REVIEWS
Depression and Somatization: a Review
Part I
WAYNE KATON, M.D.
ARTHUR KLEINMAN, M.D.
GARY ROSEN, M.D.
Seattle, Washington
From the Department of Psychiatryand Behavioral
Sciences, University of Washington, Seattle,
Washington.Reprint requests should be addressed
to Dr. Wayne Katon, Department of Psychiatry and
Behavioral Sciences, RP-10, University of
Washington, Seattle, Washington 98195. Manu-
script accepted August 12, 1981.
The authors describe the relationship between the major depressive
disorder and somatitation. A literature review documenting the in-
cidence and prevalence of depression in primary care and the
rate of misdiagnosis is presented. Evidence is collated that points
to several factors in misdiagnosis. The patient often selectively
complains about the somatic manifestations of depression, mini-
mizes the affective and cognitive components and is treated
symptomatically. This is due to the physician’s lack of recognition
that the patient may have major dept’essive disorder and yet not
recognize and report the mood component. The authors develop a
conceptual model that elucidates the mechanism behind the se-
lective perception and focus by the patient on the somatic mani-
festations of depression. In this first part, the influence of socio-
cultural and childhood experience on the ability of the patient to
recognize and report mood changes is delineated. Understanding
this model is crucial in preventing misdiagnosis and potential iat-
rogenic harm to the patient.
The purpose of this paper is to describe the intricate relationship
between somatization and depression. We present a conceptual model
to elucidate the relationship between the psychobiologic disease of
depression and the use of somatization by the patient. We use the term
depression in this paper to describe the major depressive disorder,
which is a syndrome involving mood, vegetative symptoms of neu-
roendocrine and autonomic nervous system dysfunction and specific
cognitive schemata [ 11. Somatization in patients with the major de-
pressive disorder can be defined as the selective perception and focus
on the somatic manifestations of depression with denial or minimi-
zation of the affective and cognitive changes.
Patients who somatize either have no discernible biologic abnor-
mality but recurrently present with somatic complaints, or have dis-
cernible disease but amplify their symptoms and frequently utilize
medical services. Although we emphasize depression as one of the
most common causes of somatization, other psychiatric disorders
associated with it include somatization disorder (Briquet’s syndrome,
formerly called hysteria), anxiety disorders, obsessive-compulsive
disorder, grief reactions, hysterical personality disorder, the borderline
personality disorder, chronic factitious illness, malingering, conversion
disorders and hypochondriasis [2]. Somatization frequently expresses
social as well as emotional distress, but may at times represent only
social problems [3].
January 1992 The American Journal of Medicine Volume 72 127
DEPREsslob AN0 SOMATIZATION-KATON ET AL.
Somatization is one of the most common and trou-
blesome problems physicians in primary care face.
Studies have repeatedly demonstrated that as many as
50 percent of patients utilizing primary care clinics
actually have psychosocial precipitants as opposed to
biomedical ones as the main cause of their clinic visits
[4-61. Further, Reigier et al. [7] have demonstrated that
most people with emotional disorders are seen and
treated in primary care settings rather than by psychi-
atrists. Goldberg and Blackwell [8] have pointed out that
in addition to the substantial numbers of patients whose
emotional problems are recognized by their physicians,
there are many (termed the “hidden psychiatric mor-
bidity”) whose emotional disorders go unrecognized.
These are predominantly patients who present with
somatic symptoms and are treated symptomatically.
These same observations have been made by Lipsitt
[9] and Jacobs et al. [ lo]. Not only does mental dis-
order commonly present as physical disorder in primary
care, but also studies have revealed that early detection
is especially beneficial for the more severe disorders
[ 111. In the case of affective disorders, early detection
and treatment not only potentially shorten the course,
as there is highly effective treatment with psychother-
apy, medication and electroconvulsive therapy, but also
spare the patient unnecessary physical investigations
that tend to reinforce hypochondriacal symptom pat-
terns and carry a significant risk of iatrogenesis.
