4 per 10 000 aged 15–54 across all nine countries studied worldwide. Despite variations in the content of delusions and hallucinations (which were culturally derived), the form was found to be the same. These conclusions have been supported by a large number of epidemiological studies and similar results have been found for bipolar affective disorder. The manifestations of depressive, stress-related, and anxiety disorders show the greatest cultural variations (see pp. 836, 837). The myth that these are predominantly Western diseases held sway for a long time (based on views of Western civilisation articulated most eloquently by Freud in Civilisation and its Discontents (1930). Certain manifestations of emotional distress, termed ‘culture-bound syndromes’ by P.M. Yap, a former professor of psychiatry in Hong Kong, are particular to different cultures. These present as mixed disorders of behaviour, emotions, and beliefs and many have local names (see pp. 842, 843, 844, 845, 846, 847). Some are clear symptom-correlates of disorders found in ICD-10 and DSM-IV; others have no Western equivalent but appear to be variations of somatoform, conversion, or dissociative disorders. Some Western disorders (e.g. anorexia nervosa, deliberate self-harm) are rarely seen in non-Western countries. However, as we move towards a more global society, ‘Western influences’ appear to be making these types of disorder increasingly frequent in non-Western societies. Debate continues as to whether Western diagnostic categories are universally valid. Understanding the biological underpinnings of the common disease entities (e.g. schizophrenia, bipolar affective disorder, depression, anxiety) and the development of treatments based upon our understanding of neurophysiological and neuropharmacological mechanisms will inform this debate. However, awareness of cultural issues as they impact upon an individual, their illness (and illness beliefs), and the relationship between psychiatrist and patient, is critical if we are to successfully provide appropriate interventions. P.835
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Cultural context and the presentation of psychiatric disorders Schizophrenia Some apparently psychotic experiences may be normal when viewed within a cultural context. This applies to delusions (e.g. belief in magic, spirits, or demons) and hallucinations (e.g. seeing ‘auras’, the appearance of divine entities, hearing God’s voice). Other evidence of apparent psychosis, such as disorganised speech, may actually reflect local variations in language syntax, or the fact that the person is not completely fluent in the language used by the interviewer. Differences in non-verbal communication (e.g. eye contact, facial expression, body language) may also be misinterpreted. Historically there has been a tendency in the UK and US to diagnose schizophrenia more readily in certain cultural groups (e.g. Afro-Caribbeans). This probably does not reflect differences in the incidence of schizophrenia, but rather a lack of understanding of cultural differences. Some symptoms of schizophrenia (e.g. catatonia) are more common in non-Western countries, and even between Western countries the diagnosis of brief psychoses (e.g. boufée deliriante) varies. Interestingly the course of schizophrenia appears to be more acute and have better long-term outcome in some developing countries. Mania Often used colloquially to mean ‘changes in normal behaviour’, rather than its strict definition. It may be difficult to distinguish periods of frenzied activity (e.g. in amok—see p. 842) from increased activity, energy, and reduced need for sleep in a manic episode. This may be particularly difficult when such episodes are preceded by apparent depressive symptoms. Depression Cultural expressions of depressive symptoms vary across populations. In some cultures there is greater emphasis on somatic terms e.g. ‘nerves’ or ‘headaches’ (Mediterranean cultures); ‘problems of the heart’ (Middle East); ‘imbalance’, ‘weakness’, or ‘tiredness’ (China and Asia). This often makes the use of Western diagnostic classifications difficult, as symptoms may cross diagnostic boundaries (e.g. mood, anxiety, somatoform disorders). Equally difficult may be the interpretation of culturally normal explanations for symptom causation—which may appear delusional (e.g. spirit possession), or associated somatic symptoms (see p. 345)—that need to be distinguished from actual hallucinations. Anxiety and stress-related disorders Agoraphobia Social sanctions against members of certain populations (e.g. women) appearing in public may sometimes be confused with agoraphobic symptoms. Panic attacks In some cultures these may be interpreted as evidence of magic or witchcraft (particularly when they come ‘out of the blue’). OCD Religious and cultural beliefs strongly influence the content of obsessions and nature of compulsions. It may often be difficult to assess the significance of ritualistic behaviours unless the clinician has a knowledge of local customs. P.837
