Koro! (and other "culture-bound" diagnoses)

[Stagg737]

Was working on our consult service and had an interesting case of substance-induced vs. first-break schizophrenia as the primary diagnosis, but during one of the interviews the patient happened to mention having the belief that his penis had been gradually retracting into his body for the past year. Further questioning seemed to be pretty spot-on with Koro as a diagnosis, but my attendings were mixed on whether this was an appropriate diagnosis because the patient was white and the culture associated with Koro is SE Asian and Chinese.

I do understand some of the debates surrounding the culture-bound diagnoses (hit by the wind, Amok, etc), but Koro seems to be a very specific delusion with clearer symptoms (I'm hesitant to call them diagnostic criteria). I was interested if anyone had thoughts about making these diagnoses, specifically Koro, outside of the cultures which they are typically associated with. Is it legitimate to diagnose Koro in a white patient with no connection to Asian cultures? Is the vague "Other specified obsessive-compulsive and related disorder" more appropriate? Curious about thoughts from others on the subject.

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[calvnandhobbs68]

I was just talking about this subject with some of the attendings the other day. Delusions are by their very nature based on what we’re exposed to....not many people have delusions about things they’ve never heard of. If you’ve never been exposed to the concept of God, you probably can’t really have a delusion that you’re God or Jesus. If you don’t know who Michael Jackson was or who Drake is, you can’t really have a delusion you’ve been impregnated with their baby.

So I think this is just splitting hairs. Certain delusion are more present in certain cultures simply because of what you’re exposed to. I don’t think that means you can’t see that delusion outside that culture. It’s like a “cultural” risk factor rather than an ethnic one. For instance, Kawasaki Disease is a purely clinically diagnosed syndrome that is seen at a higher frequency in Asians (and there’s tons of debate about the so called “incomplete” Kawasaki). Doesn’t mean it can’t be diagnosed in other ethnic backgrounds.

Why would you diagnose an other obsessive compulsive disorder in this case? Seems to be a pretty clear delusion unless the guys penis really is shrinking a

 

[Mad Jack]

I was just talking about this subject with some of the attendings the other day. Delusions are by their very nature based on what we’re exposed to....not many people have delusions about things they’ve never heard of. If you’ve never been exposed to the concept of God, you probably can’t really have a delusion that you’re God or Jesus. If you don’t know who Michael Jackson was or who Drake is, you can’t really have a delusion you’ve been impregnated with their baby.

So I think this is just splitting hairs. Certain delusion are more present in certain cultures simply because of what you’re exposed to. I don’t think that means you can’t see that delusion outside that culture. It’s like a “cultural” risk factor rather than an ethnic one. For instance, Kawasaki Disease is a purely clinically diagnosed syndrome that is seen at a higher frequency in Asians (and there’s tons of debate about the so called “incomplete” Kawasaki). Doesn’t mean it can’t be diagnosed in other ethnic backgrounds.

Why would you diagnose an other obsessive compulsive disorder in this case? Seems to be a pretty clear delusion unless the guys penis really is shrinking a

Going to agree with this. Like, the reason it isn't present in the West is lack of exposure to the idea. With ideas becoming more diffuse through globalization, he might have heard of the condition and then started to fixate on it. Other possibility is that he has gained a lot of weight and he might have actually lost some perceivable size secondary to that. Definitely a specific delusion if the latter is not the case, but you might not be able to give it the cultural label typically associated (for the arbitrary reason that it has been assigned as a cultural label)

 

[WisNeuro]

Ataque De Nervios!

 

[pampiniformplexus]

Was working on our consult service and had an interesting case of substance-induced vs. first-break schizophrenia as the primary diagnosis, but during one of the interviews the patient happened to mention having the belief that his penis had been gradually retracting into his body for the past year. Further questioning seemed to be pretty spot-on with Koro as a diagnosis, but my attendings were mixed on whether this was an appropriate diagnosis because the patient was white and the culture associated with Koro is SE Asian and Chinese.

I do understand some of the debates surrounding the culture-bound diagnoses (hit by the wind, Amok, etc), but Koro seems to be a very specific delusion with clearer symptoms (I'm hesitant to call them diagnostic criteria). I was interested if anyone had thoughts about making these diagnoses, specifically Koro, outside of the cultures which they are typically associated with. Is it legitimate to diagnose Koro in a white patient with no connection to Asian cultures? Is the vague "Other specified obsessive-compulsive and related disorder" more appropriate? Curious about thoughts from others on the subject.

This is very interesting. However, I once had a patient who described erectile dysfunction as "retracting penis" -well it is true. They sometimes refer to this phenomenon as "coke-dick". Serotonin (MDMA
), adrenergic or dopaminergic system (cocaine, methamphetamine) can cause ED. Nicotine may impair the function of the endothelium. Opioids associated with hypopituitarism. Keep us posted! The case is very interesting!

