The Americanization of Mental Illness:

In short, Shorter was convinced that medicine did not just “reveal” disorders that had previously escaped medical attention, but that one could actually increase their prevalence by simply putting the disorder on the cultural map.

To explain how this could happen, Shorter made use of an interesting metaphor — that of the “symptom pool.” Each culture, he argued, possessed a metaphorical pool of culturally legitimate symptoms through which members of a given society would choose, mostly unconsciously, to express their distress. It was almost as if a particular symptom would not be expressed by a given cultural group until the symptom had been culturally recognized as a legitimate alternative — that is, until it had entered that culture’s “symptom pool.” This idea could help explain, among other things, why symptoms that were very common in one culture would not be in another.

Why, for example, could men in Southeast Asia but not men in Wales or Alaska experience what’s called Koro (the terrifying certainty that their genitals are retracting into their body)? Or why could menopausal women in Korea but not women in New Zealand or Scandinavia experience Hwabyeong (intense fits of sighing, a heavy feeling in the chest, blurred vision, and sleeplessness)? For Shorter, the answer was simple: symptom pools were fluid, changeable, and culturally specific, therefore differing from place to place.

This idea implied that certain disorders we take for granted are actually caused less by biological than cultural factors — like crazes or fads, they can grip or release a population as they enter or fade from popular awareness. This was not because people consciously chose to display symptoms that were fashionable members of the symptom pool, but just that people seem to gravitate unconsciously to expressing those symptoms high on the cultural scale of symptom possibilities. And this of course makes sense, as it is crucial that we express our discontent in ways that make sense to the people around us (otherwise we will end up not just ill but ostracized).

As Anne Harrington, professor of history of science at Harvard, puts it, “Our bodies are physiologically primed to be able to do this, and for good reason: if we couldn’t, we would risk not being taken seriously or not being cared for. Human beings seem to be invested with a developed capacity to mold their bodily experiences to the norms of their cultures; they learn the scripts about what kinds of things should be happening to them as they fall ill and about the things they should do to feel better, and then they literally embody them.” Contagions do not spread through conscious emulation, then, but because we are unconsciously configured to embody species of distress deemed legitimate by the communities in which we live.

And this is why the historian Edward And this is why the historian Edward Shorter believed that when it came to the spread of symptoms, the same “bandwagon effect” could be observed too. If enough people begin to talk about a symptom as though it exists, and if this symptom is given legitimacy by an accepted authority, then sure enough more and more people will begin to manifest that symptom.

This idea explained for Shorter why symptoms can dramatically come and go within a population — why anorexia can reach epidemic proportions and then suddenly die away, or why self-harm can suddenly proliferate. As our symptom pool alters, we are given new ways to embody our distress, and as these catch on, they proliferate.

After reading Shorter’s work, Dr. Lee began to understand what had happened in Hong Kong. Anorexia had escalated after Charlene’s death because the ensuing publicity and medical recognition introduced into Hong Kong’s symptom pool a hitherto foreign and unknown condition, allowing more and more women to unconsciously select the disorder as a way of expressing their distress.

This theory was also consistent with another strange change Dr. Lee had noticed. After Charlene’s death it wasn’t just the rates of anorexia that increased but the actual form anorexia took. The few cases of self-starving Lee treated before Charlene’s death weren’t characterized by the classic symptoms of anorexia customarily found in the West, where sufferers believe they are grossly overweight and experience intense hunger when they don’t eat. No, this particular set of Western symptoms did not match the experiences of anorexics that Lee encountered before the mid-1990s, where anorexics had no fear of being overweight, did not experience hunger, but were simply strongly repulsed by food.

This all changed as Western conceptions of anorexia flooded Hong Kong’s symptom pool in the mid-1990s. Young women now began to conform to the list of anorexic symptoms drawn up in the West. Like Western anorexics, those in Hong Kong now felt grossly overweight and desperately hungry. In short, as part of the Western symptom drained eastward, the very characteristics of anorexia in Hong Kong altered too.