Koro and the Castration Complex

Here is an in-depth analysis of a case of Koro in a Jordanian man (this is strange, because arabian societies do not generally experience penis panics)

http://www.emro.who.int/Publications/EMHJ/0503/21.htm

A 24-year-old single, male, Jordanian farmer was brought by his elder brother to the psychiatric outpatient clinic. He complained of a two-week history of difficulty in getting to sleep, apprehension, isolation, fearfulness and one night of strange behaviour. He asked for help to stop the shrinking of his penis and anxiously asked to have his genitalia checked. He was pulling at his penis to prevent it from being sucked into his pelvis. He had been kept awake the whole night with this condition.

The patient was the third of four brothers and had completed seventh grade education. His only medical history was surgery (orchidopexy) for torsion in the left testicle at the age of 19 years, after which he had become preoccupied by the idea that he might be infertile and that his manhood was defective. He had not sought medical advice about his fears.

A review of his sexual history revealed that the patient had heterosexual masturbational fantasies, had had no homosexual experience and his one sexual experience was with a prostitute 1 month prior to the onset of his symptoms, after which he was left feeling guilty and embarrassed. His brother described him as shy, sensitive and dependent, with a small social circle. The family had no history of psychiatric illnesses.

Physical examination, including the genitalia, was unremarkable and showed no clinical signs of organicities. The patient was bewildered, sweating, tremulous and caught restlessly at his crotch. He was convinced that his penis was gradually shrinking and would disappear into his abdomen. In great fear he stated that he preferred death to such a fate. There were no psychotic features. He was of average intelligence and brain magnetic resonance imaging was normal.

He was diagnosed as having a generalized anxiety disorder and panic. He was treated as an outpatient with the following medications:

• imipramine: 25 mg/day gradually increased to 75 mg/day over 3 weeks;

• alprazolam: 1 mg/day taken as 0.5 mg tablet twice daily.

In addition, he was given supportive psychotherapy and behavioural therapy.

He was asymptomatic in 3 months and at a 10-month follow-up he was completely back to normal and had ceased taking medication.

Discussion

Sporadic cases of Koro-like syndrome have been reported in non-Chinese cultures and countries other than China and South-East Asia (European, African, North American, Middle Eastern countries and India) [2,6].

These cases were usually part of, or accompanied by, variant disorders [2,7,8,9] and almost all were a non-classical, incomplete form of the syndrome (as in the case of this patient, because rather than being in fear of impending death, he preferred death to the disappearance of his genitals).

Despite a cultural heritage in Jordan that believes in ghosts and demons, and in their power to manipulate and influence behaviour (occasionally including sexual potency and the ability to inflict harm), these ghosts are not believed capable of taking away a person's genitals. Generally, Arab culture has little relation to Chinese and South-East Asian cultures, particularly in this type of belief.

In this case the patient was preoccupied with a misconception about his fertility and sexual potency after his testicular operation. Added to this were his feelings of guilt after a sexual contact with a prostitute. It is presumed that the symptoms were an expression of his premorbid sexual status and experience [3,5].

Koro seems to be an obvious manifestation of castration anxiety, perhaps the most obvious one. Although castration anxiety is the end of the Oedipus complex, it can bring powerful neuroses of its own. High neuroticism and anxiety are complementary, hence the curative effects of anti-anxiety medication for Koro. Guilt also relates to the anxiety-neurosis matrix. Neurosis is fed by a sort of libidinal horse-trading between the id and superego - in cases like this where strongly taboo id drives are gratified, they might have to pay recompense in the form of intense castration anxiety. Penis panic may have been the first thing that Freud really nailed - Schreber certainly seemed to suffer. The shift from the 19th to the 20th century in the west marked the end of evident, out in the open penis panic. Now, as the Baraboo editorial suggests, we handle our penis panic by voting and being assholes.