January 14, 2010

Everyone Goes Crazy In A Different Way, As Long As That Way Is The Same

confused chinese.jpg
"yeah, everyone in America is so fake"


The NYT writes The Americanization of Mental Illness:

In some circles, it is easy to make friends with a rousing rant about the McDonald's near Tiananmen Square, the Nike factory in Malaysia or the latest blowback from our political or military interventions abroad. For all our self-recrimination, however, we may have yet to face one of the most remarkable effects of American-led globalization. We have for many years been busily engaged in a grand project of Americanizing the world's understanding of mental health and illness.

The article cites the experiences of a Chinese psychiatrist in the 1990s who tried to explain the culture specific ramifications and meaning of anorexia in Chinese patient:  not a fear of being fat, but a vague feeling of GI distress.  This was some unconscious manifestation, a somatoform disorder.

Then a woman passed out and died from anorexia on a subway:

In trying to explain what happened to Charlene, local reporters often simply copied out of American diagnostic manuals. The mental-health experts quoted in the Hong Kong papers and magazines confidently reported that anorexia in Hong Kong was the same disorder that appeared in the United States and Europe.

What happened next seemed to surprise the psychiatrist: not only did anorexia rates start to  rise, but no longer was it due to the vague GI distress.  These new anorexics specifically cited "fat phobia" as the core. 

Western ideas did not simply obscure the understanding of anorexia in Hong Kong; they also may have changed the expression of the illness itself.
Dr. Lee surmised that because the language to describe anorexia came from America, then

When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.

There are two points to ponder: first, what are we to do with the genetic basis if the incidence of a disorder jumps so suddenly?

Second, and more importantly: if Chinese people are being nudged into developing western style diseases because they are being bombarded with western psychiatric descriptions, then what do you think happens to western people? 

That feeling you have is what Sartre called nausea.  Seroquel won't help.


II.

The article, through Dr. Lee, blames the usual suspects:

Mental-health professionals in the West create official categories of mental diseases and promote them in a diagnostic manual that has become the worldwide standard. American researchers and institutions run most of the premier scholarly journals and host top conferences. Western drug companies dole out large sums for research and spend billions marketing medications for mental illnesses... Taken together this is a juggernaut that Lee sees little chance of stopping.

In this case the problem isn't psychiatry, it is the popularization of psychiatry: it is the press, it is the media. She didn't read the DSM, she read the newspaper (and magazines and TV and...)  They're not simply popularizing western psychiatry, either-- they're popularizing western culture.  It's a safe bet that "local reporters" are going to be more westernized than "locals."  But reporters have a forum, so they get to determine the narrative.  The "local reporters" in China basically did what the American press does: "here's what we think happened.  Hit Print.  There, now it's true."

When Google threatens to pull out of China, it isn't because of human rights violations.  It's a battle for who will describe the universe.  NB: Google will win.

III.

The article describes an experiment that could be called, "You rise to the level of your diminished expectations."

A subject tried to silently train a second person to press some buttons in a specific order.  He is told that the second person had a psychiatric disorder either due to "life events" or to a "brain disease."  The only feedback they could give was to administer a very mild shock, or a very big shock, when the second person got the pattern wrong.

When the subject was told that the second person had a psychiatric disorder due to life events, they got the mild shock.  When it was due to a brain disease, they got the big shocks.  If there is already something wrong with their brain, the subject figured he had to make things obvious.

The point of this example was to illustrate that other cultures may end up stigmatizing the mentally ill if they begin to incorporate the Western idea that these are strictly brain diseases.  Too late: incorporating the western idea was what gave them the disease in the first place.  Seroquel won't help that either.

IV.

"You have a background in genetics.  How can you flippantly say that ideas are causing psychopathology?"

The interaction of genes of risk with other genes that we have not yet identified-- say, an insulin receptor or the size of your pancreas or your ability to fight a flu infection-- that we wouldn't even think is relevant, may be quite relevant.  Most of our psychiatric genes of risk are risks only in certain environments.  That may seem obvious, but consider that a person with schizophrenia, in which the mind has difficulty with reality, may be even more ill when their reality is actually less real: a Chinese teen in China saturated with western images. Perhaps if he never turned on the TV, he never would have developed the symptoms (or they would have been less.)   The Japanese hikikomori phenomenon may be an example.

