Culture in the DSM-5

This chapter focuses on the revision of the DSM-IV to DSM-5, including an increased emphasis on the role of culture in psychopathology. The DSM-5, published in 2013, includes a revision of DSM-IV’s Outline for Cultural Formulation and includes the newly added standardized and manualized Cultural Formulation Interview (CFI), the 12 supplementary modules to the CFI, and a Glossary of Cultural Concepts of Distress. With these changes, DSM-5 strives to provide clinicians with a practical interpretive framework to explore patients’ varied experiences and expression of mental distress, increasing the clinical significance of each patient’s ethnic and cultural context. This chapter explores these additions to and revision of the DSM-5, reviews some of its criticism, and offers best practices for using these tools in the evaluation and management of diverse patients.

The Cultural Formulation Interview: Progress to date and future directions

10.1177/1363461520938273 ◽

2020 ◽

Vol 57 (4) ◽

pp. 487-496

Author(s):

Roberto Lewis-Fernández ◽

Neil Krishan Aggarwal ◽

Laurence J. Kirmayer

Keyword(s):

Cultural Context ◽

Help Seeking ◽

Scale Up ◽

Implementation Strategies ◽

Cultural Formulation ◽

Treatment Expectations ◽

Future Directions ◽

Dsm 5 ◽

The Cultural Formulation Interview (CFI) developed for DSM-5 provides a way to collect information on patients’ illness experience, social and cultural context, help-seeking, and treatment expectations relevant to psychiatric diagnosis and assessment. This thematic issue of Transcultural Psychiatry brings together articles examining the implementation and impact of the CFI in diverse settings. In this editorial introduction we discuss key areas raised by these and other studies, including: (1) the potential of the CFI for transforming current psychiatric assessment models; (2) training and implementation strategies for wider application and scale-up; and (3) refining the CFI by developing new modules and alternative protocols based on further research and clinical experience.

The Cultural Formulation Interview since DSM-5: Prospects for training, research, and clinical practice

10.1177/1363461520940481 ◽

2020 ◽

Vol 57 (4) ◽

pp. 496-514 ◽

Cited By ~ 1

Author(s):

Neil Krishan Aggarwal ◽

G. Eric Jarvis ◽

Ana Gómez-Carrillo ◽

Laurence J. Kirmayer ◽

Roberto Lewis-Fernández

Keyword(s):

Clinical Practice ◽

Social Science Research ◽

Science Research ◽

Cultural Dimensions ◽

Cultural Formulation ◽

Simplified Approach ◽

Clinician Training ◽

Dsm 5 ◽

Training Research ◽

While social science research has demonstrated the importance of culture in shaping psychiatric illness, clinical methods for assessing the cultural dimensions of illness have not been adopted as part of routine care. Reasons for limited integration include the impression that attention to culture requires specialized skills, is only relevant to a subset of patients from unfamiliar backgrounds, and takes too much time to be useful. The DSM-5 Cultural Formulation Interview (CFI), published in 2013, was developed to provide a simplified approach to collecting information needed for cultural assessment. It offers a 16-question interview protocol that has been field tested at sites around the world. However, little is known about how CFI implementation has affected training, health services, and clinical outcomes. This article offers a comprehensive narrative review that synthesizes peer-reviewed, published studies on CFI use. A total of 25 studies were identified, with sample sizes ranging from 1 to 460 participants. In all pilot CFI studies 960 unique subjects were enrolled, and in final CFI studies 739 were enrolled. Studies focused on how the CFI affects clinical practice; explored the CFI through research paradigms in medical communication, implementation science, and family psychiatry; and examined clinician training. In most studies, patients and clinicians reported that using the CFI improved clinical rapport. This evidence base offers an opportunity to consider implications for training, research, and clinical practice and to identify crucial areas for further research.

How Do Clinicians Prefer Cultural Competence Training? Findings from the DSM-5 Cultural Formulation Interview Field Trial

Academic Psychiatry ◽

10.1007/s40596-015-0429-3 ◽

2015 ◽

Vol 40 (4) ◽

pp. 584-591 ◽

Cited By ~ 18

Author(s):

Neil Krishan Aggarwal ◽

Peter Lam ◽

Enrico G. Castillo ◽

Mitchell G. Weiss ◽

Esperanza Diaz ◽

...

