Examining Anger in 'Culture-Bound' Syndromes

"Hwa-byung" and "ataque de nervios," listed in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) as culture-bound syndromes, can serve as gateways to understanding anger's role in psychiatric morbidity, according to a panel of experts.

Christopher K. Chung, M.D., assistant professor and director of psychiatric emergency services at Harbor-UCLA Medical Center in Torrance, Calif., who chaired a symposium on hwa-byung and anger syndromes at the American Psychiatric Association last year, described the Korean phenomenon of hwa-byung (literally, fire disease) as "more specifically, suppressed anger syndrome." He said there was not a consensus as to whether the syndrome should be classified as culture-bound.

"Hwa-byung could be universal," he said, adding that if a term exists in a certain culture, the possibility exists that it can be better understood from a culture-general perspective.

The Korean Perspective

Sung Kil Min, M.D., Ph.D., of the department of psychiatry at Yonsei University College of Medicine, Seoul, Korea, said that according to theories of traditional Oriental medicine, fire is one of five universal elements. If found to be excessive in the body, this fire element is believed to disturb the balance of bodily elements, resulting in disease.

"Koreans commonly describe anger as fire," he said, "and think that if anger is suppressed for a long time, a group of symptoms develops that is identified as hwa-byung. Sometimes the term wool-hwa-byung is used, in which wool means 'dense, thick or pent-up.'" Because many hwa-byung patients relate their condition to the psychology of "haan," a traditional culturally determined emotional state, Min considers hwa-byung a culture-related syndrome of Korea.

According to patients' explanations, Min said, those with hwa-byung have experiences which "cause hurt, damaging, boiling, exploding [sensations] inside the chest or body." Korean patients' cultural inclinations to keep the family in harmony and peacefulness, and not jeopardize social relationships dictate that anger must be suppressed, pent up and accumulated. Then, he said, the anger becomes like a dense mass "pushing up" in the chest, resulting in a distinct syndrome whereby most hwa-byung patients are diagnosed, according to DSM-III-R criteria, as having major depression or dysthymic disorder combined with somatization disorder.

Hwa-byung is more frequently found in females in their 40s or 50s, less-educated people, those of lower socioeconomic status and those from rural areas. On mental examination, hwa-byung patients characteristically reveal a polite attitude, numerous somatic complaints and tears.

"Once provoked, they tend to talk long and in detail, as if petitioning to doctors as potential helpers or counselors," Min explained. Asked to describe symptoms, patients more commonly offer terms like mortification (as a victim) or worry as compared to anger.

"This suggests that hwa-byung patients tend to experience anger in a passive way, directing [it] inward instead of outward. Generally, they are well-aware of the cause of their illness, and want to let people around them know they are suffering," Min said.

Min described a study in which he sought to identify the psychological and somatic symptoms related to hwa-byung and to correlate those symptoms with haan, which refers to suppressed anger, hate, despair, the holding of a grudge or feelings of "everlasting woe"; as well as to disorders of anxiety, depression and obsession-compulsion.

A total of 136 patients were included: 31 patients with generalized anxiety disorder, 26 with major depression, 21 with somatization disorder, 18 with dysthymic disorder, 15 patients with phobic disorder, 14 with obsessive-compulsive disorder, and 11 with panic disorder. The control group was composed of 115 healthy parents of senior medical students at Yonsei University. Participants used a self-rating symptom scale of physical and psychological symptoms, Bond's questionnaire of defense style, and a self-rating scale of hwa-byung and haan.

Of 136 patients with a mean age of 43 years, 54 reported having hwa-byung of a mild-to-severe degree. Interestingly, in the control group eight persons reported having hwa-byung. This was despite the exclusion of anyone from that group who had physical illness, comorbid psychiatric disorder, or a history of drug and alcohol use. While the full study is beyond the scope of this article, results suggest the following.

Hwa-byung is frequently found in middle-aged women of low social class, and in a combined form of depression, anxiety and various somatic symptoms. Physical symptoms include headache, dizziness, weakness/fatigue, palpitation, blurred vision, stifling/oppression, sexual dysfunction, insomnia, anorexia, indigestion, weight loss, flushed feeling, mass in the throat or epigastrium, heat sensation, intolerance to heat, multiple pains, sighing, dry mouth and a sensation of pushing-up in the chest. The results suggest also that the psychological symptoms of hwa-byung are a pervasive depressive mood, regret or guilt, anxiety, anger, destructive impulses, "weak and sensitive mind," obsession-compulsion, irritability, paranoid feelings, and hypochondriasis.

