The challenge of diagnosing cultural syndromes: A narrative review

Abstract

Background:

In 2022 the total world migrant population was 281 million (an increase of approximately 62% compared to year 2000), of whom 169 million were migrant workers. The number of refugees, asylum seekers and others in need of international protection increased by 22% compared to 2021. Research has shown that the forcibly displaced have high rates of mental disorders (including depression, post-traumatic stress disorder (PTSD) and anxiety), with an estimated prevalence almost 6 to 7 times higher than the general population. Given the increase of the overall migration phenomenon and the challenge raised by the cultural features concerning mental health, we consider that this is an area that requires close attention to ensure that culturally sensitive health services be available to the migrant and displaced population.

Aims:

The aim of this narrative review is to provide a background to the issue and take stock of what is currently available in the literature regarding culture-bound illnesses and the relevant diagnostic tools.

Methods:

A comprehensive search was performed in PubMed, Psychinfo, Embase, Google Scholar, organized in stages to assure inclusion of all the relevant studies. Of the 703 papers initially identified, only 30 papers finally satisfied the inclusion criteria.

Results:

Eleven diagnostic scales were found, only two of which are being used for displaced people.

Conclusions:

Further work is required in this field, including a debate as to whether scales are indeed an appropriate tool for use with this population.

Keywords

Ethnopsychiatry cultural syndromes scales migrants refugees asylum seekers

Introduction

In 2020 the total world migrant population was 281 million (an increase of approximately 62% compared to 1990), of whom 169 million were migrant workers (World Migration Report 2020 ). At the end of 2022, the number of forcibly displaced persons (refugees, asylum seekers and others in need of international protection) was 108.4 million, an increase of 22% compared to 2021 (UNHCR, 2022). These numbers indicate a need for culturally sensitive mental heath services, therefore we decided to conduct a systematic review in the literature to investigate the scales/questionnaires used in the countries of origin to identify and describe cultural syndromes.

Historical background

Ethnopsychiatry is a challenging field, rendered even more so by globalization, wars and famines that trigger migrations. In his Basic Problems of Ethnopsychiatry, 16 essays written between 1939 and 1965, George Devereux (1908–1985), now considered one of the founding fathers of this discipline, maintained that both psychological and sociocultural tools are necessary to fully understand human behavior; in his view, to be able to treat people of different cultures it is essential to have a firm grasp of their habits, languages, relationships, beliefs.

Many studies have shown how different types of classification axes are used in non-Western cultures: gender, spatial (village or bush diseases), temporal (day or night diseases), genealogical (related to clan or lineage relationships), moral (transgressions of interdicts as a cause of illness). These axes are then joined together to build a complex network of intersections, which are then frequently deciphered by divination (Beneduce, 2005).

The concept of culture-bound syndromes was developed in the early 1950s by Pow Meng Yap, a Hong Kong born psychiatrist who did not believe in the universality of mental disorders and who challenged the ethnocentric assumptions frequently made by western clinicians. He proposed the term hysterical neurosis in 1951, subsequently changing it to atypical psychogenic culture-bound psychoses in 1961 and finally in 1969 to culture-bound reactive syndromes. Several studies corroborate the concept that culture and biology are interconnected and that psychological distress is culture-bound (Caspi & Moffitt, 2006; Choudhury & Kirmayer, 2009; Kirmayer, 2006).

Current approach

As Kleinman (1997) pointed out, even though DSM-4 dedicated more attention to culture than previous editions, 90% of its categories were culture-bound to Western cultures. This was to some extent remedied in DSM-5, which included specific terms denoting cultural concepts of distress such as cultural syndromes, cultural idioms of distress, causal explanations and folk diagnostic categories.

It also introduced the Cultural Formulation Interview (CFI), a brief semi-structured 16-question interview for the systematic investigation of cultural factors that has been tested at sites around the world. Aggarwal et al. focused on how the CFI affects clinical practice, reporting that its use improved clinical rapport (Aggarwal et al., 2020). It was confirmed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, (DSM-5-TR, 2022) published in 2022, which implements the section of transcultural psychiatry by recognizing that the cultural context of illness is helpful for effective diagnostic assessment and clinical management. Moreover, its definitions of culture, race and ethnicity are more specific and dynamic. Culture refers to ‘systems of knowledge, concepts, values, norms, and practices’ that are learned and transmitted across generations. In the contemporary world, this process involves the dynamic intersection of multiple cultural contexts. Furthermore, in relation to diagnosis, it is essential to recognize that all forms of illness and distress, including the disorders classified by the DSM, are shaped by cultural contexts (Alarcón et al., 2002 ). Therefore, the previous culture-bound syndrome concept has now been replaced with an approach that is more effective in clinical practice.