Go back to the story of the Chinese anorexic woman who died.  The article doesn't point put the obvious: she had already been infected by the west.  Her name was Charlene.

Certainly I don't hate the west; but when you dip your feet into someone else's culture without the accompanying mental and social infrastructure that goes with it, well, you're going to get anorexia.  Or something.










Comments

it can change the "expressi... (Below threshold)

January 14, 2010 11:59 AM | Posted by Mind, Matter, and Nothing Else: | Reply

it can change the "expression of the illness itself".

This statement suggests that a "mental illness" can exist independently of its symptoms--there is no "itself". A mental illness is only what it is as expressed as. If the "expression" changes, then it IS something else. Or, is "depression" an altered "expression" of "anxiety".

Interesting that the research gave two choices: Live events (psychology) or brain disease (neurology). Apparently, no one can think of the third magical thing that supposedly represents the knowledge of psychiatry.


Psychiatry: the medical speciality dealing with quotation marks.

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I thought this article was ... (Below threshold)

January 14, 2010 12:03 PM | Posted by mb: | Reply

I thought this article was interesting, because since med school I have often wondered what people with various disorders would look like in other cultures, or if they'd even exist. That said, there was a lot about this article that annoyed the hell out of me.

For one, they kept harping on the DSM. The DSM is not intended to be a manual for the entire world to use. The ICD would be a more valid thing to criticize than the DSM, which is a product of the American Psychiatric Association so any other group using it should understand the caveat that it by definition focuses on American culture.

I don't agree with the interpretation of the shock study, unless there was a non-fake mentally ill group they didn't talk about. If "normal" people got big shocks, then one could conclude that the "brain disease" people have LESS stigma because they're treated like the normals.

They fail to mention that good psychiatrists think those Paxil ads about chemical imbalances are stupid.

But despite the above, it was an interesting article that generated some food for thought. And the fake rorsachs were kinda neat. I thought the first one looks like a big crawfish. Yum :-)

PS Weren't there some studies a few years ago about some isolated island nation that had no eating disorders until it had more contact with Western culture? I'm surprised they didn't mention those studies.

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Hegemony, innit?You ... (Below threshold)

January 14, 2010 12:17 PM | Posted by Anonymous: | Reply

Hegemony, innit?
You can have any colour you want, as long as it's black.

What I enjoy most about your site is that you're an actual psychiatrist who knows his shit, but you're writing in the style of a cracked.com contributer. Makes me think of your post about the difference between a genius and an amatuer. I supposed you were conscious of that when you wrote the article.

Still, you know what they say, there's no praise like self-praise.

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If mental illness is a stra... (Below threshold)

January 14, 2010 12:35 PM | Posted by 56: | Reply

If mental illness is a strategy to get needs met, it makes since that being exposed to other cultures would result in new strategies being used.

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Also, are you aware that go... (Below threshold)

January 14, 2010 12:41 PM | Posted by mb: | Reply

Also, are you aware that google ads has placed a giant video ad for dianetics in the middle of your article?

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RE mb advert in the middle ... (Below threshold)

January 14, 2010 2:49 PM | Posted by Anonymous: | Reply

RE mb advert in the middle of your article`
Its not dianetics for my browser, its another advert.
I would say you were paranoid.

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The author of the article y... (Below threshold)

January 14, 2010 3:51 PM | Posted by D.T.: | Reply

The author of the article you cite (Ethan Watters) wrote an entire book about this: "Crazy Like Us" which just came out like three days ago.

He went on NPR the other day to discuss the book, and this concept.

One thing from the book that made me a little nauseated was the chapter on the westernization of the concept of depression in Japan.

Japan is a country full of depressed people, and this is more than partly due to cultural idea of melancholy as noble.

There was virtually no demand for SSRI's in Japan, because cultural ideas about depressed moods viewed only the severely depressed as needing treatment.

So GlaxoSmithKline (company that makes Paxil) started working to change the way the Japanese thought about depression, and marketed their SSRI's as a solution to a problem the Japanese didn't even used to think existed.

GlaxoSmithKline created a market for their drugs by changing Japanese cultural ideas of depression.

Maybe the Japanese needed help: they do have a high rate of suicide. But SSRI's, while effective in overall large populations, have been shown to create suicidal feelings when taken by people with no symptoms of depression, in addition to many other side effects. They are far from good science. GlaxoSmithKline created and then took advantage of this market, earning billions of dollars in the process.

