TWO CASES OF KORO SYNDROME
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Slide 1 :
TWO CASES OF KORO SYNDROME or ANXIETY DISORDERS ASSOCIATED WITH GENITAL RETRACTION FEAR Turkish J Psychiatry 2007; 18(3): 282-285 Hakan Atalay, Md (Psychiatrist) Yeditepe University Hospital Istanbul/Turkey
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DSM-IV As a cultural-bound syndrome, koro is described as an episode of sudden and intense anxiety that the penis (or, in females, the vulva and the nipples) will recede into the body and possibly cause death.
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HYSTERICAL EPIDEMICS? While the syndrome individually involves an anxiety reaction and fear of mortal genital retraction, it collectively takes the form of epidemics and mass panic.
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AN ANXIETY SYMPTOM? Recently a consensus has been reached about the fact that genital retraction is intimately related not only with ethno-cultural beliefs but also with the dramatic expression of acute anxiety and fear of impending catastrophe or death.
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A CULTURE-BOUND SYNDROME? Until the late 1970s, koro seemed to be limited to Asian/male people and koro expression was virtually undetected in western patients (Chowdhury 1996).
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A UNIVERSAL PHENOMEON? In the 1980’s, a series of reports of sporadic koro cases from different Western and Middle-East countries and from Africa shifted the focus of Koro nosology from being a regional issue to a universal formulation and led to speculation that koro may not be a truly culture-bound syndrome (Bernstein and Gaw 1990, Kovacs and Osvath 1998, Stip et al 2006, Witztum et al 1998).
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PRIMARY OR SECONDARY? 1) primary koro (either sporadic or epidemic form), in which genital shrinking is the presenting complaint, 2) secondary koro, in which the presentation is comorbid with another psychiatric disorder - anxiety disorder - schizophrenia - depression - a disease of the central nervous system (Dzokoto and Adams 2005, Kar 2005) - or different somatic conditions, such as urological diseases, withdrawal from drugs, brain tumors, epilepsy (Bernstein and Gaw 1990, Earleywine 2001).
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CASE 1 Mr. A was a 20-year-old male patient One night when he was in an African country for studying English, he experienced a sudden feeling of genital shrinking associated with the fear of death. He urgently went to the local emergency unit holding his penis lest it should run into the body. He was given an antibiotic and an analgesic in the health center but he did not feel well until returning to Turkey.
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CASE 1 (Cont’d) He was fully oriented and cooperative during his psychiatric evaluation. He appeared somehow relaxed and slightly anxious while being interviewed in our Department, he complained of insomnia and had continued worries about his fearful experiences related to his genital retraction that had occurred when he was in Africa.
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CASE 1 (Cont’d) He did not have any psychotic features in his thinking process and content. His judgment and insight were intact.
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CASE 1 (Cont’d) He was the oldest of a family of five children living in the Southeastern Anatolia. The father, a businessman, was defined as a “nervous” man and the mother as “an overprotective, modest Anatolian woman”.
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CASE 1 (Cont’d) He was circumcised at age 5 and at the time he screamed, “Help! Help!” He started to masturbate at age 13 and he felt no shame about it. He never used alcohol or any other psychoactive substance such as cannabis, which are known to be able to induce a similar clinical picture due to either intoxication or withdrawal. He had a positive family history of psychiatric illness with one uncle with a diagnosis of depression and one son of the other uncle with panic disorder.
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CASE 1 (Cont’d) He had a normal physical and neurological examination and we decided that he had an anxiety disorder not otherwise specified and prescribed an antidepressant. One month later on his follow-up visit he reported that he used his medication regularly and felt very well, but he insisted that his previous experiences about his genitalia were real.
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CASE 2 Mr. B, 36 years old, single male He had gone to an emergency service of a hospital a few days ago with the complaint of not feeling his penis at night. He masturbated to be sure that his penis is intact, but he did not feel it again in the morning and considered it retracting into abdomen. He rushed to the hospital with the belief that he lost his manhood. They told him that his neurological and physical evaluation was normal and everything was all right.
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CASE 2 (Cont’d) When interviewing him in our hospital, he told us that three months ago he felt numbness in his arms and became so excited and anxious that he thought he was having a heart attack. He had accepted having a psychiatric disorder only after he was referred to several health facilities, where he was told to be “psychologically ill”.