Methodology

A bibliographic search, organized in stages to assure inclusion of all the relevant studies, was carried out in PubMed, Psychinfo, Embase, Google Scholar. The last check was done in January 2024. Two authors (VC and OL) screened the papers (Figure 1).

All the syndromes cited in DSM-5-TR were included (see Table 1), and then explored on scientific sites. Each syndrome was matched with either of the following terms: ‘scale’ or ‘questionnaire’ (see Table 2). The initial search was carried out using headings, abstracts, and full text. As this search yielded scarce results, a manual search was conducted on the database using the full text and the exact name of the tool found with the previous inquiry. Finally, the syndromes and scales were combined with the word string ‘migrant or refugee or asylum seeker’. Articles found through specific research or present in other bibliographies were included. The following were excluded: (1) off-topic studies; (2) meta-analyses or reviews that included studies already selected; (3) articles which do not include any scale or written tool specifically developed for cultural syndromes; and (4) letters to the editor, commentaries. Only papers written in English were included, as publication on international journals was considered an indication of greater amplitude and usability of the work.

Table 1.

Culture-bound syndrome descriptions as in DSM-5-TR.

Culture-bound syndrome	Location	Epidemiology	Brief description	References
Dhat syndrome	- South Asia, especially the Indian subcontinent. - China: shen-k’uei (kidney failure) - Corollaries in Europe, USA, Russia and Australia.	- 64% of psychiatric access in India for sexual complaints and 30% of men attending general medical clinics in Pakistan - Young males of low or medium socioeconomic status. - Present also in women as vaginal discharge	- Considered as neurosis of the orient, the dhat syndrome involves many vague somatic complaints of weakness, fatigue, anxiety, loss of appetite, guilt and sexual dysfunction, which are seen as a direct result of semen loss following masturbation, nocturnal emissions or micturition. Sometimes patients believe the semen loss or vaginal discharge is a leak of a vital fluid.	Grover et al. (2014)
Koro	- Southeast Asia and Singapore	The majority of reported cases are male.	Fear of the penis retracting into the body among men and retraction of breasts among women is a central feature.	Garg K et al. (2017)
Kufungisisa	- Zimbabwe (among the Shona tribe) - Caribbean, Latin America, native Americans	Two-thirds of the cases identified in a random community sample in Zimbabwe.	- It involves dwelling on upsetting thoughts, particularly worries. ‘Thinking too much’; - As an idiom of psychosocial distress, it is indicative of interpersonal and social difficulties.	Abas and Broadhead (1997) Patel et al. (1995)
Khyâl or wind attacks	- East Asian population including Tibetans, Cambodians, Chinese, Vietnamese Trung giò, Mongolian Yadargaa - Laos Pem Lom, Tibet srog rlung, Sri Lanka vata	Traumatized Cambodian and Khmer refugees in the US	Khyâl is a wind like substance which is thought to rise in the body, specifically in the blood, stream and cause effects as compressing the lungs to cause shortness of breath and asphyxia; entering the cranium to cause tinnitus, dizziness, blurry vision, and a fatal syncope.	Kohrt et al. (2014)
Hwa byung	Korea	Middle-aged women	‘Haan’ (a mixture of sorrow, regret, hatred, revenge and perseverance) builds up to create a pushing sensation in the chest, resulting in the inability to appropriately control anger. The symptoms include insomnia, fatigue, palpitations, panic, fear of impending death, dyspnea, dysphoric affect, indigestion, anorexia, generalized aches and pain and feeling of mass in the epigastrium.	Min and Suh (2010), Chung et al. (2015)
Brain fag syndrome	West Africa (Nigeria)	2%–4% of African students	Emotional and somatic complaints such as intellectual and sensory impairment (chiefly visual), somatic affliction, most commonly of pain or burning in the head and neck, problems affecting the student’s ability to study, an unhappy, tense facial expression, a characteristic gesture of passing the hand over the surface of the scalp or rubbing the vertex of the skull.	Essien et al. (2017)
Taijin Kyofusho	- Japan - Similar syndromes are described in USA, Australia, New Zealand and Korea (taein kong po)		- Intense fear that one’s body, its parts or its functions, cause displeasure, embarrassment or offense to other people in appearance, odor, facial expressions or movements.- The typical characteristic is ‘fear of being noticed’,- while the ‘offensive type’, is characterized by ‘fear of offending or embarrassing’.	Vriends et al. (2013) Essau et al. (2012)
Olfactory reference syndrome	Japan: jiko-shu-kyofu	- Average age at onset of ORS was 25.4 years- 78% males	The core symptom is the ‘contrite reaction’, summarized into ‘deeply ashamed, embarrassed, self-abasing, and sensitive reaction of people who believe that their bodies stink and are a perpetual source of displeasure or disgust to people near them’.	Sofko et al. (2020) Zhou et al. (2018)
Ataque de nervios	- Latino populations in Puerto Rico- Haiti: Endisposizisyon- Usa: black out- Caraibi: falling out	- 15% of population in a Mexican sample- 16% in a Puerto Rico sample- 76% to 78% of those affected are female	- Culturally sanctioned response to acute stressful experiences, particularly relating to grief, threat, and family conflict.- It manifests with uncontrollable attacks of screaming, shouting, and crying, trembling, heat in the chest rising into the head, and becoming verbally and physically aggressive.- Dissociative experiences could occur and deteriorate with suicidal gestures.	Guarnaccia et al. (2010)

