Gola Khisakna as a Culture-bound Syndrome: A Case Series from India

In many Indian communities, a wide range of physical symptoms such as abdominal pain, bloating, fatigue, and emotional distress are often attributed to a “shifted navel,” a condition known locally as “Gola Khisakna” or “Gola Sarakana” or “Nabhi Khisakna.” It is widely believed that this displacement occurs after lifting heavy objects, skipping meals, experiencing emotional shock, or overexertion. Traditional healers commonly diagnose the condition using thread-based techniques or by palpating for a missing “pulse” at the navel, and treat it with oil massages, dough ring fomentation, or thread-pull maneuvers. ¹

This pattern of illness aligns with the psychiatric concept of a culture-bound syndrome (CBS), as defined by the Diagnostic and Statistical Manual 5 (DSM-5) term “cultural concepts of distress,” which refers to a culturally recognized pattern of distress characterized by shared meanings, symptom clusters, and culturally specific treatments. ² Such syndromes often provide a means for individuals to communicate emotional or psychological suffering through physical language, especially in communities where mental health stigma persists. ³

While analogous syndromes, such as Göbek düşmesi in Turkey, Taharok-e-Sorre in Persian culture, and Nawikkatin in Iraq, have been discussed in the literature, formal psychiatric documentation of Gola Khisakna in a culturally diverse and densely populated country like India remains limited. ⁴

This case series presents seven individuals from central India who reported symptoms consistent with Gola Khisakna. This study offers one of the first structured psychiatric explorations of “Gola Khisakna” in India. It bridges traditional illness models and modern psychiatry, shedding light on culturally shaped idioms of distress and their clinical manifestations.

Case Identification and Clinical Work-up

Over a one-year period, from April 2024 to March 2025, seven adult patients were referred from medical and surgical departments to the psychiatry outpatient clinic of a tertiary care hospital with complaints attributed to Gola Khisakna.

All referrals followed an initial evaluation in the medical and surgical services. As per referral notes, basic work-up typically included complete blood counts (CBC), Erythrocyte Sedimentation Rate (ESR)/C-Reactive Protein (CRP), metabolic profile (liver and renal function tests, and glucose), thyroid tests when indicated, urine routine, stool microscopy/occult blood as indicated, β-hCG where applicable, and abdominal ultrasonography (± plain radiography or additional tests as warranted). No clinically significant organic pathology was identified in these seven patients. All patients had normal abdominal examinations, imaging, and laboratory results.

After obtaining written informed consent, each underwent a semi-structured interview to explore symptom history, perceived triggers, cultural illness beliefs, and traditional treatments used.

Mental Status Examinations (MSE) were conducted, and psychiatric diagnoses were made using International Classification of Diseases, 10th Revision (ICD-10) criteria. ⁵ This manuscript adheres to the Consensus-based Clinical Case Reporting Guidelines for case series, included as supplementary online material.

This work forms part of the first author’s doctoral thesis and was approved by the Institutional Ethics Committee. Appropriate treatment and referrals were provided as needed.

Case 1

He was a 31-year-old urban man, an advocate, unmarried, who presented with a one-year history of sudden-onset abdominal discomfort that he described as a “shifting heaviness” in the lower abdomen. Episodes clustered for two to three consecutive days and were accompanied by loose stools, occasional vomiting, and inner restlessness. He attributed the symptoms to Gola Khisakna, perceived displacement of the abdominal core, and relied on traditional oil massage, which offered brief relief. MSE revealed marked apprehension, an anxious affect, and persistent focus on bodily sensations without psychotic features, supporting a diagnosis of undifferentiated somatoform disorder (ICD-10 F45.1). Pharmacological treatment with duloxetine 30 mg daily and clonazepam 0.5 mg as required was initiated. At three months, he reported substantially fewer and shorter episodes, with reduced “shifting heaviness” and inner restlessness, improved day-to-day functioning, and only brief recurrences linked to work stress.

