Mind-Body Concepts and Mental Illness: A Study of Japanese Values
Mind-Body Concepts and Mental Illness: A Study of Japanese Values
Jerome YOUNG
Originally published in The Japanese Society of Psychiatry and Neurology, 2003, vol. 105, no. 8, pp. 1016-25.
This paper examines Japanese mind-body concepts and attempts to tease out some of the ways this philosophical orientation influences the Japanese view of mental illness. An analysis of key Japanese words will demonstrate that traditionally the Japanese have viewed the mind and body as inextricably intertwined and that this interconnectedness extends to the Japanese self conceptualization. It is argued that this Japanese value orientation sheds light on the stigma associated with mental illness and equally helps to explain the Japanese tendency to somatisize psychological distress. Because "mental" illness is perceived as a character weakness, "somatic talk" becomes a culturally coded idiom of distress providing the Japanese with a culturally acceptable way to influence the behavior of others while at the same time avoiding being labeled with a psychiatric disorder. Somatization in Japan, then, can be understood as an inherently ethical event that has more to do with morals than medicine.
Keywords: Self, Harmony, Language, Stigma, Morals
1. Introduction
In the West, the idea that the mind and body are distinct has a long history but this idea is a foreign one in the Japanese socio-cultural context (1). Descartes' attempt to formulate a scientific distinction between mind and body certainly left an indelible mark on Western psychiatric thought and it was through the importation of Western psychiatry that this analytic distinction was introduced to Japan. The Western distinction between mind and body, in fact, goes much further into the past than the works of Descartes (2), though his ideas were clearly influenced by these earlier thinkers. Traditionally, in the West, the concept of mind has been understood as, among other things, the seat of rationally and was, therefore, distinguished from the body which was understood as the seat of emotions and desires and was, thus, irrational by nature. However, while the mind in the West is conceived of as rational and separate from the emotions, the Japanese conceptualization points to an interfusing of thought and feeling, reason and emotion. As we will see, through a careful analysis of key Japanese mind-body concepts, the Japanese conceptualization blurs the distinction between emotion and reason and makes it difficult, in the Western manner, to distinguish mind from body. Consequently, a psychiatric diagnostic category like "somatization", which turns on the mind-body dichotomy, has not been widely used or understood in Japan (3). Such a diagnostic category is an abstraction based on a Western value orientation that seemingly ignores the phenomenological immediacy of lived experience in which, in the Japanese context, the mind and body are experienced as one, as an integrated, inter-connected whole. For a culture which does not subscribe to a mind-body dualism, somatization is a curious fact; however, it can be understood through an awareness of the value-orientation of the Japanese.
As there has been no tradition of separating the mind and body in Japan, the idea of "mental" illness has been a problematic one. However, we can begin to understand why this is so by looking at the Japanese self conceptualization. The Japanese sense of self is different from what is found in the West in that it is conceived of as socially embedded, as socially connected with and dependent on others (4). Since social harmony is a central cultural value in this group-oriented society, there is great emphasis placed upon forms of behavior and communication that do not disrupt the social order. For the Japanese, "mental" illness is perceived as voluntary, as an act displaying weakness of the will, and as originating in the self. A physical illness, in contrast, is perceived as being beyond one's control and, therefore, as something eliciting sympathy and concern from others. Therefore, the open expression of psychological distress is considered a sign of character weakness, which reflects poorly upon both the self and the family. For this reason, "somatic talk" (5) becomes a culturally appropriate way to communicate one's distress indirectly. Somatization in Japan, therefore, becomes a culturally coded "idiom of distress" (6) arising, in part, because of a cultural emphasis on indirect communication (7). In view of the fact that mental illness is perceived culturally as a weakness in one's ability to endure difficult situations and, thus, is something entirely within one's power to control, expressing emotional distress somatically is one way of getting sympathy while, at the same time, avoiding being labeled with a psychiatric disorder, which remains very stigmatized in Japan (8). For these reasons, it is argued that somatization is an inherently ethical act meant to produce social change. The tendency to somatisize in Japan, thus, has more to do with Japanese values than with medicine or with the acceptance of a Western dualism.
2. Analysis of Mind-Body Concepts in Japan
The philosophical method used to unravel the Japanese conceptualization of mind and body is one championed by the Oxford philosopher J.L. Austin (9). Austin argued that an analysis of ordinary words can help us to get at the realities to which the words refer. As Austin said, "we are using a sharpened awareness of words to sharpen our perception of...the phenomena."(10). In this instance, the ordinary words examined are Kanji related and the goal is to see what these words tell us about how the Japanese conceptualize the mind and body. There are several Japanese words translated into English as "mind" but, in fact, they have subtle semantic nuances which suggest they are semantically quite far from the Western idea "mind". A careful consideration of these words will show that the Japanese conceptualize the mind and body as inextricably intertwined. These words connote not only interconnectedness between the mind and body but also a sense of interconnectedness that extends to the individual's connection with his natural and social environment too. What we learn from these words is that for the Japanese there is an intuition that the human being is a unity, a whole, that is not only integrated spiritually and physically, but also socially and naturally. This analysis will show that the ordinary Japanese view of the mind and body runs counter to the modern Western philosophical tradition that informs psychiatric science.
Two Japanese words frequently translated as "mind" are Atama (頭) and Zunou (頭脳). In addition to "mind", Atama is also translated as "head", "brain" and "intellect" (11). These connotations relate to the original meaning of the Kanji which is descriptive and refers to "that which is at the top" (12) of the body. When we turn to the Kanji for Zunou (頭脳), which is translated as "mind", "brain", "intelligence", or "the power to make a decision", we see that the first Kanji is Atama (head) and the second refers to the physical brain (脳). These words seem to reflect a phenomenological orientation in Eastern thinking in that the words are descriptive of anatomy rather than imbued with the heavy metaphysical connotations of the Western word. It is true that both words connote "intellect" but the point seems to be that the head is the source of decision making. For the Japanese, however, decision making requires more than just the understanding of the intellect. There is a cultural sense that feeling is also integral to the process.
One key word in the Japanese conceptualization of "mind" is the word Hara (腹). This word is significant because we can begin to see the blurring together of the concepts mind and body and thought and feeling. Semantically, the word has a variety of nuances, including "abdomen", "heart,” “mind", "intention", "courage", and "spirit". For the ancient Japanese the abdomen (Hara) was considered the physical center of the body, but, importantly, was considered the seat of the soul. Thus, in the concept Hara we see the merging of the physical (the abdomen) and the mental (thought and emotion)(13). The centrality of this concept in Japanese culture and sentiment is evident from both the diverse idiomatic expressions in which it is used and the importance it played in the ancient tradition of Seppuku (ritual suicide). A samurai warrior would commit Seppuku (that is, cut open his abdomen) because it was believed that he could only redeem his honor through the physical display of his purity, his soul. The sincerity in which this brutal act was performed is a clear testament of the importance of Hara in Japanese consciousness.
