Crazy Like Us

You've probably heard about Crazy Like Us, the new book by Urban Tribes author Ethan Watters. But you probably haven't bought it yet. You really should.

Crazy Like Us is a vivid, humane, and thought-provoking examination of "the globalization of the American psyche" - the process by which, slowly but surely, the world has adopted America's way of thinking about mental illness.

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The key to the American approach is the 844-page Diagnostic and Statistical Manual of the American Psychiatric Association - the DSM, or as the saying goes, the Bible of psychiatry. The heart of the DSM is a long list of disorders, each with a code number, and each with an accompanying list of symptoms: Major Depressive Disorder (296.2), Post-Traumatic Stress Disorder (309.81), Schizophrenia (295.90), etc. The DSM is more than just a catalogue of names and numbers, however; it's part a conceptual system, a way of deciding what kind of feelings and behaviours are normal, and which are pathological; it's almost a philosophy of life.

On the most straightforward level, Crazy Like Us is the story of how, over the past 20 years, this system has gone from being American to international, displacing the ways of thinking found in other countries and cultures. In four chapters, Watters describes the rise of anorexia in Hong Kong, PTSD in Sri Lanka following the 2004 tsunami, schizophrenia in Madagascar, and major depressive disorder in Japan.

This much is plain fact. The DSM is now the internationally-recognized standard for psychiatric diagnosis; almost all academic papers in psychiatry make use of the American criteria, or the extremely similar ICD-10. What's interesting, however, is Watters' account of how the DSM spread so quickly to other countries, displacing what were - in many cases - equally rich and complex local vocabularies of distress and disorder.

In the case of Japan, Watters' answer is simple: the big drug companies, in the hopes of opening a new market for SSRI antidepressants, promoted the concept of clinical depression as a common ailment, through campaigns in the Japanese media. (Japan did have an "indigenous" concept of depression, utsubyo, but it was seen as a rare, serious disease, like schizophrenia.)

But in "developing" countries, such as Sri Lanka, the picture is rather more complex. Sri Lankans were eager to learn from the West about mental illness because of their respect for Western science and technology. Americans can put people into space - surely, they know a lot about everything, including medicine, including psychiatry.

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Yet there's another level to the story of Crazy Like Us, a more interesting and more controversial one. Watters' argues that the globalization of the American way of thinking has actually changed the nature of "mental illness" around the world. As he puts it:

In the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.

Essentially, mental illness - or at least, much of it - is a way of unconsciously expressing emotional or social distress and tension. Our culture, which includes of course our psychiatric textbooks, tells us various ways in which distress can manifest, provides us with explanations and narratives to make our distress understandable. And so it happens. The symptoms are not acted or "faked" - they're as real to the sufferer as they are to anyone else. But they are culturally shaped.


The historian of psychiatry, Edward Shorter, has written of how, in late 19th century Europe, people (mostly women) were said to be especially prone to suffering from "hysterical paralysis", but every time and place has its own shared "symptom repertoire". Culture does not just create symptoms out of thin air - there has to be some kind of underlying stress. As Watters puts it

We can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. ... Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening.

Watters links anorexia in 1990s Hong Kong to the anxiety caused by the impending transfer of control from Britain to China, a geopolitical event which caused personal worry and social disruption as people or families emigrated. But it was the high-profile 1994 case of a young girl's death from self-starvation, and the subsequent media attention paid to the Western concept of Anorexia Nervosa (DSM code 307.1), that put self-starvation into the symptom repertoire for distressed young women and led to the rise in cases.

The idea that America has exported not just concepts of illness, but illnesses themselves, is a provocative one. Is it true? Commentators have pointed out that Watters' explanation of the rise of anorexia in Hong Kong is rather simplistic. There were many social and cultural changes going on during the 1990s, most of which had nothing to do with the DSM. How do we know that increasing media promotion of dieting, and the fashion for thinness, wasn't also important? In truth, we don't, but I do not think that Watters' argument requires psychiatry to be the only force at work.

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Overall, Crazy Like Us is a fascinating book about transcultural psychiatry and medical anthropology. But it's more than that, and it would be a mistake - and deeply ironic - if we were to see it as a book all about foreigners, "them". It's really about us, Americans and by extension Europeans (although there are some interesting transatlantic contrasts in psychiatry, they're relatively minor.)

If our way of thinking about mental illness is as culturally bound as any other, then our own "psychiatric disorders" are no more eternal and objectively real than those Malaysian syndromes like amok, episodes of anger followed by amnesia, or koro, the fear the that ones genitals are shrinking away.

In other words, maybe patients with "anorexia", "PTSD" and perhaps "schizophrenia" don't "really" have those things at all - at least not if these are thought of as objectively-existing diseases. In which case, what do they have? Do they have anything? And what are we doing to them by diagnosing and treating them as if they did?

Watters' does not discuss such questions; I think this was the right choice, because a full exploration of these issues would fill at least one book in itself. But here are a few thoughts:

First, the most damaging thing about the globalization of Western psychiatric concepts is not so much the concepts themselves, but their tendency to displace and dissolve other ways of thinking about suffering - whether they be religious, philosophical, or just plain everyday talk about desires and feelings. The corollary of this, in terms of the individual Western consumer of the DSM, i.e. you and me, is the tendency to see everything through the lens of the DSM, without realizing that it's a lens, like a pair of glasses that you've forgotten you're even wearing. So long as you keep in mind that it's just one system amongst others, a product of a particular time and place, the DSM is still useful.

Second, if it's true that how we conceptualize illness and suffering affects how we actually feel and behave, then diagnosing or narrativizing mental illness is an act of great importance, and potentially, great harm. We currently spend billions of dollars researching major depressive disorder and schizophrenia, but very little on investigating "major depressive disorder" and "schizophrenia" as diagnoses. Maybe this is an oversight.

Finally, if much "mental illness" is an expression of fundamental distress shaped by the symptom pool of a particular culture, then we need to first map out and understand the symptom pool, and the various kinds of distress, in order to have any hope of making sense of what's going on in any individual on a psychological, social or neurobiological level. To put it another way, you need to understand people before you can understand psychiatry. After reading Crazy Like Us, I think I understand both a little bit better, and I strongly recommend it.

Links:

• Ethan Watters' Crazy Like Us blog.
  
• The Americanization of Mental Illness, Watters' much-read NYT article which is a fine summary of the book's argument, but being so short, misses much of the human detail which make Crazy Like Us so interesting, in particular when Watters is writing about the response of PTSD experts to the 2004 tsunami, and the life of a Madagascan woman with schizophrenia and her family.
  
• Exporting American Mental Illness, an excellent discussion of the article over at Neuroanthropology.
• Did Antidepressants Depress Japan? A 2004 article on the Japanese antidepressants and depression story.