Epidemic of Koro in North East India: An observational cross-sectional study
Rajesh Kumar *, Hemendra Ram Phookun, Arunava Datta
DepartmentofPsychiatry,GauhatiMedicalCollegeandHospital,Bhangagarh,Guwahati,Assam781032,India
1. Introduction
TheearliestWesternreferencetothetermKorohasbeenfound inB.FMatthes’dictionaryofBuginese language(1874)ofSouth SulawesiIndonesia(Chowdhury,1998).Koroisalsoknownbya varietyofnames,inChinaitiscalled‘‘Suoyang’’(Suo=shrinkink- ing, Yang=penis) (Cheng, 1997) or ‘‘suk-yeong’’ in Cantonese (Bernstein andGaw,1990),‘‘Jhinjhinia Bemar’’inAssam(India) (Duttaetal.,1982)tonameafew.Korohasbeendefinedinvarious textbooksasacultureboundsyndromethatischaracterizedbya predominatingbeliefandfearintheindividualsthattheirgenitals areretractingintotheabdomenandmaydisappearwhichmight leadtotheirdeath.
Korowasinitially thoughttobeconfinedtopeopleofSouth ChinaandYangtzevalleyandamongmigrantChineseworkersin theSouthEastAsiaregion (Duttaetal.,1982;Gwee,1963; Rin, 1965).LaterKorowasalsofoundinculturallydifferentsettings amongpeoplefromIndia(Duttaetal.,1982;Nandietal.,1983)and WesternAfrica(DzokotoandAdams,2005)amongvariousother
placesintheworld.ThoughKorousuallypresentsinepidemics, sometimespatientsofKoroalsopresentsporadicallyasreportedin America (Edwards, 1970), Britain (Barrett, 1978) and India (Chakravarty,1982;ShuklaandMishra,1981).
Koroisusuallyfoundamongpoorlyeducatedyoungmalesand femaleswhohaveanimmaturedependentpersonalityandwho lackconfidenceintheirownvirility.Theymayexhibitincreased sexualbehavior,areusuallyinconflictovertheexpressionoftheir owngenitalimpulses(Nandietal.,1983).TheetiologyofKorois unknown.Korohasbeenconsideredtobea‘‘cultureboundvariant of hysteria’’(Sachdev,1985)ora ‘‘panicdisorder’’(Tseng etal., 1992)ora‘‘sexualsomatizationdisorder’’(Chowdhury,2008).The text revisionof fourthedition of theDiagnostic and Statistical ManualofMentaldisorders(DSM-IV-TR)classificationofpsychi- atricdisorders haslistedKoro intheglossaryofCulture Bound Syndromes(AppendixI)(AmericanPsychiatricAssociation,1994).
Clinicallythediseasestartswithtinglingsensationofhandsand legs and an acute attack of sudden intense anxiety that the genitalia(andalsothenipplesincasesoffemales)(Duttaetal., 1982) will recede into the body which might result in death (Garlipp, 2008). Thepatient triestostoptheretractionoftheir genitalsbytyingstringsarounditorclampingitwithhandsor askingfamilymembersandfriendstograspthegenitaliafirmlyso astokeeptheminplace.Theseactionssometimesresultindamage ARTICLE INFO
Articlehistory:
Received5April2014
Receivedinrevisedform21July2014 Accepted28July2014
Keywords:
Koro
Cultureboundsyndrome Acuteanxiety
Epidemic Psycho-education North-EasternIndia
ABSTRACT
Objective:Koroisacultureboundsyndrome,endemicinSouth-EastAsia.Thepresentstudyattemptsto correlatethesocio-culturalanddemographicvariablesofthepatientswiththeoccurrenceoftheKoro andthedifferencesinpresentationbetweentheclassicalfeaturesoftheKoroandtheactualpresentation ofthediseasethathasbeenobservedinthepresentstudy.
Method: Across-sectionalobservationalstudywasperformedanddatacollectedduringtheperiodwas compared,analyzedandstudied.Atotalnumberof70patientswhopresentedtotheDepartmentof PsychiatrywithsymptomsofKoroovertheperiodof5daysweretakenintothestudy.
