MASKED DEPRESSION AND DEPRESSIVE

EQUIVALENTS

Stanley Lesse
 e-Book 2015 International Psychotherapy Institute

From American Handbook of Psychiatry: Volume 7 edited by Silvano Arieti

Copyright © 1981 by Basic Books

All Rights Reserved

Created in the United States of America

 Table of Contents

MASKED DEPRESSION AND DEPRESSIVE EQUIVALENTS

Concepts of Masked Depression and Depressive Equivalents

Cultural and Economic Factors Influencing the Masks of Depression

Acting-Out Behavior Masking Depression in Western Culture

Behavioral Masks of Depression Among Adults

Masked Depression in Old Age

Hypochondriasis and Psychosomatic Disorders Masking Depression

Treatment

Bibliography

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 MASKED DEPRESSION AND DEPRESSIVE
EQUIVALENTS
Stanley Lesse

Masked depression is one of the more common clinical ailments seen in

western medicine and rivals overt depression in frequency. Indeed, it is the

type of depression most often encountered by nonpsychiatric physicians. The

subject of masked depression and depressive equivalents presents us with a

paradox: In spite of the frequency of the syndrome, only a relative handful of

clinicians have a meaningful awareness or understanding of it. The depressive

affect and even many depressive syndromes may be so masked that a

nonpsychiatric or even psychiatric physician may be unaware of the fact that

a serious emotional disorder is at hand until a massive, full-blown depression

erupts and dominates the clinical scene.

The term “depression,” in the minds of most laymen and physicians

alike, usually refers only to a mood, which in psychiatric circles is more

specifically labeled as sadness, melancholy, dejection, despair, despondency,

or gloominess. If this overall mood pattern is not dominant in the clinical

picture, the patient is not considered depressed. This view is universal among

laymen. However, this narrow concept is also held by some physicians and
even by psychiatrists. The masking veneer or facade may vary depending

American Handbook of Psychiatry - Volume 7 5

upon many factors, including: (1) the culture, (2) age of patient, (3)
socioeconomic and socio-philosophic background, (4) hereditary and

congenital processes, and (5) ontogenic development.

While the masked depression syndrome, hidden behind a broad

spectrum of masking processes, is broadly represented in all cultures, the

relevant literature is very sparse and deals primarily with those syndromes
that are essentially manifested clinically as psychosomatic disorders or

hypochondriacal complaints referred to various organ systems. Masked

depression has been referred to by a variety of labels, which in themselves

have contributed to the confusion surrounding this syndrome. The various

diagnostic labels include: (1) masked depression, (2) depression sine

depression, (3) depressive equivalents, (4) affective equivalents, (5)

borderline syndromes, and (6) hidden depression. In many instances, where

the condition has not been detected by the physician, the term “missed

depression” might be appropriate.

Concepts of Masked Depression and Depressive Equivalents

In western medicine, masked depressions are most commonly hidden

behind psychosomatic disorders and hypochondriacal complaints. Less

frequently the depressions may be hidden behind various behavioral
patterns. If the clinician will look behind the presenting symptoms, a

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depressive core will be evident, a core that in most instances eventually
becomes overt if the patient is not treated. Therefore, this type of masking

hides an active depression, which can be readily discerned by careful

examination.

In other situations, a psychosomatic syndrome or hypochondriacal

symptom may represent an aspect of a clinical spectrum that eventually may

end in an overt depressive reaction. For example, individuals who

demonstrate hypochondriacal symptoms early in life are prone to develop

overt depressive reactions. Women who eventually develop postpartum or

involutional depressions frequently have histories of significant

hypochondriacal or phobic reactions earlier in life. This is not to say that all

individuals who are hypochondriacal or phobic or who have psychosomatic

disorders are destined to become depressed. However, individuals with a

history of these clinical phenomena have a greater propensity to eventually

develop overt depressions.

With this observation in mind, one should also note that the

psychodynamic mechanisms associated with hypochondriasis, phobias, and

psychosomatic disorders, as they occur in western culture, are similar to

those that are observed in depressed patients. Therefore, hypochondriasis,

psychosomatic disorders, and some acting-out behavioral patterns may be

considered either as being masks of depression or depressive equivalents.

American Handbook of Psychiatry - Volume 7 7

When these symptoms or syndromes are merely “covering up” an underlying
depressive core, they should properly be considered as depressive masks.

When these symptoms or syndromes occur in the absence of a clear-cut

depressive core, and then years later manifest symptoms and signs of an
underlying depression, they should be thought of as depressive equivalents.

