Anyone who follows psychiatry has noticed that the field is now in the midst of a debate that galvanizes its members every 10 to 20 years. At the center of the hubbub is psychiatry’s most sacred text: the Diagnostic and Statistical Manual of Mental Disorders.
The DSM, for short, is a compendium of over 350 ways our minds can fail us, from autism to kleptomania to voyeurism. What makes it onto the list matters: The DSM’s definition of “mental illness” can dictate whether an insurance company covers a treatment, or even whether a murderer is fit to stand trial. With the American Psychiatric Association gearing up to revamp the manual for the first time since 1994, mental health specialists have begun jostling over some of the most divisive issues in the field: whether someone mourning the death of a loved one can be justifiably treated for depression, for instance, or whether overdiagnosis and a black market demand for Adderall have trumped up a false ADHD epidemic.
And then there’s the back of the book.
If you turn to page 898 of the current edition — past the glossary and the alphabetical index of diagnoses — you’ll find a list of 25 little-known illnesses. These are the “culture-bound syndromes”: mental illnesses that psychiatrists officially acknowledge occur only within a particular society. Take, for instance, susto — a distinctly Latin American fear that one’s soul has panicked and left one’s body. Or pibloktoq, also known as “arctic hysteria,” in which Greenlandic Inuit strip off all their clothes and run out into the subzero Arctic tundra.
Depending on whom you ask, the notion that some cultures have their own ways of going crazy is either the ultimate in cultural sensitivity or the ultimate in Western condescension. And although these syndromes haven’t attracted nearly as much attention as Asperger’s or binge eating disorder, they are starting to come under fire from critics who don’t think that the appendix belongs in the book at all. Since the last edition of the DSM, in lectures and research journal articles around the world, a cluster of psychiatrists, anthropologists, and historians has attacked the validity of specific disorders on the list. To these critics, the very notion of a “culture-bound illness” is an outdated relic from the days of European empires.
“A group of us think that the time has come to abandon it,” says Dr. Dinesh Bhugra, the Indian-British president-elect of the World Psychiatric Association, an umbrella organization representing more than 200,000 psychiatrists in 117 different countries.
Partly in response to the critics, the DSM’s editorial task force has convened a special committee of 20 advisers to figure out what to do with the category. Helming the committee is Dr. Roberto Lewis-Fernández, a clinical psychiatry professor at Columbia University who helped write the appendix nearly 20 years ago.
What to do with the appendix, however, is proving a thorny problem to solve. It’s not because no one is sure whether pibloktoq is a real thing, although that’s an open question. It’s because the whole debate turns on an issue that psychiatry itself has yet to agree on: how much mental illnesses are a manifestation of the cultures in which they arise. And whether, when it comes to how culture and human psychology intersect, it’s time to start seeing the West as a culture too.
The notion of a culturally specific disorder dates back to 1950s Hong Kong, where a British-trained psychiatrist named Pow Meng Yap found himself growing frustrated: The complaints he was hearing from his local patients in Hong Kong didn’t always match up with the descriptions in the standard psychiatric textbooks he had studied. In 1951, he published an article titled “Mental Diseases Peculiar to Certain Cultures,” in which he attempted to document ailments from far-flung corners of the colonial world, disorders that most Western psychiatrists had never encountered.
Collecting illnesses for his list, Yap drew on florid accounts written by anthropologists and psychiatrists around the turn of the last century. For instance, he mentioned three illnesses from colonial Malaya (now Malaysia): amok, an amnesiac homicidal spree which gave us the phrase “to run amuck”; latah, in which a startled victim falls into a trance and mimics or obeys anybody around her; and koro, the fear that one’s genital organs are retracting into one’s body, and that this will eventually lead to death. Yap himself was the first to admit that existing literature on these illnesses was a jumble, part observation, part “common prejudice.” But if psychiatry didn’t start looking at non-Western cultures, he argued, the field could never fully understand the human mind.
The first edition of the DSM, published the year after Yap’s paper, never mentioned culture. Nor did its 1968 second edition. The notion crept into the 1980 third edition by way of a bureaucratic disclaimer: “Culture specific symptoms . . . may create difficulties in the use of the DSM-III-R [either] because the psychopathology is unique to that culture or because the DSM-III-R categories are not based on extensive research with non-Western populations.”
Then came the 1980s. Paradoxically, at a time when the manual was increasingly being adopted overseas as the ultimate arbiter of psychological truth, it was coming under fire in America. Critics charged it was too much a product of its own time and place — for example, it had labeled homosexuality a mental illness in earlier editions, and included a version of the possibly faddish premenstrual syndrome in later ones. At the same time, from all over the world, a critical mass of new practitioners was emerging who combined psychiatric expertise with training in anthropology. Many of these doctors worked in cultures previously unrepresented in the field, and they lobbied the American Psychiatric Association to give more space to the cultural diversity of mental illness.
The result was a seven-page appendix to the current edition of the DSM, published in 1994. After an essay advising practitioners “how to deal with culture in a clinical setting,” the appendix lists all manner of conditions specific to locales such as Iran, Haiti, Korea, and Mexico.
