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Journal of Psychiatry
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?Gilhari (Lizard) Syndrome? A New Culture Bound Syndrome

Akhilesh Jain1*, Kamal Kumar Verma2, Omprakash Jhirwal2 and Navratan Suthar2

1Head of department, Psychiatry, ESIC Model Hospital, India

2SP Medical College, Bikaner Search, India

*Corresponding Author:
Akhilesh Jain
Head of department, Psychiatry, ESIC Model Hospital
Ajmer road, Jaipur, Rajasthan 302001, India
Tel: 919414461257
E-mail: [email protected]

Received date: April 04, 2014; Accepted date: April 15, 2014; Published date: April 24, 2014

Citation: Jain A, Kamal Kumar V, Omprakash J, Suthar N (2014) “Gilhari (Lizard) Syndrome” A New Culture Bound Syndrome. J Psychiatry 17:117. doi: 10.4172/Psychiatry.1000117

Copyright: © 2014 Jain A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Keywords

Culture-bound syndrome; Gilhari (Lizard); Culture

Introduction

Culture plays a significant role in determining the psychopathology of various psychiatric disorders. Some of these psychiatric syndromes are limited to certain specific cultures. These disorders are called culture specific or culture bound syndrome [1-8]. Culture-specific syndrome or Culture-bound syndrome is a combination of psychiatric and Somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. There is no objective biochemical or structural alterations of body organs or functions, and the disease is not recognized in other cultures [9].

The term and concept of culture bound reactive syndrome was introduced in 1960, Several hundred such condition have since been cited in the literature under their indigenous names 7. Some were listed in a DSM IV glossary and in ICD 10 diagnostic criteria for research. These universally occurring dysphoric and anxiety reaction with various somatoform symptoms, known in a particular culture under a local name that designates them as appropriate for special treatment by traditional healers. Before Pow Meng Yap, such conditions were considered as phenomenon peculiar to nonwestern cultures and labeled as “Exotic psychotic syndrome” [10]. The term culture-bound syndrome denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV and ICD-10 diagnostic category [11,12]. Many of these patterns are indigenously considered to be illnesses, or at least afflictions and most have local names. They are generally limited to specific societies or culture and are localized, folk diagnostic categories that frame coherent meanings for certain repetitive patterned, troubling sets of experiences and observations [11]. Culture Bound Syndromes are mental events which may have, a sudden onset dissociative or psychotic episode or various physical symptoms with full remission without apparent after effects and explanation for which is determined by ethnic and cultural values. Sometimes the episode involves violence and automatism and at times paranoia and anxiety may be a major feature. There may be amnesia of the events during the episode and hearing Voices is often mentioned but usually in the local ethnic understanding, spirit possession or speaking to ancestors.

In India, common culture bound syndromes are Dhat Syndrome, Possession Syndrome, Koro, Gilhari syndrome, Bhanmati, Compulsive spitting, culture-bound suicide (sati, santhra), ascetic syndrome, Jhinjhinia etc. Literature regarding Gilhari Syndrome is almost scanty and its nosological status is also not clear [9].

Present study was planned after witnessing a case of Gilhari (Lizard) syndrome by Verma [13] in Bikaner, a major district of Rajasthan province in northern part of India. Patient was found to have typical presentation, ethnic explanation and with widespread familiarity of the particular belief in that area. It was also observed that almost all people of this area believed in existence of such phenomenon .Simultaneously physicians working in that locality also suggested to have come across several such cases in their clinical practice. This study presents phenomenology and diagnostic evaluation of 10 such cases that were referred to department of psychiatry from different specialties. We have also tried to understand whether this belief is specific to one geographical or culturally distinct location or have a wide spread presence regardless of such distinction.

Methodology

The study was carried out at the Emergency department of PBM hospital, Bikaner. The patient recruited in the study had presented with complain of Gilhari (a kind of Lizard) crawling underneath the skin with intense anxiety and apprehension of death and with crush skin injuries which was produced either by relatives or faith healers to kill the Gilhari. The patients were examined to exclude any systemic medical illness and substance abuse. A total of 10 patients were evaluated in detail under the study.

A questionnaire based survey was designed to assess awareness and belief of Gilahari syndrome in general public from different geographical and culturally distinct areas by including 1000 participants from each location. The sample population consisted of relatives and friends of patients attending various Departments of P.B.M. Hospital Bikaner, ESI Hospital Jaipur and NTPC Hospital, Gautam Buddh Nagar. The questionnaire included questions related to awareness, presentation, causation, and treatment of Gilahari phenomenon. Informed consent was obtained from the participants prior to their inclusion in study. They were excluded from the study if they were unable to comprehend the questionnaire or found to have major psychiatric illness or substance abuse which could restrict their understanding about the context being asked.

