by Rahi Patel, MD; Amin Ashraf, BS; Nicholas Myers, BS; and Nita Bhatt, MD, MPH

Dr. Patel is with Beth Israel Deaconess Medical Center at Harvard Medical School in Boston, Massachusetts. Mr. Ashraf and Mr. Myers are with Wright State University Boonshoft School of Medicine in Dayton, Ohio. Dr. Bhatt is Associate Professor and Associate Clerkship Director at Wright State University Boonshoft School of Medicine in Dayton, Ohio.

Department Editor: Julie P. Gentile, MD, is Professor and Chair of the Department of Psychiatry at Wright State University in Dayton, Ohio.
Editor’s Note: The patient scenarios presented in this article are composite cases written to illustrate certain diagnostic characteristics and to instruct on treatment techniques. The composite cases are not real patients in treatment. Any resemblance to real patients is purely coincidental.

Abstract: Cultural concepts of distress, previously referred to as culture-bound syndromes, are psychiatric conditions influenced by cultural beliefs, history, and social norms. In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, these syndromes manifest as culturally specific expressions of psychosocial distress, though there is a lack of formal diagnostic criteria. This article explores three cultural concepts of distress, koro, Dhat, and latah syndromes, through fictional case vignettes to illustrate their clinical presentation, underlying psychiatric associations, and potential management strategies. Each syndrome and case contain unique factors of psychosocial distress and highlights necessary considerations with avenues for improved patient care.  Keywords: Cultural concepts of distress, culture-bound syndromes, cultural beliefs, Koro, Dhat, latah syndrome, psychosocial distress

Previously known as culture-bound syndromes, cultural concepts of distress are conditions recognized in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) as expressions of psychological syndromes that vary in different cultures.¹ Cultures can influence psychiatric distress based on history, folklore, or social stigma, for example. These syndromes can pose significant psychosocial distress to a patient and can contribute to a variety of health consequences, including the potential for physical harm. While cultural concepts of distress are recognized in the DSM-5 as psychiatric problems, they continue to lack formal diagnostic criteria. Such concepts of distress include koro, Dhat, and latah syndromes. While there are several other related syndromes, these three are discussed further using fictional case vignettes.

Clinical Vignette 1

Rizu was a 39-year-old Bangladeshi man who presented as a follow-up in the outpatient psychiatric clinic. He had a complex past psychiatric history and had previously experienced homelessness. He was diagnosed with severe generalized anxiety disorder (GAD) for which he was prescribed daily fluoxetine 40mg. He endorsed taking his medication, but stated, “I still don’t feel right.”

Doctor: How are you today, Rizu?

Rizu: (sighs, looking down) I don’t know, doctor. I’m taking the medication as you tell me to, but I just don’t feel right. Something is wrong and my life is over, and for some reason, I’m not able to carry out the things to fix it without your help!

Doctor: (nodding sympathetically) I hear you, Rizu. Tell me more. What about the medication worries you? What are the things that are wrong and you are trying to fix?

Rizu: (hesitantly at first, and then rapidly) Well, my wife is asking for a divorce, and I haven’t seen my daughter in months since we’ve been separated. A divorce is too much, and I’ll have no purpose, and I can’t do anything about it without your help. I’m sure my wife is leaving me because my penis is shrinking. It’s been going slowly inside of me, I can tell. If this keeps up, I won’t even have the energy to carry out any responsibilities, and I’ll for sure be a goner. Back home this happens to some men, and they get so sick they’ll die.

Doctor: Rizu, I’m so sorry you have been feeling this way. You have mentioned to me the separation and situation with your daughter before, though this is the first time you’ve told me it’s because your penis is shrinking. Have you asked your medical doctors about this?

Rizu: Yes! And they do an inspection and lab work and tell me everything is normal. Doctor, I can tell I’m going to die because there’s not much more it can retract in. You have to help me because no one else is. I went to check with a doctor again yesterday, and he told me everything was normal. This has been happening to me ever since before my daughter was born, but this time they told me to talk to you about it.

Doctor: Rizu, what you’re describing sounds overwhelming! I took the time to review your labs along with all the workup they’ve completed. They checked and documented a lot. From my point of view, everything looks perfectly normal. You even had a daughter after you first noticed this.

Rizu: Yeah… I guess it couldn’t have been that bad if I had a daughter. It’s getting worse though, I swear. What if it’s the medications?

Doctor: Rizu, what you’re describing to me seems like it’s making you more anxious. I also want you to know that your medications don’t have any side effects similar to what you are describing to me. They’ve helped you right?

