Asian Journal of Psychiatry 12 (2014) 113–117
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Epidemic of Koro in North East India: An observational cross-sectional study Rajesh Kumar *, Hemendra Ram Phookun, Arunava Datta Department of Psychiatry, Gauhati Medical College and Hospital, Bhangagarh, Guwahati, Assam 781032, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 April 2014 Received in revised form 21 July 2014 Accepted 28 July 2014
Objective: Koro is a culture bound syndrome, endemic in South-East Asia. The present study attempts to correlate the socio-cultural and demographic variables of the patients with the occurrence of the Koro and the differences in presentation between the classical features of the Koro and the actual presentation of the disease that has been observed in the present study. Method: A cross-sectional observational study was performed and data collected during the period was compared, analyzed and studied. A total number of 70 patients who presented to the Department of Psychiatry with symptoms of Koro over the period of 5 days were taken into the study. Results: Most of the patients were, young, unmarried males belonging to a lower socioeconomic status. Most of these patients suffered the attacks in the evening mostly while at home. It was common in migrant and migrant lineage. Media had a major role to spread this epidemic. Conclusions: Koro epidemics are considered to be the result of panic that spread following the occurrence of symptoms in one or more individuals within the same geographical zone. While the issues concerning phenomenology, diagnosis and nosology of Koro are still being discussed, it is apparent that Koro which presents as an acute anxiety state is treatment responsive and has good prognosis. ß 2014 Elsevier B.V. All rights reserved.
Keywords: Koro Culture bound syndrome Acute anxiety Epidemic Psycho-education North-Eastern India
1. Introduction The earliest Western reference to the term Koro has been found in B.F Matthes’ dictionary of Buginese language (1874) of South Sulawesi Indonesia (Chowdhury, 1998). Koro is also known by a variety of names, in China it is called ‘‘Suoyang’’ (Suo = shrinkinking, Yang = penis) (Cheng, 1997) or ‘‘suk-yeong’’ in Cantonese (Bernstein and Gaw, 1990), ‘‘Jhinjhinia Bemar’’ in Assam (India) (Dutta et al., 1982) to name a few. Koro has been defined in various textbooks as a culture bound syndrome that is characterized by a predominating belief and fear in the individuals that their genitals are retracting into the abdomen and may disappear which might lead to their death. Koro was initially thought to be confined to people of South China and Yangtze valley and among migrant Chinese workers in the South East Asia region (Dutta et al., 1982; Gwee, 1963; Rin, 1965). Later Koro was also found in culturally different settings among people from India (Dutta et al., 1982; Nandi et al., 1983) and Western Africa (Dzokoto and Adams, 2005) among various other
* Corresponding author. Tel.: +91 98103 50476/95405 85856. E-mail addresses: [email protected], [email protected] (R. Kumar). http://dx.doi.org/10.1016/j.ajp.2014.07.006 1876-2018/ß 2014 Elsevier B.V. All rights reserved.
places in the world. Though Koro usually presents in epidemics, sometimes patients of Koro also present sporadically as reported in America (Edwards, 1970), Britain (Barrett, 1978) and India (Chakravarty, 1982; Shukla and Mishra, 1981). Koro is usually found among poorly educated young males and females who have an immature dependent personality and who lack confidence in their own virility. They may exhibit increased sexual behavior, are usually in conflict over the expression of their own genital impulses (Nandi et al., 1983). The etiology of Koro is unknown. Koro has been considered to be a ‘‘culture bound variant of hysteria’’ (Sachdev, 1985) or a ‘‘panic disorder’’ (Tseng et al., 1992) or a ‘‘sexual somatization disorder’’ (Chowdhury, 2008). The text revision of fourth edition of the Diagnostic and Statistical Manual of Mental disorders (DSM-IV-TR) classification of psychiatric disorders has listed Koro in the glossary of Culture Bound Syndromes (Appendix I) (American Psychiatric Association, 1994). Clinically the disease starts with tingling sensation of hands and legs and an acute attack of sudden intense anxiety that the genitalia (and also the nipples in cases of females) (Dutta et al., 1982) will recede into the body which might result in death (Garlipp, 2008). The patient tries to stop the retraction of their genitals by tying strings around it or clamping it with hands or asking family members and friends to grasp the genitalia firmly so as to keep them in place. These actions sometimes result in damage
R. Kumar et al. / Asian Journal of Psychiatry 12 (2014) 113–117
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to the genital organs (Cheng, 1997). The duration of each episode may vary from several minutes to several hours and even days. 1.1. Description of epidemic An epidemic of Koro broke out in the north eastern state of Assam, India in September 2010, when few patients with classical symptoms of Koro reported in emergency department of Gauhati Medical College and Hospital. Within next few days the number of cases reporting to different hospitals and nursing homes of the city increased rapidly and the phenomenon came to be widely reported by different media like newspaper, television and magazines. It was observed that initially all the cases belonged to a particular area of the city while the later cases were from different parts of the city as well as nearby districts of the state. Finally the epidemic spread to all communities and classes of population and affected thousands of people in the state. Patients attended primary health centers, district hospitals, nursing homes and medical colleges of the state (Roy et al., 2011). We observed that media had played significant role in spreading the news of the disease. Lots of people were seen in the Guwahati with smeared lime on ears and wearing amulets. A unit of psychiatrists was formed in Gauhati Medical College and Hospital and other institutions also to control the epidemic. Health services of Assam had started mass education programs in all communities about the illness through various mass media, social workers and doctors’ team. Consequently in next 2–3 weeks the incidence of cases reduced in all parts of the state. After diagnosing this illness as an epidemic of Koro, we attempted to study these cases with following objects in view: 1. To study the phenomenology of the current Koro cases and differences in presentation of the disease that has been observed in the previous studies. 2. To relate the socioeconomic and demographical variables of the patient population with the occurrence of the disease.
