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Khyal Cap

These general questions can be illustrated through one example. One of the nine items in the ‘Glossary of Cultural Concepts of Distress’ is khyal cap, which is described thus:

‘khyal attacks’ (khyal cap), or ‘wind attacks’, is a syndrome found among Cambodians in the United States and Cambodia. Common symptoms include those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities, as well as other symptoms of anxiety and autonomic arousal (e.g. tinnitus and neck soreness). Khyal attacks include catastrophic cognitions centred on the concern that khyal (a wind-like substance) may rise in the body—along with blood—and cause a range of serious effects (e.g. compressing the lungs to cause shortness of breath and asphyxia; entering the cranium to cause tinnitus, dizziness, blurry vision, and a fatal syncope). Khyal attacks may occur without warning, but are frequently brought about by triggers such as worrisome thoughts, standing up (i.e. orthostasis), specific odours with negative associations, and agoraphobic type cues like going to crowded spaces or riding in a car. Khyal attacks usually meet panic attack criteria and may shape the experience of other anxiety and trauma and stress or related disorders. Khyal attacks may be associated with considerable disability. Related conditions in other cultural contexts: Laos (pen lom), Tibet (srog rlunggi nad), Sri Lanka (vata), and Korea (hwa byung). Related conditions in DSM-5: panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder (ibid., p. 834).

The belief that illness can be caused by a dysfunction of a wind-like substance, described using the same word as for wind, seems to be common in parts of Asia (Hinton et al. 2010, p. 245). Khyal is thought normally to flow alongside the blood supply and can pass out of the body through the skin. But the flow can become disturbed, ‘surging upward in the body toward the head, often accompanied by blood, to cause many symptoms and possibly various bodily disasters’ (ibid., p. 245). It is thought to be caused by, for example, ‘worry, standing up, a change in the weather and any kind of fright, such as being startled or awakening from a nightmare’ (ibid., p. 246). Local treatments include dragging a coin along the skin, giving rise to characteristic abrasions.

To ‘coin’, the person dabs the tip of a finger in khyal ointment (preing ken- Laa), a Vaseline-like substance containing camphor and menthol, and then drags the fingertip along the skin to create a streak five or six inches in length. Next a coin is grasped by the fingers and the edge pushed down slightly against the skin at the proximal beginning of the streak; the coin is then dragged outward along the streak of khyal ointment. This is then repeated (ibid., p. 271).

Despite the overlap of symptoms with those defined as panic attack, for example, it is clear that the framework of beliefs that surround the conception of khyal attack differs from that of biomedical psychiatry. What then is its supposed status in DSM-5? This question calls for a general understanding of the ways in which culture might affect concepts of illness and whether any model can simultaneously aim for validity whilst admitting cultural variation. Thus, the next section will outline three general ways of thinking about the cultural dependence of mental illness categories, the possible role of cultural formulation and hence the different cultural concepts of distress in DSM-5.

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