Koro-Like Symptoms in an Adolescent Female With Schizophrenia

Koro is a disorder characterized by the fear of genitals shrinking and retracting into the body.1 While it is not included in the cultural concepts of distress in DSM-5, DSM-IV-TR described koro as "an episode of sudden and intense anxiety that the penis (or, in female patients, the vulva and nipples) will recede into the body and possibly cause death." The term koro originates from the Malay language, referring to the retracting motion of the head of turtles or tortoises into their shells. In the United States and Europe, the term genital retraction syndrome is commonly used instead of koro. In classical koro, cultural belief plays a role in its origin and spread, often in epidemics in Asian countries.2 On the other hand, Koro-like syndrome (KLS) has been reported worldwide secondary to medical and psychiatric disorders.2 Similar to koro, KLS is more prevalent in males, with only 3 documented cases in female patients worldwide (Table 1). We present the first case to our knowledge of KLS in an adolescent female patient with schizophrenia. The patient's parents gave consent for the publication of this case report.

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.

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.

Making up koro: multiplicity, psychiatry, culture, and penis-shrinking anxieties

Koro is a syndrome in which the penis (or sometimes the nipples or vulva) is retracting, with deleterious effects for the sufferer. In modern psychiatry, it is considered a culture-bound syndrome (CBS). This paper considers the formation and development of psychiatric conceptions of koro and related genital retraction syndromes from the 1890s to the present. It does so by examining the different explanations of koro based on shifting conceptions of mental illness, and considers the increased recognition of the role culture has to play in psychiatric concepts. Conceptions of culture (deriving from colonial psychiatry as well as from anthropology) actively shaped the ways in which psychiatrists conceptualized koro. Cases under consideration, additional to the first Dutch descriptions of koro, include the ways in which koro was identified in white western cases, and the 1967 Singaporean koro epidemic. Following a number of psychiatrists and psychologists who have addressed the same material, attention is also paid to the recent genital-theft panics in sub-Saharan Africa, considering the implications of the differences between koro and other genital-theft panics. Finally, the paper addresses the role played by koro in the development of the concept of CBSs, which was first presented in the DSM IV in 1994. This is explored against the backdrop of emerging ideas about culture and psychiatry from the late colonial period, especially in Africa, which are central to modern ideas about transcultural psychiatry.

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.

Chronic koro-like symptoms - two case reports

BACKGROUND

Koro is a culture bound syndrome, which has been reported usually from Asian countries. It has been described as an acute, brief lasting illness, which often occurs in epidemics. There is no description in literature of a chronic form of this syndrome.

CASE PRESENTATION

Two sporadic cases with koro-like symptoms from East India are presented where the illness had a chronic course with durations spanning more than ten years. In contrast to acute, good prognosis, psycho-education responsive form that is usually seen in epidemics; the chronic form, appeared to be associated with greater morbidity and poorer response to interventions.

CONCLUSION

There is a possibility of a chronic form of koro syndrome.

Understanding genital-shrinking epidemics in West Africa: koro, juju, or mass psychogenic illness?

A small-scale epidemic of genital shrinking occurred in six West African nations between January 1997 and October 2003. This article presents a summary and analysis of 56 media reports of these cases. A clinical formulation of these cases considers a variety of explanations from theory and research in social and cultural psychology, psychopathology, and anthropology. Of particular interest is a comparison of genital-shrinking distress in West African settings with koro, a culture-bound syndrome involving fears of genital retraction that is prominent in Southeast Asian settings. The paper concludes with a brief discussion of the role of culture in both the experience of genital-shrinking distress and conceptions of psychopathology.

Koro-misidentification syndrome in schizophrenia? A plea for clinical psychopathology

Although current diagnostic procedures favour the diagnosis of similar syndromes in different pathological processes, it cannot be overlooked that many psychiatric symptoms that share a similar 'surface grammar' differ in their 'deep grammar' or structure. In the case presented, we describe an acute psychosis where a Koro-misidentification syndrome might be diagnosed. In the discussion we point out how confusing this approach might be, as well as a feasible way to compensate for the shortcomings of contemporary descriptive psychopathology.

[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.

Koro associated with phobia for AIDS

Koro, in its complete, classic form has been described as a culture bound syndrome. It usually occurs in otherwise healthy individuals in the context of acute, severe anxiety. The incomplete form of Koro is said to occur as part of a recognizable primary psychiatric disorder. A case report is presented for the first time of Koro in association with phobia for AIDS. A cognitive-behavioral approach was utilized in the management of the AIDS phobia and symptoms of Koro.

Koro-like syndrome in a Bedouin man

A case report is presented of a koro-like syndrome in a 34-year-old Bedouin man living in the Negev desert in Israel. The patient's disturbance is accompanied by voyeurism and the onset appears to be related to his sexual practices. This is the first reported case among Bedouins, who are an Arab nomadic tribe living in Asia and Africa.

