Korea in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition



# Introduction
It is imperative to investigate the psychopathology of culture-specific syndromes using a multi-faceted approach, considering their uneven distribution and region-specific concentration. 1,2 Because culture-bound syndromes are closely related to cultural factors, understanding and management from a cultural perspective are warranted. Culture-bound syndromes cannot easily be conceptualized from the viewpoint of the pre-existing psychiatric classification system, which is mainly based on Western psychiatry. Thus, non-Western syndromes need to be described with proper characterization.The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been the most prestigious taxonomic and diagnostic tool published by American Psychiatric Association (APA). The culture-bound syndromes have been changed into the cultural conceptualizations of distress-which include cultural syndromes, idioms of distress, and explanatory models-along with the revision of DSM-IV to DSM-5, because DSM-5 emphasizes cultural formulation. 4,5 In terms of cultural formulation, as shown in, South Korea has been mentioned four and five times in DSM-IV and DSM-5, respectively. In DSM-5, hwa-byung (anger syndrome) and taein-kong-po (fear of interpersonal relations) were introduced in the section of cultural concept of distress. Furthermore, it is described that both internet gaming disorder and alcohol-metabolizing enzyme gene polymorphisms are highly prevalent in Koreans. 5

## Hwa-byung (anger syndrome)
In DSM-5, hwa-byung is predominantly regarded as one of the khyal cap (wind attack)-related conditions in other cultural contexts, and the clinical characteristics of hwa-byung have not been described at all. 5 Hwa-byung is prevalent among older married women and is etiologically associated with anger repression that arises from familial conflicts attributed to the patriarchal Korean social system. 6 A diagnosis of hwa-byung can be provisionally made on the basis of the symptom criteria including feelings of unfairness, subjective anger, expression of anger, sensation of heat, pushing up in chest, dry mouth, and sighing.The lower activity of the anterior cingulate gyrus (the neural substrate of anger) in response to neutral stimuli was observed in patients with hwa-byung.However, hwa-byung has merely been used as a folk term to describe "consequences of repressed anger or accumulated rage and sorrow." Additionally, it has been suggested that its uniqueness is not sure about "a culture-bound syndrome specific to Korean culture." Therefore, considering the perspective of cultural psychopathology and the established clinical practices specific to South Korea, the term hwa-byung could be used to improve psychiatrist-patient communication.Thus, a more detailed description for hwa-byung may be discussed in the further revision of the DSM.
Although shin-byung (divine illness) has been listed as a culture-bound syndrome in the DSM-IV, it has been excluded from the DSM-5. Furthermore, few Korean patients present with "dissociation and possession by ancestral spirits," or shin-byung.2/5 https://jkms.org https://doi.org/10.3346/jkms.2020.35.e6
Korea in DSM-5 p.205 Social anxiety disorder "The syndrome of taijin kyofusho (e.g., in Japan and Korea) is often characterized by socialevaluative concerns, fulfilling criteria for social anxiety disorder, that are associated with the fear that the individual makes other people uncomfortable (e.g., 'My gaze upsets people so they look away and avoid me'), a fear that is at times experienced with delusional intensity." p.495
Alcohol use disorder "Polymorphisms of genes for the alcohol-metabolizing enzymes alcohol dehydrogenase and aldehyde dehydrogenase are most often seen in Asians and affect the response to alcohol. When consuming alcohol, individuals with these gene variations can experience a flushed face and palpitations, reactions that can be so severe as to limit or preclude future alcohol consumption and diminish the risk for alcohol use disorder. These gene variations are seen in as many as 40% of Japanese, Chinese, Korean, and related groups worldwide and are related to lower risks for the disorder." p.797
Internet gaming disorder "The prevalence of internet gaming disorder is unclear because of the varying questionnaires, criteria and thresholds employed, but it seems to be highest in Asian countries and in male adolescents 12-20 years of age. There is an abundance of reports from Asian countries, especially China and South Korea, but fewer from Europe and North America, from which prevalence estimates are highly variable. The point prevalence in adolescents (ages 15-19 years) in one Asian study using a threshold of five criteria was 8.4% for males and 4.5% for females." p.834
Cultural concepts of distress: Khyal cap "Related conditions in other cultural contexts: Laos (pen lom), Tibet (srog rlunggi nad), Sri Lanka (vata), and Korea (hwa byung)." p.837
Cultural concepts of distress: Taijin kyofusho "The distinctive symptoms of taijin kyofusho occur in specific cultural contexts and, to some extent, with more severe social anxiety across cultures. Similar syndromes are found in Korea and other societies that place a strong emphasis on the self-conscious maintenance of appropriate social behavior in hierarchical interpersonal relationships. Taijin kyofusho-like symptoms have also been described in other cultural contexts, including the United States, Australia, and New Zealand." "Related conditions in other cultural contexts: Taein kong po in Korea." DSM-IV (APA, 1994) p.201 Alcohol-related disorders "In most Asian cultures, the overall prevalence of Alcohol-Related Disorders may be relatively low, and the male-to-female ratio high. These findings appear to relate to the absence, in perhaps 50% of Japanese, Chinese, and Korean individuals, of the form of aldehyde dehydrogenase that eliminates low levels of the first breakdown product of alcohol, acetaldehyde. When such individuals consume alcohol, they experience a flushed face and palpitations and are less likely to consume large amounts." p.413
Social phobia "Clinical presentation and resulting impairment may differ across cultures, depending on social demands. In certain cultures (e.g., Japan and Korea), individuals with Social Phobia may develop persistent and excessive fears of giving offense to others in social situations, instead of being embarrassed. These fears may take the form of extreme anxiety that blushing, eye-to-eye contact, or one's body odor will be offensive to others (taijin kyofusho in Japan)." p.846
Culture-bound syndrome: Hwa-byung

