Which of the following disorders may be influenced most by cultural differences?

F Contemplating the Existence of Culture-Bound Syndromes

Culture-bound syndromes provide a useful mirror for Western mental health professionals to examine their assumptions about the nature, diagnosis, and treatment of mental disorders. The DSM-IV-TR (American Psychiatric Association, 2000) defines and states the following about culture-bound syndromes.

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…There is seldom a one-to-one equivalence of any culture-bound syndrome with a DSM diagnostic entity. (p. 898)

Culture-bound syndromes represent a major area of concern and debate in the study of culture and mental health because their existence calls into question the very foundations on which so much Western psychiatry is based. Marsella (2000b) noted that there are many questions being debated regarding culture-bound syndromes. A fundamental question central to the debate asks, if culture-bound syndromes are limited to specific societies or culture areas, who defines the criteria for mental illness? Marsella and Yamada (2010) further pose:

Why is it that the non-Western disorders are contextualized in non-Western cultures, but those identified and coded in the West in DSMs and ICDs are the real thing? Certainly, they are as much cultural products as are those from non-Western cultures. (p. 107)

More than a decade since the first edition of this book was published (Cuéllar & Paniagua, 2000) no definitive answers have been offered in response to the following questions:

Should culture-bound syndromes be considered neurotic, psychotic, or personality disorders?

Should these syndromes be considered variants of disorders considered to be “universal” by many Western scientists and professionals (e.g., is susto [soul loss] merely a variant of depression?)?

Are all disorders “culture-bound” since none can escape cultural encoding, shaping, and presentation?

Culture-Bound Syndromes

Culture-bound syndromes are clinical presentation forms of symptoms that are culturally distinctive (Kirmayer, 2001). These syndromes offer insights into disorders that depend strongly on the sociocultural background of the individual. A classic culture-bound syndrome is koro, which is common in Southeast Asia and in China (Cheng, 1996). It implies the strong conviction that the male sexual organ is retracted inside the body (Freudenmann & Schonfeldt-Lecuona, 2005). A similar phenomenon has been described in India, with male patients fearing loss of power due to losing their semen through premature ejaculation or from passing semen in their urine (Dhat syndrome; Sumathipala, Siribaddana, & Bhugra, 2004). Taijin kyofusho is a phenomenon characterized by excessive nervousness and fear in social situations. While it has been described as a subtype of social anxiety disorder (Kirmayer, 1991), it is particularly characterized by the fear to offend or harm others. This type of anxiety has been related to the Japanese culture with its specific value of consideration for others in social situations (Suzuki, Takei, Kawai, Minabe, & Mori, 2003). Another recently described phenomenon in Japan is hikikomori, which is defined as social withdrawal for more than 6 months. It is suggested that hikikomori may be a representation of chronic schizophrenia, as patients sometimes show a strong immersion in personal interests (Teo & Gaw, 2010). Cases with no subjective psychological distress have also been described. In these cases, patients have an apathetic lifestyle with no interest in hobbies of any sort (Kondo et al., 2013). Lifelong financial dependency seems relatively acceptable in Japan, which is why a strong impact on the development of hikikomori has been proposed. However, recent reports suggest that the so-called modern type of depression is also a form of hikikomori (Kato, Shinfuku, Sartorius, & Kanba, 2011).

10.02.3 Culture-Bound Syndromes

The interest in culture-bound syndromes (CBS) in cultural psychiatry in itself illustrates a process of transformation in the approach to cultural dimensions of psychopathology. Fascination with CBS has its sources in the “bizarre characteristics of the behavior displayed” (Hughes, 1985). Originating from the voyeuristic interest on folk illnesses in “exotic” cultures, CBS are now included in the glossary of cultural terms in DSM-IV. The study of culture-bound syndromes has gained respectability from the scholarly works of pioneers such as Yap who alleged that:

It has long been known that there are, in certain cultural groups, peculiar aberrations of behavior which are regarded by themselves as abnormal. Over the years a number of terms taken from indigenous languages have crept into the psychiatric literature to denote these conditions, but many of them do not point to novel or distinct forms of disorder unknown elsewhere. Some are simply generic terms for “mental disorders” without definite meaning, others refer only to healing rituals, and still others to supernatural notions of disease causation.… To avoid stagnation in this field, it is essential to apply the concepts of clinical psychopathology to the analysis of these disorders, to integrate them into recognized classifications of disease if possible, or to broaden the classification if necessary. (1974, p. 86)