There are several studies that indicate the incidence
and prevalence of affective disorders in primary care
patients. Although most suffer from a lack of diagnostic
clarity, there is some correlation as to the prevalence
of depression and anxiety despite the utilization of dif-
fering diagnostic techniques. We give statistics for both
depression and anxiety because they often coexist in
the same patient. In a large computer-based study in
Virginia of 526,196 patient visits to 118 family practi-
tioners, depression and anxiety constituted 86.8 percent
of the psychiatric problems seen by these physicians
[ 121. In two studies of more than 2,000 primary care
patients in Philadelphia [ 131 and London [ 141, a family
physician in the first study and a psychiatrist in the latter
each found that 87 percent of the combined 492 pa-
tients with a psychiatric diagnosis had an affective
disorder, i.e., depression, mixed anxiety and depression,
anxiety state and affective psychosis. Thus, these
studies indicate that depression and anxiety constitute
the two major psychiatric syndromes seen by primary
care physicians but do not indicate the prevalence or
incidence of depression. The recent study by Hoeper
et al. [ 151 did reveal the prevalence of mental disorder
in a primary care clinic population utilizing a standard
psychiatric interview, the Schedule for Affective Dis-
orders and Schizophrenia [ 161, which is based on Re-
search Diagnostic Criteria [ 171. Hoeper’s group found
128 January 1982 The American Journal of Medicine
the prevalence of mental disorder meeting Research
Diagnostic Criteria to be 26.7 percent with depressive
disorders (major, intermittent and minor) and anxiety
(phobic and generalized), again representing more than
80 percent of the cases. Major depressive disorder
alone made up 21.7 percent of the psychiatric diag-
noses. In a study of 300 medical inpatients and outpa-
tients in a general hospital (utilizing the Beck Depression
Inventory [ 181 and the Zung Self-Rating Scale [ 191)
Raft et al. 1201 estimated the rate of depression to be
35 percent. Schuman and Ramesar and their co-
workers 121,221, in two longitudinal studies using a
structured interview and a self-rating checklist, found
the incidence of affective disorder (depression, anxi-
ety-depression) in a large family practice to be five to
six cases per 100 patients per year.
Patients with depression and anxiety in these studies
experienced substantial physical symptoms and thus
often found their way to medical practitioners for con-
sultation and treatment. Yet two studies [23,24] re-
vealed that primary care physicians diagnose depres-
sion in only 0.5 percent to 4.5 percent of their cases;
thus, significant numbers of cases appear to go undi-
agnosed. This was well demonstrated in Nielson and
Williams’ [25] recent study of depression in ambulatory
medical patients in a prepaid health program. Utilizing
the Beck Depression Inventory [ 181 as well as psy-
chiatric interview, they found 12.2 percent of patients
to have at least mild depression and 5.5 percent mod-
erate depression; the primary care physicians failed to
diagnose depression in 50 percent of the cases.
Goldberg [ 141 has shown that more than half the
patients presenting to primary care physicians had
significant somatic symptoms as part of their depressive
disorder. Too often the patient’s physical complaint is
treated symptomatically whereas the underlying disease
is left untreated. The main problem here is the inability
of the physician to conceptualize depression as existing
unless the patient perceives an affective state and re-
ports it to the physician. Thus, a patient who has not
developed the language to label and report his emo-
tional states, or who utilizes defenses or coping styles
that minimize affects or who believes his problem is a
physical one will not be recognized as depressed by
many physicians. Perhaps the prototype is the patient
with chronic pain. Sternbach [ 261 has shown that 100
patients with low back pain averaged two standard
deviations above the norm on the depression subscale
of the Minnesota Multiphasic Personality Inventory.
Blumer et al. [27] further convincingly demonstrated
that a large percentage of patients with pain are de-
pressed and respond to tricyclic antidepressants with
partial to complete alleviation of pain and depression.