Closely related to this concept is the word Shin (心), which has many shades of meaning as well as different phonetic readings—it can be pronounced as both Shin and Kokoro. Nelson translates Shin as "heart, mind, spirit; motive, sense (of duty)" and translates Kokoro as "mind, spirit; mentality; thought; heart, feeling ; sincerity, sympathy ; will; intention; mood". Even though Nelson lists "mind" as one translation of both phonetic readings, the primary everyday sense of the word is "heart". Interestingly, when the Japanese discuss their Kokoro, their thoughts, they usually point to the chest, not to the head (as they would if they were using the expressions Atama or Zunou). Similarly, when discussing feeling or heart, the concept Kokoro invariably arises in the conversation. Thus, one can also see in this concept a blending of ideas.
The Kanji 身 (which can be pronounced as either Shin or Mi) is usually translated as "body". Shin, however, has many different meanings besides body, including "person ; one's station in life ; self; heart, soul, mind; ability; life." The Japanese conceptualization of body, therefore, encompasses more than what, from a Western viewpoint, is meant by body. Since Shin connotes "person", "self", "one's station in life" and "ability" we are confronted with a word that places the body conceptually within the broader context of society as a whole. Just as that which possess life is an integral part of nature, so too that same thing is an integral part of the social nexus where one has a "station in life" and where one is recognized as a person. Hence, the Japanese sense of self is rooted in bodily experience which, in turn, is squarely enmeshed within the social nexus. What we can see from the connotation of these Kanji is that Shin (in either sense of the term) has far broader scope than mind and body in the Western sense of the words. Both words point to something that is physical (the heart in the chest) and yet also spiritual (the soul or spirit).
Another important word in the Japanese conceptualization of mind is Seishin (精神). This term is central to many aspects of Japanese life, in particular religious experience and the Japanese understanding of the self, and is a word whose subtlety is difficult to grasp. The first Kanji, Sei (精), can be translated in many ways, including "spirit; energy ; vitality; excellence, purity ; skill." The second Kanji Shin (神) can be translated as both "mind" or "soul" and "god". Together these Kanji can be translated as "mind, spirit, soul, heart; intention, motive." What we can infer from Seishin is that it "refers to one's inner being" (14) because it captures several key elements (i.e., heart, soul, and will) of the Japanese conception of self. We should not, however, immediately conclude that this implies an acceptance of a mind-body dualism; rather, what Seishin is pointing to is the Japanese dualistic view of the self which is understood, in a socially significant sense, as possessing an inner and outer dimension. What we find with Seishin is a blurring between the mind and body because the locus of Seishin may be the mind or the body, in the Western senses of the words, depending on emphasis.
What has emerged from these linguistic considerations is a view of the mind and body as an integrated whole and as something that does not lend itself to a hard and fast analytical separation. Such a separation is an abstraction which seemingly invalidates lived experience. In Japan there is no precedent for such a separation and, as is most evident linguistically, the conceptually distinct Western ideas are irrevocably blurred. Given the fact that the mind-body "problem" was an imported one, and given the inherent conceptual interconnectedness of the mind and body, we can infer that traditionally there has been no perceived separation between them. In fact, ordinary Japanese words give one the impression that the mind and body are one inextricably integrated, experiential whole. Moreover, this is a holism that extends to all aspects of lived experience. While such conceptual vagueness may be troublesome for Westerners, the Japanese do not seem to be bothered by such ambiguity and rely on an intuitive sense of its appropriateness.
3. Values, Self, and Mental Illness
The foregoing analysis has made evident that the Japanese conceptualization of mind and body is at odds with the Western conceptualization, at least the one pivotal for psychiatric science, i.e. the Cartesian tradition (15). The crucial difference is that the mind and body are conceived of as unified, as phenomenologically one. Importantly, however, this unity extends beyond nature itself because the mind-body is also conceived of as socially embedded. This is a significant finding because it forces the discussion of the nature of mental illness beyond the narrow limits of the reductionistic, biologically-oriented psychiatry that is so much in vogue today. This linguistic insight shows us that in order to fully appreciate mental illness in Japan, we must approach the issue from a broader perspective, one that sees it in its socio-cultural context. In particular, what this entails is a recognition that values matter, that they make a difference in what people believe, how they act, and how they look at the world. Since "mental disorders cannot be understood apart from the concept of self,” (16) the Japanese view of the self can shed light on how mental illness is perceived. Although a complete analysis of the Japanese self conceptualization is beyond the scope of this paper, a cursory review will help to show why mental illness is disvalued (i.e. stigmatized) in this culture.
In the West, the self is conceptualized as autonomous, independent, and free. The Japanese view of the self, in contrast, is one in which the individual is seen as socially embedded, in which dependence on and compliance to other's wishes is crucial for a harmonious social order. For this reason, the harmonious collectivity of the whole, rather than autonomous individuality, is the crucial value underlying the Japanese conception of self. This difference in value-orientation relates to the earlier linguistic analysis of mind-body concepts because this conceptual integration extends to the Japanese conception of the relationship between the self and society. The consequences of this integration are enormous for understanding how mental illness is perceived socially. Much of Japanese early socialization is tied to fostering an attitude that the self is reliant on others and that one must, on many occasions, consider the fulfillment of one's own desires and wishes as secondary to the harmony of the collectivity to which the self belongs. Hence, in order to understand the self in Japan, and to appreciate why mental illness is disvalued, it is important to recognize the centrality of the moral value of harmony in the Japanese socio-cultural context.
The desire to maintain social harmony has given rise to a social conception of the self that, in practice, is bifurcated. Inasmuch as the group-oriented values in Japan dictate conformity and co-operation, one must be cognizant of one's social environment in order to avoid conflict. For this reason, the socialization of the Japanese involves learning to be able to slide effortlessly between one's public (outer) self and one's private (inner) self (17). Consequently, for the Japanese, a person's true beliefs (Honne) are not necessarily the same as his public pronouncements (Tatemae). Frequently, one must be able to restrain one's desires, wishes, beliefs, and personal preferences in order to maintain social harmony. Crucially, the ability to control one's self for the sake of harmony is the result of a strong will, that is, a strong Seishin (精神). The concept Seishin (spirit, heart or will) is, moreover, key to understanding the Japanese conceptualization of the moral self because it "tends to dictate the way in which people ought to behave in Japanese society." (18). In public one must be patient and emotionally self-restrained (Gaman), even in very difficult situations. Any emotional outburst would be perceived as a sign of character weakness and for would be avoided strenuously because such behavior threatens social harmony. The threat of being turned out of one's group is a strong incentive to maintain control over one's emotions. Those who are not able to do so, for whatever reason, are shunned and become outsiders.