PTSD Immigrants may have emigrated to escape military conflict or particularly harsh regimes. They may have had experience of significant traumatic events, but may be unwilling (or unable) to discuss them because of language problems or fears of being sent back. Somatisation disorder Common types of somatic symptoms vary across cultures (and genders within cultures). These reflect the principle concerns of the population (or individual) e.g. worms/insects in the scalp/ under the skin—seen in South-East Asia and Africa; concern about semen loss—seen in India (see Dhat p. 843) and China (see Shenkui p. 846). Conversion and dissociative disorders More common in rural populations, in ‘less educated’ societies, and may be culturally normal. Certain religious rituals involve alteration in consciousness (including trance states), beliefs in spirit possession, and varieties of socially sanctioned behaviours that could be viewed as conversion or dissociative disorders (e.g. falling out p. 843, spell p. 846, zar p. 847). ‘Running’ subtypes of culture-bound syndromes have symptoms that would meet criteria for dissociative fugue (p. 746). Anorexia nervosa More prevalent in Western societies, with an abundance of food, and where there are strong cultural influences promoting thinness as the ideal of body shape. Immigrants from other cultural backgrounds may assimilate this ideal, or may present with primary symptoms other than disturbed body image and fear of weight gain (e.g. stomach pains, lack of enjoyment of food). Alcohol and substance misuse Cultural factors heavily influence the availability, patterns of use, attitudes about, and even the physiological or behavioural effects of alcohol and other substances. Alcohol Social, family, and religious attitudes towards the use of alcohol may all influence patterns of use and the likelihood of developing alcohol-related problems. Although it is difficult to separate cause from effect, low levels of education, unemployment, and low social status are all associated with increased misuse of alcohol. In some populations (e.g. Japanese and Chinese) up to 50% may have a deficiency of aldehyde dehydrogenase (complete absence in 10%), with low rates of alcohol problems in these populations because the physiological effects of consuming alcohol may be extremely unpleasant (e.g. flushing and palpaitations due to accumulation of acetylaldehyde). How individuals behave when intoxicated may also be culturally determined, with aggressive and antisocial behaviour (typified by ‘football hooligans’) not seen to the same extent in cultures where alcohol is more of a ‘social lubricant’, despite levels of alcohol consumption being similar. Other substances Use of hallucinogens and other drugs may be culturally acceptable when part of religious rituals (e.g. peyote in the Native American Church, cannabis in Rastafarianism). Equally, secular movements, typified by the hippie movements of the 60s and 70s, or more recently the ‘dance culture’, provide a context in which psychedelic experiences (e.g. induced by LSD or MDMA) may be experienced without any adverse social sanctions. P.838
Cultural formulation of psychiatric disorders When there are clear cultural issues impacting upon the presentation of a psychiatric disorder it is important to have a systematic way of describing the nature and form these take. This may help by engaging the patient more directly in the assessment process; identifying other predisposing, precipitating, or perpetuating factors; and allowing any proposed management plans to be more tailored to the individual patient. Issues that ought to be considered include:

  • Cultural identity—how the person regards themselves; affiliations with ethnic or religious subgroups.
  • Preferred language.
  • If an immigrant—integration into host society and culture.
  • Specific psychosocial factors that may be culturally determined.
  • Particular social stressors.
  • Support within the community (including the role of religious institutions) and from family and friends.
  • Availability and access to appropriate services.
  • Culturally-determined illness beliefs and behaviour.
  • What the patient believes to be wrong with them (the particular illness model used to explain perceived causation and nature of the condition).
  • How the patient expresses their symptoms (language used, local idioms, behavioural manifestations).
  • How the local community and family view their problems.
  • The doctor-patient relationship—differences in culture, perceived social status, communication difficulties (due to language) and how they impact on:
    • Eliciting symptoms and understanding their significance.
