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The Culture of Mental Illness

The startling effects of culture on the presentation of mental illness.

Culture can have a significant effect not only on the presentation of psychic phenomena but also on society’s reaction to these phenomena.

Depression and suicide

In traditional societies human distress is more likely to be seen as an indicator of the need to address important life problems than as a mental disorder requiring treatment. For this reason, the diagnosis of depression is correspondingly less common. Some linguistic communities do not have a word or even a concept for ‘depression’, and many people from traditional societies with what may be construed as depression present instead with physical complaints such as fatigue, headache, or chest pain rather than with psychological complaints. Thus, Punjabi women who have recently immigrated to the UK and given birth find it baffling that a health visitor should pop round to ask if they are depressed. Not only had they never considered the possibility that giving birth could be anything other than a joyous event, but they do not even have a word with which to translate the concept of ‘depression’ into Punjabi. As with depression, so with suicide and self-harming behaviour, which though very common in countries such as the UK and USA, are almost completely unheard of in many developing countries. In British men the most common method of suicide is hanging, which accounts for just under half of all completed suicides. This is perhaps surprising given that hanging is both violent and very likely to fail, and serves to highlight the important influence of culture on chosen methods of suicide.

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Psychosis

Certain psychic phenomena such as brief reactive psychosis and possession trance are regarded as a mental disorder in our society but as normal and even exalted states in some other societies. In possession trance, the person reacts to a traumatic event by entering a dissociative or trance state in which his identity is replaced by that of another person, animal, or inanimate object, or, more commonly, by a ghost, spirit, or deity. A trance state can be an accepted, even an exalted, expression of religious feeling, and may even be sanctioned and sought-after in certain cultures or sub-cultures. Even schizophrenia, which is thought of as a highly heritable and biological psychotic disorder, has been found to be more common in inner cities and urban areas than in rural areas. The reasons for this are unclear: it could be that the stress of urban living increases the risk of the disorder, or that people with the disorder have a net tendency to migrate out of rural areas and into urban ones. Interestingly, the outlook or prognosis for people with schizophrenia is generally more favorable in traditional than in modern societies. This may be because people in traditional societies are more tolerant of mental disorder and better able to pull together and support mentally disordered members of their community.

A cautionary tale

Some three years ago, a young African woman presented to me complaining of hair loss. She had recently been started on an antipsychotic drug for a psychotic episode involving auditory hallucinations, and (quite rightly) suspected the drug of being responsible for the thinning of her beautiful braided hair. I established that the auditory hallucinations consisted in the voices of several of her dead ancestors, and that the voices were castigating her for having left her native country and community. While the voices were distressing, the antipsychotic drug had not touched them, so please could I discontinue the drug and give her my blessing to consult with a witch doctor. After discussing the various options available, such as decreasing the dose of the drug or switching to another drug, I turned to her brother who had come with but mostly remained silent, and, almost as an afterthought, asked him whether he too could hear the voices. ‘Yes’, he replied sheepishly, ‘we all do.’ ‘But they upset her most.’ 

Western mental disorders

Other psychic phenomena such as eating disorders and post-traumatic stress disorder (PTSD) are almost completely unheard of in many cultures. Anorexia nervosa and bulimia nervosa are common in occidental or occidentalized societies such as Japan, but extremely rare in traditional societies, and appear to be strongly correlated with occidental values such as individualism and the idealization of thinness and beauty. PTSD is brought on by a highly traumatic event such as a car crash or a physical or sexual assault, and is commonly seen in military personnel and victims of rape. Common symptoms include anxiety, numbing, detachment, flashbacks, nightmares, partial or complete loss of memory for the traumatic event, and avoidance of reminders of the traumatic event. The symptoms of PTSD vary significantly from one culture to another: in the wake of the 2004 Asian tsunami, barely a single case of post-traumatic stress disorder could be recorded.

Culture-bound syndromes

Psychic phenomena that are exclusive to certain cultures are sometimes referred to as ‘culture-bound syndromes’, which the American classification of mental disorders, the DSM-IV, defines as ‘recurrent, locality-specific patterns of aberrant behavior and troubling experience’. Many culture-bound syndromes are thought to be idiosyncratic expressions of anxiety and stress-related disorders. Examples from Asian populations include dhat and koro. Dhat is seen in men from South Asia and involves sudden anxiety about loss of semen in the urine, whitish discoloration of the urine, and sexual dysfunction combined with feelings of weakness and exhaustion. The syndrome may have it origins in the Hindu belief that it takes forty drops of blood to create a drop of bone marrow, and forty drops of bone marrow to create a drop of semen, and thus that semen is a concentrated essence of life. Koro is seen in men from Southwest Asia. Men affected by koro fear that their penis is retracting into their body and killing them. As a result, they go to great lengths to hold it outside their body, for example, by fastening it to sticks or pieces of furniture. Koro principally occurs in the context of sexual guilt, often at night, and occasionally in local epidemics that resemble mass hysteria.

Conclusion

The important effect of culture on the presentation of psychic phenomena raises some important questions about the nature of mental illness, and also highlights their relation to genuine and important existential concerns that are often overlooked in our society.

Neel Burton is author of The Meaning of MadnessThe Art of Failure: The Anti Self-Help GuideHide and Seek: The Psychology of Self-Deceptionand other books.

Find Neel Burton on Twitter and Facebook 

Neel Burton, M.D., is a psychiatrist, philosopher, and writer who lives and teaches in Oxford, England.

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