That Seishin is a highly prized cultural value should not be underestimated. A strong Seishin manifests itself in some curious ways, one of which involves communicative style in which verbalization is perceived as unnecessary for expressing one's feelings or thoughts. For Westerners, this communicative style may seem confusing, even illogical, but for the Japanese it is perceived as necessary to be able to understand what someone wants or is thinking without that person saying anything at all. Silence is a cultural value that is a strong part of the Japanese sense of self. This sense is related to the inner dimension of the self, which is symbolized by both Kokoro (心) and Hara (腹) and which together represent what can be understood as the "pure" self (Seishin). The inner self always remains true to itself, even when it is unable, for reasons dictated by social circumstances, to express its desires, wishes, or goals. The outer self, in contrast, is symbolized by the face (顔) and mouth (口) and is something to be distrusted because it is in and of itself public by nature (19). It is for this reason that the open expression of emotional distress is viewed as socially disruptive and something to be avoided. To express such distress openly, either in words, facial expressions, or actions, would lead to social disharmony and distrust; whereas if one can maintain control and be silent, no matter the circumstances, is indicative of a strong will and character. Any deviation from normal patterns of behavior leads to conflicts and embarrassment because it reflects poorly on one's self which reflects poorly on one's group.
The centrality of Seishin in the Japanese conception of self, interestingly, plays a pivotal role in Japanese psychiatry too. Because these Kanji refer to one's "pure" (or moral) self, and because they are used in many Japanese translations of Western psychiatric diagnostic categories, a diagnosis of a mental illness implies that there is something wrong with the purity or the morality of one's self. The use of these Kanji is unfortunate because it paints a picture of a disease of the self that is often, in appearance at least, quite pejorative, conceptually devastating to contemplate, and, therefore, something to be avoided at all costs. For this reason, mental illness is ranked alongside cancer in the degree of fear it produces in Japanese. Because the words are so pejorative, advocates for the mentally ill in Japan, such as the group Zenkaren, have sought to change these diagnostic labels (20).
While mental illness is problematic culturally because there is no hard and fast distinction between the mind and body, one of the main reasons why a diagnosis of mental illness is so highly stigmatized in Japan is the result of the linguistic nuances of the psychiatric diagnostic categories. This is undoubtedly one of the reasons why Japanese patients seem to prefer to be seen as having a physical rather than a psychological disorder. Many psychiatric terms contribute to the social disvalue related to mental illness in Japan precisely because the translations of Western diagnostic categories employ Kanji with moral overtones that go far beyond the best intentions of psychiatric nosology by implying that the ill individual's problem is really a moral one.
4. Values and Medically Unexplained Somatic Symptoms
In Japan, the move to think of the mind as separate from the body is of recent origin and can probably be traced back to the publication of DSM-III (21) with its introduction of "somatoform disorders" as part of the official psychiatric nomenclature. While it is believed that medically unexplained somatic symptoms occur with regularity in general populations the world over (22) and while some even believe somatization is a universal syndrome (23), as a diagnostic category non-Western countries have had difficulty adopting this psychiatric category (24) and Japan is no exception in this regard. What makes this particular disorder problematic cross-culturally is the implicit dualistic epistemology contained in it. Subjective awareness and direct observation are blurred in the Japanese context to such an extent that to understand somatization requires seeing it in its broader social and ethical context. That is to say, we need to be cognizant of the role values play in way people present their complaints because they are explainable in light of these values.
In Japan there is a cultural tendency to view the basic cause of illness as an imbalance in the body (25). The Japanese seem to prefer a body illness over a mental one because the body is seen as weak and prone to disease. The idea, therefore, that there is an underlying psychological, rather than organic or physiological, mechanism causing medically unexplained somatic symptoms runs counter to this Japanese sense and is problematic for general practitioners to recognize. The culturally acceptable sick role is one in which the body is pivotal and the goal of most treatment is restoring equilibrium in the body. The Japanese tend to believe that once a proper balance is achieved, a complete state of health will result. In general practice, physicians who suspect there may be an underlying psychological cause for the unexplainable somatic complaints frequently ignore this suspicion and will instead treat only the physical symptoms (26). The reason for this emphasis on the body is, in part, the result of cultural values concerning the nature of illness but it is also, in part, probably the result of the stigma associated with mental illness. Suggesting that a patient's somatic complaints are psychological, in effect, suggests there is something wrong with the person's true, "pure", moral self. Hence, patients and physicians both seem to favor treating the somatic complaints rather than addressing the underlying psychological causes. It in fact, in a recent epidemiological study of somatoform symptoms in a Japanese community population it was discovered that none of the participants in the study who reported unexplained somatic symptoms sought psychiatric care (27).
Because of the importance placed on social harmony in Japan, socialization processes involve considerable training in developing proper ways to conduct one's personal relations with others. One way to understand somatization, therefore, is as a culturally coded idiom of distress because it serves as a strategy to show one's discontent about some social situation. Hence, the body as metaphor becomes a subtle but powerful way to express distress and influence the behavior of others. Hence, medically unexplained somatic distress becomes a communicative style to indirectly express distress about a social situation which culturally cannot be confronted directly. If one expresses one's disapproval of something directly by being emotional it probably would be perceived as a deliberate act causing trouble for others and as indicative of a weak self. However, as the body is perceived as being prone to illnesses beyond one's control, physical illness garners sympathy. Because conformity and co-operation are highly valued, other "indirect" methods have to be employed when seeking to change a socially unacceptable situation. Since somatic illness is one way garner sympathy, to produce a change in people (i.e. they are sympathetic, nurturing, and indulgent to the sick person), it follows that somatization is a subtle way to produce changes in the behavior of others close to the "sick" person.