Case 2

She was a 46-year-old married rural woman working as a laborer who reported a 15-day history of abrupt, twisting peri-umbilical pain with backache, weakness, and agitation, occurring two to three times daily. She attributed her symptoms to Nabhi Sarakana and used oil massage without relief. Evaluation showed restlessness, tachycardia, and autonomic arousal with catastrophic thoughts, consistent with panic disorder (ICD-10 F41.0). She was started on sertraline 25 mg daily and propranolol 20 mg daily with psychosocial support; sertraline was titrated to 50 mg. At six months follow-up, she showed substantial improvement with markedly fewer and shorter attacks, reduced tachycardia and autonomic arousal and catastrophizing, and only occasional stress-linked relapses.

Case 3

He was a 58-year-old married male farmer who experienced gradually worsening episodes of shifting abdominal pain, constipation, nausea, and fatigue over two months. Symptoms recurred every few days and were attributed to Gola Sarakana. He used thread-pulling and dough ring fomentation for relief. MSE revealed low mood, hopelessness, and loss of interest following a recent crop failure, leading to a diagnosis of moderate depressive episode with somatic symptoms (ICD-10 F32.11). Escitalopram 10 mg daily was prescribed. At three months follow-up, he reported fewer and less intense episodes of shifting abdominal pain, improved bowel habit and fatigue, brighter mood with restored interest, and had resumed routine farm chores.

Case 4

She was a 39-year-old married urban homemaker with five years of monthly, sudden-onset umbilical pain accompanied by nausea, weakness, and diffuse unease. She attributed this to Nabhi Sarakana and relied on oil massage, which provided moderate relief. As per referring notes, basic work-up (CBC, ESR/CRP, metabolic profile, thyroid tests as indicated, urine routine, and abdominal ultrasonography) showed no significant abnormality. MSE showed persistent health anxiety and heightened somatic focus without mood disturbance, consistent with hypochondriacal disorder (ICD-10 F45.2). She agreed to continue yoga and massage in addition to taking sertraline 25 mg daily. At one month, she reported her most extended symptom-free interval in years, with reduced episode frequency and unease; some health-related worry persisted, for which sertraline was titrated to 50 mg.

Case 5

She was a 42-year-old married, urban woman who described a 25-year history of sudden, continuous shifting sensations above and to the right of the navel, occurring about twice a month and accompanied by anxiety and restlessness. She believed the issue was due to Gola Khisakna, and oil massage provided only transient relief. MSE demonstrated pervasive worry extending to finances and family, muscle tension, and poor sleep, consistent with a diagnosis of generalized anxiety disorder (ICD-10 F41.1). Sertraline 25 mg daily was prescribed. At six months, she reported complete resolution of the shifting sensation, with no episodes in the preceding three months, regular sleep, and full return to routine activities; sertraline was titrated up to 100 mg.

Case 6

She was a 32-year-old married urban home maker with a two-year history of monthly episodes of peri-umbilical discomfort, palpitations, and anxiety. Symptoms began abruptly and lasted for several hours. She attributed them to Gola Khisakna, and oil-and-thumb-pulling rituals by family members provided partial relief. Evaluation revealed anxious thoughts about finances and low energy, consistent with mixed anxiety and depressive disorder (ICD-10 F41.2). She was started on sertraline 25 mg daily alongside continued traditional practices. At one month, she reported fewer and shorter episodes with reduced palpitations and anxiety, improved sleep and energy, and only brief relapses during periods of marital conflict.

Case 7

She was a 62-year-old married rural woman with a 30-year history of recurrent umbilical pain occurring every two to three months, described as a shifting sensation with weakness and agitation. She identified it as Nabhi Sarakana and regularly used oil massage and thread-repositioning rituals for relief. MSE showed low mood, poor self-esteem, and strong somatic focus, leading to a diagnosis of dysthymia (ICD-10 F34.1). Sertraline 50 mg daily was initiated. At three months follow-up, she reported longer pain-free intervals and lower-intensity episodes with improved mood and day-to-day functioning; brief flares persisted, for which she occasionally sought thread-repositioning.

Discussion

This case series (summarized in Table 1) illustrates Gola Khisakna as a CBS that aligns with the DSM-5 framework of cultural concepts of distress. ² CBS refers to culturally shaped patterns of distress that include somatic, emotional, and cognitive symptoms embedded within shared belief systems. ³ All patients in this study believed their symptoms stemmed from Gola Khisakna, a culturally understood displacement of the navel, and initially sought relief through traditional diagnostic and healing practices.

