Stigma and somatisation

In their exhaustive review of the impact of globalisation and culture on depression, Bhugra & Mastrogianni (2004) highlight the role of somatisation in many parts of the world, where it often accounts for ‘common presenting features of depression’ (p. 16). Emphasising both the ubiquity and cultural aspects of somatisation, they cite an earlier characterisation of common mental disorders that refers to the ‘black box of somatisation’ (Bhui, 1999). In doing so, however, they miss an important explanatory feature of this process with substantial practical and clinical significance - that is, the role of stigma. Despite increasing availability of effective treatments, many people with depression (perhaps even a majority) do not seek professional help because of the stigma associated with the illness. Efforts to clarify the impact of stigma are crucial for explaining cultural aspects of illness-related experience and meaning, and highly relevant for planning interventions that are culturally appropriate and locally effective.

As one effort towards elucidating the experience of depression, in a study in Bangalore, India, we examined the role of self-perceived stigma (Raguram et al, 1996). We found that greater severity of depression was associated with higher stigma scores, but more somatisation was associated with less stigma. Through qualitative analysis of patients' narratives, we also demonstrated that patients viewed depressive, but not somatic, symptoms as socially disadvantageous. Somatic symptoms were considered to be less stigmatising since they resembled illness experiences that most people could expect to have from time to time. Consequently, studying the work of culture clarifies the nature of somatisation. From a Western vantage point, somatisation may appear enigmatic, but attention to stigma helps to illuminate the internal structure of the black box.