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By Carol W. Berman, M.D.

"Doctor, my penis is shrinking into my body! I'm afraid it will kill me," my 23-year-old patient complained one afternoon. Originally, he'd consulted me only about his work performance anxiety. After giving him psychotherapy for eight months, I knew that this computer technician agonized about his penis being too small. He believed he was totally inadequate. Throughout the thirty years I've practiced psychiatry, I've encountered many men obsessed with the size of their penises, but this patient was the worst and delusional as well. Although doctors had always assured him that his penis was of normal size, he never believed them. Even in the locker room at his health club, he avoided walking around naked – although many of the men did – because he was afraid he would be mocked. He could clearly see that he wasn't that different than others, but he had a fixed, false belief that he was. Male friends joked when they saw he was vulnerable.

"Don't you think this has to do with your girlfriend leaving you and returning your engagement ring?" I asked, hoping to re-connect him to reality and to shake his delusion. No, he was convinced that his genitals were retracting into his body and he was dying. It always amazed me how valid so-called outdated Freudian concepts were. I am an eclectic practitioner, who mixes a bit of Freud with Jung, Adler, etc. Nowadays most psychiatrists employ whatever theories help in the treatment of their patients, but the Oedipal complex, castration anxiety, and penis envy were all totally relevant to my patient.

My patient had been dating his girlfriend since his first year of high school. He had never had sex with anyone else, although he often fantasized about other women. His feelings of inadequacy kept him from attempting sex with anyone else. Rationalizing, he told himself that he was being true to his girlfriend.

After he and his girlfriend became engaged, they began to fight. One Saturday night when she failed to show up, he was frantic. He texted her all night. Finally she answered, informing him that it was all over and she'd send back his ring. He couldn't believe that she would end the relationship so abruptly and callously.

"Your penis can't shrink into your body. It's impossible," I continued. I realized that he was experiencing a delusion we call "koro” which is a belief that the penis and testes are shrinking into the abdomen and will lead to death. It has been mainly reported in Malaysia and East Asia, where it is rooted in Chinese metaphysics and cultural practices. Koro patients are troubled by fears about masturbation and what they see as sexual overindulgence. Freud would have considered them to be suffering from castration anxiety. My patient was a non-Asian man who did not have any interest or knowledge about Chinese culture. When he explained his worry to his father, both parents took him to the family doctor. No matter how much reassurance he was given that his penis was perfectly normal and that it was not receding into his abdomen, he stuck to his false belief, or delusion as we say in psychiatry.

We explored his feelings about the breakup. Psychotherapy helped to decrease his anxiety, but his delusion remained. When his girlfriend finally returned his calls, he begged her to come with him to therapy. Once there, she expressed how oppressed she had felt by his controlling behavior. In the next session he told me that he realized that she reminded him of his mother and that loss of her meant loss of his mother's affection, and I thought of the Oedipal battle, in which the boy loves his mother and wants to destroy his father. Only when his girlfriend returned to him and accepted his ring once again could he stop believing that his penis was shrinking and that he would die. The couple worked out compromises: giving her more freedom and him insight into what his girlfriend was feeling. They had a few more sessions before they were married and I invited them to return if necessary.

His "koro" delusion is unusual in the West, but he had always been fixated on his penis, feeling it was inadequate. His father had bullied and humbled him during his Oedipal stage (about three years old), when he was especially vulnerable to feeling inferior. When his girlfriend left, he believed this proved his sexual inadequacy. Her abandonment was unconsciously viewed by him as a castration; hence, the development of his delusion.

Ironically, it wasn't therapy that released him from his fears, but the actual return of his girlfriend K���

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