1. health and fitness
2. disorders
3. mental disorder
4. panic and anxiety

Culture and DSM-5
Transkulturellt Centrum
November 8, 2013
Roberto Lewis-Fernández, MD
Professor of Psychiatry, Columbia University Medical Center
Director, NYS Center of Excellence for Cultural Competence
and Hispanic Treatment Program
New York State Psychiatric Institute
Overview
Main point: Culture-related changes in DSM-5
help enhance the cultural validity of
diagnostic practice
• Inclusion of culture in DSM-5
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Section I: Introduction
Section II: Disorders
Section III: Cultural formulation
Appendix: Glossary of Cultural Concepts of Distress
Inclusion of culture in DSM-5
Wish list for DSM-5
• Provide clear definitions and explain value of cultural
approach to diagnostic practice
• Include missing symptom variants in disorder criteria
• Provide more guidance in text about cultural issues
• Make Cultural Formulation more implementable
• Revise “Glossary of Culture-Bound Syndromes”
Section I
DSM-5 Basics
Introduction
Overview of culture:
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•
•
Interpretive framework for symptoms, signs, behaviors
Transmitted, revised, and recreated within families and society
Affects boundaries between normality and pathology, thresholds
of tolerance, coping, and interpretations of need for help
Awareness of impact of culture may reduce misdiagnosis
Culture may help determine support and resilience
By contrast, may contribute to vulnerability and stigma
Helps shape the clinical encounter
Affects help-seeking choices, adherence, course, recovery
Outline of cultural material in DSM-5
Revision of “culture-bound syndrome” concept
Cultural Concepts of
Distress
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Cultural idioms of distress
Cultural syndromes
Cultural explanations
Section II
Essential Elements:
Diagnostic Criteria and Codes
Changes to criteria
Add missing symptom variants
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Panic Attack
Social Anxiety Disorder
Posttraumatic Stress Disorder
Dissociative Identity Disorder
Other Specified Dissociative Disorder
Anorexia Nervosa
Changes to criteria
Contextualize presentations
Specific Phobia, Agoraphobia, Social Anxiety Disorder
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The fear or anxiety is out of proportion to the actual
threat posed by the [PHOBIC STIMULUS] and to the
sociocultural context
“De-specify” criteria/boost cross-disorder links
•
•
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•
Acute Stress Disorder
Panic Attack
Anxiety Specifier for Mood Disorders
Schizophrenia Subtypes/ Catatonia Specifier
Alternate criteria for Personality Disorders
Missing symptoms
Panic attack
Should we revise the list of Panic Attack
symptoms to include missing cultural
variants?
Panic attack symptoms
Cambodians with panic attacks (N=100)
Dizziness
Shortness of breath
Flushes/chills
Trembling/shaking
Tinnitus
Fear of death
Numbness/tingling
Sweating
Chest pain/discomfort
Neck soreness
Palpitations
Nausea
Headache
Choking
Fear of losing control/going crazy
Derealization/depersonalization
0%
20%
40%
60%
80%
100%
Hinton et al., 2010
Missing symptoms
Panic attack
Note: Culture-specific symptoms (e.g., tinnitus,
neck soreness, headache, uncontrollable
screaming or crying) may be seen. Such
symptoms should not count as one of the four
required symptoms.
Changes to text
description
Changes to criteria described in Diagnostic Features
Cultural variation in Prevalence
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12-month prevalence in the US
Range of prevalence internationally
Variation by race/ethnicity
Culture-related risk and prognostic factors
Separate section on Culture-Related Diagnostic Issues
•
•
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Cultural variations in onset, severity, symptom expression
Relationship to cultural concepts of distress
Risk factors
PTSD
Should we include cultural variability in
the risk of onset of PTSD after traumatic
exposure?
