Posts Tagged ‘Mental Illness’
Posted on February 12, 2010 - by David
The Children Formerly Known as Bipolar
According to an article I read on Wednesday, a new diagnostic category is expected to be included in the upcoming DSM-V which may provide psychiatrists with an alternative to diagnosing the most troubled kids they see with bipolar disorder. The creation of the new diagnosis, called temper dysregulation disorder with dysphoria, seems aimed at dealing with concerns over the growing prevalence of the lifelong, stigmatizing bipolar label among children.
Back in the 90’s, thanks largely to the work of one Dr. Janet Wozniak, an assistant professor of psychiatry at Harvard, the bipolar diagnosis was stripped of one of its most defining characteristics as professionals puzzled over what to do with children with ADHD who were prone to particularly persistent and disruptive outbursts. The traditional definition of bipolar was closely tied to the presence of alternating periods of mania and depression, but these kids rarely if ever experienced the typical episodic fluctuations. In order to make the new use of the diagnosis stick, some argued that in children, the episodes might be very brief and occur many times throughout the day. Critics of the extended application complained that “there wasn’t good evidence that these kids grew up to be bipolar, and that if you looked backward at bipolar adults, they didn’t necessarily have these uncontrolled anger issues when they were young.” Nevertheless, the pediatric bipolar diagnosis quickly spread, and Wozniak maintains this is “because it made clinical sense.”
The article suggests that part of the shift to childhood bipolar diagnoses may have been related to a desire to treat this kind of behavior as a disease which could be dealt with via medicine. The only other diagnostic option seemed to be conduct disorder, which usually wasn’t treated with medication and seemed to imply a parental failure. Now, with TDD, the behavioral and mood problems can still considered a medical illness, but those diagnosed aren’t necessarily lumped into a category of people required to take drugs for the rest of their lives.
What really struck me when reading this article was how the language used to talk about this stuff makes it so plainly obvious that these psychiatrists and researchers really don’t know what it is they are dealing with. First of all, the shift in diagnosis in the 90’s had nothing to do with any breakthrough discovery about how the brains of children with behavior problems function. Basically, the symptom-based definition of a particular mental illness was revised or expanded to fit the troubling phenomenon that psychiatrists were observing. That is not how science is supposed to be done. To quote the article: “research psychiatrists worried that the children were being given a label that wasn’t right for them, and saddled with the sentence of a serious mental illness for the rest of their lives.” A label? Is it an illness, or just a label? Does the naming of the thing determine its nature? And if people have a serious illness of any kind, doesn’t it exist independently of any “sentence”?
I find it strange that the word ‘label’ is used over and over again and there’s all this talk about categories or diagnoses being created and changed in order to deal with stigma and avoid offending parents, and yet these psychiatrists believe that whatever it is they are talking about is unquestionably a problem with the brain. I mean, isn’t the reason they can’t decide what to call it that they can’t pin down what is actually happening with these kids? I can’t help but shake my head when I read that “it will be seen as a brain or biological dysfunction, but not as a necessarily lifelong condition like bipolar?” How exactly did they determine that this is a biological dysfunction? Is it just the assumption that if symptoms are severe and difficult to manage, it must be a brain malfunction?
The article ends with the following two paragraphs:
Of course there is no way to predict what practical effects creating the TDD category might have. For instance, Carlson points out that even if they are successful at changing the label that clinicians use, it could be that the kids all get the same medications as before. “They may get many of the same. Absolutely,” she says. “But the difference is going to be that you won’t have to take this for the rest of your life.”
Carlson doesn’t necessarily see this as a bad thing. She emphasizes that these children have very serious problems, and though there’s been trouble naming it, there’s clearly some sort of dysfunction in their brain. Shaffer agrees. “I don’t think anyone is arguing that these are perfectly normal children that get the label [bipolar] — far from it,” he says. “We’re saying these kids are very sick. But they probably don’t have bipolar disorder. And they probably do deserve a name that adequately describes what they’re doing.”
I’m not arguing that these kids are “perfectly normal,” but I do take issue with the idea that a team of psychiatrists can create a new category and say without any evidence that the problem they are attempting to describe has its root causes in biological dysfunction. Am I the only one who finds this approach both arbitrary and dogmatic? I believe these kids deserve more than a name that fits their symptoms. They deserve an approach directed at understanding the nature and cause of whatever it is they are suffering from.