    • Forming a ‘therapeutic alliance’.
    • Discussing the possible treatment options (when ‘disease models’ may be at odds with each other).
  • The attitude of their culture towards mental illness and the implications of a psychiatric diagnosis (e.g. will preclude marriage in some cultures).

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Culture-bound syndromes Culture-bound or culture-specific syndromes comprise a wide range of disorders occuring in particular localities or ethnic groups. The behavioural manifestations or subjective experiences particular to these disorders may or may not correspond to diagnostic categories in DSM-IV or ICD-10. They are usually considered to be illnesses and generally have local names. They also include culturally accepted idioms or explanatory mechanisms of illness that differ from Western idioms and outside of their cultural setting may be mistaken for psychosis. Awareness of culture-bound syndromes is important to allow psychiatrists and physicians to make culturally appropriate diagnoses. According to Littlewood and Lipsedge (1987)1. these disorders share a number of common general characteristics:

  • Occur in young men or women who are ‘powerless’ and socially neglected.
  • Usually dramatic with the individual unaware or not responsible.
  • The disorder has symbolic cultural significance (‘mystical sanction’.) and show a typical triphasic pattern:
  • Dislocation of an individual as a representative of a particular group.
  • Emergence of symptoms as an exaggerated form of this extrusion.
  • Restitution into normal relationships.

In fact, these features could also be applied to many of the Western neuroses (where ‘mystical sanction’ is provided by the medical model). Although controversial, some commentators regard the neuroses (including dissociative states, somatoform and conversion disorders) as examples of Western culture-specific syndromes2 This would include a range of specific syndromes such as neurasthenia, fugue, and trance states, as well as the more modern neuroses: multiple personality disorder, anorexia nervosa, chronic fatigue syndrome, alien abduction syndrome, recovered memory syndrome, ritual or satanic abuse, Gulf War syndrome, and even shoplifting and overdosing (!) If culture-bound syndromes are categorised according to primary phenomenology, a number of common subtypes emerge (see opposite). Descriptions of specific syndromes are outlined in the following glossary (pp. 842, 843, 844, 845, 846, 847) illustrating the vast range of manifestations3. P.841
Subtypes of culture-bound syndromes

  • Startle reaction e.g. latah, amurakh, irkunii, ikota, olan miryachit, menkeiti, bah-tschi, bah-tsi, baah-ji, imu, mali-mali, silok
  • Genital retraction e.g. koro, suo yang, jinjinia bemar, rok-joo
  • Sudden assault e.g. amok, cafard/cathard, mal de pelea, fighting sickness, juramentado, Puerto Rican syndrome, iich’aa, going postal
  • Running e.g. pibloktoq/arctic hysteria, grisi siknis
  • Semen loss e.g. dhat, jiryan, sukra prameha, shenkui
  • Food restriction e.g. anorexia nervosa, bulimia nervosa, anorexia mirabilis/holy anorexia
  • Spirit possession e.g. bebainan, spell, zar
  • Obsession with the deceased e.g. ghost sickness, hsieh-ping, shin-byung
  • Exhaustion e.g. neuraesthenia, chronic fatigue syndrome/ME, brain fag/brain fog, shenjian shuairuo, nervios
  • Suppressed rage e.g. hwa-byung/wool-hwa-bung, bilis, colera

References 1 Littlewood R and Lipsedge M (1987) The butterfly and the serpent: culture, psychopathology and biomedicine. Cult Med Psychiatry 11, 289–335. 2 Showalter E (1998) Hystories, Picador Press. 3 For further reading see: Simons RC and Hughes CC (eds.) (1985) The culture-bound syndromes: folk illnesses of psychiatric and anthropological interest. Dordrecht, The Netherlands: D. Reidel Publishing Company. P.842