Results

Table 1 shows sociodemographic characteristics of total 10 patients who attended emergency department of PBM hospital in acute condition. Out of these 10 patients 3 (30%) were male and 7 (70%) were female. All the patients were from rural background and educated up to primary or middle level but majority of them were illiterate. All females were housewife and male were laborer by occupation. Four (40%) patients had past psychiatric history of somatoform disorder and they were mainly females. Three (30%) patients reorted to have family history of somatoform disorderin Ist degree relatives. All the patients were diagnosed as Somatoform disorders NOS (DSM–IV TR) or other specified neurotic disorders F48.8 (ICD–10) as they didn’t fulfill the criteria of any other disorder and as it was limited to a specific region and fulfilling the guidelines to be called as culture bound syndrome.

S. No. Age Sex Marital status Education Domicile Occupation Past H/o Psych disorder Family H/o psychiatric
disorder
Type of family DSM–IV TR
1 32 M Married Illiterate Rural Farmer No No Joint Somatoform
Disorder NOS
2 25 M Married Illiterate Rural Labour No No Joint Somatoform
Disorder NOS
3 60 F Widow Illiterate Rural House
wife
Somatoform
disorder
No Joint Somatoform
Disorder NOS
4 21 M Unmarried Illiterate Rural Labour No Yes (mother
somatoform disorder)
Joint Somatoform
Disorder NOS
5 30 F Married Illiterate Rural House
wife
Somatoform
disorder
Yes (Father somatoform disorder) Joint Somatoform
Disorder NOS
6 28 F Married Middle Rural House
wife
Somatoform
disorder
No Joint Somatoform
Disorder NOS
7 23 F Married Middle Rural House
Wife
Somatoform
disorder
No Joint Somatoform
Disorder NOS
8 19 F Unmarried Illiterate Rural Labour No Yes (Sister Somatoform  disorder) Joint Somatoform
Disorder NOS
9 25 F Married Primary Rural House
wife
No No Joint Somatoform
Disorder NOS
10 22 F Married Middle Rural House
wife
No No Joint Somatoform
Disorder NOS

Table 1: Patient’s Socio–demographic characteristics.

Table 2 shows symptomatology and belief. The most common symptoms were that the swelling arises at the back underneath the skin accompanied by apprehension and palpitation with shouting, crying and running spell with the fear of death as the swelling will reach the neck and causes difficulty in breathing which may cause fatality (100%). Half of the patients (50%) also complained of swelling arising from neck itself whereas 60% reported abnormal rolling movement of body and 40% reported fits of unconsciousness. The cultural belief was that if the swelling which they believed and described as Gilhari is not crushed then they may die due to breathing difficulty caused by this swelling. Crushed skin wound, made by faith–healer or relative of patient was present in all (100%) patients.

S. No. Sign and Symptom No. of Patients
1 Swelling underneath the skin in the back
Swelling in neck
Difficulty in breathing
Feeling of obstruction in the airways
Fear of death
Palpitation and apprehension
Abnormal body movements
Fits of unconsciousness
Rolling movement of the body
Maladaptive behavior (Shouting, Running, Crying etc.)
10
5
10
7
10
10
10
4
6
10
2 Cultural belief that if the swelling (Gilahari) will not be crushed, they will not improve 10
3 Presence of crushed skin wound 10

Table 2: Presenting Complaint of Patients.

Table 3 Describe the socio-demographic characteristics of surveyed population from three different geographical and cultural loacations (n=1000). Samples were randomly selected from the relatives of the patients attending Psychiatric OPD from the three centers i.e., Bikaner, Jaipur and Delhi. The mean age was 42.18 ± 8.94, 42.73 ± 11.53 and 41.8 ± 10.77 of surveyed population in Bikaner, Jaipur and Delhi respectively. Most of the patients from Bikaner division were middle aged, from rural background and were less educated. Otherwise surveyed population was socioeconomically similar in all the three centers.

