This first part of this article presented 13 interesting descriptions of unusual psychiatric disorders that may present in primary care. This ranged from alcoholic hallucinosis to Capgras delusion. 

14. Diogenes syndrome

Shanju Rai

Diogenes, 4th century Greek philosopher, whose beliefs were: ‘life according to nature’, ‘self-sufficiency’, ‘freedom from emotion’, ‘lack of shame’, ‘outspokenness’, and ‘contempt for social organisation’ is the reference for the nomenclature of Diogenes syndrome.1,2 Diogenes syndrome is a reference to the isolation and rejection of the outside world and its material possessions practised by the philosopher, Diogenes. However, the syndrome differs from the philosopher as it incorporates refusal or rejection of help from the world as its foundation; rather than rejecting the world and its material possessions like the philosopher.1

This syndrome creates irrational relationships with:

  1. Society – refusal or rejection of help.
  2. Body – extreme self-neglect
  3. Objects – hoarding (syllogamania).

These unreasoned relationships eventually lead to social isolation, physical illness and hoarding an excessive amount of possessions that are valueless to others.1,2,3

The main ‘symptom’ is the refusal or rejection of help. This makes it distinct from hoarding, which is often used interchangeably with Diogenes.

Diogenes Syndrome

It is associated with social isolation, not wanting/seeking help or refusing help, psychiatric illnesses like chronic psychotic illness, OCD, alcohol abuse, dementia with frontotemporal and frontal lobe dysfunction. There may be varied pre-morbid personality traits; being unfriendly, aloof, stubborn, aggressive, compulsivity, paranoia etc.1, 3 Over the years, Diogenes syndrome has been referred to as ‘senile breakdown’, ‘social breakdown’, or ‘senile squalor syndrome’.1,2 However, the much-debated terminology Diogenes is still used more frequently over others.


  1. Browne D, Hegde R. Diogenes syndrome: Patients living with hoarding and squalor . Progress in Neurology and Psychiatry 2015; 19(5)
  2. Lavigne B, Hamdan M, Faure B, et al. Diogenes syndrome and Hoarding disorder: Same or different?. L'Encéphale 2016; 42(5)
  3. Catherine Oppenheimer. Oxford Textbook of Old Age Psychiatry , 2nd ed.: Oxford University Press; 2013


15. Ekbom syndrome

Shanju Rai

Ekbom Syndrome, named after the Swedish neurologist Karl-Axel Ekbom1, is also known as Delusional parasitosis or delusional infestation.2 It commonly affects middle aged females and people who have cognitive, psychiatric disorders.1 Some neuroimaging studies have identified that the putamen maybe involved.3

Ekbom syndrome

It is a psychiatric disorder where the person has a fixed false belief that he/she is infested with small living organisms in the skin, such as bugs, parasites or insects.1-4 The person has tactile hallucinations and can also have visual hallucinations of the organisms.2,4 Differentials might be:

  • Actual parasitosis, where the person is infested with an organism e.g. scabies or demodex mites etc. and can be proven with lab tests
  • Insect phobias, where the patient has an irrational fear of insect bites or infestation occurring; the patient with Ekbom’s believes that they are already infested.1

It is a delusion as the belief that they are infested with these organisms is unshakeable and cannot be altered, even with evidence.2 Due to this, patients often seek help from various specialties such as physicians, entomologists, dermatologists, psychiatrists etc.2 The delusional nature of this syndrome requires neuroleptic medications, such as those used in schizophrenia.2


  1. Whonamedit? Ekbom's syndrome II, Available at: 21/02/2017).
  2. Nancy C. Hinkle (2010) 'Ekbom Syndrome: The Challenge of “Invisible Bug” Infestations', Annual Review of Entomology, 55
  3. Bhatia MS, Gautam P, Kaur, J. (2015) 'Ekbom syndrome occurring with multi infarct dementia ', Journal of Clinical and Diagnostic Research, 9(4)
  4. Kimsey, LS. (2016) 'Delusional infestation and chronic pruritus: A review.' Acta Dermato-Venereologica, 96(3), pp. 298-320