Glossary of culture-bound syndromes Amok, Amuck (Malayan males) Literally ‘battling furiously’: sudden, unprovoked, random acts of violence, for which the subject is amnesic, and after which they may commit suicide. May be preceded by a period of depression or brooding, anxiety, or feelings of hostility following perceived loss of face or being insulted. Also called Matal/Mata Elap(‘darkened eye’). Similar syndromes are reported in other countries of Southeast Asia, the Philippines, Polynesia (cafard or cathard), New Guinea (ahade idzi be), Puerto Rico (mal de pelea; fighting sickness; Puerto Rican syndrome), the Andes of Bolivia, Columbia, Ecuador, and Peru (colerina), and the US (going postal; iich’aa in Navajo Native Americans). Amurakh (Siberian women) ‘Copying mania’ characterised by echopraxia. (See lata.) Artic hysteria (See piblokto.) Ashanti (West African women e.g. Ghana) Consists of two subtypes: ‘frenzied guilt and fear’(FGF) where, sometimes following physical illness and fever, the person believes they are being punished for some offence, becomes frightened, and then frenzied, followed by a period of withdrawal, hallucinations, hebephrenic behaviour, dancing, singing, tearing off, clothes, and eating faeces; and ‘depressive’ (DP) where those affected accuse themselves of being witches and harming someone else without conscious intent. In younger women this often follows a difficult childbirth and subsequent illness, or the death of an infant. Ataque de nervios (Puerto Ricans and other Hispanics) Dissociative trance disorder, usually following an acute stressful event (e.g. death or conflict) with brief symptoms including: a trance-like state (with narrowing of awareness, perceptual distortions, depersonalisation, loss of consciousness, and partial or global amnesia), anxiety, somatic complaints, impulsive behaviour, and depression. Bangungut (young male Filipinos) ‘Oriental nightmare-death syndrome’ where a series of terrifying dreams culminate in death from presumed cardiac arrhythmia. (See also hmong sudden death syndrome.) Bebainan (Indonesia) Possession state, believed to be caused by a spirit power, deity, or other person, in which the subject assumes a new identity, associated with stereotyped involuntary movements and amnesia. Beserk, Berserk, Beserkergang (Northern Europe) ‘Fighting fever’, very similar to amok. Bilis and colera (Latin America) An idiom of distress in which physical or mental illness is explained as due to extreme emotion (anger) that upsets the humours (described in terms of hot and cold.) Brain fag, brain fog syndrome (West African students) ‘Brain fatigue’, an idiom of distress with symptoms attributed to over-work, tiredness, and ‘too much thinking’. The subject complains of reduced concentration, poor memory, blurred vision, and head/neck pain (often described as tightness, pressure, heat, or burning). Symptoms closely resemble anxiety, depressive, or somatoform disorders. P.843
Cathard, cafard (See amok.) Colerina (See amok.) Curanderismo (Mexican Americans and other Spanish-speaking people) Folk medicine in which the healers (curanderos [male] or cunderas [female]) use a combination of herbal infusions, dramatic healing rituals, and prayers to treat a variety of physical and psychological symptoms including: embrujo(witchcraft), empacho(intestinal distress), mal ojo(evil eye), mal puesto(hexing), and susto(soul loss.) Delahara (Philippine women) A syndrome similar to amok. Dhat (India, rural areas of Nepal, Sri Lanka, and Bangladesh) Semen-loss syndrome—a belief in the passage of semen in the urine following the breaking of taboos concerning masturbation or sexual intercourse. Associated with somatic symptoms (weakness, exhaustion), severe anxiety, hypochondriasis, whitish discolouration of the urine, and sexual dysfunction. Traditional remedies consist of herbal tonics to restore semen/humoral balance. Similar to jiryan(India), sukra prameha(Sri Lanka), and shenkui (China). Echul (Native Americans of South California) Sexual anxiety and convulsions following severe stress (e.g. the death of a child). Evil eye, mal Ojo (See curanderismo.) Falling out, blacking out (African Americans and Afro-Caribbeans) Collapse, without loss of consciousness, sometimes preceded by dizziness. The subject feels paralysed, but can hear and understand, and may claim to be blind. A type of dissociative/conversion disorder, usually following a traumatic event. Fighting sickness (See amok.) Frenzied anxiety state (Kenya) Frigidophobia (See wind illness.) Ghost sickness (Native