Mediation between the shamanistic model and the psychiatric model in a shamanistic climate: A viewpoint of medical anthropology

Abstract  It is suggested that any clinician working on the Miyako islands, Okinawa, Japan, be a mediator or a negotiator between two worlds, namely the shamanistic and the modern psychiatric ones. On these islands, to subscribe to either is possible only by ignoring conflicting clinical realities. The main point is to summarize the complementary practices of these two medical systems on these islands. Psychiatric illness attributed to kamidaari is introduced. The initiatory illness for seeing a shaman is called kamidaari or kamburi . From the viewpoint of medical anthropology, aspects of the treatment of such patients in a shamanistic 'climate' (which is called fudo in Japanese), will be reported. In the shamanistic fudo , it must be recognized that, at a critical moment, shamanistic epistemology and psychiatric epistemology penetrate each other, and they exist together in a clinical 'mesh'. Two epistemologies must join in a coalition to access, and build continuity into, psychiatric and shamanistic medical care. It is demonstrated that these two worlds almost merge in dialogue but do not fuse, and that clinical relations occur on the boundary between these two epistemologies. 'Climatic' specific therapeutic stances are introduced and are clinically illustrated.     

Research on culture-bound syndromes: new directions.

The unprecedented inclusion of culture-bound syndromes in DSM-IV provides the opportunity for highlighting the need to study such syndromes and the occasion for developing a research agenda to study them. The growing ethnic and cultural diversity of the U.S. population presents a challenge to the mental health field to develop truly cross-cultural approaches to mental health research and services. In this article, the authors provide a critique of previous analyses of the relationship between culture-bound syndromes and psychiatric diagnoses. They highlight the problems in previous classificatory exercises, which tend to focus on subsuming the culture-bound syndromes into psychiatric categories and fail to fully investigate these syndromes on their own terms. A detailed research program based on four key questions is presented both to understand culture-bound syndromes within their cultural context and to analyze the relationship between these syndromes and psychiatric disorders. Results of over a decade of research on ataques de nervios, a Latino-Caribbean cultural syndrome, are used to illustrate this research program. The four questions focus on the nature of the phenomenon, the social-cultural location of sufferers, the relationship of culture-bound syndromes to psychiatric disorders, and the social and psychiatric history of the syndrome in the life course of the sufferer.     

Koro--discussing a transcultural psychopathological phenomenon

Koro describes a psychopathological phenomenon mainly found in Asia. It is the syndrome of an assumption of male genital shrinking. This idea is rarely described in Western culture. Inspired by a current case report--a patient, suffering from schizophrenia described Koro-like symptoms--we will discuss Koro on the basis of a literature review in its transcultural psychiatric context.     

A cross-cultural study of the possession-trance in Singapore

Possession-trance is a common culture-bound syndrome in Singapore. The characteristic features as seen in 36 young men of the three different ethnic communities are described. At follow-up four to five years later, none of the 26 who could be contacted showed any evidence of mental illness. The psychopathology of the possession-trance is discussed.     

Is there a suicidality syndrome independent of specific major psychiatric disorder? Results of a split half multiple regression analysis

Biological findings such as low 5-HIAA levels in cerebrospinal fluid (CSF) in suicidal patients compared to non-suicidal patients independent of the type of psychiatric disorder indicate a broad basis for suicidality. It is therefore important to ask whether a suicidality syndrome can be delineated on a phenomenological level, and whether it is independent of specific major psychiatric disorders which are otherwise considered to be aetiologically different. This paper reports on a study of 2383 schizophrenic and 1920 depressive unselected patients with and without suicidality. They were assessed during the first 24 h after admission to a psychiatric in-patient facility using a comprehensive psychopathological assessment (AMDP system). Using multiple variance analysis and logistic regression analysis based on single symptoms, for both suicidal and non-suicidal patients it was shown that a suicidality syndrome independent of the underlying illness can be delineated. In schizophrenia as well as in major affective disorders it was found that hopelessness, ruminative thinking, social withdrawal and lack of activity are core symptoms of this suicidal syndrome. The finding of a suicidality syndrome, not associated with a specific major affective disorder, indicates the need to identify this syndrome, which should be seen as an independent dimension and diagnosed separately, and not regarded merely as a secondary symptom of major psychiatric disorders, particularly affective disorders.     

Four culture-bound psychiatric syndromes in India

This paper describes four culture-bound psychiatric syndromes seen in India. It highlights their phenomenology and briefly comments upon the socio-cultural correlates of such symptom constellations.     

