Culture-bound Syndrome: Ignored Diagnosis of Regional Psychological Disorder

Han Kang, a Korean female writer, won the Nobel Prize in Literature in 2024. In her work “The Vegetarian,” she depicts the tragic life of a homemaker after she stopped eating meat. The book reveals not only the fate of repressed women in Korean patriarchal society but also Hwa-Byeong (HB), a culture-bound syndrome exhibiting “the rare, exotic, unpredictable and chaotic behaviors among uncivilized people.” With the development of the standard classification of mental disorders, psychologists nowadays ignore its specificity to a certain degree and mistakenly consider the syndrome as a combination of existing conclusive diagnoses, which is largely based on Westernoriented studies. The misperception overemphasizes the importance of Western clinical treatments under specific cultural norms, hindering further domesticated investigations.

Psychological disorders are named and diagnosed in the context of the Western diagnostic system, recorded in the Diagnostic and Statistical Manual of Mental Disorders-5-TR (DSM-5). When psychiatrist Pow Meng Yap first discovered and clarified regionally special mental illnesses as culture-bound syndrome in the 1960s, he considered it essential to figure out to what extent they could be categorized in the existing system and whether such a "standard" classification indeed exists. Unfortunately, many investigations acquiesced to its validity and ignored the link between cultural background and symptoms. They are dedicated to describing them using existing terminology. HB is depicted as a comorbidity with anger disorders, generalized anxiety disorder (GAD), and major depressive disorder (MDD). With the development of the economic system and cultural interaction in which boundaries among cultures become vague, DSM-5 similarly abandons the term and replaces it with cultural concepts of distress, referring to “ways individuals experience, understand, and communicate behavioral problems, or troubling thoughts and emotions.” It also declares DSM diagnoses, based on clinical results, can be widely applied even if patients are raised in different cultural backgrounds. DSM-5 promotes general mental disorders rather than discussing them from several cultural backgrounds.

However, the limited sample size and unrepresentative candidates make the claim untenable to a certain degree. In psychological studies, over-sampling American college students is common. The Western, educated, industrialized, rich, and democratic societies (WEIRD) formed as much as 80% of study participants in the database but only 12% of the world’s population. When a mental disorder was first named, the supportive studies were under Western cultural construction. Posttraumatic Stress Disorder (PTSD), for instance, was included in DSM-3 (1980) based on returning Vietnam War veterans. Although DSM-5 has paid special attention to the universality of PTSD diagnoses and shown its cross-cultural validity, the terminology still cannot fully apply to multiple cultural backgrounds. Therefore, inadequate but highly-conclusive diagnoses may interrupt psychologists’ judgment, resulting in ineffective remedies. Semantically, if we assume all cultural concepts of distress can be concluded by combinations of DSM diagnoses, the uniqueness of divergent cultures is automatically neglected. Conversely, if its uniqueness cannot be explained, the trend of treating clients in Western ways can be misleading during therapies among different cultures. Yet cultural convergence becomes prevalent, cultural differences influenced by geography, political system, religious belief, social structure, and population distribution still exist and create diversity on the Earth. From another perspective, it is possible that standardized psychological diagnoses and therapies, along with the progress of technologies and economic growth, promote convergence and assimilation across cultures. The neglect of cultural diversity in the psychology field is manually setting blocks for culture-based mental illnesses.

Specifically, current remedies for HB include Western biomedicine, psychotropic medications, psychodynamically-oriented supportive treatment, and cognitive-socialphysiological therapy. However, normal therapies do not necessarily apply to the diagnosis and treatment of HB. Research reveals that they are limited to alleviating and reducing symptoms rather than fundamentally addressing the distress caused by environmental and cultural factors. More often, Western clinical therapies are typically not approachable under Korean cultural norms. Although 36.3% of the Korean population of Millennials and Generation Z (born between 1980 and 2005) suffer from the disorder, only 44.54% of them consider it treatable. Moreover, few of them seek treatment from doctors as mental disorders represent weakness and inability to take care of their families and communities in their culture. Therefore, Koreans tend to hide their soft part to avoid criticism and reproach.

Although they have similar symptoms, such as headache and trembling, it is not proper to categorize and recognize HB in the current DSM diagnoses of GAD and MDD because of its cultural particularity and distinctive symptoms. Several studies conclude that diagnosed females experience significantly higher levels of family conflicts derived from their obedience to traditional Confucian ideas and patriarchy, in which females are not allowed to express their distress to their husbands-in-law. Indeed, emotional internalization twists mindsets and confuses personal identities. Besides, further study reveals patients experiencing HB exhibit combined symptoms of emotional distress, including a sense of helplessness, isolation, accumulated anger under an unfair and overwhelming environment, and somatic pain, including sorrow in the guts. The symptom is termed “Han” in the Korean language, supporting the significance of innovating culture-based therapy.

To understand culture-bound syndrome more comprehensively, according to Guarnaccia and Rogler, investigators should regard it as a new mental disease by identifying the salience, the rapidity, and extent of its recognition within a cultural group; phenomenology, the subjective symptoms of the disorder and location in the social context. Then, the elaborate portrait can be reexamined under the current standard classification, identifying the commonalities and differences. The culture-bound syndrome should not be fully diagnosed by prevalent DSM operationalized prototypes. To treat the patients, Segal implies the inseparability of cultural and biological approaches. Cultural backgrounds cause variations of mental disorders, and the disorders conversely deepen the understanding of an individual, containing one’s experience and cultural influence. The approach can maximize biological medicine's advantages and help understand mental disorders beyond scientific meanings.

In the process of globalization, human beings employ statistics, formulas, and models to ensure the stable functioning of the world. Suddenly, they realize something attributed to uncertainty and ambiguity cannot be identified by simple numbers. Psychological states of individuals, the combination of harmony and chaos, secretly affect the operation of “the immense machine.” Against this backdrop, emphasizing the significance of culture-bound syndrome will encourage precise but humanistic diagnosis and treatments, which leads to a higher order of equality and respect towards patients from divergent cultural backgrounds, as well as reduce conflicts and uneven distribution of clinical resources.