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Hwa-byung is a Korean folk syndrome that is a psycho-somatic illness with multiple symptoms and is characterized by the suppression of anger.

Symptoms

Hwa-byung symptoms include a feeling of panic, fear of impending death, fatigue, insomnia, anorexia, dyspnea, dysphoric affect, palpitations, indigestion, headache, dizziness, weakness, blurred vision, stifling/oppression, sexual dysfunction, insomnia, weight loss, flushed feeling, mass in the throat or epigastrium, heat sensation, intolerance to heat, multiple pains, sighing, dry mouth and a sensation of pushing-up in the chest, and/or generalized ached and pains. The results suggest also that the psychological symptoms of hwa-byung are a pervasive depressive mood, regret or guilt, anxiety, anger, destructive impulses, "weak and sensitive mind," obsession-compulsion, irritability, paranoid feelings, and hypochondriasis.

Hwa-byung patients' REM sleep on polysomnograph resulted in alpha rhythm intrusion into the delta rhythm. This, Chung said, may explain why the hwa-byung patient complains of difficulty sleeping. While the person is in a period of deep sleep, the brain is 'awake.'" Thyroid-stimulating hormone (TSH) levels in hwa-byung patients almost double and prolactin levels are a lot higher.

The epigastrium is also called the "gate of life." It is the center of the body and produces vital energy. Therefore, in hwa-byung the somatization centers around the epigastrium and lower chest. Patients who have explosive anger, who shout or destroy things, soon realize that this only worsens the situation.

Koreans believe in the five governing bodies of the universe: earth, water, wood, metal, and fire. According to patients, suffers of HB can experience deep feelings of haan which is attributed to destruction, personal loss, suffering, suppressed anger, hate, despair, the holding of a grudge or feelings of "everlasting woe"; as well as to disorders of anxiety, depression and obsession-compulsion, and unbearable pain. They feel trapped in their situations and victimized. It causes sensations in the chest and body such as pain, boiling, and exploding hurt.

Sung Kil Min, M.D., Ph.D., of the department of psychiatry at Yonsei University College of Medicine, Seoul, Korea stated that "according to theories of traditional Oriental medicine, fire is one of five universal elements. If found to be excessive in the body, this fire element is believed to disturb the balance of bodily elements, resulting in disease. "Koreans commonly describe anger as fire," he said, "and think that if anger is suppressed for a long time, a group of symptoms develops that is identified as hwa-byung. Sometimes the term wool-hwa-byung is used, in which wool means 'dense, thick or pent-up.'"

In English, hwa-byung is literally translated as "anger syndrome." In South Korea, HB is also called ulhwabyeong. Hwa-byung is also known as wool-hwa-byung in some cultures. . Hwa-byung has been found in America as well as the Eastern world contrary to some beliefs. Sung Kil Min, M.D., Ph.D., of the department of psychiatry at Yonsei University College of Medicine, Seoul, Korea, said that “because many hwa-byung patients relate their condition to the psychology of "haan," a traditional culturally determined emotional state, Min considers hwa-byung a culture-related syndrome of Korea. According to patients' explanations, Min said, those with hwa-byung have experiences which "cause hurt, damaging, boiling, exploding [sensations] inside the chest or body." Hwa-byung mostly affects middle-aged women with a low socioeconomic status. Korean patients want to keep harmony and peace around the family, and not hinder social relationships. Hwa-byung sufferers are afraid to speak of their feelings, and instead bottle it up for years.

Characteristics of HB patients include a polite attitude, an abundance of somatic complaints, and tears. Min explained, "once provoked, they tend to talk long and in detail, as if petitioning to doctors as potential helpers or counselors. When asked to describe symptoms, patients more commonly offer terms like mortification (as a victim) or worry as compared to anger. This suggests that hwa-byung patients tend to experience anger in a passive way, directing [it] inward instead of outward. Generally, they are well-aware of the cause of their illness, and want to let people around them know they are suffering." Si-Hyung Lee, M.D., Ph.D., a psychiatrist in the department of neuropsychiatry at Kangbuk Samsung Hospital in Seoul, explained HB well with this image:

"While a mother is praying, in front of big trees and rocks, to have a son, her daughter is watching curiously." In a [traditional] Korean family, he explained, the daughters haven't been counted as family members. "If she doesn't have a boy, then the mother is no longer treated as a mother. Sometimes she might be kicked out of the family." For women, the causes of hwa-byung seem to originate in external events (e.g., spousal infidelity, in-law troubles or a child's illness).

"These experiences can be encountered in any human society," Lee said. "But in order to become hwa-byung, three characteristic features are encountered. They have to do with coping strategies, somatic symptoms and long lamentation with deep sighing." Coping with the situation (e.g., of a husband's unfaithfulness) as best she can is the only choice some patients have. She may think of divorce as a radical solution, since there is a strong social stigma against it. Also, she feels a strong responsibility to care for her children and cannot afford to live independently. So, too, she believes it is a woman's virtue to bear misfortune, misery and mistreatment silently, so her anger is not to be expressed but rather contained within.

