ARTHUR KLEINMAN

NEURASTHENIA A STUDY OF SOMATIZATION

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DEPRESSION: CULTURE IN CHINA

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Report N u m b e r One o f the University o f Washington - Hunan Medical College Collaborative Research Project 1, 2

ABSTRACT The author reviews conceptual and empirical issues regarding the interaction of neurasthenia, somatization and depression in Chinese culture and in the West The historical background of neurasthenia and its current status are discussed, along with the epidemiology and phenomenology of somatization and depression. Findings are presented from a combined clinical and anthropological field study of 100 patients with neurasthenia in the Psychiatry Outpatient Clinic at the Hunan Medical College. Eighty-seven of these patients made the DSM-III criteria of Major Depressive Disorder; diagnoses of anxiety disorders were also frequent. Forty-four" patients were suffering from chronic pain syndromes previously undiagnosed, and cases of culture-bound syndromes also were detected. For three-quarters of patients the social significances and uses of their illness behavior chiefly related to work. Although from the researchers' perspective 70% of patients with Major Depressive Disorder experienced snbstartlial improvement and 87% some improvement in symptoms when treated with antidepressant medication, fewer experienced decreased help seeking, and a much smaller number perceived less social impairment and improvement in illness problems (the psychosocial accompaniment of disease including maladaptive coping and work, family and school problems) These t'mdings are drawn on to advance medical anthropology and cultural psychiatry theory and research regarding somatization in Chinese culture, the United States and cross culturally. The author concludes that though neurasthenia can be understood in several distinctive ways, it is most clinically useful to regard it as bioculturally patterned illness experience (a special form of somatization) related to either depression and other diseases or to culturally sanctioned idioms of distress and psychosocial coping.

"I visited (1956) in Peitaiho a hospital for mental cases. But everyone was reluctant to call it a mental hospital: it was 'for cadres who are overtired'. The only mental illness which was acceptable was neurasthenia, and throughout the years innumerable were the cases of neurasthenia, transient or permanent, that I would hear about There is something very Victorian about this coyness; one thinks immediately of the word 'decline' which covered so many cases of tuberculosis and cancer in the nineteenth century." Han Suyin: My House Has Two Doors New York: Putnam, 1980; p. 155 "That he (Mao Zedong) ruminated aloud on extraphysical factors in illness is suggestive in light of the striking coincidence of Mao's own bouts of sigkness with setbacks in his work. Now once more, as he brooded about ZhanffGuotao, anxiety was the harbinger of illness.* * Mao confessed to Liang Shuming, at Yanan in 1938, that now and then he fell victim to nervous exhaustion (neurasthenia)."
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Ross Terrill: A Biography of Mao New York: Harper and Row, 1980; p. 134

Culture, Medicine and Psychiatry 6 (1982) 117-190. 0 1 6 5 - 0 0 5 X / 8 2 / 0 0 6 2 - 0 1 1 7 $07.40 Copyright 1982 by D. Reidel Publishing Co., Dordrecht, Holland, and Boston, U.S.A.

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Neurasthenia

A striking difference in the epidemiology of psychiatric disorders in China and the West is the very high prevalence in the former and low prevalence in the latter of neurasthenia. For example, in the Psychiatric Outpatient Clinic of the Hunan Medical College this diagnosis is the most commonly applied diagnosis to all other patients but those suffering schizophrenia; whereas at the University of Washington, this diagnosis is virtually never given to patients. The diagnosis is equally popular in psychiatric and medical clinics throughout China, and just about as unpopular in similar clinics in the United States and Britain. Neurasthenia, moreover, is widely diagnosed in other Chinese cultural settings that differ markedly from China in political economy and social structure: i.e., Hong Kong and Taiwan. But in the West (more specifically, the United States) where it originated, this diagnosis, though it is still to be found in several nosological systems, tends to be regarded as old fashioned, an anachronistic carryover from earlier times (circa. 1880-1930) when it was a popular diagnosis in lay as well as professional medical circles. Sir George Picketing, a famous British practitioner, points out that neurasthenia was often applied in the 1920s, when he was a student of medicine, and was defined in Osler's widely used textbook of medical practice, from which he himself was taught, as: A condition of weakness or exhaustion of the nervous system, givingrise to various forms of mental and bodily inefficiency. The term covers an ill-defined,morley group of symptoms, which may be either general and the expression of derangement of the entire system, or local, limited to certain organs; hence the terms cerebral, spinal, cardiac, and gastric neurasthenia. (Pickering 1974:166). Picketing further notes that neurasthenia is now recognized as the manifestations of psychoneurosis. That is to say, physicians in the United States, Great Britain and other Western societies diagnose depression, anxiety states, hysteria, stress-related psychophysiological reactions where several generations ago they would have diagnosed neurasthenia. Indeed, it has been suggested that neurasthenia may be currently employed in Chinese settings in the same way it was earlier in the West: as a more respectable somatic mantle of a putative physical disorder to cover mental illnesses and psychological and social problems that otherwise raise embarrassing issues of moral culpability and social stigma (Kleinman 1980:119-178). The term neurasthenia was apparently introduced into China by Western physicians and medical missionaries in late nineteenth and early twentieth centuries, but this fascinating example of cultural diffusion, as far as I know, has never been a subject of historical inquiry.

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George M. Beard (1880), the American neurologist who popularized the term beginning in 1868, regarded neurasthenia (or nervous exhaustion) as an organizing category that identified a family of disease problems long recognized by laymen and medical professionals in the West under such terms as 'general debility', 'nervous prostration', 'nervous debility', 'nervous asthenia', 'spinal weakness', and the like. The Greek-based word, neurasthenia, meant literally 'lack of nerve strength'. Beard del~med the condition as 'a chronic, functional disease of the nervous system', the basis of which is improvedshment of nervous force, waste of nerve-tissue in excess of repair; hence the lack of inhibitory or controlling power - physical and mental - the feebleness and instability of nerve action, and the excessive sensitiveness and irritability, local and general, direct and reflex The fatigue and pain that temporarily follow excessive toil, or worry, or deprivation of food or rest, are symptoms of acute neurasthenia, from which the chronic form differs only in permanence and degree . . . . The vague and multitudiness symptoms that accompany neurasthenia are largely the result of reflex irritation that takes place, not only through the ordinary motor and sensory nerves, but through the sympathetic system and vaso-motor nerves. (p. 115)
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Beard regarded neurasthenia as a disease of the neurological system's functioning without structural organic changes but distinct from mental illness (insanity). Intriguingly, he claimed that it was an 'American disease', much more c o m m o n in the United States (especially the Northeast) than in Europe, which was, greatly increased in prevalence owing to the "pressures" of modern civilization. He held it to be routinely misdiagnosed as either hysteria or hypochondriasis on the one hand, or organic (heart, gastrointestinal, gynecological, spinal) pathology on the other. Beard's clinical impression was that neurasthenia was more c o m m o n in women but still quite c o m m o n in men, that its greatest prevalence occurred between 1 6 - 5 0 , that it was particularly frequent among members of the educated and wealthier class, especially physicians, that its symptoms were 'real' not made up, that it led to overutilization of physicians' services, that it was not infrequently associated with drug addiction and alcoholism, that its chronic course fluctuated but would respond to appropriate treatment. Therapy was a multisided approach involving diet, hygiene, massage, medication, electric stimulation and appropriate use of rest, work and change of work. He went out o f his way to criticize a major social therapy of his day, travel, which he felt further debilitated neurasthenia. Though it sometimes was inherited, 'shocks' o f bereavement, domestic troubles, and worry owing to financial and work difficulties contributed to its development. Among its many and variegated symptoms, he noted headache, pain of various kinds, pressure and heaviness in the head, noises in the ears, lack of concentration, irritability, hopelessness, morbid fears (general anxiety and specific phobias, including fear of disease and o f work), dizziness, insomnia, poor appetite, dyspepsia, sweating,

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tremors, dysesthesia, exhaustion, temporary paralysis, sudden failure of sensory functions, palpitations, involuntary emissions, impotence, etc. (Beard 1880: 1 5 - 8 5 ) . Beard viewed neurasthenia as a mimic o f organic diseases and an intimate associate of neurosis, which like neurasthenia involved an abnormality of neurologic function. Gilbert Ballet, professor in the faculty of medicine in Paris, in the third edition of his Neurasthenia (Ballet 1908) disputed Beard's contention that it was an American disease, but agreed that it was a disease whose symptoms medical writers had reported throughout history but which had become more c o m m o n in the nineteenth century owing to the 'pressures' of society. He saw degeneracy as a heredity vulnerability and excessive brain work and poor education as social ones. But unlike hysteria, hypochondriasis, anxiety neurosis and melancholia which were mental disorders, "Neurasthenia whatever be its etiology consists in a state of nervous exhaustion; now nervous exhaustion is something real, which can be appreciated and even measured." (Ballet 1908: 120). Nonetheless in Ballet's influential view The depressing emotions, that is to say, vexation, anxiety, disappointments, remorse, thwarted affection, in a word all states of sorrow and disquiet - these are the usual causes of nervous exhaustion. (p. 25). Moreover, Ballet pointed up the problem of somatization that neurasthenia posed for the clinician. Some [neumsthenics] describe minutely with unwearying insistence symptoms of a secondary order, and hardly mention those of real importance. Others speak abundantly of their headache and their muscular weakness, but deliberately conceal their emotionalism, their childish fears, their states of anxiety, and the powerlessness of their intellectual faculties, all symptoms which it would offend their self esteem to confess. (p. 42). Ballet regarded headache, backache, weakness (neuro-muscular asthenia), insomnia, and dyspepsia as primary symptoms; to which he added cerebral depression - i.e., weakness of personality, will, memory, and moral weakness leading to hypochondriacal complaints. The cause of this mental weakness was organic weakness in the nervous system, whether due to pressures, traumas or excessive masturbation, just as it was the cause of primary symptoms and a wide range o f secondary somatic symptoms, o f which vertigo, dysesthesia, and palpitations were foremost. Ballet's somatopsychic Cartesianism captures the feeling of the most distinguished medical men of his day who had contributed to the voluminous neurasthenia literature, e.g., Galton, Charcot, Krafft-Ebing, Meynert, Freud, Dejerine, and Weir Mitchell, most of whom agreed with him that though the cause was organic the treatment should principally consist of psychological and social therapies. Although neurasthenia no longer is listed as a disease entity in the latest

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Diagnostic and Statistical Manual (DSM4II) of the American Psychiatric Association, it was listed as Neurasthenia Neurosis in prior editions. In the Ninth Revision of the WHO's International Classification of Disease (ICD-9), Neurasthenia is defined as: A neurotic disorder characterized by fatigue, irritability, headache, depression, insomnia, difficulty in concentration, and lack of capacity for enjoyment (anhedonia). It may follow or accompany an infection or exhaustion, or arise from continued emotional stress. (DSMIII 1980: 425-426) Except for pointing out that this diagnosis was rarely used in the recent past, DSM-III's authors enigmatically refer readers who search the Index for this term to read about Dysthyrnic Disorder (i.e., Neurotic Depression) without explaining why. DSM-I, published in 1952, did not include it in the section on "Disorders of Psychogenic Origin or Without Clearly Defined Physical Cause or Structural Change in the Brain," but referred to it as psychophysiologic nervous system reaction, while DSM-II, published in 1968, labeled it Neurasthenic Neurosis and stated This condition is characterized by complaints of chronic weakness, easy fatigability, and sometimes exhaustion. Unlike hysterical neurosis the patient's complaints are genuinely distressing to him and there is no evidence of secondary gain. It differs from Anxiety neurosis (q.v.) in the nature of the predominant complaint. It differs from Depressive neurosis (q.v.) in the moderateness of the depression and in the chronicity of its course. This definition marked the official transition from somatopsychic to psychosomatic conceptualization of neurasthenia, just as DSM-III marks the transition from the 'American Disease' to 'not a disease in America'. The European-based ICD-9, which had to meet with approval from WHO's non-Western members, including China's official health representatives, ambiguously implies both psychogenic and organic etiology, thus maintaining a core feature of the diagnosis that can b e traced back to the creation of the term and further back historically to its progenitors. Could it be that this liminal status was meant to bridge biomedicine's Cartesian dualism with a polysemous medical term which symbolized psychophysical integration and biopsychosocial holism even ff it stood for organicity first? (Perhaps a similar function is filled by the concept of 'stress' in contemporary biomedicine in the West.) Or should we view neurasthenia's historical vicissitudes as evidence of a process of major cultural transformation which in its 100 years trajectory took it from somatic to psychosomatic to psychic state, and eventually completely out of America's medical nosology as a pseudo-disease that represented neither contemporary biological nor psychological constructions of reality? Might it have played a role in popular Western culture in the past that was superseded by culture change in which psychosomatic and psychological pathology became sanctioned constructs for interpreting

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problems in everyday living and no longer required euphemisms, indirection, or liminal ambiguity for their expression? Or are we observing but a single instance of the inductive march of positivist science from obscurity to clarity about the nature of the real word, or witnessing a professional transformation from one paradigm of how to produce and interpret data to others, depending or~ the views of the reader? In standard Chinese, neurasthenia is rendered as shen]ing shuairuo, literally neurological (shenjing) weakness (shuairuo). In Taiwan and Hong Kong as well as China, this term is widely recognized and applied by laymen, for whom it appears to connote an ailment with vague, protean signs and symptoms due to weakness of the nervous system, the brain, and the body generally, in which bodily weakness, fatigue, tiredness, headaches, dizziness, and a range of gastrointestinal and other complaints are to be found. Psychiatrists in China have routinely responded to my inquiries about the nature of neurasthenia with the reply that it is a disorder of brain function involving asthenia of cerebral cortical activity. In this viewpoint, any psychological symptoms present have the same origin as somatic symptoms in the organic pathology held to underlie neurasthenia. This explanation is quite similar in form to the somatopsychic orientation of traditional Chinese medicine, at least as currently practiced. Moreover, it squares with the biological orientation of current Chinese psychiatry and is also consistent with the somatopsychic views of Russian neuropsychiatry which were influential in China in the 1950s, when many of China's leading psychiatrists were completing their training) In Taiwan, where there is a heavy influence of American psychiatric theory, the term is current among general practitioners but psychiatrists tend to translate it into other diagnostic categories, especially the neuroses and personality disorders associated with hypoehondriasis, yet they too are still willing to speak about 'neurasthenia' with patients and to a lesser extent colleagues. Interestingly, in the first volume of the important text, Foundations of Psychiatry, put out by the Department of Psychiatry of the Hunan Medical College in 1981, which contains 640 pages, neurasthenia is covered in a single paragraph (whereas depression is covered in a total of six pages in two different sections). Can this be taken as evidence of uncertainty about the scientific status of this popular cultural and professional term? In the Hunan textbook, neurasthenia is discussed under "Illnesses of Neurological Function (Neurological Illnesses)." These, echoing Beard's definition of neurasthenia as well as a concern to distinguish it from psychosis, are said to be: .. those that cannot be confirmed to have any organic basis. The patient has fairly good powers of self-understanding, and normally does not confuse subjectivepathological experience and fantasy with external facts. Although their behavior can he greatly influenced, they still inwardly keep within the limits tolerated by society, and their personality also remains intact.

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These authors proceed to define neurasthenia in this light and end up with a statement that save for its strong emphasis on abnormal neurological functioning and failure to mention anhedonia is rather in keeping with the ICD-9 definition.

Neurasthenia is a type of functional diagnosis with loss of neurological function which includes weariness, irascibleness, unstable and depressed mood, difficulty in concentrating attention, a definite decrease in recent memory, and sleep with many dreams or loss of sleep. It can come about after infection or exhaustion, or be set off after sustained neurological stimulation. It does not include physical diseases or illnesses due to neurological defects already diagnosed above. (Hunan Medical College 1981: 268-9)
Notably missing is life stress as a precipitant, but my conversations with the authors of this book lead me to believe that they are now prepared to accept this as another provoking agent.

Depression
The comparative epidemiology of depression in Chinese and Western societies is the reverse of neurasthenia. Here high rates of the disorder are reported for the West, and extremely low rates for China. For example, Boyd and Weissman (1981), reviewing a large number of English language reports which they interpret using the recent Rssearch Diagnostic Criteria (RDC) for depression, note that 9 - 2 0 % of the population are diagnosed as depressed in community surveys. The point prevalence of clinical depression (not including Manic-Depressive Disorder) in industrialized Western countries in studies employing varying diagnostic systems is between 1.8 and 3.2 cases per 100 population for men and between 2.0 and 9.3 cases per 100 population for women. Using newer diagnostic techniques, the point prevalence in industrialized nations is 3.2 cases per 100 males and 4.0 to 9.3 per 100 females. (Interestingly, the highest rates currently reported are for Africa (14.3 for men and 22.6 for women), where 25 years ago very low rates were reported, a point I shall return to below.) Boyd and Weissman also note that where the Schedule for Affective Disorders and Schizophrenia (SADS) and RDC are used, the lifetime prevalence of Major Depressive Disorder 4 is 8 - 1 2 % for men and 20-26% for women. For comparison, the lifetime prevalence of Manic-Depressive Disorder they cite as less than 1%. Depressive disorder rates in China are either unreported or extremely low. In the Psychiatry Outpatient Clinic at the Hunan Medical College in a one week period there were 361 patients, 30% of whom were diagnosed as neurasthenic and 1% of whom were diagnosed as depressed (see Tables 1 and 2). Relatively similar figures have been reported to me from other psychiatric clinics in China: namely, neurasthenia accounts for a third to half of all outpatient diagnoses, while minimal numbers are recorded for depression. Heretofore there has been

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no study reported for China, either a community or clinic-based survey, that uses Research Diagnostic Criteria to determine the prevalence (untreated or treated) of depression. Indeed the most recent epidemiological reports of psychiatric disorders in China still frequently do not refer to depression, and where they do, present data either for Manic-Depressive Disorder (for which only 10w rates are reported) or for involutional psychosis (Lin and Kleinman 1981). Causal factors of a number of kinds have been hypothesized as responsible for depressive disorders. While there is impressive evidence implicating abnormalities of neurotransmitters in the central nervous system and family history of depression in. first-degree relatives suggests a genetic predisposition, the somewhat simplistic bioamine hypothesis that has been the dominant biological schema of depressive etiology is being called into question. The still dominant psychoanalytic hypothesis of depression being caused by anger turned inward against the self as a defense against loss of a particular kind has never received much empirical support. There is research evidence for the contribution of stressful life events and impaired social support, but the more interesting and important work has centered around interdisciplinary frameworks relating psychological and social variables that influence individual responses to loss. Brown and Harris (1978) present data in support of a hypothesis that hopelessness is the key factor in the genesis of clinical depression and loss is probably the most likely cause of profound hopelessness. But it is not just loss of a particular 'object' that has to be dealt with so much as its implications for our ability to find satisfactory alternatives (p. 234). The immediate response to loss of an important source of positive value is likely to be a sense of hopelessness, accompanied by a gamut of feelings, ranging from despair, depression, and shame to anger. Feelings of hopelessness will not always be restricted to the provoking incident - large or small. It may lead to thoughts about the hopelessness of one's life in general. It is such generalization of hopelessness that we believe forms the central core of a depressive disorder (p. 235).
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These authors demonstrate that vulnerability factors (working.class background, marriage, presence of small children in the home, lack of employment outside the home, absence of a confiding intimate relationship, loss of a maternal figure in childhood, optimistic or pessimistic personality factors) predispose women to depression by lowering self-esteem so that provoking agents like loss or threat of loss or long term difficulty yield specific hopelessness which is generalized into depression. Brown and Harris also indicate that in the absence of provoking agents factors such as those Beck (1971) describes as negative cognitive schemata about self, others and the environment make individuals susceptible to depression. Although Brown and Harris don't explain how these vulnerability, provoking and susceptibility factors relate to the biological changes characteristically found in clinical depression, an extensive psychiatric literature points toward physiological alterations both in the etiology and the effects of

