An outbreak of Koro among 19 workers in a jute mill in south Bengal.

Koro is a culture-bound syndrome that is characterized by the belief of retraction of genitals into the abdomen. It was initially reported in Asian countries, as having a usual acute and brief course. Two case clusters have been described in this article. Both occurred in the same jute mill in southern West Bengal among the workers. The case clusters depict unique socioeconomic factors and interesting health-seeking behavior toward koro. All the cases had a self-limiting course and reasonably good outcome. The case cluster yet again confirms that koro is not as rare as it is thought of and social and economic factors continue to play an important role in the etiology of the disease.

Culture-bound syndrome, koro Koro is a culture-bound syndrome that is characterized by the belief of retraction of genitals into the abdomen.[12] The word “Koro” means “to shrink” or “sukyeong” (shrinking penis). It was initially described as a culture-bound depersonalization syndrome.[3] Koro was first introduced in western science as a malady of the southern Sulawesi people of Indonesia.[4] Though initially it was thought to be restricted to Southern Chinese immigrants in Hong Kong and South East Asia,[5] reports of epidemics outside these areas are not uncommon,[67] along with a few sporadic outbreaks as well.[8] In this article, we describe two case clusters of koro, constituting 19 workers of a jute mill in Nodakhali, southern West Bengal, with interesting sociopsychoanalytical conglomerations.

CASE REPORT

Case 1

A 26-year-old male, an unmarried rickshaw puller working temporarily in a jute mill in Nodakhali, southern West Bengal, presented to the psychiatry outpatient department with persistent fear for 2–3 days that his penis was shrinking into his abdomen which was making him progressively weak. He became intensely anxious and was unable to sleep well at night and repeatedly brooded over the thought. He denied any addiction or habitual intake of any psychotropic drugs, while his informant and medical records failed to show any premorbid psychiatric illness. He thought his symptom was due to his recent nocturnal emission and masturbatory practices. He promptly reacted by immersing himself in a nearby pond for 14–16 hours overnight which resulted in symptomatic chest infection in his lungs. His action quickly gained recognition in the inhabitants of the nearby worker's quarters. Two days following the event, six laborers presented with similar symptoms and they promptly followed similar preventive measure as well. None of the cases could qualify for any other codable Axis I diagnosis. The occurrence led us to arrange for a small medical camp in the vicinity to spread awareness and group psychotherapy, and the outbreak subsided after 5–6 days.

Case 2

A 53-year-old divorced senior worker, who was show caused by the authority recently for irregularities in his professional commitment, working as a mechanic in the same jute mill suddenly noticed his penis growing smaller and shrinking into his abdomen. This resulted in a panic, and he frantically reached for help in the emergency department of the hospital. He had learnt that a similar occurrence had occurred 1 week back nearby his quarter, which caused the victims to immerse themselves in ice-cold water. He admitted taking country liquor at least on two to three occasions per week, amounting to 1–2 pints each time on an average, though he was abstinent for the last 15 days. There were no other significant premorbid medical or psychiatric illnesses. He was given chlordiazepoxide 80 mg in divided doses and thiamine and was reassured. His condition caused his nephew, who had been on a vacation in Bihar, to come back to the state. In 2–3 days, the nephew started having similar complaints that resulted in intense panic and had to be admitted to surgery observation ward following abrasive injury over the glans which reportedly occurred as he tried to pull out his penis from the abdomen, which he thought was retracting. He recovered within 3 days but the news was followed by an outbreak of similar illness among 11 workers in the same jute mill and they resorted to immersing themselves in a pond nearby. They believed that the disease was occurring due to increased heat accumulated within the body that needed to be cooled down. Another medical camp was arranged, and assurance followed by group psychotherapy resulted in reduction of symptoms within 6–7 days. Close individual psychiatric interviewing revealed most of the cases to be unmarried. Immediately prior to the outbreak, there was a prolonged cease work in the jute mill discussed and the workers were not getting their salaries for the last 1 year which led to financial instability. The demographics and other relevant particulars of the two case clusters discussed herewith are briefly summarized in [Table 1].

Table 1

Demographics of the Koro clusters consisting of jute mill workers

DISCUSSION

Koro has been characterized with three cardinal symptoms, i.e. (1) a belief or delusion of retraction of penis into the abdomen; (2) intense panic with physical signs of anxiety; and (3) the use of mechanical means to prevent penile retraction.[910] Koro has been discussed in connection with a few koro-like syndromes or genital retraction syndrome, otherwise unclassified.[11] In this article, all the cases suffered from the syndrome failed to qualify for any other Axis 1 psychiatric diagnosis and the mode of presentation of the mass hysteria was characteristic of koro. Most of the cases believed that the disease was caused either due to overindulgence to masturbatory practices or nocturnal emission. Both may be considered as a violation to the prevailing folk rule system governing sexual practices in the community. Possibility of sexual inadequacy in a few cases may also be considered to be a potential precipitating cause.[51213]

Moreover, economic instability and uncertainty over the future may have arisen in a few cases due to longstanding cease work in the jute mill prior to the event, which may be considered as an important psychodynamic triggering factor. This may indicate an anthropological basis of the disease as well.[14] Comorbid substance abuse was found in a few cases which has been linked with the occurrence of koro. However, course of Koro is usually acute, brief, and self-limiting, though a few chronic koro-like syndromes have been described.[11] Most of the cases encountered in this article had such a characteristic short course without any significant residual illness.

In this article, all the cases were males with a relatively low socioeconomic background. Most of the cases were unmarried (84.21%) and were employed but irregularly paid at the office (87.47%). Only a few cases admitted of having a premorbid psychotic illness (12.53%) or substance abuse (12.53%), and a few admitted of homosexuality (15.79%) and commercial sex worker exposure (12.53%). Commonest health-seeking behavior observed in these cases was immersing in water (57.89%), while surgical emergency was encountered in one of the cases (5.26%).

CONCLUSION

Koro remains prevalent in non-Chinese and non-Indonesian nations, contrary to the common belief. It is still more prevalent in areas where literacy levels have not reached satisfactory levels. Prevailing socioeconomic upheavals and economic uncertainty continue to play an important role in causation of the disease. The case clusters described in the article show how group psychotherapy and awareness campaigns can effectively eradicate the syndrome.