Table 2.

Key words and % of findings.

Key-words	%
(Ataque De Nervios) and (Migrant)	0.2
Shen-K’Uai	0.2
(Dhat Syndrome) and (Migrant)	0.2
(Pica) and (Refugee)	0.2
(Khyâl attack) and (Refugee)	0.2
(Koro) and (migrant)	0.4
YBOCS-ORS	0.7
(Black-out) and (Scale)	0.7
Kufungisisa	0.7
Fan Nao	1.1
Shenjing Shuairuo	1.3
(Brain Fag) and (Scale)	1.4
(Dhat Syndrome) and (Scale)	1.6
Ataque De Nervios Questionnaire	1.6
Taijin Kiofusho Scale	2.4
Ataque De Nervios Scale	2.5
Taijin Kiofusho Questionnaire	5
Olfactory Reference Syndrome Scale	6.1
(Dhat Syndrome) and (Diagnosis)	8.1
Susto	13.1
Koro Syndrome	18.4
Olfactory Reference Syndrome	31.2
Subsequent Targeted Researches	0.7
From Other Bibliographies	0.9
(Shen-K’Uai) and (migrant)	No results
(Kufungisisa) and (migrant)	No results
(Fan Nao) and (migrant)	No results
(Shenjing Shuairuo) and (migrant)	No results
(Brain Fag) and (migrant)	No results
(Taein Kong Po) and (Scale)	No results
(Endespozisyon) and (Scale)	No results
Maladi Moun	No results
(Kufungisisa) and (Scale)	No results
(Khyal Cap) and (Scale)	No results
Khyal Cap	No results
Ashaktapanna	No results
Sainkei-suijaku	No results
(Taijin Kyofusho) and (Migrants)	No results
(Taijin Kyofusho) and (Refugee)	No results
(Taijin Kyofusho) and (Refugee)	No results
(Taijin Kyofusho Scale) And (Refugee)	No results
(Taijin Kyofusho Scale) And (Validation)	No results

Results

Seven hundred three papers were initially identified with the key word search; other 26 papers were found through subsequent targeted research and in other bibliographies. Of these, 53 were duplicates, 550 were excluded by the exclusion criteria mentioned above and a further 96 were excluded after a further assessment. Thirty papers satisfied the inclusion criteria.

Table 3 summarizes the results of these studies, in particular clustering papers according to the 11 scales.

Table 3.

Summary of results.

References	Name of tool	Cultural syndrome	Number of items	Typology (Dichotomous/Multiple Choice/Free Questions)	Method of Administration: Self-reported (0)/ By a Clinician (1)	Articles found by matching ‘Asylum Seeker/Refugee/Migrant + Scale	Target population
Abas and Broadhead (1997), Patel et al. (1997)	SSQ	Kufungisisa	14	Dichotomous	1	No	Zimbabwe: High density suburbs in Harare
Choy et al. (2008)	TKSQ	Taijin Kiofusho – Offensive Type	30	Multiple Choice, Continuous	1	No	Jiangxi Province, China
Chung et al. (2015), Park et al. (2001), Min and Suh (2010), Kwon et al. (2008)	HBS	Hwa Byung	31	Dichotomous	1	No	South Korea
Ren et al. (2020), Greenberg et al. (2016, 2018), Sofko et al. (2020), Zhou et al. (2018), Phillips and Menard (2011)	ORS-YBOCS	Olfactive Reference Syndrome	12	Dichotomous	1	No	USA
Ginzburg et al. (2022), Liebowitz et al. (1994), Guarnaccia et al. (2010)	Ataque de Nervios Questionnaire	Ataque de Nervios	25	Dichotomous	0	Yes	Hispanic population in the USA
Grover et al. (2014, 2016)	Questionnaire for Assessment of Dhat Syndrome	Dhat Syndrome	91	12 Multiple Choiche, 76 Dichotomous, 3 Free Questions	0	No	Indian
Hinton et al. (2012)	CSSI	Khyal Attacks	18 + 19 (syndrome-related item)	Multiple Choice, Continuous	-	Yes	Cambodian refugees
Joshi et al. (2022)	Questionnaire for Assessment of Female Dhat Syndrome	Dhat Syndrome	-	-	0	No	Indian
Lessa et al. (2014)	Screening for Abnormal Olfactory Experiences	Olfactive Reference Syndrome	-	-	-	-	-
Ola and Igbokwe (2011), Ola and Morakinyo (2010), Essien et al. (2017); Adayonfo and Akhigbe (2015)	BFFS	Brain Fag	7	Multiple Choice	0	No	USA
Vriends et al. (2013), Tarumi et al. (2004), Kleinknecht et al. (1997), Fan et al. (2023)	TKS and Short Form	Taijin Kiofusho	31	Dichotomous	0	No	Japan and Korea

