Strange Maladies

Whenever a piece of glass breaks, Gede Sudiasih opens the notebook that lies on his living room table and makes an entry. He writes down what the glass was and the exact time, the day and the year that it broke. He then checks and rechecks his entry. Only after he is assured the information is accurate can he close the notebook and return to his daily routine. Decades of incidents have been recorded in this notebook.

Gede is an anxious, haggard-looking man who lives in a small village on the Indonesian island of Bali. Like many other Balians with mental illness, he is treated no differently than his fellow villagers and shows up for work as a government employee every day. But his compulsions are very real. Recording broken glass, in fact, is far from his only obsession. He keeps track of the name of every person who passes by his house; and he is driven to revisit dead chickens he sees along the road, until he has inspected their most minute details. If he can't get the names or information he needs, Gede is overtaken with feelings of anxiousness so strong that it makes him want to die.

To rid himself of this curse, Gede has gone to traditional healers known as balians. One balian diagnosed Gede as a victim of black magic; the prescribed cure, which involved receiving a magical gold amulet and performing a purification ritual, left him feeling no better.

A Western psychologist would make another diagnosis: obsessive-compulsive disorder (OCD). People with OCD are compelled to perform repetitive tasks in a repetitive way, coupled with uncontrollable thoughts or impulses. But the way the illness presents itself in Gede is quite different from the way OCD presents itself in an American. And that difference may give researchers like myself an opportunity to understand the illness better.

So much is still unknown about how biology drives behavior in people afflicted with mental illness. One way for researchers to get a handle on this question is to study the way certain illnesses express themselves in people living in other cultures. Mood disorders such as depression are in many ways shaped by culture—not only in what triggers the depression itself but also in how the mood is expressed. Even diagnoses have to contain some knowledge of the culture of the patient; someone who is battling unseen tormentors would appear psychotic in Western eyes but perfectly normal (if unlucky) in a region where spirits are believed to be real and powerful.

So-called normal behavior is defined differently from country to country. For a true understanding of a person's mental state, psychologists might have to piece together a complete cultural case study, much as an anthropologist would. For example, psychiatrist and anthropologist Devon Hinton, Ph.D., has studied how panic attacks are set off—and how they are expressed—among Cambodian refugees in America who suffered trauma at the hands of the Khmer Rouge. Hinton posits that the physical symptoms of panic are described as very different bodily experiences, such as the feeling of wind flowing through the body, and that these sensations better describe the panic attacks than the more psychological language used by post-traumatic stress disorder sufferers in the West.

What's more, by combining psychology and anthropology, a scientist can search for the universal biological cause that can create a multitude of behaviors. An illness such as depression or OCD can be thought of as a lens that magnifies certain aspects of a culture, and understanding the way the same illness differs across cultures can help researchers understand the way that lens is shaped. In 1997, I examined Balinese people who appeared to suffer from obsessive-compulsive disorder. In the people I studied, the outward signs of the illness—and the patients' own view of their behavior—was markedly different from what psychologists generally encounter in the West.

An estimated 3-million Americans suffer from obsessive-compulsive disorder. In most instances, the rituals of OCD victims are seen as a way to ward off some dreaded danger: repeated hand washing, for example, to prevent catching a disease, or hoarding seemingly useless items because they might one day come in handy.

Now, to be sure, many of us experience little compulsions from time to time, ranging from the desire to remember the name of a song to jumping over a crack that might "break your mother's back." But when obsessions stand in the way of doing everyday activities, psychologists begin to wonder if OCD may be driving those impulses.

Not everyone with OCD has the same obsessions. And the differences are especially marked when OCD is compared across cultures. In the U.S. and Europe, cleanliness pops up again and again. What's more, the worrying isn't simply about health: One of the more common obsessions is the ungrounded fear that one will commit some terrible sexual act.

Interestingly, though, the obsessions in predominantly Islamic countries focus on a different aspect of life. Research conducted in Saudi Arabia and Egypt shows that religion and the correct observance of religious ritual—not contamination—are very common compulsions. Assuming that OCD has the same biological effect on both Egyptians and Americans, what is it that creates such a different set of symptoms? And could studying the way obsessive-compulsive disorder drives behavior in people as different as Eskimos and Ethiopians help unlock the secret of exactly how the brains of people with OCD differ from healthy people?

That's the hope, at least. And it's the reason I went to Bali to talk to people who might have OCD. (I say "might" because few Balinese receive a formal diagnosis for a mental illness. For 3 million Balinese, there are fewer than 10 psychiatrists and just one psychologist.) The culture of Bali is quite different from that found anywhere else. The society has been influenced by a blend of Malay, Chinese, Indian and Indonesian cultures. This blended society is one that prizes friendliness and grace. Indeed, visitors are struck by what a pleasant place Bali is.