We still have another 3 years to go before the DSM-V is published. It will be interesting to see if this the unofficial diagnosis comes into common use before then.
Posted on February 9, 2010 - by David
Allan Horwitz on the Medicalization of Depression
A few weeks ago a friend of mine sent me a link to a podcast interview with sociologist Allan Horwitz, author of a book called The Loss of Sadness which looks at the medicalization of depression. If you’re going to listen to the podcast, skip ahead to 4:51, where the interview (which lasts about 20 minutes) actually begins.
at 6:50 into the podcast, Horwitz says:
… In the current environment, genetic explanations are, one, given tremendous credibility, so if you can link things to genes that somehow makes it more important explanation than linking them to life histories or linking them to social circumstances… and that’s a cultural phenomenon, [there’s] no reality that they’re more important… And the second important phenomenon, which I also think is purely social, is that if phenomena are linked to gene it makes them seem as if they’re disorders whereas in fact there’s genes for perfectly normal personality dispositions or there’s probably genes that make us grieve when somebody close to us dies, certainly doesn’t mean bereavement is a disorder, but that the cultural valence of genes associates them with mental disorders..
At first, I was happy to hear someone point out that the prominence of genetic explanations of mental illness is a cultural phenomenon, not a reflection that they are actually more important than other perspectives. However, I got more and more confused as I considered what Horwitz actually says in this interview. Let’s just look at the above statement piece by piece.
1. It is a cultural phenomenon that genetic explanations of mental illness are given such prominence. Ok, check, I follow.
2. Linking phenomena to genes makes it seem as if they are disorders. Ok, I think I’m still with you, but are you telling me they have succesfully linked specific genes to mental disorders?
3. There are genes for behavior which we would consider normal, such as expressing grief when someone close to us dies. Wait, so are you saying there’s a gene for everything I do? Have they even linked sarcasm in blog posts to genes?
Let’s look at another piece of the interview, at 12:36
Horwitz: Depression is probably one of the very few psychiatric illnesses that’s been recognized for thousands of years, so it’s certainly not something that’s a new condition. From the ancient Greek philosophers, through the renaissance period, through the early psychiatrists, even through Sigmund Freud and the DSM I and the DSM II – it had always been a contextualized illness so that the people who become sad or even intensely sad in contexts where we would expect people to be sad – the loss of intimates, diagnoses of a serious physical condition, serious economic difficulties- these sorts of things were always clearly distinguished from the mental illness of depression, which either arises with no context or persists longer than the original context in which it arose or features extremely severe symptoms- vegetative symptoms, hallucinations and delusions, these sorts of things.
Interviewer: So you’re saying that there’s been this historical legacy of seeing depression as a pathology only when it doesn’t fit the context, when it doesn’t fit the situation.
Horwitz: Precisely, the symptoms are identical but one is contextually appropriate and the other is without cause or without reason.
Now I guess I’ll have to read his book to see if he gives evidence for his claim that depression has been recognized for thousands of years and has “always been clearly distinguished” from normal, “contextually appropriate” sadness. (I will point out that all the examples he rattles off are clearly part of Western culture). It’s a bit confusing that he says the symptoms of “the mental illness of depression” are more severe than expressions of normal sadness, and then later says “the symptoms are identical” but in some cases they are not contextually appropriate. I do get the point he is trying to argue- that social and other contexts should be taken into consideration when making a diagnosis of depression- but I’m don’t think he’s being very clear or convincing.
He is critical of the emphasis on genetic explanations of mental illness because it confuses normal reactions to life with disorders, but at the same time he claims that the “the mental illness of depression,” where the symptoms are severe and not contextually appropriate, has been recognized for thousands of years. So his argument basically amounts to a claim that the prevalence of depression is greatly overestimated because context is no longer considered when diagnoses are made. But where does this leave us with regards to the real, true cases of depression? Apparently, context can help explain why some reactions aren’t disorders, but Horwitz says nothing about how cultural context can account for the phenomena which actually are disorders. In fact, Horwitz seems to inadvertently reaffirm the prominence of the biomedical/genetic account of mental illness. By essentially suggesting that phenomena which can be explained by social and cultural contexts are not actually disorders, he places the true, severe, undeniable forms of mental illness in a category which only biology and medicine can touch.