In this second context, depressive equivalents may be viewed as part of

a clinical spectrum having certain psychobiologic and psychodynamic origins

with features in common. These symptoms or syndromes may be seen as

separate entities or as steps in a continuum that may or may not manifest

themselves as phenotypical, full-fledged, overt depressions. Many years might

pass before an overt depressive reaction emerges.

These observations raise the question of differentiating between those

patients who have hypochondriasis, phobic reactions, or who have

psychosomatic syndromes without ever developing overt depressions, from

those who manifest the same symptoms and syndromes and who have a
marked propensity to become depressed. Genetic studies suggest that

hereditary factors may play a role in some depressive equivalents. For

example, the relatives of bipolar patients have a higher prevalence of

hypertension, obesity, and thyroid dysfunction than do relatives of unipolar

patients. In contrast to this observation, a higher incidence of chronic

alcoholism and drug dependence has been noted in families of unipolar

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patients.

From a genetic standpoint, depressive equivalents may be thought of in

two ways: (1) as a different genetic subtype of affective disorder consistent

with a model of heterogenic inheritance, or (2) as part of a continuum in a

homogenic model of mood disturbances.

Cultural and Economic Factors Influencing the Masks of Depression

It was found that depressive episodes that are masked by

hypochondriasis and psychosomatic disorders are relatively uncommon in

lower socioeconomic groups in the United States. For example,

faciopsychomyalgia, more commonly described as atypical facial pain of

psychogenic origin, is rarely seen among blacks or Puerto Ricans in lower

socioeconomic levels. However, this syndrome is seen among blacks and

Latinos who rise in the socioeconomic scheme and who become part of the
more affluent aspect of our society.

Acting-out behavior represents the more common type of masking

process among lower socioeconomic groups in western society. This parallels

the observation that acting-out behavior represents the common masking

process in agricultural societies. For example, in India, a developing Third

World country, 85 percent of the people are engaged in agriculture.

Psychosomatic disorders are relatively uncommon among the nonliterate

American Handbook of Psychiatry - Volume 7 9

rural groups. In contrast to this observation, psychosomatic disorders and
hypochondriasis are much more frequently seen among the better educated

groups living in more industrialized, westernized centers such as Bombay or

New Delhi.

In general, there is an evolutionary continuum of defensive confusion,

anger, and acting-out from relatively frank and direct behavior in nonliterate
cultures to increasing disguise and distortion in modern societies. Modern

societies, with their greater sophistication, use deeper disguises and more

personally damaging methods of coping with problems.

In keeping with this general observation, masked depressions occur in

their least severe form in most nonliterate cultures. These milder ailments are

more open to spontaneous remission or shamanistic and priestly

ministrations. If, however, the nonliterate cultures were strongly influenced

by the European conquerors, masked depressions of the more severe type are

encountered.

Simple and open confusion is the most common masking pattern in

primitive or nonliterate peoples. Among these groups, confusion may be seen

as a cry for help that brings the nuclear or extended family group to seek the

aid of a priest or shaman. In more modern societies, however, people are

relatively reluctant to show such dependent attitudes.

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 Hostility is a mask of depression in all societies. The direction the

hostility takes, however, depends on the degree of cultural sophistication the

society has attained. In nonliterate cultures, hostility is usually directed

toward groups of people. In western cultures, the chief target of hostility is

usually the person who is the one closest to the hostile individual. The

diffusion of the objects of hostility and anger noted in technologically more

primitive cultures may be accounted for, at least in part, by the fact that
nonliterate cultures have more diffuse patterns of authority in the form of an

extended family system.

The diffusion of hostility differs among various nonliterate societies.

Opler points out that among the Arctic Eskimos and the Ute Indians of

Colorado and Utah, children are often adopted out of the nuclear family by

relatives. This causes diffused object relations that are associated with a

broad focus of hostility. In a similar fashion, when a Malaysian runs amok,

there is a very diffuse portrayal of violent aggression toward anyone who

crosses the path of the attacking individual. Opler also points out that acting-
out among nonliterate peoples usually occurs in the presence of relatives or

neighbors. In a similar fashion, Indonesian women who display the latah

syndrome utter obscenities in the presence of friends and relatives.

Among more primitive peoples, acting-out may also be in the form of

imitative or negativistic behaviors; this is what occurs in Arctic hysteria and

American Handbook of Psychiatry - Volume 7 11

 in the imu illness of the Ainu of the island of Hokkaido in Japan. A similar
pattern may be seen as far south as Malaysia.