Americans) Preoccupation with death or the deceased. Subjects may say they have been ‘bewitched’ and complain of nightmares, weakness, dizziness, episodes of collapse, anxiety, poor appetite, hallucinations, confusion, feelings of futility or apprehension, and sometimes a sense of suffocation. Grisi siknis (Miskito Indians, Nicaragua) Headache, anxiety, anger, and aimless running. Similar to pibloko. Gururumba episode (‘wild man behaviour’) (New Guinea) Subject (usually male) breaks into houses to steal small items (they believe to be valuable) and then runs off into the forest for some days, later returning (without the items) to their normal life. There is associated amnesia and during the episode they may appear vague, agitated, behave in a clumsy way, and have disturbance of normal hearing and speech. Hmong sudden death syndrome (Laos) The death of a person whilst sleeping, attributed to being attacked by spirits in a dream, and often following a traumatic event. (See bangungut and voodoo death.) P.844
Hi-wa itck (Mohave American Indians) Insomnia, depression, loss of appetite, and sometimes suicide associated with unwanted separation from a loved one. Hsieh-ping (Taiwan) A brief trance state during which the subject is believed to be possessed by an ancestral ghost, who often attempts to communicate to other family members. Symptoms include tremor, disorientation, delirium, and (visual/auditory) hallucinations. Hwa-byung, wool-hwa-bung, ‘anger syndrome’ (Korea) Epigastric pain attributed to a mass in the upper abdomen that the patient fears will lead to death. The belief is related to ideas of bodily imbalances caused by anger (cf. bilis and colera.) Other symptoms may include tiredness, muscular aches and pains, breathlessness, palpitations, insomnia, dysphoria, panic, loss of appetite, and other GI problems (indigestion, anorexia). Imu (See lata.) Juramentado (Malays and Moros) Marked agitation, indiscriminate assault or stabbing, followed by stupor, and subsequent amnesia on awakening. (Similar to amok.) Kimilue (Native Americans of Southern California) Apathy, anhedonia, loss of appetite, and vivid sexual dreams. Koro (Malaysia) Literally ‘to shrink’ or referring to a ‘tortoise’ (a popular word for penis). ‘Genital retraction syndrome’—the fear or delusion that the genitals are retracting into the abdomen, and that death will occur once this has happened. Prodromal depersonalisation usually occurs and elaborate measures may be taken to prevent the penis from retracting (e.g. grasping of the genitals, splints or other devices, herbal remedies, or fellatio). Occurs more frequently in predominantly young, single males, in Asia and the Middle East (epidemics have been described in the Malay Archipelago, Thailand, China, India, Singapore, and Israel.) Sporadic cases have been reported in Africa, Europe, and North America. The female equivalent (fear or delusion that the labia or nipples are retracting) occurs rarely and most reported cases have been during epidemics. There are no specific associations with other psychiatric disorders, although phobic anxiety disorders, depression, schizophrenia, and depersonalisation syndromes are described. Other names for this syndrome include: suk-yeong/ suo yang(Chinese: ‘shrunken penis’), kattao(Indian: ‘cut off’), jinjinia bemar(Assam), and rok-joo(Thailand.) Lata, latah, lattah (Malay population) Exaggerated startle reaction seen predominantly in young girls. Following sudden fright/trauma, there is a behavioural response consisting of echopraxia, automatic obedience, coprolalia, and dissociative or trance-like behaviour. May be a symptom of disease (e.g. acute psychosis, conversion/dissociative state) or be an isolated behavioural abnormality. Related syndromes include: amurakh, irkunii, ikota, miryachit, menkeiti, and olan/olonism(Siberia), imu(Ainu of Japan), bah-tschi, bah-tsi, and baah-ji(Thailand), mali-mali and silok(Philippines), Lapp panic(Lapps), the Jumpers of New England (a 19th-century Shaker sect), and jumping Frenchman(Canada). P.845