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depression (Depue 1979; Klerman MS). That biological, psychological and social processes are interrelated in depression has become, at least for some clinical researchers and epidemiologists, an accepted truth (Akiskal and McKenney 1973), but it is not known how this relationship is organized and sustained. Nonetheless, the evidence is compelling that, in addition to biological change and psychological experience, social relations and meanings are implicated in the onset, process and consequences of depressive illness. The crude Cartesian dichotomy between reactive (psychosocial) and endogenous (biological) depression, which persists in spite of psychiatrists' awareness of its inadequacy, is scientifically untenable. Thus far, however, there has not been significant crosscultural research on the social factors and their sociosomatic correlates; we simply do not know how they apply to Chinese depressives. Since the writings of Hippocrates in the West, melancholia (depression) was viewed as organically based in an excess of black bile (Simon 1978: 229). This cause was passed down well into modem times through Galen's influential writings (Jackson 1969), and while the humoral theory eventually gave way to chemical and mechanical causal attributions, the somatopsychic or physiological psychology orientation continued to dominate the medical literature and lay views (Jackson 1980). By the seventeenth and eighteenth centuries the long association of hypochondriasis with melancholia was beginning to break apart, and Willis and later Sydenham separated the former off as an independent disorder. But clearly medical men for sometime in the West had associated depression with the hypochondriacal amplification of somatic complaints and continued to relate it to melancholy as an affect if not melancholia as a disease. Hypochondriacal melancholy was associated with problems involving the spleen and later with 'pathologial vapors'. Hence contemporary biological views of depression and somatic preoccupation are underpinned by a long Western medical tradition of viewing mental problems as organically based that related both of these syndromes and, as we have already seen, neurasthenia as well to somatic pathology. It is only in very recent times in the West, beginning perhaps in the Victorian period and accelerating after Freud, that psychological and psychosomatic views of these disorders have become popular both in medical and lay circles. Attempts at integrating biological, psychological and social features of depression in clinical research are only a few decades old. Appreciation among practicing psychiatrists of the importance of social and cultural determinants in depression is still poor. There is a striking gap between contemporary theory and practice.
Somatization

Hoeper et al. (1979) used the SADS-L interview schedule in a primary care

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population and diagnosed mental disorder in 27%. Of these over 80% were cases of depression and anxiety, a finding also reported in several very large surveys of primary care practices in the United States and Britain (Marshland et al. 1976; Hesbacher et al. 1975; Goldberg 1979). Nielson and Williams (1980) diagnosed 12% of ambulatory patients in a prepaid health program as at least mildly depressed, and 6% as moderately depressed. In 50% of their cases the primary care physicians failed to diagnose depression. These and other studies too numerous to cite disclose that depression is the commonest psychiatric disorder and one of the commonest of all disorders in primary care practice (Katon et al. 1982). But many of these cases, psychiatrists demonstrate, are misdiagnosed by nonpsychiatric physicians. For example, Eastwood (1971) revealed that in 124 medical outpatients determined to be suffering from psychiatric illness, almost half of the women and almost 60% of the men were not so recognized by their general practitioners. Much the same kind of Finding has been reported by Marks et al. (1979) and Hesbacher et al. (1975). Goldberg and Blackwell (1970) term such patients 'the hidden psychiatric morbidity'. Goldberg (1979) found that over half the patients seen by primary care physicians had significant somatic symptoms as part of their depressive disorder. Singh (1968) showed that 65% of a depressed outpatient group presented to the clinic with a physical complaint. Weissman et al. (1981) documented that patients with depression who did not receive treatment for their emotional problems made significantly more visits to nonpsychiatric physicians than patients without psychiatric diagnoses. Stoeckle and Davidson (1962) recognized that depression often masqueraded as a vague physical complaint, most often fatigue and loss of appetite. Raft et al. (1975) determined that while 29% of outpatients in a general hospital fit criteria for depression, 12% had 'masked depression': meaning that they complained of physical complaints associated with depression, but not of psychological complaints. Widmer and Cadoret (1978, 1979) discovered in the clinical charts of 154 depressed patients in family practice that when compared to controls in the half year prior to when depression was diagnosed, there was an increase in the number of patient initiated clinic visits, in hospitalizations, and in presenting complaints of three types: "functional complaints, pain of undetermined etiology and complaints of tension and anxiety." Pain complaints seem to be an especially common feature of depression. Von Knoring (1965) found that 60% of his patients with depression had experienced some form of somatic pain. Ward et al. (1979) described a 100% prevalence of pain complaints in a study of depressed psychiatric inpatients. Lindsay and Wykoff (1981) found that 87% of 300 pain center patients fit RDC for Major Depressive Disorder. When these patients were compared with 196 patients whom they treated for Major Depressive Disorder, they found that 59% of the latter also had significant pain complaints, principally involving head (60%), abdomen (29%),

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back (38%), and chest (20%). Depression has been reported to be highly prevalent among groups of patients with 'nonorganic' abdominal pain (Hill and Blendis 1967), diabetic neuropathy (Turkington 1980), chronic headache (Diamond 1964; Sherwin 1979), and low back pain (Stembach 1974), and each clinical investigator found marked alleviation of both pain and depression after treatment with tricyclic antidepressants. Blumer et al. (1980) showed that compared to placebo significantly more chronic pain patients received partial to complete alleviation of pain when treated with tricyclic antidepressant drugs, thus disdosing by their treatment response that a large percentage of these patients were depressed. Most of these 'pain' patients ostensibly denied depressed mood despite having the vegetative symptoms of depression which stem from autonomic nervous system, endocrine, and limbic system involvement in depressive disorder. Blumer, along with many others, has shown that various social and psychological 'gains' the patient and/or family derive from pain complaints maintain chronic illness behavior, thereby creating a vicious circle. Psychological 'gains' include binding anxiety, relieving dysphoria, fulfilling disguised dependency needs, sanctioning anger and aggressive wishes by troubling others and expressing distress in personally and culturally legitimated idioms that cope with symptoms by externalizing them. Secondary 'gains' include disability payments, change in family systems, avoiding stressful situations, sanctioning of failure, etc. A WHO survey revealed that of a sample of 1165 adult patients in primary health care facilities in India, Sudan, and the Phillipines, at each center 11% to 18% of cases had psychiatric disorders. Less than one-third of these were recognized by health workers and appropriately treated. Most patients in this sample complained of physical symptoms: headaches, other pain, weakness, dizziness (Climent et al. 1980). As with the previous studies cited, these authors point out the importance of early identification and proper treatment of depression and other forms of psychopathology to prevent chronic illness behavior, overutilization of health facilities, polypharmacy, addiction to narcotic drugs, expensive and unnecessary biological tests and surgeries, and serious iatrogenesis. Other studies indicate that depression and most other mental illnesses, especially in non-Western societies and in rural, ethnic and lower class groups in the West, are associated preponderantly with physical complaints. For example, a recent study in North America indicated that the most common complaints of depressed patients in decreasing order of frequency are impaired concentration, weakness, agitation, daytime drowsiness, headaches, excessive perspiration, dizziness, dry mouth, rapid breathing, blurred vision, constipation, tinnitus, dry skin, delayed ejaculation, flushing, slurred speech, premature ejaculation, chest pain, excessive salivation, weight gain, amenorrhea, impotence, etc. (Mathew et al. 1981). Intriguingly, many of these complaints appear in Beard's list of the symptoms of neurasthenia.

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Cross-cultural studies document high rates of somatization among depressed Saudi women (Racy 1980), depressed Iraqis (Bazzoui 1970), depressed patients in Benin, West Africa (Binitie 1975), depressed Peruvian compared to American patients (Mezzich and Raab 1980), depressives in several areas of India (Teja et al. 1971; Sethi et al. 1973), Chinese depressives in general practice in Hong Kong (Cheung et al. 1981), Taiwanese patients with Major Depressive Disorder (Kleinman 1977, 1980), Native American depressives (Manson et al. in press), and, as Marsella (1979) describes in a major review paper, among depressed patients generally in non-Western cultures. Cheung et al. (1981) examined the symptom presentation of depressed patients seen at a general medical clinic in Hong Kong. Their symptoms as noted on a symptom check list were feelings of sadness/downheartedness (82%), agitation and restlessness (80%), irritability (74%), tension and nervousness (86%), inertia or retardation in thoughts and actions (70%), guilt or an inclination to self-reproach (61%), suspiciousness of others (37%), suicidal ideation (17%), insomnia (65%), early morning waking (62%), loss of interest in social (68%) and sexual (43%) activities, anorexia (53%). But the three most frequent symptoms checked on the list were feelings of tiredness and fatigability (90%), pains and aches (89%), and gastrointestinal/cardiovascular symptoms (87%). The chief presenting somatic complaints in decreasing order of prevalence were sleep disturbance (31%), tiredness/malaise (29%), headache (20%), dizziness (20%), menopausal complaints (20% of women), abdominal pain (14%), anorexia (14%), weakness (13%), palpitation (13%), fearfulness (11%), epigastric pain (1 0%). The central nervous system was most frequently the source of complaints, followed by gastrointestinal, gynecological, cardiovascular, respiratory and urinary systems in decreasing order. These authors noted that not all depressed patients were aware of their depressed mood, and most did not complain primarily of their emotional distress. The range of symptoms were variegated and not different from those brought by nondepressed patients with medical disorders. Frequently, however, depressed patients complained of vague and diffuse somatic symptoms in a pattern the authors regarded as a "somatic facade [that] concealed the depressive-ridden state of mood"; but when directly questioned about their mood, most of the depressed patients admitted to feelings of sadness. There was a substantial admixture of anxiety complaints. The authors concluded that somatization as a mode of manifestation of depression may involve different psychological processes. The depressed patient simply may not experience sadness as an important symptom. Even if aware of dysphoria, he may rationalize and camouflage his troubles out of fear of the social stigma attributed to mental illness. Or the tendency to somatize may reflect difficulties in verbalizing inward feelings. "For most working class Chinese who are used to more concrete modes of expression, conceptualization at the psychic level may seem too abstract."

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(Cf. Lesser 1981 on alexithymia, a clinical hypothesis that somatiziug patients may be unable to express emotions or fantasies verbally.) Because many patients in the study recognized and admitted psychological symptoms of depression when directly asked, the authors reason that somatization among this group of Chinese depressives is due more to the cognitive style of communicating inward feelings in outward somatic terms than because of unconscious denial. Gender differences did not seriously affect the form of somatization. Other research reveals that depression not only produces somatic symptoms as a psychophysiological component of the integrated affective, cognitive, physiological arid social dysfunctions that represent the core of depression as a biopsychosocial disorder (Katon et al. 1982), but that depression is a not infrequent consequence of medical disorders, especially severe medical illnesses such as renal failure, cancer and heart disease. Cushing's syndrome, diabetes, thyroid disease patients often suffer depression, and the first has been shown to produce many of the symptoms of the Major Depressive Disorder (Starkman et al. 1981). A substantial number of depressed patients have been found to have endocrine abnormalities, most commonly failure t o suppress on the dexamethasone supression test of hypothalamic-pituitary-adrenal axis function (Carroll et al. 1981) and to a lesser extent a blunted response to the thyrotropinreleasing hormone stimulation test of hypothalamic-pituitary-thyroid axis regulation (Targum et al. 1982). There is also convincing evidence of autonomic nervous system and limbic system abnormalities (Depue 1979; Kupfer and Foster 1972); and depression has been shown experirnentally and clinically to significantly impair immunological function. Somatization has been defined by Katon et al. (1982; cf. Rosen et al. 1982) as both the expression of physical complaints in the absence of def'med organic pathology and the amplification of symptoms resulting from established physical pathology (e.g., chronic disease). The latter is frequently associated with subjective reports of disability (both symptoms and social impairment) that strike medical observers as excessive and unexplained by the existing pathology. Besides depression a number of other psychiatric disorders are commonly associated with somatization, including anxiety disorders, hysteria, chronic personality problems, and factitious illness. In addition, somatization has been reported in the absence of psychopathology as an expression of and means of interpreting and coping with social stress and personal distress (Good 1979; Katon et al. 1982; Kleinman 1980). Mechanic (1980) confirms in a longitudinal study that "developmental experiences are particularly relevant in directing attention to inner experience and in forming an inclination to monitor the body."
The e x t e n t to w h i c h this actually occurs in later life d e p e n d s o n t h e occurrance o f illness,

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adverse life experiences that result in psychophysiological changes, and personal stresses that reinforce a tendency toward self-attention and evaluation. . . . although the relationship between attention on internal states and reports of discomfort may be more substantial in the case of psychological symptomology.., psychological and pliysieal symptoms are not dearly distinguished and tend to occur concomitantly. Thus psychological distress may produce bodily discomfort, increase body monitoring, and make persons more sensitive to changes (Mechanic 1980: 154). Mechanic offers an hypothesis to explain what differentiates the determinants of physical and psychological complaining: the two major determinants of differential responses are actual adult experiences with symptoms and illness on the one hand, and cultural influences on the det'mitlon of illness on the other. Whereas reporting physical symptoms is culturally more neutral, reporting psychological symptoms is more dependent on social acceptability (Mechanic 1980: 154).
. .

Parker (1981) in a study of field dependence and the differentiation of affective states showed that field dependence did not affect the overall levels of symptom intensity but did influence the extent to which individuals differentiated neurotic symptoms as being associated with particular emotions. Field independent subjects discriminated at a significantly higher degree symptoms as being associated with particular emotions, especially cognitive and to a lesser degree somatic ones. Field dependent subjects tended to experience global and diffuse disturbance rather than discrete patterns of cognitive and somatic experiences as distinguishable entities. Field dependence is a cognitive style associated with women more commonly than men, with lower social class, and appears to be highly prevalent among individuals in traditional non-Western societies. Whatever this measure of perceptual style is getting at, it suggests that culturally and socially constituted cognitive styles may significantly determine which symptoms are perceived and elaborated. This is an important question for research on the differential prevalence of somatization cross culturally. Several hypotheses have been advanced to account for somatization as resulting from cognitive style: amplification of normal sensations, misattribution and labeling as illness o f the somatic symptoms, of affective arousal, and utilization of externalizing cognitive coping processes to handle stress as a final common cognitive-behavioral pathway along which is channelled dysphoria or disease. Social situation and cultural learning, it is held, can influence these cognitive processes such that perception, attribution, labeling, coping, and communication styles will support a somatizing mode of behavior. Thus somatization need not result from or represent psychopathology, but might be regarded as a particular cognitive-behavioral type whose adaptive or maladaptive consequences would involve assessment of particular social and cultural as much as personal variables. It is obvious that community studies are necessary as a complement to clinical studies if the full scope of somatization is to be appreciated, and that the former

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may demonstrate less evidence of pathology than the latter, and may even reveal that somatization has certain adaptive effects.

Language, Somatization and Meaning

That European psychiatrists in Africa in the Ftrst half of this century failed to diagnose depression among their indigenous patients, whereas later investigators, both Africans and Europeans who are fluent in the relevant languages, have diagnosed levels of depression among the highest reported worldwide has been taken as indicative of the crucial role of language in somatization. Left (1981), noting that verbal equivalents of anxiety and depression are absent from a number of languages in the non-Western world, suggests that there is a historical and cross-cultural development of words for unpleasant emotional states. At an early stage one word denotes the somatic accompaniments of dysphoria. At this stage the somatic experience is relatively undifferentiated so that a range of words is unnecessary. At the next linguistic developmental stage, the meaning of the word broadens to include the psychological as well as the bodily experience of emotions. Since the psychological experience is as undifferentiated as the bodily experience, one word encompasses it. Thereafter, there comes a shift to psychological experience and away from somatic experience. "Eventually the root word split into a number of phonetically related variants as the global psychological experience of unpleasant emotion was differentiated into several distinct categories" (Left 1981: 45). This evolutionary explanation holds that a number of non-Western languages remain at an early developmental stage, "lacking words for depression and anxiety and instead possessing words for the bodily experience of emotion which are relatively undifferentiated." Left notes that in cross-cultural perspective, psychologizing emotions is more recent and therefore should be highlighted against the older background of somatization. In support of this argument he notes that depression and anxiety have no direct equivalents in Yoruba, a Nigerian language, that the Xhosa people of South Africa have no word meaning depression, but instead refer to this state via a word meaning 'his heart is sore', and that the same holds for Luganda, an Uganda language. In Chinese men conveys the sense of depression as a physical sensation of something pressing on or depressing into the chest and heart. MarseUa (1979) points out the same striking fact that indigenous categories of mental disorder in a number of non-Western societies possess no concepts of depression as disease or symptom. Left recognizes that some non-Western languages do possess highly differentiated psychological terminology, but this he takes as an exception. Left also presents evidence indicating that unpleasant emotions seem to be less well differentiated in non-Indo.European centers that participated in the WHO's International Pilot Study of Schizophrenia than in

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Indo-European ones. He takes this to mean that "languages with a restricted vocabulary of emotions do impair patients' ability to express emotions in a well-differentiated way" (Leff 1981: 48). He also shows that psychiatrists from the more developed societies tend to impose greater differentiation of the emotions on patients from developing countries, perhaps because this is what they have come to expect from patients in their own culture. Left suggests this may hold for psychiatrists in Western societies especially where they work with lower class, less well educated and ethnic patients. Ebigbo (in press) argues that Nigerians use somatic terms which are culture specific (e.g., a peculiar crawling sensation in the head), and which even if they refer to shared experiences convey meaning pertinent to a particular cultural context. Good (1977), working in Iran, has shown that there is a unique semantic network of meaning associated with the somatization term 'heart distress', and that this network conveys 'key social and psychocultural information to its indigenous members, information that holds considerable cultural significance and serves social and personal functions. The late Michelle Rosaldo (1980) provides ethnographic evidence to support the cultural relativist view that emotions are inseparable from the way they are categorized and used in a particular society's practical discourse of daily life. Hence even if there is an equivalent word for depression or anxiety, these emotions mean and therefore are different experiences in distinctive groups, who hold particular views of the self, the body, social relations, normal behavior and illness (cf. White 1982). Her work with the Ilongot of the Philippines offers detailed examples of the cultural construal and construction of emotional experience. Lutz (1982) presents complementary data from studies of indigenous psychologies that lend themselves to a similar interpretation (see also Heelas and Lock 1981). Anthropologists working from such a meaning-centered perspective would criticize Leff's formulation as well as others like it as both empirically and conceptually flawed. They would point out that historically in Buddhism, for example, one can find psychological terms and ideas present from the very beginning, while in many non-Western languages, like Tamil in South India, there is no Cartesian dualistic separation between psychological and somatic aspects of experience,s Both are integrated in language usage. From this perspective it is an example of Western Cartesianism to assume that overt somatic complaints are any less 'real' than allegedly hidden psychological problems. The very metaphor of the former 'masking' the latter so popular with Western psychiatrists and psychologists would be seen as a reflection of this Cartesian bias that misrepresents a much more complex reality even when the culture of patients also shares this conceptual dualism. Indeed, these critics would further argue that Left's historical linguistic account is even wrong for the Western world, where medical and psychiatric discourses may have been psychologically impoverished in the