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CASE 2 (Cont’d) He had two sisters and one brother. His father was a hard-working and emotionally distant manufacturer, and his mother an overly protective housewife. The father provided good opportunities for his education and he graduated the most famous university of the country.
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CASE 2 (Cont’d) Having completed his education, he felt obligated to work with his father and thereafter his behavioral problems such as occasional but heavy drinking of alcohol began. However, he maintained a regular work life and had a stable and long-term relationship with his girl friend until five years ago when he was sentenced to six month in prison for a financial crime.
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CASE 2 (Cont’d) Two years ago he reportedly began to severely abuse alcohol immediately after he witnessed his older sister’s daughter falling down to death from the third floor of their building. He stopped drinking since the onset of his recent complaints i.e., for three months, and he had not experienced any withdrawal symptoms during this period.
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CASE 2 (Cont’d) He appeared slightly anxious and complained of insomnia during our evaluation. However, he was fully conscious and cooperative. His thought process was normal and it seemed that the idea of penile loss had disappeared, but he was scared of the recurrence of his bad experiences. His judgment and insight were intact. He had a positive family history of psychiatric disorders, with his older sister and one uncle being diagnosed with psychotic disorders.
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CASE 2 (Cont’d) We diagnosed him with an anxiety disorder not otherwise specified and prescribed an antidepressant. One month later when we phoned him, he said that he felt well and he did not have any signs of anxiety but after taking the drug he had become more “expressive” than he previously was. Due to the behavioral changes, his girl friend left him. Fortunately, he did not have any worries about his penis, although his anxiety related to his work persisted.
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DISCUSSION Although koro-like symptoms have been observed in many psychiatric or medical conditions, its etiology remains unknown. Psychodynamic explanations tend to emphasize the role of castration anxiety as an etiological factor of genital retraction fear (Yap 1964).
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DISCUSSION Whatever causative factors play a part in koro syndrome; a severe anxiety with associated clinical features is usually the predominant clinical picture. Our cases also illustrate the occurrence of severe anxiety in two patients with koro syndrome that heightens to panic.
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DISCUSSION In most of the cases described in the literature, the patients have also been under considerable stress and anxiety before developing the syndrome. (Sajjad 1991)
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DISCUSSION There were stressful life events for our patients that preceded the onset of symptoms (separation from his family and being lonely in an unfamiliar environment in the first case and being in prison for six months and witnessing the death of a beloved one in the second).
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DISCUSSION Although the history of alcohol abuse in one of them might lead to the confusion about the diagnosis, since koro is defined in terms of its phenomenological aspects we were interested in the clinical symptomatology of koro rather than its etiology, treatment or course.
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DISCUSSION Also, we do not know how its course might be and whether their symptoms would have faded away without medication, since we treated both patients with antidepressants
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DISCUSSION However, it is obvious that in both cases, fear of genital retraction was not culture-bound. It did not occur in the context of an epidemic, either.
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DISCUSSION We ruled out the possibility of any psychiatric or medical disorder other than anxiety disorder, since 1) they were fully oriented, 2) physical examination and laboratory testing carried on other health facilities had revealed no sign of a medical disorder, 3) they did not demonstrate any bizarre thought and behavior except for their genital retraction fears, 4) their perception and their thought process were found to be normal, and finally 5) the most prevailing characteristic of their clinical picture was a sudden and severe feeling of anxiety.
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DISCUSSION Given the raised questions on the term “koro” because of its specific cultural connotations and our findings we may wonder whether genital retraction is one of many symptoms of anxiety rather than a specific symptom of culture-bound koro syndrome (Kennedy and Flick 1991).
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DISCUSSION Therefore the term “anxiety disorder associated with genital retraction fear” will be a more appropriate term that reflects the universal nature of the disorder (Man-Lun 1999, Bernstein and Gaw 1991).
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DISCUSSION According to Bracha (2006), maintaining the description of these syndromes as “culture-bound” may prevent science-based treatment and may be stigmatizing.
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DISCUSSION Therefore, it is reasonable to think of our cases in a way that koro-like symptoms are more likely to be manifestations of severe anxiety state (Bernstein and Gaw 1990, Dzokoto and Adams 2005, Cheng 1996, Chiniwala et al 1996).
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