Lycanthropy as a culture-bound syndrome: a case report and review of the literature

Lycanthropy is an unusual belief or delusion that one has been transformed into an animal, or behaviors or feelings suggestive of such a belief. We report a case of lycanthropic delusions of becoming a snake in a 47-year-old woman who suffered from a major depressive disorder with psychotic features. We also present a literature review of articles published on the subject in English or French since 1975 identified via a MedLine search using the terms "lycanthropy" or "werewolf." Many case reports have described lycanthropy as a delusional disorder occurring acutely in patients who think they suffer from a demonic possession as a punishment for their acts. In these cases, symptoms are generally rapidly reversible. Lycanthropy seems to be a nonspecific manifestation of many psychiatric diseases, most commonly major depressive disorder with psychotic features. It is largely influenced by the cultural environment of the patient so that the animal species frequently represents the patient's delusional representation of evil. Lycanthropy could be considered a culture-bound syndrome that occurs in association with Axis I, DSM-IV psychiatric pathology.     

Running Amok: A Modern Perspective on a Culture-Bound Syndrome

Running amok is considered a rare culture-bound syndrome by current psychiatric classification systems, but there is evidence that it occurs frequently in modern industrialized societies. The historical origins of running amok as a psychiatric condition are reviewed in this article, and its relevance to modern day episodes of violent behavior is discussed. Psychotic illnesses, personality disorders, and mood disorders are all possible causes of amok, and the identification and treatment of patients who are at risk for manifesting violent behavior are discussed.     

Dhat syndrome as a functional somatic syndrome: developing a sociosomatic model

Dhat syndrome is a widely recognized condition from the Indian subcontinent with fatigue and preoccupation with semen loss as the main presenting symptoms. This condition has been considered to be a culture-bound syndrome, but little is known about its illness characteristics and similarities with other conditions with medically unexplained symptoms. In this paper we review the current research on dhat syndrome, discuss its similarities and differences with other functional somatic syndromes, and propose an integrated model that incorporates both psychological and sociocultural factors. Under stress, persons predisposed to amplification of somatic symptoms and health anxiety may focus attention on physiological changes such as turbidity of urine and tiredness, and misattribute them to loss of semen in the light of widely prevalent health beliefs. This attribution may then be confirmed by traditional views as well as by local practitioners subscribing to similar beliefs. The clinical and research implications of understanding this condition as a functional somatic syndrome, the presentation of which is significantly modified by culture, are discussed.     

The ‘Dhat syndrome’ : a culturally determined symptom of depression?

The status of the ‘Dhat syndrome’ is called into question by the results of an epidemiological study of men attending general medical clinics in Lahore. The Dhat complaint was reported by 30% of men attending medical clinics, and to an equal extent by patients with ‘functional’ and ‘organic’ diagnoses. It was strongly associated with depressed mood, fatigue symptoms, and a DSM-III-R diagnosis of depression. It is argued that the Dhat complaint should be primarily regarded not as the focus of a culture-bound syndrome, but as a culturally determined symptom associated with depression.     

From peculiar psychiatric disorders through culture-bound syndromes to culture-related specific syndromes

This article reviews the historical evolution and progress of nosological concepts from exotic psychiatric disorders and culture-bound syndromes to culture-related specific syndromes. Approaches to classification and subgrouping these disorders are disccused and an argument offered for finding a place for culturally unique syndromes in the existing classification system. The characteristics of various syndromes are elaborated and suggestions are made for future research. Finally, emphasis is given to the need to be concerned with the impact of culture on every psychiatric disorder, not only culture-specific syndromes, to promote culturally competent care for every patient.     

Dhat syndrome: is it a distinct clinical entity?

Dhat syndrome is a culture-bound neurotic disorder seen in the Indian subcontinent. The disorder has recently been included in ICD-10. In the present study, illness behaviour of 50 dhat syndrome patients was studied using a Hindi version of Illness Behaviour Questionnaire (IBQ) and was compared with 50 controls. Sixty-six percent of dhat syndrome patients received unspecified diagnoses on DSM-III-R. Patients with dhat syndrome showed a distinct illness behaviour profile consisting of higher scores on IBQ factors of general hypochondriasis and affective discomfort and lower scores on denial compared with controls, suggesting that the disorder may be a distinct entity.     