Questionnaires: Description

Questionnaire for assessment of Dhat syndrome and Scale for Assessment of Female Dhat syndrome (SAFeD) – India and Pakistan

The ‘Dhat syndrome’ is widespread in South Asia, accounting for 64% of psychiatric accesses for sexual complaints in India and 30% of male cases attending general medical clinics in Pakistan. This syndrome occurs in young male patients who attribute their various symptoms to semen loss (DSM-5, 2013 ) accompanied by general weakness, lack of energy and concentration, impaired sexual functions, and vague somatic troubles, often associated with an anxious or dysphoric mood state (Grover et al., 2014). The cardinal feature is anxiety and distress about the loss of dhat, a white discharge seen during defecation or urination (DSM-5, 2013). DSM-5 relates it to the depressive and anxious disease spectrum so scales for these diseases are widely used in the clinical evaluation of patients suffering from this complaint.

We found only one specific scale for the assessment of Dhat syndrome, named Dhat Syndrome Questionnaire (DSQ): it consists of a total of 92 items divided in various sections, 12 multiple-choice questions, 76 dichotomic, and three open-answer questions used to guide the clinical interview. It is generally administered by a clinician and appears to be a useful instrument for the comprehensive assessment of the Dhat syndrome (Grover et al., 2014, 2016).

SAFeD is a modified version of DSQ. It is used for the assessment of beliefs, associated symptoms, and other features in patients with non-pathological vaginal discharge. This scale, which was administered to 70 women with symptoms of vaginal discharge, investigates the various aspects of the Dhat syndrome as frequency, consistency, color, and quantity of discharge; situations in which patient has the discharge, their beliefs about the composition of discharge, reasons for passage of discharge; consequences of excessive discharge; accompanying somatic, anxiety, and depressive symptoms; comorbid sexual dysfunction and beliefs about help-seeking and treatment (Joshi et al., 2022). All authors identified in this study investigating dhat are native to India.

Shona Screen Questionnaire – SSQ (Shona screen for mental disorder) – Sub-Saharan Africa – Zimbabwe

Kufungisisa means ‘thinking too much’ in the Shona language; it is a cultural explanation of distress, seen as both a symptom and a cause, that originated in Zimbabwe. In Sub-Saharan African cultures ‘thinking too much’ is considered to be dangerous for the mind. In Nigeria, it is said to cause a cultural syndrome known as ‘brain-fag’, with symptoms including feelings of heat or crawling sensations in the head (DSM-5, 2014). Like the Dhat syndrome, Kufungisisa is usually associated with major depression or anxiety. However, according to Patel et al. (1995) the term is strongly related to biomedical constructs of non-psychotic mental illness but is not specifically related either to depression or anxiety.

The SSQ is a 14-item scale specifically designed for this kind of distress; it has dichotomic answers and can be self-administered (Abas & Broadhead, 1997; Patel et al., 1997). The items can strongly predict the presence of a type of mental disorder with a high level of internal consistency (Cronbach’s alpha = .85). This is the first scale developed in sub-Saharan Africa (Zimbabwe) to measure mental disorder and appears to be a useful clinical and epidemiological instrument. It has been described as an innovative way of combining etic and emic methods in the evaluation of mental disorders (Patel et al., 1997).