Initial interests in CBS have given rise to a host of “folk” taxonomies from different cultures (Simons & Hughes, 1985). More common CBS include the following:

Latah. Originating from Malaysia and Indonesia, Latah refers to the exaggerated startle response followed by odd behaviors. The afflicted person typically responds to a frightening stimulus with an exaggerated startle or jump, sometimes throwing or dropping a held object, uttering some improper word, or matching the words or movements of people nearby (Simons, 1985, p. 43). The pattern is a highly stereotypic, culturally labeled state which, though contravening the social norm, is differentiated from insanity.

Amok. Amok refers to the sudden mass assault taxon indigenous to Malayo-Indonesians, but may find parallel instances of indiscriminate homicide in other parts of the world. It is defined as “an acute outburst of unrestrained violence associated with homicidal attack, preceded by a period of brooding, and ending with exhaustion and amnesia” (Carr, 1985, p. 199). It is believed to have originated from the cultural training for warfare of the early Javanese and Malays which was intended to terrify the enemy into believing that they could expect no mercy and could save themselves only by flight.

Pibloktoq. The term is also labeled as arctic hysteria, polar hysteria, or transitional madness, referring to a group of hysterical symptoms among the Polar Eskimo of Greenland brought on by the depressing or monotonous effects of the Arctic's winter climate. The syndrome is composed of a series of reactive patterns with different combinations of the features in different cases. Disturbance of consciousness during the seizure and amnesia for the attack are the central clinical features. Some frequent behavioral symptoms are tearing off of clothing resulting in nudity, glossolalia, fleeing, and running across or rolling in snow. Gussow (1985) suggested that Pibloktoq is a reaction of “the basic Eskimo personality” to “situations of unusually intense, but culturally typical stress” (p. 282).

Susto. Illness arising from spirit separating from the body due to fright is widespread in one form or another in Latin America. The folk interpretation of Susto is based on the belief that a person comprises spiritual and organic elements. The spiritual element may be detachable from the host organism under unsettling experiences that disturb the equilibrium or when the unsettled spiritual element is seized and controlled by the spirits of the natural environment. The situation results in loss of appetite, weight, and strength; restlessness in sleep; listlessness when awake; and depression and introversion. “For recovery, the captured spirit must be retrieved from its captor, ransomed in the folk treatment process, and ‘led back’ to be reincorporated into the victim's body” (Rubel, O'Nell, & Collado, 1985, p. 334).

Most of the initial interest in CBS has surrounded the description of these phenomena. According to Prince and Tcheng-Laroche's (1987) definition of CBS, the culturally distinct meaning of the illness for individuals and cultures affects the occurrence of signs and symptoms of diseases in some cultures but not in others. The difference in occurrence depends on the psychosocial features of those cultures. CBSs have also been called culture-reactive syndromes, which suggests that the psychopathology is deemed to be rooted in social environmental forces and/or situations. The signs and symptoms reflect an attempt by the patients to adapt to major problems in their lives.

In the following section, one of the more popular syndromes in the literature, Koro, will be discussed in greater detail to illustrate how the cultural context of CBS affects their manifestation.

1 Introduction: Development of the Concept and Definition

The concept of ‘culture-bound syndromes’ has been the focus of an ongoing debate in the field of transcultural or comparative cultural psychiatry between psychiatric universalists who interpret these conditions as cultural elaborations of universal neuropsychological or psychopathological phenomena, and cultural relativists who see them as generated and expressive of distinctive features of a particular culture. The 8th edition of Kraepelin's textbook of psychiatry in 1909 was the first handbook describing clinical pictures which were later labeled ‘culture-bound syndromes,’ namely latah, koro, and amok. In the past the term ‘exotic’ was used to emphasize the non-Western character of culture-related conditions. It was not anticipated then that a disorder such as anorexia nervosa in young women would become common due to sociocultural factors operant in modern Western society, so that it has now been recognized as a Western culture-reactive syndrome (DiNicola 1990). The concept of culture-specific psychiatric disorders was originally introduced into psychiatric literature in the 1950s and 60s by Yap, who also made the first attempt to order what he called ‘culture-bound reactive syndromes,’ known under a great variety of folk names, in a diagnostic classification schema (Yap 1967).