Results:Mostofthepatientswere,young,unmarriedmalesbelongingtoalowersocioeconomicstatus.
Mostofthesepatientssufferedtheattacksintheeveningmostlywhileathome.Itwascommonin migrantandmigrantlineage.Mediahadamajorroletospreadthisepidemic.
Conclusions: Koro epidemics are considered to be the result of panic that spread following the occurrenceofsymptomsinoneormoreindividualswithinthesamegeographicalzone.Whiletheissues concerningphenomenology,diagnosisandnosologyofKoroarestillbeingdiscussed,itisapparentthat Korowhichpresentsasanacuteanxietystateistreatmentresponsiveandhasgoodprognosis.
ß2014ElsevierB.V.Allrightsreserved.
* Correspondingauthor.Tel.:+919810350476/9540585856.
E-mailaddresses:[email protected],[email protected] (R.Kumar).
ContentslistsavailableatScienceDirect
Asian Journal of Psychiatry
j our na l ho me p a ge : w ww . e l se v i e r . com / l oc a te / a j p
http://dx.doi.org/10.1016/j.ajp.2014.07.006 1876-2018/ß2014ElsevierB.V.Allrightsreserved.
tothegenitalorgans(Cheng,1997).Thedurationofeachepisode mayvaryfromseveralminutestoseveralhoursandevendays.
1.1. Descriptionofepidemic
Anepidemicof Korobrokeoutin thenortheasternstateof Assam,IndiainSeptember2010,whenfewpatientswithclassical symptomsofKororeportedinemergencydepartmentofGauhati MedicalCollegeandHospital.Withinnextfewdaysthenumberof casesreportingtodifferenthospitalsandnursinghomesofthecity increasedrapidlyandthephenomenoncametobewidelyreported bydifferentmedialikenewspaper,televisionand magazines.It wasobservedthatinitiallyallthecasesbelongedtoaparticular areaofthecitywhilethelatercaseswerefromdifferentpartsof thecityaswellasnearbydistrictsofthestate.Finallytheepidemic spreadtoallcommunitiesandclassesofpopulationandaffected thousandsofpeopleinthestate.Patientsattendedprimaryhealth centers,districthospitals,nursinghomesandmedicalcollegesof thestate(Royetal.,2011).Weobservedthatmediahadplayed significantroleinspreadingthenewsofthedisease.Lotsofpeople wereseenintheGuwahatiwithsmearedlimeonearsandwearing amulets.Aunitof psychiatristswasformedinGauhati Medical Collegeand Hospitaland otherinstitutions also to control the epidemic.Health servicesof Assamhad startedmass education programsin all communities abouttheillness through various massmedia, socialworkersand doctors’team. Consequentlyin next2–3weekstheincidenceofcasesreducedinallpartsofthe state.
After diagnosing this illness as an epidemic of Koro, we attemptedtostudythesecaseswithfollowingobjectsinview:
1.To study the phenomenology of thecurrent Koro cases and differencesinpresentationofthediseasethathasbeenobserved inthepreviousstudies.
2.Torelatethesocioeconomicanddemographicalvariablesofthe patientpopulationwiththeoccurrenceofthedisease.
2. Materialsandmethod
2.1. Cases
TheKorooutbreakwasreportedfromcertainareasofcityof Guwahati,Indiaandneighboringdistrictsandpeakwaveoccurred fromlastweekofSeptember2010tofirstweekofOctober2010.
Weconductedacross-sectionalobservationalstudyon70casesof Koroovera5daysduration(27-9-10to1-10-10)(Graph1)who attended Gauhati Medical College and Hospital. Patients were attendedeitherinemergencydepartmentor outpatientdepart- mentofthehospital.Allcaseswereinterviewedbymembersof thepsychiatricunit thatwasformedtomanage cases.A semi- structured case history sheet was developed to maintain uniformcaseinformation.Elaboratehistorywastakenfromcases
pertainingtoage,gender,levelof education,maritalstatusand clinicalvariables likevarioussymptomsofthedisease,place of occurrenceofthediseaseandpreviousknowledgeofthedisease andothertemporallyrelatedeventsorotherprecipitatingfactors.