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past, but where religious discourse has always been rich in psychological terms and their sophisticated use. These proponents of cultural relativism might conclude that it is in the study of particular meanings, not generic words, in particular situations, not dictionaries, that the psychological and social significances of illness and emotions are to be understood, and though found present in all human societies will be distinctive. Somatization, then, receives a rather different treatment when it is regarded as a culture-bound component of contemporary Western society's system of symbolic meanings. For example, the Afghan psychiatrist Waziri (1973) reports that Afghans with depression generally "had no words to describe their feelings of sadness." But they could differentiate it from grief for a dead loved one. They complained of a feeling "as if a strong hard hand was squeezing" their hearts. This symptom was the one most stressed in his interviews with patients, the one for which they principally sought relief. Yet Waziri did not examine the semantics of this term, nor did he explain its status in Afghan cultural rules and norms. But it has a striking resemblance to Good's work on heart distress in a Turkish area of Iran and would have been an ideal subject for an interpretative account. Rather the term is adduced to demonstrate somatization with the assumption that its real meaning is an underlying affective disturbance (in the Western sense). The related assumption in much of the psychiatric literature on non-Western peoples is that psychological mindedness comes with higher education and Westernization as a new language learned to express previously unrecognized or unstated emotions. Because researchers writing from this perspective often are Western-educated members of indigenous communities, there is the lingering suspicion that such writers are somewhat divorced from (and perhaps embarrassed by) their own native cultures and tend to see things only from a mental health perspective, a decidedly Western point of view. Here is an excellent reason why anthropological field research on the cultural meanings of illness behavior and emotions is needed as a complement to biomedical and psychological studies. Only an ethnographic field approach is likely to elucidate the culture-specific significance of symptoms. To the evolutionist and relativist interpretations, Izard (1979), building on work begun by Darwin, offers a universalist alternative. Focusing on studies of the facial expression of emotion, she shows that the same emotional experiences are detectable in a wide variety of cultures and appear to derive from basic neurophysiological correlates of human and animal behavior. These should have the same somatic, affective and cognitive expressions cross culturally. She and others suggest that depression may occur in nonhuman primates. For example, Suomi et al. (1978) produced depressive-like reactions in young rhesus monkeys by repeated separations and improved these to a greater extent than placebo did with an antidepressant drug. Hence the major interpretations of emotions cross

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culturally seem to fail into three quite distinctive interpretive frameworks. Each can be (and has been) applied to elucidate somatization. THESTUDY In order to contribute to the understanding of neurasthenia, depression and somatization in Chinese culture, and thereby perhaps help clarify the conceptual issues in the relation of culture and affect, I undertook an empirical study in the People's Republic of China in summer 1980. One hundred patients with the diagnosis of neurasthenia who attended the Psychiatric Outpatient Clinic, #2 Aff'tliated Hospital, Hunan Medical College, were selected for the study once they met inclusion criteria. They had to be between 18 and 56 years of age, since we wished to avoid children and the aged in our sample, attending the clinic for the first time with their present complaints, free of major medical illnesses (e.g., diabetes, thyroid disease, multiple sclerosis, mitral valve prolapse) and organic mental disorder, willing to participate in the study and available and willing to return for follow-up. At each weekday morning clinic, the first two or three patients (depending on whether sufficient time was available to complete the assessment of three patients) who met the criteria entered the study. Since patients at the Hunan Medical College and generally in China carry their own medical records, including reports of laboratory tests and documentation of medication and other treatment received, we reviewed the medical records in full and requested all relevant data including report of patient's initial interview and physical examination in the psychiatry clinic. In a few cases where there was a question of an underlying medical or organic mental disorder not fully worked up in the recent past, pertinent blood chemistries, X-rays and cognitive function tests were obtained. Each patient participated in a lengthy interview that consisted of a complete description of symptoms, course, illness behavior, help seeking, and ethnomedical beliefs associated with the current illness. Each received a psychiatric assessment using the Schedule for Affective Disorders and Schizophrenia (SADS, Third Edition, Part 1), which had been modified to yield DSM-III diagnoses for Major Depressive Disorder, Dysthymic Disorder, Cyclothymic Disorder, Manic-Depressive Disorder, Panic Disorder, Generalized Anxiety Disorder, Phobic Disorder, Obsessive-Compulsive Disorder, Somatization Disorder, Conversion Disorder, Schizophrenia, and Substance Abuse Disorder. 6 This instrument was translated into Chinese by psychiatrists who are bilingual in both standard Chinese and the native Hunanese dialect, then back-translated into English, and tested for validity and reliability in a pilot sample of 10 subjects. It was administered by the author and at least one native speaking postgraduate psychiatrist. In addition, each patient was interviewed about past experiences with symptoms covered by

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the SADS and with the psychiatric disorders listed above, as well as about past medical history, and work, educational, family, marital and personal histories. A questionnaire was constructed to gather information on stressful life events in the six months prior to the onset of the illness and, in cases of chronic illness, prior to the most recent exacerbation. It also inquired about coping, social support network, explanatory model, perceived social impairment, and significant psychosocial problems (i.e., family, marital, work, school, fmancial, doctor-patient, hereafter referred to as illness problems) associated with the illness experience and its treatment. Stressors, social impairment and illness problems were scaled on a five point scale of perceived severity. Following these assessments, each patient underwent an open-ended ethnographic interview to determine the social significance and uses of their symptoms in terms of their day-to-day illness behavior in their concrete social contexts. When family members and/or co-workers were available, they were queried about many of the same points and also asked to provide whatever additional information they were willing to contribute. Patients were asked to return five to six weeks following the initial interview for follow-up assessment which consisted of review of current symptoms, assessment of change in past symptoms, perceived social impairment, specific illness problems, help seeking, and compliance. Each was scaled as in the initial interview. Ethnographic interviews were repeated to reasses the social significance and uses of illness behavior. Post-treatment explanatory models were collected, and in a few cases psychological and biological tests were performed to rule out medical disease or organic mental disorder. Family members and co-workers who accompanied patients to the follow-up also were queried about these issues. Seventy-six patients returned for the full follow-up interview, and 23 of these returned for a second follow-up. The major reason for not returning was living at too great a distance from the hospital. Several patients who failed to return sent back replies about their current condition, or their local doctors did so. But these data, which were quite incomplete, are not included in the outcome data. The research team was responsible for providing treatment for the patients in the study, which consisted almost entirely of psychopharmacological medication. This doubtless inhibited the ethnographic interviews, and rendered the compliance evaluation questionable, but was probably also responsible for the very full replies to the psyehosocial questionnaire and clinical assessments. RESULTS The chief findings are summarized in Tables I-XXXIV.

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ARTHUR KLEINMAN TABLE I Demography of Psychiatry Outpatient Clinic, Hunan Medical College N = 361 Consecutive Patients a

Sex
Males 184, Females 177

Occupation
Peasant - farmers Cadres Workers Students Professionals Housewife or retired 22% 17% 42% 11% 0% 8% 7% 25% 50% 17% 2%

Age Structure
15 and under 15-25 26-45 46-60 over 60 a These were all the patients seen in one week of 10 half-day clinic sessions.

TABLE II Diagnoses of 361 Consecutive Patients, Psychiatry Clinic, Hunan Medical College a % of Cases c Schizophrenia Other psychosis (including organic mental disorder) Neurasthenia Neurasthenia syndromes Neurasthenia (all forms) Neurosis b Hysteria Depression Neurological disorders No diagnosis 31 4 19 12 31 15 4 1 11 4

a Diagnoses made by psychiatrists in the Department of Psychiatry, Hunan Medical College, using their own diagnostic system. b Including neurological headaches, vascular headaches, anxiety states, phobias, obsessivecompulsive disorders. c Percentages add to more than 100% owing to rounding.

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TABLE III

100 Neurasthenia Patients Males 52, Females 48

Accompanied 28, Unaccompanied72 Referred by doctors 48, Self referred (or by family or friends) 52

Occupation Peasant-farmers Cadres Workers Teachers Professionals Students

2 16 48 18 - 10 6

(13 political, 3 technical) (45 laborers, 2 office workers, 1 retired, 1 unemployed)* (6 primary, 6 junior middle school, 6 senior middle school) (3 engineers, 3 nurses, 2 doctors, 2 senior technicians) (4 college, 2 senior middle school)

Age Structure 18-25 16% 26-45 66% 46-56 18% Mean Age 36, Males 33, Females 38
* Unemployed worker is listed as one of the 45 laborers.

Demography o f the Sample

As Table III shows there were more men (52) than women (48). This Fmding is surprising in cross-cultural psychiatry research, since evidence from many cultures reveals that women more commonly suffer from depression, anxiety states and various somatization syndromes than men. But it is in keeping with the demography of the Psychiatry Outpatient Clinic at the Hunan Medical College, where in a one-week period there were 184 men and 177 women in attendance. Again this finding is unusual in cross-cultral perspective, since in most societies women predominate in psychiatric clinics. Before generalizing from these data, it is essential that we learn more about the demography of psychiatric clinics throughout China than we presently know. The f'mding in the initial visit that there were many more patients unaccompanied than accompanied by family or co-workers also is opposite to what we have come to expect for Asian and other non-Western societies (including other Chinese settings), where most patients tend to be accompanied so that the doctor-patient interaction is at least triadic and frequently involves several family members and friends. Future descriptive studies will indicate whether this f'mding is valid for the Hunan Medical College and for other psychiatric clinics in China. While slightly more patients were self-referred or referred by family or friends to the clinic than were referred through the formal medical system, as we shall see later on most patients' pathways of help seeking did in fact pass through Western medicine and Chinese medicine clinics. That nearly half the patients received

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a medical referral suggests that general physicians recognized that there was some sort of psychiatric problem. Although this recognition rate comes close to that we cited above for somatization patients treated in primary care in the West, we did not determine if in the other cases there was a failure to identify psychiatric problems. The neurasthenia patients and the psychiatric clinic sample show some differences in age structure. We did not include children or the elderly in the neurasthenia group in order not to have to deal with childhood psychopathology and dementia. In both groups there is a preponderance of patients in the 26 to 45 years age range. Some major differences in occupation were documented. There is a marked underrepresentation of peasant-farmers in the neurasthenia sample compared with their general prevalence in the psychiatry clinic, and a slight underrepresentation of students. Although accounting for 8% of patients in the Psychiatry Outpatient Clinic, housewives do not appear in the neurasthenia group and there was only one retiree (a worker); the latter doubtless were excluded by the age criteria. The overrepresentation of professionals (especially health professionals) in the neurasthenia group should be noted. Though the excess of professionals and teachers fits with Chinese stereotypes of neurasthenia, the preponderance of workers and the presence of 16 cadres indicate that neurasthenia covers major segments of the Chinese urban population. Rural research should help clarify whether the very small number of peasant-farmers in our sample can be interpreted to mean that this disorder is less frequently diagnosed among members of this group or that neurasthenia patients, unlike schizophrenia cases, are not brought to the psychiatry clinic because this problem is not deemed serious enough to warrant travel and time away from a very busy season of agricultural work. These 100 patients had 422 family members whom they either lived with or regarded as members of their household or family, fla. The patients and their family members occupied 239 rooms. A mean of 4.4 members per family occupied 2.5 rooms, yielding a rate of almost two persons per room. One quarter of the patients lived in dormitories.

Psychopathology
The DSM4II diagnoses of the 100 neurasthenia patients, as displayed in Table 4, reveal depression as far and away the predominant form of pathology. Of the 93 cases with clinical depression of one kind or another, 87 met the diagnostic criteria for Major Depressive Disorder. As can be seen in Table VIII, moreover, most of the patients easily met the cut-off criteria of at least four vegetative symptoms required to make the Major Depressive Disorder diagnosis. The mean

NEURASTHENIA AND DEPRESSION TABLE IV Diagnosesa of 100 Neurasthenia Patients

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Number of Cases, Major DepressiveDisorder Manic DepressiveDisorder (Depressed) Dysthymic Disorder (DepressiveNeurosis) Cyclothymic Disorder (Depressed) Depression (all forms) Panic Disorder Generalized Anxiety Disorder Phobic Disorder Anxiety States (all forms) Somatization Disorder (Briquet's Syndrome) Conversion Disorder Somatoform Disorders (Hysteria, all forms)
Shen kui Syndrome ('kidney weakness') Frigophobia (pa leng, fear of 'cold')

87 3 2 1 93 35 13 20 69 15 10 25 11 3 14 2 1 1 44

Culturt-Bound Disorders Obessive-CompulsiveDisorder Alcoholism. Drug Abuse (intoxication and addiction) Chronic Pain Syndrome a Mort than one diagnosis per patient (mean 2.5).

number of symptoms per case was almost 6, only 10% of cases had the minimum, 62% experienced 6 or more, and 13% demonstrated all 8 diagnostic symptoms. Thus there were few equivocal diagnoses: these patients were clearly clinically depressed. Anxiety Disorders were diagnosed in 69 cases, with Panic Disorder (35) the most frequent. The overlap of anxiety and depression, as was noted earlier, has often and widely been reported in the clinical literature. A quarter of the sample showed the classical stigmata of hysteria as more narrowly defined under DSMIII's Somatoform Disorders category. Again there was some overlap between hysteria (especially Conversion Disorder) and depression. In keeping with what is know about psychopathology among Chinese generally (I_in et al. 1981), the two cases of Obsessive-Compulsive Disorder and the single case of Alcoholism indicate the small numbers of these problems, especially the latter, in Chinese culture. Chinese seem to be protected by their culture against alcoholism, which is one of the commonest mental health problems

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worldwide. The single case of sedative-hypnotic drug intoxication and addiction, along with the absence of narcotic drug problems, further illustrates the impressive contrast in the People's Republic of a problem (drug abuse) which afflicted China as a major plague before 1949, and is still significant in Hong Kong and among overseas Chinese, but is now extremely well controlled. Forty-four of the neurasthenia patients were suffering from chronic pain syndrome (i.e., pain in a single site or several sites lasting for more than two years and causing disability wth social impairment in family and work settings). None of them had previously been diagnosed as suffering from this disorder, though they had received frequent medical attention for specific pain complaints, had undergone numerous diagnostic tests, and had been prescribed many different types of pain medication. Similarly, none of the 14 patients exhibiting culture-bound syndromes had been diagnosed as such. These syndromes have been reported for Chinese in Hong Kong, Taiwan, Singapore, Malaysia, and other overseas Chinese communities, but to the best of my knowledge not by psychiatrists in the People's Republic of China. Eleven cases of Shen kui Syndrome demonstrated the classic complaints of excessive loss of semen via urination, 'masturbation, intercourse; fear of lack of energy, infertility and impotence; sexual inhibition and abstinence, guilt and anxiety; and a range of hypochondriacal preoccupations including dizziness, blurring of vision, cold sweats~ memory disturbance, palpitations, and alleged discoloration of urine (cf. Wen and Wang 1981 : 365 for data from an empirical study of this syndrome in Taiwan). The 11 patients all believed they were suffering from Shen kui (kidney weakness), had been diagnosed as such by friends, family, or Chinese-style doc[ors, but had not previously reported these ideas to their Western-style doctors or psychiatrists. This disorder is inseparable from the traditional Chinese medical belief that vital essence is stored by the kidney in the semen and that its excessive loss will lead to weakness, illness and eventually death. Three other patients fit the pattern described by psychiatrists in Taiwan as fear of cold (pa leng) or Frigophobia (Chang et al. 1975) in which, based on the traditional belief in the balance between Yin/Yang and 'hot'/'cold' components of the body, patients develop a morbid fear that their bodies are excessively cold owing to loss of 'hot' substance. These patients bundle up even in warm weather, fear 'catching cold', avoid going out of doors, eat only 'hot' foods and tonics, refrain from eating 'cold' substances, and organize their hypochondriacal preoccupation around this culturally constituted fear to such an extent that they suffer signifi. cant disability. (One case in our sample wore a long sleeve shirt, sweater and outer jacket on a day when the local temperature was an uncomfortably hot 37C. and made us switch off an electrical fan and close the windows to the examining room because he feared 'catching cold'.) The fact that my Chinese research colleagues implicitly understood these complaints suggests that the

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failure to report t h e m is most likely due to a systematic effort to translate them into biomedical equivalents and not to use traditional Chinese-style medical concepts in the day-to-day practice o f psychiatry. Such cases I was told are usually found in traditional Chinese-style medicine clinics. Hence that is the setting where culture-bound syndromes should be studied in China. F e w o f the patients used the Chinese-style medical terms in their presenting complaints, and therefore it is plausible that patients themselves actively translate between biomedical and indigenous medicine terms in the appropriate setting. We can compare the diagnoses o f these patients to those o f 51 cases with somatization attending general medical clinics and folk healers' shrines in Taiwan (see Table V). Almost all o f the latter had carried the diagnosis o f neurasthenia. Only 43% o f the Taiwanese subjects made the criteria for Major Depressive Disorder (see Table VI), however, a statistically significant difference. This can

TABLE V Diagnoses of Somatization Cases in Taiwan N = 51 a Number of Cases Major Depressive Disorder Dysthyrnic Disorder Atypical Affective Disorder, Pathological Grief Depression (all forms) Panic Disorder Generalized Anxiety Disorder Phobic Disorder Anxiety (all forms) Somatization Disorder (Briquet's Syndrome) Conversion Disorder Hysteria (all forms) Chronic Pain Disorder Obsessive Compulsive Disorder Chronic Personality Disorder Schizophrenia No Mental Illness Culture-Bound Disorder Alcoholism and Drug Abuse
a

% 43 4 2 49 10 27 0 37 4
8

22 2 1
25

5 14 0 19 2
4

6 15 3 3 2 1 1 0

12 29 6 6 4 2 2 0

Note: 58 cases of somatization were included in the "Taiwan Comparison of Western and Traditional Healing", but fun psychiatric assessment data were available for only 51 of these cases. Almost all of these cases had been diagnosed at one time or another by Western-style or Chinese-style doctors or shamans as neurasthenia, or had self-diagnosed themselves or been diagnosed by family members with this label.