Periods of confusion, occurring either as masks of mild depressive states

or as expressions of agitated euphoria, have been noted among African

patients. The periods of agitated euphoria may be viewed as compensations

for the underlying depressions. In general, patients in primitive societies who

have masked depressions can readily be restored to “health” through the

psychosocial interventions of a shaman or curing cultist when the ailment is

in its early phases.

Acting-Out Behavior Masking Depression in Western Culture

Masked Depression in Children

The more primitive the culture the more direct and frank the clinical
manifestations masking an underlying depression. In similar fashion, acting-

out behavior, which is quite direct, is the most common type of depressive
expression among children and, to a gradually decreasing extent, adolescents.

Indeed, when viewed in this light, one can state that almost all depressions
seen in childhood are masked depressions.

The literature dealing with childhood depression is quite limited. Mosse

points out that childhood depressions are usually subsumed under the

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classification of psychoneurotic disorders. She also points out that the classic
and obvious symptoms of depression as they are known in adult life occur

infrequently in childhood. Children who are depressed show a very diverse

symptomatology. Therefore, the depressions of children and young

adolescents may not be recognized at all, or are classified as minor aspects of

other diagnostic entities.

The masking symptoms of depression, such as defiance, truancy,

restlessness, boredom, antisocial acts, and so forth, which are so common

among children and adolescents, are all too often not given appropriate

attention by laymen and physicians alike. A study of suicidal behavior by

children and adolescents indicates that months before their suicidal attempts

almost half of them showed marked and definite behavioral changes that

were not recognized as serious indications of depression by their parents or

their teachers.

Mosse points out that in most child psychiatric studies no clear

distinction is made between children and adolescents. She observes that both
physically and psychologically there is a qualitative, and not just a

quantitative, difference between childhood and adolescence and that this

change affects the character of the psychopathology that is evidenced. This

difference is most significant where depression is concerned.

American Handbook of Psychiatry - Volume 7 13

 It is most important to appreciate that suicidal attempts have been

overlooked in children and adolescents due to the erroneous concept that

they do not experience depression. In fact, it is only recently that the subject

of childhood depression has been discussed at all. Some child psychiatrists

contend that depression does not exist in children. Toolan points out that a

popular book on child psychiatry, and several detailed monographs dealing

with clinical and research aspects of depression, do not even mention

childhood depression.

The scotoma that currently exists in regard to childhood depression

parallels the blindness of some psychiatrists who denied the diagnosis

“childhood schizophrenia” in the late 1940s and early 1950s. Psychiatrists

and psychologists of that period were still fond of stating that children did not

develop schizophrenia since schizophrenia could not appear until after

puberty. This is no different from the ludicrous nineteenth-century belief that

men could not be hysterics since hysteria was due to a “wandering uterus.”

Spitz and Wolf described a severe type of developmental retardation in

infants that was associated with deprivation reactions and depressive

elements. They labeled this syndrome “anaclitic depression.” This syndrome

was noted in infants and small children who had been isolated from maternal

care; it was most commonly seen in children raised in institutions. These

children demonstrated physical, intellectual, and emotional retardation.

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Initially, they protested actively, but finally became apathetic, showed
decreased mental and physical activity, and rejected all adults.

Similar findings were observed in the Pavlov Institute in Leningrad in

their studies of puppies. If puppies, at the time of the appearance of the

“awareness reflex,” receive electroshocks whenever they are fed, they will

withdraw from their handlers, crawl to the back part of their cages, and even
refuse all food. They lose weight and hair. No matter how the future

environment is improved, these puppies do not recover. If the same

experiment is performed with older puppies who had initially been treated in

a very humane fashion, they too withdraw in this fashion. However, among

this older group, if the environment is improved, the dogs will again begin to

relate to people and the overall environment in a positive fashion.

Others have also described intellectual and social retardation in

institutionalized children who were deprived of close ties with their mothers

or maternal substitutes. John Bowlby described three stages that a child

undergoes when separated from the mother: (1) protest, (2) despair, and (3)

detachment. Often the stage of detachment is misinterpreted by a hospital

staff as a sign that the child is beginning to adjust to his situation, whereas in
reality it is evidence of a profound disturbance, which Bowlby labeled

“mourning” and which Toolan described as “depression.”

American Handbook of Psychiatry - Volume 7 15

 Among older children, sociopathic manifestations and acting out are

more likely to mask depression. This may take the form of disobedience,

temper tantrums, truancy, or running away. Several authors have noted that

underlying depressions are responsible for so-called school phobias.