Table 1.

Case Summary for Gola Khisakna.

Case	Age/Sex	Trigger	Presenting Complaints	Duration of Presenting Symptoms	MSE Findings	Provisional Diagnosis	Traditional Treatment	Psychiatric Treatment	Outcome
Case one	31/M	Work stress, lifting water can	Shifting abdominal heaviness, loose stools, inner restlessness	One-year	Anxious affect, somatic preoccupation	Somatoform disorder (F45.1)	Oil massage	Duloxetine 30 mg Once daily (OD) + Clonazepam 0.5 mg SOS	Mild improvement
Case two	46/F	Heavy lifting	Twisting peri-umbilical pain, backache, agitation	15 days	Autonomic arousal, catastrophic thoughts	Panic disorder (F41.0)	Thread-pull, herbal infusions	Sertraline 25 mg OD, later hike up to 50 mg + Propranolol 20 mg OD	Mild-to-moderate improvement
Case three	58/M	Crop failure, domestic strain	Shifting navel pain, constipation, fatigue	Two months	Low mood, hopelessness	Moderate depressive episode (F32.1)	Thread-pulling, dough ring fomentation	Escitalopram 10 mg OD	Moderate improvement
Case four	39/F	Gardening (bending)	Once-monthly umbilical pain, nausea, unease	Five years	Health worry, somatic focus	Illness-anxiety disorder (F45.2)	Oil massage, yoga	Sertraline 25 mg OD	Moderate improvement
Case five	42/F	Sedentary lifestyle	Monthly abdominal shifts, anxiety, and insomnia	25 years	Restlessness, pervasive worry	Generalized anxiety disorder (F41.1)	Oil massage	Sertraline 25 mg OD	Mild improvement
Case six	32/F	Skipped meals, child lifting	Peri-umbilical discomfort, palpitations, anxiety	Two years	Anxious ruminations, low energy	Mixed anxiety-depressive disorder (F41.2)	Oil-and-thumb ritual	Sertraline 25 mg OD	Mild-to-moderate improvement
Case seven	62/F	Prolonged agricultural work	Recurrent umbilical pain, weakness, and agitation	30 years	Dysthymic mood, somatic fixation	Persistent depressive disorder (F34.1)	Thread-repositioning, goddess-blessed ring	Sertraline 50 mg OD	Partial improvement

Diagnostic rituals such as the thread test (Figure 1), where asymmetry in thread length from the navel to the toes signified misalignment, were widely used. Palpation by local elders (Figure 2) to detect the “loss of navel pulse” was also common. Patients commonly report folk remedies for Gola Khisakna that include abdominal oil massage; Nabhi Basti (warm oil retained within a dough ring over the umbilicus); application of heat or negative pressure at the navel (e.g., cupping or placing cups, bowls, or other objects over the umbilicus); simple manual “repositioning” maneuvers; and yoga or abdominal core postures (Figure 3). In one case, a spiritual object, such as a goddess-blessed ring, was worn. These interventions offered short-term relief and emotional reassurance but failed to address the underlying psychological distress, resulting in repeated help-seeking and chronic suffering.

Figure 1.

A cotton string is fixed at the umbilicus and stretched to the great toe on each side; any side-to-side difference in length is interpreted as a “navel shift,” prompting manual repositioning rituals.

Figure 2.

Peri-umbilical Abdominal Palpation to “Check the Navel” (Perceived Loss/Shift of the Navel Pulse) as a Diagnostic Ritual Before Attempted Repositioning.

Figure 3.

Inverted Steel Vessel (“Lota/Katori”) Pressed Over the Umbilicus to Create Negative Pressure. A Standard Home Remedy for Gola/Nabhi Khisakna is Intended to “Pull the Navel Back.”

Female predominance in this series (five of seven cases) likely reflects greater exposure to physical triggers such as child lifting and domestic work, differences in help-seeking behavior, and culturally shaped somatic expression of distress. Local idioms around a “shifted navel” also seem to circulate more actively within women’s social networks, shaping symptom labeling and the pathway to care.

