Koro Syndrome in Female: A Case Report of a Rare Anxiety Disorder with Cultural Influence on Psychopathology

Abstract

Koro syndrome is a culture-specific disorder occurring primarily in Southeast Asian regions, presenting as acute anxiety with fear of retraction of the external genitalia or its part, fear of death by the thought of complete disappearance of genitals. Most cases are reported in males, Koro syndrome in females is very rare.

Case Presentation: A 25-year-old woman presented with complaints that the skin over the vagina is retracting inside her body and feeling that something will happen to her if it gets fully retracted for 9 months. She had multiple consultations with the gynecologist who found no anatomical abnormality on examination and referred the patient to a psychiatrist, where she was diagnosed with Koro syndrome and was started on psychotropic medication.

Conclusion: Female with Koro syndrome is expressed mainly in an epidemic setting due to cultural and psycho-social factors such as cultural taboos that suppress the expression of atypical sexual symptoms, inadequate knowledge, and misconceptions.

Introduction

Culture-specific syndrome or culture-bound syndrome combines psychiatric and somatic symptoms within a specific society or culture. Koro syndrome is most observed in Southeast Asian regions. The term Koro is thought to derive from the Malay word “kura,” which means “tortoise” with symbolic meaning that the penile retraction is compared with the retraction of the head of the tortoise into the shell. In India, it is known as Jhinjhinia Bemar, especially in Assam and West Bengal regions. ¹

There are two types of Koro syndrome: an endemic culture-related epidemic in Southeast Asia and a non-cultural type with sporadic cases throughout the world.

In Koro syndrome, patients may have acute anxiety with fear of retraction of genitals, accompanied by fear of death induced by the thought that the complete disappearance of genital organs will result in death. The presentation may vary as retraction of penis in males, retraction of breast and labia in females, or retraction of any protruded organ such as nose and tongue in either of them. ¹ Koro syndrome sometimes seems to be spread socially and maybe a kind of mass hysteria, causing widespread panic and concern, as well as a disorder among individuals. Affected persons may resort to clamps, ties, pegs, or hooks to keep the genitals from fully receding, sometimes resulting in damage to the organs. ²

In classical or cultural Koro syndrome, three symptoms must be present:

Perception of acute retraction of breast or vulva in females (or penis in males)

Acute panic-like reaction

Acute fear of impending danger, most commonly death or physical or sexual disability, at the background of some related cultural beliefs.

The whole episode lasts from a few minutes to an hour. ³

In Koro-like symptom presentation, the background cultural myth is absent; the onset is gradual rather than sudden, and the fear of death is absent and is usually associated with other mental health diagnoses such as schizophrenia, affective disorders, and recreational/regular drug use. ³

There is a dearth of literature on sporadic female cases of Koro syndrome, especially in our part of the globe. This report discusses a case of female Koro syndrome, contributing to the limited literature on this phenomenon.

Case Presentation

A 25-year-old, homemaker, married, Hindu, female patient, educated up to 10th standard, presented to the psychiatry OPD with complaints of sensations of skin over vagina retracting inside her body and feeling that something will happen to her once it gets fully retracted inside her body. The patient reported experiencing an intense sensation of “shrinking” of her genital area and a belief that this retraction could lead to serious health consequences. She became preoccupied with this belief and started checking and touching her genitalia repeatedly to ensure that her genitalia had not retracted, leading to significant distress in the form of palpitation, perspiration, and fearfulness that something would happen to her. Patient was also having interference with daily activities in the form of neglecting her daily chores, isolating herself from people, and worries about her health for the last eight to nine months. During the interview, it came to light that the patient was raised in a conservative family with strong orthodox cultural beliefs, and talking about sex was considered taboo, she always felt ashamed discussing sexual health and had significant distress because of the same. It was also found that patients had various myths regarding the dissolution of sutures and its effects on the body.

The patient had no prior history of psychiatric illness, and her medical history suggested a history of episiotomy 10 months back and multiple consultations (three to four times) with the gynecologist for the same complaints. The patient’s family history was not significant. The patient has two children, the first child was born without episiotomy and the second with episiotomy. There was no significant finding upon physical examination, and pelvic and external genitalia examination revealed no anatomical abnormalities.

