[GAP: Definition of culture-bound syndromes as patterns of illness recognized as diseases within specific cultures but not easily mapped onto Western diagnostic categories.] [GAP: The term was coined by Yap in 1967 and used for conditions like amok, susto, taijin kyofusho, and koro.] [GAP: The concept implies a paradox that Western diagnostic categories are culture-free, which is unsupported by evidence.] Watters argues that the United States has been exporting mental illness categories for thirty years, making American definitions and treatments the international standard.(Watters, Ethan, 2010)
Origins and the Problem of Definition
The concept emerged from colonial and early cross-cultural psychiatry, where Western-trained clinicians encountered illness presentations in colonized populations that did not match European nosologies. George Devereux, writing in 1956, argued that what appears as a “culture-bound” syndrome is better understood as a disorder whose specific symptom pattern is socially sanctioned in one culture but not in another — the underlying psychopathological processes are universal, but their manifest form is culturally shaped.(George Devereux, 1980) This framing preserved a universalist core while acknowledging cultural variation in expression.
Research across cultures has found that mental illnesses appear in radically different forms: Indonesian men have been known to experience amok, in which a minor social insult launches a period of brooding punctuated by murderous rage; Southeastern Asian males sometimes suffer from koro, the debilitating certainty that their genitals are retracting into their body; across the Fertile Crescent there is zar, related to spirit possession and bringing forth dissociative episodes of crying, laughing, shouting, and singing.(Watters, Ethan, 2010) These syndromes have no Western equivalents and cannot be mapped onto DSM categories.
The formal inclusion of culture-bound syndromes in DSM-IV (1994) placed them on pages 845–849, far from the main diagnostic categories.(Watters, Ethan, 2010) The placement effectively framed non-Western conditions as carnival sideshows, exotic curiosities that could be found “far back” in the manual, distinct from the legitimate diagnostic categories that occupied the body of the text.(Watters, Ethan, 2010)
Arthur Kleinman’s critique went further. He argued that the concept of culture-bound syndromes is itself a category fallacy: it presupposes that some conditions are culturally shaped while others — the conditions listed in the DSM — are not. But all psychiatric categories are outcomes of historical development, cultural influence, and political negotiation.(Arthur Kleinman, 1988) Kleinman proposed that Western conditions like agoraphobia and anorexia nervosa are as culture-bound as any non-Western syndrome — their prevalence, presentation, and meaning are inseparable from the cultural contexts that produce them.(Arthur Kleinman, 1988)
The Symmetry Argument
All mental illnesses, including categories as seemingly universal as depression, PTSD, and schizophrenia, are shaped by cultural beliefs and expectations as much as conditions like hysteria or zar or any other illness in the history of human madness.(Watters, Ethan, 2010)
Kleinman’s evidence from Japanese psychiatry made this point concretely. Taijin kyofusho — the fear that one’s body, appearance, or bodily functions are offensive or embarrassing to others — bears a surface resemblance to social phobia as defined in the DSM. But the underlying structure differs significantly: where social phobia centers on the patient’s fear of being negatively evaluated (a self-referential anxiety), taijin kyofusho centers on fear of causing discomfort to others (an other-referential anxiety rooted in Japanese moral concepts of shame and social obligation).(Arthur Kleinman, 1988) Mapping one onto the other loses precisely the cultural content that makes the condition intelligible to the people who experience it.
The same logic applies in the other direction. Anorexia nervosa, Kleinman argued, is best understood as a Western culture-bound syndrome: its prevalence is concentrated in Western industrialized societies, it is intimately connected to culturally specific ideals of beauty, gender, and bodily control, and its rapid spread to non-Western populations correlates with exposure to Western media and values rather than with any biological substrate.(Arthur Kleinman, 1988)
The Symptom Pool
The mechanism by which cultural categories shape illness experience has been most clearly theorized through Edward Shorter’s concept of the “symptom pool.” Shorter argues that psychosomatic illnesses spread when patients unconsciously adopt culturally legitimized expressions of distress: people in a given moment of history who need to communicate psychological suffering have a limited number of symptoms to choose from, and when someone latches onto a behavior in the symptom pool, they are doing so because it is a culturally recognized signal of suffering.(Watters, Ethan, 2010) The symptom pool expands when medical authorities officially name and codify a disorder, because the naming disseminates a model of how the patient is to behave and the doctor to respond.(Watters, Ethan, 2010) This process is not conscious deception — the suffering is real — but the specific form it takes is shaped by what the surrounding culture makes available and recognizable.