16. Fetishism

Naa Quaye

Fetishism is an example one of the 8 paraphilia’s listed in the DSM-5. Paraphilia is defined as abnormal sexual desire. In order for a diagnosis to be given the patient must exhibit recurrent, intense sexually arousing fantasies, sexual urges and behaviours that involve either the use of non-living objects and/or a non-genital body part for at least a period of 6 months.1 Sexual interests in fetishist can lead them to perform criminal activities. An example of this might be when an underwear fetishist breaks into a female hall of residence to steal underwear.2


  1. Kafta MP. The DSM Diagnostic Criteria for Fetishism. Arch Sex Behav.2009;39(2):357-62.
  2. Seto MC, Kingston DA, Bourget, D. Assessment of paraphilias. The Psychiatric Clinics of North America.2014;37(2):149-161


17. Fregoli delusion or the delusion of doubles

Ying Yeo

Fregoli syndrome is a subtype of delusional misidentification.1 In this condition, a person believes that a familiar person, usually someone he believes to be his persecutor, is impersonating multiple familiar people.1 It is usually associated with schizophrenia.2

Fregoli syndrome is named after a famous Italian actor, Leopold Fregoli, who had a remarkable skill in changing appearance during his stage act.3 In 1927, a report written by P. Courbon and G. Fail first reported the syndrome.4 According to the report, a young woman had a strong belief that two actresses whom she often went to see at the theatre were persecuting her. The woman believed that these two actresses were disguising themselves as people she knew.

The causes of Fregoli delusion include traumatic brain injury, lesions on the brain and long-term treatment with levodopa.3 The syndrome can be treated with antipsychotics, anticonvulsants or antidepressants.3


  1. Andrew B, Nina H, Charlotte G, Gil M. Oxford Handbook of Clinical Specialties. Oxford, UK: 'Oxford University Press'
  2. Fregoli Syndrome [cited 2017 28 February ]; Available from:
  3. contributors W. Fregoli delusion Wikipedia, The Free Encyclopedia. Available from:
  4. Ellis HD, Whitley J, Luauté JP. Delusional misidentification: The three original papers on the Capgras, Frégoli and intermetamorphosis delusions. History of Psychiatry. 1994


18. Frotteurism

Naa Quaye

Frotteurism is described as recurrent, intense sexually arousing fantasies, sexual urges or behaviours which involve touching and rubbing against a non- consenting person and in which the condition lasts over a period of at least 6 months.1 This type of paraphilia tends to occur in crowded public places such as on buses or trains and it is sometimes difficult to identify the perpetrator because of the crowded circumstances.2 


  1. Diagnostic and Statistical Manual of Mental Disorders. Am Psychiatr. Assoc.2013. DC: Psychiatr.Assoc.5th ed.
  2. Beech AR, Miner MH, Thornton D. Paraphilias in the DSM-5.Annu.Rev. Clin. Psychol.2016;12:386-496

19. Fugue state

Ying Yeo

Fugue state is a rare dissociative disorder.1 The fugue is a condition in which involves a sudden loss of all autobiographical memories and knowledge of personal identity.2 This is associated with unexpected, purposeful wanders away from home or the person’s place of work.2



In order to diagnose a person with fugue, the following criteria should be fulfilled:3

(a) Features of dissociative amnesia

(b) Purposeful travel beyond the usual everyday range

(c) Maintenance of basic self-care and simple social interaction with strangers

The fugue state may last from hours to months, with a subsequent amnesia gap on recovery and usually precipitated by stressful events.1,4


  1. Fugue state Wikipedia, The Free Encyclopedia. [cited 1 March 2017]; Available from:
  2. Andrew B, Nina H, Charlotte G, Gil M. Oxford Handbook of Clinical Specialties. Oxford, UK: 'Oxford University Press'
  3. The ICD-10 Classification of Mental and Behavioural Disorders. [cited 2017 28 February]; Available from:
  4. David S, Roger S. Oxford Handbook of Psychiatry. Oxford, UK: 'Oxford University Press'

20. Ganser’s syndrome 

Chloe Desmond

Ganser’s syndrome, also known as “prison psychosis”, was first described by a German psychiatrist, Sigbert Ganser, in 1898 while working inside a prison.1 He discovered three inmates, who when asked simple questions, would give approximate answers in response. He studied their behaviour and discovered the syndrome was characterised by four aspects:1

  1. Giving approximate answers to questions
  2. Visual/auditory hallucinations
  3. Developing somatic symptoms
  4. “Clouding of consciousness” which often fluctuated.