Variables Bikaner (n=1000) Jaipur (n=1000) Delhi (n=1000)
SEX
Male 638 680 660
Female 362 320 340
X2=3.91 P<.9  NS
LOCALITY
Rural 787 612 318
Urban 213 388 682
X2=548.95  P<.0001  HS
EDUCATION
Illiterate 482 387 250
Primary 276 289 215
Secondary 102 215 350
>Graduate 150 109 185
X2=235.12P<.001  HS
AGE IN YEAR
<30 180 170 176
31 – 40 260 271 264
41 – 50 328 287 281
51 – 60 176 210 180
60+ 56 62 99
Mean ±  SD 42.18 ± 8.94 42.73 ± 11.53 41.8 ± 10.77
MONTHLY INCOME (in Thousands) in INR
  -5 389 337 342
5 – 10 385 329 302
10 – 20 188 259 285
20+ 038 75 71
Mean Income ±  SD 7.64 ± 5.19 9.09 ± 7.60 8.36 ± 6.09

Table 3: Socio-demographic characteristics of surveyed population.

Table 4 shows response of the surveyed population to understand the awareness and knowledge of Gilhari Syndrome. None of the study sample from Eastern Rajasthan (Jaipur) and North India (Delhi) was aware of such kind of entity and had never heard of such illness and symptoms. Only the sample group from Western Rajasthan (Bikaner) in surveyed study population had knowledge about the Gilhari Syndrome (n=928, 92.8%). Out of this population who was aware about this phenomenon, around 12% reported to have have seen the case of Gilhari syndrome. These respondents also reported that the main complaints was the feeling of sensation of Gilhari running on the back of body under the skin as a swelling and also difficulty in breathing (n=928), followed by the symptoms i.e. pain at the site (n=908, 97.8%) and fear of death (n=605, 65.1%). It was believed that Gilhari starts from the back (n=612, 65.9%) and ends at neck (n=800, 86.2%) causing death by chocking of respiratory process (n=910, 98.06%). According to them the treatment was to cut or crush the Gilhari till it dies, mainly done by local expert and faith healers.

Proforma Questionnaire Bikaner (n=1000) Jaipur (n=1000) Delhi (n=1000)
Have you Ever heard about Gilhari (Lizard) Syndrome
Yes 928 0 0
No 72 1000 1000
Have you Ever saw Gilhari (Lizard) Syndrome patient
Yes 120 0 0
No 648 1000 1000
Not Sure 160    
Symptoms of Gilahari Syndrome
Pain at place of Gilahari 908 NA NA
Fear of death 605 NA NA
Difficulty in breathing 928 NA NA
Shouting, Crying 423 NA NA
Leading to Unconscious 120 NA NA
Feeling sensations of Gilahari running on back of body 928 NA NA
Talking like mentally ill person 432 NA NA
Other symptoms 354 NA NA
Where does Gilhari start in-
Back 612 NA NA
Leg 138 NA NA
Neck 50 NA NA
Not Sure 128 NA NA
Where does Gilhari Ends -
Neck 800 NA NA
Not sure 128 NA NA
Content of swelling
Dirty Water 367 NA NA
Dirty Blood 780 NA NA
Wastage of body 100 NA NA
Air 543 NA NA
Little lizard alive or dead 173 NA NA
Not known 300 NA NA
How to death by Gilahari Syndrome
Stopping breathing 910 NA NA
Poison transmit in the whole body 214 NA NA
Fear of death 217 NA NA
Treatment by people 119 NA NA
Other 354 NA NA
What you know about the treatment of Gilahari Syndrome
Cut or crush the Gilahari till it dies 852 NA NA
Treatment given by local expert  person or faith healer 472 NA NA
Concern with Doctor 290 NA NA

Table 4: Responses of Surveyed Population.

Discussion

On surveying the relative of patients attending PBM hospital Bikaner, ESI hospital Jaipur and NTPC hospital Delhi it was found that the Gilahari syndrome is prevalent in Bikaner region supporting the fact that it is confined to a specific culture. This population believed that it starts as feeling of Gilhari running on back of body associated with intense pain and anxiety and finally Gilhari reaching the throat causing stoppage of breathing. The belief was that the swelling contains mainly dirty blood and only less than 18% of people surveyed believed that it contain lizard alive or dead. The response to the question if they had ever seen the Gilahari syndrome patients, only 12% responded to have seen whereas majority of study population had only heard from others indicating that this belief is culture specific confined to Bikaner region as in other two regions people were not even aware of this entity.