Most of the patients with “pain” overtly denied the af-
fective component of depression despite having all of
Volume 72

the vegetative symptoms, i.e., insomnia, anorexia,
anhedonia, weight loss, loss of libido, or minimized
depressed mood as being only “secondary” to their
physical pain. For many, this belief and its associated
treatment expectations are shared by their physicians
who frequently reify “pain” as the disorder and tech-
nologic intervention targeted at physical symptoms as
the treatment.
Unfortunately, the end result of the misconception
that depressed patients will perceive their affective
state and report it to physicians is that many patients
who have chronic pain and other patients who recog-
nize only the somatic symptoms of depression fre-
quently receive treatments that result in iatrogenic harm
and do not receive specific treatment for depression.
The average patient visiting a pain clinic usually pre-
sents with several unnecessary surgical procedures and
is often addicted to minor tranquilizers and/or narcotics
[28,29]. Because the hypochondriacal patterns many
patients use to cope with dysphoric affect and social
stress are reinforced by physician interest, lengthy
workups and costly treatment, eventually secondary
gain occurs that further sustains these symptoms.
Secondary gain commonly takes the form of disability
payments and change in family systems that enable
patients to avoid stressful situations like work and to
fulfill dependency needs by becoming passive recipi-
ents of care by others. Other secondary gains include
the sanctioning of failure, “addiction” to the health care
system for social support and the manipulation of social
relationships. Most physicians are aware of the extreme
difficulty that is basic to working with patients in whom
substantial secondary gain is an active disincentive to
getting well.
DEPRESSION AND SOMATIZATION: A COGNITIVE
MODEL
The major depressive syndrome, besides its social
significance, has cognitive, affective and somatic
components. Patients with depression have charac-
teristic cognitive schemata described and validated by
Beck’s studies in which they recurrently interpret
themselves, their experiences and the future in an idi-
osyncratic manner [30,31]. For instance, a person with
depression tends to see himself as defective, inade-
quate, diseased or deprived-he attributes his un-
pleasant experiences to psychological, moral or
physical defects in himself. He believes he is undesir-
able and worthless because of these putative defects,
and he underestimates and criticizes himself because
of them.
The affective state of depression is similar to sadness
but is longer lasting and more pervasive. In some pa-
tients, irritability and loss of interest may be the pre-
January 1982 The American Journal of Medicine Volume 72
DEPRESSION AND SOMATIZATION-KATON ET AL.
dominant affects. Moreover, characteristic somatic
symptoms occur including anorexia, weight loss, in-
somnia or hypersomnia, psychomotor agitation or re-
tardation, decreased energy and libido, decreased ability
to think and concentrate, dry mouth, constipation,
headaches and backaches [32]. Chronic pain also
seems to be a common somatic complaint. Watts [33]
reported that 27 percent of his depressive patients in
a primary care clinic presented with pain as a com-
plaint, while Von Knorring [34] found that 60 percent
of his patients who presented with depression had ex-
perienced some form of somatic pain. Ward et al. [35]
described a 100 percent incidence of pain complaints
in a study of depressed psychiatric patients. Hill and
Blendis [36], in a study of persons with persistent
“nonorganic” abdominal pain, and Turkington [37], in
patients with diabetic neuropathy, reported a high in-
cidence of depression. Ward et al. [ 351, Hill and Blendis
[36] and Turkington [37] all found marked alleviation
of both pain and depression after treatment with tricyclic
antidepressants.
Along with the characteristic affective change, at
least four of these somatic and cognitive symptoms
(suicidal ideation and thoughts of self-reproach,
worthlessness, hopelessness, guilt) must be present
every day for a period of two weeks to fit the diagnostic
criteria for the major depressive disorder [ 11. Most
dysphoric individuals not demonstrating these symp-
toms fall into the categories of dysthymic disorder
(formerly depressive neurosis or reactive depression),
cyclothymic disorder, or adjustment disorder [ 11.