The historian Shorter traced the dramatic late-nineteenth-century rise in anorexia cases specifically to the 1873 paper by Charles Laségue that first codified the condition: once a precise disorder with a specific at-risk population was officially defined, cases multiplied rapidly.(Watters, Ethan, 2010) The same mechanism operates in reverse: when a Western diagnostic label enters a culture that previously held its own illness category, the local category’s ability to communicate distress is diminished, and the Western symptom cluster progressively displaces the indigenous one.(Watters, Ethan, 2010)
Western mental health exports carry this process within them as a structural feature, not an accidental side effect. They embody cultural assumptions about human nature — that emotional fragility is normal, that verbal expression of distress is healthier than stoic silence, that many emotional experiences qualify as illnesses requiring professional intervention, and that biomedical treatment is the appropriate response.(Watters, Ethan, 2010) Drug company profit motives amplify the process: universal disease categories enable worldwide drug sales, providing financial incentives to promote American definitions of illness as international standards.(Watters, Ethan, 2010)
Brief Reactive Psychoses and Cultural Diversity
Among the conditions most clearly shaped by cultural context are the brief reactive psychoses — acute episodes of psychotic behavior with sudden onset, short duration, and cultural salience. These constitute a much larger proportion of acute psychoses in non-industrialized societies than in the West, show the greatest diversity in form of all psychotic disorders, bear the strongest causal relationship to immediate life stressors, and respond well to indigenous healing systems.(Arthur Kleinman, 1988) Their cultural diversity is so marked that many of them — including amok, latah, and pibloktoq — have traditionally been classified as culture-bound syndromes.
The inclusion of brief reactive psychoses in the culture-bound category reveals the definitional instability of the concept. DSM-III required a six-month duration criterion for schizophrenia, which effectively excluded most acute-onset cases common in non-Western settings. Acute-onset psychosis of short duration is probably not the same disease as chronic-onset, long-duration psychosis — but the diagnostic system’s structural assumptions made this difference invisible by excluding the non-Western presentation from the main category and relegating it to the culture-bound supplement.
Case Study: Anorexia Nervosa in Hong Kong
The clearest documented case of a Western diagnostic category displacing a local illness form comes from psychiatrist Sing Lee’s longitudinal research on anorexia in Hong Kong. Beginning in the late 1980s, Lee found that Chinese anorexics displayed a fundamentally different symptom cluster from their Western counterparts: most did not show the classic fear of fatness common in the West, nor did they misperceive their frail bodies as overweight.(Watters, Ethan, 2010) Instead, they attributed their food refusal to somatic complaints — stomach fullness, bloating, throat blockage, lack of appetite — rather than to fat-phobia or body image distortion.(Watters, Ethan, 2010)
Lee traced this pattern historically and found that European anorexia cases from before the twentieth century — long before the disorder had an official name — presented similarly, with patients citing painful digestion and somatic reasons for their food refusal rather than fear of fat.(Watters, Ethan, 2010) This suggested that the fat-phobic symptom cluster was not a universal feature of the underlying disorder but a historically and culturally specific form, shaped by modern Western preoccupations with body image.
The Chinese cultural context explained the earlier form of the illness: Chinese medical tradition looked to bodily sensations to indicate psychological distress, reflecting a cultural integration of mind and body rather than the Cartesian split assumed by Western psychiatry. Lee also observed in his patients echoes of Confucian asceticism — an almost monk-like self-denial and lack of worry about bodily decline, without the body-image anxiety characteristic of Western anorexia.(Watters, Ethan, 2010)
Eighteen studies attempting to link Western acculturation to eating disorders in immigrant populations failed to find a connection; some found an inverse relationship, with more traditionally oriented women showing higher rates of disordered eating than those who had assimilated into Western culture.(Watters, Ethan, 2010) This challenged the simple “exposure to Western values causes anorexia” hypothesis.