2. Materials and method 2.1. Cases The Koro outbreak was reported from certain areas of city of Guwahati, India and neighboring districts and peak wave occurred from last week of September 2010 to first week of October 2010. We conducted a cross-sectional observational study on 70 cases of Koro over a 5 days duration (27-9-10 to 1-10-10) (Graph 1) who attended Gauhati Medical College and Hospital. Patients were attended either in emergency department or outpatient department of the hospital. All cases were interviewed by members of the psychiatric unit that was formed to manage cases. A semistructured case history sheet was developed to maintain uniform case information. Elaborate history was taken from cases
20 15 10 5 0
Patients Graph 1. Datewise presentation of koro patients taken in the study.
pertaining to age, gender, level of education, marital status and clinical variables like various symptoms of the disease, place of occurrence of the disease and previous knowledge of the disease and other temporally related events or other precipitating factors. Patients with co-existing psychiatric illness like schizophrenia, delusional disorder, other psychosis or any significant medical and surgical genital’s illness were excluded from the study. We have used DSM-IV-TR (American Psychiatric Association, 1994) diagnostic criteria for Koro to diagnose the patients. Written informed consent was taken for the study. The data collected during the period were compared, analyzed and studied. 3. Results We studied 70 cases of Koro who attended Gauhati Medical College and Hospital. 3.1. Sociodemographic and clinical variables: (Tables 1 and 2) 3.1.1. Gender Typically patients of Koro were males 97.1% (n = 68) and only 2.8% (n = 2) were female. 3.1.2. Age group Most common presentation was among young males in age group of 21–30 years in 61.4% (n = 43) followed by 31–40 years in 18.6% (n = 13) and 11–20 years in 12.8% (n = 9). Only 7.1% (n = 5) patients were above 40 years of age. The female patients belonged to 31–40 years of age group. 3.1.3. Marital status Most of them 70% (n = 49) were unmarried males. 44.9% (n = 22) had preoccupation with masturbatory practice and 36.7% (n = 18) complained of passing of semen in their urine and spontaneous ejaculation of semen in night (Dhat syndrome). 30% (n = 21) of patients were married and 28% (n = 6) of them staying alone away from wife. In few of the married patients the shortening of penis was noticed by their wife during intercourse. All of the patients were concerned about their future sexual life. Table 1 Showing socio demographical variables. Socio demographic variables Gender Male Female Age (years) 11–20 21–30 31–40 Above 40 Marital status Married Single Place of presentation Casuality department Outdoor patient department Religion Hindu Islam Sikh Socioeconomic status Lower socioeconomic status Middle socioeconomic status Higher socioeconomic status Education Illiterate Below high school Above high school
Total n = 70
Percentage
68 2
97.1 2.8
9 43 13 5
12.85 61.42 18.57 7.14
21 49
30 70
48 22
68.57 31.42
45 24 1
64.25 34.28 1.4
44 26 –
62.85 37.14 –
7 13 50
10 18.57 71.42
R. Kumar et al. / Asian Journal of Psychiatry 12 (2014) 113–117 Table 2 Showing clinical presentation variables. Clinical presentation variables
Total n = 70
Percentage
Prior knowledge of koro Hearsay and discussion about the illness Witness of the Koro in their community Attack of place Home Working place Time of attack Night Day Tingling sensation Apprehension Palpitation Increased sweating Breathlessness Chest discomfort Restlessness
58 49 21
82.85 70 30
60 10
85.71 14.28
51 19 63 60 49 53 42 42 60
72.85 27.14 90 85.7 70 75.7 60 60 85.7
3.1.4. Place of presentation Most of the patients 68.5% (n = 48) attended the hospital in casualty department at night time around 8–11 PM for immediate medical intervention because of physical and mental distress. Rest of the patients 31.4% (n = 22) presented in outpatient department. 3.1.5. Religion Majority of the patients were Hindus 64.2% (n = 45) while the rest of the sample consisted of Islam patients 34.3% (n = 24) and a solitary Sikh patient 1.4% (n = 1) of study sample. 3.1.6. Time and place of onset of episode In most of the cases these episodes started when they were indoors 85.7% (n = 60) and first manifestation occurred during evening and early night 72.8% (n = 51). In 14.2% (n = 10) patients, episodes started when they were in their workplace. 70% (n = 49) patients also reported about the hearsay and discussion with friends and family about the illness. Some of them 30% (n = 21) also had been witness of Koro in their community. 3.1.7. Prior knowledge about the disease Assam has had epidemics of Koro in the past and it remains a well discussed matter in the community. The knowledge about the previous epidemic and news regarding current Koro epidemic were seen in 82.8% (n = 58) of patients. 30% (n = 21) also had been witness of Koro in their community. 3.1.8. Socioeconomic status 62.3% (n = 44) of the patients belonged to the lower socioeconomic status with most of them being daily wage earners such as fishermen, farmers, manual laborers and masons. 37.1% (n = 26) of patients belonged to middle socioeconomic status being students, shopkeepers and clerks.
