Returning home from medical school for the holidays, I had an all-too-familiar experience for medical trainees, but with a cultural twist. My Chinese American family bombarded me with medical questions. “I wake up at 4 a.m. every day, 不舒服 (bù shū fu; body feels uncomfortable), feels like 心跳 (xīn tiào; heart palpitations).” “I get woken up at 3 a.m. every day, 胃痛 (Wèitòng; stomach pains), but I had a CT, MRI, and colonoscopy last year, and they said nothing is wrong. Do I have cancer?” A Western cultural model may recognize these medically unexplained symptoms as somatic manifestations of psychological distress, which are formally categorized in the DSM-5 as somatic symptom and related disorders (APA). However, due to cultural stigma surrounding mental disorders, many patients of Chinese heritage are unable or unwilling to consider any connection between physical symptoms and their mental health, thus preventing them from receiving appropriate treatment and creating significant mental health disparities. In order to better serve these patients, it is imperative for clinicians to recognize somatic symptom presentations in Chinese heritage patients, offer appropriate medical as well as psychiatric treatment, and address cultural barriers that may prevent patients from accessing psychiatric care.

In studies of cross-cultural psychiatry, Chinese patients demonstrate a tendency to focus on somatic complaints in place of psychological ones. A classic example is “身精衰弱” (shēn jīng shuāiruò; neurasthenia, or weakness of body and spirit), which can be described as a condition characterized by fatigue, headaches, difficulty concentrating, dizziness, sleep disturbance, and memory loss, thought to be caused by outside stressors that lead to inner turmoil. In a study of 100 Chinese outpatients with neurasthenia, 87 also met DSM criteria for major depressive disorder, and 70% of these patients experienced significant reduction of symptoms when treated with antidepressants. Despite this promising response to antidepressant treatment, Chinese American patients may be hesitant to seek psychiatric treatment due to the cultural stigma surrounding mental illness. Despite being the largest Asian demographic in the United States, Chinese Americans are relatively under-represented in mental health settings, likely due to cultural perspectives of mental health that discourage utilization of these services 5,6. In traditional Chinese communities, those who experience neurasthenia may be labeled as 神经病 (shénjīngbìng; mentally unwell), a term that is associated with shame and social ostracization. Parents may be unwilling to allow their child to marry into a family with a member who is mentally unwell. In domestic arguments, accusing the opposition of 神经病 (shénjīngbìng; mentally unwell), 疯 (fēng, crazy), or 强迫症 (qiǎngpò zhèng; OCD) is a common attack. 去死吧 (Qù sǐ ba; go kill yourself) is the ultimate insult. Societal rejection of individuals who have been labeled as mentally ill drives stigmatization and denial of mental disorders among Chinese populations, which in turn leads to higher rates of somatic symptom disorders.

Chinese heritage individuals may also experience internal barriers to accessing mental health care. In Chinese culture, mental health issues can be perceived as a weakness or a source of familial disgrace, leading to reticence in seeking help or disclosing psychological struggles. This may explain lower reported rates of depression in Chinese Americans than in any other Asian subgroup. Traditional Chinese values emphasize preserving family honor and avoiding shame, or 好面子 (Hǎo miànzǐ; good face). Mental illness can be viewed as a reflection of poor familial upbringing, creating a significant barrier to seeking psychiatric help. The collectivist values of Chinese society place great importance on social stability and harmony, often at the expense of individual emotional expression, which can further complicate an individual’s capacity to acknowledge and seek treatment for mental disorders. These internalized views of mental health contribute to the under-utilization of Western mental health services.

Perhaps another reason that Chinese heritage individuals deny psychological diagnoses is a fear of mental illness being incurable. In an attempt to prioritize hope and repel negative energy, individuals may tell their families they do not want to be informed of terminal diagnoses. The 2019 film The Farewell depicts this belief, as an entire Chinese American family works to deceive their beloved grandmother about her cancer diagnosis to protect her from the emotional burden of her terminal prognosis. There is widespread fear that conditions such as 憂鬱症 (yōu yù zhèng; depression) are incurable. In Chinese news, mental illness is typically portrayed in only the most extreme circumstances, such as dramatic suicide attempts by jumping off buildings or a killing spree by a 疯子 (Fēngzǐ; madman). In light of these beliefs, suppression or rejection of negative emotions becomes the most acceptable coping mechanism.

Taken together, cultural stigma, negative internal attitudes toward mental illness, and unfamiliarity with or even distrust of Western mental health treatments all pose significant barriers to Chinese heritage patients who may benefit from psychiatric care. Clinicians would do well to maintain a high bar of suspicion for somatic symptom disorders in this population and to offer compassionate and culturally responsive care. While more research is sorely needed, some best practices may include:

• To address the under-reporting of psychiatric symptoms, keep a broad differential that includes somatic symptom disorders when a culturally Chinese patient presents with vague or medically unexplained somatic symptoms.
• To address stigma and shame, build rapport over time, and support community-based de-stigmatization efforts.
• To honor collectivistic values, invite family participation and emphasize the benefit of mental health treatment on the family’s functioning as a whole.
• To accommodate cultural conceptualizations of mental illness, invite and validate the patient’s perspective of their illness.
• To combat unfamiliarity with Western mental health treatments, offer clear and unbiased information regarding diagnosis and evidence-based treatments. Provide psychoeducation about the physical manifestations of stress, anxiety, and depression.
• To address reluctance to seek mental health treatment, emphasize the practical and/or functional benefits of treatment and frame treatment as a type of mental strengthening or training, as opposed to self-care or self-indulgence.

Michelle Zhu is a medical student. Angela Liu is a psychiatry resident. Ashley Wu is a child and adolescent fellow. Thomas Pak is a psychiatry resident.