The Balinese follow a distinct brand of Hinduism combined with elements of Buddhism and other ancient beliefs; and that religion plays a large role in everyday life. Temples are numerous, and Balinese frequently honor their ancestors or appease local gods. But belief in sorcery and witchcraft is also very strong; the flip side of Balinese friendliness is, for some, a constant vigilance for signs of offense and a fear of retribution through black magic or sorcery.

As part of a study of mental health in Indonesia sponsored by the World Health Organization, I interviewed 19 Balinese who were gathered from a survey and displayed the symptoms of OCD. Many of these people were obsessed with several of the same anxieties as was Gede Sudiasih. Some of the obsessions that trouble Gede would be familiar to a Westerner: He checks and rechecks the locks on his front door and constantly asks coworkers the time to ensure that his watch is working. Gede hordes empty bottles of medicine, hiding them in his bedroom to keep family members from throwing them out; and he is compelled to keep himself clean to avoid passing along a contagion to his village.

But Gede's obsession with collecting information about people who pass his house or dead chickens seems utterly alien to us. This compulsion to uncover certain facts is seldom seen in the West, but it is one of the most common manifestations of OCD seen in Bali. Again and again, I met people who were obsessed with knowing the business of everyone they saw. One man, Made Balik, was so concerned that he carried around a little notepad: When a person wearing a motorcycle helmet rides through his village, he quickly jots down the license plate number so that he can use that as a lead to find out the rider's identity.

Even the briefest encounter can haunt Made for days. He told me about a woman he met on a bus. "I said to myself, 'I think I know her from somewhere.' She could have been one of my coworkers or maybe someone I knew before. I could not put her face out of my mind. It was an obsession for me to know who she was." For days afterward, Made asked his friends about the woman. It drove Made to such distraction, he couldn't sleep. Then he had a break: Someone who had also been on the bus remembered the woman and told Made when she climbed aboard and where she got off. A great weight was lifted, and soon Made got some long-delayed sleep.

Another man I interviewed, a 60-year-old retired chauffeur who lives with his family, Wayan Mukti, was obsessed with more than simply the strangers he met. Whenever he watched television, he was compelled to discover the name of every actor, official or news reporter who appeared on the screen. Even the songs played during the programs had to be identified. If he had not discovered the answer to all his questions by bedtime, he woke up family members and pestered them with questions. "I can't think of anything else," Wayan told me.

It isn't just information that bedevils Balinese with OCD. I met a wood-carver who became obsessed with his tools—even though he had been working with wood for a number of years, he now thought that if he picked up his tools, he would stab himself. Another man, who had suffered a serious motorcycle accident (and may have suffered brain damage), became compelled to create small figures out of rice and place them at "dangerous" places, such as intersections and homes of people who had recently died, to appease local spirits. While this was a common Balinese offering, this man recognized that he was spending far too much time on his rice people, but was unable to stop.

To a Western psychologist, such behavior would seem, at first, to border on delusional. But this obsession with rice people makes a kind of sense from the Balinese point of view. Millions of ordinary Balinese make religious offerings every day to please deities and demons; the man's obsession is just an exaggerated form of a normal activity. Spirits and symbolic objects play a role in everyday life, and that makes it difficult for a Western observer to tease apart the boundary between normal and abnormal behavior.

As I noted, anxieties about cleanliness and contamination—so common in the West—are seldom found as primary obsessions in Bali. Instead, I found obsessions centered on information, especially information about people, and on objects of symbolic importance. Again, that makes sense in the Balinese context: On an island steeped in ritual, with a strong, often unspoken fear of black magic and the possible evil intentions of others, a stranger in town presents another person whom you might inadvertently offend. The best way to protect yourself, in the mind of a Balinese with OCD, is to find out everything you can about him.

A visitor might find that Balinese people are outgoing and accommodating, but the culture has a dark side. In a controversial and sometimes criticized essay, the anthropologist Margaret Mead called Balinese culture one based on fear—fear of inadvertent insult and unspoken offense. Much the way fear of contamination in the West or of religious impropriety in Islamic cultures become exaggerated and distorted through the lens of obsessive-compulsive disorder, I think the possibility of danger from simple social interactions drives the behavior of Balinese with OCD.

It's a fear that takes a heavy toll. If Gede Sudiasih, the man with the notebook devoted to broken glass, sees people from outside his village, he will rush outside and stop them—not to drive them away, but to find out who they are, where they live and what they are doing in his village. If he can't catch them, he will begin interrogating his neighbors, driven by a compulsion to find out basic information on the strangers. Until Gede can get the information he craves, he is filled with a powerful dread. To avoid spotting a stranger, any stranger, Gede keeps his windows covered with heavy blinds. He essentially shuts out the world. It is a sad testament to the power of his obsessions. And to the culture that shapes them.

Read More About It

• Of Spirits and Madness: An American Psychiatrist in Africa Paul Linde, M.D. (McGraw-Hill, 2000)
• The Thread of Life: Toraja Reflections on the Life Cycle D. Hollan and J.C. Wellenkamp (University of Hawaii Press, 1996)