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ARTHUR KLEINMAN TABLEVI Neurasthenia Patients Hunan Taiwan 22 (43%) 29 (57%) 51

Major DepressiveDisorder

Yes No Total

87 (87%) 13 (13%) 100

Chi-square (ld.F.) is significant. (Chi-square= 30.2; P < 0.005) best be explained by the high probability that patients attending a psychiatric clinic will demonstrate more significant psychopathology than patients in primary care. A more appropriate comparison would be a neurasthenia sample in a primary care clinic at the Hunan Medical College, a study I hope to conduct in future. The difference also doubtless partially reflects the different diagnostic methods used. In the Taiwanese study, diagnosis was made by a Taiwanese psychiatrist via standard clinical interview and Zung Depression Scale and later transformed from the local diagnostic system into equivalent DSM-III diagnosis by the author. Nonetheless, the comparison suggests that the population of neurasthenia patients we studied needs to be regarded as a psychiatric sample that may and probably does differ in important ways from the great bulk of neurasthenics in primary care clinics, who are likely to possess less Major Depressive Disorder and other forms of psychopathology. That two patients in the Taiwan sample had no mental illness should make us cautious about assuming that neurasthenia can be regarded simply as a disguise for underlying mental illness, though it frequently does appear to be accompanied by it. Community studies would inform us about the frequency of neurasthenia as social behavior independent of psychopathology. Unlike the Taiwan study, we did not systematically assess for Personality Disorder in the Hunan sample because we felt there is no reliable instrument for assessing these disorders in China or elsewhere. It was my clinical impression, however, that about half the sample had personality problems, usually not of a severe kind, relating to their experiences of chronic depression and other chronic psychiatric disorders. One-third of the Hunan patients with Major Depressive Disorder gave evidence of Melancholia 4 (see Table VII), in 60% the depression was chronic (more than two years' duration) in keeping with the chronic course of neurasthenic complaints among most patients in the sample. A history of recurrence was not uncommon. The vast majority of patients with Major Depressive Disorder complained of dysphoria (97%) as it is defined in DSM-III (see Table VIII) and 61% voiced anhedonic complaints, though as I shall show below most of these

NEURASTHENIA AND DEPRESSION TABLE VII Major Depressive Disorder (N = 87) Number of Cases With Melancholia Acute Cttronic Recurrent (both Acute and Chronic) 26 35 32 18

143

% 30 40 60 21

TABLE VIII DSM-III Symptoms, Major Depressive Disorder N = 87 Mean number of symptoms per case Number of cases with 4 symptoms Number of cases with 6 or more symptoms Number of cases with all 8 symptoms Number of cases with dysphoriaa Number of cases with anhedonia 5.9 9 (10%) 54 (62%) 11 (13%) 84 (97%) 53 (61%)

a Depressed mood, hopelessness, irritability. (Note: most of these complaints were not spontaneously expressed, but elicited in response to specific questions about them.) This def'mition of dysphoria follows DSM-III (see Note 4).

complaints were n o t spontaneously expressed b u t rather were elicited in response to specific inquiry.

Pain

Table IX documents the enormous burden o f pain complaints in the neurasthenia sample: 90% had some form o f pain. Eighty-seven percent o f the patients with Major Depressive Disorder exhibited pain - a finding similar to ones reviewed earlier for studies o f pain and depression in the West. The data in Table X show that headache was the primary form o f pain in 87% o f the pain patients, while back pain, chest pain, neck pain, limb pain, abdominal pain, whole b o d y pain, and still other forms o f pain were the primary source o f pain in the remainder. This is a clear cultural difference when compared to U.S. findings where there is less headache and much more low back pain.

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ARTHUR KLEINMAN TABLE IX Pain Complaints and Depression in Neurasthenia Patients (N = 100) Chronic Pain Syndrome Pain Complaints without Chronic Pain Syndrome 41 (89%) 3 (7%) 2 (4%) 46 Total (Pain all forms) 78 (87%)a 5 (6%)a 7 (8%)a 90

With Major Depressive Disorder With other forms of Depression Without Depression Total

37 (84%) 2 (5%) 5 (11%) 44

Note: Ninety percent of patients with Major Depressive Disorder and 90% of the entire sample of neurasthenia patients have pain complaints, while 43% of the former and 44% of the latter have Chronic Pain Syndrome. a Percentages add to more than 100% owing to rounding.

TABLE X Breakdown of Patients with Pain, N = 90 Types of Pain Complaints Headache (primary) Headache (secondary) Other paine (primary) Other pain (secondary) Chronic Pain Syndrome 38 (86%) 3 (20%) 6 (14%) 12 (80%) 44 a (15)b Pain complaints (without CPS) 40 (87%) 3 (13%) 6 (13%) 21 (88%) 46 a (24)b Pain (all forms) 78 (87%) 6 (15%) 12 (13%) 33 (85%) 90 a (39)b

a Primary complaints. b Secondary complaints. c Back pain, chest pain, neck pain, limb pain, abdominal pain, whole body pain, etc.

Presenting Complain ts
Looking at the presenting complaints of the 100 neurasthenia patients in Table XI, we see that a mean n u m b e r of 7 complaints were volunteered per patient, of which 5 were somatic and 1.8 psychological. This finding quantitates the somatic preponderance of neurasthenic complaints. Out of the psychological complaints there were slightly more affective than cognitive ones; but 39 patients expressed n o affective complaints and 38 n o cognitive ones. The chronicity of neurasthenia is well illustrated b y the 7.8 years mean length of time that the chief presenting complaints were experienced.

NEURASTHENIA AND DEPRESSION TABLEXI Major Categoriesof Presenting Complaints of Neurasthenia Patients N = 100

145

Mean number of complaints pet patient 7 Mean number of somatic complaints pet patient 5 Mean number of psychologicalcomplaints per patient 1.8 Mean number of affective complaints per patient (but 39 had none) 1 Mean number of cognitivecomplaints pet patient (but 38 had none) 0.8 Mean length of time of chief presenting complaints 7.8 years (range 6 months - 30 years) Turning to just those patients with Major Depressive Disorder (N = 87), we note again the somatic preponderance, this time in illness idioms (see Table XII). Thirty percent of patients complained entirely of somatic symptoms, and 70% of somatic and psychological complaints together but with a decided emphasis on the former, a somatopsychic illness idiom. Remarkably, none of the patients complained entirely or even mostly of psychological symptoms. Table XII lists the chief presenting complaints in all 93 cases of depression (Major Depressive Disorder, Manic-Depressive Disorder, Dysthymic Disorder, Cyclothymic Disorder). It is interesting to compare this list to the lists cited above for neurasthenia patients in nineteenth-century America, depressives in primary care in Hong Kong, patients with mental illness in primary care in the WHO collaborative study in several non-Western societies, patients with Cushing's syndrome (Starkman et al. 1981), and in the Mathew et al. (1981) recent survey of the physical symptoms of depression. These lists contain many of the same items, though the frequencies differ. Together they describe the phenomenology of somatization. A psychiatrist or psychologist reading the lists would be struck by symptoms of autonomic nervous system and neuroendocrine origin. A nonpsychiatric observer would be struck with the preponderance of similar somatic complaints in depression and other psychiatric disorders, and would wonder why these are not listed among the DSM-III criteria of Major Depressive Disorder and related psychiatric disorders. Clearly psychiatrists have emphasized psychological complaints over somatic complaints that seem to be even more common in psychiatric disorders, but are regarded as epiphenomenal when one holds a psychological orientation. Seen from a general medical one, however, the psychological complaints would be regarded as less frequent and less important. I will return to this conflict in cultural constructs of somatization in the Discussion where I compare American and Chinese psychiatric formulations of this problem. The somatic features of depressive experience obviously_ are not well studied and understood. Further phenomenological research should help determine ff psychiatric disorders present the same wide range of somatic complaints or if there are particular patterns of complaints with different

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ARTHUR KLEINMAN TABLE XII Illness Idioms a in Major Depressive Disorder N = 87 Number of Cases

% 30 70 0

Somatic: entirely somatic complaints Somatopsychic: somatic and psychological complaints, but somatic viewed as most important Psychological or psychosomatic: entirely or mostly psychological a Forms of expressing complaints.

26 61 0

TABLE XIII Chief Presenting Complalntsa in all Depressive Cases (N = 93) Number of Cases Headaches (primary and secondary insomnia Dizziness Pain (other than headaches; primary and secondary) Loss of or poor memory Anxiety Weakness Loss of energy Feeling of swelling or fullness in head, neck or brain Irritability Disturbing dreams Palpitations Poor appetite Stomach complaints Tingling of head Poor concentration Non-specified dysphoria (displeasure or unhappiness) Fear or panic Coldness in limbs, head, rest of body Restlessness Depression Heaviness (or pressure) in head Heaviness (or pressure) in chest Ringing in ears Sweating Paresthesias (numbness) Feeling of shaking, tin~ng, picking in brain Hotness of body or head Trembling or jumping in hands or feet Hair falling out Speech unclear 84 70 68 45 40 36 33 28 27 21 20 17 17 15 12 11 11 10 9 9 8 8 8 7 6 5 4 4 4 4 3 % of Cases 90 78 73 48 43 39 35 30 29 23 22 18 18 16 13 12 12 11 10 10 9 9 9 8 7 5 4 4 4 4 3

a Spontaneously expressed by patients when asked to describe their chief problems. b Percentages add to greater than lOOgo since there were more than one complaint per case.

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TABLE XIV Comparison of Presenting Affective and Cognitive Complaintsa in All Depressive Cases N= 93 Numb~
Cognitive Complaints loss of or poor memory dreams Poor concentration speech unclear A ffective Complaints Specific, Differentiated anxiety depression Nonspecific, Poorly Differentiated or Undifferentiated irritability (general, vague) displeasure-urthappiness fear or panic (general, vague) restlessness Total Affective and Cognitive Complaints 74 40 20 11 3 95 b 44 36 8 51 21 11 10 9 169 b

43 22 12 3

39 9 23 12 11 10

a Spontaneously expressed by patients when asked to describe their chief problems. b Note: These numbers add to more than 93 since certain cases had more than one affective and one cognitive complaint. disorders, such as is the case with the weU-recognized vegetative complaints of the Major Depressive Disorder and the physiological concomitants o f anxiety in the hyperventilation syndrome. The mixture o f psychological and somatic complaints illustrates the psychophysiological integration of the illnesses we are studying, whether we interpret them from a psychosomatic or somatopsychi'c point o f view. It also suggests that just as a fairly narrow spectrum o f psycho. logical reactions limits the range o f outcomes o f cultural patterning of emotions, so, too, a relatively restricted range o f physiological signs and symptoms o f emotional arousal and pathology limits the cultural shaping o f somatization. In Table XIV, I analyze the presenting affective and cognitive complaints in all the cases o f depression. Anxiety was spontaneously expressed much more often than was depressive affect, which was complained o f in only 8 o f the 93 cases. But nonspecific, undifferentiated or poorly differentiated affects were expressed in even more cases than these differentiated ones. The former included irritability, displeasure-unhappiness, general or vague fear, and restlessness. The commonest cognitive complaint, loss o f or poor memory, has been shown to be a neuropsychological concomitant o f depression, a characteristic and measurable cognitive deficit.

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Symptoms Elicited in Psychiatric Interview

TABLE XV Elicited Psychological Symptomsa for All Depressive Disorder Patients N = 93 Number of Cases Dysphotiab (depression, sadness, displeasure, unhappiness, irritability) Anhedonia Hopelessness Helplessness Low self-esteem, worthlessness Guilt Poor memory Mind slowed down Trouble concentrating or making decisions or difficulty in thinking Hypochondriacal preoccupation (including fear or brain tumor in 13 cases and fear of going 'crazy' in 17 cases) Diurnal mood variation, mornings worse Suicidal thoughts Suicidal plans Suicide attempts % of Cases

93 57 46 39 56 8 37 58 78 47 21 8 1 1

100 61 50 42 60 9 40 62 84 51 23 9 1 1

a Obtained during clinical diagnostic interview in response to specific questions regarding each symptom. b This definition of dysphoria is different from that in DSM-III and includes such undifferentiated complaints as displeasure and unhappiness, but does not include hopelessness.

In contrast to presenting complaints, where psychological symptoms were expressed relatively infrequently, a number of psychological symptoms were elicited from the depressive patients during specific questioning regarding each symptom. Hence dysphoria (clef'reed here differently than in DSM-III to include nonspecific displeasure and unhappiness, but excluding hopelessness) was found to be present in all patients with depression, anhedonia in 61%, hopelessness in 50%, helplessness in 42%, and low self-esteem in 60%. Even if we use the DSMHI criteria o f dysphoria, there was no patient with a depressive disorder who did n o t admit to feeling either dysphoria or anhedonia. Irritability, hopelessness and displeasure-unhappiness were more frequently elicited from these patients than were complaints o f depression or sadness. (Needless to say, the DSM-III dysphoric complaints, 'blue', 'low', 'down in the dumps', were n o t expressed by any o f the Chinese depressives and are clearly culture-specific Americanisms.) These findings demonstrate that even though dysphoria or anhedonia must be

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present for a case to make the DSM-III diagnosis for Major Depressive Disorder, all the neurasthenics with Major Depressive Disorder met this criterion. Hence it appears that, at least in this sample, we can say that Chinese depressives suppressed affective presenting complaints. Difficulty concentrating or making decisions or in thinking generally was elicited in 84%, again underlining the importance of perceived cognitive changes in depression. Half of the depressive patients maintained marked hypochondriacal preoccupation, including fear of brain tumor in 13 cases and of going 'crazy' in 17 others.6 These were almost somatic delusions in several of the cases. As has been shown in the past, few Chinese depressives admitted to feelings of guilt. Yap (1965), for example, reported this f'mding for Cantonese. (Surprisingly Cheung et al. (1981) found guilt or self-reproach in a relatively high proportion of their Hong Kong sample. But they do not say exactly how common guilt specifically was, and in our sample feelings of worthlessness were also relatively common though guilt was uncommon. Could many of their patients have been Westernized Christians?) Sethi et al. (1973) noted little guilt among Indian patients as did Rao (1973); and the same has been reported for Iraqi (Bazzaui 1970), West African (Binitie 1975) and many other non-Western depressives. Murphy et al. (1967) associated guilt with Christianity, and others have added Islam (El-Islam 1969), but not with Buddhism, Hinduism or African religions. But this cross-cultural distinction has been challenged. Rao (1973) refers with some disquiet to karmic guilt, and more recently Orley and Wing (1979) present evidence that there was more guilt among Ugandan depressives than among Londoners. Guilt in non-Western samples has also been said to be more prevalent with higher social class, education and modernity. But anthropologically sophisticated analyses of guilt in depression have yet to be conducted, and in their absence we should be cautious of making too much of the findings of superficial psychiatric surveys lest we repeat the kind of fiasco created by the naive early distinctions between guilt and shame. In the present study, I did not explore the meaning of guilt among those few patients who reported it or its absence among most of the depressed patients. Hence I am uncertain if guilt for these Chinese means the same thing it does in the West, or whether the same meaning may not be conveyed in the semantic field of other Chinese terms. For this reason I hesitate to place too much importance on our finding that while only 9% of depressed neurasthenics admitted harboring feelings of guilt, 60% reported low self-esteem or worthlessness. Some studies have correlated reduced rates of low self-esteem and feelings of worthlessness with the relative scarcity of guilt, while others like our own have demonstrated these psychological symptoms to vary independently of each other. There was an impressively small number of suicidal thoughts, plans and attempts among the depressed Hunan patients. While some suicidal preoccupation

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may have been consciously suppressed,it is intriguing to speculate that somatized depression may involve less suicidal behavior, perhaps because it is an experience of bodily distress rather than intrapsychic alienation and distress. Suicidal ideas have been reported as less prevalent in a number of studies of non-Western depressives, but the explanation given is that owing to the absence of guilt the depression these patients experience is less serious. The hypothesis that I am putting forth suggests that if lack of guilt plays a role in reducing suicidal ideas and actions, it does so only because the depressive experience is not psychological or existential. This is the main factor affecting suicide and perhaps also explains why there is so little guilt. In the event, this is a testable hypothesis awaiting further study. TABLE XVI Culture-Bound Complaints a in Neurasthenia Number of Complaints
Men as 'heaviness or pressure depressing into head

or chest' Fear of excessive loss of semen with diminished vital energy (shen kui) Huoqi da (excess of hot inner energy) Fear of cold (pa leng) in body (frigophobia) Fear of ghosts Suan ('sourness' in heart and body) 'Cold fire' in body Total

16 11 7 3 2 1 1 41

a Most of these were not spontaneously expressed, but offered in response to specific questions about them. Table XVI lists a number of culture-bound complaints (i.e., complaints so tied to Chinese cultural beliefs that they are virtually untranslatable) experienced by the neurasthenic patients (of. Kleinman 1980). Sixteen patients used men to refer to depression as a somatic experience of something physically pressing or depressing into their head or chest but with the clear cultural connotation of psychological depression. We might regard this as a somatopsychic metaphor understandable only in a Chinese context. Huoqi da is a complaint with two distinctive physical meanings and one specific emotional connotation. It can refer to a sensation of burning in the upper abdomen or lower chest, what Western physicians might regard as dyspepsia, gastric irritation or esophageal reflux, as well as a sensation of bad taste in the mouth or tenderness and swelling of the

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gums, which in biomedicine might be associated with an upper respiratory infection or flu syndrome. The psychological connotation is irritability and irascible disposition. While the idea of ghosts can be expressed directly in English, for the Chinese in our sample this fear included the possibility of spirit possession and bad fate. Suan is a special form of bitterness best rendered as "sourness" that is part of the Chinese tradition of systematic correspondences and that is occasionally used to indicate the physiological component of grief when referred to the heart. (I have treated several Chinese depressives whose first symptom of exacerbation or recurrence was a feeling of suan in the upper abdomen in the absence of evidence of gastric acid hypersecretion or any other gastric pathology.) These symptoms were not spontaneously expressed, but were elaborated under specific questioning.
Explanatory Models

Table XVII and XVIII summarize patients' Explanatory Models of neurasthenia, the beliefs they articulated about the nature, name, cause, expected course of mad desired treatment for their problem. Again we see evidence of these patients' strong somatic orientation. In spite of the fact they were in a psychiatric clinic, 78% of patients held that their disorder was wholly or partially organic. Only 22% regarded their problem as principally or wholly psychological. Forty-four percent named their disorder neurasthenia, 27% called it a neurological disorder, and only 18% classified it as a minor psychological problem. Notably, none labeled it depression. Not too surprisingly, given the biomedical setting, no patient volunteered Chinese~style medicine or folk healing terminology for their disorder. (On direct questioning 41 patients were either unfamiliar with or could not articulate a traditional Chinese medical assessment of their problem, while of those who could do so half claimed not to believe in Chinese medical theories. That is to say, our subjects were oriented to biomedical ideas.) The most frequent attribution of cause was work problems (61%), followed by political problems (25%), separation (of work sites, not divorce) (25%), marital and family problems (20%), exam and school problems (16%), etc. Only small numbers of patients thought their neurasthenia was due to another disorder (13%), nutritional problems (9%), or heredity (5%). An equally small number (12%) specifically attributed their illness to emotional causes. Although psychosocial stressors were listed as causes, they were perceived as producing organic disease. Patients seemed quite familiar with a stress model of physical disease, but one somewhat different than in Western psychiatry. Psychosocial stressors like grief or job dissatisfaction or school failure were thought of as bringing about bodily change directly, just as an accident or physical illness might, and were held to bypass emotions.

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Most patients expected a chronic course and had experienced just that, but almost a third feared their illness would progressively worsen. Only 2% felt their illness was improving at the time of our initial interview. In Table XVIII we see that 40% of patients left the choice of treatment to their doctors, but the rest

TABLE XVII Explanatory Models (EMs) of Neurasthenia Patients N = 100

1. Nature o f Problem

Wholly or partially organic

Organic problem Mixed organic and psychological problems (somatopsychic > psychosomatic EM)

44% | 34%

78%

Psychological problem
2. Name o f Problem a

22%

Neurasthenia Neurological disorder (e.g., neurological pain, brain tumor, etc.) Minor psychological problem (general, vague) Psychosis Other Don't know
3. Perceived Cause c

44%b 27% 18% 10% 7% 4% 61% 25% 25% 20% 16% 13% 12% 12% 12% 9% 5%

Work problems Political problems Separation Marital/Family Problems Exam and school stress Another illness Economic problems Grief (loss of close relative) Emotional tension or stress Nutritional Genetic
4. Expected Course

Acute (will quickly end) Chronic stable Progressive worsening Improving Don't know

4% 57% 31% 2% 6%

a No traditional Chinese medicine or folk illness categories spontaneously expressed by patients in answer to question: What is the name of your problem? b Percentages add to more than 100% since a small number of patients gave more than one name of problem. e Percentages add to more than 100% since more than one cause was expressed by patients.