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genitalia, restlessness, help seeking behavior, increased sweating and a fear of death. All male patients complained about the feeling of shortening and retraction of penis in the abdomen and leading to death. Similarly two female patients complained about feeling of shortening and retraction of nipple and female genitals inward and fear of death. The tingling sensation over leg and foot was also reported in 90% (n = 63) of patients. This tingling sensation started over legs or feet and then moved toward abdomen and other parts of the body rapidly. It was named as ‘‘Jhinjhinia Bemar’’ in Assamese (Jhinjhinia means tingling). People considered this was caused by ‘‘bad air’’ or ‘‘bad spirits’’ that was in the air and entered in the body through toes and foot. The onset of symptoms was sudden and severe in intensity. These episodes had a short course lasting 10 min to 5 h with an average duration of half an hour. These symptoms were also associated in 85.7% (n = 60) of the patients with increased worry and apprehension about death due to retraction of penis in the abdomen, dissolution of genitals, genital dysfunctions, impotency or future marital life. Other associated complaints among patients were increased palpitation 70% (n = 49), increased sweating 75.7% (n = 53), breathlessness 60% (n = 42), chest discomfort 60% (n = 42) and restlessness 85.7% (n = 60). These patients had expressed help seeking behavior from various sources like faith healer, quack doctors (unregistered medical practitioner), local traditional (alternative medicine) treatment, religious help and medical help. They attended primary health centers, civil hospitals or medical colleges for immediate medical intervention. Popular treatments as per the local beliefs involved pouring water on the genitals and body; sitting in water tub or tank; in acute phase it was recommended to apply lime (calcium carbonate) on the earlobes; to wear amulets or talismans containing cucumber seed or chanted paper to ward off the evil spirits that was responsible for the disease for people to stay safe. There were instances of patients coming to the emergency department sitting in a water tub (Fig. 1) or with a wet cloth. As per local belief the body heat was also the reason for the symptoms and pouring water or sitting immersed in water keeps genitals cool and prevents the retraction of the penis. They also used strings (sutoli) to tie around the penis to prevent the retraction of that. These methods of prevention of retraction of penis often led to physical injury in patients. 3.3. Management of the patients: The presentation of disease occurred in an epidemic form and they demanded immediate medical intervention apart from traditional local therapy for their physical and mental distress.
3.1.9. Education 71.4% (n = 50) were high school or above educated followed by 18.5% (n = 13) below high school educated and 10% (n = 7) were illiterate. These patients had poor knowledge about their sexuality, sexual practice, anatomy and physiology of genital’s organ. 3.2. Clinical presentation: (Table 2) During the study we found that the patients were complaining of three common symptoms: (1) feelings of retraction or shortening of the penis, (2) tingling sensation that starts from the thigh and goes to the abdomen or other parts of the body, (3) severe degrees of anxiety with increased worrying about his
Fig. 1. Patient came in casuality department for treatment sitting in the water tub.
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R. Kumar et al. / Asian Journal of Psychiatry 12 (2014) 113–117
Patients were treated with various pharmacotherapy, psychotherapy and mass education programs. 3.3.1. Pharmacotherapy We used benzodiazepines like lorazepam, clonazepam, etizolam in adequate dosage for acute anxiety state. In some patients we also prescribed selective serotonin reuptake inhibitors (SSRI) like escitalopram, paroxetine, fluoxetine and tri-cyclic antidepressants (TCA) like amytriptyline for 2–3 weeks to reduce the anxiety. Patients had significant response to this medical treatment. 3.3.2. Psychotherapy Psychiatric unit had given insight oriented psychotherapy, supportive therapy, and interpersonal psychotherapy to all patients either on an individual session or in group sessions. Mass education programs were also conducted by doctors, psychiatric social workers and media like newspaper, television (TV) educating public about the nature, course, prognosis, prevention and myths of the disease in the community.
4. Discussion Assam has a multi-ethnic, multi-linguistic and multi-religious society. The large number of ethnic and linguistic groups among the population composition in the state has led to it being called an ‘‘India in Miniature’’ (Taher, 1993). Geographically Assam is accessible from Tibet in the north, from Burma in south east. In the west both the Brahmaputra valley and the Barak valley open widely to the Gangetic plains. Assam has been populated via all these accessible points in the past. Pre-historically there were groups of people migrating from South East Asia, Tibet and Southern China. There is a fair amount of ethnic and religious diversity in state. Koro syndrome is common in migrants and people of migrant lineage as reported in various studies (Constable, 1979; Edwards, 1984; Rin, 1965). There have been many epidemics in Assam (Dutta et al., 1982) and neighboring states of West Bengal and Tripura (Ghosh et al., 2013; Nandi et al., 1983) in past years. The knowledge about the previous episodes of Koro remains prevalent in the community (82.8%) and these populations are suggestible and vulnerable for generation of disease and epidemics. During our study we found that the patients were complaining of three common symptoms: (1) tingling sensation that starts from the thigh and goes to the abdomen or other parts of the body. (2) Shortening of the penis. (3) Severe degrees of anxiety with increased worrying about his genitalia, restlessness, help seeking behavior, increased sweating and a fear of death. The onset of symptoms was sudden, severe in intensity and had a short course. The phenomenological features like physical sensations, emotions and thought of the person while experiencing the syndrome share with anxiety disorders. The clinical features of the Koro cases in our study resembled those from the previous epidemic in Assam as reported by Dutta et al. in 1982. The symptoms have been found is comparable with anxiety disorders (Chowdhury, 1996; Constable, 1979; Cremona, 1981; Dutta et al., 1982). The number of patients who came for medical treatment were however less in comparison to previous epidemics. The reason may be attributed to the short course of illness and intensive intervention from various agencies of health care. Typically patients of Koro are young unmarried males. This population has poor sexual knowledge and they also do experiment with sexual act (Cheng, 1997). The reason behind low incidence of disease in female (2.8%) may be patients were reluctant to report their symptoms because of feelings of guilt and