## Taein-kong-po (fear of interpersonal relations)
The translated Chinese term for fear of interpersonal relations is pronounced differently in Korean (taein-kong-po) and Japanese (taijin-kyofusho).An offensive subtype of taein-kong-po (taijin-kyofusho) had initially been conceptualized as a "Japanese culture-specific diagnostic label," and was clinically characterized by the fear of offending others or making them uncomfortable by staring inappropriately, making rude and improper facial expressions, etc. The offensive subtype is also noted in individuals from New York, Switzerland, and Indonesia along with East Asian countries including Korea and Japan. It is possible that the offensive version of taein-kong-po may be not a culture-bound syndrome, but a clinically relevant syndrome associated with interdependent or independent self-construals. 11,It has previously been reported that 80% of patients in Korea that are suffering from taein-kong-po are primarily treated with pharmacotherapy (antianxiety, propranolol, antidepressant, and antipsychotic) and supportive group-psychotherapy. 13

## Internet gaming addiction
Internet addiction is regarded as one of most serious public mental health problems in Korea, because of its high prevalence and association with pharmacotherapy and/ or hospitalization among the Korean children aged 6-19 years. 14 An epidemiological study reported that patients categorized in the internet gaming addiction group were characterized by greater proportions of individuals who were unmarried and unemployed, with high frequencies of suicidal ideation, planning, and attempts than those in the non-internet game addiction group in Korea. Herein, "escape from negative emotions" was considered as the primary reason to indulge in internet games among Korean adults diagnosed with internet gaming addiction and depression.A meta-analysis of empirical studies reported that internet addiction was associated with "escape from self " and "self-identity" in terms of self-related variables; "attention problem," "self-control," and "emotional regulation" in terms of control and regulation-related factors; "addiction and absorption traits" in terms of temperamental variables; "anger" and "aggression" in terms of emotion-and mood-related factors; and "negative stress coping" in terms of coping-related factors in Korea.Moreover, a national study reported that, among Korean adolescents, internet addiction was more predominantly present in female students in girls' schools rather than in those in coeducational schools. 17

## Other important psychopathological issues in korea
Finally, the following psychopathological issues in Korean neuropsychiatry may need to be considered during the revision of DSM-5: First, to reduce the stigma attached to schizophrenia in Korea, the corresponding Korean term for schizophrenia has been changed from jungshinbunyeolbyung ( in Chinese characters; mind-splitting disorder) to johyeonbyung (; attunement disorder) in 2011 after collecting diverse opinions.Additionally, the Korean term for epilepsy has been revised from gan-jil (; convulsive disease) to noi-jeon-jeung (; cerebroelectric disorder).Second, due to the cultural deviation between South and North Koreans, the latter have reported a unique