Some children will show equivalents of depression in the form of

anorexia, colitis, and various other psychosomatic disorders; they may also

display accident proneness and masochistic and destructive behavior.

Hypochondriacal and psychosomatic disorders may take the form of

headache, tics, choreiform movements, abdominal complaints, nausea and

vomiting, and so forth. The parents of such patients not infrequently present a

history of depression.

Meyers reports on a group of eighty-two childhood schizophrenics who

had extensive residential and day-care treatment during their early school
years. The biannual follow-ups revealed a strikingly low incidence of

depressive response when the patients reached the ages of fifteen to twenty-

six years. This absence of depression was even more impressive when one

noted the degree of impairment in adaptation and the failures and defeats
these schizophrenic individuals faced in their attempts to attain satisfying

relationships with their environments. In contrast to this group, the

emergence of depressive symptoms was greater in older children and in

children with greater ego development and object relatedness. Meyers also

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 observed that in severely ill schizophrenic children the grief of the mourning
reaction is usually shallow, if it occurs at all. Instead there is blandness,

apathy, anger, or a variety of atypical responses.

Depression may also be masked among mentally retarded children who

are very often aware of their deficiencies. This is particularly true among

children who are only slightly to moderately retarded. These children are
frequently rejected by their peers, by their siblings, and even by their parents.

Often the depression that they evidence may be masked by irritability, rage

outbursts, and destructive behavior. They tend to automatically fight

authority figures, but if their rage is blocked by fear of adult punishment, it

may be directed toward younger children, small animals, or inanimate

objects. This type of masked depressive reaction is commonly misdiagnosed

and mismanaged, especially in large institutions.

Masked Depression in Adolescents

Many of the depressive facades that were described for the older child
are similar to those found in early adolescence. As the adolescent approaches

young adult life, depressive episodes may become more overt and the masks

will more closely resemble those seen in adult life. School phobia and

underachievement in school may conceal underlying depressions in younger

adolescents as well as those attending high school and even college. Among

American Handbook of Psychiatry - Volume 7 17

the older group, depressions are frequently manifested by changing courses,
failures to take final examinations, dropping out of school, or changing from

fulltime to part-time schooling. The threat of graduation, laden as it is with the

fears of unknown responsibilities, is often associated with depressive

reactions masked by acting-out behavior or hypochondriacal and

psychosomatic disorders.

Among adolescents one often encounters masks of depression in the

form of pervasive boredom, restlessness, frantic seeking of new activities, and

a reluctance to be alone. The bored teenager often complains that he or she is

tired. This type of adolescent may manifest an alternation between

complaints of fatigue and evidence of almost inexhaustible energy.

Complaints of feeling empty, isolated, or alienated, so often described by

adolescents, may also be indicative of underlying depression. He may describe

himself as being unworthy and unlovable. The depressed adolescent often

evinces a paradoxic combination of resentment toward his parents coupled

with overdependence upon them.

The post-World War II period, particularly the past decade and a half,
has been characterized by a decreased psychosocial threshold to psychologic

or physical pain and frustration. This pattern has been enhanced by a

multibillion-dollar advertising industry that preaches ad nauseam of one’s

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birthright to wallow in material, physical, and emotional pleasure while
expending little or no effort. Among older adolescents the compulsive use of

drugs and sexual acting-out has become progressively more common as

masks of depression. Sexual acting-out may be seen as seeking a significant

other person in an attempt to relieve feelings of aloneness and alienation. At

times, a depressive propensity may be aggravated by marked guilt feelings

associated with this sexual behavior. Teenage pregnancies, which have

increased in frequency at an astounding rate, too often compound the

problem.

Chwast has pointed out that depressive reactions may be masked under
the guise of delinquent behavior among adolescents from lower

socioeconomic backgrounds. Among these adolescent offenders, evidences of

depression are commonly hidden behind sociopathic behavior patterns in a

fashion also seen among adult criminals. Chwast found that in a total sample

of 121 delinquents, more than 75 percent appeared at least somewhat

depressed, with almost 50 percent being substantially or severely depressed.

Delinquent girls were usually more depressed than delinquent boys.

Among some delinquents the sociopathic acting-out served to ward off

decompensating, schizophrenic defensive mechanisms. With regard to others,

Chwast felt that fighting and destructive behavior should be seen as an

attempt to combat depressive manifestations that threaten to become overt.