shame. Koro is common to population belonging to the low socioeconomic background. In most of cases these attacks started when they were indoors and first manifestation occurred during evening and early night. The time and place for attack were corresponding to findings of Dutta et al. (1982) and Ngui (1969) that Koro attacks are more prone to develop at night when a person gets more time for introspection, sexual stimulation and sexual acts. This particular time is also important when people entertain with TV or other media. Hearsay and media (print or audio-visual) played a major role to spread the news. We found certain risk factors in the study population such as exposure to rumors and suggestibility (Gwee, 1968), commonly shared belief (Tseng et al., 1992), geographical seclusion (Tseng et al., 1988), mostly young poorly educated male susceptible to superstitious beliefs (Cheng, 1997; Sachdev, 1985; Tseng et al., 1988, 1992), suggestion (Nandi et al., 1983), belief in concept of Koro (Tseng et al., 1992) prominent among others. In our study we found no history of extramarital intercourse or venereal disease and scrotal filariasis in any of the patients. This finding contradicts the finding of Chowdhury (1989). One of reasons maybe attributed to the endemicity of fibrosis in different parts of India. No significant premorbid sexual psychopathologies were found among the various subjects studied in the present study (Sachdev, 1985). The external body parts like penis, scrotum, breasts and vulva have characteristics of changing in its size and shape in related to different stimuli. The appearance of penile retraction or diminution of scrotum is affected by cold, anxiety, apprehension or fear (Oyebode et al., 1986). We observed that apprehension or fear of death that was prevalent in the patients and pouring of water to the genitals, further aggravated the symptoms. People considered these episodes to be caused by ‘‘bad air’’ or ‘‘evil spirit’’ (Tseng et al., 1988) that was in the air and entered in body through the toes and foot. People were afraid to go out of home or to their workplace to save themselves from the disease, as the belief was that ‘‘bad air’’ was the cause behind the disease. They had taken treatment to ward off the evil spirits that were responsible for the disease for people to stay safe. There are a number of inherent limitations in this study: a proper follow-up of the patients after their treatment in their acute stage was not done; an accurate assessment of the prior knowledge of the patients about the disease could not be assessed as there was widespread publicity in the local newspapers and television which might have biased certain people. In conclusion Koro epidemics are considered to be the result of panic that spread following the occurrence of symptoms in one or more individuals within the same geographical zone. While the issues concerning phenomenology, diagnosis and nosology of Koro are still being discussed, it is apparent that Koro which presents as an acute anxiety state is treatment responsive and has a good prognosis. The current study offers an insight into phenomenology, course and treatment of the Koro. Conflict of interest None. All the authors assure that there are no commercial or financial involvements that might present an appearance of a conflict of interest in connection with this article. Acknowledgments We would like to thank Dr. (Prof.) D. Bhagabati, Dr. Sonia Chawla, Dr. Vipin Dagar, Dr. Ranjita Das Dagar, Dr. Vishesh Agarwal, Dr. Sunil Mittal and Mr. Ranjan Kumar for their active help and co-operation for this research work.
R. Kumar et al. / Asian Journal of Psychiatry 12 (2014) 113–117
References American Psychiatric Association, 1994. The Diagnostic and Statistical Manual of Mental Disorders, fourth ed. American Psychiatric Association, Washington, DC. Barrett, K., 1978. Koro in a Londoner. Lancet 312 (8103) 1319. Bernstein, R.L., Gaw, A.C., 1990. Koro: proposed classification for DSM-IV. Am. J. Psychiatry 12, 1670–1674. Chakravarty, P.K., 1982. Koro a peculiar anxiety neurosis (a case report). Indian J. Psychiatry 24, 192. Cheng, S.T., 1997. Epidemic genital retraction syndrome: environmental and personal risk factors in Southern China. J. Psychol. Hum. Sex. 9, 57–70. Chowdhury, A.N., 1989. Biomedical potential for symptom choice in Koro. Int. J. Soc. Psychiatry 35, 329–332. Chowdhury, A.N., 1996. The definition and classification of Koro. Cult. Med. Psychiatry 20, 41–65. Chowdhury, A.N., 1998. Hundred years of Koro. Int. J. Soc. Psychiatry 44, 181–189. Chowdhury, A.N., 2008. Ethnomedical concept of heat and cold in koro: study from Indian patients. World Cult. Psychiatry Res. Rev. 3, 146–158. Constable, P.J., 1979. Koro in Hertfordshire. Lancet 1, 163. Cremona, A., 1981. Another case of Koro in a Briton. Br. J. Psychiatry 138, 180–181. Dutta, D., Phookun, H.R., Das, P.D., 1982. The koro epidemic in lower Assam. Indian J. Psychiatry 24, 370–374. Dzokoto, V.A., Adams, G., 2005. Understanding genital-shrinking epidemics in West Africa: koro, juju or mass psychogenic illness? Cult. Med. Psychiatry 29, 53–78. Edwards, J.G., 1970. The Koro pattern of depersonalization in an American schizophrenic patient. Am. J. Psychiatry 126, 1171–1173. Edwards, J.W., 1984. Indigenous Koro, a genital retraction syndrome of insular Southeast Asia: a critical review. Cult. Med. Psychiatry 8, 1–24.