Risk factors
% meeting all PTSD criteria
PTSD Onset after Hurricane Andrew (N=404)
*
60
50
50
38
40
31
30
16 18
20
10
9
Non-Hispanic
White
Non-Hispanic
Black
21
10 10
Latino-Spanish
0
Low
Moderate
Personal Trauma
Includes only significant effects on PTSD from SEM
High
*p<.05
Perilla et al., 2002
Risk factors
PTSD
Risk and prognostic factors
Environmental: …cultural characteristics (e.g.,
fatalistic or self-blaming coping strategies)… minority
racial/ethnic status…
Culture-related diagnostic issues
Risk of onset and severity of PTSD may differ across
cultural groups as a result of variation in:
▫ Other cultural factors (e.g., acculturative stress)
Section III
Emerging Measures and Models
Cultural Formulation
DSM-IV Cultural Formulation
A. Cultural Identity
Cultural reference group(s)
Language
Cultural factors in
development
Involvement with culture of
origin and host/majority
culture
B. Cultural Explanations
of Illness
Idioms of distress and local
illness categories
Meaning and severity
Causes and explanatory
models
Help-seeking experiences and
plans
C. Cultural Factors Related
to Psychosocial
Environment and Levels of
Functioning
Social Stressors
Social Supports
Levels of functioning and
disability
D. Cultural Elements of the
Clinician-Patient
Relationship
Perceived similarities and
differences
E. Overall Cultural
Assessment
Applying information to
diagnosis and treatment
Revision of the
Cultural Formulation
DSM-IV
Limitation
DSM-5 Solution
Lack of
operationalization
•Cultural Formulation Interview (CFI)
Limited guidance
•Use at beginning of initial evaluation
•16 standardized questions in 4 sections
•Apply with all patients
Risk of stereotyping
•Person-centered approach
•Collaborative, shared decision making
CFI structure
CFI sections
1. Cultural definition of the problem* (#1-3)
2. Cultural perceptions of cause, context, and
support
A. Causes* (#4-5)
B. Stressors and supports (#6-7)
(e.g., kinds of support that make problem better)
C. Role of cultural identity (#8-10)
(e.g., aspects of background or identity that make a
difference to your problem)
*Explores role of “family, friends, or others in your community”
CFI sections
3. Cultural factors affecting self-coping and
past help seeking
A. Self-coping (#11)
B. Past help seeking (#12)
C. Barriers to care (#13)
CFI sections
4. Cultural factors affecting current help
seeking
A. Preferences for care* (#14-15)
B. Clinician-patient relationship (#16)
(“Sometimes doctors and patients misunderstand each other
because they come from different backgrounds or have
different expectations.
Have you been concerned about this and is there anything
that we can do to provide you with the care you need?”)
*Explores role of “family, friends, or others in your community”
Glossary of Cultural
Concepts of Distress
DSM-IV & Caribbean
cultural concepts
Major Depression
GAD
Ataques de nervios
Altered perceptions
PTSD
Panic Disorder
Schizophrenia
Dissociative Disorder NOS
Undiff. Somatoform D/o
Borderline Personality D/o
Suffer from nerves
Be sick with nerves
Be loco
Have facultades
Suffer from a demon
Be nervous since
childhood
Examples
Includes description, DSM differential diagnosis, related categories in other
cultures, and sometime prevalence/distribution
Concept
Main Type
Region
Ataque de nervios
Syndrome
Latin America
Dhat syndrome
Explanation
South Asia
Khyal cap
Syndrome
Cambodia
Kunfungisisa
Idiom
Zimbabwe
Maladi moun
Explanation
Haiti
Nervios
Idiom
Latin America
Shenjing shuairuo
Syndrome
China
Susto
Explanation
Latin America
Taijin kyofusho
Syndrome
Japan/Korea
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright
© 2013). American Psychiatric Association. All rights reserved
Differential diagnosis
Ataque de nervios
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Panic attack
Panic disorder
Other specified anxiety disorder
Other specified dissociative disorder
Other specified trauma- and stressor-related disorder
Conversion (functional neurologic symptom) disorder
Intermittent explosive disorder
V code
Normal reaction to adversity
Conclusions
Completed wish list
• Provide clear definitions and explain value of cultural
approach to diagnostic practice
• Include missing symptom variants in disorder criteria
• Provide more guidance in text about cultural issues
• Make Cultural Formulation more implementable
• Revise “Glossary of Culture-Bound Syndromes”
Cultural inclusions in
DSM-5
Enhance validity of diagnostic criteria and text
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Reduce over-specification and de-contextualization of
diagnoses
Provide information on risk, severity, course
Clarify relationship between diagnoses and cultural
concepts of distress
Provide systematic cultural evaluation in CFI
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For use with every patient
Person-centered to avoid stereotyping
Operationalized and implementable
To guide assessment and treatment negotiation
Ultimate goal
•
A nosology that helps integrate
cultural information into diagnostic
practice in order to inform treatment
Conducting an initial cultural
assessment: The core CFI
Transkulturellt Centrum
November 7, 2013
Roberto Lewis-Fernández, MD
Professor of Psychiatry, Columbia University Medical Center
Director, NYS Center of Excellence for Cultural Competence
and Hispanic Treatment Program
New York State Psychiatric Institute
DSM-5 definition of
culture
• Values, orientations, knowledge, and practices that individuals use
to understand their experiences, based on their identification with
diverse groups, such as:
▫ Ethnic groups, faith communities, occupational groups, veterans, etc.