Because the cultural values underlying a Japanese sense of illness and those influencing communicative style are so internalized, people are largely unaware of their influence. For this reason, somatization is a seemingly unconscious way of dealing with social problems or emotional distress. For example, within the context of the family a person expressing psychologically-based somatic distress would, in effect, be unconsciously trying to influence the behavior of those around her. Hence, a claim can be made that there is little and perhaps sometimes no subjective awareness that the somatic complaints are the results of psychological distress. Moreover, in a clinical setting, these social dynamics would need to be decoded in order to find the underlying psychological cause of the medically unexplained somatic symptoms. Such a decoding process requires interpretation rather than direct observation: the practitioner becomes a kind of cultural rather than disease detective. Inasmuch as the practitioner is also influenced by cultural values concerning social harmony, the self and illness, addressing the underlying psychological basis of the somatic complaints becomes a highly delicate operation. Somatization in Japan provides strong grounds for concluding that the nature of this illness is by nature ethical.
The phenomenon of somatization in Japan involves a wide array of Japanese values concerning the mind, body, self, illness and the proper way to express dissatisfaction within one's group. I argued that somatization has more to do with morals than medicine because medically unexplained somatic symptoms in Japan constitute a communicative style, one eminently suited to the Japanese, aimed at producing social change. Somatization can be understood as a non-confrontational form of distress which uses body language rather than emotional confrontation to influence the behavior of others.
5. Conclusion
In this paper, key Japanese words related to the mind and body were examined. This analysis showed that these words have semantic implications that go far beyond their Western counterparts. These words, we discovered, not only imply a unity of the mind and body but also a unity between man and nature and between the self and society. The argument then briefly discussed the Japanese conception of self, discussing how the concept Seishin is central for this conceptualization and discussing how its use in psychiatric diagnostic categories is one important factor for understanding why mental illness is stigmatized in Japan. What we found is that the cultural and linguistic connotations of many Japanese psychiatric diagnostic categories are so pejorative that no one "in his right mind" would ever admit to suffering from such problems because it frequently entails an admission of having a moral problem. The argument then looked at how these ideas influence the presentation of psychological distress, particularly in relation to medically unexplained somatic symptoms. It was argued that the tendency toward somatization in Japan can be understood as a culturally coded idiom of distress which is inherently ethical. Because mental illness is highly stigmatize, it is necessary to resort to a somatic illness to seek redress from socially and emotionally disturbing situations. For this reason, I argued that the presentation of medically unexplained symptoms has more to do with morals than medicine.
References
1) Lock, M.: Popular Conceptions of Mental Health in Japan. In Cultural Conceptions of Mental Health and Therapy (ed. By Marsella, A.J. and White, G.M.) D. Reidel Publishing Company, Dordrecht, 215-233, 1982
2) Cf. Porter, R.: Madness : A Brief History. Oxford University Press, Oxford, 2002
3) Nakane, Y.: Classification of Somatoform Disorders in Japan. In Somatoform Disorders—A Worldwide Perspective, (ed. by Ono, Y., Janca, A., Asai, M., Sartorius, N.), Springer Verlag, Tokyo, p. 47-56, 1999
4) Doi, T.: The Anatomy of Dependence, (trans. Bester, J.), Kodansha International, Tokyo, 1973
5) Kawanishi, Y.: Somatization of Asians: An Artifact of Western Medication? Transcultural Psychiatric Research Review 29 ; 5-36, 1992
6) Kleinman, A.: Rethinking Psychiatry : From Cultural Category to Personal Experience. The Free Press, New York, 1988
7) Cf. Morsbach, H.: Aspects of Nonverbal Communication in Japan. The Journal of Nervous and Mental Disease, 157 ; 262-277, 1973
8) Cf. Munakata, T.: Japanese Attitude toward Mental Illness and Mental Health Care. In Japanese Culture and Behavior (eds. Lebra, T. and Lebra, W.). University of Hawaii Press, Honolulu, p. 369-378, 1986
9) Austin, J.L.: A Plea for Excuses. In Philosophical Papers. Oxford University Press, Oxford, cf. 130-134, 1961
10) Austin, op. cit. note 9, p. 130
11) Nelson, A.N.: The Modern Reader's Japanese-English Character Dictionary, 2nd Edition. Charles E. Tuttle Company, Tokyo, 1962. All subsequent translations, unless otherwise noted, are from this text.
12) Soga, M. & Yusa M.: Basic Kanji. Taishukan Publishing Co, Tokyo, 184-185, 1989
13) Kimura, K.: Are the Japanese Really Inscrutable? Minerva Press, London, 1998
14) Moeran, B.: Individual, Group and Seishin: Japan's Internal Cultural Debate. In Japanese Culture and Behavior (ed. By Lebra, T. and Lebra, W), University of Hawaii Press, Honolulu, p. 62-79, 1986
15) Interestingly, the Japanese conceptualization is not that far off from other, earlier Western conceptualizations, such as those found in ancient Greece. This should not, however, be thought of as a sign of an inferior conceptualization—Foucault's work should stand as a cautionary tale against such thinking.
16) Marsella, A.: Culture and Mental Health. In Cultural Conceptions of Mental Health and Therapy (ed.Marsella A.J. & White, G.M.). D. Reidel Publishing Company, Dordrecht, p. 359-388, 1982
17) Doi, T.: Omote and Ura: Concepts Derived from the Japanese 2-fold Structure of Consciousness. The Journal of Nervous and Mental Disease, 157; 258-261, 1973
18) Moeran, op. cit. note 14, p. 74 (italics in original).
19) Lebra, T.: Japanese Patterns of Behavior. University of Hawaii Press, Honolulu, p. 159, 1976
20) Nakai, K.: Before and After the Replacement of the Term Schizophrenia—A Viewpoint of Family. Paper presented at the XII World Congress of Psychiatry, Yokohama, Japan, 2002
21) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder, 3rd edition. American Psychiatric Association, Washington, DC, 1980
22) Janca, A., Isaac, M. and Costa e Silva, J.A.: World Health Organization International study of Somatoform Disorders—background and rationale. European Journal of Psychiatry 9 ; 100-110, 1995
23) Isaac, M., Janca, A., Orley, J.: Somatization—A culture-bound or universal syndrome? Journal of Mental Health 5 ; 219-222, 1996
24) Mayou, R.: European Concepts. In Somatoform Disorders—A Worldwide Perspective (ed. by Ono, Y., Janca, A., Asai, M., Sartorius, N), Springer Verlag, Tokyo, p. 26-37, 1999
25) Ohnuki-Tierney, E.: Illness and Culture in Contemporary Japan : An Anthropological View. Cambridge University Press, Cambridge, pg. 75ff, 1984
26) Lock, M.: East Asian Medicine in Urban Japan. University of California Press, Berkeley, 1980
27) Ono Y., Yoshimura, K., Yamauchi, K., Asai, M., Young, J., Fujihara, S., Kitamura, T.: Somatoform Symptoms in Japanese Community Population: Prevalence and association with Personality Characteristics. Transcultural Psychiatry, 37 (2) ; 217-228, 2000
Jerome YOUNG
Originally published in The Japanese Society of Psychiatry and Neurology, 2003, vol. 105, no. 8, pp. 1016-25.