The transformation came through a single event. In November 1994, fourteen-year-old Charlene Hsu Chi-Ying collapsed and died on a Hong Kong street. Her death was covered extensively in local media and identified as anorexia. The coverage did not merely report the Western model of the disorder — it imported it, delivering both the diagnostic category and the symptom template to Hong Kong’s population.(Watters, Ethan, 2010) Where Lee had been seeing two or three anorexic patients a year, he was now seeing that many new cases each week.(Watters, Ethan, 2010) A survey of adolescent anorexics between 1992 and 1997 showed the shift clearly: by 1997, fat phobia had become the single most important reason given by patients for their self-starvation, reported by 80 percent of cases. By 2007, almost all of Lee’s anorexic patients reported fat phobia.(Watters, Ethan, 2010)
Lee concluded that the importation of the Western DSM diagnosis had not merely changed how patients talked about their condition — it had changed the actual disease experience. Patients were not reporting fat phobia to satisfy diagnostic criteria; they were experiencing it, because the cultural salience of the earlier somatic explanations had been displaced by the newly available Western illness model.(Watters, Ethan, 2010) A similar dynamic followed Princess Diana’s 1995 public disclosure of bulimia: media coverage immediately brought purging behaviors into Hong Kong’s symptom pool, and patients themselves reported to their doctors that reading or hearing about others with the disorder had prompted them to try the techniques.(Watters, Ethan, 2010)
The Hong Kong case also illustrated the self-perpetuating quality of the symptom pool. Researchers and educators who study and publicize eating disorders keep them in the pool; professional attention to the disorder may be as much a vector for its spread as a response to it.(Watters, Ethan, 2010) By 2009, Lee had concluded that the intellectual battle against DSM dominance was lost: Western diagnostic categories had gained such global dominance that the microcultures shaping individual illness experience were being discarded worldwide, not only for anorexia but for depression, ADHD, and psychological trauma.(Watters, Ethan, 2010)
Case Study: PTSD in Sri Lanka
The 2004 Indian Ocean tsunami triggered what Watters described as the largest international psychological intervention in history, with trauma counselors pouring into Sri Lanka, Indonesia, India, and Thailand from the United States, Britain, France, Australia, and New Zealand — all operating on the assumption that PTSD was a universal, cross-culturally valid response to disaster.(Watters, Ethan, 2010) Faculty at the University of Colombo immediately warned the arriving counselors not to reduce survivors’ experiences “to a question of mental trauma,” arguing that trauma processing is culturally mediated: a victim processes a traumatic event as a function of what it means, and that meaning is drawn from their society and culture.(Watters, Ethan, 2010)
Western trauma counselors interpreted local children’s eagerness to return to school and refusal to discuss the tsunami as “denial,” applying DSM assumptions about expected trauma responses as universal norms.(Watters, Ethan, 2010)
Researcher Gaithri Fernando’s fieldwork documented what Sri Lankan trauma actually looked like. Sri Lankan survivors of catastrophic loss were far more likely to experience physical symptoms — joint pain, chest pain — than the psychological symptoms listed in the DSM PTSD criteria.(Watters, Ethan, 2010) More significantly, Fernando found that every one of the twenty-six symptoms described by Sri Lankans was bound to damaged social relationships rather than to individual psychological damage. Where the Western PTSD model assumes the breakage is primarily in the individual mind, Sri Lankans interwove the social and the psychological to the point where the two could not be separated.(Watters, Ethan, 2010) Taking time away from one’s social duties and roles to pursue individual counseling with strangers may therefore actually worsen distress in a culture where mental health is constituted through connection to social networks, not intrapsychic work.(Watters, Ethan, 2010)
The cross-cultural research literature had already documented that PTSD symptom presentations vary dramatically across cultures and history.(Watters, Ethan, 2010) Salvadoran women who endured a protracted civil war often experience something called calorias, a feeling of intense heat in the body.(Watters, Ethan, 2010) Some Cambodian refugees are most distressed by being visited by vengeful spirits.(Watters, Ethan, 2010) The Quechua peoples of the Ayacucho highlands have two distinct semantic categories for suffering: nakary, conveying collective suffering, and llaki, referring to individual sorrow.(Watters, Ethan, 2010) Medical anthropologist Allan Young noted that PTSD “can be real in a particular place and time, and yet not be true for all places and times.”(Watters, Ethan, 2010)