Rizu: Yeah… I do feel less anxious. What if I got surgery to fix this?

After some discussion, Rizu decided to continue taking his anxiety medication, though he was hesitant. He endorsed that he would be willing to try cognitive behavioral therapy (CBT) as recommended by his doctor, though mentioned that he would be seeking out a plastic surgeon to help with this matter. While Rizu initially discussed his divorce and other family circumstances, the real nature of this visit fit a culturally bound phenomenon known as koro syndrome. Even after the explanation, Rizu continued to insist on the need for enhancement and mentioned thoughts of fixing the problem himself, though acknowledged that he felt more anxious due to these symptoms. Rizu continued to follow up in the clinic and repeatedly echoed worries about his anti-anxiety medication causing his penis to shrink, though continued to take his medication. He never followed through with his CBT referral.

Practice Point: Avoiding patient harm with the use of pharmacotherapy and psychotherapy in patients with Koro syndrome

Koro is a cultural concept of distress often seen in East and Southeast Asia that involves the intense fear that one’s genital organs are retracting into the body, which will ultimately lead to death.² Koro presents more commonly in male patients with concerns of one’s penis shrinking into their body. In female patients, this presentation includes concerns of a retracting nipple, entire breast, or vulva. Cases of koro have been seen to present in part with anxiety, depression, and psychosis.² Koro can be classified into two subtypes: an endemic culture-related subtype and a sporadic noncultural subtype.² Notably, the sporadic subtype involves the belief one’s genitals are shrinking but does not result in death.³

Although there are no specific diagnostic criteria for endemic koro outlined in the DSM-5, a diagnosis of endemic koro can be made by meeting three criteria:³

The perception of acute retraction of genitals, such as the penis, breast, or vulva.

Acute panic-like reaction to the perception involving psychological and somatic manifestations.

Acute fear of danger, including death.

Distress related to koro syndrome can be significant. There are several psychiatric risk factors for koro, including cultural beliefs, feelings of inadequate masculinity, anxiety, major depressive disorder, schizophrenia, and obsessive-compulsive disorder (OCD).² As such, careful assessment is important, particularly in individuals with underlying psychiatric illness. Physical risk factors, such as genital pain, have been associated with koro.⁴ As seen with Rizu, koro can present with acute fear or danger (including fear of death) related to the perception of genital retraction. Additionally, Rizu was undergoing management of severe GAD, a common comorbid diagnosis.

Studied treatments that are effective for koro are limited to several case studies. Overall management can involve both medical and psychological interventions. Medications targeting a patient’s underlying psychiatric disorder in combination with supportive psychotherapy have been found to improve symptoms of koro.² One study demonstrated that the use of trimipramine 150mg daily in combination with psychotherapy improved symptoms of koro.⁵ In another case study, olanzapine 30mg daily plus supportive psychotherapy to address the patient’s guilt related to koro was utilized, treating both the patient’s underlying psychiatric disorder and koro symptoms.⁶

Reports have been noted of severe distress and self-attempts to reverse penile shrinkage in patients with koro syndrome. Depression, attempts or thoughts of suicide, and physical injury induced by self or others, for example, due to the application of caustic lotion, mechanical penile retraction, or introduction of metal wiring into the penile urethra, have been reported.⁷

Previous case studies demonstrated the effectiveness of reducing symptoms of koro by addressing underlying psychiatric disorders. Left untreated, patients might resort to self-treatment methods, which could result in significant physical harm. Therefore, emphasis on pharmacotherapy and psychotherapy might ultimately lead to reduced patient harm with the preservation of cognitive and physical health.

Clinical pearls

• Koro syndrome is often associated with underlying psychiatric conditions, including anxiety, depression, delusional disorder, and schizophrenia.
• Several case reports have shown that targeting underlying psychiatric disorders might alleviate symptoms of koro.
• Possible therapies include selective serotonin reuptake inhibitors (SSRIs) and antipsychotic therapies, with the addition of psychotherapy.
• Emphasis on treating underlying psychiatric illness with the use of SSRIs, antipsychotics, or psychotherapy might lead to avoidance of potential physical harm.

Clinical Vignette 2

Simi was a 24-year-old male patient who presented with concerns of fatigue, weakness, and feelings of worthlessness over the past several months. He reported muscle weakness and occasional pains occurring in random points on his body. He also endorsed increased worry, difficulty concentrating, irritability, and insomnia.