This paper examines Japanese mind-body concepts and attempts to tease out some of the ways this philosophical orientation influences the Japanese view of mental illness. An analysis of key Japanese words will demonstrate that traditionally the Japanese have viewed the mind and body as inextricably intertwined and that this interconnectedness extends to the Japanese self conceptualization. It is argued that this Japanese value orientation sheds light on the stigma associated with mental illness and equally helps to explain the Japanese tendency to somatisize psychological distress. Because "mental" illness is perceived as a character weakness, "somatic talk" becomes a culturally coded idiom of distress providing the Japanese with a culturally acceptable way to influence the behavior of others while at the same time avoiding being labeled with a psychiatric disorder. Somatization in Japan, then, can be understood as an inherently ethical event that has more to do with morals than medicine.
Keywords: Self, Harmony, Language, Stigma, Morals
1. Introduction
In the West, the idea that the mind and body are distinct has a long history but this idea is a foreign one in the Japanese socio-cultural context (1). Descartes' attempt to formulate a scientific distinction between mind and body certainly left an indelible mark on Western psychiatric thought and it was through the importation of Western psychiatry that this analytic distinction was introduced to Japan. The Western distinction between mind and body, in fact, goes much further into the past than the works of Descartes (2), though his ideas were clearly influenced by these earlier thinkers. Traditionally, in the West, the concept of mind has been understood as, among other things, the seat of rationally and was, therefore, distinguished from the body which was understood as the seat of emotions and desires and was, thus, irrational by nature. However, while the mind in the West is conceived of as rational and separate from the emotions, the Japanese conceptualization points to an interfusing of thought and feeling, reason and emotion. As we will see, through a careful analysis of key Japanese mind-body concepts, the Japanese conceptualization blurs the distinction between emotion and reason and makes it difficult, in the Western manner, to distinguish mind from body. Consequently, a psychiatric diagnostic category like "somatization", which turns on the mind-body dichotomy, has not been widely used or understood in Japan (3). Such a diagnostic category is an abstraction based on a Western value orientation that seemingly ignores the phenomenological immediacy of lived experience in which, in the Japanese context, the mind and body are experienced as one, as an integrated, inter-connected whole. For a culture which does not subscribe to a mind-body dualism, somatization is a curious fact; however, it can be understood through an awareness of the value-orientation of the Japanese.
As there has been no tradition of separating the mind and body in Japan, the idea of "mental" illness has been a problematic one. However, we can begin to understand why this is so by looking at the Japanese self conceptualization. The Japanese sense of self is different from what is found in the West in that it is conceived of as socially embedded, as socially connected with and dependent on others (4). Since social harmony is a central cultural value in this group-oriented society, there is great emphasis placed upon forms of behavior and communication that do not disrupt the social order. For the Japanese, "mental" illness is perceived as voluntary, as an act displaying weakness of the will, and as originating in the self. A physical illness, in contrast, is perceived as being beyond one's control and, therefore, as something eliciting sympathy and concern from others. Therefore, the open expression of psychological distress is considered a sign of character weakness, which reflects poorly upon both the self and the family. For this reason, "somatic talk" (5) becomes a culturally appropriate way to communicate one's distress indirectly. Somatization in Japan, therefore, becomes a culturally coded "idiom of distress" (6) arising, in part, because of a cultural emphasis on indirect communication (7). In view of the fact that mental illness is perceived culturally as a weakness in one's ability to endure difficult situations and, thus, is something entirely within one's power to control, expressing emotional distress somatically is one way of getting sympathy while, at the same time, avoiding being labeled with a psychiatric disorder, which remains very stigmatized in Japan (8). For these reasons, it is argued that somatization is an inherently ethical act meant to produce social change. The tendency to somatisize in Japan, thus, has more to do with Japanese values than with medicine or with the acceptance of a Western dualism.
2. Analysis of Mind-Body Concepts in Japan
The philosophical method used to unravel the Japanese conceptualization of mind and body is one championed by the Oxford philosopher J.L. Austin (9). Austin argued that an analysis of ordinary words can help us to get at the realities to which the words refer. As Austin said, "we are using a sharpened awareness of words to sharpen our perception of...the phenomena."(10). In this instance, the ordinary words examined are Kanji related and the goal is to see what these words tell us about how the Japanese conceptualize the mind and body. There are several Japanese words translated into English as "mind" but, in fact, they have subtle semantic nuances which suggest they are semantically quite far from the Western idea "mind". A careful consideration of these words will show that the Japanese conceptualize the mind and body as inextricably intertwined. These words connote not only interconnectedness between the mind and body but also a sense of interconnectedness that extends to the individual's connection with his natural and social environment too. What we learn from these words is that for the Japanese there is an intuition that the human being is a unity, a whole, that is not only integrated spiritually and physically, but also socially and naturally. This analysis will show that the ordinary Japanese view of the mind and body runs counter to the modern Western philosophical tradition that informs psychiatric science.
Two Japanese words frequently translated as "mind" are Atama (頭) and Zunou (頭脳). In addition to "mind", Atama is also translated as "head", "brain" and "intellect" (11). These connotations relate to the original meaning of the Kanji which is descriptive and refers to "that which is at the top" (12) of the body. When we turn to the Kanji for Zunou (頭脳), which is translated as "mind", "brain", "intelligence", or "the power to make a decision", we see that the first Kanji is Atama (head) and the second refers to the physical brain (脳). These words seem to reflect a phenomenological orientation in Eastern thinking in that the words are descriptive of anatomy rather than imbued with the heavy metaphysical connotations of the Western word. It is true that both words connote "intellect" but the point seems to be that the head is the source of decision making. For the Japanese, however, decision making requires more than just the understanding of the intellect. There is a cultural sense that feeling is also integral to the process.
One key word in the Japanese conceptualization of "mind" is the word Hara (腹). This word is significant because we can begin to see the blurring together of the concepts mind and body and thought and feeling. Semantically, the word has a variety of nuances, including "abdomen", "heart,” “mind", "intention", "courage", and "spirit". For the ancient Japanese the abdomen (Hara) was considered the physical center of the body, but, importantly, was considered the seat of the soul. Thus, in the concept Hara we see the merging of the physical (the abdomen) and the mental (thought and emotion)(13). The centrality of this concept in Japanese culture and sentiment is evident from both the diverse idiomatic expressions in which it is used and the importance it played in the ancient tradition of Seppuku (ritual suicide). A samurai warrior would commit Seppuku (that is, cut open his abdomen) because it was believed that he could only redeem his honor through the physical display of his purity, his soul. The sincerity in which this brutal act was performed is a clear testament of the importance of Hara in Japanese consciousness.
