A Bad Case of the Brain Fags

And other mental problems you probably won’t get in America.

In 1951, Hong Kong psychiatrist Pow-Meng Yap authored an influential paper in the Journal of Mental Sciences on the subject of “peculiar psychiatric disorders”—those that did not fit neatly into the dominant disease-model classification scheme of the time and yet appeared to be prominent, even commonplace, in certain parts of the world. Curiously these same conditions—which include “ amok” in Southeast Asia and bouffée délirante in French-speaking countries—were almost unheard of outside particular cultural contexts. The American Psychiatric Association has conceded that certain mysterious mental afflictions are so common, in some places, that they do in fact warrant inclusion as “culture-bound syndromes” in the official Diagnostic and Statistical Manual of Mental Disorders.

The working version of this manual, the DSM-IV, specifies 25 such syndromes. Take “Old Hag Syndrome,” a type of sleep paralysis in Newfoundland in which one is visited by what appears to be a rather unpleasant old hag sitting on one’s chest at night. (If I were a bitter, divorced straight man, I’d probably say something diabolical about my ex-wife here.) Then there’s gururumba, or “Wild Man Syndrome,” in which New Guinean males become hyperactive, clumsy, kleptomaniacal, and conveniently amnesic, “Brain Fag Syndrome” (more on that in a moment), and “ Stendhal Syndrome,” a delusional disorder experienced mostly by Italians after gazing upon artistic masterpieces. The DSM-IV defines culture-bound syndromes as “recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular diagnostic category.”

And therein lies the nosological pickle: The symptoms of culture-bound syndromes often overlap with more general, known psychiatric conditions that are universal in nature, such as schizophrenia, body dysmorphia, and social anxiety. What varies across cultures, and is presumably moulded by them, is the unique constellation of symptoms, or “idioms of distress.”

Some scholars believe that many additional distinct culture-bound syndromes exist. One that’s not in the manual but could be, argue psychiatrists Gen Kanayama and Harrison Pope in a short paper published earlier this year in the Harvard Review of Psychiatry, is “ muscle dysmorphia.” The condition is limited to Western males, who suffer the delusion that they are insufficiently ripped. “As a result,” write the authors, “they may lift weights compulsively in the gym, often gain large amounts of muscle mass, yet still perceive themselves as too small.” Within body-building circles, in fact, muscle dysmorphia has long been recognized as a sort of reverse anorexia nervosa. But it’s almost entirely unheard of among Asian men. Unlike hypermasculine Western heroes such as Hercules, Thor, and the chiseled Arnold of yesteryear, the Japanese and Chinese have tended to prefer their heroes fully clothed, mentally acute, and lithe, argue Kanayama and Pope. In fact, they say anabolic steroid use is virtually nonexistent in Asian countries, even though the drugs are considerably easier to obtain, being available without a prescription at most neighborhood drugstores.

So culture-bound syndromes certainly aren’t reserved to exotic, foreign countries that are difficult to pronounce: America has its own hodgepodge collection based on our singularly weird hang-ups. But let’s talk about those unpleasant fags—which seem to be  quite a problem in Africa and some other parts of the world. Brain Fag Syndrome has historically affected Nigerian college students, but has also been documented among non-Caucasians in Liberia, Uganda, the Ivory Coast, and South Africa, and very rarely those in Brazil, India, Malaysia, China, and Ethiopia.

The phenomenonology of Brain Fag Syndrome is captured in a prototypical case described by Bolanie Ola and his colleagues in a 2009 review from the African Journal of Psychiatry:

A Yoruba male … who when studying for an exam began to have sharp pains in his head and could not grasp what he was reading. He slept more than usual, and had difficulty forcing himself to go to school in the morning. When writing the examinations, he felt he knew the answers, but was unable to recall them; his mind was blank. His right hand was weak and shook so that he couldn’t write. Because of these symptoms, he was forced to postpone the writing examinations for several years. His symptoms improved greatly with Largactil (an antipsychotic medication) and reassurance.

From this example we can see the abbreviated origins of the fags—it refers to “brain fatigue,” not the derogatory term for homosexuals. (Nigeria isn’t exactly known for its progressive attitudes toward gay rights, so you’d be forgiven for thinking otherwise; but in fact we gays are much more likely to be referred to as old-school Sodomites worthy of God’s smiting than “fags” over there.) The important thing here, as in the foregoing condition of muscle dysmorphia, is the unique cultural constellation of symptoms of brain fag, such as painful sensations around the head and neck, cognitive impairments that hinder studying and reasoning, and sleepiness.