Simi was rubbing his hands together and bouncing his leg as the physician entered the room. He appeared anxious as the encounter began.

Simi: Doctor, I’m not feeling well.

Doctor: I’m sorry to hear that, Simi. Tell me about what’s going on.

Simi: Well, I constantly feel weak, have no energy, and have pains around my body. I think I’m losing something important to my strength.

Doctor: That sounds distressing. Have you noticed anything that makes this better or worse?

Simi: I think it’s because I’m losing semen.

Doctor: Tell me more about that.

Simi: I notice after I masturbate or ejaculate in my sleep my symptoms worsen. I notice my urine is cloudy sometimes. I think I’m losing semen in my urine too. This is really bothering me, and I am constantly worrying about my health. My girlfriend won’t want to marry me if I can’t have any kids.

Simi stated that his symptoms are often exacerbated by nocturnal emission or masturbation. As a result, he avoided sexual activity and frequently checked his undergarments for semen loss because he felt that was contributing to his symptoms. He endorsed excessive worry about losing his youthfulness, stating he was “aging faster than others because he was losing too much semen.”

Upon further questioning, it was revealed that Simi had a history of major depressive disorder and was not currently on any pharmacotherapy. Simi was reassured that it was unlikely that he was losing semen in his urine and that ejaculation was unrelated to his symptoms. Simi continued to appear anxious but was willing to explore treatment options.

Practice Point: Symptomatic Treatment of Comorbidities in Dhat Syndrome

Dhat syndrome is another established cultural concept of distress, primarily affecting individuals of the Indian subcontinent,⁸ though it has been reported in other areas as well.⁹ This syndrome is characterized by significant anxiety over the perceived loss of one’s semen, either through ejaculation, nocturnal emission, or other means.⁸ Dhat syndrome has also appeared in female individuals. This occurs when the female patient believes it is harmful to their health when they pass white discharge from their vagina that is not related to any pathologic process.¹⁰

According to the tenth version of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), diagnostic criteria for Dhat syndrome include passage of whitish discharge in urine, causing undue anxiety about irreversible semen loss.⁸ Established risk factors include younger age, male sex, rural upbringing, being unmarried or recently married, being of low-to-middle socioeconomic status, and having a conservative approach to sex.⁸

Patients with Dhat syndrome typically present in distress about their nocturnal emissions. Simi had a history of depression, somatic symptoms of fatigue, and seemingly random aches and pains throughout his body. Mental illness can carry stigma in South Asian communities and somatic symptoms may be more socially acceptable to report. It is important to understand the cultural meaning of the patient’s symptoms and to examine and treat each patient accordingly. Understanding the cultural meaning of these symptoms is important to avoid putting the patient through unnecessary urological testing and helps guide empathic care.

Current treatments for Dhat are limited due to a lack of research; however, treating the comorbidities and similar symptoms of depression with methods such as SSRIs/ serotonin-norepinephrine reuptake inhibitors (SNRIs) or CBT has yielded some promising results.⁸ Depressive symptoms are often related to the perceived deficiency in regard to childbearing and social isolation. Reassurance  and CBT are also recommended.⁸

Comorbidities are common with Dhat syndrome; clinicians should observe for signs of depression, anxiety neurosis, and somatoform and hypochondriacal disorders, which have co-occurred at rates of 40 to 66 percent, 21 to 38 percent, and 40 percent, respectively.¹¹ Dhat syndrome can also be confused as a prodromal symptom of psychotic illness, in which it is considered an initial delusion where the patient will begin to develop other symptoms of schizophrenia such as disorganized speech, hallucinations, and negative symptoms.¹²

Clinical pearls

Comorbidities associated with Dhat include depression, anxiety neurosis, somatoform disorders, hypochondriacal disorders, and schizophrenia.

Research on treatment is limited but focuses on comorbidities, and symptomatic treatments have shown to be effective.

Treating depression with SSRIs and CBT are the best treatment options according to the limited research.

Clinical Vignette 3

Ani was a 42-year-old woman who recently immigrated from a rural Indonesian village. She was brought in by her younger sister due to “strange behavior” that had worsened since the move, though this behavior had been present for several years. Previously, Ani worked as a street vendor selling fruit; she had become increasingly “jumpy” and “easily controlled,” by others.

When the physician entered the room, Ani appeared hesitant and avoided all eye contact. While greeting the patient, the doctor had deliberately dropped the clipboard onto his desk.

Ani: (flinching, gasping loudly, and then laughing nervously) I’m sorry, I—I didn’t mean to do that.