Closely related to this concept is the word Shin (心), which has many shades of meaning as well as different phonetic readings—it can be pronounced as both Shin and Kokoro. Nelson translates Shin as "heart, mind, spirit; motive, sense (of duty)" and translates Kokoro as "mind, spirit; mentality; thought; heart, feeling ; sincerity, sympathy ; will; intention; mood". Even though Nelson lists "mind" as one translation of both phonetic readings, the primary everyday sense of the word is "heart". Interestingly, when the Japanese discuss their Kokoro, their thoughts, they usually point to the chest, not to the head (as they would if they were using the expressions Atama or Zunou). Similarly, when discussing feeling or heart, the concept Kokoro invariably arises in the conversation. Thus, one can also see in this concept a blending of ideas.
The Kanji 身 (which can be pronounced as either Shin or Mi) is usually translated as "body". Shin, however, has many different meanings besides body, including "person ; one's station in life ; self; heart, soul, mind; ability; life." The Japanese conceptualization of body, therefore, encompasses more than what, from a Western viewpoint, is meant by body. Since Shin connotes "person", "self", "one's station in life" and "ability" we are confronted with a word that places the body conceptually within the broader context of society as a whole. Just as that which possess life is an integral part of nature, so too that same thing is an integral part of the social nexus where one has a "station in life" and where one is recognized as a person. Hence, the Japanese sense of self is rooted in bodily experience which, in turn, is squarely enmeshed within the social nexus. What we can see from the connotation of these Kanji is that Shin (in either sense of the term) has far broader scope than mind and body in the Western sense of the words. Both words point to something that is physical (the heart in the chest) and yet also spiritual (the soul or spirit).
Another important word in the Japanese conceptualization of mind is Seishin (精神). This term is central to many aspects of Japanese life, in particular religious experience and the Japanese understanding of the self, and is a word whose subtlety is difficult to grasp. The first Kanji, Sei (精), can be translated in many ways, including "spirit; energy ; vitality; excellence, purity ; skill." The second Kanji Shin (神) can be translated as both "mind" or "soul" and "god". Together these Kanji can be translated as "mind, spirit, soul, heart; intention, motive." What we can infer from Seishin is that it "refers to one's inner being" (14) because it captures several key elements (i.e., heart, soul, and will) of the Japanese conception of self. We should not, however, immediately conclude that this implies an acceptance of a mind-body dualism; rather, what Seishin is pointing to is the Japanese dualistic view of the self which is understood, in a socially significant sense, as possessing an inner and outer dimension. What we find with Seishin is a blurring between the mind and body because the locus of Seishin may be the mind or the body, in the Western senses of the words, depending on emphasis.
What has emerged from these linguistic considerations is a view of the mind and body as an integrated whole and as something that does not lend itself to a hard and fast analytical separation. Such a separation is an abstraction which seemingly invalidates lived experience. In Japan there is no precedent for such a separation and, as is most evident linguistically, the conceptually distinct Western ideas are irrevocably blurred. Given the fact that the mind-body "problem" was an imported one, and given the inherent conceptual interconnectedness of the mind and body, we can infer that traditionally there has been no perceived separation between them. In fact, ordinary Japanese words give one the impression that the mind and body are one inextricably integrated, experiential whole. Moreover, this is a holism that extends to all aspects of lived experience. While such conceptual vagueness may be troublesome for Westerners, the Japanese do not seem to be bothered by such ambiguity and rely on an intuitive sense of its appropriateness.
3. Values, Self, and Mental Illness
The foregoing analysis has made evident that the Japanese conceptualization of mind and body is at odds with the Western conceptualization, at least the one pivotal for psychiatric science, i.e. the Cartesian tradition (15). The crucial difference is that the mind and body are conceived of as unified, as phenomenologically one. Importantly, however, this unity extends beyond nature itself because the mind-body is also conceived of as socially embedded. This is a significant finding because it forces the discussion of the nature of mental illness beyond the narrow limits of the reductionistic, biologically-oriented psychiatry that is so much in vogue today. This linguistic insight shows us that in order to fully appreciate mental illness in Japan, we must approach the issue from a broader perspective, one that sees it in its socio-cultural context. In particular, what this entails is a recognition that values matter, that they make a difference in what people believe, how they act, and how they look at the world. Since "mental disorders cannot be understood apart from the concept of self,” (16) the Japanese view of the self can shed light on how mental illness is perceived. Although a complete analysis of the Japanese self conceptualization is beyond the scope of this paper, a cursory review will help to show why mental illness is disvalued (i.e. stigmatized) in this culture.
In the West, the self is conceptualized as autonomous, independent, and free. The Japanese view of the self, in contrast, is one in which the individual is seen as socially embedded, in which dependence on and compliance to other's wishes is crucial for a harmonious social order. For this reason, the harmonious collectivity of the whole, rather than autonomous individuality, is the crucial value underlying the Japanese conception of self. This difference in value-orientation relates to the earlier linguistic analysis of mind-body concepts because this conceptual integration extends to the Japanese conception of the relationship between the self and society. The consequences of this integration are enormous for understanding how mental illness is perceived socially. Much of Japanese early socialization is tied to fostering an attitude that the self is reliant on others and that one must, on many occasions, consider the fulfillment of one's own desires and wishes as secondary to the harmony of the collectivity to which the self belongs. Hence, in order to understand the self in Japan, and to appreciate why mental illness is disvalued, it is important to recognize the centrality of the moral value of harmony in the Japanese socio-cultural context.
The desire to maintain social harmony has given rise to a social conception of the self that, in practice, is bifurcated. Inasmuch as the group-oriented values in Japan dictate conformity and co-operation, one must be cognizant of one's social environment in order to avoid conflict. For this reason, the socialization of the Japanese involves learning to be able to slide effortlessly between one's public (outer) self and one's private (inner) self (17). Consequently, for the Japanese, a person's true beliefs (Honne) are not necessarily the same as his public pronouncements (Tatemae). Frequently, one must be able to restrain one's desires, wishes, beliefs, and personal preferences in order to maintain social harmony. Crucially, the ability to control one's self for the sake of harmony is the result of a strong will, that is, a strong Seishin (精神). The concept Seishin (spirit, heart or will) is, moreover, key to understanding the Japanese conceptualization of the moral self because it "tends to dictate the way in which people ought to behave in Japanese society." (18). In public one must be patient and emotionally self-restrained (Gaman), even in very difficult situations. Any emotional outburst would be perceived as a sign of character weakness and for would be avoided strenuously because such behavior threatens social harmony. The threat of being turned out of one's group is a strong incentive to maintain control over one's emotions. Those who are not able to do so, for whatever reason, are shunned and become outsiders.