Posted on February 2, 2010 - by David
Fish Oil the Latest in Psychiatric Treatment?
This article summarizes the results of a study from the University of Melbourne, which suggests that the omega-3 fatty acids found in fish oil may help prevent psychosis in adolescents and young adults who have been identified as “at-risk.”
The study involved 81 individuals ages 13-25 “who met at least one of the following three criteria: having low-level psychotic symptoms; having transient psychotic symptoms; or having a schizophrenia-like personality disorder or a close relative with schizophrenia, along with a sharp decline in mental function within the past year.”
For 12 weeks, half the group was given fish oil capsules and the other half recieved placebo. Participants were then monitored for next 40 weeks. Only 2 of the 41 people given fish oil developed a psychotic disorder compared to 11 of 40 of the placebo group. The omega-3 group also “also showed significant reductions in their psychotic symptoms and improvements in function.” The researchers hope to replicate the findings in a multicenter trial involving 320 people.
Certainly, the lack of adverse side effects compared to the commonly used anti-psychotic medications would make this treatment a much preferred choice for patients. While these findings are definitely positive, it was a very small and relatively short-term study, so further research is obviously needed to determine the value of fish oil as a treatment or preventitive measure for serious mental illness. Also, this once again highlights how little is understood about what is happening in the brain of the schizophrenic patient. The article mentions some of the potential reasons this novel treatment may be effective:
There are a number of mechanisms through which omega-3s could protect the brain, Amminger said; they are a major component of brain cells. They are also key to the proper function of two brain chemical signaling systems, dopamine and serotonin, which have been implicated in schizophrenia. Fish oil also boosts levels of glutathione, an antioxidant that protects the brain against oxidative stress.
In the quest to understand the cause and progression of this illness, nearly every neurotransmitter and every part of the brain has been implicated in some way or another. While hopefully this study will lead to new ways of dealing with the symptoms of schizophrenia without the devastating side-effects of many commonly prescribed drugs, it seems to be another example of a “scientific” answer which amounts to, “this might work, and if it does, these might be some of the reasons why.”
Posted on January 29, 2010 - by David
Ethan Watters on the Daily Show
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The other night, Ethan Watters appeared on the Daily Show with Jon Stewart to talk about his new book, Crazy Like Us: The Globalization of the American Psyche.
At a little past 4 minutes into the clip, Stewart says:
We could make the argument that when we went over into parts of the undeveloped world with vaccines, and they thought we were poisoning them, you know, we weren’t, we were just trying to cure some diseases, why should we neccesarily give deference to something that might be a superstition, only because it has the value of “well it’s their culture” ?
Watters response echoes one idea which is central to the book: In our attempts to share medical knowledge and treatment with the world “we often bring cultural ideas that may be replacing ideas that actually are helpful in those other places…”
This answer glosses over the main difference between sharing vaccines and sharing treatments for mental illness: Our vaccines actually worked! And they are used to prevent illnesses which we actually understand! Unfortunately, Watters misses his chance to make a bigger point about differences in the nature of mental illness from culture to culture. Still, I think he’s doing a lot to shift the focus of the discussion towards cultural factors.
Posted on January 28, 2010 - by David
Crazy Like Us, Part 4: Depression in Japan
Chapter 4 – The Mega-Marketing of Depression in Japan
One of the main ideas in Ethan Watters’ book, Crazy Like Us: The Globalization of the American Psyche is obviously that the active exportation of Western conceptions of mental illness has had a largely negative effect of the expression of these illnesses in other cultures. Nowhere is his criticism of this process more evident than in the final chapter on depression in Japan. Watters shows how drug companies went about actively creating a market for their products by both determining effective, culturally specific messages and ghostwriting research studies which would give credence to their claims of the need for, and efficacy of the SSRI anti-depressants. But what I’m most interested in looking at in this chapter is the evidence that depression as we know it is still missing from Japan.
