Outline for Cultural Formulation in DSM-5

A Culture of Diagnostics – Professional
knowledge and cultural contexts
Oslo Akershus University
The Cultural Formulation – an
attempt to introduce cultural
awareness to clinical psychiatric
Sofie Bäärnhielm, MD, PhD
Outline of presentation
Discuss the Cultural Formulation (CF)
• The Swedish context
• Clinical challenges
• Our interest in the CF in DSM-IV and 5
• A case presentation
Some facts about Sweden
15.1% born in another country
19.1% including two parents born abroad
Main country of origin Finland 166 723
Iraq 125 499 (2011)
Mental health care in Sweden
• Meet refugees and immigrants - from all
over the world
• A variety in expressions of distress
• A variety in expectations of help and
Mental health care in Sweden
• Much epidemiological data on inequalities
in health
• Poor adaption of the health and mental
health care system to cultural diversity
• Mental health care is working in a context
of increasing social segregation
Example of a multicultural
suburban area
• Rinkeby 89.3% foreign born background
• At the top of all ill health, disability and
poor income index lists…..
…… but not regarding alcohol
Clinical challenges - my
• Difficult to understand patients’
expressions of distress
• Difficult to make meaningful diagnostic
• Sometimes able to help patients
sometimes not – random
• To summarize: our way of working is not
good enough
Outline for a Cultural Formulation in
DSM-IV, Appendix I
”mini-ethnographic”, narrative assessment
(Lewis-Fernández, 1996).
Outline for Cultural Formulation in
The CF in DSM-IV, culture related to:
• Identity
• Conceptualization of distress
• Psychosocial stressors and cultural
features of vulnerability and resilience
• Features of the relationship between the
individual and the clinician
• Overall assessment
Outline for Cultural Formulation
in DSM-5
Included in Section III
Emerging Measures and Models
pp. 749-757
Cultural Formulation Interview (CFI)
CFI –Informant version
Supplementary Modules
The Cultural Formulation Interview
• 16 questions
Any patient, any setting, especially:
• cases of social and cultural differences
• difficulties evaluating symptoms
• difficulties evaluating severity and
• disagreement over course of care
• limited engagement in treatment
The Cultural Formulation Interview
Cultural definition of the problem
1. What brings you here today?
The Cultural Formulation Interview
Cultural definition of the problem
1. What brings you here today?
invites further information and probing of:
- the patient’s view
- the patient’s illness understanding
- cultural and contextual factors
Supplementary modules
1. Explanatory Model
2. Level of Functioning
3. Social Network
4. Psychosocial Stressors
5. Spirituality, Religion, and Moral Traditions
6. Cultural Identity
Supplementary modules
7. Coping and Help-Seeking
8. Patient–Clinician Relationship
9. School-Age Children and Adolescents
10. Older Adults
11. Immigrants and Refugees
12. Caregivers
On the Web
Interview guide – contextualising
the CF
• Research on the CF in DSM-IV
• Interview guide
Bäärnhielm, Scarpinati Rosso, 2009
Scarpinati Rosso, Bäärnhielm, 2012
A case: background
- some details changed to protect confidentiality
• Affaf 28-year-old women from Iraq, a 3year-old son
• Referred from primary care to a psychiatric
outpatient clinic
• Depression?
Psychiatric interview
• Conducted using a female Arabic
• Came to Sweden to marry a man she did
not know
• Her GP has prescribed anti-depressive
medication – she has not followed the
Psychiatric interview
• Social problems: no work, no network,
divorced, little money, rejected by her
family in Iraq, isolates herself, does not
understand Swedish
• Complicated family situation – her family in
Iraq do not accept her divorce
• She says that she feels hopeless
• Denies trauma and PTSD symptoms
Preliminary diagnosis
• Adjustment Disorder with Depressed
Mood 309.0 (?)
• Depressed mood?
• Is distress a reaction to a demanding
social and family situation?
