“We may indeed be far along in homogenizing the way the world goes mad”

Ethan Watters

I recently received a letter from a reader of this newspaper suggesting very indignantly, that according to a review she read of Ethan Watter’s book “ Crazy Like Us: The Globalization of the American Psyche, the United States exports to the world not only American music and pop culture but also mental illnesses. One such illness is anorexia nervosa.

Coincidentally, I had recently read an essay in the New York Times by Watters regarding his book, so I knew what she was referring to. We’ve known for some time that mental illness can be shaped by the ethos of a culture.

A breed apart: This is why the American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders (DSM) has classified some indigenous disorders in a separate appendix outlining cultural formulation and cultural bound syndromes.

For example, in some Southeast Asian cultures men can suffer from a mental illness called “Amok”, an episode of murderous rage followed by amnesia. Another example of an indigenous disorder in the same region is Koro, where men fear that their genitals are retracting into their bodies and where women fear that their vulva and nipples are retracting. What is to be noted is that the expectations and beliefs of the sufferers, shaped by their culture, also shape their suffering. A case in point is anorexia,which has existed in Hong Kong for the longest time.

Seeing things differently: However, anorexic patients there have typically declined to eat not out of fear getting fat (like Western anorexics) but because they complained of having bloated stomachs. It wasn’t till a teenage anorexic girl collapsed and died in downtown Hong Kong in the 1980s and the local media went wild with the story that the perception of the disease changed. In trying to explain what happened, local reporters copied out the DSM and the mental-health experts in Hong Kong reported that it was the same disorder as that which appears in the US. From then on, the manifestations of anorexia nervosa in Hong Kong were similar to those in the US. It was a teachable moment.

What we in the mental health community have learned to appreciate is that there are cultural differences in the manifestations of mental disorders and, more importantly, that as authorities on mental health we can have an effect on those differences.