At the end of the chapter, Watters concludes that the “mega-marketing” scheme seems to have worked in terms of profit. In its debut year in Japan , sales GlaxoSmithKline’s Paxil (the main drug discussed in the chapter) brought in over a hundred million dollars. By 2008, less than ten years after it was introduced, sales had grown to over a billion. This kind of gives the impression that depression, or at least its treatment, is now nearly the same in Japan as in the U.S. However the results of one small, impromptu survey I’ve been a part of twice suggest that the prevalence of depression in Japan is still nothing compared to America. Once a few years ago, and again this past November, I was present in Liah Greenfeld’s modernity seminar at Boston University when professor Chikako Takeishi of Chuo University in Tokyo brought a group of her students to class as part of larger U.S visit to cultural sites and institutions. Greenfeld asked her American students if they were friends with someone who had been depressed, and every hand went up. She then asked how many of us had been depressed ourselves, and I’d say a third, if not more of us, (including myself), raised our hands again. The responses of the Japanese students were strikingly different. Out of about 20 students, I believe no more than 3 said they had friends who had been depressed, and none of them had been depressed themselves. These were our Japanese counterparts – university students from an industrialized and technologically advanced nation under as much, if not more, pressure to succeed than we were. Of course, a number of objections could be made regarding the methodology of our little study, but Watters book makes one thing clear: thanks in large part to the efforts of companies like GlaxoSmithKline, it was no longer possible for these students to be ignorant of what we were talking about when we used the word “depression.” They knew conceptually, but none of them knew intuitively, experientially, like we did, what it was to suffer from this illness.
One of the reasons depression might appear to be a problem in Japan is the cultural prominence of the melancholic personality type. While in the West, we associate melancholy with depression to such a degree that the two are almost synonymous, this is not so in Japan. The typus melancholicus was adapted into Japanese psychiatry in the 1960’s from a German professor named Hubert Tellenbach. It seems the idea caught on not as a result of any forceful marketing but because the description of this personality type corresponded to certain highly valued characteristics. As Watters writes, “its association with such prized Japanese traits as orderliness and high achievement meant that having such a sadness-prone personality was something not to be feared but aspired to” (208). Some have identified the importance of Buddhist beliefs about suffering as an explanation for the value placed on sadness in Japanese culture. So while on the outside, Japanese sadness may look like our depression, the difference seems to be that, for the most part, the Japanese experience is not maladaptive to the culture or a cause of dysfunction. Watters quotes professor Margaret Lock of McGill University, who believes that some experiences which we see as negative symptoms may actual serve to strengthen social ties among the Japanese:
Feeling sad and reacting sensitively to losses, particularly of loved ones, is an idea that has singular appeal in Japanese. The theater, a range of literature and indigenous popular songs, traditional and modern, positively wallow in nostalgia, sensation of grief and loss, and a sense of the impermanence of things. People cry freely (by North American and northern European standards) about separation and lost loved ones, but at the same time they seem to draw strength from these experiences, to tighten their bonds with those who remain living, and to reaffirm group solidarity (212)
While this tendency towards melancholy may account for some of the confusion, there is an even greater reason why many see the Japanese as a deeply depressed culture: the astounding suicide rate. I agree with Watters, who writes that “most Americans would certainly assume that suicidal acts are nearly always caused by mental illness, most commonly depression” (218). The Japanese, though, have a long cultural history of suicide for reasons other than what we might expect. Watters references psychiatrist Masao Miyamoto, who has argued against the notion that the rise in suicide is related to depression. “A peculiarity of the Japanese is that they often die for the sake of the group,… They die for shame” (219)