All patients had undergone thorough biomedical evaluations, including clinical assessments, laboratory investigations, ultrasonography, and X-rays, which failed to identify any organic pathology. It often led to increased patient frustration and reinforced their existing cultural beliefs. Psychiatric evaluation, however, revealed a range of previously undiagnosed conditions, including somatoform disorder, panic disorder, moderate depression, health anxiety, mixed anxiety-depressive disorder, and dysthymia. MSE commonly revealed anxious affect, somatic focus, persistent worry, and low mood. Most patients expressed initial surprise but gradual acceptance of the psychiatric diagnosis. They acknowledged that understanding the mind-body link helped relieve anxiety and were open to continuing psychiatric care.

Gola Khisakna served as a culturally sanctioned idiom of distress, offering a socially acceptable way to express emotional suffering in a context where discussing mental illness is often stigmatized. By localizing psychological distress to a tangible and culturally familiar site, the “navel,” patients were able to seek care and communicate their suffering without social judgment.

Although recruitment occurred in the psychiatry-OPD, we likely captured a subset with medically unexplained symptoms; patients with clear organic pathology are under-represented. Direct evidence that patients with confirmed organic disease (e.g., Inflammatory Bowel diseases [IBD] or appendicitis) self-label their pain as Gola Khisakna, Dharan, or Nabhi Sarakna is scarce. However, symptom overlap is present: A 20-case “navel sliding” series recorded surgical/medical differentials such as umbilical hernia, enteritis, and Irritable Bowel Syndrome (IBS) before folk attribution was invoked, underscoring the need to exclude organic causes systematically, while another brief report frames Dharan/Nabhi Sarakna within medically unexplained presentations.^4,6 Separately, low and middle-income countries’ data show cultural beliefs and initial use of home or traditional remedies can delay appendicitis care, and surgical delay is linked with worse outcomes.^7,8 So, red-flag evaluation should not be deferred.

This pattern is not unique to India. Similar idioms of distress have been identified globally, such as Gas Syndrome in South India and Khyâl attacks in Southeast Asia.^9,10 These conditions reflect a shared human tendency to express internal turmoil through bodily symptoms shaped by cultural narratives. Recognizing such syndromes is critical to culturally competent psychiatric care.

For clinicians, these cases underscore the importance of cultural humility. Rather than challenging traditional beliefs, a more effective approach involves respectful engagement, validation of patients’ perspectives, and gentle introduction of biopsychosocial explanations. Psychoeducation framed through metaphors such as “mind-body balance” or “energy flow” may resonate better with patients and increase openness to psychiatric care. Where needed, pharmacological and psychological treatments can be integrated as supportive tools for overall well-being, avoiding the stigma of mental illness labels.

This small, single-center case series used purposive psychiatry-OPD recruitment, introducing selection bias and likely under-representing co-occurring organic pathology. Findings rely on self-reports and culturally framed narratives; therefore, recall and social desirability bias are possible. As only a structured interview was used and standardized symptom-severity measures were not used, change over time could not be quantified. The series may not capture the full cultural variability of Gola Khisakna across India; mixed medical, surgical, and psychiatry-OPD recruitment would better represent the spectrum.

This exploratory case series suggests several directions for future research. Longitudinal studies could explore psychosocial risk factors, such as chronic stress, gender roles, or economic hardship, that are linked to Gola Khisakna. Additionally, integrative treatment models that combine traditional healing with psychiatric care (e.g., CBT or low-dose medication) should be evaluated for feasibility and effectiveness, potentially enhancing community acceptance and adherence. Future work should use brief validated measures of somatic symptom burden, anxiety and depression, health anxiety, and functioning, with longer follow-ups.

Conclusions

Gola Khisakna represents a culturally rooted idiom of distress, through which individuals express psychological suffering in socially acceptable somatic terms. This case series reinforces its characterization as a CBS, highlighting the importance of culturally sensitive psychiatric engagement. Recognizing such beliefs not as superstition but as meaningful explanatory models allows clinicians to build rapport, reduce stigma, and introduce appropriate care. Integrating cultural understanding with psychiatric practice is essential for adequate, inclusive mental healthcare. As global psychiatry evolves, conditions such as Gola Khisakna remind us of the value of contextually grounded approaches to emotional and psychological healing.

Supplemental Material

Supplemental material for this article available online.