• Aspects of a person’s background, experience, and social contexts
that may affect his or her perspective, such as:
▫ Geographical origin, migration, language, religion, sexual orientation,
race/ethnicity, etc.
• The influence of family, friends, and other community members
(the individual’s social network) on the individual’s illness
experience
Cultural Formulation
DSM-IV Cultural Formulation
A. Cultural Identity
Cultural reference group(s)
Language
Cultural factors in
development
Involvement with culture of
origin and host/majority
culture
B. Cultural Explanations
of Illness
Idioms of distress and local
illness categories
Meaning and severity
Causes and explanatory
models
Help-seeking experiences and
plans
C. Cultural Factors Related
to Psychosocial
Environment and Levels of
Functioning
Social Stressors
Social Supports
Levels of functioning and
disability
D. Cultural Elements of the
Clinician-Patient
Relationship
Perceived similarities and
differences
E. Overall Cultural
Assessment
Applying information to
diagnosis and treatment
Revision of the
Cultural Formulation
DSM-IV
Limitation
DSM-5 Solution
Lack of
operationalization
•Cultural Formulation Interview (CFI)
Limited guidance
•Use at beginning of initial evaluation
•16 standardized questions in 4 sections
•Apply with all patients
Risk of stereotyping
•Person-centered approach
•Collaborative, shared decision making
CFI structure
Cultural definition of
the problem
Cultural definition of the problem
• Q1: Own definition of problem or concern
• Q2: How describe to social network*
• Q3: Most troubling aspect
*Explores role of “family, friends, or others in your community”
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©
2013). American Psychiatric Association. All rights reserved
Cultural perceptions of cause,
context, and support
Causes
• Q4: Cause of problem
• Q5: Cause according to social network*
Stressors and Supports
• Q6: How environment is supportive
• Q7: How environment is stressful
*Explores role of “family, friends, or others in your community”
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©
2013). American Psychiatric Association. All rights reserved
Cultural perceptions of cause,
context, and support
Role of Cultural Identity
• Q8: Key aspects of background or identity
• Q9: Effect on problem
• Q10: Other concerns regarding cultural identity
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©
2013). American Psychiatric Association. All rights reserved
Cultural factors affecting
coping and help seeking
Self-coping
• Q11: Methods of self-coping
Past help-seeking
• Q12: Past help seeking from diverse sources
Barriers
• Q13: Barriers to obtaining help
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©
2013). American Psychiatric Association. All rights reserved
Current help seeking
Preferences
• Q14: Most useful help at this time
• Q15: Other help suggested by social network*
*Explores role of “family, friends, or others in your community”
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©
2013). American Psychiatric Association. All rights reserved
Current help seeking
Clinician-Patient Relationship
• Q16: Misunderstanding and how to provide care
“Sometimes doctors and patients misunderstand
each other because they come from different
backgrounds or have different expectations.