A list of 168 so-called culture-bound syndromes was compiled in a glossary by Hughes (1985), while the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition, contains a glossary with 25 entries. These listings also include colloquial and local names for some well-known ubiquitous conditions. The Diagnostic Criteria for Research of the 10th Revision of the WHO International Classification of Diseases list 12 examples of ‘culture-specific disorders’ and suggest diagnostic codes while also stating that these conditions cannot be easily accomodated in established psychiatric classifications. Indeed, attempts at a nosological classification of culturally related syndromes have never been quite satisfactory due to (a) the overlap of diagnostically relevant symptoms, and (b) the fact that the various indigenous terms for similar syndromes are charged with different culture-specific meanings and traditional interpretations that codetermine the illness behavior of the patient and the reaction of the human environment.

On the basis of the data to be presented in this article, culture-specific psychiatric disorders are defined as clusters of symptoms and behaviors that can be plausibly related to specific cultural emphases, or to specific sociocultural stress situations, which are typical of a particular population.

1.11.6.1.10 Hwa-Byung

Hwa-Byung (HB) is a comparatively new culture-bound syndrome in psychology research. Similar symptoms have been reported in other populations though this syndrome is typically found in older Korean women (Park et al., 2001). Similar to depression, HB presents with feelings of hopelessness, guilt, excessive sleeping/insomnia, overeating/low appetite, and loss of interest. Somatic symptoms differentiate HB from depression, with people who endorse suffering from this syndrome reporting the feeling of a mass in their chest or abdomen and difficulty breathing (Lee et al., 2014). Additionally, individuals exhibiting HB also report feelings of impending doom and anger.

Anger is conceptualized as a form of “fire energy” and is likened to a pathogen in Traditional Chinese Medicinal practices (Suh, 2013). Thus, HB is derived from the Chinese words Hwa, which translates to fire, and Byung, which translates to illness. It is thought that repressing or suppressing anger (fire) over time leads to the development of this culture-bound syndrome and interpersonal conflict often precedes an episode of HB (Lee et al., 2014). Marital satisfaction has been found to have a negative association with HB symptoms among middle-aged Korean women (Kim et al., 2019). Prevalence rates of HB symptoms have not been widely studied, but a recent review estimates that 5% to 15% of middle-aged Korean women report symptoms of this syndrome (Lee et al., 2014). The same review found prevalence rates of HB symptoms in men to be considerably lower, at around 1.5%–3.2%.

Abstract

Cultural psychiatry’s focus has shifted its focus on ‘culture-bound syndromes’, to cultural competence training, to addressing mental health disparities and related injustices. Tools to hardwire culturally competent approaches include cultural formulation interviews and frameworks to address implicit biases. Professional organizations have elaborated on the components of culturally effective child and adolescent psychiatric care and have supported the principles that cultural assessment is important in ensuring access to mental healthcare, in ensuring accurate formulation and appropriate treatment, and in appreciating the acculturative and related stressors that can increase youth psychiatric risk. With these principles in mind and with consideration of lessons learned from a case vignette, the authors propose that, from a population health perspective, the specialty should work towards reducing—as with other types of trauma and other known risk factors for psychopathology—stressors that adversely affect healthy cultural identification and cultural adjustment in children globally.

Eating Disorders in Non-Western Nations

Eating disorders were once thought to occur mainly in the Western world and were even described as ‘culture-bound syndromes’. Non-Western societies were thought to be protected from eating disorders by cultural factors, such as a lack of an individualist ethos or healthy diets. Beginning in the 1970s, however, they have been documented in parts of Latin America, Africa, Asia, and the Pacific, in both high-income countries (e.g., Japan) and low-income countries (e.g., Fiji). They now count among the World Health Organization’s priority health concerns. While their rise was once blamed on Westernization and Western media in particular, there is now ongoing debate about their causes and core symptoms. This debate has raised new questions about the nature of eating disorders as well as the nature of globalization, which are relevant for cross-cultural studies of body image.