Doctor: That’s okay! Does this happen often?

Ani: (nods rapidly) Yes. If someone calls my name suddenly, or if I hear a loud noise, even if I’m just tapped on the shoulder. I can’t help it, and I try so hard.

Sister: Doctor, it’s even worse than that. Sometimes, when someone is talking to her, she just repeats words back. Other times, she’ll just listen to what someone else says. Yesterday even, someone on the street shouted “Jump!” and Ani actually tried to!

Doctor: (looking at Ani) Is this true? Do you feel like you have no control when people tell you to do something?

Ani: (looking away, embarrassed) Sometimes if people tell me to do things, I do it before I even think. My body moves before my mind even processes what happened.

Doctor: Does it only happen when you’re startled?

Ani: Mostly, but sometimes even when I’m not scared.

Sister: Doctor, in Indonesia, people used to scare her on purpose and laugh at her.

After further questioning, Ani revealed that this began in her late 20s, shortly after the unexpected death of her husband. At first, only the startled response was present, though it was sometimes accompanied by grasping and jerking movements. Over the years, it had escalated to include echolalia and echopraxia. She denied suicidal ideations and admitted to avoiding social situations due to fear of being ridiculed.

The physician then explained to Ani that her symptoms aligned with latah syndrome, a cultural concept of distress commonly observed in Southeast Asia, which is characterized by the symptoms she was experiencing. Ani was reassured that this was not a sign of severe illness; rather, this stemmed from her body reacting to stress and was more common in individuals who had been through trauma.

Practice Point: Trauma-informed care for cultural concepts of distress

Latah is a culture-specific neuropsychiatric startle syndrome predominantly observed in Southeast Asia, particularly in Indonesia and Malaysia. It is characterized by an exaggerated startle response, often accompanied by involuntary behavior such as echolalia (repeating others’ words), echopraxia (mimicking others’ actions), coprolalia (involuntary swearing), and forced obedience (compulsively following commands).¹³ These responses are typically triggered by sudden stimuli, such as loud noises or unexpected touch.

The pathophysiology of latah is not well understood; it is believed to involve psychological and neurological components. Patients with latah exhibit increased startle reflexes, divided into an early motor startle reflex and a later orienting reflex, which is influenced by psychological factors.^13,14 As this syndrome is associated with significant psychosocial distress, including trauma, further research is warranted to better understand its mechanisms. In cases like Ani’s, where the trauma of an unexpected loss is a key factor, it is reasonable to approach latah through a trauma-informed lens.

To date, there have been no formal studies on the treatment of culture-specific startle syndromes. Pharmacotherapy includes benzodiazepines, but this has not been formally studied. Nonpharmacologic treatments have included habit reversal training, desensitization through exposure-based treatments, and operant training.¹⁴ A combination of CBT and psychodynamic psychotherapy have been reported previously to improve the startle stimuli; this patient case also exhibited an increase in self-esteem during daily tasks.¹⁵ While the overall health consequences are minimal, treatment is generally unsuccessful.

A potential avenue for treatment could be trauma-informed care (TIC). TIC emphasizes understanding how traumatic experiences shape psychosocial behaviors and responses.¹⁶ Physicians should attempt to address the psychosocial distress that latah can cause while providing a safe space for patients to explore these traumatic experiences without fear of judgment or dismissal.

Clinical Pearls

• Latah is a culture-related startle syndrome most commonly observed in Southeast Asia; it is characterized by echolalia, echopraxia, coprolalia, and forced obedience.
• Its pathophysiology is not fully understood.
• While health consequences are minimal, patients can experience social isolation and fear of ridicule, which can exacerbate symptomatology.
• Treatments have largely been unsuccessful, though there have been some successes with nonpharmacologic therapies.
• Latah is associated with traumatic experiences, such that TIC might provide an avenue for treatment.
• Empathetic, nonjudgmental communication for patients to express their experiences with trauma might reduce the distress caused by Latah.
  

Conclusion

A deeper understanding of cultural concepts of distress is essential for accurate diagnosis and management due to the potential risks they pose to patients. By integrating this knowledge into clinical practice, treatment strategies can be developed to enhance quality of life and reduce psychosocial or physical harm. Clear evidence on optimal treatment approaches is lacking and will likely remain limited. Approaches to treatment based on existing knowledge may guide care. Addressing the common underlying themes across these syndromes, such as anxiety, stigma, and cultural beliefs, can lead to more effective interventions and ultimately improve patient outcomes.

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