American Handbook of Psychiatry - Volume 7 19

To some of these individuals, the gang was a search for “significant other
persons” in an attempt to compensate for a void in meaningful attachments. A

separation from the gang may cause some culturally deprived persons to have

feelings of inadequacy and hopelessness and to show even overt depression.

Automobile accidents and direct suicidal attempts are the two

commonest causes of death among college students. Many of these

adolescents and young adults had exhibited masked or overt depressions.

Herschfeld and Behan expressed the opinion that failures in academic or

social performance, which were considered “unacceptable disabilities,” were

converted into “acceptable disabilities” in the form of automobile accidents.

Behavioral Masks of Depression Among Adults

In the vast majority of instances, masks of depression in adults take the

form of hypochondriasis and psychosomatic disorders. But depression is also

frequently masked by multivariant forms of acting-out. Drug dependency is

one of the more common acting-out behavioral masks of depression in adults.

While public attention has been focused upon problems that are secondary to

narcotics addiction, which is so commonly associated with major crime in

large cities, the excessive use of alcohol remains the most commonly

encountered type of drug abuse.

Chronic alcoholism frequently serves to mask depression. Feelings of

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hopelessness, rejection, or overwhelming retroflex rage may appear
precipitately following an alcoholic debauched When the mask slips, that is,

when the alcoholic sobers up, massive guilt and profound depressive feelings

are uncovered. Suicidal acts have followed failures in sexual performance, a

problem commonly associated with alcoholism.

Marijuana, a wide spectrum of hallucinogenic agents, cocaine,

amphetamines, barbiturates, antianxiety agents, neuroleptics, antidepressant

drugs, and so forth, are available on the streets of American cities in vast

quantities. Psychedelic drugs are often taken to mask underlying depressive

syndromes. It is well known that weeks may pass before a covertly depressed
patient who has been “on a trip” suddenly manifests overt depression.

Narcotics addiction may sometimes be seen as an attempt to cope with

an underlying endogenous depression. Some of the suicidal attempts made

when addicts are taken off narcotics may be ascribed to the emergence of

massive depressive reactions that had been masked by the addiction.

Individuals dependent on amphetamines and other stimulant drugs

commonly have a depressive core. Precipitous depressive reactions very often

result following rapid withdrawal of amphetamines from chronic users. While

amphetamines are dispensed frequently to depressed patients, they usually

serve only to mask the depression if it is profound enough.

American Handbook of Psychiatry - Volume 7 21

 Barbiturate habituation is a massive problem. There is an

overproduction of barbiturates in this country, with the excess finding its way

onto the streets where it is dealt with as a highly profitable, marketable

product. Adolescents and adults from lower socioeconomic groups buy their

barbiturates from “street pharmacists.” In addition, there are literally tens of

thousands of iatrogenically created barbiturate habituates. These drugs may

mask underlying depressions for long periods of time, depressions that may
rapidly become overt when the drugs are withdrawn.

Anger and rage are among the most commonly observed masks of

depression. Spiegel has stated that “the role of the equivalence of anger needs

to be understood by both the patient and the therapist; and when anger or

rage is dominant, the therapist should consider a relationship to depression.”

This is a very cogent observation. Patients with masked depression are almost

without exception extremely angry individuals. The rage could either be overt
or covert; in most instances, it is overt. Covert anger is more difficult to

manage from a therapeutic standpoint. Covert anger arises from severe

childhood trauma. It is most commonly seen in patients who have been

abandoned emotionally by their parents. It also occurs when parents are so

hostile, domineering, critical, and sadistic that the patient, as a child, became
terrified by the aggressive, punitive atmosphere. Attempts by the child to

protest were usually met with overwhelming and crushing punishment. These
patients, in general, are unable to react with appropriate anger in later life,

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even when it is justified.

Most patients with masked depressions are overtly hostile. In this type
of patient, in contrast to the patient who had developed covert rage, the

domineering, critical parent did not completely destroy the child’s

compensatory rage capacities or block the patient from expressing anger. This
excessive anger is a compensatory mechanism that tends to dominate the

patient’s personality.

In the definitive treatment of patients with masked depressions, a

pointed effort is made to unfold gradually the full degree of the patient’s

unconscious hostility. This anger is strongly guilt-linked.

Many of the patients are afraid of the intense degree of their latent
anger, which is often tied to unconscious, symbolic, murderous fantasies.

Many depressed patients, particularly those with covert anger, must be taught
how to express anger and must be made aware of the fact that anger can be a

normal, healthy reaction to certain types of stress.