Mental illness complicated by the santeria belief in spirit possession

Santeria, a religious system that blends African and Catholic beliefs, is practiced by many Cuban Americans. One aspect of this system is the belief in spirit possession. Basic santeria beliefs and rituals, including the fiesta santera (a gathering at which some participants may become possessed), are briefly described, and four cases in which the patients' belief in possession played a role in their mental illness are presented. The belief in possession can complicate the diagnosis and treatment of mental illness, but it should not be considered a culture-bound syndrome. Rather, it may be a nonspecific symptom of a variety of mental illnesses and should be evaluated in the context of the patient's overall belief system and ability to carry out usual activities.     

Physical morbidity in a psychiatric population in Nigeria

The rate of physical morbidity amongst 191 psychiatric in-patients in a Nigerian general hospital was found to be 27.2%. Older psychiatric patients were observed to be significantly more likely to suffer from physical morbidity. Infective processes constituted 57.7% of the physical health problems identified in the study population. Organ systems most frequently involved were the central nervous system (mainly as acute organic brain syndrome from septicaemia) (28.9%), cardiovascular/haematological (19.2%), and gastrointestinal (17.3%). Over 70% of physical disorders remained undiagnosed by the referring sources. It is emphasized that adequate attention should be paid to the physical status of psychiatric patients (both new and old cases) at all levels of health care. Collaborative work between medicine and psychiatry should also be encouraged in developing countries, and this should extend beyond clinical services and training (undergraduate and postgraduate) into the areas of evaluative research.     

Neurasthenia and chronic fatigue syndrome: the role of culture in the making of a diagnosis

Chronic fatigue syndrome is an increasingly popular diagnosis consisting of multiple psychiatric and somatic symptoms. It bears a striking resemblance to the nineteenth-century diagnosis of neurasthenia. Both disorders arose during periods characterized by a preoccupation with commerce and material success and major changes in the role of women. They illustrate the role of culture in the development of a new diagnosis that emphasizes a "medical" rather than "psychiatric" etiology. The authors argue that chronic fatigue syndrome will meet the same fate as neurasthenia--a decline in social value as it is demonstrated that the majority of its sufferers are experiencing primary psychiatric disorders or psychophysiological reactions and that the disorder is often a culturally sanctioned form of illness behavior.     

Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems

Psychiatric diagnosis and classification reflect the social and political context of an era and are embedded in it. In the last few decades, culture-bound syndromes reported in non-Western societies constituted the major focus of contention over the validity and universality of psychiatric diagnosis. In contemporary times, social, economic, and political factors, such as the hegemony of the DSM discourse, the managed care culture, pharmaceutical forces, and the global burden of disease study, have virtually made culture-bound syndromes 'disappear'. Once widely believed to be rare outside of the developed West, depression has rapidly become the master narrative of mental health worldwide. In the context of global mental health, the field of psychiatric classification must go beyond routine debates over categories. In order to address the growing discrepancy between needs and services, international cultural psychiatry must engage key social forces, such as psychiatric epidemiology, primary care psychiatry, integration of diagnostic systems, stigma, and advocacy.     

Interface between shamanism and psychiatry in Miyako Islands, Okinawa, Japan: a viewpoint from medical and psychiatric anthropology.

This study is the first report regarding the borderland between psychiatry and shamanism in Miyako Islands, Okinawa, Japan. Folk healing practices are still flourishing on the islands. Most mentally ill persons we examined admitted to having consulted shamans. Although there is a need to assess the positive and negative effects of shamanistic practices on Miyako Islands' health care system as a whole, this report indicates the urgent need to come to terms with the interaction between shamanism and psychiatry on a multidimensional level. We describe here psychotic illness attributed to kandaari. These cases underline the importance of understanding "the explanatory model" (Kleinman 1979) of people as regards the causes and the effective healing of illness. From the viewpoint of medical and psychiatric anthropology, aspects of the treatment of such patients in the biocultural context are described.     

Development of a scale to assess Hwa-Byung, a Korean culture-bound syndrome, using the Korean MMPI-2

This study documents the development of an MMPI-2 scale designed to assess features of the Korean culture-bound syndrome, Hwa-Byung (HB). An American research team and psychiatric practitioners in Korea created an 18-item HB scale via rational item selection and psycho-metric refinement. Principal components analysis of scale items revealed four components, reflecting content domains of general health, gastrointestinal symptoms, hopelessness, and anger. This four-component solution applied well to both Korean men and women, but not to an American sample. Although some findings were encouraging, future studies employing clinical samples are needed to provide further validation of this scale.