Have you been concerned about this and is there
anything that we can do to provide you with the
care you need?”
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©
2013). American Psychiatric Association. All rights reserved
Field Trial
• Led by:
▫ Study Group on Gender & Culture
▫ NYSPI Cultural Competence Center
• N=321 outpatients in 12 cities and 6 countries
• Aims are to assess:
▫ Feasibility: Can clinicians do it? Do patients answer?
▫ Acceptability: Do patients and clinicians like it?
▫ Perceived clinical utility: How useful do they think it is?
Field Trial sites
Montréal, Québec
Amsterdam, Netherlands
Toronto, Ontario
Minneapolis, MN
Sacramento, CA
San Francisco, CA
New Haven, CT
New York, NY
New Delhi, India
Lima, Peru
Nairobi, Kenya
Pune, India
Methods
Training
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Review CFI guidelines
Video
Role-playing
}
1½-2 hrs
Recruitment
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New or existing patients
Existing patients referred by usual clinicians
Patients could be accompanied by relatives
Methods
Procedure
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CFI, followed by diagnostic interview
Debriefing
▫ Questionnaires
▫ Qualitative interviews
▫ Relatives
From CFI-14 to CFI-16
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Specify definition of culture in guidelines
Shorten questions
Ask about perspective of family, friends, and
others in patient’s community
▫ Description of problem, causes, kinds of help
From CFI-14 to CFI-16
•
•
Provide definition of “background or
identity”
Change questions about identity
▫ Most important aspects, impact on problem,
cause of concern in itself
•
Change how ask about patient-clinician
relationship
Informant version
Collects information from informant
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To supplement patient information
When patient unable to provide information
Follows same format as patient CFI
Clarifies informant’s relationship with patient
Obtains informant’s views about illness and
care in addition to social network’s
•
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•
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(e.g., Why do you think this is happening to
[INDIVIDUAL]?)
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©
2013). American Psychiatric Association. All rights reserved
Supplementary modules
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Explanatory model
Level of functioning
Social network
Psychosocial stressors
Spirituality, religion, and moral traditions
Cultural identity
Coping and help-seeking
Patient–clinician relationship
School-age children and adolescents
Older adults
Immigrants and refugees
Caregivers
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition, (Copyright © 2013). American Psychiatric Association. All rights reserved
Culture and Psychiatric
Diagnosis
Transkulturellt Centrum
November 7, 2013
Roberto Lewis-Fernández, MD
Professor of Psychiatry, Columbia University Medical Center
Director, NYS Center of Excellence for Cultural Competence
and Hispanic Treatment Program
New York State Psychiatric Institute
Overview
Main point: Culture-related information
enhances the validity and clinical usefulness of
diagnostic practice
• Value of culture-related information for diagnostic
practice
• Reasons for engaging DSM-5 revision
▫ Limitations of DSM-IV
▫ Psychiatric diagnoses and cultural concepts of distress
Value of culture-related information
for diagnostic practice
DSM-5 definition of
culture
• Values, orientations, knowledge, and practices that individuals use
to understand their experiences, based on their identification with
diverse groups, such as:
▫ Ethnic groups, faith communities, occupational groups, veterans, etc.
• Aspects of a person’s background, experience, and social contexts
that may affect his or her perspective, such as:
▫ Geographical origin, migration, language, religion, sexual orientation,
race/ethnicity, etc.
