Hektoen International

A Journal of Medical Humanities

Men, women, and idioms of distress

Mary Seeman
Toronto, Ontario, Canada


An unsure woman looking at a pregnancy test, a representation of what pedisyon, an idiom of distress, may feel like
What pedisyon may feel like. Photo by Tima Miroshnichenko on Pexels.

In all cultures there is a place for illness that is not easily explained by individual pathology. It is usually attributed to larger societal unrest, with some individuals responding to that unrest with somatic or psychological symptoms. When a community is stressed, by natural disasters or by wars, by feelings of powerlessness, loss, or insecurity, the distress is filtered through the community’s history and traditions and expressed through body and mind symptoms in individual community members.

Cultural anthropologists believe that such symptoms should be viewed as repercussions and reflections of local social phenomena, not as indications of individual pathology. Interestingly, response to social upheavals is often expressed in different ways by women and men.

Koro, for instance, (derived from the Japanese word for the head-retracting tortoise) is a male syndrome, periodically occurring in epidemic form in many parts of the world. It consists of a somatic sensation and a belief that the penis is shrinking into the abdomen. This is particularly frightening to the sufferer because of the conviction that death is inevitable once the penis totally disappears. Outbreaks of koro tend to peak and then decline in local communities. On medical examination, the penis is intact. Explanations for koro are that the epidemics reflect regional sociopolitical shifts, and that the men’s loss of perceived status or power are being expressed via body symptoms.1 A thematically related male syndrome prevalent in India is dhat, its somatic manifestation being the passage of white-colored urine, which is believed to be seminal fluid.

A man screaming and covering his eyes, a representation of running amok, an idiom of distress
Artistic representation of running amok. Photo by Alex Iby on Unsplash.

According to Ayurvedic concepts, semen represents power,2 so that, again, loss of social standing is symbolically somatized.

Women’s status in many cultures is determined by the ability to reproduce. An illustrative syndrome among Haitian women is called pedisyon (perdition).3 It is a form of a relatively common global phenomenon called pseudocyesis in Western medicine—a woman seemingly pregnant for many months but never producing a baby. Pedisyon and its analogues occur most frequently in pronatalist countries where offspring are needed for the family’s survival and where infertility is always attributed to the woman. A woman who fails to produce what her husband’s family expects of her—many children, especially boys—is stigmatized and, in some parts of the world, relegated to minor wife status. The interesting biological correlate is that the stress of being barren can raise prolactin levels, which in turn can result in many of the physical symptoms of pregnancy.4

A woman screaming, a representation of Uzr, an idiom of distress
Representation of Uzr. Photo by Liza Summer on Pexels.

An example of a relatively new sociomedical syndrome is hikikomori, manifested as social withdrawal and first observed in Japan and currently reported in several countries outside Japan. The affected person is usually a young male who withdraws from his social group, from school, or from his workplace and spends the day in his room at his parents’ house, interacting only with his electronic devices.5 Various hypotheses as to the origin of hikikomori have been suggested, including the downturn in the Japanese economy and subsequently diminished employment opportunities. Easy access to the internet is said to have also contributed, as well as a social trend to adolescent dependence on parents6 and the culture of shame in Japan, which places high value on masculinity as represented by academic and financial success.7

Going amok (meaning: engaging furiously in battle) is another syndrome of men, prevalent in Malaysia and Indonesia. Typically, persons who go amok are young or middle-aged, mild-mannered men. Apparently on sudden impulse, these men appear in a crowded public area with a weapon and violently attack anyone they meet. Amok is considered a form of rage against a society in which men feel weak and under-appreciated. After the attack, the men usually lose consciousness and subsequently claim amnesia for the incident. They afterwards believe that their honor has been restored because, in the eyes of others, they have been seen to be fearsome.8

Woman suffering from anorexia nervosa, an idiom of distress
Woman suffering from anorexia nervosa. St Bartholomew’s Hospital Archives & Museum. CC BY 4.0.

Uzr is an Egyptian analogue in women. Attributing their unusual state to spirit possession, subservient women undergoing Uzr are temporarily able to express personal grievances. For women who chronically suffer at the hands of more powerful others, this is more than a catharsis. The fact of having been possessed by a spirit heightens their social position in the community. Uzr has been described as a strategy of indirect social control.9 Similarly, rapid-onset anger and irritation in women is called tension (pronounced tens´an) in South Asia and considered a reaction to the social problems of modernity.10,11

Anorexia nervosa is a syndrome of affluent countries,12 mainly expressed by women. It spotlights the reciprocal relationship between the self and the wider society and is a response to standards of attractiveness and female desirability as formulated by massive media promotion, standards that ignore the reality that female bodies come in many shapes. The ideal of feminine beauty has become linked to a slim body in Western countries in much the same way that tiny feet once were in ancient China. In high-income countries, it is reportedly not one’s perceived wealth or power or beauty that correlates with mental health, but rather one’s rank in the hierarchy, the comparison of status relative to others. The attempt to raise one’s rank or to explain away the inability to do so because of pain or fatigue can also be reflected by fibromyalgia13 and chronic fatigue syndrome,14 both female-associated syndromes.

Anthropological perspectives on health link illness not only to pathophysiology, as Western medicine does, but also to social, economic, and political conditions that produce hardship and suffering that are perceived as inequitable or unmerited. Approaching mental health through an anthropological lens, it becomes easier to understand local idioms of distress and the somewhat different impact of social conditions on women and men.

An idiom of distress is a metaphor for psychosocial suffering that has local meaning but can seem totally incomprehensible to outsiders. Stressors that give rise to suffering are multiple. Among the many causes are precarious socioeconomic circumstances, the position of one group of persons in relation to comparison groups, war, political violence, migration, loss of social networks, infant mortality, unemployment, crime, and ethnic tensions. Social stressors affect the most disadvantaged and most vulnerable first. They tend to impact health in ways that symbolize, through body language, the precipitating stressors. While men and women are affected to equal degrees by social factors, the metaphors they utilize to represent their distress are often sexually dimorphic.



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MARY V. SEEMAN, MD, a pioneer in women’s mental health, was awarded a Doctor of Science degree from the University of Toronto in 2002, and was appointed Officer of the Order of Canada in 2006. At the Centre for Addiction and Mental Health, Dr. Seeman established the first outpatient clinic dedicated to women affected by psychosis. She serves on the editorial boards of several psychiatric journals and is an inaugural member of the College of Reviewers of the Canadian Institutes of Health Research. She has written a number of books, book chapters, and journal articles about varied aspects of psychiatry.


Spring 2021  |  Sections  |  Psychiatry & Psychology

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