Troubled minds: madness and culture
At the florid heights of their illness, many people with schizophrenia believe that the voices on the radio or television are speaking to them personally. But is this experience of madness universal, especially in places where there is no TV? A growing network of psychiatrists argue that culture is key when diagnosing a troubled mind.
Imagine experiencing extreme fear that you're going to die, convinced that your penis is shrinking and receding into your body. In Malaysia and China, to suffer from this condition, called Koro or Suo Yang, is a terrible plight for a man. In 1967 an epidemic of this disturbing condition in Singapore goes down in the history books as one of the more bizarre of its time.
In India men suffer from another penis-centric anxiety called Dhat or Jiryan. This distressing syndrome is marked by an acute anxiety about the loss of semen.
In Japan, taijin kyofusho is not an uncommon problem. It's a deep fear that one's body is offensive to others in appearance, expression or odour.
In Australia and many other parts of the world, skeletal young women defiantly continue to starve themselves because they think they're too fat. Their condition is well known as anorexia nervosa.
Koro, Dhat, taijin kyofusho and anorexia nervosa have all been described by various commentators as "culture-bound syndromes". Anthropologists and psychiatrists alike have long been fascinated by such curious behaviours, apparently unique to different cultures and locales.
But how are we to make sense of conditions like these? The label of 'culture-bound' has itself attracted considerable controversy. Some argue that it imperialistically establishes a divide between the exotic and the familiar, between 'us' and 'them'.
Are "syndromes" like Koro or Dhat a sign of real illness or pathology? Or are they simply idiosyncratic behaviours and beliefs, validated by the culture in which they're experienced? Could they even serve particular social functions in this context?
As it turns out, traditional Western psychiatry may not offer us the most suitable lens through which to look for answers to these complex questions about culture, medicine and mental health.
What's your neurosis?
Health professionals the world over consult a book called the Diagnostic and Statistical Manual of Mental Disorders, more commonly known by its abbreviated name, the DSM-IV. This epic 'bible' of the mind, first published by the American Psychiatric Association in 1952, is now in its fourth edition and classifies all known mental disorders.
Most people agree that the DSM-IV represents a major achievement of contemporary psychiatry and medical science. It's a document compiled from considerable empirical research data but it has also become one that is highly politicised. It's most vocal critics claim that it has been hijacked by the commercial needs of the medical insurance and pharmaceutical industries, rather than those of patients and their doctors
The DSM-IV sets the benchmark for what is considered to be normal and abnormal behaviour, and therein lies a fundamental criticism of its approach. It could be argued after all, that what's considered normal is ultimately subjective - it depends on your point of view and this in turn is also defined by the culture in which you live.
Take the hypothetical case of a 20 year old Anglo man in Sydney, Australia. He washes his hands for hours a day, concerned that he is picking up germs from everything he touches. It's making his life unbearable. His suite of symptoms point to a diagnosis of Obsessive Compulsive Disorder (OCD), according to the DSM-IV.
What about the immigrant woman who lives next door? She carries out rituals such as repetitive praying, washing and ordering objects - but no one can work out why. The local doctor thinks she has OCD as well, despite her behaviour being sanctioned by her own culture as important religious practice.
Despite its critics, the DSM-IV makes the job of your local shrink a whole lot easier, offering them a handy armory of universal labels and symptoms that they can apply to their patients, independent of what language they speak and where they live. This is science at its objective best - or is it?
It begs the question - just how universal is the experience of a troubled mind?
The globalisation of mental illness
A number of the culture-bound syndromes, such as Koro and Dhat, have made it into the DSM-IV. Though relegated to the appendix, some believe this represents a significant step towards acknowledging the cultural specificity of mental illness. Others argue that a more radical rethink is needed to improve the cultural sensitivities of those trained in the Western psychiatric tradition, in how they handle all presentations of mental illness.
"My own perception is that classification has become an industry. So many categories have been manufactured", says Dr R. Raguram, professor of psychiatry at the National Institute of Mental Health and Neurosciences in Bangalore, India. "There has been a growing need to universalize psychological distress, and people from developing countries feel the need to be universal too".
Putting culture back into psychiatry
Raguram is part of a growing movement of psychiatrists worldwide who work under the banner of "transcultural" or "cultural psychiatry", and take an interest in the social and cultural influences on psychopathology and treatment. Australia, by virtue of its multicultural makeup, is acknowledged as a leader in the field.
"A person with schizophrenia may have hallucinations and delusions irrespective of the cultural context", Raguram acknowledges. "But the experience for the individual and their family, and the kind of understanding they bring to their suffering, will differ according to the social and cultural context in which they are immersed.
Another strong indicator that culture is key to the experience and expression of mental illness, are the now famous research findings that the prognosis of schizophrenia is more favourable (shorter term, less florid symptoms) in developing and pre-industrial nations like India. A greater acceptance of difference, and traditional beliefs about illness and care, are thought to play a role here.