• The influence of family, friends, and other community members
(the individual’s social network) on the individual’s illness
experience
Culture in mental health
• Culture is NOT ONLY geographic origin, race or
ethnicity
• Culture is dynamic, not static
• Cultural identity varies from person to person
• Cultural Competence refers to the ability of mental
health professionals and services to provide personcentered care to patients by taking into account the
multiple, ever-changing, and highly individualized
cultural identities of each person receiving services…
Diagnosis is central to
care-seeking pathway
Illness
Treatment
interpretation
Risk
Access choice
factors
to care
Treatment
participation
Treatment
Symptoms Selfgoals
and
coping
Treatment
Impairment
retention
DIAGNOSTIC
EVALUATION
Diagnosis is central to
care-seeking pathway
Illness
Treatment
interpretation
Risk
Access choice
factors
to care
Treatment
participation
Treatment
Symptoms Selfgoals
and
coping
Treatment
Impairment
retention
DIAGNOSTIC
EVALUATION
Culture, symptoms and
impairment
Altered perceptions
• Auditory
▫ Name
▫ Noises (knocking, steps, chains)
• Visual
▫ “Glimpses” or shadows (celajes)
▫ Spirits of the dead
• Tactile
▫ Presence around person
▫ Touched or pushed
Lewis-Fernández et al., 2005
Altered perceptions as
outcome marker (N=2,554)
Adjusted OR’s (95% CI) of perceptions vs. no
perceptions:
MH-related disability
Suicidal ideation
Outpatient MH care
1.8
2.3
1.7
(1.2-2.7)
(1.5-3.6)
(1.1-2.6)
Adjusted for age, gender, education, income, marital status, psychiatric
disorders, chronic medical conditions, traumatic exposure, ethnic origin,
time in US, language, use of religion for MH problems
Lewis-Fernández et al., 2009
Re-diagnosis using Cultural
Formulation (n=323)
80
70
Of n=70 with psychosis
60
50
49%
Psychotic to
Nonpsychotic
Diagnosis
40
30
20
Of n=253 without
psychosis
10
Nonpsychotic to
Psychotic Diagnosis
5%
0
Re-diagnosis
Adeponle et al., 2012
Diagnosis is central to
care-seeking pathway
Illness
Treatment
interpretation
Risk
Access choice
factors
to care
Treatment
participation
Treatment
Symptoms Selfgoals
and
coping
Treatment
Impairment
retention
DIAGNOSTIC
EVALUATION
Culture and treatment
choice
44-year old Dutch man
UN Peacekeeper in Bosnia
Witnessed mass graves
PTSD, Cluster B PD traits
Strong military culture
Rejects individual therapy
Favors group therapy with
military patients and
therapist
Diagnosis is central to
care-seeking pathway
Illness
Treatment
interpretation
Risk
Access choice
factors
to care
Treatment
participation
Treatment
Symptoms Selfgoals
and
coping
Treatment
Impairment
retention
DIAGNOSTIC
EVALUATION
Culture and treatment
goals
54-year old Dominican
woman with MDD
Lives with 28 yo bipolar,
violent son w/ SUD
IPT less effective
Unable to renegotiate
role dispute
Resolved by son’s
providers
Reasons for engaging
DSM-5 revision
From DSM-IV to DSM-5
Limited role of cultural psychiatry in DSM-IV
Major achievement, OCF, placed in Appendix
•
•
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•
•
•
•
Exoticized by link to Glossary of CBSs
Uncertain future of OCF in DSM-5
Maturation (Crisis?) of psychiatry created an
opening for culture focus
Opportunity to further develop OCF
Increasingly globalized use of DSM
Fuller diagnostic
assessment in DSM-5
•
•
•
•
Dimensional measures
Fuller assessment of impairment
Inclusion of evaluation instruments
Chapter subheadings for contextual factors
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Development and course
Risk and prognostic factors
Culture-related diagnostic issues
Functional consequences
Critiques of DSM-III
to DSM-IV:
Neurobiology to anthropology
•
•
Reliability >> validity
Inadvertent reification
▫ Symptoms AS diagnosis, not SIGNS of diagnosis
•
•
Missing symptom variants
Limited attention to “environment”/ context
in mechanisms of disease
Critiques of DSM-III
to DSM-IV:
Neurobiology to anthropology
•
Result in over-specification and decontextualization of disorders
▫ Yield: Potential misdiagnosis
Overuse of Not Otherwise Specified diagnoses
Artificially high comorbidity
▫ Hide: Dimensionality of psychopathology
Cross-cutting etiologies and mechanisms
12-mo. prevalence of
Social Anxiety Disorder
Prevalence of Social Anxiety
Disorder, by percentage
15
South Korea
China
Nigeria
10
Japan
Australia
6.8%
South Africa
5
0
Mexico
Europe
0.8%
0.2%0.2%0.3%
CIDI for DSM-IV
1.3%
1.7% 1.9%
2.3%
U.S.
