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© 2019 Donald E. Mclawhorn Ó 2019 Donald E. McLawhorn, Jr. WEAK NERVES IN CHINA: NEURASTHENIA-DEPRESSION CONTROVERSY AS A WINDOW ON PSYCHIATRIC NOSOLOGY BY DONALD E. MCLAWHORN, JR. DISSERTATION Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in East Asian Languages and Cultures in the Graduate College of the University of Illinois at Urbana-Champaign, 2019 Urbana, Illinois Doctoral Committee: Professor Robert Tierney, Chair Associate Professor Alexander Mayer Associate Professor Michael Kral Assistant Professor Roderick Wilson Assistant Professor Jeffery Martin Clinical Assistant Professor Thomas Laurence ABSTRACT Although shenjing shuairuo (SJSR) has remained a salient clinical and cultural concept in China since the first decade of the twentieth century, in 1980 neurasthenia was removed from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. This roughly coincided with the opening of China after Nixon’s famous visit, and for the first time in many years, Western academics were welcomed back into China to research and collaborate. Several publications arising from one such collaboration sparked what has become known as the neurasthenia-depression controversy and initiated a paradigm in cultural psychiatry termed the new cross-cultural psychiatry (NCCP). Almost without exception, research on SJSR has cited and relied upon the perspective and interpretation of writers situated within the paradigm of NCCP. Unfortunately, there has been no effort in the literature to make a comprehensive criticism of the predominant views of SJSR as they have been propagated over the past 40 years through NCCP writings. In this dissertation, I undertake this effort by first addressing the origins of neurasthenia in the West and then making a study of how SJSR came to be a salient category in China. After establishing this background, I attempt a comprehensive exegesis of the hegemonic efforts of Western psychiatry to frame SJSR within the NCCP and the responses of Chinese scholars to those efforts. In addition, I develop an explanation for how psychiatric distress can vary across cultures. I argue that culturally salient categories are conformed to consciously or unconsciously through a process of belief and expectation, and that codified experiences can be translated from the mind to the body and back again. I maintain that neurasthenia arose as a diagnostic category in the context of a long historical discourse of “nerves” and “nervousness,” but that SJSR became a salient conceptual category in the absence of any such historical discourse. As such, it became a temporally, geographically, and culturally specific mode of manifesting human distress and inner perturbation. SJSR will continue to defy attempts at reductionistic redefinition under the influence of American psychiatry, as it (and categories like it) serves an important function in capturing certain forms of human experience. ii TABLE OF CONTENTS CHAPTER 1: INTRODUCTION ........................................................................................1 CHAPTER 2: WESTERN ORIGINS OF NEURASTHENIA ..........................................40 CHAPTER 3: WEAK NERVES IN CHINA .....................................................................84 CHAPTER 4: WESTERN PSYCHIATRY ENGAGES SHENJING SHUAIRUO .........130 CHAPTER 5: SHENJING SHUAIRUO SURVIVES INTO THE TWENTY-FIRST CENTURY ..................................................................174 CHAPTER 6: CONCLUSION ........................................................................................217 REFERENCES ................................................................................................................240 iii Chapter 1: Introduction “Our golden arches do not represent our most troubling impact on other cultures; rather, it is how we are flattening the landscape of the human psyche itself. We are the engaged in the grand project of Americanizing the world’s understanding of the human mind”.1 In 1980 the American Psychiatric Association (APA) published the third edition of its clinical manual, The Diagnostic and Statistical Manual of Mental Disorders (DSM-III).2 One of the many changes that made up the new version of the manual was the removal of the clinical category neurasthenia (nerve debility/nervous exhaustion), which had been a globally recognized disease category for over one hundred years. Both China and Japan had traditionally employed the category in their respective neuropsychiatric nosologies, but after 1980, Japan followed the United States and also abandoned shinkei suijyaku (り) for having no validity as a disease concept.3 While in both the USA and Japan, the category has been subsumed under other clinical “entities”, the Chinese language equivalent, shenjing shuairuo is still a debated category that can be found on China’s public health websites, in its professional neurology and psychiatric literature, and in its diagnostic manual, CCMD-3 (Chinese Classification of Mental Disorders Version 3).4 Physicians in China (and the Indian subcontinent) have continued to make use of the category, though drastically less so, and it has wide popularity as a health concern among laypeople within China. Neurasthenia has also been retained in the World Health Organization’s publications of the International Classification of Diseases, in its current tenth edition (ICD-10) and with an eleventh in development. Neurasthenia is increasingly rarely employed as a diagnostic category outside of China and India. This can probably be attributed to the global influence of the DSM, which moved beyond its previous abandonment of neurasthenia, reintroducing it as a cultural syndrome in 1994. A cultural index only appeared in the DSM in the 1990s, after nearly three decades of collaboration between anthropologists, psychiatrists, and other mental health researchers. In 1994 the APA 1 Ethan Watters, Crazy like Us: The Globalization of the American Psyche, (SImon and Schuster, 2010), 1. 2 Hereafter, DSM, with the edition listed either as a Roman numeral for I-IV or 5 for the most recent edition. 3 To state that neurasthenia was abandoned for having no validity as a disease construct is somewhat of an overstatement. This subject is briefly touched upon in the concluding chapter. 4 , 、, vol. 3 [CCMD-3] (: , 2001). 1 published DSM-IV, which included a section titled, “Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes” (p. 843). Listed among these “culture-bound syndromes” is the following: Shenjing shuairuo (neurasthenia): In China, a condition characterized by physical and mental fatigue, dizziness, headaches, other pains, concentration difficulties, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and various signs suggesting disturbances of the autonomic nervous system. In many cases, the symptoms would meet the criteria for a DSM-IV mood or anxiety disorder. This diagnosis is included in the Chinese classification of mental disorders, second edition. (CCMD-2).5 By situating it as a “locality-specific pattern of aberrant behavior and troubling experience” (DSM-IV, p. 848), the APA defines neurasthenia as a culture-bound syndrome that belongs to the Chinese experience, which continues with both the DSM-IV Text Revision and the 2013 publication of DSM-5. This has raised questions about whether the “real” underlying problem that patients experience is better described as a form of mood disorder, anxiety disorder, somatization (), or if there are instances of SJSR that simply cannot be explained by any other category of experience. Whatever the case, the last two versions of the DSM have relegated the category to the periphery as a “local” issue. Nevertheless, shenjing shuairuo (hereafter abbreviated SJSR) has historically been very “real” to Chinese people and has entered into the lexicon of all native Chinese speakers. References to the illness in literature and magazines, webpages, and online shopping websites are numerous, and a simple web-search of the Chinese term yields a seemingly infinite array of information from countless perspectives. Professionally, in the decades approaching the turn of the twenty-first century, SJSR is claimed to account for up to half of all psychiatric diagnoses in China, and some Chinese neurologists and psychiatrists continue to insist that it is not merely a disorder of somatization, but a valid clinical category that may or may not have a clear correlate in mainstream Euro-American experience. It can be given as an account for undesirable behaviors, failure at work or school, difficulties in the home, and other functional impairments of daily life. Self-help instruction continues to be published on the topic as it has since the final decade of the nineteenth century; in 5 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-IV (American Psychiatric Association, 1998), 848. 2 fact, such material is more plenteous today. Medicines of all kinds are still on offer for those who might have developed the disorder. Furthermore, Chinese researchers continue to publish scientific papers based on neuroimaging, nerve conduction, and other methodologies in order to argue for the validity of this clinical category or for the purpose of finding effective treatment. A search for the term り in the Chinese academic database, CNKI, from 1990 to the present yields over 6,000 articles across a
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