The harms of PTSD intervention were not only structural but documented at the village level. Anthropologist Alex Argenti-Pillen studied Sri Lankan villages where communities had developed complex systems of “cautious speech” — elaborate rules for how villagers could reference horrifying events without explicitly bringing them to mind, serving as a form of collective containment against revenge violence.(Watters, Ethan, 2010) Western trauma counseling’s central tenet — that traumatic experiences must be retold and mastered through direct verbal expression — ran directly counter to these local practices. The result was that the counseling program “empowered” precisely the women the community recognized as most socially dangerous: those labeled “fearless” who had a propensity for direct and unambiguous speech about violence, whose behavior Western-trained counselors validated as healthy and empowered.(Watters, Ethan, 2010)
The evidentiary basis for psychological debriefing was also questionable. Randomized controlled studies in the 1990s found that debriefing after trauma either had no positive effect or caused harm: a study following car accident victims over three years found that those who were debriefed were significantly more likely to be anxious, depressed, and fearful of riding in cars three years later. The British Medical Journal study concluded that psychological debriefing was “ineffective and has adverse long-term effects.”(Watters, Ethan, 2010)
Arthur Kleinman argued that Western traumatologists were pathologizing non-Western responses to disaster — effectively saying “you don’t know how to live with this situation” while stripping people of their own cultural narratives.(Watters, Ethan, 2010) Medical anthropologist Derek Summerfield went further, noting that Western mental health discourse introduces core components of Western culture — a theory of human nature, a definition of personhood, a sense of time and memory, a source of moral authority — and presents just one version of human nature as definitive: contemporary Western culture now emphasizes not resilience but vulnerability, inviting people to see a widening range of experiences as liable to make them ill.(Watters, Ethan, 2010)
PTSD itself originated not as clinical science but as a political movement. The term “post-Vietnam syndrome” emerged from rap sessions held by Vietnam Veterans Against the War and supervised by antiwar psychoanalysts; the original intent was to show that being a soldier in the Vietnam War was an experience utterly distinct from that of being a soldier in any other conflict, not to carve out a universal diagnosis applicable to all victims of terrifying events.(Watters, Ethan, 2010) The diagnosis’s subsequent expansion far beyond that political intent illustrates how the symptom pool can be enlarged by the operations of professional and institutional interests as much as by clinical observation.
Case Study: Schizophrenia in Zanzibar
Two World Health Organization international studies conducted over twenty-five years found that people with schizophrenia in developing nations — India, Nigeria, Colombia — fared significantly better than those in industrialized countries, with only 24 percent severely impaired compared to more than 40 percent in the United States, Denmark, or Taiwan.(Watters, Ethan, 2010) The finding was consistent across both studies and challenged the assumption that schizophrenia is a uniform biological disease with a universal natural history.
The cultural shaping of schizophrenia is visible even at the level of symptom content. Delusional guilt is most common in Judeo-Christian cultures; religious hallucinations such as hearing the voice of God are rarer in Islamic, Hindu, and Buddhist populations. Pakistani patients are more likely to have visual hallucinations of ghosts and spirits than British patients, who more often hear persecuting voices. In traditional Southeast Asian villages where personal status-seeking is frowned upon, delusions of grandeur are rare; in the United States, where celebrity, wealth, and power are cultural fixations, people with schizophrenia commonly believe they are famous or all-powerful.(Watters, Ethan, 2010)
Anthropologist Juli McGruder’s ethnographic research in Zanzibar provided a detailed account of why developing-nation outcomes are better. She documented a family caring for two relatives with schizophrenia who displayed unusually low “expressed emotion” — low levels of criticism, hostility, and over-involvement — a family environment that existing research had already correlated with lower relapse rates.(Watters, Ethan, 2010) Cross-cultural comparison of expressed emotion (EE) rates found that urban Anglo-Americans show the highest rates globally, with over 67 percent of Anglo-American families with a schizophrenic member rated as high-EE; Indian families show the lowest rates, at 23 percent.(Watters, Ethan, 2010)