One issue is that the symptoms and subjectivities of patients with eating disorders differ in different regions. Key diagnostic criteria for eating disorders in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) include weight control behavior and body image distortion. In Hong Kong, Sing Lee found, however, that food refusal was not linked to weight concerns. Nearly half of those diagnosed with anorexia nervosa instead complained of physical problems such as stomach pains, gastric bloating, or lack of appetite. A lack of fat phobia was also found among patients with anorexia in Japan and Singapore. These studies have cast doubt on the universal validity of Western models of eating disorders and influenced ongoing discussion of the cultural bases of mental disorders in the DSM-V.

Another important question concerns the role Western culture plays in the global growth of eating disorders. In the non-Western world, eating disorders were first documented in highly industrialized societies such as 1970s’ Japan. In some poorer nations like Fiji, their appearance followed shortly after the increased presence of television in the mid-1990s. Such facts have led to an assumption that Western culture is primarily to blame for eating disorders. There are, however, a number of problems with this approach that may interfere with understanding the causes and wider significance of the spread of eating disorders.

For one, the same media images often have different meanings for different populations. Global media are filled with glamorous images of very thin Western women. While some Fijian women were fascinated by these images, they did not value thinness in itself, as Anne Becker points out. Rather, a thin body was seen as a means to an end: the consumer lifestyle and material wealth they associated with this body type. Postwar Japan seemed to follow a Western path to a consumer society. But this similarity masks deeper structural and symbolic differences in Japan’s gender system. Kathleen Pike and Amy Borovoy argue that Japanese women faced different gendered conflicts than those experienced by American women trying to balance work and family. Japanese state policies and cultural expectations made motherhood a dominant, even exclusive, path to maturity and independence – yet one that became less acceptable for a new generation of young women. Drawing on life histories, they argue that eating disorders are partly a response to culturally specific contradictions in gender roles. The rise of eating disorders may thus reflect not simply a desire to be or even look European, nor again the influence of Western values, but rather a new permutation of local conflicts and aspirations.

The second problem with viewing Westernization as the primary cause of eating disorders is that they have simply not appeared in some highly Westernized societies. Eileen Anderson-Fye points out that Belize underwent rapid development and experienced heavy exposure to North American media. It also has a tradition of intensely scrutinizing female bodies. Despite these factors, surprisingly this country did not experience clinically significant eating disorders. She argues that Belizean women were more interested in body shape than body weight. Local beauty standards favored a ‘Coca-Cola’ or ‘Fanta’ shape, the local idiom for a curvaceous figure. This bodily ideal persisted despite the prevalence of glamorous images of thinner bodies in media, and few women developed extreme distress about body size. A distinct ethnopsychology – expressed in the common phrase ‘never leave yourself ’ – helped protect women from obsessive weight concern and eating disorders. Transmitted by intimates to younger girls, this ethos centered on self-care and self-affirmation and conflicted with behaviors like counting calories or overexercising. Anderson-Fye argues that the Belize case can be seen as an ‘ethnographic veto’ of the thesis that heavy exposure to Western media is the principal cause of eating disorders.

Globalization is thus not a linear or hegemonic process that mechanically leads to acculturation to Western values. Rather, media reception often equals authorship. As images are consumed, they assume a new significance as they are translated into other systems of meaning and used as symbolic resources in local conflicts. The term ‘indigenization’ has often been used to refer to this process of appropriating global forms by local actors.

II.A. Culture-Specific Treatments

1.

Assess and explore the indigenous cultural belief systems of the culturally different client. Study and understand culture-bound syndromes and the explanatory basis of disorders. For example, “sustos” is the folk belief among some Latinos and people from Mexico and other Latin American countries, that the soul has left the body because of a frightening event resulting in illness. Healing results in the return of the soul to the body. In “rootwork,” a belief found in certain African-and Euro American populations, generalized anxiety and somatic problems are thought to be the result of witchcraft or sorcery. Cure is effected by utilizing a “root” healer who can remove the spell. DSM-IV lists a number of culture-bound syndromes that reveal the belief system underlying the cause and treatment for disorders found in different cultural groups.

Become knowledgeable about indigenous healing practices. As opposed to Western beliefs and practices, indigenous practices often involve the support of the disturbed individual though the use of communal and family networks, efforts to problem solve or develop treatment through a group context, reliance on spiritual healing, and the use of shamans or a respected elder from the community. Although we may not subscribe to these particular beliefs or practices, the psychotherapist can assist as a facilitator of indigenous support.