In his classic study on suicide, sociologist Emile Durkheim identified altruistic suicide as one of three definitive types of suicide. In contrast to egoistic suicide, which results when society is not well-integrated and is unable to hold the individual members together, altruistic suicide occurs when the individual is so totally absorbed in the group that his own life loses value. A suicide “for the sake of the group” falls into the altruistic category. We can see in the story of young Oshima Ichiro, (featured prominently in this chapter), how excessive social integration and lack of individual identity can lead to suicide. In 1990, Ichiro, 24, joined the Dentsu advertising agency, which Watters describes as “the largest company of its kind in the world” (214). The Japanese market was in the midst of a dramatic economic downturn, while only a few months earlier it had been the envy of the world. By Watters’ description, Ichiro pretty much handed his life over to the company. Apparently, he was working an average of 47 overtime hours a week, though interestingly, based on his time sheets he only averaged 12 to 20 hours overtime. This suggests to me that he saw it as his duty to put in the time necessary to help his company succeed without demanding excessive compensation. Also, it seems the treatment he received at work was by American standards far below acceptable. Watters writes:
At one late-night drinking binge at the office, Oshima’s boss poured beer into his own shoe and demaned that Oshima drink it down. When he momentarily refused the request, his boss beat him. (216)
Also striking is the fact that an hour before his family found him hanging in the bathroom, Ichiro called the office to tell them he was sick and wouldn’t be making it in. Obviously his identity had been completely absorbed by the Dentsu advertising agency. Even in the moments before his death he could not forgo his duty to at least notify the company that he would be absent that day. While many American identities are wrapped up in work, Oshima Ichiro’s identity belonged to the company that employed him, and I believe this is an important difference. Perhaps the most typical question asked when two Americans meet for the first time is ‘what do you do?’ , and we all understand that this means ‘what do you, as an individual, do for work?’ While our identities are linked to our individually chosen pursuits, it seems for the Japanese, identity is much more about who you are connected to. For Ichiro, failure would not be merely personal, it would mean letting all the other members of his company down, as well as his family and society as a whole.
While I’ve tried to show that suicide in Japan is not necessarily the result of depression, there are ways in which it may be related to modern societal changes. The third type of suicide which Durkheim mentions, anomic suicide, is caused by a lack of regulation in society. While this type is closely related to egoistic suicide, (and Greenfeld’s definition of anomie goes a long way towards reconciling the two into one), Durkheim focuses much of his discussion of anomic suicide specifically on lack of economic regulation. It seems likely that the huge economic swings related to competition in the global marketplace introduced a new level of stress to the Japanese workforce, further augmenting the cultural tendency towards suicide. For centuries, the Japanese have been dying for shame and the sake of the group, and their marriage to the modern economy seems to be a deadly union.
These two articles from the New York Times archives give some relevant background information on the topic of depression in Japan, as well as introduce what I see as one of the major problems with the whole discussion of depression in general. The first I believe is representative of the “depression is a serious brain disease” camp, while the second tends towards the “we have medicalized sadness” stance. For some reason, it seems that the implied middle view- the possibility that something is indeed seriously wrong, but the root causes of the problem are not simply biological or genetic- hardly even exists in the discussion. I guess I’m trying to do what little I can to change that.
Posted on January 24, 2010 - by David
Crazy Like Us, Part 3: Schizophrenia in Zanzibar
Chapter 3- The Shifting Mask of Schizophrenia in Zanzibar
In the first two chapters of Ethan Watters’ new book, Crazy Like Us: The Globalization of the American Psyche, we encounter the idea that differences in source of identity and social integration between cultures may account for differences in the expression, (and prevalence), of mental illness. The third chapter suggests that cultural differences may also explain the rather enigmatic finding that those diagnosed with schizophrenia in the “developing” world seem to fare better than their Western counterparts. I found anthropologist Juli McGruder’s case studies particularly interesting, as they raise the possibility that the cause, or at least trigger, for schizophrenia may lie in cultural conditions.
I think it’s worth noting, as Watters points out, that despite the privileged position science has been given in the study of schizophrenia and all the technological advances of the last few decades, we still know very little about the causes of this strange affliction.