The most striking feature of this syndrome is giving approximate answers to questions. Patients may give answers which are nearly, but not quite correct, e.g. saying there are five legs on a horse or recalling the month as September instead of August. They can comprehend the question, but they give incorrect responses. An example was a South African man1 who when asked to recall the words “honesty, window and lace”, gave the response of “modesty, house and shoe”.

Ganser Syndrome

The aetiology behind Ganser’s syndrome was initially suggested to be a form of malingering1 in prisoners. This has evolved over time and is now classified as a dissociative disorder in ICD-10.3 It is thought to be due to a severe stress reaction rather than a factious disorder, with some suggesting that there could be underlying brain injury.2 Due to its rarity, there is little literature on the syndrome, with Ganser himself stating “I must openly admit that after observing many details there is a great deal that is obscure to me.”1


  1. Dwyer J, Reid S. Ganser's Syndrome. Lancet 2004; 364:471-473.
  2. Ouyang D, Duggal H, Jacob NJ. Neurological Basis of Ganser Syndrome. Indian Journal of Psychiatry 2003; 45(4): 255-256.
  3. World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders, 1992

21. Huntington’s chorea

Chloe Desmond

From the Ancient Greek word “choreia” meaning dance, chorea is described as “involuntary, purposeless, and rapid distal movements of the limbs”1 and is a characteristic feature of Huntington’s disease.2 Chorea was first accurately described by Thomas Sydenham, a British physician in the 17th Century.1 However, its history reaches far back into the Middle Ages, when it was initially called “dancing mania”, at a similar time to the appearance of the black death.1

It has also been described as “Saint Vitus’s dance”, due to reports that patients with the condition were supposedly cured following touching Saint Vitus’s relics. 

From 1850, chorea was mostly described in association with rheumatic heart disease.1 It was not until 1872 that George Huntington first described Huntington’s chorea.3 At this period, the full extent of the disease was unknown, only the most prominent motor feature. In the 1980’s more non-motor symptoms of the disease were established. Therefore, the name was changed to Huntington’s disease to encompass the wide variety of clinical features.

Huntington’s disease is a progressive neurodegenerative disorder that follows an autosomal dominant inheritance pattern. A CAG trinucleotide repeat in a protein called Huntingtin drives the disease, which causes chorea, cognitive decline, dystonia2 and behavioural disturbances.3 Mean onset is usually around 30-50 years of age and there is currently no cure.3 However, Huntington’s chorea can be treated using dopamine antagonist agents, with tetrabenazine found to make the most significant improvement.3


  1. Vale TC, Cardoso F. Chorea: A Journey through History. Tremor and Other Hyperkinetic Movements 2015; (accessed 22 February 2017)
  2. Walker FO. Huntington's Disease. Lancet 2007; 369(9557): 218-228
  3. Roos R. Huntington's Disease; a Clinical Review. Orphanet Journal of Rare Diseases 2010; 5(40)

22. Jerusalem syndrome

Sasha Wilson

Jerusalem syndrome is a behavioural phenomenon, by which visitors to the city of Jerusalem, suffer psychotic decompensation.1 The main symptom of this syndrome is religious delusions in which the patient identifies with a biblical character, and their behaviour subsequently mimics that of the selected character.1

Jerusalem syndrome

There are three distinct classifications of the illness:

  • Type 1: Patients who are already diagnosed with a mental disorder characterised by psychotic illness, which has influenced their decision to visit Jerusalem, based on their pre-existing mental illness. This may involve delusions of a higher purpose to their visit.1,2
  • Type 2: Patients with a mental disorder that is characterised by idiosyncratic ideation, that is not categorised as psychotic or delusional.1
  • The patient experiences strange thoughts related to politics or religion in Jerusalem.1
  • Type 3: Occasionally described as ‘pure’ form of Jerusalem syndrome, this describes patients who suffer an acute psychotic reaction while in Jerusalem, and who have no previous mental illness.1 Recovery is rapid and uncomplicated on leaving, and the patient resumes normal state of mind.1