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Garlipp, P., 2008. Koro – a culture-bound phenomenon intercultural psychiatric implications. Ger. J. Psychiatry 11, 21–28. Ghosh, S., Nath, S., Brahma, A., Chowdhury, A.N., 2013. Fifth Koro epidemic in India: a review report. World Cult. Psychiatry Res. Rev. 8 (1) 8–20. Gwee, A.L., 1963. Koro – a cultural disease. Singap. Med. J. 4, 119–122. Gwee, A.L., 1968. Koro – its origin and nature as a disease entity. Singap. Med. J. 9, 3–6. Nandi, D.N., Banerjee, G., Saha, H., 1983. Epidemic Koro in West Bengal, India. Int. J. Soc. Psychiatry 29, 265–268. Ngui, P.W., 1969. The Koro epidemic in Singapore. Aust. N. Z. J. Psychiatry 3, 263. Oyebode, F., Jamieson, M.J., Davison, K., 1986. Koro – a psychophysiological dysfunction. Br. J. Psychiatry 148, 212–214. Rin, H., 1965. A study of the aetiology of Koro in respect to the Chinese concept of illness. Int. J. Soc. Psychiatry 11, 7–13. Roy, D., Hazarika, S., Bhattacharya, A., Das, S., Nath, K., Saddichha, S., 2011. Koro: culture bound or mass hysteria? Aust. N. Z. J. Psychiatry 45, 683. Sachdev, P.S., 1985. Koro epidemic in north-east India. Aust. N. Z. J. Psychiatry 19, 433–438. Shukla, G.D., Mishra, D.N., 1981. Koro like syndrome. Indian J. Psychiatry 23, 96. Taher, M., 1993. The peopling of Assam and contemporary social structure. In: Ahmad, A. (Ed.), Social Structure and Regional Development. Rawat Publications, New Delhi, India. URL: http://en.wikipedia.org/wiki/People_of_Assam. Tseng, W.S., Kan-Ming, M., Hsu, J., Li-Shuen, L., Li-Wah, O., Guo-Qian, C., Da-Wie, J., 1988. A sociocultural study of Koro epidemics in Guangdong, China. Am. J. Psychiatry 145, 1538–1543. Tseng, W.S., Kan-Ming, M., Li-Shuen, L., Guo-Qian, C., Li-Wah, O., Hong-Bo, Z., 1992. Koro epidemics in Guangdong,China. A questionnaire survey. J. Nerv. Ment. Disord. 180, 117–123.
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Epidemic of Koro in North East India: An observational cross-sectional study Rajesh Kumar *, Hemendra Ram Phookun, Arunava Datta Department of Psychiatry, Gauhati Medical College and Hospital, Bhangagarh, Guwahati, Assam 781032, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 April 2014 Received in revised form 21 July 2014 Accepted 28 July 2014
Objective: Koro is a culture bound syndrome, endemic in South-East Asia. The present study attempts to correlate the socio-cultural and demographic variables of the patients with the occurrence of the Koro and the differences in presentation between the classical features of the Koro and the actual presentation of the disease that has been observed in the present study. Method: A cross-sectional observational study was performed and data collected during the period was compared, analyzed and studied. A total number of 70 patients who presented to the Department of Psychiatry with symptoms of Koro over the period of 5 days were taken into the study. Results: Most of the patients were, young, unmarried males belonging to a lower socioeconomic status. Most of these patients suffered the attacks in the evening mostly while at home. It was common in migrant and migrant lineage. Media had a major role to spread this epidemic. Conclusions: Koro epidemics are considered to be the result of panic that spread following the occurrence of symptoms in one or more individuals within the same geographical zone. While the issues concerning phenomenology, diagnosis and nosology of Koro are still being discussed, it is apparent that Koro which presents as an acute anxiety state is treatment responsive and has good prognosis. ß 2014 Elsevier B.V. All rights reserved.
Keywords: Koro Culture bound syndrome Acute anxiety Epidemic Psycho-education North-Eastern India
1. Introduction The earliest Western reference to the term Koro has been found in B.F Matthes’ dictionary of Buginese language (1874) of South Sulawesi Indonesia (Chowdhury, 1998). Koro is also known by a variety of names, in China it is called ‘‘Suoyang’’ (Suo = shrinkinking, Yang = penis) (Cheng, 1997) or ‘‘suk-yeong’’ in Cantonese (Bernstein and Gaw, 1990), ‘‘Jhinjhinia Bemar’’ in Assam (India) (Dutta et al., 1982) to name a few. Koro has been defined in various textbooks as a culture bound syndrome that is characterized by a predominating belief and fear in the individuals that their genitals are retracting into the abdomen and may disappear which might lead to their death. Koro was initially thought to be confined to people of South China and Yangtze valley and among migrant Chinese workers in the South East Asia region (Dutta et al., 1982; Gwee, 1963; Rin, 1965). Later Koro was also found in culturally different settings among people from India (Dutta et al., 1982; Nandi et al., 1983) and Western Africa (Dzokoto and Adams, 2005) among various other
* Corresponding author. Tel.: +91 98103 50476/95405 85856. E-mail addresses: [email protected], [email protected] (R. Kumar). http://dx.doi.org/10.1016/j.ajp.2014.07.006 1876-2018/ß 2014 Elsevier B.V. All rights reserved.
