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Anxiety and depression rates skyrocketed during the pandemic as mental health hotlines and hospital wards filled up with people in need of immediate professional help. But mental health issues have long been on the rise even before COVID, increasing by as much as 20% between 1993 to 2014.
The common reaction is to brush off the increased incidents of mental illness. Many people just think that the increased rates aren’t so much increased occurrence of mental illness, but rather increased reporting due to the lesser social stigma around mental health in the past decade.
What few people consider is how our changing environment and social structures affect our mental health. As the world becomes more industrialized, changes in our daily routine and overall lifestyle have revealed an increased risk factor for serious mental illness in cities compared to rural areas.
How our social and cultural environments affect our mental wellness becomes clearer when you start to consider culture-bound syndromes.
What Defines Culture-Bound Syndromes? The Four Ds of Psychological Disorders
To understand culture-bound syndromes, we first need to look at what mental illness is in the first place. Unlike physical illnesses, psychological disorders and mental illnesses are rarely so clear-cut. It’s easy to tell if someone has a cold but harder to tell if they have depression or if their reserved social habits are simple introversion.
One of the first things taught in an Abnormal Psychology course is the “4 Ds of Disorder”. The “4 Ds” stand for deviance, distress, dysfunction, and danger. Together, they make up the dimensions through which mental illness is defined and measured. The “4 Ds” are a checklist for mental illness If all four are present, then it’s a psychological disorder. Miss one and it isn’t.
Let’s crack open a dusty DSM-V.
Danger is the easiest one to understand. It just means that a mental illness causes danger, either to the one suffering from it or the people around them, or both. Most of the time, it’s the first one; no matter how pop culture demonizes the mentally ill.
Next is dysfunction. Dr. David Barlow and Dr. Mark Durand define it as “a breakdown in cognitive, emotional, or behavioral functioning.”
It’s normal to feel wary about going out on a date with someone you don’t know well yet; but if you’re having full-on meltdowns and cry sessions before the date because you believe your date is an axe murderer who’ll chop you up and bury you in the middle of nowhere, you might have a problem.
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If your irrational fear of dating is making you feel upset because you think you’re going to end up alone forever because of it, that’s where distress comes in. You’re starting to realize that something is wrong and that it’s hurting you physically, mentally, socially, or all of the above.
It’s deviance where things start to get interesting because deviance simply means deviating from a standard; that is, being different.
We’re all deviants in some way, ranging from mild to severe. BDSM practitioners are, in a way, deviants. I know someone in the BDSM community is going to get mad about this but I’m saying it in an academic and not an “I’m judging you” sense. Seriously, just stay with me here.
BDSM practitioners can be considered deviants because their behavior, the stuff that turns them on, isn’t what we normally think of as sexually arousing. For a lot of people, there’s no fun in getting hogtied.
On the other end of the scale, where the more “extreme” behaviors are, you have things like cannibalism which most cultures wouldn’t see as socially acceptable (or legal for that matter). But for the Guayaki people of Paraguay, cannibalism isn’t just normal: it’s a way of paying your respects to the dead.
The question of whether cannibalism or BDSM is “wrong” often only depends on the culture that the one judging it comes from. If you scroll down to the comments to call me morally reprehensible for trying to portray either of these behaviors as normal, that just tells you and I that you aren’t a Guayaki and you aren’t part of the BDSM community.
But that’s the crux of it: What we think of as deviant depends on what we think of as normal. What we think of as normal is shaped by where we’re from.
D Is for Deviance: A List of Culture-Bound Syndromes
1. Amok
Have you ever wondered where the phrase “running amok” comes from? Cambridge Dictionary defines it as “to be out of control and act in a wild or dangerous manner” which gives you an idea of what this culture-bound syndrome is.
Amok is more than just a sudden outburst of violent behavior ‒ it’s a legitimate mental illness in the sense that it’s how Southeast Asian cultures understand mental breakdowns. Expressing emotional distress by crying or verbally venting is not widely accepted in most Asian cultures.
This often comes down to the belief that these forms of emotional expression are useless and accomplish nothing more than making the person expressing them, and the people associated with that person, “lose face.”
Running amok is a socially acceptable way of “losing it.” The culture-bound syndrome, a weird stew of depression and dissociative symptoms, is framed as a possession or a curse, putting it outside the control of the person running amok.
By alleviating responsibility, the resulting violent outburst becomes more acceptable. People become more likely to take pity than be angry when the person who ran amok kills everyone in the neighborhood.
Culture-bound syndromes are often delegitimized in “formal” (read: Western) psychology. But if you’re a student in the U.S., the idea of running amok might not sound so strange to you.
2. Ataque de Nervios
Former Spanish colonies have the Spanish to thank for two things: paellas and ataque de nervios, a culture-bound syndrome characterized by, you guessed it, anxiety.
Ataque de nervios covers the whole gamut of anxiety disorders and then some. It doesn’t have any exact one-to-one equivalent but squint a little and you’ll see the connection.
