Long-Standing Depression and Anxiety in a Korean Woman

Ms. D met the criteria for major depressive disorder with anxious distress of moderate severity. In addition, particular characteristics of somatization, possibly associated with her stressors, were noted. Even though her symptoms overlap partially with DSM-5 somatic symptom disorder and posttraumatic stress disorder, the most appropriate diagnosis is major depressive disorder with anxious distress. The repetitive stressful events she experienced throughout her life may have served as environmental risk factors in causing depression.

The clinical features of this case are frequently exhibited in depressed Korean patients. Such patients tend to reveal culture-specific somatic complaints (1) because they feel shame or fear stigma if they are seen as mentally ill. Traditional Eastern medicine considers body and mind as one system (2), which may lead Koreans to elaborate somatic symptoms to express emotional distress, instead of psychological differentiation. In addition, Koreans may express emotional and psychological distress through metaphorical somatic idioms, since it is traditionally deemed unacceptable to express one’s feelings in bare emotional terms (3).

Like Ms. D, a significant portion of Korean patients with depression—in particular, women past middle age—label themselves as having hwa-byung when speaking to a physician. Lin et al. (4) suggested that hwa-byung symptoms may be a cultural pattern of expression for Koreans experiencing depression. Somatic symptoms, anger, and repeated mention of unfair situations are typically observed in such patients (5; see also the entry for hwa-byung in the list of culture-bound syndromes in appendix I of DSM-IV). Hwa-byung is suggested to stem from the Korean culture’s emphasis on conformity, family integrity, and traditional gender roles; this originates in Confucianism, where the individual is expected to sacrifice personal desires for family needs (6).

Korea has experienced rapid changes over the past century, among them the Japanese colonial era, the Korean War, the acceleration of industrialization, and the financial crisis of 1997–1998. Although individualization is growing among Westernized youth, Confucianism has remained a major force in shaping Korean social principles (7). These opposing values lead to conflicts, as well as a generation gap. Elderly Korean patients with depression complain of not being understood by the younger generation (e.g., when Ms. D talked about her difficult life, her daughter-in-law did not seem to understand), and vice versa.

As with Ms. D, depression in Korea manifests somewhat different clinical characteristics than it does in Western cultures. Culture influences symptom experience and expression; diagnosis; attitude toward treatment; and doctor-patient relationships (8). According to the ethnopsychiatric view, hwa-byung may be a culturally patterned set of somatic idioms of distress due to interpersonal problems and a collective emotional reaction against injustice (9). Clinicians should therefore remember that symptoms in depressed patients labeling their condition as hwa-byung may indicate not only physical distress but also interpersonal issues. Although there is little ethnic diversity in Korea, other factors, such as the patient’s generation, socioeconomic status, gender, religion, and educational background, can influence the definition of the problem, the perception of context, self-coping, and help-seeking patterns. Using the DSM-5 Cultural Formulation Interview to integrate these data may help the clinician understand each patient better.

Depression may be associated with Korea’s high suicide rate, which is the highest of all member countries of the Organization for Economic Cooperation and Development (10) and has only grown since the financial crisis. Effects of governmental efforts to reduce depression and suicide have yet to yield results, and many Koreans remain reluctant to visit a psychiatrist because of fear of the shame and stigma associated with mental illness. In Korean culture, people are expected to regulate depressive symptoms by themselves, using willpower (3). As in Ms. D’s case, depressed patients often seek help from churches, practitioners of traditional Korean medicine, or physicians to treat somatic symptoms, rather than asking for psychiatric care. It seems to take longer for Korean patients with depression to receive proper treatment after the onset of symptoms. Therefore, clinicians should be alert for unexplainable somatic symptoms to ensure a timely depression diagnosis. Addressing psychopathology-related stigma and misconceptions should be a priority in South Korea.