Consult with and seek the services of traditional healers within a specific culture. A liasion with indigenous healers can help deliver treatment more effectively. When the problem is clearly defined as primarily rooted in cultural traditions, referral to traditional healers becomes necessary. Advice regarding specific intervention strategies and how they can be reinterpreted to fit the specific culture can lead to more effective outcome.

Developing indigenous helping skills entails working in the community, making home visits, and expanding roles to include activism, prevention, outreach and social change. The culture-specific approach can be helpful to therapists in exposing them to multiple cultural perspectives, becoming aware of different philosophical and spiritual realities, and developing a more holistic outlook on treatment.

Techniques based on the universal perspective on psychotherapy are discussed in the context of the multicultural counseling and therapy theory. MCT provides a culture-centered element in traditional forms of intervention. Indeed, the different Eurocentric approaches to psychotherapy can be effectively employed when modified to be appropriate with multicultural populations. Following are some suggested steps in multicultural psychoterapy:

Role preparation and establishing rapport. To establish a working alliance, a therapist must be able to establish rapport with a client. The client must feel understood and respected. Some ethnic group members are responsive to emotional aspects of the interview process; for others “credibility” can be demonstrated through the identification of appropriate issues. For many ethnic minorities, therapy is a foreign process. To enhance the working relationship, it is helpful to explain what happens in therapy, the roles of the both the client and the therapist, and confidentiality. Determining the expectations of the clients, their understanding of the treatment process, their degree of psychological mindedness and difficulties they might have with the therapy is an important aspect of role preparation. The concept of “co-construction”—that solutions will be developed only with the input and help of the client is introduced. Explain that problems are often complex and can be influenced by family, social, and cultural factors, and that you work together to determine if these are areas that need to be addressed.

Assessment—incorporating contextual and environmental factors. A culture-centered assessment would begin with an exploration of issues that may be faced by members of ethnic minorities such as immigration or refugee experiences, difficulties at work or in school, language and housing problem, possible issues with discrimination or prejudice, and acculturation conflicts (Recent immigrants or even individuals from first and second generations often show a pattern in which the children acculturate more quickly than the parents, and this difference often leads to conflict within the family). Social and community supports should also be identified. The assessment allows one to determine the possible impact of environmental, cultural, and social issues on the presenting problem. If the therapist determines the problem is external in nature, the therapist must help the client not to internalize the problem. Instead, the therapist might assist the client with developing strategies to cope with the external issues.

Ethnic or cultural identity The cultural identify of both the therapist and client can affect both the problem definition and goals. Different identity development models have been developed for specific ethnic groups, but they all describe the process in which an individual moves from the host culture frame of reference to an acceptance of one's own cultural group. Determining the degree of ethnic identity of a particular client can help prevent stereotyping. Some clients will show little adherence to ethnicity and consider it unimportant whereas others may have a very strong ethnic identity that may influence how they perceive the presenting problem. Intervention strategies will depend on the stage of ethnic identity of the client. Those with a strong desire for assimilation into White society may reject attempts to explore ethnic variables. If the clinician determines that the presenting problem does not involve a rejection of the client's own ethnic identity, then mainstream psychotherapy approaches can be useful. At another stage of ethnic identity, the individual may become angry over issues of racism and oppression and respond with suspicion to the therapist. They may feel that therapy attempts to have them adjust to a “sick” society. Ethnic identity issues have to be identified to determine if this should be a focus of therapy.

Although controversial, a number of ethnic researchers and clinicians posited models of White Racial Identity Development that apply to EuroAmerican therapists. Hypothesized stages are: (a) conformity or the obliviousness and lack of awareness of racism. Success in life is seen to be dependent on effort and not race. Ethnic minorities are evaluated according to Euro American standards. The therapist professes to be “color blind” and does not question the relevance of applying therapy approaches to ethnic groups; (b) disintegration or the conflict produced by the beginning recognition of discrimination and prejudice against ethnic minorities. An individual at this stage may avoid contact with people of color; (c) Reintegration that involves resolving conflict by returning to beliefs of minority inferiority; (d) Pseudoindependence or the acknowledgement of societal biases and the recognition of White privilege. However, the individual may perpetuate racism by attempting to have minorities adjust to White standards; (e) immersion/ emersion that is marked by a personal focus on one's own biases and to directly combat racism and oppression; and (f) autonomy in which the individual accepts one's whiteness and is comfortable acknowledging and accepting ethnic differences.