Brain-Fag Syndrome Scale (BFSS) – Africa – Nigeria

Brain-fag syndrome, mentioned above, is said to affect two to four out of every 10 African students, and is one of major causes of premature termination of foreclosure of education. BFSS is a self-administered screening tool developed by Prince (1960) and refined by Morakinyo (1990) for the diagnosis of brain-fag syndrome using seven multiple-choice items (never, sometimes, often). The score ranges from 1 to 14 and scores of six and above are considered positive. Ola and Igbokwe (2011) considered this scale to be a valid and reliable two-dimensional instrument for measuring the typical sensations of crawling and burning in the head. The Cronbach Coefficient Alpha of the BFSS yielded a reliability coefficient of 0.521 with a standardized item alpha of 0.528 estimated internal consistencies. The same team conducted another cross-sectional study to ascertain the types of study habits associated with brain-fag symptoms among a sample of senior secondary school students in Ile-Ife (Nigeria). The results suggested that homework and assignments, examinations, and written work were significant study habit variables associated with the syndrome (Ola & Morakinyo, 2010). Essien et al. tried to determine the pattern and sociodemographic predictors of brain-fag in their cross-sectional study: they found a prevalence of 20.4% for brain-fag syndrome and a strong correlation with the female gender. School type and local government of location, residence type, parental marital status and maternal educational status were also found to have statistically significant relationships with the disorder (Essien et al., 2017). Finally, Adayonfo et al. ran a cross-sectional study to investigate whether there was an association between the use of stimulants and brain-fag symptoms, finding a significant association between brain-fag and stimulant use, thus giving credence to Morakinyo’s Psychophysiological Theory of Causation (Adayonfo & Akhigbe, 2015).

Hwa Byung scale (HBS) – Korea

Hwa Byung is a syndrome described in Korea (DSM-5, 2014); it occurs when ‘haan’ (a mixture of sorrow, regret, hatred, revenge and perseverance) builds up to create a pushing sensation in the chest, resulting in the inability to appropriately control anger (Min & Suh, 2010). Hwa-byung affects middle-aged women in Korea who have experienced years of interpersonal conflict, typically in the context of an abusive marital relationship (Kohrt et al., 2014). This syndrome matches with panic attack and generalized anxiety disorders in DSM-5.

The Hwa Byung scale has 31 items, can be self-administered and is composed of dichotomic answers. It is considered a reliable and valid diagnostic tool by the Korean community, and it seems that the personality traits it includes are predictive of positivity. Chung et al. (2015) validated this scale in their study, revealing satisfactory reliability (α = .922), construct validity (% of total variance = 68.1%) and a suitable cut-off score (28 points). They also performed a multiple regression analysis which showed that toleration and victimization personality traits were predictive of Hwa Byung. Park et al. (2001) studied social aspects of the disease: the rates were higher in women with low socioeconomic status living in rural areas, among the divorced or separated, smokers, and drinkers. Min and Suh (2010) studied the major comorbidities, and their results suggested that this syndrome, which comprises unique anger-related symptoms, is comparable to major depression and generalized anxiety disorder in comorbidity profile. However, they did declare a number of limitations to their study, including the small sample size, the lack of axis II diagnoses assessment, and the non-inclusion of patients with psychotic features. Finally, Kwon et al. (2008) asserted that the personality characteristics related to Hwa-Byung did not differ from those related to depression, although the symptoms were different.

Cambodian Somatic Symptom and Syndrome Inventory (CSSI)

Cambodians conceptualize the somatic symptoms caused by psychological distress through ‘Khyâl attacks’ (or ‘wind attacks’). The symptoms include panic attacks, such as dizziness, palpitations, shortness of breath, cold extremities, and anxiety and autonomic arousal. Khyâl is a wind-like substance which rises in the body, specifically in the blood, causing shortness of breath and asphyxia by compressing the lungs; it enters the cranium causing tinnitus, dizziness, blurry vision, even a fatal syncope. ‘Khyâl Attack’ is one of the nine cultural concepts of distress included in DSM-5 (2013).

Hinton et al. (2010, USA) described khyâl attacks in traumatized Cambodian refugees with PTSD, finding a strong correlation between the severity of attacks and that of PTSD. The authors considered this cultural syndrome to be a key aspect of trauma ontology in this population, a kind of culturally specific experiencing of anxiety and trauma-related disorder. This scale is unique in this review as it is specifically used with refugees, but it has not yet been officially validated. CSSI is a culturally sensitive questionnaire for the assessment of the effects of trauma in the Cambodian refugee population in the USA. It is investigated with 19 items referring to symptoms perceived in the previous 4 weeks; these items are divided into five areas: somatic-focused syndromes (10 items), agoraphobia or motion-sickness-type syndromes (two items), emotion-focused syndrome (one item), cognitive-deficit syndrome (one item) and spiritual-type syndromes (four items). Hinton et al. used the CSSI scales in a study in 203 and found it had excellent internal consistency (alpha .91 for somatic scale and 0.88 for the syndrome scale).