Keyword(s):

Cultural Competence ◽

Field Trial ◽

Cultural Formulation ◽

Dsm 5 ◽

Competence Training ◽

The cross-cultural assessment of migrants

Oxford Textbook of Migrant Psychiatry ◽

10.1093/med/9780198833741.003.0031 ◽

2021 ◽

pp. 275-280

Author(s):

Neil Krishan Aggarwal

Keyword(s):

Assessment Tool ◽

Cross Cultural ◽

Immigrants And Refugees ◽

Dsm 5 ◽

Healthcare Settings ◽

Common Definition ◽

Mental Health Settings ◽

Treatment Plans ◽

Dsm Iv ◽

For close to 40 years, cultural psychiatrists have struggled to institutionalize cross-cultural assessments with the recognition that culture influences ideas about desired and undesired treatments, social norms of appropriate and inappropriate communication in healthcare settings, and the ways that clinicians interpret symptoms into diagnoses. This chapter first establishes a common definition for the terms ‘culture’ and ‘migrant’, which can be used in mental health settings. Next, it traces how the care of migrants formed a central concern as psychiatrists, psychologists, and anthropologists made cultural recommendations for DSM-IV and DSM-5. Finally, the chapter discusses the DSM-5 Cultural Formulation Interview Supplementary Module for Immigrants and Refugees as a clinical assessment tool that can help clinicians ask patients about their backgrounds; pre-migration-, and post-migration trajectories; resettlement life; and plans for the future. This supplementary module may help clinicians systematically and comprehensively develop diagnostic assessments and treatment plans for immigrants and refugees in a patient-centred way.

DSM-5® Handbook on the Cultural Formulation Interview

10.1176/appi.books.9781615373567 ◽

2015 ◽

Cited By ~ 18

Author(s):

Roberto Lewis-Fernández ◽

Neil Krishan Aggarwal ◽

Ladson Hinton ◽

Devon E. Hinton ◽

Laurence J. Kirmayer

Keyword(s):

Cultural Formulation ◽

Dsm 5 ◽

Does the Cultural Formulation Interview for the fifth revision of the diagnostic and statistical manual of mental disorders (DSM-5) affect medical communication? A qualitative exploratory study from the New York site

Ethnicity and Health ◽

10.1080/13557858.2013.857762 ◽

2013 ◽

Vol 20 (1) ◽

pp. 1-28 ◽

Cited By ~ 41

Author(s):

Neil K. Aggarwal ◽

Ravi Desilva ◽

Andel V. Nicasio ◽

Marit Boiler ◽

Roberto Lewis-Fernández

Keyword(s):

New York ◽

Mental Disorders ◽

Exploratory Study ◽

Cultural Formulation ◽

Medical Communication ◽

Statistical Manual ◽

Diagnostic And Statistical Manual ◽

Dsm 5 ◽

Training on the DSM-5 Cultural Formulation Interview improves cultural competence in general psychiatry residents: A pilot study

10.1177/1363461517700812 ◽

2017 ◽

Vol 54 (2) ◽

pp. 179-191 ◽

Cited By ~ 10

Author(s):

Stacia Mills ◽

Anna Q. Xiao ◽

Kate Wolitzky-Taylor ◽

Russell Lim ◽

Francis G. Lu

Keyword(s):

Cultural Competence ◽

Cultural Diversity ◽

Assessment Tool ◽

Cultural Knowledge ◽

Psychiatry Residents ◽

Cultural Formulation ◽

Dsm 5 ◽

General Psychiatry ◽

The Mean ◽

The objective of this study was to assess whether a 1-hour didactic session on the DSM-5 Cultural Formulation Interview (CFI) improves the cultural competence of general psychiatry residents. The main hypothesis was that teaching adult psychiatry residents a 1-hour session on the CFI would improve cultural competence. The exploratory hypothesis was that trainees with more experience in cultural diversity would have a greater increase in cultural competency scores. Psychiatry residents at a metropolitan, county hospital completed demographics and preintervention questionnaires, were exposed to a 1-hour session on the CFI, and were given a postintervention questionnaire. The questionnaire was an adapted version of the validated Cultural Competence Assessment Tool . Paired samples t tests compared pre- to posttest change. Hierarchical linear regression assessed whether pretraining characteristics predicted posttest scores. The mean change of total pre- and posttest scores was significant ( p = .002), as was the mean change in subscales Nonverbal Communications ( p < .001) and Cultural Knowledge ( p = .002). Demographic characteristics did not predict higher posttest scores (when covarying for pretest scores). Psychiatry residents’ cultural competence scores improved irrespective of previous experience in cultural diversity. More research is needed to further explore the implications of the improved scores in clinical practice.