"She begins to realize there is no choice," Lee said, "but to accept the present situation. She tries hard to endure the situation as her fate or destiny, but then refuses to take it as fate. 'Why me? What have I done wrong?' This makes hwa-byung a very chronic [cyclic] process, with episodic eruptions of anger."

"A woman tries to suppress and accept it, but then she can't, so the suppression is never complete," Lee said. "[That] leads to a characteristic tight, stuffy feeling that consolidates into an epigastric 'mass.'"

"There are many purposes of lamentation and sighing, but they can be summarized into self-pity [to the extent] that the patients can talk to anybody hoping for relief," Lee said. Luke I.C. Kim, M.D., Ph.D., clinical professor of psychiatry at the University of California, Davis, stated that "the need to suppress anger may be attributed in part to Korea's geography and the penchant for countries to war against each other." Kim said that throughout history, "frequent war and political and social upheavals have been the norm...They have brought about destruction, suffering, personal loss and unbearable pain for many Koreans, who experienced deep feelings of haan and felt trapped and victimized." Women endured and suffered hardship and injustice because Korea was a very hierarchical, class-oriented society where women were subservient to men. "Korea has been a nation of suffering, a nation of the haan...For their own survival, as well as to live in harmony with the teachings of Confucius, they have had to swallow and suppress their feelings," stated Kim. HB speaks through a wide array of physical symptoms, in response to emotional disturbance, such as stress from troublesome interpersonal relationships or life crises.

Possible Causes

The causes of HB are yet to be pin-pointed. (There have been few studies pertaining to hwa-byung.) Korean psychiatrists presume to believe that cultural, biological, and psychological factors are involved though. Haan might be the direct cause of hwa-byung. One hypothesis is that suppressed anger is turned inward attacking one's self as a defense mechanism against a loss of some kind. "Patients with hwa-byung suffer from a narcissistic disorder, which begins as a shame-bound self, and then more shame is added by an ignorant society. The Western world views hwa-byung as major depression or dysthymic disorder combined with somatization disorder instead of hwa-byung in the DSM-III-R criteria. The reasoning for this is due to the Western world's reluctance to recognize HB as a mental illness. Patients then face double damage that makes self-acceptance impossible and recovery an elusive goal, always just beyond their reach. I will examine the process of how the vulnerable self is formed in Korean culture, and how such a self comes to suffer from Hwa-Byung when the narcissistic self meets a life crisis. It is reported that many Hwa-Byung patients resort to religion, especially Christianity, for the cure of their illness." Women who have certain personality types like "explosive-like-fire" or quick-temperedness tend to develop hwa-byung. Women with HB find themselves continuing to endure, hoping their life will improve in the future. Eventually, hope makes it to despair. Hwa-byung may be the physical occurrence of the despair of a Korean woman of the painful life process experienced as a Korean woman."

Possible Remedies to Hwa-byung

Researchers in Oriental medicine believe HB originates at the heart, and, in turn, try to calm the heart with different methods such as yoga and aroma therapy. According to Chinese medicine, when yin and yang become unbalanced, diseases result. The statement, "the mind and body are not a separate thing but one," explains this belief well. Stress is also a contributing factor of HB. Eliminating stress is an integral part for healing. Herbal remedies, acupuncture, and controlling respiration are just a few methods. Some believe that rubbing aroma on the skin will rid the body of aches and sinews. Prescription medicine is not the first avenue, instead, sun exposure, exercise, and natural cleansing methods are sought out. A structured nursing intervention program was introduced to patients with HB to provide therapies consisting of music therapy, drama, and group therapy. Health care programs currently provide insufficient help for the needs of patients with HB, and, in turn, they have a lower quality of life. The most important factor for this program was culture cognizance. Studies on this program concluded that patients who received individualized, caring treatment had an increased quality of life.

Diagnosis and Cognizance Advances

Some have suggested a model to diagnose hwa-byung, which consists of six concepts: stagnation of vital energy, depression of liver energy, imbalance between heart-yang and kidney-yin, accumulation of fire, fire syndrome caused by the disorders of the five emotions, and a deficiency of yin, which leads to fire. "As yet the prevalence rate of HB has not been investigated based on a national sample, but some studies report that about 4.2% of the general population in Korea (Min, Namkoong, & Lee, 1990) and about 11.9% of Korean American people may suffer from HB symptoms (Lin et al., 1992)."

Open-ended questions can be directed to a sufferer of HB such as: When did you feel happy in your lifetime? When did you feel sad in your lifetime? When did you feel angry in your lifetime? When did you feel satisfaction in your lifetime? When did you feel extreme unfairness or feel victimized? When did you feel regret? How do you feel when you do not receive thanks for your efforts? and How do you evaluate your life? Real examples to support or to illustrate their answers are presented in the following findings...

