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Crazy Like Us

Do cultures now go mad in the same way?

Source: NPR

"We are flattening the landscape of the human psyche," warns Ethan Watters in Crazy Like Us: The Globalization of the American Psyche. "We are engaged in the grand project of Americanizing the world's understanding of the human mind."

A bracing, thought-provoking read, Crazy Like Us is timely in light of current concerns about DSM-5, the soon-to-be revised fifth edition of the world's diagnostic bible of mental health. Drawing on several fascinating case studies, including of eating disorders in Hong Kong and of models of schizophrenia in Zanzibar, Watters argues that the model of mental illness the DSM advances has started to permeate and change how other cultures think about suffering, to the point of redrawing their social and psychological landscapes.

Is that a good thing? Might some elements of uniformity be useful, in pointing to shared patterns of distress? Or is a loss of cultural self-understanding the almost unavoidable outcome? In absorbing but troubling accounts of how PTSD diagnoses have come to proliferate in Sri Lanka and what the "mega-marketing of depression" has done for mental health diagnoses in Japan, Watters voices concern that well-meaning but mistaken Western psychiatrists have helped to export their conceptions of mental illness around the world. The outcome, according to Watters, is closer to medicalization—and banalization—than a helpful collation of knowledge and understanding.

With DSM-III editor Robert Spitzer acknowledging in Scientific American last April that his colleagues must now fight to "save PTSD from itself," it's worth asking: Are the definitions of disorders now daily invoked around the world sometimes faulty, even wrong?

That matter would seem to have acquired some urgency, as the American Psychiatric Association is moving to propose that "temper dysregulation" in children be considered a mental disorder. The organization also is listing as its first suggested criterion for the recently proposed "Hypersexual Disorder," "A great deal of time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior." Hopefully by 2013, when DSM-5 is slated to appear, the APA will have figured out what it means by "a great deal of time," especially because it's given a statement about desire in which most men, straight and gay, would recognize themselves. A sizeable number of women would, too. And isn't spending "a great deal of time . . . consumed by sexual fantasies and urges" a fairly good working definition of adolescence?

Related to the issue of accuracy is Watters' account of the consequences of exporting such models of illness, including by contributing to a massive spike in mental health diagnoses in Japan. As he shows persuasively, the key factor driving that spike was not a newly uncovered epidemic of disorders; the key factor was instead a concerted push by GlaxoSmithKline to market Paxil, its antidepressant, aggressively for diagnoses of social anxiety disorder. Watters underlines that GSK spent "an immense amount of money" to help create "Japan's First Mental Health Epidemic." A year later, the Wall Street Journal described such matters in a piece called "Waiting for Prozac: Drug Companies Push Japan to Change View of Depression" (Landers). As a result of such encouragement, according to the WSJ, sales of Paxil in Japan "reached ¥12 billion ($96.5 million) in 2001, its first full year on the market," and rose sharply in subsequent years. I found evidence of a similar practice of marketing new disorders after alighting on documents that revealed how GSK decided internally to push Paxil for social anxiety disorder in Europe and North America.

While researching my book on social anxiety disorder, I also came across startling but exasperating articles that sought to describe such large-scale phenomena as "Social Phobia in Saudis" on the basis of thirty-five outpatients, even as the author of that particular study acknowledged that "only 22 (63%)" of them had actually presented with social phobia" and that four of their files had been lost. The central rationale for such articles was determining how closely their patients' profiles fit DSM-IV criteria, a matter that would seem in many cases to beg the question rather than answering it.

That the DSM cannot be treated as gospel should long have been clear to its many readers (DSM sales since 2000 have exceeded $40 million). At the same time, Watters is drawing urgent and much-needed attention to the effects of its thinking, including most especially the consequences of all those millions of diagnoses. "We should worry about [a] loss of diversity in the world's differing conceptions and treatments of mental illness," he says, "in exactly the same way we worry about the loss of biological diversity in nature." Follow me on Twitter @christophlane

Chaleby, K. "Social Phobia in Saudis," Social Psychiatry 22.3 (1987): 167-70.

Landers, P. "Waiting for Prozac: Drug Companies Push Japan to Change View of Depression," Wall Street Journal (October 9, 2002).

Watters, E. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, 2010.

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