Taijin Kyofusho Scale (TKS) and short form – Asia

Taijin Kyofusho means ‘interpersonal fear disorder’ in Japanese; this is a cultural syndrome characterized by anxiety about interpersonal situations due to the patient’s conviction that their appearance and actions are inadequate or offensive and the consequent avoidance of these situations. In the United States, the variant involves having an offensive body odor and is named ‘olfactory reference syndrome’. Taijin Kyofusho is associated with social anxiety disorder in DSM-5 (DSM-5, 2014; Essau et al., 2012; Fan et al., 2023; Kleinknecht et al., 1997; Tarumi et al., 2004; Vriends et al., 2013). The Taijin Kyofusho scale is composed of 31 self-reported items. Vriends et al. (2013, Switzerland) used this scale with a group of Indonesian and Swiss, finding more severe anxiety symptoms in the former than in the latter, but they pointed out that Taijin Kyofusho symptoms might be clinically relevant in all individuals or cultures. Other authors found a higher prevalence of ‘offensive-type’ Taijin Kyofusho (Tarumi et al., 2004) and a high co-occurrence of social phobia, assessed using specific scales (Kleinknecht et al., 1997). Finally, Fan et al. (2023, China) developed and validated a shortened version of the TKS and a computerized adaptive test (CAT); they then compared the precision of the short TKS (12 items), the CAT version (average 11.72 items) and the original version (31 items). They found that the accuracy and precision of the short TKS and the CAT version are similar to the original TKS. The short form is indicated for use as an initial assessment or screening in a community population, while the CAT version is more suitable for ad hoc clinical treatments to detect changes in the severity of Taijin Kyofusho.

Taijin Kyofusho Syndrome Questionnaire (TKSQ) – USA?

Choy et al. (2008, USA) developed a 30-item questionnaire for the assessment of Taijin Kyofusho symptoms, with particular attention to the offensive subtype which they found to be strongly represented in the US population. This tool provides self-administered multiple-choice questions and assesses the severity of 10 symptoms when a patient feels embarrassed, uncomfortable or offensive to others. The authors recognized some limitations of their study, including absence of pre-existing psychometric data and the lack of clinical validation for the US sample. Nonetheless, the TKSQ subscales revealed good internal consistency in both the US and the Korean sample, and also showed consistent findings with clinical TKS subtyping.

Yale-Brown Obsessive-Compulsive Scale Modified for Olfactory Reference Syndrome (ORS-YBOCS)

Olfactory reference syndrome is included in the obsessive-compulsive diseases section in DSM-5 but is not specifically classified as a disorder. This syndrome is associated with Jikoshu-kyofu and Taijin Kyofusho, as described above (DSM-5, 2014). It has recently been included in the ICD-11 (Ren et al., 2020).

The ORS-YBOCS is a 12-item self-administered scale with two additional questions being added to a normal YBOCS (1 – ‘Are you very worried about how you smell? 2 – Do you spend a lot of time thinking about your body odor concerns and wish you could think about them less?’) (Chernyak et al., 2021, India). Greenberg et al. (2016) reported an age of onset of 21.1 years with a chronic and unremitting course; odors were most often reported to emanate from the armpits, feet, and breasts; nearly all the participants engaged in time-consuming rituals to try to hide or eliminate their perceived smell.

Ren et al. (2020) investigated whether ORS should be considered as a categorical or dimensional construct: they used a mixed sample of student and general population and suggested that ORS should be conceptualized, assessed, and treated dimensionally. Greenberg et al. (2018) positively correlated ORS with a number of logistical, financial and stigma barriers and they highlight the importance of increasing awareness and enhancing access to care for individuals with ORS. Another study found cognitive, olfactory, and emotional processing deficits in individuals with ORS (Sofko et al., 2020). In addition, symptom severity was associated with poorer insight, greater avoidance, and higher functional impairment, but was not associated with gender. In Zhou et al.’s (2018) study, 2.4% of the sample presented clinically significant ORS symptoms. Phillips and Menard (2011) confirmed the source of the smell as being the armpits, feet, and breasts, and also the typical repetitive behavior associated with the syndrome (e.g. excessive showering); they also noted that this syndrome appears to be characterized by high morbidity and the seeking of non-psychiatric treatment.

Brief Screening Test for Olfactory Reference Syndrome

Chernyak et al. (2021, India) proposed a screening tool of three open questions administered by a clinician which could substitute the ORS-YBOCS. Three questions concerned offending others, reference and social avoidance.

Screening for abnormal olfactory experiences

Lessa et al. (2014, Brazil) used this scale to compare the sociodemographic and psychiatric features of treatment-seeking patients with and without primary hyperhidrosis attending an outpatient dermatological clinic. We did not succeed in searching this scale which is most likely similar to previous reported (i.e. Brief Screening Test for Olfactory Reference Syndrome?).

Ataque de Nervios questionnaire – USA

Ataque de nervios (attack of nerves) is a cultural Hispanic syndrome, characterized by intense emotional upset, acute anxiety, anger, or grief. Those affected by this syndrome are given to bouts of uncontrollable screaming and shouting, attacks of crying, trembling; they complain of heat in the chest rising into the head, and may become verbally and physically aggressive. Dissociative experiences are known to occur and may deteriorate into suicidal gestures. DSM-5 does not contemplate a specific corresponding disease, but has found a symptomatic overlap with panic disorders, other specified or unspecified dissociative disorders and conversion disorders (DSM-5, 2014).