A Mother's Prayer

Si-Hyung Lee, M.D., Ph.D., a psychiatrist in the department of neuropsychiatry at Kangbuk Samsung Hospital in Seoul, began his discussion of the clinical causes of hwa-byung with a poignant image:

"While a mother is praying, in front of big trees and rocks, to have a son, her daughter is watching curiously." In a [traditional] Korean family, he explained, the daughters haven't been counted as family members. "If she doesn't have a boy, then the mother is no longer treated as a mother. Sometimes she might be kicked out of the family."

For women, the causes of hwa-byung seem to originate in external events (e.g., spousal infidelity, in-law troubles or a child's illness).

"These experiences can be encountered in any human society," Lee said. "But in order to become hwa-byung, three characteristic features are encountered. They have to do with coping strategies, somatic symptoms and long lamentation with deep sighing."

Coping. As described, the woman copes with the situation (e.g., of a husband's unfaithfulness) as best she can. She may think of divorce as a radical solution, since there is a strong social stigma against it. Also, she feels a strong responsibility to care for her children and cannot afford to live independently. So, too, she believes it is a woman's virtue to bear misfortune, misery and mistreatment silently, so her anger is not to be expressed but rather contained within.

"She begins to realize there is no choice," Lee said, "but to accept the present situation. She tries hard to endure the situation as her fate or destiny, but then refuses to take it as fate. 'Why me? What have I done wrong?' This makes hwa-byung a very chronic [cyclic] process, with episodic eruptions of anger."

Somatic symptoms. According to Korean folk belief, the epigastrium is also called the "gate of life." It is the center of the body and produces vital energy. Therefore, in hwa-byung the somatization centers around the epigastrium and lower chest. Lee explained that patients having explosive anger, shouting or destroying things, soon realize that this only worsens the situation.

"A woman tries to suppress and accept it, but then she can't, so the suppression is never complete," Lee said. "[That] leads to a characteristic tight, stuffy feeling that consolidates into an epigastric 'mass.'"

Lamentation. "There are many purposes of lamentation and sighing, but they can be summarized into self-pity [to the extent] that the patients can talk to anybody," Lee said, describing this talkativeness as having a beneficial, cathartic effect, allowing the patient some hope that her situation can yet improve.

Haan as 'Everlasting Woe'

Luke I.C. Kim, M.D., Ph.D., clinical professor of psychiatry at the University of California, Davis, discussed the phenomenon of haan and its relationship to hwa-byung.

"In the haan," he explained, "the Chinese character originally [symbolized] revenge, getting even, and so had a more action-oriented, vengeful meaning. But in Korea the vengeful motive or desire, while there, is secondary. The primary meaning of haan is the suppressed, unexpressed anger felt inside."

The need to suppress anger may be attributed in part to Korea's geography and the penchant for countries to war against each other. Kim said that throughout history, "frequent war and political and social upheavals have been the norm...They have brought about destruction, suffering, personal loss and unbearable pain for many Koreans, who experienced deep feelings of haan and felt trapped and victimized."

Kim said: "I myself escaped from the North to South Korea just before the Korean War, and I still have uncles and aunts and nephews and cousins in North Korea that I haven't seen for the last 50 years...Many other Koreans share the same story.

"In this connection, many Korean scholars believe that haan is not just a private emotional state of a person, but also a shared collective emotional state of Korean people.

"Under those periods of occupation and domination," Kim continued, "the conquering powers and the elite ruling classes had absolute power over the people. In that sociopolitical environment they were basically slaves. [In such situations] there is no such thing as fair treatment, civil or individual rights."

He added that the old Korea was a very hierarchical, class-oriented society where the young ruling class abused and oppressed the poor, and the women were subservient to men. "So as a result women suffered and endured much hardship and injustice.

"Korea has been a nation of suffering, a nation of the haan...For their own survival, as well as to live in harmony with the teachings of Confucius, they have had to swallow and suppress their feelings."

Biological Manifestations

Because hwa-byung has such significant somatization, Chung and others compared it to other psychiatric diagnoses that have somatization tendencies. Taking a culture-general perspective, he and his colleagues used sleep studies to compare the disorder with major depression, chronic fatigue syndrome (CFS), primary fibromyalgia and neurasthenia.

The pilot study he discussed included seven hwa-byung patients and four controls. As is seen in patients with CFS, primary fibromyalgia and neurasthenia, hwa-byung patients' REM sleep on polysomnograph revealed alpha rhythm intrusion into the delta rhythm. This, Chung said, may explain why the hwa-byung patient complains of difficulty sleeping.

