“Chotikatwa”, a new culture-bound dissociative syndrome from Northern India: a case series-based report

The author proposes a new culture-bound syndrome, proposed to be named “Chotikatwa”. The syndrome’s genesis is based on frequent occurrence of tail lock of hairs of female patients getting cut under mysterious circumstances. Such cases are being reported from different North Indian states. The description of four cases is being presented in the report. The occurrences have occurred only with females under settings of stress and comorbid cluster B traits are not uncommon. The aetiology of the phenomenon is unknown and various theories, including act of evil, organised gang, and insects cutting hairs, etc. are being discussed in electronic, print, and social media. The phenomenon has not been discussed in academic literature yet as per the knowledge of the author. The report goes into the details of four casestheir investigation, treatment, and details of the phenomenology. A discussion regarding the possible psychological underpinnings has followed in the report.


INTRODUCTION
The following cases elucidate the genesis of a new culturebound dissociative syndrome proposed to be named "Chotikatwa" syndrome based on frequent occurrences of a new syndromal presentation in short span of approximately three months from different parts of Northern India.

CASE 1
A middle-aged female from lower socioeconomic strata presented to the medical emergency and was later transferred to psychiatry ward with complaints of the alleged distal end of tail lock cut by unknown (Figures 1 and 2). The patient had stable vitals and her physical examination was under normal limits. She had the previous history of dissociative loss of consciousness which were possibly psychogenic nonepileptic seizures (PNES). Pre-morbidly she had occasional interpersonal issues with everyone in the family, had the sensitivity to trivial criticisms, mood swings. She reported her distal hair lock being cut by unknown forces around midnight when everyone including her was asleep in her house closed from inside. Her two daughters were sleeping with her at time of occurrence. Later on further probing, she said "I felt as if it was a tall male", but her account kept varying. Based on history and examination findings, a diagnosis of dissociative disorder with borderline-histrionic traits was made.

CASE 2
A 16-year-old female from the rural area of Patna, India from lower socioeconomic status reported to a private clinic catering medical services, with nearly ten relatives alleging her tail lock being cut by some unknown person/force. The patient and the relatives looked too anxious. The psychiatric call was sought by the physician. The patient was married two and half months back. The patient reported that she was sleeping alone in her house when her hair was cut. The patient denied any stressor though recent marriage is a certain stressor where the females are sent to live permanently at in-laws house and are responsible for carrying out all kitchen work and household chores. Her pre-morbid adjustment was fairly good. The affect was anxious and she had avoidant gaze. She was unsure about her hair cut incidence. She was given a supportive session and 0.25 mg of clonazepam with which she reported reduced anxiety levels and was discharged on request by afternoon.

CASE 3
A 25-year-old female from lower socioeconomic status was admitted to medical emergency with her lock of hair cut by unknown factors. A psychiatric call was given and she was transferred to the psychiatry ward for detailed evaluation. The patient, a housewife had previous episodes of loss of consciousness and clenching of teeth lasting hours, often precipitated by an altercation with her mother-in-law who resided in the same house. She had pre-morbid adjustment difficulties in her in-law's house and showed frequent mood swings. The patient and husband though were unsure but repeatedly cursed the governmental failure to find the cause. At times the patient and her husband suspected role of insect.

CASE 4
The patient, a middle-aged female from lower socioeconomic status, mother of five children, wife of a rickshaw puller, a housewife staying at village in one of the northern districts of Bihar, India was brought in the medical emergency of Nalanda Medical College, Patna, India by her relatives with complaints of her hair being cut by unknown person. The family had no suspicion of any other person. She was referred to psychiatric emergency where she came walking with the help of the family members and did not make eye contact. She vocalised with unclear sounds. The mood reported was sad and she avoided most of the questions during the interview by either not making eye contact or delaying responses and at times no response at all. She often said that she does not remember. The husband reported that she was aware of the fact that a lady in a nearby village had her hair cut two days back in similar circumstances which she came to know through hearsay. She was admitted to inpatient facility of the hospital where detailed psychiatric interview revealed sensitivity to trivial criticism, adamant nature, mood swings, extreme emotionality, attention seeking pre-morbid self. There was no history suggestive of an organic lesion (neurological deficit). She was diagnosed with diabetes mellitus two months back and was advised dietary restrictions and exercise with which her blood sugar levels were found to be within normal limits, done in inpatient facility as a routine measure.