That's at least a little nauseating.

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This reminds me of allergie... (Below threshold)

January 14, 2010 5:24 PM | Posted by Eddie Sylvano: | Reply

This reminds me of allergies. An awfully large number of people claim to be allergic to certain foods or irritants, despite the relative paucity of demonstrable pathology. What leads them to this conclusion? Something started the ball rolling - either a genuine feeling of illness or a sense that having allergies is valuable.

I'm inclined to believe that people essentially confabulate their life stories, anyway, so it makes sense that they would adopt ideas syntonic with their subjective state. In the past, it was an imbalance of humours, but everyone's too savvy for that shit now...

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Excellent article. I for on... (Below threshold)

January 14, 2010 10:48 PM | Posted by John: | Reply

Excellent article. I for one would like to hear your take on Hikikomori and how it may or may not relate to western phenomena.

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A liver cancer is the same ... (Below threshold)

January 14, 2010 11:21 PM | Posted by Jack Coupal: | Reply

A liver cancer is the same in Tokyo and in New York City

A depression is different in Tokyo and in New York City

Weird.

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Eh, I was seriously annoyed... (Below threshold)

January 14, 2010 11:32 PM | Posted by Bitcher: | Reply

Eh, I was seriously annoyed at that article for several reasons. First, they clearly don't seem to understand statistics. Western anorexia seems to turn up in addition to the Chinese one, not replace it. Secondly, the data on schizophrenia seems to be rather poor. We really don't know what kind of understanding of the association people were making when being told of the biological basis, and considering schizophrenia wasn't always called that, longitudinal statistic's aren't all that helpful.

And finally, considering that he's arguing that mental illness is a cultural construct, it seems absurd to argue that seeing a biological basis for behaviour is a cultural universal.

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Well, liver cancer, like al... (Below threshold)

January 14, 2010 11:33 PM | Posted, in reply to Jack Coupal's comment, by Anonymous: | Reply

Well, liver cancer, like all real diseases, do not vary by culture.

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Anonymous 11:33, you're kid... (Below threshold)

January 15, 2010 12:16 AM | Posted by Meat Robot: | Reply

Anonymous 11:33, you're kidding, right? Have you never even superficially looked at differential epidemiology of "real diseases" across cultures, including different clinical manifestations, comorbidities, and outcomes?

Methinks ye speak whereof ye know not.

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RE:"When the subject was to... (Below threshold)

January 15, 2010 8:09 AM | Posted by mark p.s.2: | Reply

RE:"When the subject was told that the second person had a psychiatric disorder due to life events, they got the mild shock. When it was due to a brain disease, they got the big shocks."
Big shock or small shock doesn't matter , what is important is making an US and THEM. Making a prejudice, or an excuse for a prejudice that the person giving-the-shock needs.
They come from the wrong side of town, they have the wrong religion, they have the wrong sexuality, they have the wrong skin color, they have the wrong kind of brain.
They need to be helped for their own good.
This is about authorities power ( it tells the "facts" about how different the ill/wrong is) to exploit gullible-naive people emotions for authories benefit ( the person is ill/wrong).
Got to keep shocking the person underneath you in the food chain.

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Yes, even superficially it ... (Below threshold)

January 15, 2010 4:56 PM | Posted, in reply to Meat Robot's comment, by Anonymous: | Reply

Yes, even superficially it is quite clear that cancer is cancer regardless of and independent of culture and depression is an abstraction entirely dependent upon culture.

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@: D.T: "Japan is ... (Below threshold)

January 15, 2010 6:34 PM | Posted by Anne from the East: | Reply

@: D.T:

"Japan is a country full of depressed people, and this is more than partly due to cultural idea of melancholy as noble."

actually you'll have to blame Aristotle for this idea of melancholy as being the nark of genius and thus a noble thing to have.

@laspsych: you're perfectly right, however: I think it is impossible to stop such an import of westernization by the East. Rather, a higher degree of awareness might help us importers and you exporters become more skeptic regarding such... confabulations, as nicely worded by someone above. Awareness would make one think before swallowing.

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*mark of genius i meant, no... (Below threshold)

January 15, 2010 6:35 PM | Posted by Anne from the East: | Reply

*mark of genius i meant, not nark

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nice to see mention of hiki... (Below threshold)

January 15, 2010 7:41 PM | Posted by the0ther: | Reply

nice to see mention of hikikomori. i have been thinking about taking this route.