"While the person is in a period of deep sleep, the brain is 'awake.' Patients' sleep architecture was different as compared to [controls]," he said.

The study showed no great biological difference in hypothalamic/pituitary/adrenal (HPA) axis activity in hwa-byung patients versus controls. However, thyroid-stimulating hormone (TSH) levels in hwa-byung patients were almost double that of controls, and prolactin levels were much higher than in controls.

"Hwa-byung may have quite a significant component of PTSD [posttraumatic stress disorder]," Chung said. "A traumatic event, psychologically perceived, may become PTSD." A major difference exists, however, in that the PTSD patient suffers to the extent that he or she was traumatized, while hwa-byung patients experience an additional layer of suffering in their psychological need to know the reason for their suffering.

Hwa-byung in America

Keh-Ming Lin, M.D., M.P.H., became familiar with hwa-byung in the United States almost 20 years ago in Seattle, and was the first to publish a paper on the topic in this country (American Journal of Psychiatry, January 1983). He is a professor of psychiatry and director of the Research Center of the Psychobiology of Ethnicity at Harbor-UCLA Medical Center.

"I had volunteered as a psychiatrist in Chinatown at the International District Health Clinic," Lin said. "About that time, Korean immigrants started to come to the United States in large numbers. One of the first patients I saw there was a Korean widow, [age] 65, who said that she had an epigastric mass that was growing that could kill her."

The patient said she had two or three previous attacks since immigrating, and that each time when she was seen in the emergency room she was assured she had no problem. Her fear persisted until she was sent to the Chinatown clinic, whereupon she explained to Lin the stressors with which she was dealing. As a new immigrant, she was dependent upon her two daughters, one of whom had moved away, leaving the mother in the care of the second daughter, who was having marital problems.

"The patient assured me that she could handle all these psychosocial stressors, insisting the main reason she was there was because of this 'mass,'" Lin said. "When we inquired why she would be worried so much about the mass while all the exams were negative, she told us that she had this condition called hwa-byung.

"The fascinating thing for me about this concept has been that [while hwa-byung] looks like somatization, it shows that patients are aware of psychological factors, which contradicts the common Western perception that somatization is something that's either/or. It's a conversion of symptoms from psychological to somatic."

Lin cited neurasthenia and CFS as two disorders that have been sanctioned as bonafide disease entities with their own respective diagnostic criteria. While no hwa-byung patients self-label as having neurasthenia or CFS, he said, all fulfill ICD-10 criteria for neurasthenia. One patient has exhibited symptom patterns that fit Centers for Disease Control criteria for CFS, an exclusively Western syndrome. The similarities of all three syndromes suggest the need for further studies, including a guideline for systematically documenting information of a cultural nature in patients, he said.

Ataque de Nervios

Ataque de nervios, which occurs among Hispanics was described by Michael W. Smith, M.D., assistant professor of psychiatry at UCLA and a principal investigator of the Research Center on the Psychobiology of Ethnicity.

"Ataque de nervios includes a dissociative episode," he said, "one in which patients seem to move out of themselves. Symptoms include palpitations, tight chest, trembling, shortness of breath, problems with memory and striking out at people-which frequently gets the attention of police or forensics." Falling down and convulsing often follow, which can create difficulty in learning whether epilepsy or a psychiatric condition is involved.

As with hwa-byung, traditional sex roles and historical context seem to play a part in nervios. The concept of machismo, where the male is felt to be responsible for the welfare and honor of the family, and a history of being a conquered people form a parallel with the Korean anger syndrome.

"Hwa-byung and ataque de nervios are very similar," Smith said, "but while hwa-byung is a syndrome of repression of anger that develops into somatic symptoms, ataque de nervios is more of an episodic expression of anger that comes from having to put up with a buildup of anger over time."

In discussing cultural psychiatry, Albert C. Gaw, M.D., an advisor on cross-cultural issues for the DSM-IV, noted that the "DSM-IV is a product itself of culture, a system of nomenclature inherited through scientific endeavors, usually with a Western perspective...If you just look at the [local folk] phenomenon, it could be this, it could be that. But if you put in the background, the context, the cultural aspects of it, then the whole thing stands out like a rose. It's understandable. You can smell it; you can see the colors. And that is why it is also important not to look just at isolated phenomena, the syndromes-but to also understand the context.

"And that also, I think, is a unique contribution of cultural psychiatry."