Update on Koro research methodology

Sir,

As a Koro researcher for the past 35 years (Arabinda N Chowdhury - ANC), it is a great pleasure to observe that the Indian Journal of Psychiatry is publishing quite a few research articles on Koro in recent years. These Koro publications are a valuable addition to our understanding of the phenomena, especially from the Indian subcontinent. This is a great academic contribution of the Indian Journal of Psychiatry. We hope many more publications on Koro will emerge in the years to come. One of the reasons for writing this note is to share some of our Koro research methodology understanding to all the new researchers so that they can contribute a more precise and scientifically coherent documentation of the Koro phenomena in their research work. It is noted that many of the reporting lack the crucial clinical findings and draw a very superficial conclusion about the Koro phenomenon. Following is a brief suggestion about some of the methodological clinical standards that the researchers should address in their work.

RESEARCH ISSUES

Koro-clinical diagnostic issues

The three symptoms must be present to call it a Koro: (1) perception of acute retraction of the penis (or breast or vulva in female), (2) acute panic-like reaction (with both psychological and somatic manifestations), and (3) acute fear of impending danger, most commonly death (or sexual disability) from this malady. The whole episode lasts from few minutes to an hour. This episode is accompanied by a preventive maneuver (by self or others) either by manual or mechanical means of pulling the penis outward to prevent retraction. Commonly, there is a myth or community folk beliefs of this Koro illness prevailing in the background. The suddenness of the episode and the clinical picture described above constitute the culture-bound classical Koro. If the retraction is chronic over a period of days or weeks with health concern (sexual or somatic in nature) but without fear of impending death and acute anxiety attack, it is not classical Koro but either Koro-like symptom or chronic Koro.[1,2,3,4] This clinical differentiation may put things in the right perspective. Because, in recent years, few reporting from faculty of urogenital services noted the “shortening of penis” secondary to some urogenital pathology and designated these as Koro.[5,6]“Shortening of penis” is different from retraction of the penis (with accompanied acute anxiety and fear of death) in Koro. In adolescent sexual clinics, more and more cases are reporting for “false penis shortness”[7] or feelings of penile deficiency due to small penis[8] make the contextual understanding of penile symptoms in Koro more challenging. Moreover, in psychotic background, the delusion of penile dissolution by malevolent force or envy person(s)[9,10] also needs a careful differentiation from Koro symptom. In Koro, the penile pull is a dynamic phenomenon with marked suddenness and rapidity, but in delusional complaints (or in hypochondriacs), it is usually a longstanding or slow process with a different ideational component (of psychotic or health anxiety related). Hence, adherence to the Koro diagnostic criteria yields more clinical precision without other clinical contamination.

Demography of cases

Ethnicity, age, marital status, and education data are important to understand the global comparative distribution of Koro cases – be it in an epidemic setting or in sporadic cases. World Koro research data show that in epidemic setting, the adolescent or young adults with less number of educational years are more prone,[11] but in sporadic cases, no such trend is noted. Koro in the same family (kinship) is an interesting area and should be looked for as it sheds focus on the role of shared psychopathology in the psychiatric epidemic.[12]

Comorbidity addiction/other mental and physical illness

This is a very important issue to differentiate secondary Koro from primary Koro. In recent literature, the association of schizophrenia, affective disorders, medical disorders, and substance abuse (cannabis/heroin) with Koro has been reported. Hence, this information will help to clarify the role of primary mental health morbidity or addiction (especially cannabis) in the dysmorphophobic penile perception of the victim.[13] Delusion of penile shortening in psychosis is an example of secondary Koro.[14] Detailed sexual history is important to examine the role of psychosexual dysfunction or guilt[15] in the genesis of patho-perception of penile morphology.[16] Comorbidity in Koro is an interesting and expanding research area, and thus, every researcher should be alert not to miss the opportunity.

DSM-5[17] placed Koro under “Other specified Obsessive -Compulsive and related Disorders” (300.3), and few research papers already published pointing Koro as an obsessive-compulsive disorder (OCD) manifestation.[18] Hence, it would be wise to enquire about the OCD spectrum in Koro cases, which will enrich our insight about the Koro phenomenology. It is worth remembering that Koro lost its culture-bound tag after the publication of DSM-5 in 2013, and it is now the researchers' task to examine the Koro symptoms in the clinical frame of OCD spectrum!

Boundness with culture

This is a very important and debated aspect so far, as the culture boundness of Koro is concerned. The researcher should elicit whether there is any particular cultural myth/belief present behind the presentation or the sufferer has any such beliefs or is there any such cultural construct in circulation in the community during the time of the Koro episodes. This is a very dearth area, and more elaborative research is needed. Narratives from the victims (or family members/folk healers) would be a valuable contribution. Culture boundness is clearly visible in epidemic setting but not so much in the sporadic secondary cases.

Epidemic specificity

If it is a report of Koro epidemic, the nature of the spread of the epidemic (geographical epicenter and radius of epidemicity/epidemic type) should be outlined; index case, number of cases and their demographic features, mode of transmission of news (mobile phone, radio, newspaper, and TV news), previous acquaintance, individual and community/professional response, time span, etc., should be sufficiently reported. This will enrich our understanding of the psychosocial dynamics and social pathology networking of the psychiatric epidemic. The role of mobile phone or other social media in recent years is a novel research agenda in the spread of Koro or other mass psychogenic illness. There are many extraordinary or unusual incidents of clinical importance happen in the community during an epidemic, and it would be a rich research contribution to report all these in the context of an ongoing epidemic.[19]

Explanatory model analysis

Patient's perception is important in the understanding of Koro phenomena. It needs a very detailed qualitative research to probe the patient's perception about the specific cause of his/her malady in their verbatim (may be accompanied with a participatory mapping of pathology) with a folk or cultural focus.[20] Most of the Koro reporting in the literature lack this important aspect.

Treatment traditional/modern

Detailed of the treatment and its outcome should be recorded along with the specifics and healing time. If any psychotropic medication was helpful that should be noted in detail, it is applied to folk treatment as well – the detailed of such treatment should be recorded with its reason for application and/or complication (health hazard) if any.[21] The analysis of help-seeking behavior sheds light on the cultural dynamics of Koro.

Recurrent Koro

This is a very important aspect of the course of Koro morbidity. Be it in the epidemic setting or solitary case, recording of this information is valuable. There will be a definite time gap between two or more episodes of Koro attacks, which may range from few hours to days. The unusual time gap indicates the probability of some secondary psychiatric diagnosis.

It is expected that if these points are carefully addressed in any research on Koro, we will get more robust scientific clinical material to substantiate the complex psychosomatic presentation of Koro either in the cultural context or as a secondary pathology evolved from an ongoing mental health morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.