Posted on January 21, 2010 - by David

Crazy Like Us, Part 1: Anorexia in Hong Kong

Last week, after reading Ethan Watters’ article in the New York Times, I picked up his new book, Crazy Like Us: The Globalization of the American Psyche. The basic argument goes something like this:

• Mental illness is not the same in all cultures, nor has its expression remained constant within individual cultures over time.
• Because of the importance of science in Western culture, the biochemical disease model of mental illness is now accepted, almost without question, as scientific fact.
• The Diagnostic criteria that come from the DSM definitions of mental illnesses have been aggressively exported to “developing nations,” effectively changing the cultural expression of mental illness and eroding local modes of healing.
• Despite all our science and wealth, sufferers in more traditional, less “developed” nations still seem to fare better in terms of course and severity of illness than we Americans do. It seems that the particularly American “hyperindividualism” and the lack of meaningful social integration do not make for healthy minds.

The book has four chapters, each treating a different mental illness in a different culture. Anorexia in Hong Kong, PTSD in Sri Lanka, Schizophrenia in Zanzibar, and Depression in Japan. All four chapters raise important questions about the relationship between mental illness and modern culture, so I’ll be devoting a post to each one.

The Rise of Anorexia in Hong Kong

I find it particularly interesting that despite the prominence of the biomedical explanation of mental illness, the commonsense understanding of anorexia implies that culture is to blame. As Watters writes:

Most assume that anorexia, with its attendant fear of fatness and body dysmorphic disorder, is born of a peculiar modern fixation with a slender, female body type, and that popular culture transmits this fetish to young women. (11)

While Watters points out that in many ways, Hong Kong was already primed with Western culture and its attendant messages about body image, as of the 1980’s, cases of self-starvation were extremely rare, and the specifically Western version was nowhere to be found. Watters’ main source for the chapter, Dr. Sing Lee, found that the few women he encountered who were unwilling to eat knew that they were underweight and expressed no fear of getting fat. Instead, they tended to complain of stomach pain and sadness.

So when did anorexia as we know it appear in Hong Kong? Watters and Dr. Lee trace this back to the highly publicized death of Charlene Hsu Chi-Ying, a skeletally thin 14-year-old girl who dropped dead on a busy Hong Kong street in November of 1994. In attempting to understand and explain what went wrong with Charlene, “Chinese reporters looked to Western sources and experts,”  and the culture was quickly infused with the language of the DSM and the Western “symptom pool” of anorexia.  Informative campaigns were soon launched, and new, western-looking cases of anorexia began showing up more and more frequently at doctors’ offices.

Clearly, Watters is attempting to demonstrate how the introduction of an official diagnosis and all its attendant symptoms has a direct impact on the way an illness is expressed. He traces the development of the “anorexia nervosa” diagnosis in the late 19^th century and notes the increase in number of cases and homogeneity of symptoms as the new illness gained recognition. He also sees the 20^th century feminist movement and highly publicized celebrity cases of anorexia as expanding the reach of this disorder. Watters turns to medical historian Edward Shorter to explain why a cultural awareness of a new disease model actually shapes the experience of individual sufferers:

People at a given moment in history in need of expressing their psychological suffering have a limited number of symptoms to choose from – a “symptom pool” as he calls it. When someone unconsciously latches onto a behavior in the symptom pool, he or she is doing so for a very specific reason: the person is taking troubling emotions and internal conflicts that are often indistinct or frustratingly beyond expression and distilling them into a symptom or behavior that is a culturally recognized signal of suffering.

If it is true that the way distressed individuals express their suffering is influenced by modern, Western cultural models of mental illness, my question is, what is causing the number of distressed individuals in places like Hong Kong to grow? I believe the evidence Watters gives in this chapter begins to hint at the answer. He references the work of Clark University professor Jeffrey Jensen Arnett, who sees the Western emphasis on individual identity and independence as the primary cause of the turbulence of adolescence:

“If it is true that cultural values of individualism lie at the heart of adolescent storm and stress,” Arnett concludes, “it seems likely that adolescence in traditional cultures will become more stormy and stressful … as the influence of the West increases.”(40)

Watters again turns to Dr.Lee, who “believes that stress from the rapid social changes occurring in Hong Kong led to a “general loading of psychopathology” within the population.”(52)

This “stress from rapid social changes” fits Liah Greenfeld’s definition of anomie. As Hong Kong experienced these modern changes, traditional sources of identity were weakening, resulting in a condition of cultural insufficiency. Greenfeld’s work on mental illness suggests that problems with identity formation are caused by this chronic condition of cultural insufficiency, (anomie), which characterizes modern culture.

Therefore, it seems Watters might agree that as a culture moves towards modernity, the number of people experiencing crises of identity which ultimately result mental illness will increase. The question that remains for me is, in determining the source of specific expressions of mental illness in “developing” nations, how can we separate the influence of the introduction of Western diagnostic models from the influence of modern culture in general?

part 2

part 3

part 4