Patientswithco-existingpsychiatricillnesslikeschizophrenia, delusionaldisorder,otherpsychosisoranysignificantmedicaland surgicalgenital’sillnesswereexcludedfromthestudy.Wehave usedDSM-IV-TR (American PsychiatricAssociation,1994)diag- nosticcriteriaforKorotodiagnosethepatients.Writteninformed consentwastakenfor thestudy.The datacollected duringthe periodwerecompared,analyzedandstudied.
3. Results
We studied70cases ofKorowho attendedGauhatiMedical CollegeandHospital.
3.1. Sociodemographicandclinicalvariables:(Tables1and2) 3.1.1. Gender
TypicallypatientsofKoroweremales97.1%(n=68)andonly 2.8%(n=2)werefemale.
3.1.2. Agegroup
Mostcommon presentation wasamong youngmalesin age groupof21–30yearsin61.4%(n=43)followedby31–40yearsin 18.6%(n=13)and11–20yearsin12.8%(n=9).Only7.1%(n=5) patientswereabove40yearsofage.Thefemalepatientsbelonged to31–40yearsofagegroup.
3.1.3. Maritalstatus
Mostofthem70%(n=49)wereunmarriedmales.44.9%(n=22) hadpreoccupationwithmasturbatorypracticeand36.7%(n=18) complainedofpassingofsemenintheir urineandspontaneous ejaculation ofsemenin night (Dhatsyndrome). 30%(n=21) of patientsweremarriedand28%(n=6)ofthemstayingaloneaway fromwife.Infewofthemarriedpatientstheshorteningofpenis wasnoticedbytheirwifeduringintercourse.Allofthepatients wereconcernedabouttheirfuturesexuallife.
0 5 10 15 20
Patients
Graph1.Datewisepresentationofkoropatientstakeninthestudy.
Table1
Showingsociodemographicalvariables.
Sociodemographicvariables Totaln=70 Percentage Gender
Male 68 97.1
Female 2 2.8
Age(years)
11–20 9 12.85
21–30 43 61.42
31–40 13 18.57
Above40 5 7.14
Maritalstatus
Married 21 30
Single 49 70
Placeofpresentation
Casualitydepartment 48 68.57
Outdoorpatientdepartment 22 31.42
Religion
Hindu 45 64.25
Islam 24 34.28
Sikh 1 1.4
Socioeconomicstatus
Lowersocioeconomicstatus 44 62.85
Middlesocioeconomicstatus 26 37.14
Highersocioeconomicstatus – –
Education
Illiterate 7 10
Belowhighschool 13 18.57
Abovehighschool 50 71.42
3.1.4. Placeofpresentation
Mostof thepatients 68.5% (n=48) attendedthehospital in casualtydepartmentatnighttimearound8–11PMforimmediate medicalinterventionbecauseofphysicalandmentaldistress.Rest ofthepatients31.4%(n=22)presentedinoutpatientdepartment.
3.1.5. Religion
MajorityofthepatientswereHindus64.2%(n=45)whilethe restofthesampleconsistedofIslampatients34.3%(n=24)anda solitarySikhpatient1.4%(n=1)ofstudysample.
3.1.6. Timeandplaceofonsetofepisode
Inmostof thecases theseepisodesstarted whentheywere indoors 85.7% (n=60) and first manifestation occurred during eveningandearlynight72.8%(n=51).In14.2%(n=10)patients, episodesstartedwhentheywereintheirworkplace.70%(n=49) patients also reported about the hearsay and discussion with friendsandfamilyabouttheillness.Someofthem30%(n=21)also hadbeenwitnessofKorointheircommunity.