1. What brings you here today?
Swedish: Vad har du för besvär?
Norwegian: Hva slags plager har
Affaf responds by talking about:
Tired, worried, brooding, lacks energy
Further details of how complicated the
divorce situation was
Struggles with herself to take care of her son
Often sits alone in a dark room
Has grown to like the darkness of the
Swedish winter - mirrors her mood
2. How would you describe your
problem to your family?
She has not told her family about her problems.
She does not want them to know. She has told
them that she is tired, has become ill, has sleeping
problems and that she sometimes cannot eat.
4. What do you think are the causes of
your [problem]?
Her divorce has impaired her relation with
her parents and relatives (in Iraq)
Feels punished by relatives because she
has betrayed her own traditions
7. Is there any kind of stress that
makes your [PROBLEM] worse, such
as difficulties with money, or family
Affaf responds by talking about:
Her family’s view and says:
”A woman is not allowed to divorce. A
women is not allowed to live alone. A women
has to endure everything”
She feels pressured by the family
She is afraid of the family
The CFI Supplementary Module
11. Immigrants and refugees
Aims to explore:
Experiences of migration and resettlement
Affaf responds by talking about:
• Her father arranged the marriage – made
migration possible to escape Iraq
• Knew nothing about Sweden when she
• Migration – no trauma
• Returned to Iraq to negotiate with the
family about the divorce (did not help)
Witnessed bombings
People dying, mutilated corpses
Recurrent visions of maimed people
Avoided situations triggering these
• Going back to Sweden, the Iraqi border
was closed
• Succeeded in returning to Sweden through
great creativity and personal strength
Asks the interviewer
”Why do I sometimes think about
Clinical benefits of the CFI in this
• identifying a depressed mood
• evaluating severity and impairment
• identifying personal resources &
symptoms of PTSD
Diagnosis was revised to: Major Depressive
Disorder, single episode, Moderate, 296.22
PTSD 309.81
Clinical benefits of the CFI in this
Improved understanding of:
• context
• culture and traditions affecting her
• her illness perspective
• the family’s view
• identified a depressed mood
revised diagnostic evaluation
Possible clinical benefits of the CFI
Improved understanding of:
• culture and context in an individualised
• frames of normality
• meaning of symptoms
• severity & impairment
• cultural stressors and resilience factors
Canadian study on the CFI (DSM-IV) –
psychotic patients
• Misdiagnosis for psychotic patients
occurred with patients from all
ethnocultural groups, especially recently
settled immigrants.
After using the CF, 49% of the patients with
an intake diagnosis of psychotic disorder
were re-diagnosed as non-psychotic and 5
% of the patients with a referral diagnosis of
non-psychotic disorder were diagnosed as
having a psychotic disorder.
Adeponle, A.B., Thombs, B.D., Groleau, D., Jarvis, E., Kirmayer, L.J. (2012).
Using the Cultural Formulation to Resolve Uncertainty in Diagnoses of
Psychosis Among Ethnoculturally Divers patients. Psychiatric Services, 63(2),
Swedish study – non psychotic
• Adding the CF to ordinary psychiatric
diagnosing led to major revisions of
diagnosis for 56%
• Anxiety disorders, especially PTSD
Bäärnhielm, Åberg Wistedt, Scarpinati Rosso (in press) Revising psychiatric
diagnostic categorisation of immigrant patients after using the Cultural
Formulation in DSM-IV, Transcultural psychiatry.
The Outline for a Cultural
May be a method to:
- improve cultural awareness in clinical
psychiatric diagnosing
- gain an insight in patients’ meanings and
context related to illness
- improve the diagnostic evaluation
The Swedish context
• The inclusion of the CFI in DSM makes
this type of mini-ethnographic work and
research socially acceptable within
Swedish psychiatry
The Swedish context
• In a situation of constant cut backs of
• Increasingly more manualised
/standardised psychiatric care
Thanks for your attention!
[email protected]

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