A sociocultural study of koro epidemics in Guangdong, China

Koro: a socially-transmitted delusional belief

INTRODUCTION

Koro is a delusion whereby a man believes his penis is shrinking into his abdomen and this may result in his death. This socially-transmitted non-neuropsychological delusional belief occurs (in epidemic form) in South-East and South Asia. We investigated whether the two-factor theory of delusion could be applied to epidemic Koro.

METHODS

We scrutinised the literature on epidemic Koro to isolate features relevant to the two questions that must be answered to provide a two-factor account: What could initially prompt the Koro delusional hypothesis? Why is this hypothesis adopted as a belief?

RESULTS

We concluded that the Koro hypothesis is usually prompted by the surprising observation of actual penis shrinkage-but only if the man has access to background beliefs about Koro. Whether the hypothesis is then adopted as a belief will depend on individual factors such as prior belief in the Koro concept or limited formal education and sociocultural factors such as deference to culture, to media, or to rumours spread by word of mouth. Social transmission can influence how the first factor works and how the second factor works.

CONCLUSION

The two-factor theory of delusion can be applied to a socially-transmitted delusion that occurs in epidemic form.

The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine

INTRODUCTION

The "lost penis syndrome" (LPS) is a term often used in non-clinical settings to describe the subjective perception of the loss of cutaneous and proprioceptive feelings of the male organ during vaginal penetration. Although deserving clinical attention, this syndrome did not receive any consideration in the medical literature. Notwithstanding, it represents a relatively unexceptional condition among patients in sexual medicine clinics, and it is often reported together with other sexual dysfunctions, especially delayed ejaculation, anejaculation, male anorgasmia and inability to maintain a full erection.

OBJECTIVES

To draft a new conceptual characterization of the LPS, defined as a lack of penile somesthetic sensations during sexual penetration due to various causes and leading to several sexual consequences in both partners.

METHODS

Based on an extensive literature review and physiological assumptions, the mechanisms contributing to friction during penovaginal intercourse, and their correlation to LPS, have been explored, as well as other nonanatomical factors possibly contributing to the loss of penile sensations.

RESULTS

Efficient penile erection and sensitivity, optimal vaginal lubrication and trophism contribute to penovaginal friction. Whenever one of these processes does not occur, loss of penile sensation defined as LPS can occur. Sociocultural, psychopathological and age-related (ie, couplepause) factors are also implicated in the etiology. Four types of LPS emerged from the literature review: anatomical and/or functional, behavioral, psychopathological and iatrogenic. According to the subtype, a wide variety of treatments can be employed, including PDE5i, testosterone replacement therapy and vaginal cosmetic surgery, as well as targeted therapy for concomitant sexual comorbidity.

CONCLUSION

We held up the mirror on LPS as a clinically existing multifactorial entity and provided medical features and hypotheses contributing to or causing the occurrence of LPS. In the light of a sociocultural and scientific perspective, we proposed a description and categorization of this syndrome hypothesizing its usefulness in daily clinical practice. Colonnello E, Limoncin E, Ciocca G, et al. The Lost Penis Syndrome: A New Clinical Entity in Sexual Medicine. Sex Med Rev 2021;XX:XXX-XXX.

Classical Koro and Koro-Like Symptoms: Illustration from Canada

Koro syndrome has been colorfully described as a pathological distortion of one’s body image of the genital organ. In Koro, body image dysphoria is characterized by severe anxiety related to the delusional idea that one’s genitals will shrink and retract into one’s abdomen, eventually leading to death. This syndrome was first reported in South East Asia, where endemics have been described, but it has also sporadically occurred globally. We present a systematic literature review on Koro syndrome and report 7 cases from Canada. A search review with PubMed and Google Scholar resulted in 504 entries. Sixty-seven manuscripts were eventually selected following a thorough elimination process. The resultant literature underscored the cultural diversity that underlay the reported cases. Various aspects of Koro have been examined (eg, etiological, clinical, diagnostic, and cultural aspects). It has stimulated substantial scholarly debate, discussions, correspondences, and arguments from anthropological, psychiatric, psychological, and biological perspectives. In our series, it seems that Koro could have been misattributed here. The primary concern was not with penile retraction of the cases. To our knowledge, this is the first time that a series of cases is documented from North America where the syndrome is often ignored. We highlight the potential differences between the classical Koro syndrome and a collection of beliefs related to the perception or delusion of penile retraction in other codable psychiatric disorders, Koro-like syndrome. Understanding Koro syndrome beyond geographic boundaries is in line with our collected case reports of Koro from outside Asia.

Clinical course and treatment outcome of Koro: A follow up study from a Koro epidemic reported from West Bengal, India

BACKGROUND

Koro, as a culture bound syndrome is predominantly reported from Asian countries. There is dearth of well-designed research focussing on course and outcome of Koro.