3.1.7. Priorknowledgeaboutthedisease
AssamhashadepidemicsofKorointhepastanditremainsa welldiscussedmatterinthecommunity.Theknowledgeaboutthe previous epidemic and news regarding current Koro epidemic wereseenin82.8%(n=58)ofpatients.30%(n=21)alsohadbeen witnessofKorointheircommunity.
3.1.8. Socioeconomicstatus
62.3%(n=44)ofthepatientsbelongedtothelowersocioeco- nomicstatuswithmostofthembeingdailywageearnerssuchas fishermen,farmers,manuallaborersandmasons.37.1%(n=26)of patientsbelongedtomiddlesocioeconomicstatusbeingstudents, shopkeepersandclerks.
3.1.9. Education
71.4%(n=50)werehighschooloraboveeducatedfollowedby 18.5%(n=13)belowhighschooleducatedand10%(n=7)were illiterate.Thesepatientshadpoorknowledgeabouttheirsexuality, sexualpractice,anatomyandphysiologyofgenital’sorgan.
3.2. Clinicalpresentation:(Table2)
Duringthestudywefoundthatthepatientswerecomplaining of three common symptoms: (1) feelings of retraction or shorteningof the penis, (2) tingling sensation that starts from thethighandgoestotheabdomenorotherpartsofthebody,(3) severe degrees of anxiety with increased worrying about his
genitalia,restlessness,helpseekingbehavior,increasedsweating andafearofdeath.
Allmalepatientscomplainedaboutthefeelingofshortening and retraction of penis in the abdomen and leading to death.
Similarly two female patients complained about feeling of shorteningand retractionof nipple andfemale genitalsinward andfearofdeath.Thetinglingsensationoverlegandfootwasalso reportedin90%(n=63)ofpatients.Thistinglingsensationstarted overlegsorfeetandthenmovedtowardabdomenandotherparts of the body rapidly. It was named as ‘‘Jhinjhinia Bemar’’ in Assamese(Jhinjhiniameanstingling).Peopleconsideredthiswas causedby‘‘badair’’or‘‘badspirits’’thatwasintheairandentered in thebody throughtoesandfoot.Theonsetofsymptomswas suddenandsevereinintensity.Theseepisodeshadashortcourse lasting 10minto5hwithanaverage durationof halfanhour.
These symptoms were also associated in 85.7% (n=60) of the patientswithincreasedworryandapprehensionaboutdeathdue to retraction of penis in the abdomen, dissolution of genitals, genital dysfunctions, impotency or future marital life. Other associatedcomplaintsamongpatientswereincreasedpalpitation 70%(n=49),increasedsweating75.7%(n=53),breathlessness60%
(n=42), chest discomfort 60% (n=42) and restlessness 85.7%
(n=60).Thesepatientshadexpressedhelpseekingbehaviorfrom various sources like faith healer, quack doctors (unregistered medical practitioner), local traditional (alternative medicine) treatment,religioushelpandmedicalhelp.Theyattendedprimary health centers,civilhospitalsormedicalcollegesforimmediate medicalintervention.Populartreatmentsasperthelocalbeliefs involvedpouringwateronthegenitalsandbody;sittinginwater tub ortank;in acutephaseit wasrecommendedtoapplylime (calciumcarbonate)ontheearlobes;towearamuletsortalismans containingcucumberseedorchantedpapertowardofftheevil spiritsthatwasresponsibleforthediseaseforpeopletostaysafe.
There were instances of patients coming to the emergency departmentsitting ina watertub (Fig.1)or witha wetcloth.
As per local belief the body heat was also the reason for the symptomsandpouringwaterorsittingimmersedinwaterkeeps genitalscoolandpreventstheretractionofthepenis.Theyalso used strings (sutoli) to tie around the penis to prevent the retractionofthat. Thesemethodsof preventionofretractionof penisoftenledtophysicalinjuryinpatients.
3.3. Managementofthepatients:
Thepresentationofdiseaseoccurredinanepidemicformand they demanded immediate medical intervention apart from traditional local therapy for their physical and mental distress.
Table2
Showingclinicalpresentationvariables.