The questionnaire has a 25 self-reported items and has been validated for the Latin-American population. It starts with an open question, after which 25 symptoms are evaluated; there is no cut-off point or ceiling to establish the presence of Ataque de nervios. Ginzburg et al. (2022, USA) used multivariate logistic regression models to examine the association between neighborhood factors and Ataque de nervios among a sample of Latinas/os participating in the Latino Health and Well-Being Project in the north east of the United States; neighborhood violence was statistically significant in the association with Ataque de nervios, with each unit increase in the neighborhood violence scale being associated with 1.36 times greater possibility of experiencing an Ataque de nervios. Liebowitz et al. (1994, USA) assessed subjects seeking treatment at an anxiety disorder clinic and found that 70% of the patients reported having had at least one Ataque de nervios; 80% of these were female. Ataque de nervios is frequently associated with anxiety and affective disorders. Guarnaccia et al. (2010) confirmed the higher prevalence in women, particularly those with a disrupted marital status and those more acculturated to the US; they highlighted the importance of studying this cultural syndrome as an indicator of social and psychiatric vulnerability in particular for affective, anxiety and substance abuse disorders.

Discussion

The main purpose of this study was to search the literature for diagnostic tools that investigate distress in migrants, asylum seekers and refugees. Despite the number of cultural syndromes and idioms included in our search, and the fact that recently there has been an increase in the interest in transcultural psychiatry, we found very few articles on the topic in literature. There is a particular dearth of articles from western countries. As reported in the Results section we found three scales for olfactory reference syndrome, two scales for dhat syndrome and for taijin kyofusho, one each for kufungisisa, brain-fag, hwa-byung, khyâl attacks, and ataque de nervios. Of these scales only two, the CSSI and the ataque de nervios questionnaire, were used for migrant samples with the former being specifically used for refugees (Hinton et al., 2012). The authors report that although the tool had not been validated, it showed excellent consistency in investigating culture-bound syndrome related symptoms. Indeed, using a specific culture-bound syndrome-related tool refined the diagnosis.

Despite the fact that the role of culture is increasingly recognized, Western mental health services still tend to limit their clinical evaluations of mental disorders to major diseases, even if the patient is from a different culture and cultural elements that influence how syndromes are expressed are not always considered as carefully as they should be. In 1996, Nathan (who had worked with Devereux) and Stenger analyzed the structuring function of culture in the clinical approach to migrants. They pointed out the tendency of western clinicians to generalize their practice, ignoring the cultural origins of their patients (Nathan & Stengers, 1995).

For the clinicians’ work to have a positive outcome, their assessment of their patients’ personal experiences and feelings must be accurate. When the clinician and the patient have different cultural backgrounds, there is a significant risk that ethnocentric biases will compromise this accuracy. In this context there are two perspectives: the etic and the emic. The former holds that disturbances of human psychological functioning manifest in regular patterns across different cultures, the latter that culture plays a central role in the development of the psyche and in the expression of disease. In this case an intimate knowledge of different cultures is needed in order to correctly diagnose mental illnesses (Phan & Silove, 1997). Depression, for example, can manifest in a variety of symptoms including somatization. Chun et al. (1996) noted that Asian people are more inclined to somatic symptoms than their western counterparts because their culture discourages any emotional display of distress, and therefore they deny and repress demonstrations of emotion, focusing on physical distress which is not stigmatized (Chun et al., 1996). In Africa, it is a silent epidemic (Gbadamosi et al., 2022) and continues to be manifested physically, while in the West, physical symptoms have gradually been eclipsed by those with psychic connotations. As Nathan and Devereux underlined several times in their works, cultural origins must be explored in order to find the fundamental elements for correct interpretation and an effective therapeutic intervention.

Settling in a country with a different language and culture can alter an individual’s cultural and ethnic identity (Bhugra, 2005), and this should be taken into account by mental health services (Ekblad & Kastrup, 2013 ). Also Religiosity and Spirituality issues have to be taken into account as part of the culture bound syndromes and histories of mental health problems (Santambrogio et al., 2021, 2024). Studies have shown that ethnic minorities show a disproportionate burden of illness and have unequal access to health care services (Department of Health, 2003; Fernando, 2005 ) which could be attributed to the scarce preparation of the services to meet their needs. Hwang et al. (2008) provided a conceptual paradigm, Cultural Influences on Mental Health (CIMH), to assist in understanding how culture impacts six areas of mental health, that is, prevalence of mental illnesses, etiology, phenomenology of distress, diagnosis, coping styles and treatment.

