LET US START with a little quiz. How many of these conditions have you heard of?
Taijin kyofusho, hikikomori, hwa-byung, or qi-gong psychotic reaction.
If your score was 0 out of 4, do not feel bad: your culture may be to blame. The first two conditions are mental illnesses largely endemic to Japan; the second two are endemic to China. Psychological disorders, or at least our labels for them, differ across cultures. But are these and other non-Western conditions truly distinct from those in the U.S. and Europe? Or does every mental malady, no matter how foreign-sounding in name, vary only in minor ways from a problem that is more familiar to us, such as depression or schizophrenia?
The evidence to date strongly suggests that culture can influence the expression of mental illnesses. Whether radically different cultures can give rise to entirely new psychiatric disorders, however, is a matter of fierce debate.
This issue is of more than academic importance. Psychotherapists often consider cultural differences in their treatment, to be sure, but they typically assume that depression, for example, looks pretty much the same everywhere with minor exceptions. If so-called culture-bound syndromes—mental illnesses that are specific to a particular society—are merely variations of Western disorders, then mental health professionals in Western countries can safely continue to draw on existing knowledge about familiar disorders to treat them. In contrast, if some psychiatric ailments are entirely distinct from those in Western countries, psychologists and psychiatrists may need to start from scratch in figuring out how best to treat them.
In the past century the presumed role of culture in mental illness has swung from one extreme to the other. For decades many cultural anthropologists, sociologists and psychologists assumed such enormous diversity in psychiatric disorders across the globe that they were skeptical of any attempts to classify them. But that viewpoint came under serious scrutiny in 1976, when Harvard University anthropologist Jane Murphy reported powerful evidence that some syndromes did, in fact, seem to cross cultural lines.
Murphy examined two very different societies—a group of Yorubas in Nigeria and a group of Inuit Eskimos near the Bering Strait—that had experienced essentially no contact with modern culture. Yet these populations had names for disorders that appeared strikingly similar to schizophrenia, alcoholism and psychopathy. For example, the Inuit used the term “kunlangeta” to describe someone (usually a man) who lies, cheats and steals, is unfaithful to women and does not obey elders—a sketch very much like that of a Western psychopath. When Murphy asked one of the Inuit how the group typically dealt with such an individual, he replied that “somebody would have pushed him off the ice when no one was looking.” Apparently the Inuit are no fonder of psychopaths than we are.
Later research bolstered Murphy’s conclusion. But the idea that some mental illnesses are present in both Western and non-Western cultures does not preclude the possibility that some disorders might exist only in certain societies. Indeed, in 1994 the American Psychiatric Association introduced an appendix of 25 culture-bound syndromes into the fourth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
But just as soon as this appendix appeared, many scientists contested the notion that culture-bound syndromes are unique conditions, arguing that some or perhaps even all might be variants of disorders already known in Western culture by different labels. For example, some seal hunters in Greenland experience a condition called kayak angst, characterized by feelings of panic out in the ocean, along with an intense need to seek security back on land. Although kayak angst appears on some lists of culture-bound syndromes, it strongly resembles the Western condition of panic disorder with agoraphobia, which is marked by extreme fear of situations in which escape would be difficult in the event of a sudden surge of overwhelming fear.
Another possible Western illness in disguise is taijin kyofusho, which appeared in our quiz and is also listed in the DSM-IV appendix of culture-bound syndromes. Taijin kyofusho is an anxiety disorder, common in Japan, marked by a fear of offending other people, typically by appearance or body odor. Taijin kyofusho may be an Asian form of social phobia (also called social anxiety disorder), in which people dread behaving in a fashion that is potentially embarrassing—say, making a gaffe when speaking or performing in public. Because Japanese tend to be more concerned with group harmony and cohesiveness than are Westerners, taijin kyofusho may be a form of social phobia in a culture that is especially sensitive to the feelings of others.
Nevertheless, some culture-bound syndromes may be sufficiently different from Western disorders to merit separate diagnostic criteria. In the bizarre condition of koro, found primarily in Southeast Asia and Africa, people fear that their sexual organs are disappearing or shrinking. Koro sometimes spreads in waves of mass panic and is triggered by marked anxiety. In the Malaysian condition of amok, which has given rise to the expression “running amok,” afflicted individuals, almost all of whom are males, often respond to a perceived slight by withdrawal and brooding, followed by frenzied and uncontrolled violence.
And in the disorder of “2-D love,” recently reported in Japan and some other countries, men develop what appear to be amorous relationships with animated female characters; they may carry around pillows or other tangible reminders of these characters wherever they go. Whether these mysterious maladies bear any underlying commonalities to well-documented Western psychiatric illnesses is unknown. Koro, for example, could be a type of hypochondriasis (hypochondria), but this possibility has received little systematic research.
Scientific disagreements aside, experts concur that culture can shape the overt expression of mental illness in significant ways. As a consequence, psychotherapists ought to give further consideration to learning more about cultural influences on mental illness and incorporating them into their treatment plans. Meanwhile scientists should use personality and laboratory tests to investigate the causes and manifestations of culture-bound syndromes to determine which of these disorders, if any, are distinct from those in Western culture. If some of these syndromes turn out to be unique, mental health professionals may need to construct and implement psychological interventions that differ in significant ways from those we recognize.