Locura (Latin America) Severe form of chronic psychosis, attributed to an inherited vulnerability and/or adverse life events, characterised by incoherent speech, agitation, auditory/visual hallucinations, impaired social interactions, and unpredictable (possibly violent) behaviour. ‘Lost hunter’ sequence (New Guinea) After period of social withdrawal (following perceived criticism of actions) the person (typically male) goes hunting alone in the bush and describes five episodes of tracking a large game animal, which suddenly disappears, before he is rescued by a search party. He feels he has been led astray by supernatural beings. Mal de pelea (See amok.) Miryachit, mirachat (Russian: ‘to fool’ or ‘play the fool’) (See lata.) Nerfiza, nerves, nervios (Latino populations in United States, Latin America, Egypt, Northern Europe) Chronic somatic, emotional, and behavioural symptoms (e.g. headache, sleep problems, reduced appetite, nausea, fatigue, dizziness, paraesthesia, anxiety, concentration difficulties, and emotional lability/distress). More common in women; associated with anger, emotional distress, and low self-esteem. Usually treated with traditional herbal teas, ‘nerve pills’, rest, isolation, and increased family support. (Similar to nevra in Greece.) Olonism (See lata.) Pibloko, pibloktoq (Polar Eskimo women) ‘Arctic hysteria’,—an acute dissociative state (lasting about 30 mins) following the actual (or symbolic) loss of someone or something important to the individual. Usually mild irritability or withdrawal precedes impulsive or dangerous acts (e.g. screaming, tearing off of clothes, breaking furniture, shouting obscenities, eating faeces, or rushing out into the snow). May be followed by convulsions and coma (lasting up to 12 hours) with associated amnesia. Although some researchers have suggested it may be due to hypocalcaemic tetany, it is most probably an anxiety state. Puerto Rican syndrome (See amok.) Qi-gong psychotic reaction (China) ‘Excess of vital energy’—an acute episode characterised by dissociative, paranoid, or other symptoms after participation in the health-enhancing practice of qi-gong. Rootwork (Haiti and Sub-Saharan Africa) A variety of complaints attributed to hexing, witchcraft, sorcery, voodoo, or the evil influence of another person. Symptoms include anxiety, GI complaints, and fear of being poisoned or killed. Can result in death. Associated syndromes: voodoo death(Haiti), mal puesto or brujeira (Latin America), and hex. Sangue dormido, ‘Sleeping blood’ (Cape Verde Islanders) Somatic symptoms including pain, numbness, tremor, paralysis, convulsions, blindness, and increased risk of heart attack, infection, and miscarriage. Sar (Somalian women) A possession state attributed to Sar spirits that are said to hate men. The syndrome may legitimise behavioural disturbance in women who feel neglected by their husbands. (See also zar.) P.846
Shenjian shuairuo (China) Similar to neurasthenia—symptoms include: fatigue, irritability, poor concentration/memory, sleep disturbance, and other somatic symptoms (dizziness, headaches, pain, GI upset, sexual dysfunction, and other signs of autonomic dysfunction). Most cases would meet criteria for depressive or anxiety disorders. Shenk-k’uei (Taiwan), shenkui (China) Anxiety and panic with somatic complaints, especially sexual dysfunction (premature ejaculation and impotence). Symptoms are attributed to excessive semen loss from sexual activity or ‘white turbid urine,’ which reduces ‘vital energy’. It is viewed as a life-threatening condition and described in areas with a Chinese ethnic population. Similar to dhat and jiryan(India), and sukra prameha(Sri Lanka.) Shin-byung (Korea) Possession (dissociative) state attributed to ancestral spirits with associated anxiety/fear and somatic complaints (generalised weakness, dizziness, insomnia, loss of appetite, and GI problems). Shinkeishitsu (Japan) Syndrome marked by obsessions, perfectionism, ambivalence, social withdrawal, fatigue, and hypochondriasis. Spell (Southern United States) A trance state in which individuals ‘communicate’ with deceased relatives or with spirits, often accompanied by brief periods of personality change. In context, ‘spells’ are culturally normal and do not indicate psychiatric illness. Susto, espanto, ‘magic fright’, ‘fallen fontanel syndrome’ (Peru) An acute anxiety state, seen in