 

[MacDonaldTriad]

The term culture bound syndromes would seem to infer that these are bound to certain cultures. Of course the other point is that most of the culture bound syndromes involve certain beliefs that Westerners would view as delusional, but perhaps the point is that if these exist within certain cultures, maybe they don't rise to the definition of psychosis. You are still left with the burden of decision to treat or not to treat. This doesn't change with Koro in a South East Asian or a white guy anyway.

 

[FatherPsychiatry]

Ataque De Nervios!

The bane of my neurology consults month

 

[SourceOfDenial]

Isn’t the whole DSM culture bound?

 

[splik]

The term "culture bound" has long been abandoned (by both the DSM and cultural psychiatrists) and instead the term culture-related is used. The reason for this because the concept so-called "culture bound" syndromes created what Laurence Kirmayer calls a "museum of exotica" that essentially fetishizes otherness through the Western gaze, avoids questions regarding the validity, reliability, and utility of such constructs, and obfuscates the reality that all psychopathology, where in form or content in culture-related.

As an aside, koro is not a delusional belief, as it is/was widely held belief in certain cultures to be an actual phenomena, one associated with mass hysteria, including the great koro epidemic of 1968.

 

[Stagg737]

The term "culture bound" has long been abandoned (by both the DSM and cultural psychiatrists) and instead the term culture-related is used. The reason for this because the concept so-called "culture bound" syndromes created what Laurence Kirmayer calls a "museum of exotica" that essentially fetishizes otherness through the Western gaze, avoids questions regarding the validity, reliability, and utility of such constructs, and obfuscates the reality that all psychopathology, where in form or content in culture-related.

As an aside, koro is not a delusional belief, as it is/was widely held belief in certain cultures to be an actual phenomena, one associated with mass hysteria, including the great koro epidemic of 1968.

This is a much more deftly worded response than what I had, so thank you for that. To the aside: would you consider a diagnosis of Koro in a caucasian individual with no connection to the cultures where it is typically seen to be valid? I'll describe further below, but he did display all of the typical features of the condition (other than being somewhat more chronic) and did not meet criteria for other disorders on the differential such as body-dysmorphic disorder.

Why would you diagnose an other obsessive compulsive disorder in this case? Seems to be a pretty clear delusion unless the guys penis really is shrinking a

Because Koro is actually listed as one of the 7 forms of "other obsessive-compulsive and related disorders" in the DSM V.

 

[splik]

This is a much more deftly worded response than what I had, so thank you for that. To the aside: would you consider a diagnosis of Koro in a caucasian individual with no connection to the cultures where it is typically seen to be valid? I'll describe further below, but he did display all of the typical features of the condition (other than being somewhat more chronic) and did not meet criteria for other disorders on the differential such as body-dysmorphic disorder.



Because Koro is actually listed as one of the 7 forms of "other obsessive-compulsive and related disorders" in the DSM V.

It;s important to distinguish between form and content. The important question is rather: is the patient hysterical, psychotic, obsessional, intoxicated or do they have a factitious disorder? That is your differential. Focusing on the content and not the form does not help you diagnostically.

 

[Stagg737]

It;s important to distinguish between form and content. The important question is rather: is the patient hysterical, psychotic, obsessional, intoxicated or do they have a factitious disorder? That is your differential. Focusing on the content and not the form does not help you diagnostically.

The Koro aspect of his condition was obsessional. Patient was admitted for psychosis, but per father he had made statements about his penis shrinking before he was psychotic and had at times expressed anxiety about it. It came out more easily during his hospitalization because he was extremely verbally disinhibited and would tell us about all of his bodily functions.

Per patient, the thought started after a urology appointment about a year prior (no urological problems found at that time) and he frequently had this thought that his penis would retract into him and eventually become a vagina. I did work through the form aspect quite a bit. Anxiety was present, but not to the point of panic attacks or hysteria. Did not appear to be part of his "psychosis" and was definitely not factitious. The focus on content was simply because the initial statement was highly suggestive of Koro, so I explored how consistent the obsession/delusion/ideation was with the symptoms of Koro that I was familiar with and could find through quick lit searches, which was pretty spot on.

 

[clausewitz2]

ARFID only seems to happen in a small number of very Westernized countries. It is clearly a culture-related disorder with a very narrow distribution. If someone from Indonesia who has never been outside of the country meets all the criteria for ARFID without any other apparent explanation, are you going to worry that you can't diagnose him with ARFID because he's not Western?

 

[Alemo]

The term "culture bound" has long been abandoned (by both the DSM and cultural psychiatrists) and instead the term culture-related is used. The reason for this because the concept so-called "culture bound" syndromes created what Laurence Kirmayer calls a "museum of exotica" that essentially fetishizes otherness through the Western gaze, avoids questions regarding the validity, reliability, and utility of such constructs, and obfuscates the reality that all psychopathology, where in form or content in culture-related.

