The Last Imperialism and the Invisible Pandemic
By Dr Neel Burton — Psychiatrist, philosopher, and wine writer; Fellow of Green Templeton College, University of Oxford; author of over twenty books.
Essay substantially revised on 28 August 2026.
After the Indian Ocean tsunami of 2004, Western trauma specialists descended upon Sri Lanka expecting an epidemic of post-traumatic stress disorder (PTSD). They barely found any. The suffering, though very real, took other forms.
Until fairly recently, depression was mostly unknown to the lay population of Japan. But between 1999 and 2008, diagnoses of depression more than doubled as psychiatrists and pharmaceutical companies urged people to reinterpret their distress in terms of the disorder.
When I was growing up in Switzerland, virtually in the shadow of the World Health Organisation headquarters, I did not know anyone with ADHD, an eating disorder, or a problem with self-harm. Maybe my parents and teachers sheltered me from these things. But I watched a fair amount of television, and no one seemed to talk about them there either. So either I was living in the Truman Show, or they were much less prevalent.
Have these constructs always been there, waiting to be recognised? Then how come Aristotle, who studied everything and wrote a mountain of books, never described them? Or Hippocrates, for that matter. Or do the forms of our distress change with our interpretations of them?
Culture-Bound Syndromes and What They Reveal
Culture-bound syndromes are mental disturbances that only find expression in certain cultures or ethnic groups. There are a great many of them. For instance, dhat, seen in South Asian men, involves sudden fear about loss of semen in the urine, whitish discolouration of the urine, and sexual dysfunction, accompanied by feelings of weakness and exhaustion. Dhat may be rooted in the old Ayurvedic conception of semen as the most refined and precious of the bodily substances, reflected in the Eastern 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 therefore that semen is a concentrated essence of life.
Culture-bound syndromes do not sit all too comfortably in Western classifications of mental disorder. DSM-IV simply defined them as ‘recurrent, locality-specific patterns of aberrant behavior and troubling experience…’ and listed a small number of paradigmatic forms such as dhat, koro, and susto.
DSM-5, published in 2013, replaces the notion of culture-bound syndromes with three ‘cultural concepts of distress’: cultural syndromes, cultural idioms of distress, and cultural explanations for distress. Rather than merely listing specific cultural syndromes, DSM-5 adopts a broader approach to cultural issues and acknowledges that all mental disorders, including DSM disorders, can be culturally shaped.
This is an important admission. The old concept of a culture-bound syndrome assumed that other people’s disorders were culturally shaped, whereas the West’s were an objective reflection of human biology. A man in Lahore who feared losing his vital essence in his semen was culture-bound; a man in London who understood his unhappiness as a chemical imbalance in his brain was science.
Science on Export
However, some DSM disorders are, it seems, much more culturally shaped than others. Thus, PTSD, ADHD, anorexia nervosa, bulimia nervosa, depression, and deliberate self-harm among others can all be understood as cultural syndromes—not natural kinds awaiting discovery, like Aristotle’s species, but shifting expressions of human distress. Yet, for being in the DSM, they are usually seen, and largely legitimised, as biological and therefore universal expressions of human suffering.
This matters because Western psychiatry does not stay in the West—which would be bad enough. Arm in arm with pharmaceutical companies, classifications such as DSM and ICD encourage the wholesale exportation not only of Western mental disorders, but also of Western accounts and approaches to mental disorder—and, ultimately, of Western values or tropes such as biologism, individualism, and the medicalisation of distress and deviance.
Japan, with which we began, offers a striking example. The anthropologist Junko Kitanaka has documented how depression went from being a relatively obscure condition to one of the most talked-about illnesses in recent Japanese history. The important question is not simply whether the Japanese became more depressed, but what happened when depression became available as a culturally sanctioned way of understanding distress.
Perhaps the suffering had always been there, but lacked the language—or permission—to express itself in the form of depression. But there is another possibility: that, by supplying a new language and template for distress, psychiatry did not merely reveal an existing epidemic but helped to shape one—and then sell the cure. Japan, coincidentally, happened to be rich.
A diagnosis, on this account, does not merely name something that already exists. Once established in a culture, it can influence which aspects of distress are noticed, how they are interpreted and expressed, and what is done about them. It becomes available not merely to psychiatrists but also to the people who suffer, who may be eager for an explanation of their suffering—and for a solution.
What It’s Costing Us
In Crazy Like Us: The Globalization of the American Psyche, the journalist Ethan Watters shows how psychiatric imperialism is leading to a pandemic of Western disease categories and treatments. Watters argues that changing a culture’s ideas about mental disorder actually changes that culture’s mental disorders, depleting the store of local beliefs and customs which, in many cases, provided better answers to people’s problems than antidepressants and antipsychotics. For Watters, ‘the most devastating consequence of the spread of American culture has not been our golden arches or bomb craters but our bulldozing of the human psyche itself.’
He writes:
Looking at ourselves through the eyes of those living in places where human tragedy is still embedded in complex religious and cultural narratives, we get a glimpse of our modern selves as a deeply insecure and fearful people. We are investing our great wealth in researching and treating this disorder because we have rather suddenly lost other belief systems that once gave meaning and context to our suffering.
To me, Watters seems to be describing a vicious cycle: biologism can take hold because the psyche has become impoverished, and biologism in turn further impoverishes it. The more we medicalise our suffering, the less meaning it can have; and the less meaning it has, the more we need to medicalise it. We’re receiving the signal, but attending to the sound rather than to the message.
Templates of Distress
Distressed people tend to externalise their suffering, partly to make it more manageable, and partly so that it can be recognised and legitimised. According to the medical historian Edward Shorter, our culture’s beliefs and narratives about illness provide us with a limited number of templates or models of illness by which to externalise our distress. If authorities such as psychiatrists and celebrities appear to endorse or condone a new template such as ADHD or deliberate self-harm, the template enters into our culture’s ‘symptom pool’ and the condition starts to spread. Meanwhile, tired templates seep out of the symptom pool, which may explain why conditions such as hysteria, fugue, and catatonic schizophrenia, which were once common, have become so rare.
The number of cases of bulimia nervosa rose in 1992, the year in which the journalist Andrew Morton exposed Princess Diana’s ‘secret disease’, and peaked in 1995 after Diana went public with her eating disorder. It began to decline in 1997, the year of her tragic death. This synchronology suggests that Diana’s iconic status combined with intense press coverage of her bulimia—and bulimia in general—led to an increase in the incidence of the disorder. Something similar happened in South Korea in 2010-12, when diagnoses of panic disorder shot up after several celebrities disclosed that they suffered from the condition.
Of course, Diana may simply have encouraged people who were already suffering from bulimia to recognise it and come forward. But Shorter’s more unsettling possibility is that, by making a particular template of distress culturally available, she also made it more likely that distressed people would stumble into it.
This does not mean that people consciously choose their symptoms, still less that they are pretending. Culture operates at a much deeper level than that. Just as we do not choose the language in which we dream—or even the contents of our dreams—so we do not choose the language in which we suffer.
And this brings us back to the central paradox of psychiatric imperialism. By exporting Western psychiatric templates, we may be creating the very universality that we claim merely to have discovered. And there are strong commercial drivers for doing so: universal disorders create universal markets. In exporting the diagnosis, we help to create the disease—or, on a global scale, an invisible pandemic.
The danger for us psychiatrists and health professionals when treating people with mental disorder is to treat the template without addressing or even acknowledging the very real distress that lies beneath—to hand out the tablets without asking what the suffering is about, and how it might actually be alleviated.
Continue Exploring
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