Clinicalpresentationvariables Totaln=70 Percentage
Priorknowledgeofkoro 58 82.85
Hearsayanddiscussionabouttheillness 49 70 WitnessoftheKorointheircommunity 21 30 Attackofplace
Home 60 85.71
Workingplace 10 14.28
Timeofattack
Night 51 72.85
Day 19 27.14
Tinglingsensation 63 90
Apprehension 60 85.7
Palpitation 49 70
Increasedsweating 53 75.7
Breathlessness 42 60
Chestdiscomfort 42 60
Restlessness 60 85.7
Fig.1.Patientcameincasualitydepartmentfortreatmentsittinginthewatertub.
Patientsweretreatedwithvariouspharmacotherapy,psychother- apyandmasseducationprograms.
3.3.1. Pharmacotherapy
We usedbenzodiazepineslikelorazepam,clonazepam,etizo- laminadequatedosageforacuteanxietystate.Insomepatientswe alsoprescribedselectiveserotoninreuptakeinhibitors(SSRI)like escitalopram,paroxetine,fluoxetineandtri-cyclicantidepressants (TCA) like amytriptyline for 2–3 weeks to reduce the anxiety.
Patientshadsignificantresponsetothismedicaltreatment.
3.3.2. Psychotherapy
Psychiatric unit had given insight oriented psychotherapy, supportive therapy, and interpersonal psychotherapy to all patientseitheronanindividualsessionoringroupsessions.Mass educationprogramswerealsoconductedbydoctors,psychiatric socialworkersandmedialikenewspaper,television(TV)educat- ing publicabout the nature,course, prognosis, prevention and mythsofthediseaseinthecommunity.
4. Discussion
Assam has a multi-ethnic, multi-linguistic and multi-reli- gioussociety.Thelargenumberofethnicandlinguisticgroups among the population composition in the state has led to it beingcalled an‘‘IndiainMiniature’’(Taher,1993).Geographi- callyAssamis accessiblefromTibetin thenorth, from Burma in south east. In the west both the Brahmaputra valley and the Barak valley open widely to the Gangetic plains. Assam hasbeenpopulated viaall these accessiblepointsin the past.
Pre-historically there were groups of people migrating from South East Asia, Tibet and Southern China. There is a fair amountofethnicandreligiousdiversityinstate.Korosyndrome is common in migrants and people of migrant lineage as reported in various studies (Constable, 1979; Edwards, 1984;
Rin,1965).
TherehavebeenmanyepidemicsinAssam(Duttaetal.,1982) andneighboringstatesofWestBengalandTripura(Ghoshetal., 2013;Nandietal.,1983)inpastyears.Theknowledgeaboutthe previousepisodesof Kororemains prevalentin thecommunity (82.8%)andthesepopulationsaresuggestibleandvulnerablefor generationofdiseaseandepidemics.
Duringourstudywefoundthatthepatientswerecomplaining ofthreecommonsymptoms:(1)tinglingsensationthatstartsfrom thethighandgoestotheabdomenorotherpartsofthebody.(2) Shortening of the penis. (3) Severe degrees of anxiety with increasedworryingabouthisgenitalia,restlessness,helpseeking behavior,increased sweatingand a fear of death. The onset of symptomswassudden,severeinintensityandhadashortcourse.
Thephenomenologicalfeatureslikephysicalsensations,emotions andthoughtofthepersonwhileexperiencingthesyndromeshare withanxietydisorders.TheclinicalfeaturesoftheKorocasesinour studyresembledthosefromthepreviousepidemicinAssamas reportedbyDuttaetal.in1982.Thesymptomshavebeenfoundis comparablewithanxietydisorders(Chowdhury,1996;Constable, 1979;Cremona,1981;Duttaetal.,1982).Thenumberofpatients whocameformedicaltreatmentwerehoweverlessincomparison topreviousepidemics.Thereasonmaybeattributedtotheshort courseofillnessandintensiveinterventionfromvariousagencies ofhealthcare.