The mechanism linking cultural values to expressed emotion was identified by researcher Jill Hooley: high-EE relatives of schizophrenic patients score high on internal locus of control, believing in personal will over fate, which leads them to assume the ill family member could overcome their symptoms if they tried harder.(Watters, Ethan, 2010) McGruder connected this to core American cultural values: mental illness is feared in Western culture precisely because it represents a reversal of what Western humans prize as the essence of human nature — self-control, control of circumstances, and the capacity to manage one’s own mental states.(Watters, Ethan, 2010)
In Zanzibar, two cultural resources worked in the opposite direction. The Zanzibari Islamic belief that God does not place more burden on a person than they can bear fostered a fatalistic acceptance of the schizophrenic family member’s behavior, reducing expressed emotion and lowering the pressure on the ill person to “get better.”(Watters, Ethan, 2010) Belief in spirit possession provided an explanatory framework for bizarre behavior that, counterintuitively, reduced stigma: because nearly everyone believed in spirit possession and had personal experience with it, applying the explanation to mental illness made the behavior more understandable and forgivable, keeping the sick person within the social group during periods of remission.(Watters, Ethan, 2010)
Studies across multiple countries showed that adoption of the biomedical “brain disease” model of schizophrenia is correlated with increased rather than decreased desire for social distance from the mentally ill.(Watters, Ethan, 2010) Studies in Germany found the public’s desire to maintain distance from diagnosed schizophrenic patients increased between 1990 and 2001. A Turkish study found those who attributed schizophrenic behavior to brain illness (akil hastaligi) were more inclined to see schizophrenics as aggressive than those who attributed it to spiritual disorder (ruhsal hastagi).(Watters, Ethan, 2010) An experiment by Sheila Mehta found subjects administered more severe shocks to a partner described as having a “disease like any other” than to one whose illness was attributed to childhood events.(Watters, Ethan, 2010)
McGruder’s fieldwork documented the inverse process directly. She observed one Zanzibari family member, Abdulridha, who had adopted the Western biomedical model of schizophrenia and used it to justify controlling every aspect of his sister’s existence. His increasing alliance with Western medicine stripped away the local beliefs held by other families McGruder had studied, replacing them with the high-EE dynamic characteristic of Western families — and worsening outcomes accordingly.(Watters, Ethan, 2010)
Case Study: Depression in Japan
The creation of a depression market in Japan by GlaxoSmithKline represents perhaps the most explicit documented case of a pharmaceutical company intentionally changing a culture’s understanding of mental illness for commercial purposes. In Japan before the campaign, the word utsubyō described a severe, rare, effectively incurable psychotic condition comparable in gravity to schizophrenia — not ordinary sadness or work-related distress.(Watters, Ethan, 2010) Japanese psychiatry at that time focused almost exclusively on the severely mentally ill; there was no professional or cultural infrastructure for treating ordinary melancholy as a medical condition.
Traditional Japanese culture had actively idealized melancholy. States of sadness described by the words yuutsu and ki ga fusagu were venerated in television, film, and popular music. These emotional states were understood as jibyo — personal hardships that build character — and connected to Buddhist belief that suffering is more enduring and definitive of human experience than transient happiness.(Watters, Ethan, 2010) Research on word associations illustrated the depth of this cultural difference: when asked to free-associate to yuutsu, Japanese subjects produced mostly external words (rain, dark, gray); American subjects asked about depression produced internal emotional states (sad, lonely, down).(Watters, Ethan, 2010) These were not merely linguistic differences but reflections of fundamentally different conceptions of where suffering is located — in the world or in the self.
Eli Lilly had declined to enter the Japanese market in the early 1990s because its executives believed the Japanese would not accept the diagnosis of depression.(Watters, Ethan, 2010) GlaxoSmithKline took the opposite approach. Beginning around 2000, the company hosted a series of lavish closed-door academic conferences, spending hundreds of thousands of dollars to bring together cross-cultural psychiatrists — including Laurence Kirmayer — not to market Paxil directly but to learn how cultures shape illness experience.(Watters, Ethan, 2010) The company’s internal analysis of what made Japan resistant to the depression diagnosis was explicitly used to engineer the campaign that would overcome that resistance.