Intake forms. Background information, history, description of the problem, mental status exam, and other means of gathering data should include a section determining whether the characteristics or behaviors are considered normative for the particular cultural group. If the clinician determines the problem may have cultural aspects, a determination has to be made if it applies to a particular individual. This would reduce the chances of stereotyping. When using DSM-IV-TR, it is especially important to do a thorough assessment of Axis IV (psychosocial and environmental problems) to eliminate the possibility that the presenting problems may actually be “other conditions that may be a focus of clinical attention” rather than a mental disorder. It is essential that the therapist remain aware of validity issues with different types of assessment and clinical judgments involving specific ethnic minorities. DSM-IV-TR warns that there may be a tendency to overdiagnose schizophrenia in certain ethnic groups. Behaviors considered normative in a specific ethnic group may be seen as pathological from another group's perspective. Asian Americans tend to score low on assertiveness and high on social anxiety. Rather than being considered negative attributes, these may represent the Asian values of modesty and group orientation. African Americans may show a “healthy paranoia” or suspiciousness resulting from experiences associated with oppression and racism.

Problem definition. Consider the clients’ perspective on problems. How did they arise and how are they affecting functioning? Are specific cultural factors involved? In interviewing an individual make certain information about family, friends, and possible cultural/environmental factors is also obtained. When working with a family, these areas are also explored along with the possibility of acculturation conflicts between the parents and children.

Goal definition. First, identify the different theoretical therapeutic techniques or processes used to attain goals. What assumptions underlie the techniques, and are they acceptable to members of other cultural groups? What kinds of modifications may have to be made or new techniques adopted? Second, the therapist should acquire knowledge of the experiences of ethnic minorities in the United States and issues involving oppression and discrimination. Many are still affected by their minority status and face conflicts over acculturation issues. There must be a willingness to acknowledge and address cultural and value differences with clients. Third, therapists should seek continuing education and consultation when working with ethnic minority populations and be willing to take on different roles such as advisor, advocate, and consultant.

Non-Western Cultures

Anxiety disorders can be seen across the world; they are not simply a Western phenomenon. A number of culture-bound syndromes, or disorders specific to a particular region, resemble DSM-IV-TR diagnoses, but often with a focus that more reflects culturally specific fears. Ataque de nervios, seen in Latin American and Latin Mediterranean cultures, is associated with a sense of being out of control, uncontrollable shouting, trembling, crying, heat in the chest rising to the head, and fainting or seizure-like episodes, and somewhat resembles panic disorder. Koro, found in south and east Asia, refers to extreme anxiety and panic regarding the penis (in men) or vulva and nipples (in women) retracting into the body and causing death. In Korea, shin-byung is characterized by excessive anxiety, dissociation, and somatic complaints (e.g., weakness, dizziness, insomnia, gastrointestinal problems) that are attributed to possession by ancestral spirits. Numerous other culture-bound syndromes exist as well.

Culture-Bound Syndromes

In addition to somatic expressions of distress, those working with diverse populations also need to be aware of and address culture-bound syndromes, some of which are included in Appendix I of the DSM-IV (American Psychiatric Association, 2000) and Appendix III (the Glossary of Cultural Concepts of Distress) in DSM-5 (American Psychiatric Association, 2013). Culture-bound syndromes have been defined as culture-specific idioms of distress that form recognized symptom patterns and have distinct clinical characteristics, symptom constellations, and social meanings (American Psychiatric Association, 2000; Levine & Gaw, 1995). Culture-bound symptoms have been documented in many different cultures within the US and around the world. They are commonly known as cultural manifestations of distress that tend to be more emic than etic.

Two of the most-researched culture-bound syndromes include ataque de nervios and neurasthenia. Ataque de nervios, often characterized as a form of panic attack among Latinos, is associated with feelings of being out of control due to stressful events that relate to family difficulties (American Psychiatric Association, 2000). Unlike traditional panic attacks, it is not associated with the hallmark symptoms of acute fear or apprehension. Other symptoms include trembling, uncontrollable shouting or crying, somatic feelings of heat rising through the chest to the head, dissociative experiences, seizure-like fainting episodes, and aggressive behavior (American Psychiatric Association, 2000). Recent evidence suggests that although a portion of those diagnosed with ataque de nervios also meet criteria for panic disorder, the majority of subjects with ataque de nervios do not, which suggests that ataque de nervios is a unique construct (Lewis-Fernandez et al., 2002). Key features that distinguish ataque de nervios from panic disorder include a more rapid onset of attack, being preceded by an upsetting event in one’s life, and greater fears of losing control, going crazy, depersonalization, sweating, and/or dizziness (Lewis-Fernandez et al., 2002; Liebowitz, Salmán, Jusino, & Garfinkel, 1994).