More than any other mental illness in the Western world, this one belonged to the “hard scientists” who looked for the causes in bad genes, biochemistry, and the structure of the brain. The advent of brain scans – allowing a researcher to see into the head of live patients – brought with it a seemingly endless series of theories about the root cause of the illness. Abnormalities supposedly key to schizophrenia have been reported in the frontal cortex, the prefrontal cortex, the basal ganglia, the hippocampus, the thalamus, the cerebellum – and pretty much every other corner of the brain as well. No firm consensus had emerged about the location or cause, but there was wide agreement that the exciting advances in understanding the disease were coming from the laboratories of brain researchers.(134)
In the meantime, there are others like Juli McGruder who, (like sociologist Liah Greenfeld), believes that “culture and social setting play a more complicated role in the disease than simply influencing the content of the delusions.” (136) Scholars on the cultural side of the fence point to the results of two international studies by the World Health Organization. The WHO research, which began in the 1960’s and lasted 25 years, suggests that the severity of schizophrenia is not the same worldwide. Watters summarizes the findings:
What they found was that those diagnosed with schizophrenia living in India, Nigeria, and Colombia often experienced a less severe form of the disease (had longer periods of remission and higher levels of social functioning) than those living in the United States, Denmark, or Taiwan. Whereas over 40 percent of schizophrenics in industrialized nations were judged to be “severely impaired,” only 24 percent of patients in the poorer countries ended up similarly disabled. (137)
Liah Greenfeld believes that anomie, which she considers a built-in feature of modern culture, causes problems with identity formation which often lead to mental illness. In Nationalism and the Mind, she describes this phenomenon and its effects on individuals:
Anomie, commonly translated as “normlessness,” refers to a condition of cultural insufficiency, a systemic problem which reflects inconsistency, or lack of coordination, between various institutional structures, as a result of which they are likely to send contradictory messages to individuals within them. On the psychological level anomie produces a sense of disorientation, of uncertainty as to one’s place in society, and therefore as to one’s identity: of what one is expected to do under the circumstances of one sort or another, of the limits to one’s possible achievement… (14)
The chronic, modern state of anomie may not (yet) be a built-in a feature of Zanzibari culture, but when we use the word “developing” to describe a country or culture, we imply that they are developing into something more like us, i.e moving towards modernity. This process of modernization is necessarily anomic:
Anomie, is, in fact, the ultimate cause of cultural change. It both breaks the old cultural routine and encourages the formation of a new one. The general pattern of human history can be imagined as an alteration between relatively brief and rare periods of widespread (though culturally localized) anomie and cultural routine. Widespread anomie, most commonly implying gross inconsistencies between elements of culture impinging on individual identities, specifically inconsistencies within the system of social stratification which defines a person’s position in the social world in general and vis-à-vis particular others, affects large groups of individuals and expresses itself in social turmoil. (14-15)
I wasn’t surprised, then, to see the title ‘Revolution and Madness’ above the section introducing McGruder’s first case study. Watters describes the state of affairs in the country at the time when Hemed began to experience symptoms of schizophrenia:
After years of being a British colony, Zanzibar embarked on the uncertain path to self-governance. There were three political parties, twenty-two trade unions, and sixteen partisan newspapers stirring up anger and resentment on all sides. Hemed’s first experience of derangement, McGruder believes, was sparked by the social upheaval of the time. (142)
Given what was going on in that moment in the history of Zanzibar, the amount of stress felt by Hemed must have been intense. He was a middle-class man from a high-profile Arab minority at a time of growing racial and class distrust. His curly dark hair and facial features made him identifiably Arab. There seemed to be no safe political refuge. Even the political party he belonged to, the Zanzibar Nationalist Party, was internally split between those who considered themselves African and those of Arab heritage. No one knew whom to trust. (143)
We can also see how conflicting cultural messages may have played a role in the experience of Kimwana, Hemed’s daughter who suffered from the same illness.
She was a happy child even though her early years were turbulent times for the island. Her mother and classmates remember her as the brightest student in the class. Particularly skilled with numbers, she graduated from secondary school and took a job with the Ministry of Finance. This was 1983, a time of rapid change for women on the island. To fill in for the many educated men who had fled the political upheaval, women were beginning to enter the professional workforce by the thousands. (144)
While we in the West would see these new opportunities for women aa a change for the better, there still existed traditional guidelines on behavior which seemed to contradict this elevation in social status. It was only a few months after Kimwana started her new job that she began to hear male voices “gossiping that she was a disloyal and disrespectful daughter and sister” (146). Before the cultural changes which led to an influx of women into the workplace, Kimwana’s identity would have been based primarily on her relationship to her family and in behaving according to the prescriptions of the Islamic religion.