As mentioned above, cultural differences may affect the diagnostic accuracy of the clinical assessment, and an understanding of these differences is essential to understand the development, progression and treatment of mental illness. However, while the importance of culture is recognized as an element of great utility in shaping the understanding of psychiatric illness, assessing cultural dimensions is not considered as part of routine care.

As Kohrt et al. (2014) pointed out, cultural progress and appropriate application of specific tools in mental health services of the host countries is impeded by the poor quality of the studies available. The psychiatric diagnosis tends to be limited to diseases usually diagnosed in western patients; diseases associated with cultural syndromes are frequently misdiagnosed with consequent negative outcomes, as for example the case reported by El Hamad et al. (2009), where a case of dhat syndrome was tested for several diseases before a correct diagnosis was made. Specific diagnostic instruments for cultural syndromes would be very useful for detecting culturally based mental health problems and evaluating appropriate interventions, but also for identifying vulnerable groups and cultural biases in psychiatric diagnostic criteria. They could also facilitate the necessary integration between ethic and emic perspectives. It is important to validate diagnostic tools for migrants, especially asylum seekers and refugees, and try to find algorithms for using them based on the patient’s cultural origin. As Kohrt and his colleagues reported in the systematic review mentioned above, the literature on cultural concepts of distress and psychiatric disorders is characterized by a lack of epidemiological rigor (e.g. unclear prevalence reporting, use of non-validated instruments and lack of control), and this situation does not appear to have improved.

The Cultural Formation Interview (CFI) is a semi-structured interview proposed by DSM-5 in 2013; its usefulness was subsequently reconfirmed by DSM-5-TR but it is still only rarely used. Aggarwal et al. (2020) found it to be a support in the initial evaluation of patients of different cultures, appreciated by both clinicians and patients. As noted by Jarvis et al. (2020), the CFI focuses clinical attention on the patients’ perspectives and social context, and improves culturally sensitive diagnosis and treatment. Preliminary evidence indicates that the CFI can improve clinical communication by enhancing the clinician-patient rapport and providing clinicians with the means of rapidly obtaining cultural data, and stimulating patients’ perspectives on the cause of their symptoms, helping them to become aware of their problems in more culturally sensitive ways. This instrument was validated internationally in the United States, Canada, Kenya, Peru, the Netherlands, India, and Mexico and generally has been found to be clinically acceptable and useful in these varied settings. While the CFI provides a simple and effective tool to begin cultural assessment, it should be inserted in an approach that uses culturally sensitive scales, such as those we identified in this study, in order to obtain a greater insight into the patients’ problems.

Limitations

While interpreting the data emerging from this study, it is important to keep in mind that the literature offers a very limited number of papers concerning cultural syndromes and specific scales for their diagnosis and the majority of these studies adopted different inclusion and exclusion criteria and different systems of control of potential confounders. Many of the scales and tools found are used only infrequently and/or have not been systematically validated.

Conclusions

Although there is evidence of an increased interest in transcultural psychiatry, supported also by the swelling migratory phenomena and the increasing number of asylum seekers and refugees who applied for mental health services, and despite an ongoing project to give these patients proper psychological and psychiatric support, there has not been a similar increase in interest in diagnosing cultural syndromes. In this narrative review we found only eleven scales for eight different cultural syndromes, although the scales searched for were all cultural syndromes described in DSM-5-TR. In addition, only one of these scales had been designed specifically for refugees and one was used exclusively for the Hispanic community in the USA.

Assuming the goal is person-centered care, clinicians who are treating persons from others culture must arm themselves with valid tools for understanding, analyzing and investigating all those aspects that are foreign to their own culture, but which facilitate understanding of their patients and their disorders. Indeed, it is essential that the immigrant’s culture of origin be systematically considered in the first psychiatric evaluation; too often these patients are evaluated in the same way as western patients. The uniqueness of the patient can only be appreciated by exploring the diversity of their cultural context of origin. As no tools are currently available that consider all the potential cultural facets of the migrant/refugee/asylum seeker population, the CFI proposed by the DSM could be used as systematically as possible; in the meantime new, culturally sensitive tools should be created and existing scales validated, so that the pattern of culturally determined symptoms can be taken into account and studied in transcultural mental health services. This will contribute to optimizing the diagnosis and treatment of these patients whose mental health is deeply bound to their culture of origin.

The research done on this paper leads us to express the hope that in the immediate future more tools will be developed that take into account the cultural makeup of immigrants, migrants, refugees, travelers, all those who find themselves in need of mental health services in another country.

Further work is required in this field, and should include a debate as to whether scales are indeed an appropriate tool for use with this population.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jacopo Santambrogio

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