Neurasthenia (NT), or “shenjing shuairuo” (pronounced as shénjīngshuāiruò, “神經衰弱”) in Mandarin Chinese, is commonly referred to as a Chinese form of depression, and is characterized by two highly overlapping symptom domains including increased fatigue after mental effort (eg, poor concentration, increased distractibility, inefficient thinking) or physical weakness or exhaustion that is accompanied by physical pains and inability to relax (eg, headaches, dizziness, sleep difficulties, gastrointestinal problems, anhedonia, and bodily pain) (Organization, 1992). This diagnosis continues to be used in China and is included in the Chinese Classification of Mental Disorders, Second Edition-Revised and Third Edition (Chinese Medical Association and Nanjing Medical University, 1995; Chinese Psychiatric Society, 2001). However, it is considered to be a culture-bound syndrome (eg, a culture-specific emic) by the West (American Psychiatric Association, 2000, 2013).

Nevertheless, neurasthenia tends to be more highly prevalent than major depression in China, as well as among Chinese Americans in the US (Weissman et al., 1996; Zheng et al., 1997). There continues to be controversy about whether neurasthenia is merely major depression with a cultural label or whether it is a distinct diagnostic entity. For example, Kleinman (1982) found that 87% of psychiatric patients diagnosed with NT in a Chinese clinic could be differently diagnosed with major depression in a Western clinic. However, these results are likely to be biased because those seeking help in China do so as a last resort, and therefore are likely to have more severe symptoms. Greater clinical severity is associated with less variability in the expression of distress. Clinical populations are also less representative than the general population. In contrast, a recent epidemiological study of Chinese Americans in Los Angeles found that 78% of those diagnosed with neurasthenia did not meet criteria for major depression or an anxiety disorder, with the prevalence rate of neurasthenia being as high as that of major depression (Zheng et al., 1997). This study indicates that neurasthenia is a diagnostically distinct entity, and may be a more valid research study than Kleinman’s because it includes a randomly selected nonpsychiatric help-seeking population.

Many other culture-bound syndromes have also been documented (Levine & Gaw, 1995). Unfortunately, there is less empirical research to help us understand these syndromes, which affect people from all around the world. In regards to Asian heritage populations, a number of culture-bound disorders have been identified including, Amok among Malaysians (a frenzied dissociative state that affects groups), Shin-Byung among Koreans (anxiety, somatic complaints, dissociation, and possession), Dhat among Asian Indians (hypochondriasis and anxiety about loss of semen—also known as Shen-Kui in Chinese), Taijin Kyofusho among Japanese (similar to social phobia but focused on fear of embarrassing others with one’s body parts and odors), Qi-gong induced psychosis among the Chinese (psychotic episodes associated with misbalanced Qi or energy), Hwabyung among Koreans (an anger sickness associated with somatic symptoms, depression, and maltreatment of women), and a number of syndromes (eg, Koro) associated with fear of the penis shrinking into the body that are present in many different Asian, African, and some European heritage cultures (American Psychological Association, 1994; Levine & Gaw, 1995).

It is important to note that there is a clear link between cultural definitions of mental illness and how people express their problems. Even common disorders, such as eating disorders, can be misconstrued as culture-universal etics, rather than being culture-specific emics. Specifically, for many cultures around the world, eating disorders did not exist until the birth of mass media, globalization, and internationalization. Many international and developing countries simply did not value being thin, or there were economic reasons such as food shortages and poverty that would preclude the development of eating disorders. Therefore, eating disorders, such as anorexia nervosa and bulimia, could be seen as Western culture-bound syndromes “emics”—that rapidly spread through mass media and became culture-universal “etics” (Banks, 1992; Keel & Klump, 2003). This speaks to the pathoplasticity, or malleability and changing nature of psychiatric problems, as well as how they are expressed and influenced by culture.