The resulting marketing strategy coined the phrase kokoro no kaze — “a cold of the soul” — to rebrand depression as common, non-stigmatized, and easily treatable, simultaneously communicating that utsubyō was not the severe condition it was once understood to be, that taking medication for it should be as simple as buying a cough syrup, and that the condition was as ubiquitous as the common cold.(Watters, Ethan, 2010) Because Japan prohibited direct-to-consumer drug advertising, GlaxoSmithKline circumvented the ban through recruitment advertisements for drug trials, ghostwritten articles, and patient advocacy websites that appeared to be independent consumer coalitions but were secretly funded by the company.(Watters, Ethan, 2010)
The intellectual context within which the campaign operated was also manipulated. The Japanese legal case of Oshima Ichiro, a Dentsu employee who died by suicide in 1991 after extreme overwork, had already begun shifting public understanding: when Oshima’s parents won a lawsuit against Dentsu, media coverage connected his death to depression as a treatable medical illness for many Japanese who had heard neither the diagnosis nor the concept applied to suicide before.(Watters, Ethan, 2010) A psychiatrist who participated in the GlaxoSmithKline conferences, Dr. Tajima, later described his role as a form of “prostitution” and concluded that the drug was massively overprescribed as a result.(Watters, Ethan, 2010)
The commercial success was substantial. Paxil earned over 100 million dollars in Japan in its first year on the market and grew to over one billion dollars annually by 2008.(Watters, Ethan, 2010) But the scientific foundation of the entire campaign was compromised. The serotonin depletion theory of depression — the biological narrative underlying all SSRI marketing globally — was first proposed by George Ashcroft in the 1950s and abandoned by Ashcroft himself by 1970, after more sensitive measurements failed to detect lower serotonin levels in depressed patients or suicide victims.(Watters, Ethan, 2010) Of seventy-four antidepressant studies submitted to the FDA, thirty-seven of thirty-eight positive studies were published in professional journals, while only three of thirty-six negative studies reached print — the remainder went unpublished or were reported in ways that claimed positive outcomes different from those the studies had set out to examine.(Watters, Ethan, 2010) Paxil’s clinical trial data for adolescents, later revealed through lawsuits, showed the drug was no better than placebo, with five-times-higher rates of serious adverse effects and eight-fold elevated suicidality; the published results had been ghostwritten to claim “remarkable efficacy and safety.”(Watters, Ethan, 2010)
Anthropologist Kalman Applbaum observed that drug company executives viewed different national markets as being at different “stages of evolution” toward the American standard, explicitly describing their role as “speeding the evolution along.”(Watters, Ethan, 2010) An earlier historical precedent made the pattern visible: Japanese neurasthenia (shinkeisuijaku) at the beginning of the twentieth century functioned as an “illness of modernity” in exactly the same structural way that DSM depression was marketed a century later — both reframed ordinary distress as a medical condition requiring treatment, and both spread when the cultural conditions were right for a new illness narrative.(Watters, Ethan, 2010)
The DSM-5 Revision
By 2013, the accumulation of cross-cultural evidence had forced a terminological shift. DSM-5 replaced the appendix of “culture-bound syndromes” with the concept of “cultural concepts of distress,” a framework encompassing three dimensions: cultural syndromes (clusters of symptoms recognized within specific cultural groups), cultural idioms of distress (shared ways of expressing suffering), and cultural explanations of distress (perceived causes of suffering). This shift acknowledged that culture shapes not only which symptoms cluster together but how distress is communicated and what causal frameworks are applied — and that these processes operate in Western populations no less than in non-Western ones.
The revision was an improvement, but the fundamental tension remained. The DSM’s main diagnostic categories continued to function as if they described culture-free biological entities, while the cultural concepts section invited clinicians to attend to cultural context as an additional consideration rather than as a constitutive dimension of the disorder itself.
