Transcultural Psychiatry

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On the Nature of Culturally Bound Syndromes in the Nosology of Mental

Disorders
Curtis C. Hsia and David H. Barlow
TRANSCULT PSYCHIATRY 2001; 38; 474
DOI: 10.1177/136346150103800405
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transcultural
psychiatry
December
2001
COMMENTARY

On the Nature of Culturally Bound Syndromes in

the Nosology of Mental Disorders
CURTIS C. HSIA AND DAVID H. BARLOW
Boston University

The unique and creative research into kyol goeu by Hinton and colleagues
is important on several levels. It provides clinicians with valuable information focused on a syndrome commonly seen among a population about
whom we have little information, while also providing insight into how the
categorization of culturally bound syndromes is limited.
Hinton and his coauthors noted that many of the Khmer they interviewed were affected by kyol goeu either directly or indirectly, and thus it
stands to reason that clinicians who work with Khmer refugees and their
families need to be aware of this syndrome. Kyol goeu is perhaps best
described as a culturally influenced variant of panic disorder. As with Asians
in general, and Southeast Asians in particular (Tung, 1985), it is likely that
Khmer underutilize mental health facilities but may seek help within their
own community (e.g., herbalists, Eastern doctors and monks) or from
medical settings such as hospitals. To better serve this and other populations, Hinton et al. have taken very important first steps by providing
services to the Khmer, and by thoroughly documenting the symptomology
of kyol goeu.
Perhaps just as importantly, Hinton et al. compare kyol goeu with ataque
de nervios, noting that the physiological symptoms and cognitions are
similar. In reviewing other culturally bound syndromes with anxiety
symptoms listed in DSM-IV (American Psychiatric Association, 1994), one
Vol 38(4): 474476[13634615(200112)38:4;474476;020114]
Copyright 2001 McGill University

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Hsia & Barlow: On the Nature of Culturally Bound Syndromes

possibility is that these disorders are fundamentally identical, but with

culturally mediated presentations. Much as there are similarities between
kyol goeu and ataque de nervios, there also seem to be commonalities in
physiological manifestations with ghost sickness, falling out, brain fag,
hwa-byung, shenjing shuairou, shenkui, and shin-byung. If these presentations represent the same syndrome, then perhaps rather than trying to
categorize different culturally bound syndromes and giving each its own
unique niche, it is more important to look for similarities across these
syndromes while gaining a better understanding of the cultures that help
shape the underlying disorder into an idiosyncratic presentation.
If these syndromes do have substantial overlap, this would also lead us to
reconsider how to approach therapy in the treatment of these syndromes.
Is there a systematic approach that would be able to take into account the
cultural differences of these syndromes, yet still be effective? Current
psychological treatments in manualized form have been shown to be effective in treating panic disorder and other related disorders (Barlow, in press;
Barlow & Craske, 2000). It may be that this basic approach with proven
efficacy in North America and Europe may well be effective with what seem
to be cultural variants of panic disorder if appropriate modifications are
made. But what are these modifications? How much would the program
have to be modified to be suitable in one culture versus another? For
example, in cultures that are more collectivistic in nature, it would seem that
there would need to be more involvement of the family in therapy. One
must be careful, however, as the reverse may also be true. An individual may
not want his or her family to be aware of the help-seeking behavior, as it can
be perceived as dishonoring the family. In addition, cultural differences
would seem to require modification of exposure exercises in which patients
confront anxiety-provoking situations (e.g., in general Asian cultures stress
the importance of family honor, and the possibility of embarrassing oneself
publicly by having a panic attack may require sensitivity on the part of
the therapist; Uba, 1994). Cognitive restructuring, also a part of the
psychological treatment of panic disorder, would have to take into account
not only what metaphors are used as examples, but also underlying
culturally bound thought processes, which may differ. Identifying these
networks of beliefs would require extensive anthropological research. It
seems likely that if these cultural issues are taken into account, the
application of models of psychological treatment could be more fully
evaluated for different culturally bound syndromes.

References
American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: American Psychiatric Press.
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Barlow, D. H. (in press). Anxiety and its disorders: The nature and treatment of
anxiety and panic (2nd ed). New York: Guilford Press.
Barlow, D. H., & Craske, M. G. (2000). Mastery of your anxiety and panic: Client
workbook for anxiety and panic (3rd ed.). San Antonio, TX: Graywind Publications/Psychological Corporation.
Tung, T. M. (1985). Psychiatric care for Southeast Asians: How different is
different? In T. Owan (Ed.), Southeast Asian mental health: Treatment, prevention, services, training and research. Washington, DC: U.S. Department of
Health and Human Services.
Uba, L. (1994). Asian Americans. New York: Guilford Press.
CURTIS C. HSIA received his PhD from Hofstra University in 2000 and is currently
a postdoctoral fellow at the Center for Anxiety and Related Disorders at Boston
University. He has previously worked at UCLA with Ivar Lovaas, and at the BioBehavioral Institute in New York. His research interests include anxiety disorders,
cross-cultural psychology and diversity issues in psychology. He is also the current
president of the Cross-Cultural Behavioral Therapy Special Interest Group at the
Association for the Advancement of Behavior Therapy. Address: Center for Anxiety
and Related Disorders, Boston University, 648 Beacon Street, 6th Floor, Boston,
MA 02215, USA. [E-mail: chsia@bu.edu]
DAVID H. BARLOW received his PhD from the University of Vermont in 1969 and
has published over 400 articles and chapters and over 20 books. His major interests over the past 30 years have been the study of anxiety and its disorders, and
developing new psychological procedure for practice settings. Prior to his current
position as Director of the Center for Anxiety and Related Disorders at Boston
University, he founded clinical psychology internships at Brown University and the
University of Mississippi Medical Center. He is the recipient of the 2000 American Psychological Association Distinguished Scientific Award for the Applications
of Psychology. Other awards include the Career Contribution Award from the
Massachusetts Psychological Association, and a MERIT award from the National
Institute of Mental Health for long-term contributions to the clinical research
effort. He is Past-President of the Division of Clinical Psychology of the American
Psychological Association. He is also a Diplomat in Clinical Psychology of the
American Board of Professional Psychology and maintains a private practice.

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