''Hwabyeong'' or ''Hwapyŏng'' () is a Korean

somatization disorder Somatic symptom disorder, also known as somatoform disorder or somatization disorder, is chronic somatization. One or more chronic physical symptoms coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those sym ...

, a

mental illness A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is ...

which arises when people are unable to confront their anger as a result of conditions which they perceive to be unfair. Hwabyeong is known as a Korean

culture-bound syndrome In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or c ...

. Hwabyeong is a colloquial name, and it refers to the

etiology Etiology (; alternatively spelled aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek word ''()'', meaning "giving a reason for" (). More completely, etiology is the study of the causes, origins ...

of the disorder rather than its symptoms or apparent characteristics. In one survey, 4.1% of the general population in a rural area in South Korea were reported as having hwabyeong. Hwabyeong is similar to Amuk.

History

The first reported case of hwabyeong in Korea was

Prince Sado Crown Prince Sado (; 13 February 1735 – 12 July 1762), personal name Yi Seon (), was the second son of King Yeongjo of Joseon. His biological mother was Royal Noble Consort Yeong of the Jeonui Yi clan. Due to the prior death of Sado's ...

Lady Hyegyeong ''Lady'' is a term for a woman who behaves in a polite way. Once used to describe only women of a high social class or status, the female counterpart of lord, now it may refer to any adult woman, as gentleman can be used for men. "Lady" is al ...

, Prince Sado's wife, mentions her husband's anger and symptoms many times in her autobiography as Hua-tseung, meaning fire symptoms. Prince Sado's impulsive actions, thought to stem from unfair treatment from his father,

King Yeongjo Yeongjo (; 31 October 1694 – 22 April 1776), personal name Yi Geum (), was the 21st monarch of the Joseon dynasty of Korea. He was the second son of King Sukjong by his concubine, Royal Noble Consort Suk of the Haeju Choe clan. Before asc ...

, led him to threaten officials and often beat his eunuchs. He once walked in his chambers holding the severed head of the eunuch he had killed; killing court officials became common.

's hwabyeong was displayed in the movie “ The Throne". Hwabyeong was first discussed in 1967 and 1970, and surveys of the illness were done in rural areas in 1975. In 1983, psychiatrist Keh-Ming Lin from UCLA Medical Center suggested that hwabyeong was a culture-bond syndrome, after treating three Korean-American women. The word hwabyeong is composed of ''hwa'' (the Sino-Korean word for "fire" which can also contextually mean "anger") and ''byeong'' (the Sino-Korean word for "syndrome" or "illness"). It may also be called ''ulhwabyeong'' (, ), literally "depression anger illness".

Symptoms

Physical symptoms include: *

palpitation Palpitations occur when a person becomes aware of their heartbeat. The heartbeat may feel hard, fast, or uneven in their chest. Symptoms include a very fast or irregular heartbeat. Palpitations are a sensory symptom. They are often described as ...

s *

anorexia Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by Calorie restriction, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. Individuals wit ...

dry mouth Xerostomia, also known as dry mouth, is a subjective complaint of dryness in the mouth, which may be associated with a change in the composition of saliva, reduced salivary flow, or have no identifiable cause. This symptom is very common and is o ...

insomnia Insomnia, also known as sleeplessness, is a sleep disorder where people have difficulty sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low ene ...

* thoracic/chest pressure * respiratory difficulties *

epigastric In anatomy, the epigastrium (or epigastric region) is the upper central region of the abdomen. It is located between the costal margins and the subcostal plane. Pain may be referred to the epigastrium from damage to structures derived from the fo ...

mass *

headache A headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of Depression (mood), depression in those with severe ...

* a whole-body sensation of heat (distinct from

heat intolerance Heat intolerance is a symptom characterized by feeling overheated in warm environments or when the surrounding environment's temperature rises. Typically, the person feels uncomfortably hot and sweats excessively. Compared to heat illnesses lik ...

, a symptom of

hyperthyroidism Hyperthyroidism is a endocrine disease in which the thyroid gland produces excessive amounts of thyroid hormones. Thyrotoxicosis is a condition that occurs due to elevated levels of thyroid hormones of any cause and therefore includes hyperth ...

) Psychological symptoms include: * being easily startled * externalization of anger, also known in Korean as "bun" (분, 憤; "eruption of anger"), a Korean culture-related sentiment related to social unfairness * generally sad mood * frequent sighing * a feeling of "eok-ul" (억울, 抑鬱; eeling ofunfairness) * being easily agitated * feelings of guilt * feelings of impending doom Diagnosed patients may also have a medical history of prior major

depressive disorder A mood disorder, also known as an affective disorder, is any of a group of conditions of mental disorder, mental and Abnormal behavior, behavioral Disorder (medicine), disorder where the main underlying characteristic is a disturbance in the per ...

dysthymic disorder Dysthymia ( ), known as persistent depressive disorder (PDD) in the DSM-5-TR and dysthymic disorder in ICD-11, is a psychiatric condition marked by symptoms that are similar to those of major depressive disorder, but which persist for at least ...

anxiety disorders Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause phys ...

somatoform disorders Somatic symptom disorder, also known as somatoform disorder or somatization disorder, is chronic somatization. One or more chronic physical symptoms coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those sympt ...