NEURASTHENIA AND DEPRESSION TABLE XVIII Desired Treatment a of Neurasthenia Patients Choice of treatment is up to the doctor Traditional Chinese medicine Drugs of Any Kind Western medicine Electroencephalogram to rule out brain tumor Other diagnostic tests of brain Hospitalization Psychotherapy Rest and change work Don't know a Patients were asked: What treatment do you wish to receive?

153

40% 16% 12% 7% 6% 6% 3% 3% 2% 5%

wanted medicine or diagnostic tests o f one kind or another. That Chinese medicines were requested more than Western medicines in a psychiatric clinic is n o t unusual in China, since the former are widely used in such clinics and are popularly regarded as more effective for treating chronic illness. It is surely n o t e w o r t h y that few patients wanted psychotherapy, which is neither routinely legitimated nor available as a treatment in China, and, in line with what we will say later on concerning the social significance and uses o f illness behavior, that only 2 patients openly expressed a desire to change work so as to improve their illness.

Help Seeking and lllness Behavior

Table X I X - X X I I present data on the help seeking and illness behavior o f the neurasthenia patients. As has been found for patients in Taiwan (Kleinman 1980) and in the United States (Demers et al. 1981), self.treatment was quite popular in our sample. But unlike Taiwan, where most patients in an earlier

TABLE XIX Help Seeking of Neurasthenia Patients N = 100 % of Cases Self treatment (total) Self treatment (f'trst used before any other treatment) Sacred folk (religious) treatment Resort to shamans, sorcerers, other religious experts
85

34 23 14

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ARTHUR KLEINMAN TABLE XX Self (Family) Treatment % of Cases

Special foods, diet, tonic Traditional Chinese medicines Western medicines Western exercise Traditional Chinese exercise

76 51 18 38 14

TABLE XXI Illness Behavior of Neurasthenia Patients Mean visits to doctors 1.9 per month (range 0.5-8 per month). Perceived percentage of time sick past year: 75% (mean). Percentage of eases who viewed themselves as sick 100% of time past year: 33%. Percentage of cases perceiving self as at least moderately socially impaired a in past year: 52%. Percentage of cases perceiveing self as seriously socially impairedb: 15%. a Moderately socially impaired: Illness interferes with work, school, personal and/or other relationships and prevents normal social performance. b Seriously socially impaired: because of illness unable to work, attend school, or carry out relationships or activities in unit or family.

TABLE XXII Prior Medical Treatment Received %of Cases Western physicians Traditional Chinese doctors Mostly saw Western physicians Mostly saw Chinese doctors Sedatives (all types) in past year Benzodiazepines in past year Received mostly traditional Chinese medicine pasf year 98 84 76 24 58 47 60

study resorted first to self care (Kleinman 1980), only a third of the Hunan neurasthenia patients did so. This discrepancy most probably reflects the ready access to inexpensive care in the People's Republic. In spite of active suppression of religious healing in China, almost a quarter of our sample engaged in such treatment and, even though the study took part in a large city, 14%had sought

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out help from shamans, sorcerers and other religious experts, suggesting that folk healing is still actively pursued in China. Special foods, tonics, dietary changes, traditional Chinese medicine, and Western exercises in that order were by far the most common self-treatments. There was only quite limited lay resort to Western medicinals. Perhaps patients were reluctant to admit such use to the researchers, who were themselves Western-style physicians. As a group the neurasthenia patients demonstrated a degree of illness behavior that was considered excessive by local standards. They made on the average almost two visits to doctors per month (see Table XXI), a high figure for patients at the Hunan Medical College. Moreover, they perceived themselves as sick 75% of the time during the preceding year, and one-third of patients regarded themselves as sick 100% of that time. More than half regarded their illness as interfering with work, school, personal and/or other relationships and believed it prevented normal social activities. Fifteen percent of patients were so seriously socially impaired because of the illness that they were unable to work, attend school, or carry out normal social activities and relationships in their unit (danwei) or family. Table XXII indicates that virtually all patients had consulted Western-style physicians for their illness and that a great many had also sought out care from traditional Chinese doctors. But for most the chief source of care was Westernstyle physicians. Intriguingly, in spite of this fact, patients were receiving mostly traditional Chinese medicines, which were being prescribed by Western-style as well as Chinese-style doctors. It was a surprise and a concern to learn that 58% of patients had received sedatives in the past year, and that almost half had received benzodiazepines. In short, patients were receiving polypharmacy (more than three drugs per person) with traditional herbs, sedatives and anti-anxiety agents, along with vitamins, tonics and pain medicines. This situation is encountered often with chronic pain and other somatization patients in the United States and is consistent as well with the high utilization rate and frequent changes in care-givers and medical regimens.

Family History
More :than a third of patients had a family history of neurasthenia, and in 70% of those with an affected family member it was the patient's mother (see Table XXIII). More than half gave a family history of chronic illness, a quarter had chronic pain patients in their families, and approximately the same number had a positive family history for mental illness (54% of the time affecting the patient's mother). Depression accounted for 62% of all mental illness in the family. Sixty-four percent of patients reported significant psychological problems in their families, 35% substantial family discord, and 12% reported step-parents

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ARTHUR KLEINMAN TABLE XXIII Family History of Neurasthenia Patients

% of Cases Family history of neurastheniaa Family history of chronic pain Family history of chronic illness Family history of mental illnessb Family history of significant psychological problems Family hisotry of significant family problems Family history of members working in health field Family history of "step parents" (remarriage) 36 25 57 24 64 35 28 12

a Mothers of patients made up 70% of these. b Mothers of patients made up 54% of these, and depression accounted for 62% of all mental illnesses in families.

(owing to remarriage) with whom they had often maintained poor relationslups. In 28% of families there was a member working in the health field. In the absence of a control group or valid community data, it is difficult to know how to interpret these findings, but it was the impression of my psychiatric colleagues that these would be unusual fmdings for most Chinese families, indicating high rates of physical and mental illness, family pathology, and contact with the health care professions. Although I can't rule out a genetic basis to neurasthenia, and there is good evidence from many studies for a genetic contribution to depression, these data could also be interpreted to support a social learning hypothesis of neurasthenia as chronic illness (somatization) behavior. Patients grew up with family models of chronic illness, pain, depression and neurasthenia, particularly their mothers. This burden of illness behavior and the reported high levels of personal and family problems may well have seriously affected parenting and social support, and offered a family language of bodily complaints and perceptual style of bodily preoccupation as a dominant response to stress as Mechanic (1980) hypothesizes. Perhaps it also provided an ethos of demoralization and hopelessness (cf. Brown and Harris 1978) that impaired the development of a sense of personal and social efficacy while fostering vulnerability to despair and depression (cf. Beck 1971; Minuchin et al. 1978) and chronic help seeking, especially from the medical system with which these families were so familiar. These are issues to be examined in future that we do not possess enough information to confirm in the present sample.

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Major Stressors
TABLE XXIV Types of Major Stressors Experienced by Neurasthenia Patients Number of major st~essors per patient in 6 months prior to onset of illness, mean 3.3 (range 0-6)
% of

Cases Work Separation a Financial Political Death of spouse or other family member School (including exams)b Family 75 57 45 31 29 26 19

a Owing to different work sites and involving a mean time of 6.2 years (range 4 months to 20 years). b Either experienced by patients dkeetiy or visda-vistheir children.

The lack of a matched control group also affects the interpretation of Table XXIV which presents the types of major stressors experienced by the 100 neurasthenic patients in the six months prior to illness onset or, in case of chronic illness, most recent exacerbation. On the average, patients experienced 3.3 stressors that they themselves reported as major during this period. Work stress affected 75% of the sample, separation owing to work site 57%, financial problems 45%, significant political problems 31%, death of spouse or other family member 29%, school and examination stress was reported by 26%, and major family stress by 19%. From these data it is clear that work stress was the single most important stressor. Separation of spouses, or less often parents and children, because of different and distant work sites was an impressive stressor with a mean time of separation of 6.2 years and on the average a few usually brief visits home per year. There were only several cases of actual divorce in the sample. It was the impression of the Chinese psychiatrists who collaborated with me that though these patients had experienced substantial stress, the same stressors had been experienced by large numbers of individuals in China. Certainly, separation owing to different work sites, which may strike Westerners as unusual, has been accepted by Chinese historically for economic reasons and probably conveys different cultural and personal significance than in the West. It will take the development of culturally valid instruments to measure perceived stressful life event change that provide substantial data for normals and patients

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suffering other diseases as well as for neurasthenic patients before the relationship of stress to neurasthenia can be better understood.
lllness Problems

TABLE XXV Illness Problems of Neurasthenia Patients Number of illness problems per patient, mean 3.4 (range 1-6). Percentage of cases with maladaptive coping with illness: 96%. Percentage of cases in which illness was used to change job, or to try to change job, or to return from separation due to different work sites, or to try to do so, or to go on sick leave to avoid or reduce work: 74%.

Table XXV summarizes the illness problmes (i.e., psychosocial accompaniments of sickness and treatment) suffered by the members of the neurasthenia sample. There was a mean of 3.4 illness problmes (e.g., family, marital, fmancial, work, school, doctor-patient problems) per patient. Moreover, only four of the hundred patients were assessed as coping adaptively with their illness; the rest exhibited evidence of varying kinds and degrees of maladaptive coping, ranging from excessive utilization of medical services and noncompliance with treatment regimens to giving up. Almost three-fourths of the patients either were in process of using or had already used their neurasthenia illness behavior as a reason to change jobs, or to return from separation due to different and distant work sites, or to go on sick leave to avoid or reduce work. This f'mding illustrates both the important social consequences of chronic illness and the problems they pose for society and the medical profession. In many societies, including China and the United States, illness once legitimated places the individual in a sick role that releases him or her, at least temporarily, from routine social responsibilities. Over time these social responsibilities must be negotiated with employers, co-workers, family and agencies of the State. Our data suggest that Hunan is no different than Seattle in this regard. Nonetheless, a number of large questions are provoked by this finding which, if it is substantiated in future research, require much further study. Medical anthropological field investigations could help determine to what extent neurasthenia offers important social leverage on local work-disability systems, how changing work owing to chronic illness behavior is handled by medical, work and political institutions; besides neurasthenia what are the other chief somatic modes of social manipulation; and whether psychiatrists or other physicians play a special role in this process as negotiators between patients and families on the one hand, and cadres, co-workers, and members of other social

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agencies on the other. I will return to this datum's important social implications in the discussion section.

TABLE XXVI Types of Illness Problems of Neurasthenia Patients N = 100 %of Cases Work Family School Maritala Financial Doctor-Patient Conflict Otherb 90 80 56 52 45 15 23

a Also includes problems with girlfriends or boyfriends. b Includes excessive anxiety about illness and its effect on life style, personality and social relations.

Table XXVI shows that patients' illness behavior was accompanied by work problems in 90% o f the cases and by family problems in 80%. School and marital problems also were prevalent in more than half o f cases, while illness was associated with financial problems in 45% of cases. Although only 15% of cases involved doctor-patient conflict, there are such a large number of neurasthenics in China and such conflicts are so uncommonly observed in its health care system that if this finding is substantiated, the total number of such conflicts may be quite large and neurasthenic patients may represent a large portion of 'difficult or problem patients'. Characteristic illness problems included inability to carry out one's job, marital strain, family conflicts and breakdown, school and examination failure, substantial financial loss, and contrastive medical and lay views of what is wrong and what should be done. These problems illumine the everyday life burden of illness.

lllness Meanings
In the initial and follow-up ethnographic interviews 98 of the neurasthenia patients were assessed for the significance of illness, and in each case it was possible to work out at least one meaning associated with the illness behavior and frequently additional ones as well (see Table XXVII). The most c o m m o n significance (in 93% of Cases) was to express personal or interpersonal distress or

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ARTHUR KLEINMAN TABLE XXVII Significance (Meaning) of lllness N = 98 a % of Casesb

Communicate personal or interpersonal distress or unhappiness Manipulate interpersonal relations Time off from work or other social obligations Receive love and care from family and friends Personal threat Personal loss Avoid unpleasant situation Receive medical attention Keep together family or marriage Sanction failure Receive financial compensation Avoid intrapsychic conflict Break up family or marriage

93 74 72 66 55 46 39 33 26 22 9 5 4

a Two of the 100 neurasthenia cases were not assessed for significance of illness. b % is greater than 100% since more than one significance was assigned for most cases.

unhappiness, followed by manipulation of interpersonal relations (in 74% o f cases), time off from work or other social obligations (72%), and receive love and care from family and friends (66%). All the rest were present in half or less of the cases: personal threat (55%), personal loss (46%), etc. Illness significances included both keeping together a family or marriage (26%) and breaking them up (4%), sanctioning failure (22%) (especially examination failure), and receiving financial compensation (9%). These meanings tend to be somewhat superficial and mostly social since it would take long.term relationships of trust and greater familiarity with informants' life situations to elicit deep personal meanings, as occurs in psychotherapy. Ethnographic and psychodynamic data, limited as they were, do tend to support each other but no attempt was made to gauge the validity of these results which are best regarded as merely tentative impressions and interpretations.
Ou tco m e

Table XXVIII shows that when patients with Major Depressive Disorder, all of whom were treated with antidepressant drugs, were asked at time of follow-up to assess their symptoms, 82% regarded themselves as at least slightly i m p r o v e d , while 65% evaluated their symptoms as substantially improved. Nine percent did not feel there was any improvement, and 10% felt their symptoms had

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TABLE XXVIII Patient Self-Assessment of Symptom Outcome of Major Depressive Disordera N-71 b Number of Cases
Improved (1-4) Substantially improved (1-3) (1) Completely (no current problems) (2) Greatly (only minor current problems) (3) Partially (still has some problems but substantially less than before) (4) Slightly (still has significant current problem) No Improvement Worse

%c 82 65 1 42 21 17
9 10

58 46 1 30 15 12
6 7

a All patients treated with tricyclic antidepressants. b Major Depressive Disorder patients who returned for follow-up 71/87 = 82%. c Percentages of 4 improved subcategories, no improvement, and worse categories add to more than 100% owing to rounding. Percentages of 1-4 and 1-3 add to less than 82 and 65, respectively, owing to rounding.

TABLE XXIX Physician Assessment of Symptom Outcome of Major Depressive Disorder Patients a N= 71b Number of Cases
Improved (1 --4) Substantially improved (1-3) (1) Completely (no current problems) (2) Greatly (only minor current problems) (3) Partially (still has some problems but substantially less than before) (4) Slightly (still has significant current problems) No Improvement Worse

% 87 70 4 41 25 17
4 9

62 50 3 29 18 12
3
6

a All patients treated with tricyclic antidepressants. b Major Depressive Disorder patients who returned for complete follow-up 71/87 = 82%.

worsened. On the whole this is an expectable response of the symptoms of Major Depressive Disorder to antidepressants, and it is corroborated in the assessments made b y me and m y Chinese colleagues as depicted in Table XXIX. Here, 87% of patients were assessed by us as having experienced symptomatic improvement

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(at least slight), whereas the symptoms of 70% were evaluated as substantially improved. Only 4% exhibited no symptomatic improvement, while 9% appeared worse. Eighty-two percent of Major Depressive Disorder patients returned for follow-up. Several of those who didn't wrote that they lived too far away to return for follow-up, b u t we do n o t know why others failed to return. This unaccounted for proportion of nonreturning patients should caution against overinterpreting the outcome data. TABLE XXX Major Depressive Disorder Patient Self-Assessmentof Change in Social Impairmenta N=71 Number of Cases Less socially impaired c No change in social impairment More socially impaired 26 24 21

%b 37 34 30

a Assessment made by patients, and by family or co-workers who accompanied them at time of follow-up interview. b Percentages add to greater than 100% owing to rounding. c Patients were asked at fLrst and follow-up interview to assess the degree to which they were socially impaired on a 5 point scale of none, minimal, moderate, serious, extreme social impairment, and concrete examples were provided to operationally deKmeeach degree of impairment.

TABLE XXXI Change in Help Seeking of Neurasthenia Patienta N = 76 b Number of Cases (A) No further help seekingC Further help seeking Visit to Chinese-style doctor Visit to Western-style doctor Self or family treatment Total visits to clinics 48 28 11 4 14 Number (B) 34

% 63 37 15, 39 d 5, 14 d 18, 50 d

a This assessment was made at time of follow-up interview. b Neurasthenia patients who returned for follow-up interview, whose help seeking was assessed, 76%. c Since first interview, approximately 5 weeks before. d Percentage of those who sought further help. Percentages add to greater than 100% since more than one form of help seeking was chosen by certain patients.

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As Table XXX indicates, a smaller percentage of Major Depressive Disorder patients assessed their social impairment as less (37%). Not only did 34% experience no change in social impairment but notably 30% became more socially impaired after treatment. Thirty-seven percent of patients engaged in further medical help seeking from Chinese~style and Western-style doctors and their families and selves (see Table XXXI), despite the fact that 82% regarded their symptoms to be at least partially improved and all were scheduled for follow-up in psychiatry. These patients made 34 visits to clinics outside the psychiatric clinic. These outcome f'mdings indicate that perceived social impairment and to a lesser extent help seeking did not improve as much as symptoms did; or, put differently, that in spite of symptomatic improvement, there was less change in help seeking and especially in perception of social impairment. We could say that the improvement in illness behavior lagged well behind the improvement in disease manifestations, and that patients maintained the sick role even as their sicknesses got better. This f'mding supports the notion that illness in many members of this group performed a positive social function. TABLE XXXII Outcome of Patient Illness Problemsa N = 76 No Probleme Improved Family problems b Marital problems Work problems School problems c Financial problems d Maladaptive coping with illness Doctor (or staff) - patient conflict 12% 38% 4% 19% 44% 0 87% 45% 33% 41% 32% 25% 37% 13% Same 31% 12% 35% 29% 15% 54% 0 Worse 12% 17% 20% 20% 15% 9% 0

a Assessed in initial interview and at time of foUow-up (see Katon and Kleinman 1981 ; and Kleinman 1978). N is neurasthenia patients who returned for follow-up, 76%. b Family problems include problems with in-laws, parents, children, and various relatives except for spouse. c School problems refers both to problems experienced by patients and by children of patients. d Percentage adds to less than 100% owing to rounding. e No problem at time of ftrst visit and at follow-up.
\

Table XXXII lists the outcome of illness problems among patients with Major Depressive Disorder. Almost two-thirds of patients with maladaptive coping (noncompliance, doctor shopping, giving up, passive-hostile behavior, unwillingness to carry out normal social activities, withdrawal and isolation, failure to successfully mobilize or alienation of social network supports, etc.) either stayed

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the same or got worse. A substantial number o f work problems either remained unchanged (35%) or worsened (20%), and the same was true to a lesser extent o f family and school and Fmancial problems. Almost as many marital problems stayed the same or worsened as improved. These findings would seem to indicate that although antidepressant drugs may have significantly benefited symptoms, they frequently did not have a major effect on illness problems. Again we have evidence of much less improvement in an important psychosocial aspect o f illness. This table demonstrates that medical treatment without significant psychosocial intervention exerts only a limited effect on the overall sickness.