Those who had seen this swelling reported that it appears mainly in back and moves up towards the neck. The possible explanation of the swelling may be that it could be a muscular contraction or movements of specific group of muscles due to intense anxiety, stresses and suggestibility as culture specific belief of lizard. In survey it was found that it affects mainly young adult, the possible reason could be proposed as they are subjected to more of physical, biological and mental stresses. The most common cause of death due to Gilhari syndrome which was found in survey was breathing obstruction by lizard. People believed that Gilhari must be crushed to death or it will kill patients and the treatment is mainly received from local expert or faith healers. The people believed that Gilhari enters in body while working or walking in the field but how, there is no logical explanation which also indicates that’s it’s a culture specific belief.

In medicine and medical anthropology a culture specific syndrome or culture bound syndrome is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. The American Psychiatric Association (APA, 1994) [11] states that the term culture bound syndrome denotes recurrent, locality specific pattern of behavior and troubling experiences that may or may not be linked to a particular DSM IV diagnostic category, these patterns are indigenously considered to be illness or at least affliction and most have local names. According to Wikipedia free encyclopedia a culture-specific syndrome is characterized by categorization as a disease in the culture (i.e., not a voluntary behavior or false claim); widespread familiarity in the culture; complete lack of familiarity of the condition to people in other cultures; no objectively demonstrable biochemical or tissue abnormalities (merely symptoms). Cultural factors have been shown to influence the presentation of various psychiatric disorders. The condition usually is recognized and treated by the folk medicine of the culture. Gilahari (Lizard) Syndrome as McDonough Ga illustrated in his website www.visionandpsychosis.net/Culture_Bound_Syndromes.htm in India - is a belief that a blood filled swelling is moving toward the neck and will stop the victim's breathing if it is not crushed. Verma [13] has also reported one case of this kind in his case report where swelling was reported on back. He argued that if the belief that a swelling is moving to the neck is a hallucination, then suspicion that Gilhari (Lizard) Syndrome is a CBS would be raised. The first question to ask is what activities do victims have that would expose them to repeating Subliminal Distraction. The next problem is what happens in the culture to create this fear. The fear is too specific unless there is communication of the proposed malady between victims. The citing article reported that other women interviewed stated that they too had experienced the problem. All the patients were thoroughly investigated, did not show, any systemic medical disease. We may call these symptoms as hallucination or delusion colored by the culture belief prevalent only in this specific culture and area. On the basis of clinical presentation, these patients could be diagnosed only as somatoform disorder NOS with some difficulty but the prevalence only in western part of Rajasthan and the strong belief among the public about the illness that the Gilahari will crawl to neck and obstruct the air ways leading to death, create severe anxiety and associated maladaptive behaviors in the patient which cannot be explained by another mental disorder. Cultural factors have also been found to influence the menifestation of various psychiatric disorders. Role of culture has been studied in disorders such as schizophrenia, major depression, anxiety disorders and attention deficit hyperactive disorder [14,15]. In this context cultural influence is evident at various levels like culture and society shape the meanings and expressions people give to various emotions [16], cultural factors also determine which symptoms or signs are normal or abnormal [17] , culture helps define what comprises health and illness [18]. Finally, it also determines the illness behaviour and help seeking behaviour [19]. So, it would not be invalid to emphasize that cultural influence on psychiatric disorders may include conditions other than CBS.

DSM-IV has included the cultural footing of the presentations of various mental and behavioral are included in DSM IV in the text descriptions of the individual disorders. Also, it has incorporated the description of the CBS and the outline for assisting the clinicians in systematic evaluation of these conditions in its glossary section. Highlighting the acceptance of the importance of the cultural variables in shaping the psychiatric conditions and their management. Similarly, ICD-10 has also described some of these conditions [20].

Conclusion

The widespread familiarity of the condition in the particular culture; categorization as a disease in the culture (i.e., not a voluntary behavior or false claim); complete lack of familiarity of the condition to people in other culture; no objectively demonstrable biochemical or tissue abnormalities merely symptoms); the condition usually is recognized and treated by the folk medicine or method of the culture. The belief that the Gilahari (lizard) will rise in the back and after reaching in the neck will kill the person is so strong that the patient himself and/or the relatives produce him for crushing or killing the Gilahari in vital area which is very painful and cruel leading to serious consequences. The perception and belief is so strong that it may be described as delusion and tactile hallucination. The patient repeatedly keeps on showing the swelling and the relatives also believe and argue that they have noticed the swelling but on examination no such swelling was observed. These observations seem to be sufficient to diagnose this Gilhari (Lizard) syndrome as a specific cultural bound syndrome. We will appreciate suggestions and comments on the matter.

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