children and adolescents, usually following an acute stressor or violent (often supernatural) fright. Characterised by anxiety, agitation, dejection/apathy, sleep disturbance, significant weight loss, other somatic symptoms, and a belief that the soul has been, or will be, stolen from the body. (See curanderismo.) It is also seen in Latinos of the United States, Mexico, and other Central/South American countries. Related syndromes: lanti(Philippines), malgri(Aborigines of Australia), mogo laya(New Guinea), narahati(Iran), and saladera(in regions around the Amazon). Tabanka (Trinidad) Depression associated with a high rate of suicide that is seen in men abandoned by their wives. Taijin kyofusho (Japan) Fear and guilt about embarrassing others with one’s appearance or behaviour, prominent in younger people and similar to the Western concept of social phobia. Ufufuyane, saka (Kenya, Southern Africa; Bantu, Zulu; and affiliated groups) Anxiety state attributed to the effects of magical potions (given to them by rejected lovers) or spirit possession, with characteristic sobbing, repeated neologisms, paralysis, trance-like states, or loss of consciousness. Usually seen in young, unmarried women, who may also experience nightmares with sexual themes, and rarely episodes of temporary blindness. May be related to aluro(Nigeria), phii pob(Thailand), and zar(Egypt, Ethiopia, Sudan). Uquamairineq (Inuits of the Arctic Circle) Syndrome akin to a sleep-state transition disorder or dissociative disorder in which sudden paralysis P.847
is associated with a sleep state, marked anxiety/agitation, and hallucinations. Usually lasts minutes and may be preceded by a transient sound or smell. Traditionally viewed as the result of soul loss, soul wandering, or spirit possession. Vimbuza (Northern Malawi and Zambia) A culturally specific response to sickness involving herbal medicines and ‘vimbuza dancing’ that is performed late at night. Often others will dance on behalf of the patient, keeping the rhythm with metal belts, and inducing a trace state from which the ‘healed’ patient emerges. If the illness is considered severe, the family of the patient may sponsor a ‘chilopa’—an entire night of dancing followed by an animal sacrifice at dawn. The patient drinks some of the animal’s blood and then begins to dance again. The larger the animal (usually either a chicken, a goat, or a cow), the more effective the expected cure. Voodoo death (See hmong sudden death syndrome and rootwork.) Wacinko (Native American groups—Oglala Sioux—of North America) Anger, withdrawal, mutism, and immobility frequently leading to suicide. Often related to disappointment or interpersonal problems. Wihtigo, whitigo, witiko, windigo, wendigo (Native American groups e.g. Cree, Algonkian Indians of central and northeastern Canada) The fear or delusion of being transformed into a wihtigo, or giant monster that eats human flesh. There is a prodrome of anxiety about physical symptoms (e.g. reduced appetite, nausea and vomiting) and the person may commit suicide or be the target of violence. The existence of this syndrome is questioned as no single case has been described in the psychiatric or anthropological literature. Wind illness, p’a leng, frigidophobia (China, Southeast Asia) Anxiety/fear of being cold or of the wind; associated with a loss of yang and upset of natural balance in the body (believed to produce fatigue, impotence, and death), leading a person to do everything they can to stay warm. Described in areas with Chinese ethnic populations. May be related to agua frio, aire frio, frio of Mexico, Central and South America. Wild man behaviour (See gururumba.) Zar (East and North Africa, the Middle East e.g. Ethiopia, Somalia, Sudan, Egypt, and Iran) Dissociative symptoms including shouting, laughing, head banging, singing, weeping, and other demonstrative behaviours. The person believes they are possessed by a spirit, and may develop a long-term relationship with the spirit. Other symptoms may include apathy, withdrawal, refusal to eat, and refusal to carry out tasks of daily living. Such behaviour may be regarded as culturally normal (See sar.)

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