In physiologic perspective, depression is a psycho-
biologic disorder with multi-level impairment in brain
neurotransmitters [38], hormonal systems [39], the
automatic nervous system [ 391, circadian rhythms and
rapid-eye-movement (REM) sleep [40]. As we dem-
onstrate later on, depression is also a social phenom-
enon; hence it fits Engel’s [41] model of disease as
always expressing biopsychosocial interrelation-
ships.
The perceptions of a group of depressive patients
about their illness vary widely. Many seem to selectively
perceive various vegetative symptoms and therefore
seek the help of physicians for somatic complaints.
Singh [42] noted that 65 percent of a depressed out-
patient group presented with a physical complaint.
Widmer and Cadoret [43,44] noted that, compared with
control subjects, in the records of 154 depressed family
practice patients in the seven months prior to the di-
agnosis of depression, there was (1) an increase in the
number of patient-initiated visits, (2) an increased in-
cidence of hospitalizations, (3) an increased number of
presenting complaints of three types: ill-defined
“functional” complaints, pain of undertermined etiology
and complaints of tension and anxiety.
129
DEPRESSION AND SOMATIZATION-KATON ET AL.
I
DEPRESSION
DEPRESSION
\\
\\
\\
‘.
.N
Figure 1. Chart of the components of depression and somatization
Other patients present to psychiatrists, psychologists
and other physicians with complaints about their so-
matic as well as affective symptoms. There seems to
be a spectrum here with some patients rigidly adhering
to a somatic model of their illness, others feeling as
though it is primarily psychological due to the affective
and cognitive changes and the vast majority somewhere
in between, perceiving both the somatic and affective
components and not sure which is primary.
The patient’s subjective experience of the depressive
syndrome is influenced by culture, past family experi-
ence, his cognitive coping mechanisms and his current
social environment, i.e., medical care, work-disability,
family and larger social network and the sociopolitical
system (Figure 1). The key concept here is cognition.
Cognition refers both to the content of thought and to
thinking processes [45,46]. It includes ways of per-
ceiving the environment and processing information
from it, problem-solving strategies, attitudes and attri-
butions and the mechanisms and content of recall,
memory and communication [46].
The affective component of depression can only be
known to the patient through cognition: perceiving, la-
beling, ordering and giving value to internal feelings.
Without cognitive perception of the feeling component,
the depressive disorder exists as a somatic syndrome
expressed by vegetative symptoms. The ability to
perceive the associated affective state depends on the
130 January 1992 The American Journal of Medicine
AND SOMATIZATION
__-___
--em__
Y
Social consequences
I e seconddry gam
vocabulary for emotions the patient has learned and on
the cognitive mechanisms he has developed to manage
feelings. Similarly, perception is the basis for feedback
molding illness experience in terms of social conse-
quences (Figure 1).
SOCIOCULTURAL FACTORS
Historically, somatization of depression was the norm
in Western society. Patients did not go to indigenous
healers and physicians with existential depressions.
They did not complain of mood or affective changes but
presented with somatic and vegetative complaints. The
development of “psychological mindedness” is largely
a 20th-century phenomenon in Western culture. A
majority of cultures in the world even today do not value
and often stigmatize the expression and perception of
emotions. In many cultures, stoicism is considered a
virtue. Thus, the ability to perceive an affective state
and report it to a physician seems to be a very recent
development. Cross-cultural evidence points to the fact
that depression occurs in all cultures, but the form it
takes varies [47,48]. Cross-cultural studies show the
core of vegetative symptoms of depression are similar
but the cognitive changes like intense guilt and self-
depreciation seen in Western culture are absent or di-
minished, as is the expression of depressed affect
[47,48]. Racy [49] studied depression in the Middle
Volume 72

East and discovered that traditional Arabs presented
with somatic complaints such as gastrointestinal
symptoms, loss of appetite and decreased weight. Guilt
and self-depreciation were rare. However, as Arabs
became Westernized, the form of depression became
closer to that seen in the West. Pfeiffer [50] reviewed
40 reports of depression in 22 non-European countries
and found that the vegetative symptoms were always
found, including insomnia, decreased libido, decreased
appetite and weight loss, but self-depreciation, hope-
lessness and guilt were rarely found. Mezzich and Raab
[51] compared depressive symptoms and their so-
ciocultural context in a Peruvian sample of 93 depres-
sive patients and a United States sample of 64 de-
pressive patients. A basic common core of depressive
signs and symptoms was found in both samples (in-
cluding vegetative, cognitive and affective symptoms),
but more complaints and higher scores on somatic
symptoms were found in the Peruvian group and higher
scores on suicidal manifestations were noted in the
United States group. Somatization also correlates in the
United States with lower socioeconomic class, tradi-
tionally oriented ethnic groups that discourage and
disparage undisguised expression of emotions, blue-
collar workers, rural living and lower educational levels
[2,3,52-561.
