In The Other Side of Normal, Jordan Smoller recounts the case of a man who sought help at a clinic in Taiwan in 1965. He had first noticed a couple of months before that, a day or two after sex with a prostitute, his penis would start to retract into his abdomen. He would grab onto his wang, knowing that if it retracted all the way, he would die, but the overwhelming anxiety would cause him to faint. More recently, he had found every night that his pecker had shrunk to less than 1 cm in length; he would pull it back out and then he could sleep.
Smoller notes that the case wouldn’t fit well into any of the categories in the Diagnostic and Statistical Manual, the Bible of clinical psychiatry, but was instantly recognized by the Chinese doctor as koro, a condition known for centuries in East Asia. The remarkable thing about koro is that it occurs in epidemics—for example, when a rumor spread in Thailand that Vietnamese immigrants had poisoned Thai food with koro powder, over two thousand cases turned up in emergency rooms. Though traditionally Asian, the disease can turn up elsewhere, as in Khartoum, where an outbreak was triggered by shaking hands with foreigners. You see the pattern…doesn’t exactly restore one’s faith in human nature.
One naturally wonders what our own culture-dependent mental disorders are, and Smoller offers an example that surprised me: multiple personality disorder and its sidekick, recovered memory. Apparently MPD was extremely rare until the late 1980s, when cases turned up in the thousands, so many that they strained the capacity of mental-health institutions. Then after only a few years, the diagnosis was removed from the DSM. The condition was supposedly caused by early memories that were so traumatic that they had to be suppressed and could only be recovered through techniques such as hypnosis. As the practice of memory recovery spread, the nation was shocked by revelations of horrifying and widespread ritual abuse, including a case where workers at a day-care center were given long prison terms based on testimony by small children that they had witnessed ritual baby-murders on a spaceship. Hmmm.
I find it fascinating to try and guess what these culture-dependent disorders say about us, but Smoller’s main point is that they pose a serious problem for a system like the DSM, which is based on groups of symptoms, with little consideration of the underlying brain/mind systems that are malfunctioning. Smoller doesn’t use this analogy, but it is as though a manual of auto repair classified problems as Rattling Disorders, squeaking and Squealing Disorders, Stopping and Starting Disorders, etc., rather than relating them to the engine, brakes, transmission, and so on. Smoller thinks that, with our modern understanding of genetics and fancy brain imaging, we should be able to describe the basic functions that our brains evolved to deal with the world. For example, if we know how the fear/alarm system is supposed to wwork, then we can see which aspect of it is malfunctioning in anxiety disorders, namely the system that causes the amygdala to stand down if a given stimulus in the past was not actually followed by disaster.
Though he notes the limitations of the DSM’s black-box approach, Smoller considers it a vast improvement on the mess that came before, especially psychoanalysis, which (to take up the automotive analogy) posited a fantastical menagerie of trolls and gremlins running on little exercise wheels under your hood. You can hardly read anything Freud wrote about women (e.g., that they lack a conscience because they can’t be made to fear castration) without being amazed that he was allowed to practice medicine—but it wasn’t just Uncle Siggy. Smoller quotes aauthoritative pronouncements from thee 1950s to the effect that schizophrenia is caused by the mother’s inability to love her child and autism results from the mother’s wish that the child did not exist. Now anybody can be wrong, but how many people have ever tarted up their wrongness iwith so much pomposity and used it to such cruel and destructive ends? Imagine having your life torn apart by your child’s sstruggle with schizophrenia and then being told it’s your own fault…I’m just saying , there ought to be a prize for these guys, and it ought to be delivered rectally.
Smoller doesn’t have Olliver Sacks’ gift for tpathological portraiture (who does?), but I find his scientific expositions much easier to follow. For some reason,, when Sacks talks about the brain, I just end up with a jumble of fusiform this and hippocampus that and serotonin the other, and no sense of how it fits together. I didn’t experience that kind of frustration with The Other Side of Normal.