As an aside, koro is not a delusional belief, as it is/was widely held belief in certain cultures to be an actual phenomena, one associated with mass hysteria, including the great koro epidemic of 1968.

I take issue with the idea that “all psychopathology is culture bound.” Yes there is regional variability (sometimes stark) in many diagnoses, but this could largely be due to flawed reports and lack of standardized testing/assessment. The general affective, psychotic, and anxious illnesses have been observed in all human populations (to my knowledge; see Kraepelin in the East Indies). I’d be interested to see if there are any genetic linkages across populations that correlate to disease prevalence.

obviously the epigenetic effects of one’s environment dictate to some degree phenotype. But psychiatric illness as a concept, although it manifests in various social/behavioral ways, is bound to genotype and neural development (again, to some degree).

 

[splik]

I take issue with the idea that “all psychopathology is culture bound.”

Did you even read my post? I specifically said psychopathology was NOT culture bound, but culturally-related.

 

[Alemo]

We are also not studying mental illness at the pathophysiological level like we would cardiomyopathy. It’s hard enough to make an intracultural comparison between normal and abnormal behavior, and in so doing perhaps diagnose a mental illness. Between cultures....you’re gonna need a good translator.
There are those who say Freud’s ideas on drives and the libido were not adequately expressed in the German to English translation.
On a related note there’s an interesting article in the most recent Schizophrenia Bulletin by Kendler that discusses “hermeneutics” and compares the analysis of the original descriptions of mental illness (like Kraepelin and Kaulbaum) to constitutional interpretation and the interpretation of Judie-Christian texts.

 

[Alemo]

Did you even read my post? I specifically said psychopathology was NOT culture bound, but culturally-related.

Well I guess I was looking for a definition of “related.”
It also depends on what the definition of “is” is.

 

[Mad Jack]

I take issue with the idea that “all psychopathology is culture bound.” Yes there is regional variability (sometimes stark) in many diagnoses, but this could largely be due to flawed reports and lack of standardized testing/assessment. The general affective, psychotic, and anxious illnesses have been observed in all human populations (to my knowledge; see Kraepelin in the East Indies). I’d be interested to see if there are any genetic linkages across populations that correlate to disease prevalence.

obviously the epigenetic effects of one’s environment dictate to some degree phenotype. But psychiatric illness as a concept, although it manifests in various social/behavioral ways, is bound to genotype and neural development (again, to some degree).

They manifest differently in different cultural contexts though. Somatic complaints predominating in depression in eastern cultures, the cultural and religious differences in psychosis presentations (atheists might hear the menacing FBI, Native Americans or South Asians benign spirits, Christians Satan or Jesus, etc), and the varying ways anxiety will be focused based upon cultural pressures and norms. Illness is universal, but shaped by experience.

 

[Stagg737]

ARFID only seems to happen in a small number of very Westernized countries. It is clearly a culture-related disorder with a very narrow distribution. If someone from Indonesia who has never been outside of the country meets all the criteria for ARFID without any other apparent explanation, are you going to worry that you can't diagnose him with ARFID because he's not Western?

I would not, and my response to my poll question would be "yes". However, when discussing with several attendings (in my program and community) there were mixed responses with some saying that Koro would be correct and others saying that one should not diagnose a "culture-bound" diagnosis outside of the culture where it is identified. Hence, the creation of this thread.

 

[clausewitz2]

I would not, and my response to my poll question would be "yes". However, when discussing with several attendings (in my program and community) there were mixed responses with some saying that Koro would be correct and others saying that one should not diagnose a "culture-bound" diagnosis outside of the culture where it is identified. Hence, the creation of this thread.

My point is that ARFID is clearly such a diagnosis. Arguably anorexia nervosa was until pretty recently. The fact that your attendings might have hesitation about culture-related syndromes when it's a diagnosis more typical of a foreign culture is about their attitudes re: foreign cultures, not a principled psychiatric stance. I am glad you do not share it!

 

[Crayola227]

This is very interesting. However, I once had a patient who described erectile dysfunction as "retracting penis" -well it is true. They sometimes refer to this phenomenon as "coke-dick". Serotonin (MDMA
), adrenergic or dopaminergic system (cocaine, methamphetamine) can cause ED. Nicotine may impair the function of the endothelium. Opioids associated with hypopituitarism. Keep us posted! The case is very interesting!

Acute caffeine withdrawal can do the same, as I've learned first hand. In the case of caffeine withdrawal induced ED, normal function usually returns in 2-4 weeks.

OTOH, if a patient has ED at baseline, they may find that they don't do as well. There is some evidence of caffeine giving improvement in ED.

TLDR
Caffeine may be good for your boner. Withdrawal may lead to temporary decline in function.