The Disappearance Problem
Ethan Watters uses the metaphor of botanists cataloguing rain forest biodiversity ahead of bulldozers to describe cross‑cultural psychiatrists documenting diverse illness models as Western psychiatry obliterates them.(Watters, Ethan, 2010) The DSM had become a worldwide standard for mental illness categorization, giving American cultural assumptions about the mind global authority.(Watters, Ethan, 2010)
The consequence was not merely academic. When a local illness category is displaced by a Western diagnostic label, the therapeutic resources attached to it — the indigenous healing practices, the social meanings, the community responses — are displaced as well.(Watters, Ethan, 2010) Watters argued that the loss of diversity in cultural understandings of mental illness is as serious as biological extinction: modes of healing and culturally specific beliefs about how to achieve mental health can be lost with the grim finality of an animal or plant lapsing into extinction, and often before their value has been comprehended.(Watters, Ethan, 2010)
The Zanzibar case showed that belief in spirit possession reduced stigma for mentally ill family members and allowed them to re-enter the social group during periods of remission.(Watters, Ethan, 2010) The introduction of Western trauma counseling in a Sri Lankan village undermined local “cautious speech” practices that limited revenge violence by prohibiting direct discussion of atrocities.(Watters, Ethan, 2010) The Japan case showed that pharmaceutical marketing can systematically change a culture’s understanding of depression through mega-marketing, as demonstrated by Paxil’s sales growth from zero to over one billion dollars annually by 2008.(Watters, Ethan, 2010)
Cultures become particularly vulnerable to new beliefs about mind and madness during times of social anxiety or discord.(Watters, Ethan, 2010) The Western form of anorexia entered Hong Kong’s symptom pool during the uneasy years between the Tiananmen Square massacre and the British handover. PTSD frameworks gained a hold in Sri Lanka when populations were disoriented from a tsunami. GlaxoSmithKline’s version of depression caught hold in Japan during a lengthy and painful recession. In each case, the social disruption that created vulnerability was itself partly a product of the same globalization that Western psychiatry claimed to be treating.(Watters, Ethan, 2010)
Watters concluded that offering Western mental health theories to ameliorate the psychological stress caused by globalization is not a solution but part of the problem: by undermining both local beliefs about healing and culturally created conceptions of the self, Western psychiatric export accelerates the disorienting changes that cause much of the world’s mental distress. He compared it to handing out blankets to sick people without considering the pathogens hiding in the fabric.(Watters, Ethan, 2010)
The Ongoing Manufacture of Categories
The creation of new diagnostic categories continues as a social and cultural process as much as a scientific one. As evidence of this, the American Psychiatric Association publicly solicited suggestions for the DSM-5 through a web form that allowed anyone to submit proposals for new disorders to add or existing ones to delete.(Watters, Ethan, 2010) In 2009, following the global financial crisis, the pharmaceutical industry’s advocacy group PhRMA announced 301 new medicines in development for mental illness, including 66 for depression and 54 for anxiety — illustrating the reflex to medicalize economic anxiety.(Watters, Ethan, 2010)
A proposed DSM-5 category of “post-traumatic embitterment disorder” (PTED) was first “discovered” among East Germans who had become unmoored, unemployed, and insecure following the fall of the Berlin Wall — applying a medical framework to what was effectively a socially produced form of suffering.(Watters, Ethan, 2010) Western mental health exports carry within them a particularly American brand of hyperintrospection and hyperindividualism, still deeply influenced by Cartesian mind-body separation, that encourages people to separate the health of the individual from the health of the group — and that biomedical scientific research into brain function has, at the cultural level, further removed understanding of the mind from the social and natural world it navigates.(Watters, Ethan, 2010) Drug company advertising made this reduction explicit: one antidepressant website explained brain chemistry with a cake recipe metaphor, reducing the Western mind — “endlessly parsed by generations of philosophers, theorists, and researchers” — to a batter of chemicals in the mixing bowl of the skull.(Watters, Ethan, 2010)
The cultures that Western psychiatry is displacing have not yet made this separation. In those places, cultural conceptions of the mind remain intertwined with religious and cultural beliefs and with the ecological and social world; they have not separated the mind from the body, nor disconnected individual mental health from that of the group.(Watters, Ethan, 2010)
Significance
The history of culture-bound syndromes is, in miniature, the history of cross-cultural psychiatry’s central insight: that the categories through which any society understands mental suffering are products of that society’s history, values, and social organization. The concept began as an attempt to accommodate non-Western illness patterns within a Western framework, but the evidence it generated ultimately challenged the framework itself. Bodily metaphors predominate in cross-cultural idioms of distress because in all societies the body represents both a rich source of symbols for communicating about social groups and a way to express the materiality of misery, much of it socially caused.(Arthur Kleinman, 1988) The question is not which syndromes are culture-bound, but whether any syndrome is not.
[HUMAN NOTE]: None yet.
See Also
- ethnopsychiatry
- category-fallacy
- explanatory-models
- neurasthenia
- hikikomori
- nostalgia
- illness-disease-distinction
- medical-anthropology
- anti-psychiatry
- somatization
- expressed-emotion
- symptom-pool
- pharmaceutical-industry
- psychiatric-imperialism
Sources
Evidence cited from: kleinman-rethinkingpsychiatry-1988, watters-crazylikeus-2010, devereux-basicproblemsethnopsychiatry-1980