Lewis-Fernández et al., 2010
DSM-IV & Caribbean
cultural concepts
Major Depression
GAD
Ataques de nervios
Altered perceptions
PTSD
Panic Disorder
Schizophrenia
Dissociative Disorder NOS
Undiff. Somatoform D/o
Borderline Personality D/o
Suffer from nerves
Be sick with nerves
Be loco
Have facultades
Suffer from a demon
Be nervous since
childhood
Symptom domains &
cultural concepts
Dissociation
Anxiety
Cultural
Concept
Somatization
Depression
Symptom frequency
of 1st ataque de nervios
Panic-like symptoms
Became nervous
Trembled a lot
Palpitations
Chest pressure
Felt like was suffocating
Heat in chest
Afraid of going crazy
Afraid of dying
Dizzy
Dissociative symptoms
90%
77%
75%
75%
61%
56%
53%
39%
35%
Loss of control
Became hysterical
69%
Lost/afraid of losing control 64%
Screamed a lot
56%
Guarnaccia et al., 1996
(N=77)
Surroundings unreal
Body felt unreal
Lost consciousness
Period of amnesia
53%
42%
35%
29%
Anger and aggression
Felt anger
Broke things
52%
26%
Suicidality symptoms
Suicidal thoughts
Suicide attempt
26%
14%
Other symptoms
Cried/attacks of crying
Fainted
88%
43%
Differential diagnosis
Ataque de nervios
•
•
•
•
•
•
•
•
•
Panic attack
Panic disorder
Other specified anxiety disorder
Other specified dissociative disorder
Other specified trauma- and stressor-related disorder
Conversion (functional neurologic symptom) disorder
Intermittent explosive disorder
V code
Normal reaction to adversity
Ataque as outcome
marker (N=2,554)
Adjusted OR’s (95% CI) of ataque vs. no ataque:
MH-related disability
Suicidal ideation
Outpatient MH care
2.25
2.4
2.2
(1.5-3.4)
(1.5-3.7)
(1.3-3.8)
Adjusted for age, gender, education, income, marital status, psychiatric
disorders, chronic medical conditions, traumatic exposure, ethnic origin,
time in US, language, use of religion for MH problems
Lewis-Fernández et al., 2009
Conclusions
Culture-related
information
•
Fits expanded DSM-5 approach to diagnosis
•
Enhances validity and clinical usefulness of
diagnostic practice
▫
▫
▫
▫
Limits misdiagnosis and overuse of NOS
Better guides treatment choice, goals, and retention
Identifies new markers of morbidity
Calibrates risk and severity assessments
Conducting a comprehensive
cultural assessment: The CFI
supplementary modules
Transkulturellt Centrum
November 8, 2013
Roberto Lewis-Fernández, MD
Professor of Psychiatry, Columbia University Medical Center
Director, NYS Center of Excellence for Cultural Competence
and Hispanic Treatment Program
New York State Psychiatric Institute
Comprehensive
assessment
Informant CFI and supplementary modules expand on
core CFI
May use in two ways:
•
•
▫
▫
•
•
As adjuncts to core CFI for additional information on
specific aspects of illness
As tools for in-depth cultural assessment independent of
core CFI
May use individual questions, subdomains, domains,
modules or entire set of modules
May use at intake or any time over course of care
Comprehensive
assessment
Especially useful in cases of:
•
▫
▫
▫
▫
▫
•
Cultural differences that complicate diagnostic assessment
Uncertainty of fit between symptoms and DSM categories
Difficulty in judging severity or impairment
Disagreement between patient and clinician on course of care
Limited treatment engagement or adherence
Helpful to identify area of concern to select approach
Modules that expand
sections of CFI
1. Explanatory model
(14 items)
Clarifies patient’s understanding of the problem based on his/her ideas about cause and mechanism (explanatory
models) and past experiences of, or knowing someone with, a similar problem (illness prototypes). The patient
may identify the problem as a symptom, a specific term or expression (e.g., “nerves,” “being on edge”), a
situation (e.g., loss of a job), or a relationship (e.g., conflict with others). In the examples below, the patient’s
own words should be used to replace “[PROBLEM]”. If there are multiple problems, each relevant problem can be
explored.