In Israel there is a dedicated facility, Kfar Shaul Mental Health Centre, which deal with these cases of tourists suffering from acute psychosis, triggered by and related to Jerusalem.3 On average 100 tourists are seen annually at the facility, with 50 being admitted for treatment.1,3


  1. Bar-el Y, Durst R, Katz G, Zislin J, Strauss Z, Knobler HY. (2000) ‘’Jerusalem syndrome’’. British Journal of Psychiatry, 176, 86-90
  2. Kalian M, Witztum E. (1999) "The Jerusalem syndrome—fantasy and reality a survey of accounts from the 19th and 20th centuries." Israel Journal of Psychiatry and Related Sciences, 36(4):260-71
  3. Kalian M, Witztum E. (2000) "Comments on Jerusalem syndrome". British Journal of Psychiatry, 176, 492

23. Kleptomania

Sasha Wilson

Kleptomania is the repetitive impulse to steal items as a means of relieving intrusive thoughts to steal.1 To distinguish this from ordinary theft, in kleptomania there is no monetary incentive to steal and the items that have been stolen are usually of trivial monetary value, and serve no personal use to the person - e.g. only stealing one shoe.2

Kleptomania is generally accepted to be categorised as an impulse control disorder.1 It is thought to have strong links with other psychiatric disorders, such as drug and alcohol abuse, eating disorders and other impulse control disorders, such as trichotillomania (the impulse to pull out hair).3

The stereotypical patient is female, although males can be affect also.4 Kleptomania is thought to begin in adolescence, usually in the form of shop-lifting.4 One of the most common reasons for patients to seek help is due to the legal consequences of kleptomania, if apprehended by law enforcement; this usually occurs in middle age.4

Historically, the mainstay of medical treatment has been using SSRI’s. However, there is emerging evidence that anti-epileptics and lithium may have a future role to play in the treatment of kleptomania.1


  1. Grant, J.E. (2006). "Understanding and treating kleptomania: new models and new treatments". The Israel Journal of Psychiatry and Related Sciences, 43 (2): 81–7
  2. American Psychiatric Association, ed. (2000). DSM-IV-TR (4th ed.). Arlinton, VA: American Psychiatric Association. pp. 667–668
  3. Grant JE, Grant MPH. Odlaug BL, et al. (2010) "Kleptomania: Clinical Characteristics and Relationship to Substance Use Disorders". The American Journal of Drug and Alcohol Abuse, 36 (5): 291–295
  4. Talih F (2011). ‘’Kleptomania and potential exacerbating factors: A review and case report’’. Innovations in Clinical Neuroscience, 8(10): 35–39

24. Koro

Andrea Sangheli

Koro is a culture-bound syndrome illustrated by the belief that the genitalia are retracted into the abdomen, in the absence of any true pathology of the genitals, or breasts into the chest. The name could be derived from a river and local tribe which resided in Sulawesi, Indonesia, hence the first Western reference of the term in B.F. Matthes' Dictionary of Buginese Language (1874) of South Sulawesi, Indonesia.1 In Makassarese language koro means “to shrink”. The fundamental symptoms of the syndrome are:

  • Delusional belief of retraction of the penis into the abdomen
  • Signs of anxiety and associated intense panic
  • Practice of mechanical means to avert penile retraction.2
  • Associated belief of death following the disappearance of the organ has also been described.
  • However, a belief in breast shrinkage is also reported. 

The highest prevalence has been in South East Asian countries, often appearing in the form of epidemics, such as in Singapore3 and North Bengal4. In an outbreak of Koro on a tea plantation in West Bengal, India, females complained of retraction of their breasts, with fear of impending death.5

Koro Syndrome

Following several reports of similar epidemics, researchers have hypothesised that this is a ‘mass psychogenic illness’ and ‘mass hysteria’ in which a group of people, usually from low socioeconomic and literacy backgrounds, start exhibiting symptoms following a triggering factor.6

Several case reports have outlined the link between cannabis use and the development of Koro. In these cases, several factors are thought to act synergistically, such as cannabis lowering the threshold for a panic reaction, previous knowledge of cannabis-induced Koro and poor body image or body dysmorphia.