TABLE XXXIII Compliance as a Function of Symptom Outcome of Patients with Major Depressive Disorder a N = 71 Number of Cases Substantial improvement Overall improvement (at least slight) Same (no change) or worse 25 37 9 Compliance b (Mean Score) 3.4 3.1 1.8

% 35 52 13

a Outcome and compliance assessed by psychiatrists at time of outcome. b Compliance Scores: 1 = None 0 2 = Partial (< 50%) 3 = Mostly Complies (>50%) 4 = Complies (100%)

TABLE XXXIV Depressed (all forms) Patients' Name of Their Disorder at Time of Follow-Up a N = 73 b Number of Cases Neurasthenia Depression Other Change of EM from Neurasthenia (lst visit) to Depression (Follow-up) 50 8 15 5 % of Casesc 69 11 21 7

a All patients in this group had been told at time of initial visit their problem was depression, had been given a biomedical EM of depression, and had been treated with antidepressants (in more than 70% of 71 cases evaluated at follow-up by psychiatrists with substantial improvement). b Number of depressed patients for whom a follow-up EM could be obtained; in two via correspondence. c Percentages add to more than 100% owing to rounding.

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The penultimate table shows that compliance varied directly with perceived symptom improvement. This finding could be interpreted to argue against a major role for social determinants of noncompliance in this patient sample. But we simply did not collect sufficient information on this topic to go beyond a superficial level of analysis, and our measure of compliance (patient reports) was indirect and crude enough to render even this conclusion uncertain. This may simply be another example of the well-known fact that you can't accurately assess compliance by having the providers of patients' care ask them about compliance in the very setting in which they are being treated. The last table relates to the fact all patients diagnosed as suffering Major Depressive Disorder were informed of this diagnosis before treatment and were even given biomedical explanation of depressive disease. Moreover, as has already been discussed, most of these patients experienced symptomatic improvement after taking drugs identified to them as antidepressants. Yet only 11% reported at follow-up that their disorder was depression, while 69% held to the notion (or came to believe) they were suffering from neurasthenia. That is to say, there was only a 7% change in explanatory models from neurasthenia to depression not withstanding explanations to the contrary and positive response to treatment identified as specific for depression. A large percentage of patients called their disorder neurasthenia after treatment than prior to it. Indeed most patients actively denied that their disorder was depression when we tried to assert that it was. I will return to this fascinating finding below when we discuss the place of neurasthenia and depression in Chinese psychiatry and society. To illustrate the real life persons and problems behind the statistics I will present several brief case synopses of neurasthenia patients with Major Depressive Disorder presenting in somatic and psychological modes. BRIEF CASE VIGNETTES 7

Major Depressive Disorder with Melancholia, Partially Psychologized Case 1: 18-year-old male senior middle school student who one year before unexpectedly failed an examination and as a result was moved out of a special high-level group in his class and into a mid-level group. As a result of exam failure, his parents, both of whom are top-level cadres who hold great expectations for this their eldest son, yelled at him, blaming him for not working hard enough in school and severely criticizing him for his poor test performance. They told him he would have no future ff he didn't work harder. At the same time his schoolmates laughed at him for falling from a special group who were being primed for the university entrance exam down to a mediocre group who were not expected to go on to the university. The patient felt demoralized and

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humiliated. Even before this time he had harbored self doubts about his own academic skills and being able to achieve at the high level expected of him by his parents. After failing the exam the patient became depressed, felt hopeless and worthless, lost interest in things that previously were pleasurable, thought of death, and experienced insomnia, headaches, dizziness, loss of energy, early morning waking, poor appetite, weight loss, poor concentration, and marked anxiety. He developed a haggard look and felt dizzy and complained of dry mouth and constipation. But the patient quite openly expressed his demoralization and sad mood, and in his Explanatory Model related his dysphoria and anhedonia to stress and his own psychological make-up. But fascinatingly, even though the patient and family regarded his problem to be a psychological one and sought out appropriate counseling and psychiatric care, his illness idiom was still dominated by somatic complaints which they viewed as more worrisome than the psychological complaints and for which they sought out medical care. His Explanatory Model, furthermore, was somatopsychic, since he regarded stress and his personality as affecting his brain and producing organic pathology that was responsible for his mood disturbance.

Major Depressive Disorder with Somatization Case 2: Thirty-five-year-old female physician, who works in a local factory clinic and was a graduate of the Hunan Medical College, presents with a history of chronic headaches. In 1968 the patient decided to end a budding relationship with a fellow medical student in order to heed the Cultural Revolution's call to serve the people and forsake personal interests. Within a year she felt that she had made a mistake and at the same time began to experience headaches, palpitations, insomnia and agitation. She grieved the loss of her boyfriend who had become engaged to another classmate. The patient underwent several medical work-ups for her headaches, all of which were reported as 'negative'. These headaches continued over the subsequent decade, worsening when she was under personal stress, or when she was criticized in the Cultural Revolution by her co-workers and unit leaders for not assuming enough responsibility in her work. The headaches have become particularly severe in the past several months, following an order that she transfer to a new and smaller clinic in a distant suburb, something the patient express a strong desire not to do. For the past 10 years her headaches have been diagnosed as part of a neurasthenia syndrome. For the past two months she has felt a lack of energy, insomnia wth early morning waking, difficulty concentrating, poor memory, loss of interest in her work, marked restlessness, and a sense of being in a hopeless situation that makes her seem worthless. Under direct questioning she admitted to feeling depressed, but attributed this feeling to the inability to control her worsening

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headaches~ which she regards as her real illness. These symptoms all were present a decade ago at the onset of her illness. She has tried more than 10 different drugs and visited five different clinics in two months in pursuit of an effective remedy for her headaches. She decided to visit the psychiatry clinic after reading a paper in a medical journal on Pavlov's view of neurasthenia as due to "negative localization in the brain". She believed she had organic brain pathology and requested an electroencephalographic assessment. Six weeks later at time of follow-up and after treatment with a tricyclic antidepressant, the patient had normal sleep and appetite, greatly improved social functioning at work and home, and felt her mood was '70%' better. Though her headaches were still present, they were described as '60%' better. The patient is still trying to avoid transfer to a new work site on the grounds of her health problem, which she calls 'neurasthenia'. She is actively negotiating a modifiedwork schedule to accommodate her illness, one that she reports is feasible at her current work site but not in the new clinic she has been asked to head up.
Case 3: Forty-year-old female factory worker, mother of three children, with a two-year history of dizziness, headaches, weakness and marked lack of energy. Patient's husband, who comes from a landlord background, has had recurrent problems with the leading cadres of his factory and two and a half years ago was sent to a factory in another city to work. His wife has failed to receive bonuses and promotion, she believes because of her husband's problem. She has been very unhappy with her husband's separation from the family, and also dislikes her work as a machine operator. For the past 18 months she has repeatedly asked to change jobs because of her illness, which has been diagnosed by different doctors as 'neurasthenia'. She also has requested that her husband be transferred back to Changsha to help care for her. She has stayed home from work the past several months and has received her full salary. She is uncertain if she will be able to return to work since her illness has not responded to treatment and she is pessimistic that she will ever get well. The patient states that work makes her illness worse, and that she is hypersensitive to noise and cold temperature at work. She admits to great anger and frustration over her situation. For two years she has had insomnia, poor appetite, which has worsened over the past half year with a 10 lb weight loss, felt both slowed down and restless, had difficulty with concentration, and thought about death but not been suicidal. She also reports fear of leaving her house and being in groups of people. Under questioning, she assents to feeling displeased, hopeless, helpless, and no pleasure in activities which in the past gave her considerable pleasure. This patient reported that she had felt low self esteem and periodic hopelessness since childhood, and that she had always been regarded by family members as excessively concerned about her health and fearful of falling ill. She was briefly hospitalized with symptoms

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similar to those she now experiences after the birth of her second child. She lives with her husband's parents with whom she has always had a poor relationship and who she feels fail to give her support, but do take care of her when she is ill. After treatment of her Major Depressive Disorder and Agoraphobia with Imipramine, the patient experienced a substantial improvement in symptoms but she still regarded herself as socially impaired and had not returned to work. At time of second follow-up she reported a negotiation with the leading cadres in her factory regarding part-time lighter work and the possibility of her husband receiving a transfer back to Changsha sometime the following year.
Case 4: The patient is a 52-year-old cadre with a history of multiple vague

gastrointestinal complaints of about two years' duration. After numerous medical workups, her problem was diagnosed as neurasthenia and she was referred to the psychiatry clinic. The patient has experienced abdominal pains, headaches, whole body pain, periodic nausea and vomiting, and persistent constipation. Over the same two.year time span she has had insomnia with early morning waking, poor appetite, lack of energy, trouble concentrating, a marked slowing down in speech, thinking and bodily movements, an acute fear that she may have either an intestinal or a brain tumor, and strong feelings of guilt and low serf-esteem. She appeared profoundly depressed, almost in a depressive stupor, but initially denied feelings of depression or sadness. She did admit to irritability, a vague unhappiness about which she refused to elaborate, anhedonia, and pervasive hopelessness. The onset of her symptoms coincided with the return of her husband to Changsha as a cadre in the civil administration, after 20 years of living in the countryside on different communes. Before 1958, the husband had been an up-and-coming young cadre who in 1958 was labeled a rightist and subsequently was sent to the countryside to work as a peasant with infrequent visits home once each year or two for a brief time. During this period and especially during the Cultural Revolution, the husband received a great deal of political criticism, and his wife had a very difficult time keeping the family going. She could not Fmd work, had limited income, and was frequently criticized by neighbors for her husband's problem. During the 60s her children could not attend senior middle school because of the family's political problem, and instead had to accept menial jobs. During the Cultural Revolution, two of her four children were sent to distant communes, and the family's situation, she reported, further worsened. In 1978, her husband was rehabilitated and returned home. Shortly after he returned home, the patient's symptoms began. After the psychiatric diagnostic assessment, I asked her if her Major Depressive Disorder could have resulted from marital incompatibility and strain that only emerged once she and her husband were reunited. She disagreed with this formulation, and offered an alternative one in terms of a striking metaphor that

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I will now paraphrase. Suppose, she said, looking at the ground, you were climbing a mountain and this mountain was very steep and terribly difficult to climb. To the right and the left you could see people falling off the mountainside. Holding on to your neck and back were several family members so that if you fell so would they. For 20 years you climbed this mountain with your eyes fixed on the handholds and footholds. You neither looked back or ahead. Finally you reached the top of the mountain. Perhaps this is the first time you have looked backward and seen how much you had endured, how difficult your life and your family's situation had been, how blighted your hopes . . . . She ended by asking me if this was not a good enough reason to become depressed. DISCUSSION: NEURASTHENIA, DEPRESSION AND SOMATIZATION The results of this descriptive study address the relationship between neurasthenia, somatization and depression for patients in the psychiatry clinic where it was conducted in Hunan. But since I am not aware of a similar attempt to unravel this relationship elsewhere in China, I am tempted to generalize to the wider Chinese context so that an hypothesis is advanced that can be tested in future research in other local settings. If stated in general enough terms, moreover, such an hypothesis could be applied to those many areas of the world where neurasthenia may not be a common diagnosis but somatization is highly prevalent. Although I recognize that both the restricted nature of the sample and the preliminary quality of the investigation make this a somewhat risky undertaking, I believe that with appropriate restraint such an exercise can be useful in forcing us to critically think through the broad implications of our study for psychiatry in China and cross culturally. It is in this exploratory spirit of theoretical inquiry that I offer the following analysis, one that seeks to integrate clinical and anthropological approaches to our f'mdings in order to raise fundamental questions as much as to suggest possible answers. Our best understanding of somatization, I believe, is based on the now widely accepted distinction between illness and disease. When we become sick we first experience illness: i.e., we perceive, label, communicate, interpret, and cope with symptoms, and we usually do this not alone but together with family members, friends, workrnates, and other members of our social network. Personal, interactional, and cultural norms guide this lived experience. That is to say, shared cultural beliefs (about the body, specific symptoms, and illness generally), constraints in our concrete social situation, and aspects of the self (personality; coping style, prior experience, etc.) together with our explanatory model for the particular episode of illness orient us to how to act when ill, how to diagnose and treat, and how to regard and manage the life problems illness creates.

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When we visit medical professionals (or for that matter folk healers) the initial basis for clinical communication is commonsense understandings that patient and practitioner share as members of the same culture. Thus, at the outset patients and practitioners discuss illness. But during the clinical transaction the practitioner begins to construe the patient's problem as disease: i.e., he perceives, labels, interprets and treats it as a specific abnormality in his profession's nosological system. For the patient who complains of excessive thirst, urination and hunger, the biomedicallytrained physician will seek out evidence to determine whether the patient is suffering from diabetes mellitus. Through this process illness as lay experience becomes transformed into disease as biomedical explanation and a clinical entity is created. That is to say, the practitioner constructs a new social reality, the disease, which will also come to influence how the patient thinks and lives his illness. Indeed, in the biomedical viewpoint the disease is an abnormality in biological structure or function that generates the symptoms of illness. As Eisenberg (1977) has shown, however, the interplay between disease and illness aspects of a given sickness can be and frequently is powerful and complex, and in the course of a chronic disorder either aspect may become the major source of exacerbation and remission. My purpose here is not to elaborate this distinction further (see Kleinman 1 9 8 0 : 7 2 - 8 0 for additional details), but simply to apply it first to somatization and thereafter to neurasthenia and depression. In my understanding of somatizati0n, we have cases either in which physical complaints are expressed but a corresponding organic lesion cannot be detected, or in which such complaints are amplified so that symptomatology and perceived disability exceed what would be expected from a particular lesion. As I have akeady shown, depression, anxiety and other psychiatric disorders can produce either situation. Major Depressive Disorder in the course of heart disease can prolong recovery, exacerbate symptoms, and substantially worsen disability - all of which can be reversed by effectively treating the depression. Panic Disorder in the absence of any other pathology can produce disabling physical symptoms that resemble those of cardiovascular disease, respiratory disease, epilepsy and other medical disorders. When the Panic Disorder is alleviated, so are the physical complaints. But as the work of Mechanic (1980) illustrates, stress can so affect a susceptible individual that entirely normal bodily experiences are misinterpreted as symptoms of illness or, more lig~ly, the psychophysiological correlates of affective arousal and personal distress are amplified and labeled as illness. In this case psychological and somatic symptoms may not be differentiated, for personal and cultural reasons, and expressed separately. Instead the individual complains of the physical symptoms that are the correlates of depressed, anxious, or angry affect. Although in the sick person's social group there may be implicit understanding

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that these complaints convey integrated psychological as well as physical meanhag, the Cartesian dualistic framework and biological reductionism that biomedical professionals bring to the clinical encounter tend to press them to diagnose a physical disorder. Furthermore, many of the lay terms, applied to such syndromes of personal distress also emphasize their physiological properties. Frequently, psychosocial care for personal and family distress is provided indirectly as part of the 'medical' treatment of the putative physical illness. In these instances, then, somatization is created out of the illness experience associated with a medical or psychiatric disease, or out of the coping behavior associated with stress, or, when it is the practitioner who somatizes, out of a failure to recognize the biopsychosocial integration ha these behaviors and a press to label and treat them as 'real' (read, medical) disease. In the course of chronic disease, say a chronic pain syndrome associated with minor trauma to a limb, psychological and social factors such as an out-of-awareness desire to be dependent, or an all-too-aware desire to obtain f'mancial compensation or time off from school, or a partially aware wish to avoid an embarrassing situation or indirectly express resentment at a spouse may amplify the symptoms which, if the individual is further rewarded for displaying them, by fhaancial compensation based on persistent disability or by love and attention from an otherwise emotionally distant spouse, over time congeal into the chronic illness behavior of somatization. This pattern has been extremely well documented in the clinical literature (cf. Katon et al. 1982). If it persists, such behavior often leads to inappropriate and excessive utilization of health care resources, unnecessary and dangerous tests, inappropriate and poor treatment, iatrogenesis, enhanced personal and family suffering, and therefore it becomes a major burden for the health care system and the society. Chronic pain syndrome, for example, is one of the major sources of disability in the United States. Early recognition and appropriate treatment, as ha the case of previously undiagnosed depression causing chronic pain, can prevent acute and subacute somatization from becoming chronic somatization (Rosen et al. 1982). Once chronic somatization becomes well established as an illness career, it is quite difficult to reverse because the complex and powerful interplay between chronic disease and illness sustains a vicious cycle. Because it has been studied largely by physicians or by social scientists working within a disease epidemiology framework, somatization is usually assumed to be maladaptive and many psychiatrists seem to regard it as deffmitely pathological. But anthropologists have described somatic idioms of distress as one of a series of cultural idioms that articulate distress in religious, moral, naturalistic and medical terms ha order to cope with it effectively. Nichter (1982), working with South Indian Havik women, presents examples of somatization as personally and socially adaptive coping in addition to illustrations of its

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maladaptive and pathological aspects. He shows that somatization may occur through distinctive cultural idioms of diet, bodily constitution, common complaints of women and children, the physiology of reproduction and child development, commensality and sexuality and other biological categories given salience in particular cultures. I have observed similarly adaptive examples of somatization in my ethnographic research in Taiwan and in my clinical practice in the United States, and encountered some of the same as well as other somatic themes. I suspect that future psychological ethnographies and surveys of communities will demonstrate that somatization can be expressed in a large but generally quite familiar number of lay conceptualizations of human biology and that it is a ubiquitous coping pattern that most often is utilized adaptively, though it sometimes creates greater problems than it seeks to resolve. Indeed, Picketing (1974) offers dramatic instances of somatization supporting rare creativity, as for example in the case of Darwin's hypochondriasis. Few will have had such experiences, but many of us will recall various small benefits achieved from illness: permission to be passive, warrant for avoiding difficult social situations, protection from criticism, attention and affection from family and close friends, etc. And sometimes the benefits are not small. Sickness can reintegrate a family on the point of disintegration, or provide a safety valve and escape hatch for a person no longer able to cope and feeling a push to suicide, or legitimate personal failure that otherwise would be unbearable. This does not mean that we malinger or that we rationally choose to somatize. But there can be little question that the sick role can at times be rewarding, and that once legitimated there may be unaccountable, though admittedly usually unconscious, delay in leaving it owing to intimate personal and social reasons. Not the least of illness's properties is the medium of communication it affords to express distress, demoralization, unhappiness and other difficult and otherwise unsanctioned feelings in terms that must be heard and may lead to change. Similarly, affection and support can be expressed through concern with others' health and care for their illnesses~ Now suppose that somatization is positively sanctioned by cultural norms, which it appears to be in a number of societies, whereas psychologization is stigmatized, the case classically described in Chinese culture. There will then be pressure to selectively perceive and express the physiological components of the psychophysiological symptoms of distress, and to deny and suppress the psychological ones. The former will be socially efficacious, the latter socially unacceptable and inefficacious. One will have grown up a witness to the expert deployment of the former coping style, but will have had little experience of the latter. In fact the cultural sources of social support will be structured in terms of somatic patterns of help seeking (e.g., medical facilities and treatments), but not psychological ones (e.g., psychotherapy), and this implies as well the