The apparent states of remission in depressed suicidal patients are the

most serious and at times the most complicated type of masked depression.
They may occur in patients who have a history of suicidal ideas or who have

made suicidal attempts but in whom the drive for self-destruction appears to

have been ameliorated. Too frequently, the psychiatrist or psychotherapist

American Handbook of Psychiatry - Volume 7 23

who treats a suicidal patient may be so relieved to record some improvement

that he or she may overestimate its true degree.

The availability of multiple therapies (including electroshock,

psychotropic drugs, and some psychotherapies) that may be effective for

various types of depressed and suicidal patients gives some psychiatrists a

false sense of security simply because they use these techniques. The suicidal

impulses may be merely blunted or masked by various psychotropic drugs or

with electroshock therapy, particularly if the frequency or number of

treatments is inadequate.

Psychotropic drugs also may result in a similar premature relaxing of

clinical vigilance. Some suicidal patients may demonstrate an apparent

remarkable remission following the administration of tranquilizers or

antidepressant drugs. At times this apparent change may be purely a tenuous

placebo reaction with the suicidal drive being only superficially masked. Any

relaxation of clinical precautions during the early phase of treatment of

suicidal patients, no matter what technique is used, may result in a self-

destructive act.

Masked Depression in Old Age

Among geriatric patients an organic mental reaction may mask an

underlying depression. Patients who demonstrate fluctuations in the intensity

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of an organic mental syndrome require particularly close scrutiny. Organically
confused patients commonly show a decrease in the intensity of a depression

and even of suicidal impulses. However, as they gain insight into the nature or

severity of their problem, a depressive reaction leading at times to a suicidal

act may occur. Among geriatric patients, depression may also be masked
behind hypochondriacal symptoms and psychosomatic disorders. Marked

irritability, obsessive thinking, or a gross increase in psychomotor activity

may also serve as masking processes.

There is an unfortunate tendency among both physicians and laymen to

attribute all changes in elderly people to organic illnesses. Not infrequently,

symptoms such as listlessness, anorexia, and insomnia may be manifestations

of an underlying depressive reaction.

Hypochondriasis and Psychosomatic Disorders Masking Depression

In the vast majority of instances among adults in highly industrialized

western countries, masks of depression assume the form of hypochondriasis

and psychosomatic disorders. While this type of depressive syndrome rivals

overt depressions in frequency, it is insufficiently appreciated by psychiatrists

and non-psychiatrists alike, at times with tragic consequences. Physicians

without formal psychiatric training are prone to treat a patient’s “physical
complaints” without probing to see whether the affect associated with the

American Handbook of Psychiatry - Volume 7 25

symptoms is secondary to a true physical deficit or whether it is a
psychological expression mimicking an organic disorder. This clinical scotoma

often results in patients being exposed to unnecessary and even

inappropriate treatment over long periods of time.

It is likely that from one-third to two-thirds of patients past age forty

who are seen by general practitioners and even specialists have masked
depressions with the depressive syndromes masked by hypochondriacal or

psychosomatic disorders. These patients, particularly those in the late middle

and older age groups, are extremely prevalent in hospital clinics; they also

occupy a sizable proportion of general hospital beds. Unfortunately, they are

usually subjected to a multitude of laboratory examinations and too often are

exposed to a variety of organic treatments, even surgery.

In most instances, it is only after many months or even years of

examinations and multiple treatments that a psychiatric consultation is

requested. By the time the patient is seen by a psychiatrist, the depressions

are usually of severe proportions. This observation is documented by the fact

that more than 40 percent of the patients with masked depressions have

suicidal ideas or drives by the time they are first seen by a psychiatrist.

The masked depression syndrome poses a sharp challenge to all

physicians, psychiatrists and non-psychiatrists. A number of clinical

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 possibilities may occur:

1. The masked depression syndrome may occur in patients without

any organic processes. On the other hand, the patient may
have a masked depression superimposed upon a true organic
deficit. This second situation may pose a significant
diagnostic problem.

2. Too often a minor organic illness is magnified by the psychogenic

overlay, and it may be misdiagnosed as being a major organic
disorder. In such a situation, the physician exaggerates the
importance of the organic component and fails to recognize
the psychogenic aspect of the problem. This usually leads to
months and years of repeated studies and organic
treatments. Most of these patients develop a massive
iatrogenic overlay that further complicates diagnosis and
treatment.