It appears then that patients in most non-Western
cultures still present with physical complaints as the
primary symptom of depression and that even in
Western culture it is probably only recently that patients
present with selfdepreciating thoughts, hopelessness
and helplessness, and are able to perceive and articu-
late depression as a discreet affect. At present, primary
care physicians, not psychiatrists, still see most of the
patients with mental illness [7,57], and the Goldberg
[ 141 and Widmer and Cadoret [43,44] studies of pri-
mary care clinic populations suggest that most de-
pressed patients somatize. Therefore, in Western so-
ciety as well as in most other cultures, somatization
represents a powerful method of coping with psycho-
social distress. Symptoms are communications of
distress, and in many cultures depression connotes
weakness, moral culpability and loss of face; besides,
there are no psychiatrists and mental illness is highly
stigmatized. Moreover, physical complaints are legiti-
mate cues for obtaining care, love, sympathy, time off
and time out-they possess social efficacy. Therefore,
it is not surprising that the affective component of de-
pression is minimized or overtly suppressed, denied or
perhaps not experienced, and the vegetative or somatic
experiences are highlighted.
Cultures influence depression in three major ways.
In many cultures, there are essentially no words to de-
scribe internal emotional states. For example, when
Leighton et al. [58] studied the Yoruba of Nigeria, they
January 1982 The American Journal of Medicine Volume72
DEPRESSION AND SOMATIZATION-KATON ET AL.
found that the Yoruba had no words for depression as
an emotional state or a single concept of depression as
a syndrome or disorder. Tseng and Hsu [ 591 reported
a similar observation among Chinese. Leff [60] re-
viewing the cross-cultural literature concludes that the
language of emotions in most societies evolves from
vague somatic terms, conveying both somatic and af-
fective complaints, to more highly differentiated somatic
and affective complaints, with fine effective distinctions
only as a late stage associated with modernization and
Westernization. Benoist et al. [61] studied French-
Canadians and found that only 5 percent labeled a case
involving sadness, insomnia, fatigue and loss of interest
as depression. The defined depression as a “nervous
condition,” like a nervous breakdown with the emphasis
on “nerves” as a physical problem. Kleinman [62]
found that of 100 patients suffering “neurasthenia” in
the outpatient psychiatric clinic at the Hunan Medical
College in China, 87 had major depressive disorder; all
presented with physical symptoms as their chief
problem, and most regarded their disorder as neuro-
logic, owing to nervous exhaustion.
Secondly, in many cultures, there are strong sanc-
tions against talking about and perceiving emotional
states like depression, and specific cognitive coping
styles are utilized that deflect affective complaints along
channels of physical symptoms. These coping devices
block introspection as well as direct expression of
feelings. They place dysphoric affects in a nonpsy-
chological idiom. Unlike the “internal” idiom used by
Westerners, it is an “external” idiom that communicates
affects indirectly as somatic, situational or dissociated
metaphors.