Much of the torment of having these male presences in her head related to Islamic rules of female modesty. While the voices were with her, she felt she must respect the codes of conduct as is she were actually in the presence of a man. At such times she could not bathe or undress and she tried not to go to the bathroom. Although she sometimes found it helpful to argue with the voices when they became critical, her sense of decorum made it difficult to do this out loud. (146-147)
In this section of the chapter, Watters highlights McGruder’s amazement at the ability of Amina, the mother and effectively the head of the household, to care for the large family and its two sick members. Her daily activities seem to far surpass western notions of busyness, and she takes the extra load created by mental illness in stride. This is possible, I believe, because she is secure in her identity in a way that neither Hemed nor her daughter Kimwana could be. She was raised to serve her family and God, and that is what she does. McGruder compares the Western, Christian attitude towards adversity to Amina’s stance and sees an importance difference.
In the cosmology of Western Christians, life’s challenges provide opportunities to become stronger and to have a closer relationship with God. The burdens God sends to Christians in the Western world are incitements to self-improvement. The comforts that Amina found in her religious belief, by contrast, were not in an encouragement to overcome or learn from hardships. Rather, simply accepting her burden was a continuous act of penance. (155)
In other words, the challenge of caring for her sick relatives did not provide a reason to change her identity. Her identity was essentially unchanged since childhood, she was merely to continue behaving and believing as she always knew she should. Unfortunately for her daughter, the conflict between the new cultural value of work for women, and the traditional emphasis on family and religion proved too much for her mind to handle.
The chapter also describes the damage often done by family members’ emotional over-involvement in the lives of their schizophrenic loved ones. This cultural tendency, according to Watters, is closely related to the Western emphasis on individual identity and the belief that individuals should be able to control their own destinies. As in the previous two chapters, the resounding message is that the highly individualistic nature of identity in modern societies and the lack of clear, shared cultural beliefs and practices lead to more widespread and more severe forms of mental illness.
Posted on January 22, 2010 - by David
Crazy Like Us, Part 2: PTSD in Sri Lanka
Chapter 2 – The Wave that Brought PTSD to Sri Lanka
In chapter 2 of his new book, Crazy Like Us: The Globalization of the American Psyche, Ethan Watters describes the wave of research and treatment professionals that swept in to Sri Lanka in the wake of the 2004 tsunami, hoping to both heal and study the abundance of psychologically scarred people they expected to see. According to the varying estimates of experts quoted in news articles, anywhere from 15 to 90 percent of the population might be suffering from post traumatic stress disorder.
And did they find this many Sri Lankans suffering from what we call PTSD? The answer seems to be no, but the certainty with which Western professionals entered the supposed psychological disaster zone seems to have made it hard for them to accept what they found. Watters cites the example of a trauma counselor interviewed on BBC radio who was worried by the fact that the children in the village he was working in were more eager to get back to school than to talk about their frightening experiences. His explanation was that they were “clearly in denial.” (77)
Watters is obviously critical of this dogmatic belief that all minds in all cultures are equally susceptible to mental illness. The idea, introduced in the first chapter on anorexia and further developed here, that more traditional cultures do not suffer the way that Westerners do, deserves special attention. By providing meaning and identity through religious beliefs and closely integrated social groups, it seems that traditional cultures avoid the specifically modern forms of mental illness that many in the West assume to be universal. In her research following the tsunami, Dr. Gaithri Fernando, a psychology professor at Cal State University and a native of Sri Lanka, found that in place of the psychological symptoms westerners would expect to see, many who lost loved ones and homes experienced physical symptoms of aches and muscle pains. Without the Western, dualist conception of mind-body split, it seems Sri Lankans felt the pain of loss in their bodies rather than their minds.
As Watters points out in the first chapter, specifically modern forms of mental illness seem to be related to the importance of individual identity and independence in Western societies. Dr. Fernando’s research suggests this difference is key to understanding the conspicuous absence of PTSD.
… Sri Lankans tended to see the negative consequences of an event like the tsunami in terms of the damage it did to social relationships. Those who continued to suffer long after a horrible experience, her research showed, were those who had become isolated from their social network or who were not fulfilling their role in kinship groups. In short, they conceived of the damage done by the tsunami as occurring not inside their mind but outside the self, in the social environment. (91)
If social integration and strong cultural beliefs are key to protecting the individual mind from turmoil, then the lack of these would presumably lead to problems. In looking at where the PTSD diagnosis began, Watters goes back to the Vietnam War and the difficulties of many soldiers upon returning home. “Beliefs that had sustained many of their fathers in World War II were suddenly insufficient and meaningless to these soldiers,” he writes (121). I believe this cultural insufficiency may help to explain why an estimated 300,000 American veterans of the wars in Iraq and Afghanistan are now suffering from PTSD.