3. In other instances, a patient may have a major organic lesion with

hypochondriacal or psychosomatic complaints
superimposed. If the physician or therapist becomes
preoccupied with the psychogenic aspects of the problem
and fails to recognize the severity of the organic lesions,
serious consequences may follow.

Clinical Characteristics

Sex and Age Distribution

American Handbook of Psychiatry - Volume 7 27

 One study of 336 patients who had depressions masked by

hypochondriasis or psychosomatic disorders reported that 246, or 73.2

percent, were women. This represents a female:male ratio of 2.7:1. However,

in a different study of 198 patients who had a type of masked depression

known as “faciopsychomyalgia” (more commonly known as “atypical facial

pain of psychogenic origin”), it was found that 86 percent were women. This

is an 11:1 female:male ratio.

The age distribution is also very characteristic. Two hundred and

ninety-five (87.8 percent) of 336 patients with masked depressions were

between thirty-six and sixty-four years of age at the onset of illness. One may

state, therefore, that the syndrome in which depression is masked by

hypochondriasis or psychosomatic disorders is primarily an ailment of

middle-aged females.

It is unusual for these patients to be seen by a neuropsychiatrist early in

the course of the illness. For example, 65 percent of the 336 patients were

seen only after two or more years had passed from the time of onset of

symptoms to the initial consultation. More than 30 percent had been ill for
five or more years prior to being correctly diagnosed.

Initial Examination

A number of general characteristics can be noted during the initial

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examination. Patients present their history in a very wordy, forceful manner;

the term “logorrhea” would be appropriate in many instances. The

descriptions are replete with medical jargon gleaned from the many

physicians or dentists who had examined and treated these patients. Quite

often the patients consult medical texts and bring this “knowledge” to the

examination.

The clinical descriptions are vague and do not represent classic

descriptions of specific organic processes. At best, they are suggestive of a

more unusual organic process. In addition, patients with masked depressions

are far more handicapped in their vocational and social performance than are
patients with true organic illnesses. These clinical descriptions, together with

a tendency to exaggerate the suffering experienced, are further colored by

iatrogenic factors that are secondary to prior multiple somatic examinations

and treatments.

These patients come with a fixed concept that their ailment is due to a

serious organic disorder. They demonstrate marked hostility toward the

psychiatrist if the diagnosis of a psychogenic process is made early in the

examination.

The initial phase of the history is directed primarily to ruling out a

primary organic cause for the patient’s complaints. Nevertheless, even the few

American Handbook of Psychiatry - Volume 7 29

clinical characteristics already described should warn the examining
physician of the likelihood that the patient’s ailments, at least in part,

represent a significant psychogenic overlay, which necessitates intensive

psychiatric evaluation.

The patients have a marked emotional and economic investment in their

illnesses. There is a strong secondary gain mechanism behind their

symptoms. Sufficient time must be allotted for the patients to expound upon

their ailments, to relate the exquisite details of their symptoms, and to

demonstrate their “knowledge of medicine.”

The pointedness of the psychiatrist’s investigations may be slowly

broadened after the patient’s confidence has been won. With gentle

interrogation one can gradually compose a psychiatric scenario that is

applicable for almost all of the patients. Patients routinely describe an

agitated state, with restlessness, floor pacing, and marked feelings of anxiety.

Insomnia, anorexia, persistent fatigue (especially in the morning), difficulty

with concentration, loss of interest in vocational and social activities, and

“feeling low” are also typical complaints. Routine personal habits become

major chores. Frequently, the patients state that they are “losing their minds”

and point to a “poor memory” as justification for this opinion.

Although the patients constantly refer to their “serious physical

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illnesses,” one can gradually obtain statements indicating that they are
moderately or severely depressed. Inevitably, this admission is accompanied

by the disclaimer, “I would be fine if only I was free of my physical illnesses.”

Once the patient admits to being depressed, one can readily elicit the

presence of feelings of hopelessness. This admission can usually be brought

out by questions such as, “Do you ever feel as though you will never get
better?” A question that brings a positive response in almost half of the

patients is “Do you ever feel as though you would like to go to bed and not

awaken the next morning?” The usual response is “If I have to suffer like this,

life isn’t worthwhile.”

One study found that more than two-thirds of the patients expressed

feelings of hopelessness. Even more startling was the observation that 44.5

percent had suicidal preoccupations or drives. This is evidence of the fact that
depression masked by hypochondriasis or psychosomatic disorders is usually

of severe proportions by the time the patient is referred for neuropsychiatric

consultation. It is crucial that the intensity and imminency of these suicidal

ideas be studied carefully. A number of patients examined by the author for

the first time were actively contemplating suicide.