places in the world. Though Koro usually presents in epidemics, sometimes patients of Koro also present sporadically as reported in America (Edwards, 1970), Britain (Barrett, 1978) and India (Chakravarty, 1982; Shukla and Mishra, 1981). Koro is usually found among poorly educated young males and females who have an immature dependent personality and who lack confidence in their own virility. They may exhibit increased sexual behavior, are usually in conflict over the expression of their own genital impulses (Nandi et al., 1983). The etiology of Koro is unknown. Koro has been considered to be a ‘‘culture bound variant of hysteria’’ (Sachdev, 1985) or a ‘‘panic disorder’’ (Tseng et al., 1992) or a ‘‘sexual somatization disorder’’ (Chowdhury, 2008). The text revision of fourth edition of the Diagnostic and Statistical Manual of Mental disorders (DSM-IV-TR) classification of psychiatric disorders has listed Koro in the glossary of Culture Bound Syndromes (Appendix I) (American Psychiatric Association, 1994). Clinically the disease starts with tingling sensation of hands and legs and an acute attack of sudden intense anxiety that the genitalia (and also the nipples in cases of females) (Dutta et al., 1982) will recede into the body which might result in death (Garlipp, 2008). The patient tries to stop the retraction of their genitals by tying strings around it or clamping it with hands or asking family members and friends to grasp the genitalia firmly so as to keep them in place. These actions sometimes result in damage
R. Kumar et al. / Asian Journal of Psychiatry 12 (2014) 113–117
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to the genital organs (Cheng, 1997). The duration of each episode may vary from several minutes to several hours and even days. 1.1. Description of epidemic An epidemic of Koro broke out in the north eastern state of Assam, India in September 2010, when few patients with classical symptoms of Koro reported in emergency department of Gauhati Medical College and Hospital. Within next few days the number of cases reporting to different hospitals and nursing homes of the city increased rapidly and the phenomenon came to be widely reported by different media like newspaper, television and magazines. It was observed that initially all the cases belonged to a particular area of the city while the later cases were from different parts of the city as well as nearby districts of the state. Finally the epidemic spread to all communities and classes of population and affected thousands of people in the state. Patients attended primary health centers, district hospitals, nursing homes and medical colleges of the state (Roy et al., 2011). We observed that media had played significant role in spreading the news of the disease. Lots of people were seen in the Guwahati with smeared lime on ears and wearing amulets. A unit of psychiatrists was formed in Gauhati Medical College and Hospital and other institutions also to control the epidemic. Health services of Assam had started mass education programs in all communities about the illness through various mass media, social workers and doctors’ team. Consequently in next 2–3 weeks the incidence of cases reduced in all parts of the state. After diagnosing this illness as an epidemic of Koro, we attempted to study these cases with following objects in view: 1. To study the phenomenology of the current Koro cases and differences in presentation of the disease that has been observed in the previous studies. 2. To relate the socioeconomic and demographical variables of the patient population with the occurrence of the disease.
2. Materials and method 2.1. Cases The Koro outbreak was reported from certain areas of city of Guwahati, India and neighboring districts and peak wave occurred from last week of September 2010 to first week of October 2010. We conducted a cross-sectional observational study on 70 cases of Koro over a 5 days duration (27-9-10 to 1-10-10) (Graph 1) who attended Gauhati Medical College and Hospital. Patients were attended either in emergency department or outpatient department of the hospital. All cases were interviewed by members of the psychiatric unit that was formed to manage cases. A semistructured case history sheet was developed to maintain uniform case information. Elaborate history was taken from cases
20 15 10 5 0
Patients Graph 1. Datewise presentation of koro patients taken in the study.
pertaining to age, gender, level of education, marital status and clinical variables like various symptoms of the disease, place of occurrence of the disease and previous knowledge of the disease and other temporally related events or other precipitating factors. Patients with co-existing psychiatric illness like schizophrenia, delusional disorder, other psychosis or any significant medical and surgical genital’s illness were excluded from the study. We have used DSM-IV-TR (American Psychiatric Association, 1994) diagnostic criteria for Koro to diagnose the patients. Written informed consent was taken for the study. The data collected during the period were compared, analyzed and studied. 3. Results We studied 70 cases of Koro who attended Gauhati Medical College and Hospital. 3.1. Sociodemographic and clinical variables: (Tables 1 and 2) 3.1.1. Gender Typically patients of Koro were males 97.1% (n = 68) and only 2.8% (n = 2) were female. 3.1.2. Age group Most common presentation was among young males in age group of 21–30 years in 61.4% (n = 43) followed by 31–40 years in 18.6% (n = 13) and 11–20 years in 12.8% (n = 9). Only 7.1% (n = 5) patients were above 40 years of age. The female patients belonged to 31–40 years of age group. 3.1.3. Marital status Most of them 70% (n = 49) were unmarried males. 44.9% (n = 22) had preoccupation with masturbatory practice and 36.7% (n = 18) complained of passing of semen in their urine and spontaneous ejaculation of semen in night (Dhat syndrome). 30% (n = 21) of patients were married and 28% (n = 6) of them staying alone away from wife. In few of the married patients the shortening of penis was noticed by their wife during intercourse. All of the patients were concerned about their future sexual life. Table 1 Showing socio demographical variables. Socio demographic variables Gender Male Female Age (years) 11–20 21–30 31–40 Above 40 Marital status Married Single Place of presentation Casuality department Outdoor patient department Religion Hindu Islam Sikh Socioeconomic status Lower socioeconomic status Middle socioeconomic status Higher socioeconomic status Education Illiterate Below high school Above high school
Total n = 70
Percentage
68 2
97.1 2.8
9 43 13 5
12.85 61.42 18.57 7.14
21 49
30 70
48 22
68.57 31.42
