Internalizing disorders as shape-shifters: Understanding individual and cultural heterogeneity in the presentation of symptoms

Contemporary psychopathology is grounded in the assumption that diagnostic categories are characterized by discrete sets of individual symptoms. As such, considerable resources have been invested over the past half-century to identify and refine these sets. There is a counter-tradition, however, that emphasizes symptom heterogeneity, especially for the internalizing disorders. This heterogeneity can be observed both within individual sufferers and across groups of sufferers in different sociocultural contexts. Rather than understanding this heterogeneity as a problem in need of a solution, we argue that variability in symptom presentation is an essential feature of internalizing distress: these disorders are, in their essence, shape-shifters. We begin by describing examples of similarities and differences in internalizing distress across cultural-historical contexts. Then, we address the complex nature of symptoms as physiological, psychological, and cultural phenomena that are experienced, interpreted, remembered, and anticipated, highlighting potential mechanisms of heterogeneity at each level of analysis. As this heterogeneity is not boundless, we also consider constraints that afford more uniform presentations and stabilize historical changes. The literature on the cultural shaping of psychological functioning is recruited throughout to illustrate the ways to conceptualize and study symptom heterogeneity. Understanding these disorders as shape-shifters has the potential to transform our approach to psychopathology, bringing a rapidly-growing literature on individual and cultural-historical variation to the very center of how we conceptualize internalizing distress.