Asian Journal of Psychiatry xxx (2014) xxx–xxx

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Letter to the Editor

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Asian Journal of Psychiatry

jo u rn al h om epag e: ww w.els evier .c o m/lo cat e/a jp

Koro presenting as acute and transientpsychosis: Implications for classification

Sir,

The phenomenology of Koro, traditionally recognized as aculture bound syndrome, has been described varyingly (Garlipp,2008). The recently published DSM-5 has included Koro under thecategory of ‘‘Other specified Obsessive-Compulsive and relateddisorder’’ adding to the debate on its nosological niche (AmericanPsychiatric Association, 2013). In this report, we describe a patientpresenting with concerns about genital retraction diagnosed asacute and transient psychosis necessitating the usage of anti-psychotics.

A 32 year old married male from a rural background inSouthern India with no relevant past, personal or family historypresented to the out-patient department with complaints of‘‘penis is shrinking’’ since 3 days. He appeared to be verydistressed about it and was preoccupied with the possibility ofeventual death due to this symptom. His beliefs were reinforcedwhen, upon his insistence, his wife inspected his penis andagreed that it ‘looked’ smaller than usual. During our interview,he had full conviction about his belief and was not amenable toany arguments or suggestions otherwise. We concluded that hewas suffering from a somatic delusion. No other delusions orhallucinations were elicited. Due to accompanying excitement,he was administered a single parenteral injection of haloperidol5 mg and promethazine 50 mg after which he slept for about16–18 h. Upon awakening, he reported that the penis was backto its usual size and appeared perceptibly calmer though he wasable to recount his terrifying experience. Currently the patient isreceiving 2 mg of oral Risperidone for past 3 months and hasresumed functioning as productively as before. No othersymptoms or signs of psychosis have been noted in follow-up.

The nosological status of Koro has been a matter of muchdebate among researchers who can be broadly grouped under‘lumpers’ and ‘splitters’. The ‘lumpers’ have proposed theassociation of Koro with anxiety disorders (Altable and Urrutia,2004), body dysmorphic disorder (Hollander et al., 1989),obsessive–compulsive spectrum disorders (Hughes and Wintrob,1995) and depressive disorders (Chadda and Shome, 1991) amongothers. On the other hand, Bernstein and Gaw (1990), haveproposed an easy to comprehend, but at the same time restrictive,classification of Koro, where they suggest that the conditionshould be grouped under somatoform disorders. The sameauthors, from a phenomenological standpoint, argue againstthe lumping of Koro with body dysmorphic disorder or delusionaldisorder – somatic type. However the present case is an exceptionto this viewpoint. Here, the patient presented with an acutelycrystallized somatic delusion of genital retraction. It did not occurin the context of an epidemic. The diagnosis under the Bernstein

Please cite this article in press as: Ramamourty, P., et al., Koro

classification. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.

http://dx.doi.org/10.1016/j.ajp.2014.03.008

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and Gaw scheme would be Genital retraction syndrome, culturespecific and may have precluded the use of anti-psychotics whichwere clearly useful in this case. Hence, we feel that a flexibleapproach is needed wherein fears about genital retraction shouldbe evaluated on the basis of phenomenology, symptom sequenceand dysfunction before assigning a diagnostic category. WhileKoro and genital retraction may present heterogeneously, moreresearch is required to establish the biological basis of thissymptom and validity of the entity as distinct from other axis Iconditions which would help us in answering the lumpers versussplitters debate.

Role of funding source

None.

Contributors

PR examined, treated, followed up the case and conceptual-ized the manuscript. VM supervised the case management andfollow up at all stages and wrote the paper. AM did the literaturesurvey, contributed to the writing and critical review of themanuscript.

Conflict of interest

None declared.

References

American Psychiatric Association, 2013. Diagnostic and Statistical Manual ofMental Disorders, 5th ed. American Psychiatric Association, Washington, DC.

Altable, C.R., Urrutia, A.R., 2004. Koro – misidentification syndrome in schizo-phrenia? A plea for clinical psychopathology?. Psychopathology 37 (5) 249–252.

Bernstein, R.L., Gaw, A.C., 1990. Koro: proposed classification for DSM-IV. Am. J.Psychiatry 147, 1670–1674.

Chadda, R.K., Shome, S., 1991. Koro-like symptoms (letter to editor). Am. J. Psychia-try 148, 1766–1767.

Garlipp, 2008. Koro – a culture-bound phenomenon intercultural psychiatricimplications. Ger. J. Psychiatry 11, 21–28.

Hollander, E., Liebowitz, M.R., Winchel, R., Klumker, A., Klein, D.F., 1989. Treatmentof body dysmorphic disorder with serotonin reuptake blockers. Am. J. Psychia-try 146, 768–770.

Hughes, C.C., Wintrob, R.M., 1995. Culture-bound syndromes and the culturalcontext of clinical psychiatry. In: Oldham, J.M., Riba, M.B. (Eds.), Review ofPsychiatry. American Psychiatric Press, Washington, DC.

Parthasarathy RamamourtyVikas Menon*

Department of Psychiatry,

Jawaharlal Institute of Post Graduate Medical Education

and Research (JIPMER), Puducherry 605006, India

presenting as acute and transient psychosis: Implications forajp.2014.03.008

Letter to the Editor / Asian Journal of Psychiatry xxx (2014) xxx–xxx2

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AJP-576; No. of Pages 2

Muraleedharan AparnaDepartment of Anatomy,

Jawaharlal Institute of Post Graduate

Medical Education and Research (JIPMER),

Puducherry 605006,

India

Please cite this article in press as: Ramamourty, P., et al., Koro

classification. Asian J. Psychiatry (2014), http://dx.doi.org/10.1016/j.

*Corresponding author at: Department of Psychiatry, JIPMER,Dhanvantary Nagar, Puducherry 605006, India. Tel.: +91

9894410296; fax: +91 413 2272067E-mail address: drvmenon@gmail.com (V. Menon).

Received 20 January 2014

presenting as acute and transient psychosis: Implications forajp.2014.03.008