Benzodiazepines, selective serotonin reuptake inhibitors and tricyclic antidepressants have all been used in successfully. Group psychotherapy, mass education programmes and awareness campaigns can be effective in the cases of mass epidemics.7


  1. Chowdhury, Arabinda N. (September 1998), "Hundred Years of Koro: The History of a Culture-Bound Syndrome", The International Journal of Social Psychiatry, 44 (3): 181–8
  2. Chakraborty S, Sanyal D. “An outbreak of Koro among 19 workers in a jute mill in south Bengal.” Industrial Psychiatry Journal. 2011;20(1):58-60
  3. Ng, B.Y. History of Koro in Singapore Singapore Med. J., 1997; 38 (8) (1997), pp. 356–357
  4. N. Chowdhury, P. Pal, A. Chatterjee, M. Roy, B. Das Chowdhury, “Analysis of North Bengal Koro epidemic with three years follow-up” Indian J. Psychiatry, 1988 30 (1) pp. 6
  5. Chakraborty A. “An epidemic of koro in West Bengal (India).” Indian Journal of Psychiatry. 1983; 25(2):138-139
  6. Debjit Roy, Susmita Hazarika, Arnab Bhattacharya, Shyamanta Das, Kamal Nath and Sahoo Saddichha, “Koro: culture bound or mass hysteria?”Aust N Z J Psychiatry, 2011; 45: 683
  7. Kumar R, Phookun HR, Datta A. “Epidemic of Koro in North East India: an observational cross-sectional study.Asian J Psychiatr. 2014 Dec;12:113-7

25. Korsakoff’s psychosis

Andrea Sangheli

In a series of three articles from 1887 to 1889, Russian neuropsychiatrist Sergei Sergeievich Korsakoff described a persistent amnestic confabulatory state that subsequently became known as Korsakoff’s psychosis or Korsakoff’s syndrome. This is a part of the Wernicke-Korsakoff syndrome or encephalopathy.1

The key features that he noted on at least 46 patients, of which two thirds were alcoholics, were:

  • Anterograde amnesia. This is an inability to form new memories after the brain insult
  • Retrograde amnesia, exemplified by deficits in remembering past events.

He emphasised the manifestation of these though the patient had clear attention and consciousness.

  • Confabulation (fabrication of memories)

De Wardener and Lennox made the important observation that thiamine (vitamin B1) depletion is the key mechanism resulting in the acute Wernicke episode, followed by Korsakoff’s syndrome in malnourished prisoners-of-war.2

It is most commonly associated with chronic alcohol abuse, but it can also result from inadequate dietary intake, reduced absorption or a reduction in the rate of conversion to the active metabolite.3

Korsakoff syndrome

Neuronal loss, micro-haemorrhages and gliosis in the paraventricular and periaqueductal grey matter represent the core neuropathology.1 Debate arises as to which specific brain lesion is critical for the manifestation of the prolonged and severe memory disorder rather than the Wernicke classical clinical triad of confusion, cerebellar dysfunction and ocular signs.4 The medial dorsal nucleus of the thalamus and the anterior principal thalamic nuclei are reported to be the key differences between patients who suffered a persistent Korsakoff syndrome and those who experienced only a transient Wernicke episode.1,5 As the chronic memory loss often follows an episode of Wernicke encephalopathy, the chronic disorder is known as Wernicke-Korsakoff syndrome.

However, Korsakoff’s syndrome can also develop in individuals without a definite prior episode of Wernicke encephalopathy.

Korsakoff syndrome is a clinical diagnosis, differential diagnoses include head trauma, anterior communicating aneurysm rupture and herpes encephalitis.

In order to prevent the development of a severe chronic Korsakoff state, it is recommended that 200 mg thiamine should be administered three times daily, preferably intravenously before any carbohydrate, should a diagnosis be suspected.4 While complete recovery is perceived as unlikely, improvement is noted to occur over the course of years in 75% of patients who remain abstinent from alcohol. However, 25% show no change, even post treatment.1 This can cause ethical dilemmas for GPs when assessing patient’s capacity. 