Ola and his colleagues, as well as other scholars studying Brain Fag Syndrome, suggest that the disorder may be a somatic manifestation of the rather sudden Westernization of African education; the collective nature of traditional African culture clashes with the highly individualistic and competitive nature of our own. As many as 40 percent of Nigerian university students may experience brain fag symptoms, says Ola, but the percentage who get the full-blown syndrome seems to be decidedly lower. In any event, if you’re an American student reading this, I wouldn’t recommend you invoke brain fag as a defense when explaining to your professor your academic failures; even if it’s true, it will only complicate matters for you.

Perhaps the best-known culture-bound syndrome is koro, in which the patient is convinced that protruding bodily organs, such as the male genitalia or female nipples, are retracting or disappearing into his or her body. Individuals experiencing this delusion are furthermore morbidly afraid that this retraction will inevitably result in their death, and so present to clinicians with debilitating anxiety. Descriptions of koro can be found as early as 2,000 years ago in China, when the Nei Jing (or, the Yellow Emperor’s Classic Text of Internal Medicine) included mention of “penis-shrinking,” and the belief that genital retraction is related to a faulty yin-yang system and prognosticates an early death.

Harvard psychiatrist Huaiyu Yang and her colleagues point out that sporadic cases expressing the same symptoms of koro have been observed in societies in which this belief in yin-yang, and the attendant cultural concept of the disease, is completely unknown to those afflicted. This casts doubt on the “culture-boundedness” of koro, they argue, offering the following case report as an example:

Mr. A was a 56-year-old, single, first-generation Italian American male with a long history of schizophrenia … his symptoms are predominantly bodily delusions including a sense of his penis having shrunken and perhaps continuing to shrink. Verbatim examples of utterances from chart notes over the past several years include: “[my] bone broken … very worried … balls gone, penis shrunk”; “losing penis”; “no penis”; “I am impotent and sterile”; and “I am close to death.”

Even though Mr. A doesn’t hail from a society in which koro is ingrained in the cultural grammar, he’s still displaying the same symptom profile as more traditional sufferers in China. In his case, however, the researchers believe that the delusion of his disappearing penis is likely owed to his increasing obesity and the fact that his psychotropic medication has rendered him impotent. In other words, “Your penis isn’t actually getting smaller, dear, your belly is just getting bigger.” It’s indeed a cruel twist of nature that the penis is the one part of the male body that maintains its slim, girlish figure while the rest of us gets fat.

In any event, this Americanized example of koro illustrates the methodological pitfalls and conceptual challenges of branding something as a culture-bound disorder, when in fact it may not be as perfectly tethered to a specific geographical region as many investigators assume. But Yang concedes there is little doubt that certain psychological disorders, including koro, are linked to their sociocultural milieus.

A similar example, also in the DSM-IV, is the East Asian phenomenon of jiko-shisen-kyofu, the phobia that one’s own glance will displease or offend other people. According to a team of Japanese psychiatrists led by Yasuhide Iwata from Hamamatsu University, this shameful feeling is the psychopathological product of East Asia’s unreasonable, perhaps even impossible, demands surrounding proper social etiquette and interpersonal relations. The authors introduce us to a taxi driver in Japan who can’t look into his rearview mirror for fear he’ll meet with his passengers’ eyes, and a young man who dropped out of society and became a solitary farmer out of the belief that his peculiar glance would deeply wound people.

Although jiko-shisen-kyofu is relatively common in Japan, it’s almost entirely unheard of in Western nations. The only similar American case, reported by Harvard psychologist Richard McNally and his colleagues in 1990, was a woman who found it difficult to avoid staring at other people’s genital areas and feared embarrassing them (but oddly not herself) with her visual tic.

This is, of course, just a small sampling of the rich variety of culture-bound disorders currently under discussion in clinical camps. Again, the DSM-IV glossary lists only 25, but depending on the criteria used, some scholars believe that as many as 175 distinct culture-bound syndromes may exist. Some of these may be included in the new version of the manual, due out in May 2013. Getting a handle on our own ethnocentric biases is key to understanding people from other cultures, so the recognition and description of such “psychiatric diversity” is by no means a trivial matter.