People who suffer from nervios experience uncontrollable bouts of crying and trembling. Some of them feel heat rising from their chest to their heads and might become verbally or even physically aggressive.
The most common trigger for an episode of ataque de nervios is bad news about one’s family, like death or illness of a loved one, which is understandable considering that Latino culture is typically strongly family-oriented.
Some sufferers of nervios can be so severely affected that they laugh hysterically at the bad news. Ataque de nervios can also feature seizure-like fainting episodes, depersonalization, and, occasionally, suicide attempts.
3. Hwabyung
There’s more to North and South Korea than their demilitarized zone. The two countries share some culture-bound syndromes, including one known as “hwabyung.”
Hwabyung is a folk medical term that means illness (byung) of fire/anger (hwa). Victims of hwabyung describe similar symptoms to sufferers of ataque de nervios in that hwabyung features a chest discomfort that makes the sufferer feel like they’re being choked.
Often, people who experience hwabyung describe feeling something “hot” rising from their chest ‒ a physical manifestation of feelings of anxiety, despair, depression, and anger that come with hwabyung.
While it sounds like a nervous breakdown, hwabyung is actually caused by anger. Not just any kind of anger but anger at being treated unfairly or unjustly.
Korean culture, and other East Asian cultures, for that matter, are socially rigid and enforce strict hierarchies with regard to social or economic rank and age. People have no choice but to swallow their anger when treated unjustly and this anger later resurfaces in some people as hwabyung.
An autobiography by the wife of Han Jung Rok, an heir to the Korean throne sometime around the 18th century, describes her husband like this:
“His [hwabyung] was so abrupt.” She wrote, “He became sad after he was treated by his father, King Yeong Jo, unjustly and it led to pent-up anger.” It later led Han Jung Rok on an amok-style killing spree which makes sense when you realize that amok is also rooted in emotions that are socially unacceptable to express.
Remember what I said earlier about there being cultural differences between cultural natives and members of a diaspora? A cross-cultural study on hwabyung in native Koreans compared with Korean immigrants in the U.S showed differences in incidence of hwabyung.
4. Kungfungisisa
The Shona people of Zimbabwe see overthinking as a form of mental illness. Except, they don’t call it overthinking, they call it “kungfungisisa.”
The word “kungfungisisa” literally means “thinking too much” in the Shona tongue and is used as an explanation for anxiety, depression, and psychosomatic problems. It’s similar to the rumination, that is, overthinking about negative thoughts, that people with depression and anxiety experience.
For the Shona, kungfungisisa comes with phantom pains. People who experience kungfungisisa might say: “My heart hurts because I’m thinking too much.” after a fight with an spouse or finding out that the cattle died of illness and they no longer have a source of income.
Interestingly, kungfungisisa is also associated with studying too much which the Shona consider a brain-damaging activity given the mental exhaustion that comes with it. Similar to hwabyung, this culture-specific mental illness includes sensations of heat on and in the head.
Depression and Eating Disorders as Culture-Bound Syndromes
If you think culture-bound syndromes are just silly mental illnesses made up by “primitive” cultures, think again. There’s evidence to suggest that formal psychology, which is really mostly just Western psychology, is also chock full of culture-bound syndromes.
One of the Western culture-bound syndromes in question is depression. Yes, depression. The one that’s as common as the common cold.
According to Christopher Dowrick, depression fulfills the criteria for culture-bound syndromes in westernized societies. Genetic studies have found a massive overlap between a wide range or psychiatric diagnoses like depression, autism, and schizophrenia.
If you know the contents of the medications used for these illnesses, you’ll have an inkling about the connections as well.
Dowrick points out that western anglophone societies have an “ethic of happiness” that make expressions of unhappiness appear abnormal similar to how anger is treated in many Asian cultures.
As to why depression is showing up everywhere despite it supposedly being one of the culture-bound syndromes comes down to the cultural dominance of the U.S. and other Western anglophone countries.
As a world superpower with a massive cultural reach, the U.S.’s cultural norms are inescapable ‒ it changes cultural perceptions on normality everywhere. In short: depression is a culture-specific syndrome of the modern age, operating at an international scale as cultures become more hegemonized.
The phenomenon of international culture-bound syndromes is easier to observe in eating disorders which were first observed in Western countries and virtually nonexistent in non-Western ones.
Fast forward from when anorexia nervosa became a medical diagnosis in 1874 to the 21st century and you start seeing global incidents of eating disorders along with the expansion of Western culture thanks to Hollywood, advertising, and the internet.
In most non-Western cultures, thinness in the degree advertised by models and A-list celebrities just wasn’t valued as a beauty standard. Contrast this with Mauritania, where women are actually force-fed to become obese.
Does this mean that depression and eating disorders aren’t real? Of course not. They still fit the “4 Ds” of psychological disorder but so do the rest of the culture-bound syndromes here. It’s just a sign that it might be time to move away from letting the American Psychological Association and Western frameworks of understanding mental illness dominate the field of psychology.
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