▫
▫
▫
▫
▫
General understanding of the problem
Illness prototypes
Causal explanations *
Course of illness *
Help seeking and treatment expectations *
2. Level of functioning
(8 items) *
Aims to clarify patient’s level of functioning in relation to his/her own priorities and those of the cultural
reference group. The interview begins with a general question about everyday activities that are important for
the patient. Questions follow about domains important for positive health (social relations, work/school,
economic viability, and resilience).
* Includes perspective of social network
Modules that expand
sections of CFI
3. Social network
(15 items)
Identifies the influences of the informal social network on the patient’s problem. Informal social network refers
to family, friends and other social contacts through work, places of prayer/worship or other activities and
affiliations. Question #1 identifies important people in the patient’s social network, and the clinician should
tailor subsequent questions accordingly. These questions aim to elicit the social network’s response, the patient’s
interpretation of how this would impact on the problem, and the patient’s preferences for involving members of
the social network in care.
▫
▫
▫
▫
▫
Composition of the patient’s social network
Social network understanding of the problem *
Social network response to problem *
Social network as a stress/buffer *
Social network in treatment *
4. Psychosocial stressors
(7 items) *
Clarifies the stressors that have aggravated the problem or otherwise affected the health of the patient.
(Stressors that initially caused the problem are covered in the module on Explanatory Models.) In the examples
below, the patient’s own words should be used to replace “[STRESSORS]”. If there are multiple stressors, each
relevant stressor can be explored.
* Includes perspective of social network
Modules that expand
sections of CFI
5. Spirituality, religion & moral traditions
(16 items)
Clarifies the influence of spirituality, religion, and other moral or philosophical traditions on the patient’s
problems and related stresses. People may have multiple spiritual, moral, and religious affiliations or practices.
If the person reports having specific beliefs or practices, inquire about the level of involvement in that tradition
and its impact on coping with the clinical problem. In the examples below, the patient’s own words should be used
to replace “[NAME(S) OF SPIRITUAL, RELIGIOUS OR MORAL TRADITION(S)]”. If the patient identifies more than one
tradition, each can be explored. If the patient does not describe a specific tradition, use the phrase “spirituality,
religion or other moral traditions” instead of the specific name of a tradition.
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Spiritual, religious, and moral identity *
Role of spirituality, religion, and moral traditions *
Relationship to the [PROBLEM]
Potential stressors or conflicts related to spirituality, religion,
and moral traditions
* Includes perspective of social network
Modules that expand
sections of CFI
6. Cultural identity
(34 items)
Clarifies the patient’s cultural identity and how this has influenced the patient’s health and well being. The
following questions explore the patient’s cultural identity and how this may have shaped his or her current
problem. We use the word culture broadly to refer to all the ways the person understands his or her identity and
experience in terms of groups, communities or other collectivities, including national or geographic origin, ethnic
community, racialized categories, gender, sexual orientation, social class, religion/spirituality, and language.
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▫
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National, ethnic, racial background *
Language
Migration
Spirituality, religion, and moral traditions *
Gender identity
Sexual orientation identity
Summary
* Includes perspective of social network
Modules that expand
sections of CFI
7. Coping and help seeking
(13 items)
Clarifies the patient’s ways of coping with the current problem. The patient may have identified the problem as
a symptom or mentioned a term or expression (e.g., “nerves,” “being on edge,” spirit possession), or a situation
(e.g., loss of a job), or a relationship (e.g., conflict with others).