Genital retraction syndrome in Korean woman. A case of Koro in Hungary

Koro is a culture-specific psychiatric disorder occurring primarily in Southeast Asian cultures. It is manifested by acute anxiety associated with the fear of genital retraction, accompanied by fear of death induced by the thought that complete disappearance of the genital organ will result in death. Koro has been described in non-Asian patients as well, leading to a debate concerning the culture-specific nature of the syndrome. Giving a psychopathological, nosological definition of this peculiar syndrome is also problematic. In this paper, we report a case of koro in a young, Korean female patient. We briefly present the etiological factors related to the development of the syndrome and the most significant psychopathological characteristics.

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.

[Castration anxiety and oral envy in sexual relations. Analytic studies with ethnological observations]

Ethno-psychoanalysis is the study of the unconscious in foreign cultures. It can however also be of use in understanding unconscious elements operative in our own culture. To illustrate the point, the author describes the "Koro" epidemic which occurs periodically on the island of Hainan off the south of coast of China. This epidemic largely affects young unmarried men and the author pinpoints the unconscious conflicts underlying this collective phenomenon. It transpires that the epidemic is in effect a species of rite of passage in which a group of young males make the communal attempt to overcome castration anxieties which are themselves the product of covert gender envy. In the second section, Gerlach reports on his psychoanalytic encounter with a young man in Germany displaying similar symptoms. The profounder dimensions of this condition were only comprehensible to the author on account of his knowledge of "Koro".

Koro following cannabis smoking: two case reports

Koro in the background of drug abuse is quite rare. The present report of Koro during the first experience with cannabis is the only account of its kind in the world Koro literature to date. The nature and extent of this genital depersonalization is discussed.

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.

Koro: culture-bound disorder or universal symptom?

A case report is presented of koro associated with a depressive illness in a 31-year-old male Briton. The specificity or otherwise of koro as culture bound and a distinct nosological entity is discussed.

[Koro syndrome--clinical and cultural aspects]

Koro syndrome is a triad which includes a deep-seated fear that the penis will shrink, disappear into the abdomen, and that death will follow. The patient experiences profound anxiety and performs preventive manoeuvres, such as pulling his penis outward. The disorder is considered culture-related, and is endemic in South-East Asia and China, where it occurs in epidemic and sporadic forms. Sporadic cases appear in the western hemisphere, often in association with an underlying psychiatric or organic disorder, usually of the central nervous system. 6 cases of koro have been published from Israel.

Glans penis perception of Koro patients

Koro is a form of sexual neurosis in which a reaction of acute anxiety accompanies the perception of decreased penis length from intra-abdominal traction. This study attempts to explore the glans penis perception of Koro patients by a grapho-motor projective test--DAPT (Draw-a-penis Test). This controlled DAPT investigation shows that Koro patients have significantly less perception of glans penis than the controls. This perceptual deviation in glans penis image is discussed in relation to the sexual-behavioral profile and Koro vulnerability of the patients.

Koro epidemics in Guangdong, China. A questionnaire survey

Koro epidemics, characterized by panic due to fear of genital retraction, involving more than 2000 victims, mainly young men, occurred in Hainan Island and Leizhou Peninsula of Guangdong Province, China, in 1984-85 and 1987. A questionnaire survey of 214 victims of these epidemics was conducted in 1988. The survey focused on symptom manifestation, personality profile, life problems, and folk belief. The results of the "koro" group were compared with those of a "clinic" group with minor psychiatric disorder and a "control" group from the non-clinical, non-koro episode population in the epidemic area. The results revealed that the victims of the koro epidemics were characterized by low intellectual endowment and strong acceptance of koro-related folk beliefs. The results support the hypotheses that: a) a koro attack is a psychologically induced anxiety-panic condition; b) the presence of an intensive belief in the culturally related concept of koro makes the subject vulnerable to the attack; and c) social crisis or tension serves as a trigger for the occurrence of the epidemic.

Koro-like symptoms in a man infected with the human immunodeficiency virus

A 32-year-old man presented with koro-like symptoms in association with a depressive illness and HIV infection.

Penis-root perception of Koro patients

Koro is an acute anxiety reaction in which the perception of decreased penis length because of intra-abdominal traction is the main feature. This study attempts to explore the penis-root perception of the Koro patients by a graphomotor projective test--the Draw-a-penis Test (DAPT). This controlled DAPT investigation shows that Koro patients perceived the penis as a detached organ with root-boundary definiteness as evidenced from their close penis-root perception. They also displayed reduced volumetric perception of penis-root than the normal subjects. These perceptual deviations in penis-root image are discussed in relation to their Koro vulnerability.