45 24 1
64.25 34.28 1.4
44 26 –
62.85 37.14 –
7 13 50
10 18.57 71.42
R. Kumar et al. / Asian Journal of Psychiatry 12 (2014) 113–117 Table 2 Showing clinical presentation variables. Clinical presentation variables
Total n = 70
Percentage
Prior knowledge of koro Hearsay and discussion about the illness Witness of the Koro in their community Attack of place Home Working place Time of attack Night Day Tingling sensation Apprehension Palpitation Increased sweating Breathlessness Chest discomfort Restlessness
58 49 21
82.85 70 30
60 10
85.71 14.28
51 19 63 60 49 53 42 42 60
72.85 27.14 90 85.7 70 75.7 60 60 85.7
3.1.4. Place of presentation Most of the patients 68.5% (n = 48) attended the hospital in casualty department at night time around 8–11 PM for immediate medical intervention because of physical and mental distress. Rest of the patients 31.4% (n = 22) presented in outpatient department. 3.1.5. Religion Majority of the patients were Hindus 64.2% (n = 45) while the rest of the sample consisted of Islam patients 34.3% (n = 24) and a solitary Sikh patient 1.4% (n = 1) of study sample. 3.1.6. Time and place of onset of episode In most of the cases these episodes started when they were indoors 85.7% (n = 60) and first manifestation occurred during evening and early night 72.8% (n = 51). In 14.2% (n = 10) patients, episodes started when they were in their workplace. 70% (n = 49) patients also reported about the hearsay and discussion with friends and family about the illness. Some of them 30% (n = 21) also had been witness of Koro in their community. 3.1.7. Prior knowledge about the disease Assam has had epidemics of Koro in the past and it remains a well discussed matter in the community. The knowledge about the previous epidemic and news regarding current Koro epidemic were seen in 82.8% (n = 58) of patients. 30% (n = 21) also had been witness of Koro in their community. 3.1.8. Socioeconomic status 62.3% (n = 44) of the patients belonged to the lower socioeconomic status with most of them being daily wage earners such as fishermen, farmers, manual laborers and masons. 37.1% (n = 26) of patients belonged to middle socioeconomic status being students, shopkeepers and clerks.
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genitalia, restlessness, help seeking behavior, increased sweating and a fear of death. All male patients complained about the feeling of shortening and retraction of penis in the abdomen and leading to death. Similarly two female patients complained about feeling of shortening and retraction of nipple and female genitals inward and fear of death. The tingling sensation over leg and foot was also reported in 90% (n = 63) of patients. This tingling sensation started over legs or feet and then moved toward abdomen and other parts of the body rapidly. It was named as ‘‘Jhinjhinia Bemar’’ in Assamese (Jhinjhinia means tingling). People considered this was caused by ‘‘bad air’’ or ‘‘bad spirits’’ that was in the air and entered in the body through toes and foot. The onset of symptoms was sudden and severe in intensity. These episodes had a short course lasting 10 min to 5 h with an average duration of half an hour. These symptoms were also associated in 85.7% (n = 60) of the patients with increased worry and apprehension about death due to retraction of penis in the abdomen, dissolution of genitals, genital dysfunctions, impotency or future marital life. Other associated complaints among patients were increased palpitation 70% (n = 49), increased sweating 75.7% (n = 53), breathlessness 60% (n = 42), chest discomfort 60% (n = 42) and restlessness 85.7% (n = 60). These patients had expressed help seeking behavior from various sources like faith healer, quack doctors (unregistered medical practitioner), local traditional (alternative medicine) treatment, religious help and medical help. They attended primary health centers, civil hospitals or medical colleges for immediate medical intervention. Popular treatments as per the local beliefs involved pouring water on the genitals and body; sitting in water tub or tank; in acute phase it was recommended to apply lime (calcium carbonate) on the earlobes; to wear amulets or talismans containing cucumber seed or chanted paper to ward off the evil spirits that was responsible for the disease for people to stay safe. There were instances of patients coming to the emergency department sitting in a water tub (Fig. 1) or with a wet cloth. As per local belief the body heat was also the reason for the symptoms and pouring water or sitting immersed in water keeps genitals cool and prevents the retraction of the penis. They also used strings (sutoli) to tie around the penis to prevent the retraction of that. These methods of prevention of retraction of penis often led to physical injury in patients. 3.3. Management of the patients: The presentation of disease occurred in an epidemic form and they demanded immediate medical intervention apart from traditional local therapy for their physical and mental distress.
3.1.9. Education 71.4% (n = 50) were high school or above educated followed by 18.5% (n = 13) below high school educated and 10% (n = 7) were illiterate. These patients had poor knowledge about their sexuality, sexual practice, anatomy and physiology of genital’s organ. 3.2. Clinical presentation: (Table 2) During the study we found that the patients were complaining of three common symptoms: (1) feelings of retraction or shortening of the penis, (2) tingling sensation that starts from the thigh and goes to the abdomen or other parts of the body, (3) severe degrees of anxiety with increased worrying about his
Fig. 1. Patient came in casuality department for treatment sitting in the water tub.
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Patients were treated with various pharmacotherapy, psychotherapy and mass education programs. 3.3.1. Pharmacotherapy We used benzodiazepines like lorazepam, clonazepam, etizolam in adequate dosage for acute anxiety state. In some patients we also prescribed selective serotonin reuptake inhibitors (SSRI) like escitalopram, paroxetine, fluoxetine and tri-cyclic antidepressants (TCA) like amytriptyline for 2–3 weeks to reduce the anxiety. Patients had significant response to this medical treatment. 3.3.2. Psychotherapy Psychiatric unit had given insight oriented psychotherapy, supportive therapy, and interpersonal psychotherapy to all patients either on an individual session or in group sessions. Mass education programs were also conducted by doctors, psychiatric social workers and media like newspaper, television (TV) educating public about the nature, course, prognosis, prevention and myths of the disease in the community.