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It's times like this where ... (Below threshold)

January 16, 2010 4:37 AM | Posted, in reply to Jack Coupal's comment, by Anonymous: | Reply

It's times like this where I really wish people had my brain.

You get like me and then tell me depression isn't biologically real.

I'm pretty sure everyone out there who writes off depression probably never experienced the irrational, desperate misery first hand.

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Once I read the NYT article... (Below threshold)

January 16, 2010 12:12 PM | Posted by rath: | Reply

Once I read the NYT article, I knew you were going to write about it here. :)

Anyway, while reading it, I could not help but be reminded of the infamous Strasburg Dancing Plague of 1518. Whatever combinations have caused the medieval dancing manias, the cultural aspect of this issue appears obviously related.

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"depression isn't biologica... (Below threshold)

January 16, 2010 2:04 PM | Posted by Anonymous: | Reply

"depression isn't biologically real"
you need to get laid, biologically like any other healthy animal.

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Okay, well, describe depres... (Below threshold)

January 16, 2010 2:24 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Okay, well, describe depression biologically.

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It's slippery, but not unco... (Below threshold)

January 16, 2010 5:45 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

It's slippery, but not uncommon. People in sharp pain become depressed. People with arthritis. People with psoriasis. People with Lyme disesase. People who've had invasive surgery. These are all identifiable circumstances that most people can appreciate. Still, these situations evoke their mood depression through similar mechanisms, generally pronounced immune responses. What if this system is haywire for no traditional or visible reason? Depression in "whiners."

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Maybe depression is caused ... (Below threshold)

January 17, 2010 1:26 AM | Posted by information addict: | Reply

Maybe depression is caused by inflammation....an immune response...perhaps there is link to vitamin D deficiency.

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And, if those things are ca... (Below threshold)

January 17, 2010 1:35 AM | Posted, in reply to information addict's comment, by Anonymous: | Reply

And, if those things are causes, it's not a "psychiatric" illness. The DSM specifically rules out medical causes of depression, including, we can assume, neurological problems such as neurotransmitter deficits or abnormal frontal lobes.

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The rise of anoxeria in Chi... (Below threshold)

January 17, 2010 10:27 AM | Posted by SusanC: | Reply

The rise of anoxeria in China might be not just caused by adopting the Western idea of "anorexia" as an illness, but also by the adoption of other ideas or values that lead to anorexia in the West (e.g. that very thin women are considered attractive; that weight gain is considered a moral failing, akin to the sin of gluttony; combined with a diet that is likely to result in weight gain).

The DSM-IV seems to assume some rather strange beliefs that are likely not culturally universal:

e.g. That the mind is separate from the body, so that it makes sense to distinguish diseases of the mind from diseases of the body, and have separate professionals for dealing with them.
(Note how many DSM-IV definitions explicitly exclude cases where the symptoms have a known medical cause. For example "The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)". If someone discovered a biological cause for a patient's depressive symptoms, would the patient cease to have depression by definition?

This does not sit well with the belief (also widely held in the West) that "mental illnesses" have biological causes, such as genetic mutations.

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First off, I've been a foll... (Below threshold)

January 18, 2010 5:28 PM | Posted by MikeS: | Reply

First off, I've been a follower of your blog for sometime. I thoroughly enjoy it. :)

Going along with your article, I read something on the BBC claiming that by 2020 depression would affect more people than any other health problem. This screams improper criteria, or lack of cultural consideration. Yet, I feel surprise to see this not discussed more atleast in academic circles. My only exposure to this kind of thought is this blog and a book I read called, "Critical Psychology: an Introduction," which was fairly dated. I'm an undergraduate in psych and it's terrifying to think that my profs haven't mentioned anything along the lines that we're learning a "western psychology."

Please tell me things get better in grad school.

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"If someone discovered a b... (Below threshold)

January 19, 2010 2:29 PM | Posted, in reply to SusanC's comment, by Anonymous: | Reply

"If someone discovered a biological cause for a patient's depressive symptoms, would the patient cease to have depression by definition?"

Yes! It's hilarious isn't it? They'd either have an endocrine disorder, or neurological disorder, or nutritional disorder, etc.

Once a cause is known, it is no longer within the domain of psychiatry.

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