METHOD

In the index study, 64 consecutive consenting patients with symptoms of Koro reported in different disciplines of a tertiary care Government Hospital of West Bengal were recruited over a period of 3 months. They were treated by standard treatment protocol and followed up for next 3 months. Data was collected on clinical course and treatment outcome by a pretested semi-structured proforma, specially developed for this study.

RESULTS

A typical subject was a young single male, educated up to primary standard, agricultural worker by occupation and belonged to Hindu rural joint family. Among the whole sample 23% were female. Majority were referred from either private doctors or hospitals or government hospitals and reported first at non-psychiatric OPD. Dropout and recovery rates were 28% (male 33%, female 13%) and 89% (male 89%, female 92%) respectively. 20%, 75%, 9%, 31%, 19% of patients needed indoor admission, oral anxiolytics, injectable tranquilizers, specific pharmacological and psychosocial treatment, supportive medical treatment respectively. There was a subtle difference in course and treatment outcome noted between the genders. A new modality of psycho-sexual intervention 'sex education in vivo' was applied on patients of Koro with favourable result.

CONCLUSION

Female counterpart represented a significant proportion. Overall improved trend of utilizing medical care facilities was observed. But sceptical attitude towards Psychiatric treatment is prevailing. An overall good treatment outcome was noted among the Koro victims.

Koro in Females: An Analysis of 48 Cases

Koro (genital retraction syndrome) is a culture-linked psychogenic reactive state. In females, the cardinal symptom is the perception of retraction or shrinkage of nipple or breast mass into the chest cavity or of labia into the abdomen with acute fear of either imminent death or sexual invalidism. This paper is the first attempt in the world literature to explore the detailed clinical characteristics of koro in 48 females drawn from an epidemic in India.

Epidemic of Koro in North East India: an observational cross-sectional study

OBJECTIVE

Koro is a culture bound syndrome, endemic in South-East Asia. The present study attempts to correlate the socio-cultural and demographic variables of the patients with the occurrence of the Koro and the differences in presentation between the classical features of the Koro and the actual presentation of the disease that has been observed in the present study.

METHOD

A cross-sectional observational study was performed and data collected during the period was compared, analyzed and studied. A total number of 70 patients who presented to the Department of Psychiatry with symptoms of Koro over the period of 5 days were taken into the study.

RESULTS

Most of the patients were, young, unmarried males belonging to a lower socioeconomic status. Most of these patients suffered the attacks in the evening mostly while at home. It was common in migrant and migrant lineage. Media had a major role to spread this epidemic.

CONCLUSIONS

Koro epidemics are considered to be the result of panic that spread following the occurrence of symptoms in one or more individuals within the same geographical zone. While the issues concerning phenomenology, diagnosis and nosology of Koro are still being discussed, it is apparent that Koro which presents as an acute anxiety state is treatment responsive and has good prognosis.

SEXUAL MEDICINE HISTORY: Koro—The Psychological Disappearance of the Penis

The aim of this article is to present a summarizing overview on ethnomedical aspects of koro (in Chinese called suo-yang), the panic anxiety state in which affected males believe that the penis is shrinking and/or retracting, and perhaps disappearing. While reduction of penile volume occurs physiologically due to vasoconstriction in cold temperature and intense anxiety, it is believed in certain cultures that genital shrinking leads to impotence and sterility, and eventually to death. Traditional Chinese medicine treats suo-yang, the reduction of the male principle yang, as a dangerous disturbance of the life-sustaining yin-yang equilibrium of the organism. Koro has therefore been held to be a Chinese "culture-bound" condition. However , the koro phenomenon is also known among diverse ethnic and religious groups in Asia and Africa, typically in cultures in which reproductive ability is a major determinant of a young person's worth. Koro epidemics of panic anxiety due to widespread fears of losing one's genitals, procreative ability, and even one's life, are triggered by rumors of genital disappearance supposedly caused in China by female fox spirits, in Singapore and Thailand by mass poisoning, and in Africa by sorcery, usually in the context of socioeconomic or political tension. Today, in contemporary Western societies, ideas of genital disappearance are not culturally endorsed. But historically, it should be remembered that in the late Middle Ages in Europe, a man could lose his membrum virile through magical attacks by witches. The conclusion is that the psychological disappearance of the penis is a universal syndrome that was described recently in Asia and Africa and already in Medieval Europe.

A conceptual history of Koro

Koro is a culture-bound syndrome characterized by a fear that the genitals or breasts will retract into the body and cause death. Here we consider the history of ideas about Koro, from early concepts in traditional Chinese medicine (TCM) to contemporary ideas from medicine and sociology. This conceptual history reveals important issues about the classification (nosology) of Koro. In doing so, it demonstrates the need to integrate standardized phenomenological criteria with etiological models in order to capture the important features of complex behavioral disorders in the cross-cultural setting.