That Seishin is a highly prized cultural value should not be underestimated. A strong Seishin manifests itself in some curious ways, one of which involves communicative style in which verbalization is perceived as unnecessary for expressing one's feelings or thoughts. For Westerners, this communicative style may seem confusing, even illogical, but for the Japanese it is perceived as necessary to be able to understand what someone wants or is thinking without that person saying anything at all. Silence is a cultural value that is a strong part of the Japanese sense of self. This sense is related to the inner dimension of the self, which is symbolized by both Kokoro (心) and Hara (腹) and which together represent what can be understood as the "pure" self (Seishin). The inner self always remains true to itself, even when it is unable, for reasons dictated by social circumstances, to express its desires, wishes, or goals. The outer self, in contrast, is symbolized by the face (顔) and mouth (口) and is something to be distrusted because it is in and of itself public by nature (19). It is for this reason that the open expression of emotional distress is viewed as socially disruptive and something to be avoided. To express such distress openly, either in words, facial expressions, or actions, would lead to social disharmony and distrust; whereas if one can maintain control and be silent, no matter the circumstances, is indicative of a strong will and character. Any deviation from normal patterns of behavior leads to conflicts and embarrassment because it reflects poorly on one's self which reflects poorly on one's group.
The centrality of Seishin in the Japanese conception of self, interestingly, plays a pivotal role in Japanese psychiatry too. Because these Kanji refer to one's "pure" (or moral) self, and because they are used in many Japanese translations of Western psychiatric diagnostic categories, a diagnosis of a mental illness implies that there is something wrong with the purity or the morality of one's self. The use of these Kanji is unfortunate because it paints a picture of a disease of the self that is often, in appearance at least, quite pejorative, conceptually devastating to contemplate, and, therefore, something to be avoided at all costs. For this reason, mental illness is ranked alongside cancer in the degree of fear it produces in Japanese. Because the words are so pejorative, advocates for the mentally ill in Japan, such as the group Zenkaren, have sought to change these diagnostic labels (20).
While mental illness is problematic culturally because there is no hard and fast distinction between the mind and body, one of the main reasons why a diagnosis of mental illness is so highly stigmatized in Japan is the result of the linguistic nuances of the psychiatric diagnostic categories. This is undoubtedly one of the reasons why Japanese patients seem to prefer to be seen as having a physical rather than a psychological disorder. Many psychiatric terms contribute to the social disvalue related to mental illness in Japan precisely because the translations of Western diagnostic categories employ Kanji with moral overtones that go far beyond the best intentions of psychiatric nosology by implying that the ill individual's problem is really a moral one.
4. Values and Medically Unexplained Somatic Symptoms
In Japan, the move to think of the mind as separate from the body is of recent origin and can probably be traced back to the publication of DSM-III (21) with its introduction of "somatoform disorders" as part of the official psychiatric nomenclature. While it is believed that medically unexplained somatic symptoms occur with regularity in general populations the world over (22) and while some even believe somatization is a universal syndrome (23), as a diagnostic category non-Western countries have had difficulty adopting this psychiatric category (24) and Japan is no exception in this regard. What makes this particular disorder problematic cross-culturally is the implicit dualistic epistemology contained in it. Subjective awareness and direct observation are blurred in the Japanese context to such an extent that to understand somatization requires seeing it in its broader social and ethical context. That is to say, we need to be cognizant of the role values play in way people present their complaints because they are explainable in light of these values.
In Japan there is a cultural tendency to view the basic cause of illness as an imbalance in the body (25). The Japanese seem to prefer a body illness over a mental one because the body is seen as weak and prone to disease. The idea, therefore, that there is an underlying psychological, rather than organic or physiological, mechanism causing medically unexplained somatic symptoms runs counter to this Japanese sense and is problematic for general practitioners to recognize. The culturally acceptable sick role is one in which the body is pivotal and the goal of most treatment is restoring equilibrium in the body. The Japanese tend to believe that once a proper balance is achieved, a complete state of health will result. In general practice, physicians who suspect there may be an underlying psychological cause for the unexplainable somatic complaints frequently ignore this suspicion and will instead treat only the physical symptoms (26). The reason for this emphasis on the body is, in part, the result of cultural values concerning the nature of illness but it is also, in part, probably the result of the stigma associated with mental illness. Suggesting that a patient's somatic complaints are psychological, in effect, suggests there is something wrong with the person's true, "pure", moral self. Hence, patients and physicians both seem to favor treating the somatic complaints rather than addressing the underlying psychological causes. It in fact, in a recent epidemiological study of somatoform symptoms in a Japanese community population it was discovered that none of the participants in the study who reported unexplained somatic symptoms sought psychiatric care (27).
Because of the importance placed on social harmony in Japan, socialization processes involve considerable training in developing proper ways to conduct one's personal relations with others. One way to understand somatization, therefore, is as a culturally coded idiom of distress because it serves as a strategy to show one's discontent about some social situation. Hence, the body as metaphor becomes a subtle but powerful way to express distress and influence the behavior of others. Hence, medically unexplained somatic distress becomes a communicative style to indirectly express distress about a social situation which culturally cannot be confronted directly. If one expresses one's disapproval of something directly by being emotional it probably would be perceived as a deliberate act causing trouble for others and as indicative of a weak self. However, as the body is perceived as being prone to illnesses beyond one's control, physical illness garners sympathy. Because conformity and co-operation are highly valued, other "indirect" methods have to be employed when seeking to change a socially unacceptable situation. Since somatic illness is one way garner sympathy, to produce a change in people (i.e. they are sympathetic, nurturing, and indulgent to the sick person), it follows that somatization is a subtle way to produce changes in the behavior of others close to the "sick" person.
Because the cultural values underlying a Japanese sense of illness and those influencing communicative style are so internalized, people are largely unaware of their influence. For this reason, somatization is a seemingly unconscious way of dealing with social problems or emotional distress. For example, within the context of the family a person expressing psychologically-based somatic distress would, in effect, be unconsciously trying to influence the behavior of those around her. Hence, a claim can be made that there is little and perhaps sometimes no subjective awareness that the somatic complaints are the results of psychological distress. Moreover, in a clinical setting, these social dynamics would need to be decoded in order to find the underlying psychological cause of the medically unexplained somatic symptoms. Such a decoding process requires interpretation rather than direct observation: the practitioner becomes a kind of cultural rather than disease detective. Inasmuch as the practitioner is also influenced by cultural values concerning social harmony, the self and illness, addressing the underlying psychological basis of the somatic complaints becomes a highly delicate operation. Somatization in Japan provides strong grounds for concluding that the nature of this illness is by nature ethical.