On mental status examination, the patient was visibly distressed and was fidgety during the interview. She was well groomed, spoke at a soft volume, and reported her mood to be anxious, while her affect was anxious and communicable. She was preoccupied with the thoughts of her genitalia being retracted in her pelvis and urged to check her genitalia for the same and would yield to the urge and would repeatedly touch her genital area and frequently check herself to ensure that her skin over her vagina not retracted. The patient reports that these thoughts are her own and did not try to control them. She also reports the origin of these thoughts after going through childbirth and episiotomy. A psychometric assessment was not done. Complete blood count, urine routine and microscopic examination, and C-reactive protein levels were done to rule out infection and inflammatory process, and liver and kidney function test parameters were within the normal range. Imaging studies in the form of an ultrasound of the pelvis suggestive of no abnormalities and magnetic resonance imaging of the brain showed no evidence of intracranial pathology.

The thoughts had no morbidity in origin as in delusions and were not intrusive or unwanted as in obsessions. Also, the origin was after the episiotomy suture and cultural beliefs secondary to the effects of sutures on the body and the cultural myths surrounding episiotomy and genitalia. Thus, based on the patient’s history, clinical examination, mental status examination, and the characteristic presentation of intense fear of genital retraction, a diagnosis of Koro syndrome was made; corresponding to an International Classification of Diseases, Tenth Revision diagnosis of F48.8 (other specified neurotic disorders). There is no specific diagnosis for Koro syndrome in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision but can be classified under other specified anxiety disorders with a specifier for culture-related anxiety disorder.

Management

The treatment plan focused on both the acute management of her anxiety and the long-term treatment of her Koro syndrome. The patient was initially treated with a low-dose benzodiazepine (clonazepam 0.25 mg twice daily) to alleviate her acute anxiety symptoms. She was also started on Tab. escitalopram, at 10 mg daily, to address anxiety symptoms and prevent the recurrence of symptoms.

Psychoeducation was provided to the patient and her family to help them understand the nature of the disorder. Emphasis was placed on the cultural context of her symptoms and reassurance that her fears were unfounded. Cognitive-behavioral therapy was initiated, focusing on challenging the irrational thoughts related to genital retraction and reducing related associated anxiety. Relaxation techniques, such as deep breathing exercises and mindfulness, were also introduced.

The patient showed significant improvement within two weeks, with a marked reduction in anxiety and cessation of her preoccupation with genital retraction. At follow-up one month later, she remained symptom-free and resumed her normal daily activities.

Discussion

Koro syndrome is characterized by the belief that the penis/vulva (external genitalia) retracts into the abdomen, and ultimately death is caused when the genitalia gets completely retracted inside the pelvis or abdomen, resulting in intense anxiety. ⁴ Koro syndrome typically occurs in male patients, but female cases are rare and highlight the need for a broader, more inclusive perspective on this culture-bound syndrome.

Koro syndrome was considered a “cognitive reinforcement” of body-related beliefs that only emerged after discussions of cultural attachments led to similar symptoms. ⁵ Prior research has primarily described Koro as a culture-bound syndrome with a higher prevalence in specific regions, such as Southeast Asia. Psychodynamic explanations tend to emphasize the role of castration anxiety as one of the etiological factors for the fear of genital retraction, which can be understood in our patients to arise from the recent childbirth requiring an episiotomy. ⁶ In most of the cases described in the literature, patients have symptoms triggered by acute stress, and are influenced by cultural and societal factors. ⁷ There was a stressful life event of childbirth for our patient that preceded the onset of symptoms, along with episiotomy which led to the development of feelings of sexual inadequacy in combination with cultural and psycho-social stresses such as an orthodox family, an authoritarian father with a history of psychosis, strict mother with strong religious attitude toward sex, inadequate knowledge and misconceptions about sexual matters and cultural beliefs surrounding the childbirth, and use of episiotomy.

Sexuality in India, for a long, has been considered as something to be discussed in hushed voices and discovered behind closed doors. Psychosexual disorders are sexual problems or issues of predominantly psychological origin in the absence of any organic pathology. Koro perception may be viewed as one of the variants of this spectrum. It is reported that psychosexual disorders may arise due to guilt, stress, anxiety, nervousness, worry, fear, depression, distorted body image, physical or emotional trauma, abuse, and rape. ³

Nevertheless, understanding the complexity of culture-bound syndromes as expressions of distress requires comprehensive research. Further research in this area will help integrate cultural and clinical knowledge and provide insights into issues of diagnostic universality and cultural specificity.

Conclusion

In this case, the patient’s irrational fear of genital retraction, despite a lack of any physiological abnormalities, underscored the psychological and cultural roots of Koro syndrome also emphasizing the importance of recognizing this condition in clinical practice. Early diagnosis and culturally sensitive management are essential for effective treatment and recovery.