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idioms we learn to use to nuture and help. I think I need not belabor the point. Somatization can be at times culturally supported, socially useful, and personally availing. Of course no social system could sustain the cost of massive resort to this idiom of distress and coping strategem. Health care resources, both familial and societal, would be overwhelmed, and there would be immense suspicion of the motives of sick people. Perhaps this is what Parsons (1951) visualized when he described the American sick role as requiring that the occupant must want to get better and must seek out help to do so. But this hardly applies to chronic illness where, despite the desire to be cured, the sick person will never fully cast off the sick role. Here illness meanings and uses are an integral and habitual part of the disease, which itself is inseparable from coping style and personality. Somatization, at least to a minor degree, is unavoidable in chronic illness for this reason, and probably alternates, even in the same person, with its opposite, denial and minimization of symptoms. Social situations and personal and cultural significance of symptoms as much as personality and coping variables doubtless influence this swing from amplification to damping. If we understand Major Depressive Disorder as disease, at least as construed in DSM-III, and somatization as iUness, then where does neurasthenia fit in? I will argue that neurasthenia is both illness, a disease-generated and socially and cuturally shaped type of somatization, and disease, a category in China's medical classificatory system and in WHO's ICD-9 as well. This double status, I believe, provides neurasthenia with some of the particular qualities that our study detected. But I also wish to suggest that neurasthenic somatization may at times represent cultural idiom and psychosocial coping style in the absence of disease/ illness. I did not study this interesting aspect of neurasthenia in China, but I think it is an important subject for research on normal populations, family relations and child and adult development: the learned practical daily life pattern of talking about distress and help. The patients in our sample experienced symptoms which at one time or another they (and members of their family and social network) came to believe were those of 'neurasthenia' or some related neurological disorder. Headaches, lack of energy, weakness, insomnia, dizziness, and a variety of other complaints, if they cannot be diagnosed as due to a specific organic lesion, do not respond to treatment, especially if they become subacute or chronic, and interfere with normal social activities and relations, seem to be viewed (with more or less agreement) in the lay culture as 'neurasthenia". This is what we learned from the ethnographic interviews with our patients and those who accompanied them. Lacking a formal ethnography of neurasthenia in particular communities in China, we must do our best with these quite limited accounts. This popular sickness category implies a common physical disorder (weakness or exhaustion

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of neurological function), but one that is understood to include social and psychological, as well as biological, antecedents and consequences. This disorder is often suspected and diagnosed by the patient and other members of his family and friendship and work network even before it is confirmed by medical professionals. There are shared expectations of what being ill with 'neurasthenia. is really like, expectations individuals have grown up with since childhood, seen exemplified in family and friends, and perhaps learned to examine their own bodies to confirm. As our Explanatory Model findings show, these cultural expectations ostensively emphasize physical complaints and etiology, but personal, family, work and other psychosocial problems are appreciated to be part of the syndrome too, albeit they are thought to be of secondary importance. Hence neurasthenia meets the definitional criteria for illness that I set out above. If our fmdings are valid, neurasthenia illness behavior includes typical meanings, uses, and social responses, inter alia: avoidance and rest from physically and psychosocially stressful situations; time off from wearying home and work commitments; excuse for poor performance in school, lack of success in career, and failure in key life tasks such as 'enduring' stress; expression of dissatisfaction, dejection and dislike; search for symptom relief and rehabilitation from official and nonofficial sources of care; aid from family, friends and co-workers, including empathy for the sufferer and recognition that his disorder is an appropriate explanation for personal irritability, distress and failure to perform his normal social role obligations and for family dysfunction. These shared cultural assumptions are held, more or less out of awareness, by laymen and health care workers alike. Therefore the patient's illness will make similar sense to the patient, his family, the members of his unit, and to his medical care providers, who, however, eventually will reinterpret it as disease. All perhaps recognize that though it frequently is of minor significance, this disorder can become a serious burden, may well have a long course and not respond to treatment, and can cause or complicate problems for each of them. As an illness, neurasthenia reflects Chinese cultural beliefs and norms, traditional and contemporary. This at first may seem curious, since the term neurasthenia came from the West in modem times. But the point I wish to make is that while the term is relatively recent (its cultural transmission having occurred in the past 100 years or so), the concept and, most importantly, the social function are ancient. The concept of weakness of vital essence causing disease is a core category in traditional Chinese medicine that can be traced back to the classical texts (see Porkert 1974). As I have already noted, a somatopsychic orientation and provision of a medical sick role for culture.bound syndromes that Westerners would diagnose as psychological problems also characterize traditional Chinese medicine. Hence there is every reason to suspect

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that neurasthenia replaced traditional medical categories that played the same role at an earlier time before the biomedical paradigm became dominant in China. This substitution would be an excellent subject for historical research on culture change. Neurasthenia, moreover, reflects other core cultural themes and processes such as the emphasis on interpersonal relations over intrapsychic concerns, the view that intimate personal revelation outside the family is shameful, the dominance of externalizing cognitive coping processes over internalizing ones, the practical situation-oriented cognitive style, the special stigma of mental illness, the strong concern with health maintenance of physical well being through nutrition and diet, exercise, abstinence, and taking medicine, etc. Elsewhere I have offered a cultural analysis of neurasthenia as a symbolic form in Chinese culture based on my work and that of many others with overseas Chinese (Kleinman 1980), and I have no reason not to believe much the same could be said about China. The upshot is that cultural as much as social and psychobiological determinants construct neurasthenia illness experience as one that is primarily somatic. I think this point is amply supported by the findings from our study on symptom idiom, expressed versus elicited complaints, Explanatory Models of etiology and pathophysiology, and patterns of help seeking. This does not mean that individuals do not experience or have insight into psychosocial problems but that these are treated as secondary. Among the forces maintaining neurasthenic somatization is the work-disability system in China. Here it would seem, if our findings are replicated elsewhere in China, that chronic illness behavior provides the worker with some additional leverage, even if not of a very great amount, over a system that otherwise does not contain many opportunities and means for changing jobs, getting out of very difficult work situations and stresses, resolving lengthy family separations due to different and distant work sites, and getting time off with compensation. Only field research in the work place in China will adequately test this hypothesis. The fact that many of the patients in our sample continued to demonstrate illness behavior even when their symptoms had been improved seems best explained by the fact that their work (and also family or school) situations had not changed for the better and in a number of instances had actually worsened. While some patients were obviously and somewhat crudely using their illness behavior to openly manipulate the work system, the great majority I do not believe were consciously doing so. Nor do I feel that most of the former were malingering. It is just that illness behavior opens up additional options for dealing with the work system and these come into play, as it were, virtually automatically because of the cultural salience of illness among Chinese. Leadership and co-workers appear to be genuinely concerned about a worker's health status and sensitive to the difficulties and dangers of working while sick. They must recognize that certain work situations may create or exacerbate sickness,

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and where feasible they probably attempt to meliorate these conditions, especially for vulnerable individuals. This care-oriented view is supported by the ideology and sociopolitical structure of Chinese Communist society as much as by abiding cultural values. Furthermore, now that the terribly hard years of famine and serious economic and social instability are no longer acutely present, perhaps there is more salience to illness as a work problem and fewer barriers to assuming the sick role than in earlier years in the People's Republic. In the aftermath of the Cultural Revolution, when virtually every family or social network possessed someone deeply hurt by this national tragedy, perhaps there is also an additional concern to help those who were among its victims, if an opportunity to do so arises, as for example when they experience work difficulties created or worsened by illness. That only two patients openly suggested in their Explanatory Models that change of work might improve their illness, whereas many regarded it as the result of work problems, indicates that this is not a subject for direct negotiation but one that is handled indirectly in terms of a sanctioned illness, not work, idiom. In the event, the work disability system in China could not respond fully or immediately to illness needs or there would be enormous dislocations and probably active and widespread malingering. Rather like many work-disability systems worldwide, America's included, there must be sufficient impediments, difficulties, and length of time involved in trying to change work through illness as well as uncertainty of outcome, including the possibility of very limited gain, no gain, or creating a worse work or ffmancial situation, so that this option is not exercised routinely. It was apparent to me that the patients in our study recognized that these were very substantial obstacles and had sought work relief only after a long period of sickness with substantial disability. That many had still not succeeded in changing their work situations illustrates the practical reality of barriers to change in this key social system. I believe this is quite similar to the situation chronic pain patients confront in the United States, though obviously the specific deterrents and the levers for coping with the system must differ in these markedly different socioeconomic settings. Another 'benefit' of chronic illness behavior in Chinese culture is worth noting. There is a long tradition in China of individuals claiming sickness as a reason to withdraw from dangerous political situations to a safer life of retirement. Not only did a number of famous Confucian ministers of early Chinese governments do this, but as one of the epigrams at the front of this paper suggests, Mao himself did this several times. Several of the patients I interviewed seemed to have utilized their illness behavior this way during the Cultural Revolution. For a few cadres chronic neurasthenia distanced them from the fire of criticism that had threatened to consume them as it did so many others, but for most it seems to have had quite temporary and not very successful results.

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This strikes me as a topic that should be studied systematically. One warrant and pragmatic use of chronic illness behavior that have special meaning in China are sanctioning repeated failure on the national university entrance exams for former members of the urban Red Guards, sent to the countryside in the late 1960s and 70s, whose education was severely disrupted by the Cultural Revolution. This generation of young adults has been described as bitter and cynical because of all that they lost during the Cultural Revolution (Frolic 1981). The ones in our sample were children of wen-educated professionals and cadres who had spent about a decade working in rural areas as peasant-farmers. They and their families had high expectations for their careers that had been shattered by the disruption of their middle school education and by repeated failures to pass the extremely competitive exams for university, which only four percent of those who take pass. Their poor prospects are compounded by unemployment and underemployment in urban settings, and the fact that better jobs aregoing to those with greater technical training and educational skills. They are unable to compete against the best students leaving senior middle school at present, who have had much better academic preparation. They do not wish to live on rural communes where they feel they do not belong, but cannot find suitable work in the cities where their families reside. For these members of a 'lost generation' a medical excuse seems to be one of the only acceptable (face saving) sanctions for seemingly intractable failure, and perhaps resort to the sick role is a less maladaptive means of coping with the personal bitterness and resentment such a profound sense of failure and loss instills than acting out via social or political deviance. It also has the potential of achieving some practical benefits for individuals who are desperate and without acceptable alternatives. I am suggesting, then, that neurasthenia as illness in China possesses social and cultural cachet. Intriguingly, the word cachet (an indication of approval carrying prestige or influence) originally referred to the small case of gelatin enclosing a dose of medicine. The capsule became the distinguishing mark, the evidence of authenticity and efficacy of what was inside, namely, the active ingredient of the medicine. In the same way, we might think of culturally approved and socially legitimated illness behavior as the distinguishing mark or symbol of authenticity and efficacy of neurasthenia. The core meaning would seem to be that the individual is too weak or exhausted because of diminished neurological functioning (a physical disorder) to carry on normal family, school, political or work activities and that he needs to rest and remove himself from sources of stress and dis-ease. Because they are not unaware of its Cultural significance and social power, the members of sanctioning agencies (health professionals and work-disability System authorities) must be cautions in legitimating this form of chronic somatization and must seek to prevent its abuse. This in turn must create difficult negotiations between patients, health professionals, and work

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authorities, several vivid examples of which I witnessed among our subjects. How the negotiations (formal and informal) are actually conducted, how effective neurasthenia is as a means of changing work and other social responsibilities, how widespread this is, what typical problems it creates for patients, families, work authorities and health professionals, what kinds of abuses ~it gives rise to, and many related questions need to be investigated before we understand the functions of somatization in China. We can now turn to neurasthenia as disease in China. If neurasthenia as illness experience is what the neurasthenia patient brings to the initial clinical encounter with health professionals, and if this is what offers patient and practitioner a common language for communication, then this situation soon changes as health professionals reinterpret the health problem as a disease within their conceptual systems and apply 'disease-specific' treatment for it within their paradigms of practice. Chinese-style practitioners, for example, might diagnose kidney weakness or a Yin or Yang disease. Similarly, internists, psychiatrists, nurses and barefoot doctors will refract neurasthenia illness through their particular theoretical lenses (not just a shared biomedical model but somewhat different models due to specialty, degree of medical knowledge, amount of assimilation of Chinese-style medical and lay views, etc.), and will come up with the diagnosis of a disease and its treatment. As a result, neurasthenia symptoms and illness behavior may be regarded by them as generated by migraine headaches, anemia, parasitic infestation, occult tumor, diabetes, depression, or some other disease. Once relabeled as a biomedical disease, neurasthenia as a lay illness category disappears for the practitioner, because he has constructed in its place an alternative social reality. This process of clinical reinterpretation serves to establish two distinctive views of the same problem, the patient's and the practitioner's, and thereby helps to remove the shared grounds for clinical communication and simultaneously establishes the basis for future conflicts. We could see this happening in our study as we reinterpreted the patients' neurasthenia as Major Depressive Disorder. For the outcome data show that few patients were converted to this psychiatric model in spite of the fact that many responded successfully to antidepressant treatment. The reasons for this are complex, but surely involve the stigmatizing implication of psychiatric diagnosis as well as the past association of 'depression' with wrong political thinking and sociopolitical alienation. Most patients preferred the diagnosis of neurasthenia as disease. However, the limited space devoted to neurasthenia in current Chinese textbooks of medicine and the hesitancy with which medical academics and specialists explain its presumed pathology indicate that neurasthenia's status as a biomedical disease is somewhat uncertain and undergoing change. Nonetheless, my Chinese psychiatric colleagues, who are experienced clinicians, well-read and

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up-to-date in the international psychiatric literature, definitely still regard it to be a neuropsychiatric disorder with a neurological basis. But as I have already noted they recognize its relationship to stress and are sensitive to the skepticism with which neurasthenia is regarded by Western, particularly American, psychiatrists. Their general medical colleagues are much less consistent:, some think it is a psychological disease, others a physiological one, and still others psychophysiological manifestations of several distinctive diseases. But even my psychiatrist research assistants varied in their opinion as to whether in a given case the psychological or physiological component was dominant. Of course we would find much the same thing for psychiatric assessment in American society: the persistent attempt to distinguish endogenous and reactive types of depression being an obvious example. Intriguingly, several of my Chinese coneagues, in pointing out the value of maintaining neurasthenia as a diagnostic category in China, expressed the personal view that there might be several subtypes of neurasthenia: depressed and nondepressed; primarily biologically based and primarily psychologically based. This might be viewed as an instance of syncretism between two opposing but not necessarily irreconcilable viewpoints. Chinese psychiatrists, heirs to a long tradition of scientific modernizers in China who have attempted to create unique Chinese scientific institutions by combining the strengths of both indigenous and Western traditions, are concerned with constructing a scientifically valid but culturally appropriate form of psychiatry, a Chinese psychiatry,s Neurasthenia offers perhaps the most revealing window on how this Chinese psychiatry is being constructed and how it differs from Anglo-American and European psychiatry. The diagnostic category neurasthenia as it is actually applied in Hunan has a range of meanings around a central somatopsychic core that allows for ambiguity, slippage, and multiple interpretations and thereby makes it a clinically flexible and easily usable concept. Where I diagnosed Major Depressive Disorder, Panic Disorder, Somatization Disorder, my Chinese colleagues might agree, or they might diagnose instead a neurasthenic syndrome or some other category in their local diagnostic system. 9 I think their treatment practice will change to the extent that antidepressants or biofeedback are found useful to treat particular patients. But this does not necessarily mean the diagnostic use of neurasthenia will change, only that subpopulations of neurasthenic patients will be identified in ways that enable the use of these treatments. Finally, the neurasthenic syndrome does recognize the importance of key somatic symptoms in mental illness that are not incorporated in the American psychiatric diagnostic criteria and therefore is sensitive to an important element in the Chinese setting, one to which Western psychiatrists need to attend more closely. That is, DSM-III's criteria of Major Depressive Disorder need to be widened to include the common somatic symptomatology that research with psychiatric patients in primary care

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teaches us is central to the disorder. Here American psychiatrists need to learn from their colleagues in China and other non-Western societies. We need to study the epidemiology, course, consequences (including suicide) and treatment response of somatized depression to see whether these data alter our understanding of depression generally, as I think they will. We must consider the possibility that somatized depression may have better outcome in certain ways and worse in others. We need to recast psychiatric categories to remove their implicit Cartesian bias, so that psychological dimensions of illness are not viewed as more fundamental and representative of a necessarily higher level of personal maturation and cultural evolution. We need to consider whether somatic complaints in depression are best understood as idioms of expression, coping styles, interpretive schema or somatic affects. And we need to take the crucial social aspects of depression into account as much as the somatic and psychological
ones.

The point I am making is that whereas much of biomedical nosology is similar in China and the United States, psychiatric nosology clearly is not. DSM-III, which only replaced the prior official diagnostic system of the American Psychiatric Association in 1980, represents a shift from a heavily psychoanalytically. oriented nosology to that of a European-style descriptive (heavily biologicallyoriented) psychiatry. My Chinese psychiatric colleagues persistently pointed out the regrettable (to their minds) shift in American psychiatric fashions from neurasthenia to anxiety and personality disorders to, most recently, depression. As one remonstrated with me:
How do we know how long DSM-III will last? Perhaps ten years from now what you call Major Depressive Disorder may be regarded as something entirely different . . . perhaps Phobic Disorder or something as yet unheard of. Look at Briquet's Syndrome: first hysteria, then Briqet's, finally Somatization Disorder. For us it has remained hysteria.

