Hwa-Byung, A Korean culture-bound anger syndrome: From conceptualization to digital therapeutics and cross-cultural extension

Abstract

Hwa-byung is a Korean culture-bound syndrome characterized by suppressed anger and accompanying somatic symptoms, historically recognized within international psychiatric classification and of growing relevance to contemporary traditional and integrative medicine. This narrative review synthesizes a multi-year line of clinical and methodological research on hwa-byung to introduce the syndrome to an international audience. The review begins with the historical and clinical conceptualization of hwa-byung as an anger-related disorder rooted in suppressed emotion and perceived social injustice. It then describes ongoing efforts to improve the original hwa-byung symptom scale, including a machine-learning-based short-form instrument designed to reduce assessment burden, and a subsequent personality-based vulnerability scale developed using comparable methods. Epidemiological findings are summarized indicating that hwa-byung remains prevalent among younger Korean adults and is independently associated with increased suicidal ideation, extending its relevance beyond the traditionally described middle-aged population. The review then synthesizes systematic-review-level evidence on mind-body medicine and psychotherapy for hwa-byung, situates these findings against the 2021 Korean medicine clinical practice guideline for hwa-byung, and describes efforts to translate this evidence into practice through digital therapeutics: a nationwide practitioner survey revealing a gap between guideline recommendations and clinical implementation, the development of a smartphone application grounded in acceptance and commitment therapy, and a pilot feasibility trial demonstrating acceptable adherence and safety. Finally, the review turns to recent survey studies among foreign residents and naturalized citizens in Korea, which found that hwa-byung is associated with experiences of racial discrimination and that awareness of hwa-byung and willingness to use Korean medicine extend well beyond the ethnic Korean population, raising the possibility that hwa-byung reflects a more universal response to perceived injustice and marginalization. Together, these findings illustrate a translational pathway from cultural psychiatric concept to modernized, cross-culturally relevant intervention, with implications for traditional medicine research internationally, including in Vietnam.