4. Discussion Assam has a multi-ethnic, multi-linguistic and multi-religious society. The large number of ethnic and linguistic groups among the population composition in the state has led to it being called an ‘‘India in Miniature’’ (Taher, 1993). Geographically Assam is accessible from Tibet in the north, from Burma in south east. In the west both the Brahmaputra valley and the Barak valley open widely to the Gangetic plains. Assam has been populated via all these accessible points in the past. Pre-historically there were groups of people migrating from South East Asia, Tibet and Southern China. There is a fair amount of ethnic and religious diversity in state. Koro syndrome is common in migrants and people of migrant lineage as reported in various studies (Constable, 1979; Edwards, 1984; Rin, 1965). There have been many epidemics in Assam (Dutta et al., 1982) and neighboring states of West Bengal and Tripura (Ghosh et al., 2013; Nandi et al., 1983) in past years. The knowledge about the previous episodes of Koro remains prevalent in the community (82.8%) and these populations are suggestible and vulnerable for generation of disease and epidemics. During our study we found that the patients were complaining of three common symptoms: (1) tingling sensation that starts from the thigh and goes to the abdomen or other parts of the body. (2) Shortening of the penis. (3) Severe degrees of anxiety with increased worrying about his genitalia, restlessness, help seeking behavior, increased sweating and a fear of death. The onset of symptoms was sudden, severe in intensity and had a short course. The phenomenological features like physical sensations, emotions and thought of the person while experiencing the syndrome share with anxiety disorders. The clinical features of the Koro cases in our study resembled those from the previous epidemic in Assam as reported by Dutta et al. in 1982. The symptoms have been found is comparable with anxiety disorders (Chowdhury, 1996; Constable, 1979; Cremona, 1981; Dutta et al., 1982). The number of patients who came for medical treatment were however less in comparison to previous epidemics. The reason may be attributed to the short course of illness and intensive intervention from various agencies of health care. Typically patients of Koro are young unmarried males. This population has poor sexual knowledge and they also do experiment with sexual act (Cheng, 1997). The reason behind low incidence of disease in female (2.8%) may be patients were reluctant to report their symptoms because of feelings of guilt and
shame. Koro is common to population belonging to the low socioeconomic background. In most of cases these attacks started when they were indoors and first manifestation occurred during evening and early night. The time and place for attack were corresponding to findings of Dutta et al. (1982) and Ngui (1969) that Koro attacks are more prone to develop at night when a person gets more time for introspection, sexual stimulation and sexual acts. This particular time is also important when people entertain with TV or other media. Hearsay and media (print or audio-visual) played a major role to spread the news. We found certain risk factors in the study population such as exposure to rumors and suggestibility (Gwee, 1968), commonly shared belief (Tseng et al., 1992), geographical seclusion (Tseng et al., 1988), mostly young poorly educated male susceptible to superstitious beliefs (Cheng, 1997; Sachdev, 1985; Tseng et al., 1988, 1992), suggestion (Nandi et al., 1983), belief in concept of Koro (Tseng et al., 1992) prominent among others. In our study we found no history of extramarital intercourse or venereal disease and scrotal filariasis in any of the patients. This finding contradicts the finding of Chowdhury (1989). One of reasons maybe attributed to the endemicity of fibrosis in different parts of India. No significant premorbid sexual psychopathologies were found among the various subjects studied in the present study (Sachdev, 1985). The external body parts like penis, scrotum, breasts and vulva have characteristics of changing in its size and shape in related to different stimuli. The appearance of penile retraction or diminution of scrotum is affected by cold, anxiety, apprehension or fear (Oyebode et al., 1986). We observed that apprehension or fear of death that was prevalent in the patients and pouring of water to the genitals, further aggravated the symptoms. People considered these episodes to be caused by ‘‘bad air’’ or ‘‘evil spirit’’ (Tseng et al., 1988) that was in the air and entered in body through the toes and foot. People were afraid to go out of home or to their workplace to save themselves from the disease, as the belief was that ‘‘bad air’’ was the cause behind the disease. They had taken treatment to ward off the evil spirits that were responsible for the disease for people to stay safe. There are a number of inherent limitations in this study: a proper follow-up of the patients after their treatment in their acute stage was not done; an accurate assessment of the prior knowledge of the patients about the disease could not be assessed as there was widespread publicity in the local newspapers and television which might have biased certain people. In conclusion Koro epidemics are considered to be the result of panic that spread following the occurrence of symptoms in one or more individuals within the same geographical zone. While the issues concerning phenomenology, diagnosis and nosology of Koro are still being discussed, it is apparent that Koro which presents as an acute anxiety state is treatment responsive and has a good prognosis. The current study offers an insight into phenomenology, course and treatment of the Koro. Conflict of interest None. All the authors assure that there are no commercial or financial involvements that might present an appearance of a conflict of interest in connection with this article. Acknowledgments We would like to thank Dr. (Prof.) D. Bhagabati, Dr. Sonia Chawla, Dr. Vipin Dagar, Dr. Ranjita Das Dagar, Dr. Vishesh Agarwal, Dr. Sunil Mittal and Mr. Ranjan Kumar for their active help and co-operation for this research work.
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