The phenomenon of somatization in Japan involves a wide array of Japanese values concerning the mind, body, self, illness and the proper way to express dissatisfaction within one's group. I argued that somatization has more to do with morals than medicine because medically unexplained somatic symptoms in Japan constitute a communicative style, one eminently suited to the Japanese, aimed at producing social change. Somatization can be understood as a non-confrontational form of distress which uses body language rather than emotional confrontation to influence the behavior of others.
5. Conclusion
In this paper, key Japanese words related to the mind and body were examined. This analysis showed that these words have semantic implications that go far beyond their Western counterparts. These words, we discovered, not only imply a unity of the mind and body but also a unity between man and nature and between the self and society. The argument then briefly discussed the Japanese conception of self, discussing how the concept Seishin is central for this conceptualization and discussing how its use in psychiatric diagnostic categories is one important factor for understanding why mental illness is stigmatized in Japan. What we found is that the cultural and linguistic connotations of many Japanese psychiatric diagnostic categories are so pejorative that no one "in his right mind" would ever admit to suffering from such problems because it frequently entails an admission of having a moral problem. The argument then looked at how these ideas influence the presentation of psychological distress, particularly in relation to medically unexplained somatic symptoms. It was argued that the tendency toward somatization in Japan can be understood as a culturally coded idiom of distress which is inherently ethical. Because mental illness is highly stigmatize, it is necessary to resort to a somatic illness to seek redress from socially and emotionally disturbing situations. For this reason, I argued that the presentation of medically unexplained symptoms has more to do with morals than medicine.
References
1) Lock, M.: Popular Conceptions of Mental Health in Japan. In Cultural Conceptions of Mental Health and Therapy (ed. By Marsella, A.J. and White, G.M.) D. Reidel Publishing Company, Dordrecht, 215-233, 1982
2) Cf. Porter, R.: Madness : A Brief History. Oxford University Press, Oxford, 2002
3) Nakane, Y.: Classification of Somatoform Disorders in Japan. In Somatoform Disorders—A Worldwide Perspective, (ed. by Ono, Y., Janca, A., Asai, M., Sartorius, N.), Springer Verlag, Tokyo, p. 47-56, 1999
4) Doi, T.: The Anatomy of Dependence, (trans. Bester, J.), Kodansha International, Tokyo, 1973
5) Kawanishi, Y.: Somatization of Asians: An Artifact of Western Medication? Transcultural Psychiatric Research Review 29 ; 5-36, 1992
6) Kleinman, A.: Rethinking Psychiatry : From Cultural Category to Personal Experience. The Free Press, New York, 1988
7) Cf. Morsbach, H.: Aspects of Nonverbal Communication in Japan. The Journal of Nervous and Mental Disease, 157 ; 262-277, 1973
8) Cf. Munakata, T.: Japanese Attitude toward Mental Illness and Mental Health Care. In Japanese Culture and Behavior (eds. Lebra, T. and Lebra, W.). University of Hawaii Press, Honolulu, p. 369-378, 1986
9) Austin, J.L.: A Plea for Excuses. In Philosophical Papers. Oxford University Press, Oxford, cf. 130-134, 1961
10) Austin, op. cit. note 9, p. 130
11) Nelson, A.N.: The Modern Reader's Japanese-English Character Dictionary, 2nd Edition. Charles E. Tuttle Company, Tokyo, 1962. All subsequent translations, unless otherwise noted, are from this text.
12) Soga, M. & Yusa M.: Basic Kanji. Taishukan Publishing Co, Tokyo, 184-185, 1989
13) Kimura, K.: Are the Japanese Really Inscrutable? Minerva Press, London, 1998
14) Moeran, B.: Individual, Group and Seishin: Japan's Internal Cultural Debate. In Japanese Culture and Behavior (ed. By Lebra, T. and Lebra, W), University of Hawaii Press, Honolulu, p. 62-79, 1986
15) Interestingly, the Japanese conceptualization is not that far off from other, earlier Western conceptualizations, such as those found in ancient Greece. This should not, however, be thought of as a sign of an inferior conceptualization—Foucault's work should stand as a cautionary tale against such thinking.
16) Marsella, A.: Culture and Mental Health. In Cultural Conceptions of Mental Health and Therapy (ed.Marsella A.J. & White, G.M.). D. Reidel Publishing Company, Dordrecht, p. 359-388, 1982
17) Doi, T.: Omote and Ura: Concepts Derived from the Japanese 2-fold Structure of Consciousness. The Journal of Nervous and Mental Disease, 157; 258-261, 1973
18) Moeran, op. cit. note 14, p. 74 (italics in original).
19) Lebra, T.: Japanese Patterns of Behavior. University of Hawaii Press, Honolulu, p. 159, 1976
20) Nakai, K.: Before and After the Replacement of the Term Schizophrenia—A Viewpoint of Family. Paper presented at the XII World Congress of Psychiatry, Yokohama, Japan, 2002
21) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder, 3rd edition. American Psychiatric Association, Washington, DC, 1980
22) Janca, A., Isaac, M. and Costa e Silva, J.A.: World Health Organization International study of Somatoform Disorders—background and rationale. European Journal of Psychiatry 9 ; 100-110, 1995
23) Isaac, M., Janca, A., Orley, J.: Somatization—A culture-bound or universal syndrome? Journal of Mental Health 5 ; 219-222, 1996
24) Mayou, R.: European Concepts. In Somatoform Disorders—A Worldwide Perspective (ed. by Ono, Y., Janca, A., Asai, M., Sartorius, N), Springer Verlag, Tokyo, p. 26-37, 1999
25) Ohnuki-Tierney, E.: Illness and Culture in Contemporary Japan : An Anthropological View. Cambridge University Press, Cambridge, pg. 75ff, 1984
26) Lock, M.: East Asian Medicine in Urban Japan. University of California Press, Berkeley, 1980
27) Ono Y., Yoshimura, K., Yamauchi, K., Asai, M., Young, J., Fujihara, S., Kitamura, T.: Somatoform Symptoms in Japanese Community Population: Prevalence and association with Personality Characteristics. Transcultural Psychiatry, 37 (2) ; 217-228, 2000