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Self-coping
Social network *
Help- and treatment-seeking beyond social network
Current treatment episode *
8. Patient-clinician relationship
(12 items) *
Addresses the role of culture in the patient–clinician relationship with respect to the patient’s presenting
concerns and to the clinician’s evaluation of the patient’s problem. We use the word culture broadly to refer to
all the ways the person understands his or her identity and experience in terms of groups, communities or other
collectivities, including national or geographic origin, ethnic community, racialized categories, gender, sexual
orientation, social class, religion/spirituality, and language.
The first set of questions evaluates four domains in the clinician-patient relationship from the point of view of
the patient: experiences, expectations, communication, and possibility of collaboration with the clinician. The
second set of questions is directed to the clinician to guide reflection on the role of cultural factors in the
clinical relationship, the assessment, and treatment planning.
* Includes perspective of social network
Modules for special
populations
9. School-age children and adolescents
(28 items)
Identifies, from the perspective of the child/youth, the role of age-related cultural expectations, the possible
cultural divergences between school, home, and the peer group, and whether these issues impact on the situation
or problem that brought the youth for care. The questions indirectly explore cultural challenges, stressors and
resilience, and issues of cultural hybridity, mixed ethnicity or multiple ethnic identifications. Peer group
belonging is important to children and adolescents, and questions exploring ethnicity, religious identity, racism or
gender difference should be included following the child’s lead. Some children may not be able to answer all
questions; clinicians should select and adapt questions to ensure they are developmentally appropriate for the
patient. Children should not be used as informants to provide socio-demographic information on the family or an
explicit analysis of the cultural dimensions of their problems. An Addendum lists cultural aspects of development
and parenting that can be evaluated during parents’ interviews.
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Feelings of appropriateness in different settings
Age-related stressors and supports
Age-related expectations *
Transition to adulthood/maturity (for adolescents only) *
Addendum for parents’ interview *
* Includes perspective of social network
Modules for special
populations
10. Older adults
(17 items)
The following questions are directed to older adults. The goal of these questions is to identify the role of
cultural conceptions of aging and age-related transitions on the illness episode.
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Conceptions of aging and cultural identity *
Conceptions of aging in relationship to illness attributions and
coping
Influence of comorbid medical problems and treatments on
illness
Quality and nature of social supports and caregiving *
Additional age-related transitions
Positive and negative attitudes towards aging and clinicianpatient relationship
* Includes perspective of social network
Modules for special
populations
11. Immigrants and refugees
(18 items)
Aims to collect information from refugees and immigrants about their experiences of migration and
resettlement. Many refugees have experienced stressful interviews with officials or health professionals in their
home country, during the migration process (which may involve prolonged stays in refugee camps or other
precarious situations), and in the receiving country, so it may take longer than usual for the interviewee to feel
comfortable with and trust the interview process. When patient and clinician do not share a high level of fluency
in a common language, accurate language translation is essential.
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Background information
Pre-migration difficulties *
Migration-related losses and challenges *
Ongoing relationship with country of origin *
Resettlement and new life *
Relationship with problem
Future expectations
* Includes perspective of social network
Modules for special
populations
12. Caregivers
(14 items)
This module is designed to be administered to individuals who provide caregiving for the patient being assessed
with the CFI. This module aims to explore the nature and cultural context of caregiving, and the social support
and stresses in the patients’ immediate environment from the perspective of the caregiver.
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Nature of relationship
Caregiving activities and cultural perceptions of caregiving *
Social context of caregiving *
Clinical support for caregiving *
* Includes perspective of social network
CFI structure
Supplementary modules
A.
B.
C.
D.
E.
F.
G.
H.
I.
PROBLEM
CAUSES
STRESSORS & SUPPORTS
CULTURAL IDENTITY
SELF-COPING
PAST HELP
BARRIERS
PREFERENCES
PATIENT-CLINICIAN
RELATIONSHIP
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Explanatory model
Level of functioning
Social network
Psychosocial stressors
Spirituality, religion, and moral
traditions
Cultural identity
Coping and help-seeking
Patient–clinician relationship
School-age children and
adolescents
Older adults
Immigrants and refugees
Caregivers
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©
2013). American Psychiatric Association. All rights reserved