Investigations
Routine haematology was performed and was within normal limits in all the cases. CAT scan of the brain with contrast in one of them was performed as requested by her husband (despite the ills of unnecessary exposure to radiation being explained to the family) which was within normal limit. The investigation facilities in the government hospitals are free and family members often request investigations beyond suggested by the treating team.

Differential diagnosis
Differentials of complex partial seizure, acute stress reaction, and trans and possession states were considered in all the cases which were all excluded with careful history and examination.

Management
All the patients received initial supportive cum ventilator session. The family was psycho-educated about the illness having possible psychogenic aetiology in settings of stress and need to cut down secondary gains. They were also put on clonazepam 0.25 mg twice a day for next three days to reduce anxiety symptoms apart from individualised treatment of medical condition like diabetes mellitus.

DISCUSSION
The cases above have the presentation similar to the series of cases of the tail lock of hair getting cut reported in different newspapers and TV channels from different parts of Northern India including Rajasthan, Gujrat, Haryana, Delhi, Uttar Pradesh, and other parts of the state of Bihar for last three months. It is being widely discussed on social media also. In most of the incidences, the patient and family are unable to tell about the reason for the incidence. The masses at large, media, and police are unclear about its genesis and a situation of confusion prevails. In the knowledge of the author, no such case has been reported in academic literature till the date of writing the report and its scientific analysis is yet to be done.
The patients reported here had been terrified and family shocked after the incidence. Such patient receives undue attention from the family and society. The different theories which the police and media are considering are an act of organised gang, insects, and the act of evil. Considering it as an act of evil, faith healing is often attempted. The concluding cause of the event is unknown in most cases.
Culture-bound syndromes [1,2] are culture-specific [3] and usually restricted to geographical areas and the expression  is affected by the deeply ingrained values and practices of the society. The role of mass media in spreading the belief and practices is understandably certain. The newer mass media communication measures like social media, mobile apps have added to already existing ones, adding to the prevailing confusion in certain situations. In the opinion of the authors, the short time (nearly three months at the time of writing of the report) in which such cases have been reported across the nation is due to the rapid spread of massage of occurrence of such episodes in unclear circumstances by mass media.
The author proposes the series of incidences to be a culture-bound dissociative syndrome which may be named "Chotikatwa" syndrome. "Choti" meaning distal hair lock and "katwa" meaning someone who cuts. Regarding the phenomenology of the proposed "Chotikatwa" syndrome, the presentation mostly occurs in police stations and sometimes in medical facilities and seldom to psychiatric centres. The occurrence has almost always occurred with females and never with males in the knowledge of the author. Only the distal lock of the hairs has been cut and never the whole head was shaven. In settings of stress, the incidence usually occurs when the patients are sleeping alone or with family and female appears terrified after the incidence. At times the incidence follows with the loss of consciousness of varying periods and clenching of teeth and symptoms of anxiety-like restlessness, palpitation, etc. Pre-morbidly adjustment issues may be there and some of them may show cluster B traits or personality.
Culturally women in India are supposed to maintain longer hair locks. The upkeep, cleaning, and maintenance of the hairs may be difficult for many of them and yet longer locks may be a symbol of femininity to them, buttressed by deeply ingrained cultural values for many creating ambivalent thoughts [4] about the length of their hair in some of the women. The author proposes that the ambivalent thoughts generating distress further precipitated by stressful life situations and their psychic demand for secondary gains may have led to such episodes.
The author further wants to emphasise that since the presentation involved features of dissociation and elements of primary and secondary gains, the syndrome be considered a "Dissociative culture-bound syndrome" like those of Pibloktoq, [5,6] etc.
The community-based study of the phenomenology and the psycho-bio-social underpinnings of the condition need to be studied further. It shall also be interesting to study the change in the presentation of the occurrences with time.

Location of work
Nalanda Medical College and Dr Sushil Singh Nursing Home, Patna, Bihar, India.