FINDINGS

Of the six women interviewed, one was in her forties, four were in their fifties, and one was in her sixties. All were married and none worked outside the home. One stated that her family had a low SES, while four indicated that they were middle class, and one had a higher SES. Their educational levels were low: Two had no formal education, two completed only primary school, and one each completed middle or high school. Three short descriptions are given to provide the reader with material that can facilitate interpretation of what the life experience of HB women are like.

Case I

Mrs. Kim, 57 years old, started to suffer from symptoms that she attributed to HB about 5 years ago. Her life history and the description of HB symptoms follow: I led a sad life. I feel guilty because of my handicapped child. My husband used to beat me and kick me and destroy furniture whenever he drank alcohol. One day several years ago, my husband kicked me in my chest and I fell down on the ground. After that, I felt palpitation s and chest tightness . At first I didn’t know why I felt symptoms like that. Nonetheless , my husband thought that I was resorting to petty tricks. I didn’t say anything, although I thought, “I lived with you for over 30 years. You should know me well. How can you think I resort to petty tricks? You are a dirty and cruel man.” I got married at 22 years by matchmaking. I don’t know what happiness is. I tried to make a living in my lifetime. Nonetheless , my husband thinks I don’t work hard. It is the only reason he beats me. I think that the basic needs of humans are not different . A woman’s role is different from a man’s role. By the way, my husband doesn’t work at all. I was so sad that I hid because of his violence. Once when my children were young,

I tried to escape once. But I couldn’t run away because of my children. Although I might die due to his violence, I couldn’t abandon my children. In my childhood, my mother abandoned me. My stepmother always beat me, didn’t give me any food, and didn’t care about me. Eventually, my mother returned home. But she sometimes beat me. One of the reasons she beat me was that she had to live with my father because of me. I lived like an orphan although I was not an orphan. I think I am worse than any animal. I think my life is meaningless . Who else has ever had such a hard life as me? I feel a mass in my chest and dryness in my mouth. I can’t fall a sleep without drugs. I am anxious, depressed, and distressed. I don’t have any hope, so I tried to commit suicide using agricultural chemicals. After that, my husband locked the storeroom. I am a humble woman. I wish that I had a rough personality. I thought the situation might be better. Now I think my husband will suffer. I think, “You made my life hard. It was a sin. You have to suffer punishment.” People used to say to me, “You are very diligent.” I often cried alone. I can’t express my loneliness in any one word. I think, “Why do my mother and husband who should have loved me mistreat me?” I’d like to ask them, “Why did you mistreat me?” I’d like to stab myself in the chest because of this mass feeling.

Case II

Mrs. Shin, 59 years old, started to suffer from HB symptoms about one year ago. Her life story and the description of HB symptoms follow: I had a shocking experience about a year ago. A relative of my husband I have known for 20 years called me and spoke ill of me. She and my husband had an infidelity relationship before. I did not know that. While talking over the telephone, I felt a severe headache and felt a flashlight in my eyes. After that time I could not see well and I had hypertension . I got married at 18 years old. Just after marriage my husband began to be sick. His job was a miner. His disease was related to his job. So I had to earn a living. I could not receive any help from my husband for a lifetime. I had to work hard and I always felt lack of sleep. One of my wishes in my lifetime was to have enough sleep.

My husband drank every day and beat me. One time he beat my head and I lost consciousness . When my consciousness returned several hours later I was lying on the ground alone. My eyes were bluish due to bleeding. At that time I had two children. But I lost both of them. I was very poor. When they were sick they could not receive any medical treatment and take any medicines. It was my deep sorrow (haan). Because of the deep sorrow I work harder and harder. There is a proverb, “Only after death married women can leave the house.” One time I wanted a divorce, so I tried to escape. But I could not escape because I heard the crying sound of other children and it was like that of my children to me. After that I was sick; I always cried. I feel victimized at being mistreated. Now I feel regret and disgust toward my husband. Even if he treats me well from now on, I can’t forgive him. I think I am dying.

Case III

Mrs. Lee, 63 years old, started to suffer from HB symptoms about 10 years ago. Her life history and the description of HB symptoms follow: After marriage I did not feel happy. Even on the night of my wedding I did not feel happy. I got married at 19 years old. My husband’s age is the same. He drank and slept that night. So I could not take off my clothes, and I continued to sit down all night. At dawn he woke up and I could barely sleep. My husband already had a woman before marriage. He kept the relationship with her after marriage. I knew about that four or five years later. He kept the relationship for about eight years. After that he ended the relationship . But he made a relationship with another woman. He continued the infidelity for his lifetime. No one knows that. What is my life? When I was young I had a hope. The hope was that the marital relationship might be better when I got older. But his attitude did not change. I felt more resentful toward him. I will blame him until the moment I die. Now I don’t have any hope. I sometimes think, “How can I follow such a thorny road? Do I have to follow such a thorny road in the future?” My mouth feels hot and pungent . My back feels like being gathered and necrotized.