Culture, depression, and somatization: A tale of two paradigms

Decades of cross-cultural research have documented a distinctive form of psychopathology among depressed non-western patient populations characterized by a number of somatic symptoms such as headache and gastrointestinal discomfort in response to psychological distress. This symptom profile is known as somatization. The presence of somatization among non-western patients differs from western concepts of depression where psychological symptoms (e.g. sad mood) are more prevalent in response to psychological distress. This distinct difference in the clinical presentation of depression among non-western and western patients highlights a critical issue regarding the utility of current diagnostic practices across cultures. For example, researchers have argued that contemporary diagnostic practices based on a traditional classification system are founded on a western biomedical model of illness that reduces genuine psychopathology to underlying physiological mechanisms. Under this model, psychopathology is universal. However, there is evidence to suggest that psychopathology may be relative to culture. These arguments highlight two fundamental paradigms—universalist and relativist—which are relevant to understanding the presence of somatization among non-western patients experiencing psychological distress. According to the universalist paradigm, people experience the same psychopathology after cultural influences are accounted for, regardless of culture. Following this assumption, the somatic symptoms reported by non-western depressed patients are merely the result of cultural values and when accounted for, these patients exhibit the same psychopathology as those in the western cultures. In contrast, the relativist paradigm asserts that psychopathology is woven within the fabric of culture. Beliefs, rituals, and other cultural influences affect the phenomenology of psychopathology. Thus, under the relativist paradigm somatization may represent a culture-bound illness that is qualitatively different from depression as experienced in western cultures. Allegiance to either the universalist or relativist paradigms has important implications for research, treatment, and diagnosis. For example, proponents of the universalist paradigm may be inclined to offer a conventional treatment for depression to a non-western patient presenting with somatic symptoms in conjunction with psychological distress because the somatic complaints are essentially a product of the patient’s culture. On the other hand, those ascribing to the relativist perspective may be inclined to treat a non-western patient who exhibits the same symptoms with a therapy that is based on the value systems within the patient’s cultural context. Given the implications of each paradigm this paper reviews the dialogue surrounding three prevalent explanatory models pertaining to non-western somatization—assessment modality, alexithymia, and language—within the context of each paradigm. I argue that the explanations provided by research investigating the effects of assessment modality and alexithymia on somatization among non-western depressed patients are dominated by the universalist paradigm. Regarding the literature surrounding the role language plays in understanding somatization and the psychopathology of depression, a number of researchers offer compelling evidence in support of the relativist paradigm. Paradigms play a critical role in understanding the nature of psychopathology. Therefore, researchers and clinicians working with diverse patient populations need to consider the implications of their allegiance to either paradigm. Suggestions are offered for future research on the topic of somatization among non-western patients