  1. Victor M., Adams R.D., Collins G.H. The Wernicke-Korsakoff syndrome. A clinical and pathological study of 245 patients, 82 with post-mortem examinations. Contemp. Neurol. Ser. 1971; 7:1–206
  2. DeWardener, H. E., & Lennox, B. (1947). Cerebral beriberi (Wernicke's Encephalopathy): review of 52 cases in a Singapore prisoner-of-war hospital. Lancet. 1947; 1, 11–17
  3. Thomson et al., A.D. Thomson, I. Guerrini, E.J. Marshall The evolution and treatment of Korsakoff's syndrome: out of sight, out of mind? Neuropsychology Review. 2012; 22 (2) (2012), pp. 81–92
  4. Galvin R, Brathen G, Ivashynka A, Hillbom M, Tanasescu R, Leone MA, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol. 2010; 17(12):1408–18
  5. Harding A, Halliday G, Caine D et al. Degeneration of anterior thalamic nuclei differentiates alcoholics with amnesia. Brain. 2000; 123:141–54

26. Kuru

Laura McManus

An epidemic started in the early 1900’s in Papua New Guinea (PNG) amongst the Fore people.1 Kuru, also known as ‘the laughing death’, features a number of early symptoms, including laughing, headaches, joint pains and progressive tremors, ataxia, depression and ultimately dysphagia, total paralysis and death. It was mostly women and children affected by the disease –although 200 a year would die in the region. Dr Michael Alpers read about this condition and travelled to PNG to research the disease. He ultimately lived among the people for over 40 years and noticed children born after 1960 didn’t contract the disease and this coincided with colonies banning their cultural and ritual practices, including endocannibalism.2

Carleton Gajdusek, a virologist, found that it was a new disease of the brain, but was confused because it didn’t appear to be infectious or transmissible. However, Alpers and Carleton used the tissue of an 11-year-old girl to infect 2 chimpanzees, the chimpanzee contracted Kuru, proving it was transmissible. Carleton won a Nobel prize for discovering, ‘unconventional viruses’ and another scientist, Prusiner, later won a Nobel prize for discovering prion aetiology.3 Prions aren’t living organisms, and they don’t have DNA or RNA. When ‘normal’ they are thought to be involved in copper binding or signal transduction. They act in a pathological manner through spontaneous changes in protein folding which creates a cascade as the miss-folded protein makes other prions miss-fold. These miss-folded proteins build up in the brain to form fibrils and plaques and cause dementia. There is currently no treatment.4

Kuru syndrome




27. Lima syndrome

Nikhita Pasanuru

Lima syndrome is named after a mass abduction in Lima, Peru in 1996. Members of a militant movement captured around 400 people who attended a party at the residence of the Japanese ambassador to Peru and held them hostage for 128 days.1 The terrorists developed empathy towards the hostages and consequently released most of them. This phenomenon is the opposite of Stockholm syndrome. Victims established a rapport with their kidnappers which encouraged them to sympathise with their victims and provide an opportunity for the victims to escape.2

On the other hand, another influential factor is the personality trait of the kidnappers. For example, there is a theory that if the kidnapper has a less marked and decisive personality or if they are young and inexperienced, it may be more likely for their behaviour to change over the course of the kidnapping by the influence of the victim’s behaviour.1 Similar to Stockholm Syndrome, time seems to plays a vital role in behavioural change.3

The key feature of this syndrome is the process of developing empathy towards one’s victims and eventually liberating them. An example of this syndrome is arguably evident in the story of Disney’s Beauty and the Beast! Initially when Belle is captured, the Beast behaves aggressively towards her. However, in response, Belle remains generous to him and converses calmly with him. Over time, this influences the Beast’s behaviour who eventually develops compassion and love towards Belle and finally releases her from captivity.