Despite the scientific quest to universalise the experience of mental illness, the devil remains in the cultural detail. For example, as you'd expect in places where television is a rarity, schizophrenic delusions are often solely attributed to spirits, ghost possession or black magic, rather than the voice from the flickering box in the corner - and this can redefine the whole experience of illness and suffering. In the small rural villages of India, where people seek healing in temples rather than in a doctor's surgery, this is not uncommon.
India provides an interesting case study. There are only 3500 psychiatrists in India, little more than 3 per one million people (compared to 100 per million people in Australia). Psychiatry in this vast and vibrant country that sustains 1/6th of the world's population, is essentially a post-colonial phenomenon. "The discipline only emerged in the British era, and a generations of psychiatrists have been groomed on British and Western textbooks", Dr Raguram says.
Depression in India
Until the 1970s the popular belief was that depression was a rare occurrence in India
Mumbai based social psychiatrist Dr Harish Shetty, paints a different picture. "We have a growing population with depression because of loneliness, lack of meaning, connectivity, and employment. We have a large number of people who are on the brink of suicide. We are seeing the age of onset of all mental illnesses going down very rapidly. It's going to become a very big problem in India", he says.
If the Global Burden of Disease project (WHO, 2001) is anything to go by, major depression will be the leading cause of disease burden in the developing world by 2020.
The failure to acknowledge depression in India before the 1970s is now seen as the fault of blinkered anthropologists from the West. "It was always the Western-trained white man who went into developing countries and examined depression using his own biased frameworks", says Raguram. "Depression as anchored in the sadness of everyday life is universal."
He argues that the biomedical understanding of depression is not sufficient to understanding sadness in all its local meanings.
Today it is understood that Indian people will often reveal depression through talking about physical aches and pains, so-called somatic symptoms. Raguram's research indicates that Indians articulate their sadness using their own cultural nuances, which may go unrecognized if left unprobed.
"We came across so many different methods of expressing sadness which were very revealing, especially of the various shades of meaning ascribed to it", he says.
For example the Buddhist notion of Dukha - is not just sadness, but a kind of spiritual suffering, that is preordained and expected. Unlike depression, Dukha has no negative connotation. Rather it's an experience that is considered one you must go through, a responsibility.
Yet another Indian word, Bejari, is used to describe a sense of sadness tinged with boredom. "So there seems to be a richness of vocabulary to articulate the inner states of feelings like sadness in all the Indian languages", suggests Raguram.
Psychiatry - a changing practice
"We have to go beyond surface representations of illness, and examine local understandings. You can diagnose according to a universalistic framework, but your interventions have to be contextualised", says Raguram. "You have to listen closely to patients, families and their own personal beliefs and tailor the treatment. Otherwise psychiatry will have an alienating affect in developing countries".
Dr Harish Shetty agrees. "Psychiatrists who are obsessed with molecules and medicines will be outdated in the 21st century. As psychiatrists we need to understand the idioms of the people, and their language, we must be rooted in the culture".
It's a matter of looking through the right cultural lens. And this is a challenge that Indian psychiatrists like R. Raguram and Harish Shetty would like their colleagues worldwide to take on. After all, culture is an influence everywhere, not just in the developing world.
So where to for the future of psychiatry?
Laurence J Kirmayer and Harry Minas, both leaders in the field of transcultural psychiatry, write in the Canadian Journal of Psychiatry, "the ongoing "biologization" of psychiatry has made culture seem mere window dressing. On this view, what lies at the base of all psychiatric disorder is some brain dysfunction, and biological research will eventually uncover the brain circuit or the variant gene that accounts for the problem. Yet biology also teaches us that we are fundamentally cultural beings".
The message here is that psychiatrists needn't be fearful that giving thought to cultural issues will somehow weaken the scientific basis of what they do. "The nervous system is inscribed with our history of socialization and cultural learning...There are human problems that are constituted by our way of life, and solutions can be found not in the physiology of the brain, but in the ways of life, values, and commitments that people choose as they navigate a world that is socially constructed in a very literal sense", argue Kirmayer and Minas.
Science is unraveling the mysteries of the mind and brain - both in wellness and sickness - at a staggering pace. These are exciting times, and as a guidebook to the troubled mind, the DSM-IV may well be the best that science has to offer for now. But without culture embedded deeply in its text, it will not stand-up as a universally useful resource.
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L.J Kirmayer, H. Minas, Cultural Psychiatry: An International Perspective, Canadian Journal of Psychiatry, June 2000
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Raguram et al. Traditional community resources for mental health: A report of temple healing from India. British Medical Journal (BMJ), 2002; 325:38-40 (6 July)
Bhargavi V Davar. Mental Health of Indian Women: A Feminist Agenda, Sage Publications, New Delhi, 1999
Natasha Mitchell travelled to India with the support of a grant from the Australia-India Council.
Published 13 March 2003