Chinese patients often present with a symptom
hsing-thing pu hao, a term that refers to general emo-
tional upset [63]. This vague term functions to reduce
the intensity of anxiety and depression by keeping the
emotions undifferentiated. Leff [64] studied Chinese
and Nigerian subjects and found that they did not dis-
tinguish between anxiety and depression. Thus, in some
cultures, patients use undifferentiated terms to cope
with depressive states. Further evidence was provided
by Tanaka-Matsumi and Marsella [65], who compared
word associations to the equivalent words depression
and yuutsu (depression in Japanese) in three groups of
patients: Japanese nationals, Japanese Americans and
Caucasian Americans. The Japanese nationals asso-
ciated more external referent terms such as rain and
cloud and somatic references such as headache to the
word yuutsu. Japanese Americans and Caucasian
Americans associated predominantly mood-state terms
such as sad and lonely to the word depression. The
association to external referents by Japanese nationals
suggests that they experience depressive feelings
“externally” in an indirect fashion as related to imper-
131
DEPRESSION AND SOMATIZATION-KATON ET AL.
sonal Nature and its culturally established emotional
referents.
Other related mechanisms that cope with emotions
like depression include minimization to overt denial,
dissociation (affects are separated from consciousness
by mechanisms like trance states and hysterical be-
havior) and somatization. Minimization is the process
in which the intensity of emotion is suppressed by
minimizing its significance. Somatizers with depression
often use this coping device, with statements like, “Yes,
I’m depressed, but anyone with this pain would be.” This
process extends to frank denial whereby emotions are
simply not acknowledged. When examined, patients
with somatized depression may appear visibly de-
pressed, have all the vegetative symptoms of depres-
sion and have family members who describe a change
in affect, yet they vehemently deny perception of de-
pressive mood. It is important to point out that a group
of these patients seem not to be just using denial or
conscious suppression but appear not to perceive and
label internal emotional states. Some may even lack
a language to express such states. Dissociation points
to a whole range of coping mechanisms in which affect
is separated from consciousness, cognition or behavior
or the specific stimuli provoking it. This dissociated
affect is expressed in isolation, most usually in a cul-
turally sanctioned way. Kleinman [63] has found that
in Taiwan one sees angry, sad and anxious feelings
expressed via trance states or hysterical behavior or
displaced to other subjects, i.e., socially legitimate
anger at strangers and deviants.
The third effect culture may have on the perception
and expression of depression is noted when there are
culturally idiosyncratic explanations for certain affective
states. For instance, in Central and South America in
people of Latin0 ancestry, there exists a disease called
susto in which symptoms include weakness, decreased
appetite, anxiety, insomnia, motor retardation and de-
creased libido [47,66,67]. In our culture, this constel-
lation of symptoms might be labeled as agitated de-
pression; in Latin0 culture, it is labeled susto. Susto
means “soul loss,” and the connotation of this disease
in terms of treatment is that it has a supernatural or
religious cause, i.e., breaking taboos, curses or
witchcraft. Just as American cultural beliefs about de-
pression may lead individuals not only to perceive vague
symptoms as a sign of depression but also to amplify
or “imagine” appropriate complaints, perhaps in susto
and other culture-bound disorders, symptoms are
construed and constructed in keeping with local beliefs
about how the disease should “be felt.” Thus, culture
provides the sick person with illness beliefs, views
about how the body works, dominant metaphors and
idioms that organize his interpretation of bodily change
[681.