In a study published this week in the Journal of Neural Engineering, researchers at the Minneapolis VA Medical Center expressed excitement upon finding that by scanning the brain using magnetoencephalography (MEG), they were able to confirm with 90% accuracy the PTSD diagnoses of 74 American vets. The article that summarizes the findings states that “the ability to objectively diagnose PTSD is the first step towards helping those afflicted with this severe anxiety disorder.” However, all the study did was confirm “objectively” that the “subjective” diagnoses of these soldiers were already fairly accurate. Brain scans do little to explain why veterans today seem to be suffering psychological battle scars at a much higher rate than ever before in U.S history. Could it be the lack of strong cultural belief in what they are doing over there? The ambiguity of the enemy? The possibility that many of these young veterans may have chosen the identity of soldier not merely because of pride and patriotism, but because other paths in life seemed closed to them? The fact that despite the horror of war, the social integration provided during active duty surpasses what they might experience at home? The lesson to be taken out of Watters chapter on PTSD seems to be that the suffering of these veterans cannot be explained by some scientific correspondence between brain malfunction and the horrific events they witnessed and experienced. Is it crazy to think that the inability of American culture to provide a solid identity for soldiers that holds up at home as well as abroad, and the contradictory messages that simultaneously value and vilify the work that they do might be partly to blame for the widespread mental devastation?
A brief article in which Watters highlights some of the main points of this chapter was written in 2007 and is available here.
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 19th century and notes the increase in number of cases and homogeneity of symptoms as the new illness gained recognition. He also sees the 20th 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?
Posted on January 12, 2010 - by David
Is America’s Idea of Mental Illness Making the World Sicker?
A friend of mine sent me a link to this New York Times article by Ethan Watters, The Americanization of Mental Illness. Watters is critical of the way the American understanding of mental illness, (the biomedical model which treats mental illness as a disease like any other) , has been exported to nations around the world, stamped as scientific fact, and been deemed the only reasonable, modern way to understand these distressing phenomena. He argues that mental illness is not the same in every culture and time period, and that by spreading our interpretation of it, we are making the world sicker:
“For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that 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. Indeed, a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.”
He cites examples from around the world where the expression of a mental illness has visibly changed after exposure to the western understanding. While Watters doesn’t deny the reality of these illnesses, he wants to bring culture back into the discussion. He seems to believe that the introduction of a new “symptom repertoire” changes the possibilities of how an illness can be expressed:
“This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.”
While I would agree that exposure to modern American culture is likely to change the way mental illness appears in a particular culture, I think Watters is claiming that it is the American interpretation more than American culture itself that is causing the changes. Still, Watters accurately points out that historically, mental illnesses have not been the same culture to culture, or even within the same culture over time. He refers to research which shows that “people with schizophrenia in developing countries appear to fare better over time than those living in industrialized nations.” I think this gets to the heart of the matter:
“These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.”
This kind of data seems to confirm Liah Greenfeld’s hypothesis. She believes that modern culture interferes with the process of identity formation and in turn, causes mental illness. Some of the people involved in the research Watters refers to believe that the higher degree of social integration in developing nations may aid in preventing relapse of illness. The contrast between the source of identity in more traditional societies, (more closely integrated social groups which provide meaning), and American society (the view that “individuals are captains of their own destiny”) is brought to the forefront of the discussion. Watters ends the article lamenting that “when we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the worlds distress.”
Ethan Watters new book, Crazy Like Us: The Globalization of the American Psyche, is in stores today.
Posted on December 15, 2009 - by David
Remember the depressed bouncing egg commercials?
Note the narration:
“While the cause is unknown, depression may be related to an imbalance of natural chemicals between nerve cells in the brain.”
and then…
“Zoloft: when you know more about what’s wrong, you can help make it right.”
I’m left amused and a bit confused.
Exploring modern culture and its effects on the mind