Typically patients of Koro are youngunmarried males.This populationhaspoorsexualknowledgeandtheyalsodoexperi- ment with sexual act (Cheng, 1997). The reason behind low incidence of disease in female (2.8%) may be patients were reluctanttoreporttheirsymptomsbecauseoffeelingsofguiltand
shame. Koro is common to population belonging to the low socioeconomicbackground.
Inmostofcasestheseattacksstartedwhentheywereindoors andfirstmanifestationoccurredduringeveningandearlynight.
Thetimeandplaceforattackwerecorrespondingtofindingsof Duttaet al.(1982)and Ngui(1969)that Koroattacksaremore prone to develop at night when a person gets more time for introspection,sexualstimulationandsexualacts.Thisparticular time isalsoimportant whenpeople entertainwithTV orother media.Hearsayandmedia(printoraudio-visual)playedamajor roletospreadthenews.
Wefoundcertainriskfactorsinthestudypopulationsuchas exposuretorumorsandsuggestibility(Gwee,1968), commonly shared belief(Tseng etal.,1992),geographical seclusion(Tseng etal.,1988), mostlyyoungpoorlyeducated malesusceptibleto superstitious beliefs (Cheng,1997; Sachdev,1985; Tseng et al., 1988,1992),suggestion(Nandietal.,1983),beliefinconceptof Koro(Tsengetal.,1992)prominentamongothers.Inourstudywe foundno historyofextramaritalintercourseorvenerealdisease andscrotalfilariasisinanyofthepatients.Thisfindingcontradicts thefindingofChowdhury(1989).Oneofreasonsmaybeattributed to the endemicity of fibrosis in different parts of India. No significant premorbid sexual psychopathologies were found amongthevarioussubjectsstudiedinthepresentstudy(Sachdev, 1985).
Theexternalbodypartslikepenis,scrotum,breastsandvulva havecharacteristicsofchanginginitssizeandshapeinrelatedto differentstimuli.Theappearanceofpenileretractionordiminu- tionofscrotumisaffectedbycold,anxiety,apprehensionorfear (Oyebodeetal.,1986).Weobservedthatapprehensionorfearof deaththatwasprevalentinthepatientsandpouringofwaterto thegenitals,furtheraggravatedthesymptoms.
Peopleconsideredtheseepisodestobecausedby‘‘badair’’or
‘‘evilspirit’’(Tsengetal.,1988)thatwasintheairandenteredin bodythroughthetoesandfoot.Peoplewereafraidtogooutof homeortotheirworkplacetosavethemselvesfromthedisease,as thebeliefwasthat‘‘badair’’wasthecausebehindthedisease.They had taken treatment to ward off the evil spirits that were responsibleforthediseaseforpeopletostaysafe.
There are a number of inherentlimitations in this study: a properfollow-upofthepatientsaftertheirtreatmentintheiracute stagewasnotdone;anaccurateassessmentofthepriorknowledge ofthepatientsaboutthediseasecouldnotbeassessedasthere waswidespreadpublicityinthelocalnewspapersandtelevision whichmighthavebiasedcertainpeople.
InconclusionKoroepidemicsareconsideredtobetheresultof panicthatspreadfollowingtheoccurrenceofsymptomsinoneor moreindividualswithinthesamegeographicalzone. Whilethe issuesconcerningphenomenology,diagnosisandnosologyofKoro arestillbeingdiscussed,itisapparentthatKorowhichpresentsas an acute anxietystateis treatment responsive and hasa good prognosis.Thecurrentstudyoffersaninsightintophenomenology, courseandtreatmentoftheKoro.
Conflictofinterest
None.Alltheauthorsassurethattherearenocommercialor financial involvements that might present an appearance of a conflictofinterestinconnectionwiththisarticle.
Acknowledgments
We would like to thank Dr. (Prof.) D. Bhagabati, Dr. Sonia Chawla, Dr. Vipin Dagar, Dr. Ranjita Das Dagar, Dr. Vishesh Agarwal,Dr.SunilMittalandMr.Ranjan Kumarfortheir active helpandco-operationforthisresearchwork.
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