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.

[The syndrome of genital retraction from a transcultural psychiatric point of view. Chinese suo yang, Indonesian koro and non-Asian forms (koro-like symptoms)]

The present article reviews the syndrome of genital retraction (SGR) from the perspective of transcultural psychiatry. It is best known as a culture-bound syndrome in Asia, e. g. koro in Indonesia or suo yang in Southern China, where it can be also observed in so-called epidemics. The syndrome is characterised by the sensation that the genitals are shrinking and being pulled back into the abdomen; this perception is associated with fear of death, because the subjects expect to die as soon as the genital has disappeared completely. Particularly in the case of suo yang, the involvement of local traditional concepts of illness can be established. In the Western world, however, SGR is observed only in single cases. The symptoms are less dramatic and do not show a particular cultural context. This form of SGR is called "koro-like" (koro-like symptoms, KLS). In contrast to the Asian form, KLS are not observed in healthy subjects, but as an unspecific syndrome related to other neuropsychiatric illnesses. In this review, we compare both forms of the SGR in terms of symptoms, cultural aspects and therapeutic strategies.

[Koro-like symptoms in a recurrent depressive disorder]

We report the case of a German male with a major depressive episode who also suffered from the terrifying perception that his penis was shrinking. These so-called koro-like symptoms (KLS) had also been present in earlier depressive episodes and subsided in the symptom-free interval of the recurrent depressive disorder. Under sufficient antidepressant medication with venlafaxine and lithium not only KLS but also the depressive symptoms remitted. The course of illness provides further evidence that KLS are not a distinct clinical entity in Western countries, but represent a concomitant syndrome that requires treatment of the underlying illness.

Culture-bound syndromes: the story of dhat syndrome

BACKGROUND

Culture-bound syndrome is a term used to describe the uniqueness of some syndromes in specific cultures. Dhat (semen-loss anxiety) has been considered to be an exotic 'neurosis of the Orient'.

AIMS

To ascertain the presence of similar symptoms and syndromes in different cultures and historical settings.

METHOD

Electronic and manual literature searches were used to gather information on the existence and description of semen-loss anxiety in different cultures and settings.

RESULTS

Most of the empirical studies on dhat syndrome have emerged from Asia, whereas its concepts have been described historically in other cultures, including Britain, the USA and Australia. The different sources indicate the universality of symptoms and global prevalence of this condition, despite its image as a 'neurosis of the Orient'.

CONCLUSIONS

It appears that dhat (semen-loss anxiety) is not as culture-bound as previously thought. We propose that the concept of culture-bound syndromes should be modified in line with DSM-IV recommendations.

Assessment of psychopathology across and within cultures: issues and findings

Research based information on the impact of culture on psychopathology is reviewed, with particular reference to depression, somatization, schizophrenia, anxiety, and dissociation. A number of worldwide constants in the incidence and mode of expression of psychological disorders are identified, especially in relation to schizophrenia and depression. The scope of variation of psychopathological manifestations across cultures is impressive. Two tasks for future investigations involve the determination of the generic relationship between psychological disturbance and culture and the specification of links between cultural characteristics and psychopathology. To this end, hypotheses are advanced pertaining to the cultural dimensions investigated by Hofstede and their possible reflection in psychiatric symptomatology. It is concluded that the interrelationship of culture and psychopathology should be studied in context and that observer, institution, and community variables should be investigated together with the person's experience of distress and disability.

Koro: a case in an Eastern European asylum seeker in Ireland

Koro is characterised as a perception that one's genital organs are shrinking and will eventually recede into the abdomen. It was initially described in South East Asia as a culture bound syndrome but this syndrome has recently been recognised in a non-culture bound context A case is described of a depressed Eastern European asylum seeker with koro like symptoms. All symptoms resolved completely with fluoxetine treatment The relevant literature to the case is reviewed, in relation to onset, symptoms and treatment of this rare syndrome. In addition comparison is made with previous reports of the non-culture bound variant.

A critical review of Chinese Koro

Koro is generally considered a culture-bound psychiatric syndrome, the dominant feature of which is anxiety or dissociation. A close examination of koro epidemics in China, where koro cases appear to be more frequent than other parts of the world, shows that koro has a sociocultural component which has not been sufficiently taken into account in previous formulations. This article analyzes koro in the natural environment in which it appears and dispels the notion of koro being individual psychopathology. Koro, at least the way it is manifested in China, is a social malady maintained by cultural beliefs which affect the whole community and not just those diagnosed with it. Further directions for research into the subject are discussed.