, or

adjustment disorder Adjustment disorder is a Mental disorder, mental and Abnormality (behavior), behavioral Mental disorder, disorder defined by a maladaptive response to a psychosocial stressor. The maladaptive response usually involves otherwise normal emotional a ...

according to the ''Diagnostic and Statistical Manual of Mental Disorders'', fourth edition (DSM-IV) criteria. Diagnosed patients are most likely to be middle-aged,

post-menopausal Menopause, also known as the climacteric, is the time when menstrual periods permanently stop, marking the end of the reproductive stage for the female human. It typically occurs between the ages of 45 and 55, although the exact timing can ...

women with low socio-economic status.

Causes

Underlying causes may include: * prior instances of

major depressive disorder Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive depression (mood), low mood, low self-esteem, and anhedonia, loss of interest or pleasure in normally ...

* prior instances of

anxiety disorder Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause phys ...

* prior instances of

* prior instances of other

somatoform disorder Somatic symptom disorder, also known as somatoform disorder or somatization disorder, is chronic somatization. One or more chronic physical symptoms coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those sym ...

s * repression of feelings of anger/resentment arising from past events Triggering causes are typically external events, including: * familial stressors, e.g. spousal infidelity or conflict with in-laws * witnessing acts/actions/phenomena that conflict with one's own moral and/or ethical principles The syndrome itself is believed to be the result of the continued repression of feelings of anger without addressing their source. In

holistic medicine Alternative medicine refers to practices that aim to achieve the healing effects of conventional medicine, but that typically lack biological plausibility, testability, repeatability, or supporting evidence of effectiveness. Such practices ar ...

the containment of anger in hwabyeong disturbs the balance of the five bodily elements, resulting in the development of

psychosomatic Somatic symptom disorder, also known as somatoform disorder or somatization disorder, is chronic somatization. One or more chronic physical symptoms coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those symp ...

symptoms such as panic, insomnia, and depression after a long period of repressed feelings. It is possible that hormonal imbalances such as those around the time of

menopause Menopause, also known as the climacteric, is the time when Menstruation, menstrual periods permanently stop, marking the end of the Human reproduction, reproductive stage for the female human. It typically occurs between the ages of 45 and 5 ...

may also be an underlying cause of hwabyeong in middle-aged women, the most often-diagnosed demographic. Middle-aged or older women have been reported to be more likely to be diagnosed with hwabyeong than men. 87.5% of women and 12.5% of men experience hwabyeong in 1987 report by (Min, Lee, Kang, Lee, 1987). The disparages for women can be pointed to gender roles in Korean culture, which adds considerable amount of stress. Additional stress of financial, domestic abuse, extramarital affairs, and social stigma can contribute to hwabyeong symptoms. Study was conducted with late 30’s to middle 60’s Korean women, which separated by two groups, native Korean and Korean immigrants to the United States. The study measured life stress by exploring factors including individual characteristics of stress response (measured by the Stress Response Inventory) and anger regulation (STAXI-Korean version). External environmental characteristics of life stress (measured by Life stress for Korean women) were also factored in. Data of demographic background, age, family structure, financial and employment status, religion, and educational background were recorded to find correlation to hwabyeong levels. In the conclusion of the study a slight number of hwabyeong have been reported by native Korean compared to Korean immigrant women, but with higher stress response and life stress also higher than native Korean women. Findings concluded that native and immigrant Korean women share overall numeral risk factors for hwabyeong, but focused on different stress factors. Partial cultural assimilation of western culture has been a factor on cognitive response to hwabyeong, by employing somatic reactions; compare to native Korean women reacting to more negative thoughts. There has been data supporting a slight increase in stress response and anger regulation for Korean immigrants, but data showing both native and immigrant groups having different proportional stress factors. Korean immigrants tend to regulate their anger better than their counterpart, decreasing the effects of hwabyeong.

Treatment

Western doctors are more likely to diagnose it as a kind of stress or depression. The ''

Diagnostic and Statistical Manual of Mental Disorders The ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM''; latest edition: ''DSM-5-TR'', published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a com ...

'' currently lists ''hwabyeong'' among its culture-bound illnesses. Outside of Korea, informally hwabyeong may be mistaken as a reference to a psychological profile marked by a short temper, or explosive, generally bellicose behavior. To the contrary, hwabyeong is a traditional psychological term used to refer to a condition characterized by passive suffering, is roughly comparable to depression, and is typically associated with older women. It is important that when diagnosing hwabyeong, the culture of the patient is well understood. Since hwabyeong can often be misdiagnosed as depression, the symptoms and culture need to be clearly and thoroughly looked into. Once hwabyeong has been diagnosed, past treatments need to be reviewed. The treatments for the patient can then be a combination of pharmacological, and therapy-based interventions. The treatment methods used to combat hwabyeong include

psychotherapy Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of Psychology, psychological methods, particularly when based on regular Conversation, personal interaction, to help a person change behavior, increase hap ...

, drug treatment,

family therapy Family therapy (also referred to as family counseling, family systems therapy, marriage and family therapy, couple and family therapy) is a branch of psychotherapy focused on families and couples in intimate relationships to nurture change and ...

, and community approaches. To be more successful, psychiatrists might need to incorporate the teachings from traditional and religious healing methods or the use of han-puri, which is the sentiment of resolving, loosening, unraveling, and appeasing negative emotions with positive ones. One example of han-puri would be a mother who has suffered from poverty, less education, a violent husband, or a harsh mother-in-law, that can be solved many years later by the success of her son for which she had endured hardships and sacrifices.

History

Symptoms

Causes

Treatment

See also

References

Further reading