If the psychiatric or nonpsychiatric physician is patient and gentle in the

history taking, a close correlation between the onset of the patient’s

American Handbook of Psychiatry - Volume 7 31

symptoms and her or his emotional traumas can often be discerned. This
requires a step-by-step account of the patient’s life situation prior to, during,

and following the onset of the “somatic” symptoms. In some instances, specific

environmental traumas cannot be documented. However, even if this is the

case, careful evaluation will elicit the fact that the patients had been under
chronic and severe stress with which they had difficulty coping.

Personality Patterns

The patients’ personality patterns are rather consistent. They are

typically aggressive, perfectionist, and highly intelligent individuals who have

a need to dominate their environment. Characteristically, they are rigid and

inflexible in their management of everyday life. In addition, they are

overbearing and verbally critical of most people. These attitudes frequently

alienate those around them. It can be stated that their compulsive need to
dominate their surroundings is an attempt to compensate for feelings of self-

derogation and inadequacy.

Although many of these patients, most of whom are women, are leaders
in their communities and claim many close friendships, most of the so-called

friends are usually just working acquaintances. By the time the patients are

seen in initial psychiatric consultation, they are quite seclusive and are unable

to function effectively vocationally, socially, or sexually. They usually express

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fears of being alone, strong guilt feelings related to their inability to function,
and confess to a lack of sexual desires. A marked feeling of worthlessness is a

characteristic clinical observation.

Family History

The family histories are also quite characteristic. Usually one or both
parents are described as being very aggressive and perfectionistic. One study

reported that 82 percent of these patients described their mothers as the

dominant individual in the home. The mother was often characterized as

being an “attentive martyr,” while the father was a rather passive, dependent
personality dominated by the mother. Frequently, the patient’s mother was

hypochondriacal, phobic, or had a history of psychosomatic disorders. In

many instances, the description of the mother indicated that she had

referential trends. Characteristically, there is a history of a running conflict

between the patient and his or her mother; this relationship universally

generated marked guilt feelings in the patient.

From a psychodynamic standpoint these patients develop feelings of

inadequacy and worthlessness beginning in early childhood. This is in

response to the parents’ real or imagined rejection. These feelings grow in

crescendo fashion and color the patient’s vocational and social relationships

through the years. They are plagued by the anticipation that parental

American Handbook of Psychiatry - Volume 7 33

surrogates and peers might have the same negative image that they have of
themselves.

These patients spend their lives compensating for feelings of inadequacy

by a high level of performance. There is a constant struggle for self-

recognition. They usually are highly critical of others (in scapegoat fashion) in

an attempt to deny their own feelings of inadequacy.

There is often a history of overreacting to even mild physical illnesses.

The physical ailments are a threat to the patient’s constant attempts to

compensate for her feelings of inadequacy. Furthermore, if one or both of the

parents had been hypochondriacal, the patient tends to mimic the parents’

particular hypochondriacal complaints.

Treatment

The treatment of choice for patients with masked depressions, when the
underlying depression is severe, is a combination of antidepressant drug

therapy and appropriately designed, psychoanalytically oriented

psychotherapy.

The results of treatment depend upon a number of factors, including:

duration of illness, amount and nature of prior medical treatment (prior drug

therapies and surgical procedures), and the organ system involved. Patients

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with problems associated with the head and face, mammary glands, or

genitourinary system are more difficult to treat for reasons that are not
entirely clear at this time.

Considered as a group, more than 75 percent of those patients in whom

the depression is masked by hypochondriacal complaints or psychosomatic

disorders obtain excellent results if the illness is of less than one year’s

duration (“excellent” meaning that their symptoms disappear, the level of

psychomotor activity becomes appropriate, and they are able to function

vocationally and socially with pride and pleasure). Approximately 50 percent

of those patients who have been ill for less than two years and who do not
have strong iatrogenic overlay secondary to surgical procedures obtain

excellent or good results during the initial period of therapy.

When a patient has been ill for more than two years, particularly if he or
she is plagued by marked iatrogenic complications resulting from prior drug

or mechanical therapies, it is difficult to predict how successful the combined

therapeutic technique will be. Overall, approximately one-third of such

patients obtain excellent or good results from combined therapy. While one
cannot be so certain of the results that will be obtained in more chronic

patients, excellent individual responses have been obtained in some who have

been ill for as long as twenty-five to thirty years.

American Handbook of Psychiatry - Volume 7 35

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