The definition and classification of Koro

Attempts at defining and classifying Koro have been undertaken by various researchers over at least the last fifty years without any consensus emerging to date. The occurrence of Koro, not only in different parts of the world but also in association with varied morbidities, has of late diluted its primary identity as a culture-bound syndrome. Further, the DSM-IIIR and ICD-10 provisions to include culture-bound syndromes like Koro are open to various diagnostic options. Consideration was given to have it included in DSM-IV. One of the fundamental problems inherent in such attempts is the semantic confusion Koro generates in its basic phenomenological analysis. The present paper deals with some of these issues based on historical analysis of world Koro literature, and with comments on the future research agendum.

The koro (genital retraction) syndrome and its association with infertility: a case report

The koro syndrome is a psychiatric disorder characterized by acute anxiety and a deep-seated fear of shrinkage of the penis and its ultimate retraction into the abdomen, which will cause death. Concurrence of the koro (genital retraction) syndrome with a pathological condition of the urogenital system has rarely been described. We report a case of koro associated with infertility. Within 3 weeks of treatment with haloperidol the classic symptoms of koro disappeared. To our knowledge this case represents the sixth report of the koro syndrome associated with urogenital pathology and the first report of its association with infertility.

Comment: the neglect of culture in psychiatric nosology: the case of culture bound syndromes

Descriptive psychopathology and clinical phenomenology inform contemporary psychiatric diagnosis and nosology. The process of psychiatric diagnosis and classification is intricate and subject to continuous revision. This paper attempts to illustrate the effect of culture on psychopathology, with special emphasis on the diagnosis and classification of culture bound syndromes. There is a need for more clarity and specificity about the diagnosis and classification of culture bound syndromes. The paper suggests some questions that need to be addressed for the better integration of these syndromes into the main body of international classificatory systems. It is presumed that answers to these questions will provide a better nosological framework for culture bound syndromes.

Koro: the delusion of penile retraction

Koro is a psychiatric syndrome in which the patient is convinced his penis is retracting. A case of koro is described. The literature and proper approach to such patients are briefly summarized.

Tarantism, dancing mania and demonopathy: the anthro-political aspects of 'mass psychogenic illness'

This study questions the widely held assumption that the phenomenon known as mass psychogenic illness (MPI) exists per se in nature as a psychiatric disorder. Most MPI studies are problematical, being descriptive, retrospective investigations of specific incidents which conform to a set of pre-existing symptom criteria that are used to determine the presence of collective psychosomatic illness. Diagnoses are based upon subjective, ambiguous categories that reflect stereotypes of female normality which assume the presence of a transcultural disease or disorder entity, underemphasizing or ignoring the significance of episodes as culturally conditioned roles of social action. Examples of this bias include the mislabelling of dancing manias, tarantism and demonopathy in Europe since the Middle Ages as culture-specific variants of MPI. While 'victims' are typified as mentally disturbed females possessing abnormal personality characteristics who are exhibiting cathartic reactions to stress, it is argued that episodes may involve normal, rational people who possess unfamiliar conduct codes, world-views and political agendas that differ significantly from those of Western-trained investigators who often judge these illness behaviours independent of their local context and meanings.

Single spies and battalions: the clinical epidemiology of mental disorders

Clinical epidemiology, a term that has been variously defined, is used here to refer to a discipline which, commencing with examination and diagnosis of the individual patient who presents in medical practice, proceeds to study the occurrence of similar, possibly connected cases in the local community, and in so doing may provide hypotheses for population-based studies of disease and its risk factors. While the relevance of this discipline to the modern practice of clinical psychiatry remains largely unexplored, its importance in the search for causes of mental disorder is attested by many instances, both historical and more recent, in which the spread or clustering of psychiatric syndromes in populations could be related to nutritional deficiency, infectious disease, the presence of environmental neurotoxins, the social communication of psychopathology or the transmission of abnormal, harmful behaviour patterns within family groups. Observations made in clinical practice have repeatedly served as the starting point for epidemiological investigation of mental disorders, while conversely epidemiological findings have influenced clinical thinking about their classification, diagnosis, prognosis and morbid risk. A review of the relevant literature underlines the need for a keener awareness of environmental risk factors and a fundamentally epidemiological frame of reference in trying to grapple with the aetiological problems of mental disorder.

[The anti-koro effect of a tricyclic antidepressant]

The authors are reporting a case of koro syndrome which was associated with major depression. Koro syndrome is a rare disease which manifests itself with a severe anxiety associated with the fear of having the penis shrinking and disappearing in the abdomen. The case reported was treated with trimipramine, a tricyclic antidepressant, at a dose of 150 mg/day associated with bromazepam, a benzodiazepine. In addition, the patient received psychotherapy, which allowed him to deal with the situation and to eliminate guilt feelings. It is hypothesized that the tricyclic antidepressant, by treating the depression, had a curative effect on the koro syndrome.