  1. F. Borghini FG, A. Borghini, G.Borghini. The Psychology of Security, Emergency and Risk. Illustrated ed: WIT Press, 2016
  2. Wilson O. International Security: Glenbridge Publishing Ltd, 2012.
  3. Guy Olivier Faure IWZ. Negotiating with Terrorists: Strategy, Tactics and Politics: Routledge, 2010

28. Latah syndrome

Nikhita Pasanuru

Latah syndrome is a culturally-bound syndrome in Malaysia and Indonesia, and is characterised by imitative and automatic response behaviour to stimuli. It is regarded as non-delusional due to the patterns of behaviour noticed and its association with the local culture. It involves an exaggerated response to sudden fright or trauma, causing behaviours such as involuntary echolalia, echopraxia or trance-like states.1

Latah Syndrome

Although startle phenomenon is a physiological response in every individual, it has been recognised more in the Malay community, particularly middle-aged women. Precipitating factors include recent death in the family, life crisis or even menopause.2 However, Latah is not considered a mental illness among the local community, but was medicalised by Western authors in the early 20th Century. It is believed that Malay communities have a predisposition to have extreme startle response to minimal stimuli and there may be a genetic determinant.1

Among the community, it is first recognised as an exaggerated startle response by onlookers. Later, while experiencing a state of emotional disorganisation, the individual may be intentionally provoked by observers purely for amusement, causing hyperarousal in the individual. It can be provoked by commands which the victim is likely to obey despite them being violent or embarrassing.2 Ronald Simon, an ethnographer, studied this syndrome among North American women and deduced that Latah can be taught and wondered if it is a culturally bound syndrome. In DSM V, Latah syndrome was removed perhaps due to the controversy that encircles it.2 


  1. Deviant Behaviour 1997;18(1):47-75.
  2. E. Howell SI. Dissociative Mind in Psychoanalysis: Understanding and Working with Trauma: Routledge, 2016.

29. Morgellon’s syndrome

Anna Ressel

Morgellon’s syndrome is an unusual variant of delusional parasitosis, where a person believes they have some form of fibres or material underneath their skin. In this sense, it differs from Ekbom syndrome, where the infestation is with insects. Morgellon’s is a relatively new condition, only being described in the 21st century, following an American mother (Mary Leitao) who noticed strands of fibres protruding from her son’s skin1.


It is a challenging condition for GPs, as the sufferer or parent usually believes totally that this is a dermatological condition and therefore may be unwilling to accept a referral to psychiatric services. A 2012 study2 found no conclusive evidence of clear aetiology or in biopsies showing any clear dermatological cause. The study did find correlation with increased rates of substance misuse and somatisation in the sufferers.

From 2002-2010 there were several websites such as Morgellon’s UK which gave information about the disorder.3 These seem to no longer be in existence, but there is a dedicated Facebook page ‘Morgellon’s Disease UK: A Crime of Silence for sufferers to share their experiences.4


  1. Harlan, Chico (2006-07-23)."Mom fights for answers on what's wrong with her son". Pittsburgh Post-Gazette. Retrieved 2016-03-03.
  2. Unexplained Dermopathy Study, Team (2012)."Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy". PLoS ONE. 7 (1): e29908. Bibcode:..729908P. PMC 3266263. 
  3. PMID22295070. doi:1371/journal.pone.0029908

30. Munchausen’s syndrome

Luke Biggs

The term Munchausen’s syndrome was first described by Dr Richard Asher in 1951,1 and was named after Baron Munchausen2, a fictional German aristocrat. The condition he described was one wherein patients told ‘dramatic and untruthful’ stories of an acute illness for any gain, be it intrinsic or extrinsic. The original definition therefore encompasses both factitious disorders and malingering, which have since been separately defined. Since Asher’s first description, Munchausen’s syndrome has been classified as a factitious illness, but no clear diagnostic criteria have been created.3

Munchausen’s syndrome is a severe factitious disorder, wherein the patient has frequent contact with medical professionals. Factitious disorder describes any condition in which a patient feigns symptoms, without any obvious benefit, other than occupying the sick role.3 These patients frequently have long medical histories with changing presentations and no well- defined diagnosis.


  1. Asher R. Munchausens Syndrome. The Lancet 1951 10 February 1951;257(6650): 339-341.
  2. Raspe R. Baron Munchausen's narrative of his marvellous travels and campaigns in Russia. 1st ed. Germany; 1785.
  3. ICD-10, F68.1. 2016; Available at:
  4. Accessed 11.29. 2016


Medical students from the universities of Liverpool and Lancaster, under the guidance of Dr Jane Wilcock and Mr Nick Mullin, provide an A-Z of unusual psychiatric conditions that GPs might encounter. Illustrations by Grace Mutton.