Cultural Formulation Interview

Encyclopedia of Social Work ◽

10.1093/acrefore/9780199975839.013.1245 ◽

2020 ◽

Author(s):

Dorie Gilbert ◽

Katarzyna Olcoń

Keyword(s):

Mental Health ◽

Social Work ◽

Cultural Context ◽

Help Seeking ◽

Cultural Factors ◽

Cross Cultural ◽

Cultural Formulation ◽

Factors Affecting ◽

Cultural Assessment ◽

Research indicates that practitioners’ cultural biases are a barrier to effective cross-cultural assessment; thus, social work practitioners must demonstrate the ability to appraise a client’s cultural context in assessing and treating mental health concerns. The Cultural Formulation Interview (CFI) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides practitioners with a standardized cultural assessment method for use in mental health practice. This article provides a comprehensive overview of the CFI with a focus on its four domains: (a) cultural definition of the problem; (b) cultural perception of cause, context, and support; (c) cultural factors affecting self-coping and past help-seeking; and (d) cultural factors affecting current help-seeking. Conceptualizations of mental health and mental illness vary across cultural subgroups, and the nation’s changing demographics underscore the need to give particular attention to how the CFI can be useful for improving cross-cultural assessment with historically excluded or marginalized racial and ethnic groups. The CFI is an important step towards culturally grounded assessments; however, it has several conceptualization and implementation limitations, including its narrow focus on individual-level cultural explanations of distress while the effects of social inequities remain masked. The article concludes with additional considerations for cross-cultural assessment and implications for social work education and practice.

Using the Cultural Formulation Interview in Denmark: Acceptability and clinical utility for medical doctors and migrant patients

10.1177/1363461520935673 ◽

2020 ◽

Vol 57 (4) ◽

pp. 556-566 ◽

Cited By ~ 2

Author(s):

Signe Skammeritz ◽

Laura Glahder Lindberg ◽

Erik Lykke Mortensen ◽

Marie Norredam ◽

Jessica Carlsson

Keyword(s):

Social Context ◽

Cultural Context ◽

Clinical Utility ◽

Middle Eastern ◽

Clinical Encounter ◽

Health Clinic ◽

Diagnostic Process ◽

Medical Doctors ◽

Cultural Formulation ◽

Previous studies have shown the importance of focusing on the cultural background of migrant patients in the psychiatric assessment. The Cultural Formulation Interview (CFI) offers a patient-focused approach to foreground the cultural context of the patient in the clinical encounter. Our objective was to explore the acceptability and clinical utility of the CFI for physicians and its acceptability for migrant patients seen at a transcultural mental health clinic in Denmark. In this study, the CFI was used in a second session following the standard clinical assessment to explore what additional information was gained from the CFI. Data on the use of the CFI data were collected immediately after the interview with questionnaires for medical doctors (MDs) ( N = 12) and patients ( N = 71). The findings showed that the CFI, in addition to standard assessment, was useful to the MDs for planning the treatment (60.0%) and for exploring the patients’ view on their cultural and social context (74.7%), but less so for the diagnostic process (9.9%). Patients reported high overall satisfaction with the CFI (93.0%) and viewed it as a welcome opportunity to tell their story. The findings add to existing knowledge on the CFI in terms of acceptability for patients of a primarily Middle Eastern origin and patients using an interpreter during the CFI session. Based on the findings of this study, the CFI is recommended to clinicians for treatment planning purposes and for exploring the cultural and social context of the patient.

The Content Validity of the Cultural Formulation Interview (CFI)

Psychiatry Journal ◽

10.1155/2018/3082823 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6

Author(s):

Behnam Shariati ◽

Amir-Abbas Keshavarz-Akhlaghi ◽

Arash Mohammadzadeh ◽

Ruohollah Seddigh

Keyword(s):

Content Validity ◽

Help Seeking ◽

The United States ◽

Cultural Factors ◽

Cultural Formulation ◽

Factors Affecting ◽

Cultural Perception ◽

Dsm 5 ◽

Back Translation ◽

Aims. The present study investigates content validity of the open-ended items in Cultural Formulation Interview in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Methods. After translating into Persian and assessing the content validity of the items and their modification by psychiatrists, the questionnaire was translated back into English by two translators and then retranslated into Persian. The final Persian version and its back-translation were submitted for approval to the DSM-5 design workshop in the United States. After obtaining the group’s approval on the back-translation and permission to use the questionnaire, samples were distributed among panel members and the content validity of the questionnaire was thus examined. Results. The content validity index (CVI) of cultural formulation interview was 0.51 and all the items were acceptable although some, especially those on the cultural perception of the context and the cultural factors affecting current help-seeking, had lower content validity ratios (CVR). Conclusion. The cultural formulation interview seems to have an overall acceptable content validity although it is weak and thus needs further studies in relation to the two domains of the cultural perception of the context and the cultural factors affecting help-seeking in the Iranian population.