132 January 1992 The American Journal of Medicine
CHILDHOOD EXPERIENCE
Each family can be visualized as a distinct subcultural
group in itself that has different norms and rules to in-
terpret and cope with many problems, including un-
pleasant emotions. Family therapists have demon-
strated the importance of these rules and the family
structure in the family’s emotional homeostasis. There
is most likely a spectrum in Western families between
families that cannot experience and express feelings
psychologically and those that perceive feelings and
express them easily and readily. We would postulate
that it is in families that have not developed psycho-
logical language for articulating unpleasant emotions
that we would be most apt to see the selective focus on
the somatic manifestations of depression. Somatization
is obviously one strategy that is used to cope with de-
pression and appears to be one of the more powerful
ways to elicit nur-turance and caring from families in all
cultures
Families are the units of the larger culture that so-
cialize children to discern the difference between
physical and emotional pain. They also teach a value
system to the child about the appropriateness of ex-
pressing emotions, and they directly model as well as
reinforce sanctioned types of interpretive systems,
coping mechanisms and defenses to handle emo-
tions.
At young ages, children do not appear to distinguish
between emotional and physical distress [69]. It is the
reaction of the child’s caretakers in labeling, classifying,
explaining and evaluating a child’s distress that teaches
the child to distinguish various mood states and separate
somatic from emotional ills. In many families, care is
provided for somatic ills but not for emotional ills. In
these families, emotional feelings are seldom labeled,
and there may be strong negative sanctions against
directly expressing these emotions. Zborowski [ 701
stressed in his description of the “old American” family
the tendency of the mother to teach the child to take
pain “like a man,” not to be a sissy and not to cry. Such
training according to Zborowski does not discourage
use of the physician but implies that such use will be
based on physical needs not psychological. The child
learns quickly by this differential reinforcement how to
elicit nurturance from a caregiver, i.e., complaining
about a headache rather than about being sad or de-
pressed. Mechanic [3] has also emphasized that
learning influences the tendency of males as compared
with females to take more risks, to be less expressive
about illness, to appear more stoical and to seek
medical care less frequently.
At early ages, children define being healthy as feeling
good, being able to do things they want and being happy.
Feeling unhealthy is associated with not being able to
Volume 72

engage in desired activities, and feeling moody and
weak [7 I]. Parents identify illness in their children by
behavioral cues. Change in a child’s activity is an es-
sential cue and the most frequently noted indicators of
illness are irritability, listlessness, crankiness and apathy
[ 721. Parents differ in their perception of such cues, in
their ability to identify illness in their children and in their
own reaction [73]. Thus, a parent’s responses may
create various degrees of reinforcement as well as
provide definitions to attribute meaning to internal
states. [ 691.
Thus, depending on parental attitudes, some children
get a strong message that talking about emotions per
se or about certain ones is taboo and such parents may
often not nurture and aid the child in discerning the
differences between mood states and physical symp-
toms and talking about them. In such families, physical
symptoms may become the socially legitimate way to
receive and accept nurturance.
Several studies lend support to this hypothesis.
Krietman et a]. [74] showed that patients who pre-
sented with persistent somatic symptoms and were
eventually recognized as depressed (due to their classic
vegetative symptoms and response to tricydic anti-
depressants) differed from patients who presented
primarily with depression in that significantly more
mothers of those in the former group had the identical
somatic symptoms. The depression subgroup also had
significantly more classic psychosomatic illness as
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January 1982
DEPRESSION AND SOMATIZATION-KATON ET AL.
children. Apley et al. [75] also noted that children with
recurrent fGnctional complaints were commonly
copying their symptoms from another family member,
usually the mother. Kreitman [74] noted that for the
patients with persistent somatic complaints and de-
pression, the internal statement “I am ill” might signify
“I am in some kind of distress but have learned no
language other than my body by which to convey this.”
Indeed, body language may be an effective way to in-
directly express dysphoria among family members
exquisitely sensitive to such bodily cues.
Minuchin et al. [76], Bruch [77] and Pallazzoli [78]
in their work with psychosomatic families, i.e., families
with psychological conflict that is expressed via a
member with somatic symptoms, point out the frequent
lack of a language of emotions, the inability of these
families to work out conflict verbally and the strong
denial by all family members that psychological prob-
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a precarious family equilibrium, often at the expense
of the affected family member. It again serves to ex-
ternalize family emotional problems like marital conflict
so that somatic treatments are often initially sought.
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