One illness on the list is dhat syndrome, particular to the Indian subcontinent. Indian men report a vast array of symptoms — among them headaches, forgetfulness, and constipation — that they attribute to a lack of vital fluid, namely, semen. Patients may blame the semen loss on excessive sexual activity, masturbation, nocturnal emissions, or even loss through urine.
West African university students are mentioned as susceptible to brain fag (“fag” being old slang for fatigue). As first described in 1958, a young Nigerian male tired from “too much study” could spontaneously lose the ability to read. In addition, sufferers have complained of a burning scalp, blurred vision, and even sexual dysfunction (one student inadvertently experienced an orgasm during an exam). The Canadian psychiatrist who coined the diagnosis speculated that the syndrome was “an unconscious rejection of the education system.”
Mediterranean peoples are wary of mal de ojo, or “the evil eye,” which can prompt crying without apparent cause. In Cape Verde, sangue dormido, or “sleeping blood,” can be blamed for paralysis, blindness, and even miscarriage. A culturally distinctive phobia in Japan is taijin kyofusho, a fear that one’s appearance, odor, or movements will displease, embarrass, and offend other people.
Looking at the list of illnesses today, just 18 years after it was published, one can barely recognize the original impulse behind it. What once seemed to be a triumph for the forces of inclusivity now looks like a ghetto — or, as critics have called it, a “museum of exotica.”
What has also struck some critics, though, is that some of these supposedly exotic disorders appear strangely familiar, if you look hard enough. Bhugra, who is also former dean of the Royal College of Psychiatrists, points out that 19th-century Americans had their own version of dhat — a semen loss anxiety that led, in part, to the development of health foods like Kellogg’s corn flakes and Graham’s crackers, whose inventors created their products as panacea for ills caused by, among other things, masturbation.
Nigerian-British psychiatrist Oyedeji Ayonrinde has similarly found an American wave of brain fag — the phrase was such a household term between 1890 and 1920 that the Chicago Tribune called it “the disease of the century.” Quack cures proliferated around the country: thermal baths, a “brain fag pillow,” even an electric hairbrush invented at Stanford University.
So what’s really going on here? Is brain fag a universal phenomenon draped in West African garb, or is it a unique condition that only appears when the right cultural circumstances align?
The question gets to the heart of a debate in psychiatry about what mental illness really is. In one camp are specialists who see underlying mental disorders, whether they’re caused by experience or biology, as universal. In the shadow of Sigmund Freud, many psychiatrists in the 20th century argued that basic human experiences shaped our psychological states — say, a child’s relationship with his father. The past few decades of psychiatry have seen a powerful shift toward looking for biological causes like mutated genes, faulty brain wiring, and chemical imbalances. But these, too, would theoretically appear in humans all over the world.
If underlying mental illness is universal, then what looks like a “culture-bound syndrome” is likely to be a common problem that happens to show up differently in different settings. In this way of thinking, susto, or “soul loss,” could be seen as just a Hispanic way of describing what Americans know as plain old depression. “Actually, [culture-bound syndromes] aren’t really different,” says Ayonrinde, who also lectures at the University of London, and has spoken out against the idea that “brain fag” is a specifically African problem. “They’re all variations of somatic disorders, depression, anxiety disorders, and not really anything new.”
However, there’s another way to see the relationship between culture and mental health. A different group of thinkers — including, most prominently, cultural psychiatrists — sees culture as doing more than just giving different names to universal mental disorders. Culture doesn’t just shape what a mentally ill person calls his or her illness, they argue — it determines what counts as illness in the first place.
“Culture tells us what is normal, what is abnormal, what is deviant, what is not deviant, and where you seek help from,” says Bhugra.
If this is true — if it’s culture that decides what’s “crazy” and what’s reasonable behavior — then there may be no such thing as an illness that isn’t culture-bound. It’s not that a handful of disorders no longer belong in a cultural appendix; it’s that perhaps they all do.
Lewis-Fernández and his team are now drafting their recommendations for how the DSM should handle “culture-bound syndromes” in the next edition. They suggest that a shorter appendix remain, winnowed down to a handful of well-documented problems. They’d also like a stronger statement about culture’s role in mental illness in the introduction, and the disorders mentioned in the DSM itself. (Whether or not the editors of the DSM-5 ultimately include the panel’s suggestions is yet to be seen.)
What is not on the table yet — and considering that the DSM is ultimately published by American psychiatrists, may never be — is a deeper acknowledgment that far more mental illnesses might be cultural than we currently think. After all, commonly cited Western syndromes like chronic fatigue syndrome or multiple personality disorder are unknown in many countries, and yet the 1994 manual includes no British or American syndromes in its “culture-bound” category.
To put them there now, Lewis-Fernández says, would be “politically unfeasible.” But for many in the global psychiatry community, that argument is already over: It’s time for Westerners to realize that their mental illnesses might be, one way or another, just as much a local product as pibloktoq.
“Diagnosis, we think, is culture-free,” Bhugra says. “But it’s not.”
Latif Nasser is a doctoral candidate in Harvard’s History of Science department. He also contributes to WNYC’s Radiolab.