Of course from the standpoint of many in American academic psychiatry, DSM-III is an advance over DSM-II because it is supported at least in part by empirical research and has been found valid and reliable in field testing. But it is quite mistaken to regard DSM-III as 'atheoretical', which is what some of those who helped create it assert. Major Depressive Disorder as a category is a good example of the influence of cultural and professional values. The fact that dysphoria is held to be the core complaint is a sign that psychologically-minded Western patients in psychiatric settings have been the chief source of data. Both in cross-cultural and primary care perspectives, dysphoria is fequently experienced as a secondary complaint, as it was in our study, and not unoften denied and suppressed. The absence from DSM-III diagnostic criteria of the kinds of physical complaints the neurasthenic patients suffered, which as I have pointed out have been detected as common physical complaints in depression, is further

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evidence of DSM-III's cultural and professional biases, as is the prominent place given to guilt and suicidal thoughts. The classification of Major Depressive Disorder, however, reflects a breakthrough in therapy - the antidepressant drugs - that make this diagnosis an increasingly popular and practically useful one. Certainly the diagnostic category neurasthenia does not inplicate an impressive therapeutic intervention. Yet therapeutic efficacy did not convince the neurasthenic patients that they were suffering from depression. Some who rejected this diagnosis riposted that antidepressants might be effective as well against neurasthenia and therefore might be regarded as antineurasthenia medication. What is more, my Chinese psychiatric colleagues, who were more impressed by the outcome f'mdings, did not regard response to antidepressant therapy as a definitive reason to regard a patient as suffering from depressive disease. By labeling drugs that have profound and not fully understood effects on the brain's neurotransmitters "antidepressants" we reify a conceptual category more than we explain their biology. There is a substantial difference, then, between Chinese and American psychiatric disease categories that is best illumined by the neurasthenia/Major Depressive Disorder question. This difference, I have tried to show, turns on distinctive cultural constructions of the same broad range of human behavior. For that reason it is unlikely to be completely resolved by empirical research alone, since the question at issue is the conceptual framework within which that research is organized and its f'mdings interpreted. The exciting possibility for collaborative cross-cultural studies in this area is that investigators from both societies are forced to examine their theoretical assumptions and therefore have an opportunity to contribute to the development of a more truly comparative psychiatry that can relate to patients in both Western and nonWestern societies. In so doing, as I believe this research shows, Western and Chinese psychiatrists need to take an anthropological view of cultural influences on their own diagnostic categories and practices as much as a clinical view of cross-cultural differences in the behavioral problems those categories explain. In summary, I interpret the f'mdings from the Hunan study as support for the contention that neurasthenia can be most fruitfully conceptualized as illness experience - a culturally-salient form of chronic somatization that acts as a final common behavioral pathway for several distinctive types of pathology, 1 of which Major Depressive Disorder is the principal disease and typically individuals suffer several psychiatric diseases at the same time. That so many of the symptoms of neurasthenia in China in the 1980s are the same as Beard listed for neurasthenia in America in the 1880s is evidence of biological shaping of neurasthenic illness behavior owing to disease pathology. Cultural shaping of the phenomenology of neurasthenic illness is clearly seen in the salience and frequency of certain symptoms, such as headache, guilt, suicidal thoughts and especially the culture-specific complaints of our Chinese patients; but it is more

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importantly evidenced in lay medical beliefs, help seeking, treatment evaluations, and certain special meanings and uses o f this form o f somatization in contemporary China. Yet there are also certain strong cultural resemblances with neurasthenia as it was conceived and handled in the nineteenth century West, and with contemporary forms o f somatization in the United States, such as chronic pain syndrome. 11 This discloses that there are universal commonalities as well as particular uniqueness in social and cultural processes. We have also seen that distinctive lay and professional (Chinese and American psychiatrists') construals o f neurasthenia give rise to dist~ctive social realities such that the same phenomenon is perceived, conceptualized, and treated differently. In this sense neurasthenia and Major Depressive Disorder are cultural constructions that illustrate the powerful effect o f meanings and interpretations on sickness and health care. But in another sense what we have charted in this paper is the dialectic between biology and culture that is fundamental to the experience and the understanding o f sickness and the therapeutic process. It is an impoverished science and clinical practice that takes a unidimensional view o f this innately multidimensional reality; anthropology and cultural psychiatry's key contributions are to take seriously the relationship between meaning, social relations, person and physiology, and to argue on behalf o f the perspectivism that crosscultural comparisons teach.

University of Washington
NOTES 1. This research project would not have been possible without the unstinfing, persistent and gracious support of Professors Ling Min-yu, Yang Derson, and Shen Qijie and their colleagues in the Department of Psychiatry, Number Two Affiliated Hospital, Hunan Medical College, Changsha, People's Republic of China. Special acknowledgement must go to the three postgraduate research psychiatrists who assisted me in the day-to-day conduct of the study: Drs. Zheng Yenping, Miao Jinsheng, and Dai Tze-shu (who is now at the Hangzhou Psychiatry Hospital). From the initial translation of the interview schedules to the last of the follow-up interviews, their competence, enthusiasm, hard work and unflagging patience assured that the research would reach a successful conclusion. Whenever we ran up against problems, the thoughtful and sensitive counsel of Dr. Yang Derson usually helped settle matters quickly and often prevented me from making cross-cultural blunders. I wish also to thank Dr. Wang Peng-chen, Vice-Director, Hunan Medical College, and Wang Po, Director of the Number Two Affiliated Hospital, for their free hospitality to me and my family. None of these individuals are responsible for the ideas expressed in this paper, with certain of which they may disagree; I alone assume that responsibility. The research was funded by a grant from the Committee on Scholarly Communication with the People's Repubfic of China, National Academy of Sciences. To Halsey Beemer and Bob Geyer of the Committee I wish to express my genuine appreciation. Finally I aeknowiedge with pleasure the support of the University of Washington,

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which made it feasible for me to free up the time spent from early June to late September 1980 in the field. 2. This study is part of the collaborative research and scholarly exchange program between the Department of Psychiatry and Behavioral Sciences, University of Washington, and the Department of Psychiatry, Hunan Medical College. The program includes a series of studies of depression of which this is the first. 3. Neurasthenia seems to have held an important place in Russian neuropsychiatry in the past, where it was underpinned by the theories of Pavlov and neurophysiologicallyoriented psychiatrists, who were widely translated into the Chinese psychiatry literature, and still is a component of contemp0miT Soviet psychiatry. For example, the dissident psychiatrist, Semyon Gluzman, in a very recent paper written from his internal exile in Siberia, has mentioned "simple conflict reactions (situational neuroses), characterized by affective instability, irritability, nervousness, tension, low moods, low productivity, and sometimes depression (all these symptoms fall into the so-called neurasthenia complex described b y Soviet authors)" (Gluzman 1982: 60). One of my Chinese colleagues attributed the idea of cortical asthenia directly to Pavlov (Yang Derson personal communication). And in his wrifiugs Pavlov does relate neurasthenia and hysteria to cortical weakness and inhibition; but fascinatingly, Pavlov recognized, at least in the case of hysteria, that the neurophysiological mechanism "makes the patient take refuge in illness in order to escape the difficulties of life and owing to which this pathological state may in the end become irremediably habitual." (Pavlov 1957: 539) Thus, even Pavlov's strict neurological psychology includes an awareness of the socialuses of illness, a point no doubt not lost on his Chinese psychiatric readers. 4. Depression has been used variously to mean a common mood, a pathological affect and a disorder. This ambiguity plagued earlier accounts as much as did different diagnostic criteria used to make the diagnosis of depressive disease. The term clinical depression is used to refer to a disorder. In the Diagnostic and Statistical Manual Number III of the American Psychiatric Association, depression (like Caesar's Gaul) is divided into three parts: (1) Bipolar Disorder, formerly called Manic-Depressive Disorder, a disease involving both depression and mania, which in a mild form may be called Cyclothymic Disorder, (2) Dysthymic Disorder (formerly Depressive Neurosis), a chronic disturbance of mood that is not of sufficient severity and duration to meet the criteria for (3) Major Depressive Disorder. The diagnostic criteria for Major Depressive Disorder are: (A) Dysphoric mood or loss of interest or pleasure in all or almost all usual activities and pastimes. The dysphofic mood is characterized by symptoms such as the following: depressed, sad, blue, hopeless, low, down in the dumps, irritable. The mood disturbance must be prominent and relatively persistent, but not necessarily the most dominant symptom, and does not include momentary shifts from one dysphoric mood to another dysphofic mood, e.g., anxiety to depression to anger, such as are seen in states of acute psychotic turmoil. (B) At least four of the following symptoms have each been present nearly every day for a period of at least two weeks: (1) poor appetite or significant weight loss (when not dieting) or increased appetite or significant weight gain, (2) insomnia or hypersomnia, (3) psychomotor agitation or retardation, (4) loss of interest or pleasure in social activities, or decrease in sexual drive, (5) loss of energy; fatigue, (6) feelings of worthlessness, self reproach, or excessive or inappropriate guilt, (7) complaints or evidence of diminished ability to think or concentrate, such as slowed thinking, or indecisiveness not associated with marked loosening of association or incoherence,

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ARTHUR KLEINMAN (8) recurrent thoughts of death, suicidal ideation, wishes to be dead, or suicide attempt. Furthermore, the clinical picture cannot be dominated by bizarre behavior or preoccupation with a mood-incongruent delusion or hallucination when the affective syndrome is absent, and the depression can not be superimposed on Schizophrenia, Schizophreniform Disorder, or a Paranoid Disorder, or due to any Organic Mental Disorder (e.g., dementia, tumor, infection, alcohol or drug intoxication or withdrawal) or Uncomplicated Bereavement. Major Depressive Disorder may be in remission or present with psychotic features (i.e., when there apparently is gross impairment in reality testing, or when there are delusions or hallucinations, or depressive stupor (the individual is mute and unresponsive). It is said to occur with Melancholia, ff there is Loss of pleasure in all or almost all activities, lack of reacting to usually pleasurable stimuli (doesn't feel much better, even temporarily, when something good happens), and at least three of the following: (a) distinct quality of depressed mood, i.e., the depressed mood is perceived as distinctly different from the kind of feeling experienced following the death of a loved one, (b) the depression is regularly worse in the morning, (c) early morning awakening (at least two hours before usual time of awakening), (d) marked psychomotor retardation or agitation, (e) significant anorexia or weight loss, (f) excessive or inappropriate guilt. DSM III, American Psychiatric Association (1980: 2 1 3 - 2 1 5 )

5. These two examples were given me by my colleagues Professors Charles Keyes and E. Valentine Daniel, respectively. 6. Because I regard hypochondriasis as a symptom constellation, a common form of somatizing that is either part of a primary psychiatric disorder (e.g., Major Depressive Disorder, Panic Disorder, Somatization Disorder) or of socially learned and determined illness behavior (e.g., Chronic Pain Syndrome) and not a disorder on its own, I did not specifically diagnosis patients as suffering from this problem. Hence the diagnosis does not appear on Table IV with other DSM-III diagnoses. But as Table XV discloses, 51% of the 93 cases with all forms of depression had hypochondriacal preoccupation including disease fears and bodily preoccupation. Since virtually all these patients also had somatization and persistent pursuit of medical care, they would make the DSM-III criteria for Hypochondriasis. However, it seems more availing to me to view disease fears as a specific mode of somatizing, since just about every somatizer has the other characteristics attributed by DSM-III's authors to hypochondriasis. In this respect one might regard such cases as a particular style of phobic (or hypochondriacal) somatization associated with depression, or as a hypochondriacal form of acute, subacute, or chronic somatization (Rosen et al. 982). A point in favor of the first view is that many of the patients with hypochondriacal fears experienced decrease ha these fears as part of their general symptom improvement after treatment with tricyclic antidepressants, suggesting that the hypochondriasis was secondary to their Major Depressive Disorder. 7. To assure anonymity, I have altered some of the identifying details in each case. 8. In a remarkable and quite comprehensive article on the philosophy of medicine in China from 1930 to 1980, Qiu Renzong (1982), a philosopher at the Chinese Academy of Social Sciences in Beijing, shows that among medical philosophers and theoretieians the discourse on disease and mind/body relations is a great deal more complex and discriminating than what I have described as the views of practitioners and patients. Qiu notes that the ascendency of Parlor's ideas in the 1950s reflected both the

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importance of Russian influence at that time as well as the ideological association of Pavlovian theory with the legitimated dialectic materialism that had become the basis of medical philosophy in China. He shows as well that the converse of this influence was the criticism o f Virchow's cellular pathology, Freud's psychology, Mendel and Morgan's genetics, and Galton's eugenics as 'bourgeois idealism'. This article demonstrates that formal metamedical theory in China has moved well beyond vulgar Marxism, but it makes one wonder how far the views of patients and practitioners have changed. Qiu discusses his own views " t h a t psychological activity is not only dependent upon matter on the levels of organism, organ and molecule, but also itself [sic] a form of matter movement. Thus we can change human psychological state and behavior by material means." I believe this notion of the material basis of psychological processes, illness and trealment is shared by a number of Chinese psychiatrists who follow dialectic .materialist philosophy. But whereas Qiu Renzong goes on to argue that the identity theory of psychology and physiology is incorrect, since it fails to recognize the effect of mind on physiology and o f the social world on mind, and therefore intemctionism is a preferable philosophical position, I'm not at all sure that psychiatrists in China share this view. Rather they may find their materialist, somatopsychic position more acceptable because it is supported b y the shared physicalist value orientation of biomedical, traditional Chinese medical and popular Marxist paradigms. This is an important topic for ethnographic research on the practical functioning epistemology of China's psychiatrists. This culturally constituted 'common sense' clinical epistemology is more influential, I believe, than formal medical philosophy in determining the theoretical foundation of Chinese psychiatry. The same is true of American psychiatry. 9. Somatization of psychiatric disorders like Major Depressive Disorder or Anxiety Disorders may not be given a psychiatric diagnosis in China for another reason as well. The threshold for symptom recognition as depression or anxiety may be higher, and therefore mild and perhaps even some moderate cases will go undiagnosed, I do not believe that this explains why most cases are not diagnosed, but I do think it may be a contributing factor. Indeed, the cultural press to differentially attend to and amplify somatic symptoms, which I regard as operating in lay and professional circles, doubtless results in a tendency only to recognize marked expressions of psychopathology. 10. Carr (1978) develops the concept of culturally constructed and socially legitimated final common behavioral pathways in his analysis of culture-bound illnesses, and I would extend his analysis to all illness experience. 11. EMslam (1975) describes a pattern of somatization among women in an Arabian Gulf society that has certain resemblances to the neurasthenia I have described in Hunan both in symptomatology and in social uses, though he too describes core cultural meanings of the syndrome that are particularly salient in the Qatari community where he practiced. Cross-cultural comparisons of similarities and differences in neurasthenialike forms of somatization would be of great interest. REFERENCES Akiskal, H. S. and W. T. McKinney 1973 Depressive Disorders: Toward a Unified Hypothesis. Science 182: 2 0 - 2 9 . Ballet, G. 1908 Neurasthenia. London: Henry Kimpton. Bazzoui, W. 1970 Affective Disorders in kaq. British Journal of Psychiatry 117: 1 9 5 - 2 0 3 . Beard, G. M. 1880 A Practical Treatise on Nervous Exhaustion (Neurasthenia). New York: William Wood and Co.

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Beck, A. 1971 Cognition, Affect and Psychopathology. Archives of General Psychiatry/ 24: 495 -500. Binitie, A. 1975 A Factor-Analytical Study of Depression Across Cultures (African and European). British Journal of Psychiatry 127: 559-563. Binmer, D. t al. 1980 Systematic Treatment of Chronic Pain with Antidepressants. Henry Ford Hospital Medical Journal 28: 15-21. Boyd, J. H. and M. Weissman 1981 Epidemiology of Affective Disorders: A Reexamination and Future Directions. Archives of General Psychiatry 38: 1039-1046. Brown, G. W. and T. Harris 1978 Social Origins of Depression. New York: Free Press. Cart, J. E. 1978 Ethno-Behaviorism and the Culture-Bound Syndromes: The Case of Amok. Culture, Medicine and Psychiatry 2: 269-293. Carroll, B. et al. 1981 A Specific Laboratory Test for the Diagnosis of Mehncholia. Archives of General Psychiatry 38: 15-22. Chang, Y. H. et al. 1975 Frigophohia: A Report of 5 Cases. Bulletin of the Chinese Society of Neurology and Psychiatry 1(2): 13. Cheung, F. M. et al. 1981 Somatization among Chinese Depressives in General Practice. International Journal of Psychiatry in Medicine 10: 361-374. Climent, C. E. et al. 1980 Mental Health in Primary Health Care. WHO Chronical 34: 231-236. Demexs, R. et al. 1981 An Exploration of the Depth and Dimensions of Illness Behavior. Journal of Family Practice 11: 1085-1092. Depue, R. A. ed. 1979 The Psychobiology of the Depressive Disorders. New York: Academic Press. Diagnostic and Statistical Manual of Mental Disorders, 1st Edition (DSM-I) 1952 Washington, D. C.: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition (DSM-II) 1968 Washington, D. C.: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III) 1980 Washington, D. C.: American Psychiatric Association. Diamond, S. 1964 Depressive Headaches. Headache 4: 255-258. Eastwood, M. R. 1971 Screening for Psychiatric Disorder. Psychological Medicine 1 : 197-208. Ebigbo, P. O. in press Somatization among Nigerian Normals and Mentally I11. Culture, Medicine and Psychiatry. Eisenberg, L. 1977 Disease and Illness. Distinctions Between Professional and Popular Ideas of Sickness. Culture, Medicine and Psychiatry 1: 9 - 2 4 . El-Islam, M. F. 1969 Depression and Guilt: A Study at an Arab Psychiatric Clinic. Social Psychiatry 4(2): 56-58. 1975 Culture Bound Neurosis in Qatari Women. Social Psychiatry 10: 25.

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Frolic, M. 1981 Mao's People. Cambridge, Mass: Harvard University Press. Gluzman, S. 1982 Fear of Freedom: Psychological Decompensation or Existential Phenomenon? American Journal of Psychiatry 139: 5 7 - 6 1 . Goldberg, D. 1979 Detection and Assessment of Emotional Disorders in a Primary Care Setting. International Journal of Mental Health 8: 3 0 - 4 8 . Goldberg, D. P. and B. Blackwell 1970 Psychiatric Illness in General Practice. British Medical Journal 2: 4 3 9 - 4 4 3 . Good, B. J. 1977 The Heart of What's the Matter. The Semantics of Illness in Iran. Culture, Medicine and Psychiatry 1: 2 5 - 2 8 . Heelas, P. and A. Lock 1981 Indigenous Psychologies: The Anthropology of the Self. New York: Academic Press. Hesbacher, P. T. et al. 1975 Social Factors and Neurotic Symptoms in Family Practice. American Journal of Public Health 65: 1 4 8 - 1 5 5 . Hill, O. W. and L. Blendis 1967 Physical and Psychological Evaluation of 'Non-Organic' Abdominal Pain. Gut 8: 221. Hoeper, E. W. et al. 1979 Estimated Prevalence of RDC Mental Disorder in Primary Care. International Journal of Mental Health 8: 6 - 1 5 . Hunan Medical College 1981 Foundations of Psychiatry, Volume 1. Changsha, People's Republic of China: Hunan Scientific and Technological Publishers. lzard, C. E. 1979 Cross-Cultural Perspective on Emotion and Emotion Communications. In Handbook of Cross-Cultural Psychology, Vol. 3, Basic Processes. H. C. Triandis and W. Lonner (eds.), Boston: Allyn and Bacon, Inc. Jackson, W. W. 1969 Galen - On Mental Disorders. Journal of the History of the Behavioral Sciences 5: 3 6 5 - 3 8 4 . Jackson, W. W. 1980 Two Sufferers' Perspectives on Melancholia: 1690s to 1790s. In Essays in the History of Psychiatry. E. R. Wallace and L. C. Pressly (eds.), Columbia, South Carolina: University of South Carolina Press. Katon, W. and A. Kleinman 1981 Doctor-Patient Negotiation and Other Clinical Social Science Strategies in Primary Care. In The Relevance of Social Science for Medicine, L. Eisenberg and A. Kleinman (eds.), D. Reidel Publ. Co., Dordrecht, Holland. Katon, W. et al. 1982 Depression and Somatizalion: A Review, Parts I and II. American Journal of Medicine 72: 1 2 7 - 1 3 5 , 2 4 1 - 2 4 7 . Kleinman, A. 1977 Depression, Somatization and the New Cross-Cultural Psychiatry. Social Science and Medicine 11: 3 - 1 0 . 1978 Recognition and Management of Illness Problems. In Psychiatric Medicine Update: Massachusetts General Hospital Reviews for Physicians. T. C. Manschreck (ed.), pp. 2 3 - 3 2 . New York: Elsevier. 1980 Patients and Healers in the Context of Culture. Berkeley: University of California Press.

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