DSM-IV-TR Cultural Formulation of Psychiatric Cases: Two Proposals for Clinicians

Abstract

This article reviews some limitations of the current guideline for the DSM-IV-TR Cultural Formulation (CF) from the perspective of psychiatric practice that are based on the author's experience conducting doctoral courses on cultural psychiatry from 1996 to 2007 in the Department of Psychiatry at the Universidad Autónoma de Madrid (Spain). Two proposals are presented for facilitating use of the CF by general clinicians. These proposals offer a procedure for embedding only the most relevant clinical information in a psychiatric history, followed by a brief cultural formulation. The approach is illustrated with a clinical case. Although the CF has considerable promise for revealing knowledge about patients, health practices, and health systems that is essential for clinical care, substantial research must be carried out to facilitate widespread use of the CF in clinical practice.

Culture and Psychiatric Evaluation: Operationalizing Cultural Formulation forDSM-5

“…Guidance has been lacking on when, with whom, and why to use the OCF (Cuéllar & Paniagua, 2000), and it may duplicate information from the clinical assessment (Caballero, 2009). Clinicians have struggled to find ways to cover the four domains within the time constraints of various practice settings (Lewis-Fernández, 2009).…”

“…Kirmayer and colleagues (2003, 2014) advocate its use in specialized clinical consultations for patients where cultural factors are complicating care. Others suggest reserving it for patients whose presentation includes cultural content unfamiliar to the clinician (Caballero, 2009). Whereas most published case studies feature patients from cultural backgrounds unfamiliar to the treating clinician such as immigrants or ethnic minorities, some also include reports of culturally similar patients and clinicians, indicating how the OCF may clarify intra-cultural issues (Aggarwal, 2012a; Rohlof, Groen, van Dijk, & Starmans, 2010).…”

“…Some authors suggest that the assessing clinician could incorporate portions of the OCF into the clinical evaluation, for example, by including questions in the domain of Cultural Explanations of the Individual's Illness in assessment of the history of present illness (Aggarwal, 2012b; Caballero, 2009; Jadhav, 2010a). This approach may encourage attention to this aspect of the OCF without a full interview for every patient.…”

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

“…Second, researchers have questioned the reliability of reproducing data without a standardized design (Alarcón 2009) given the different OCF-inspired questionnaires (Group for the Advancement of Psychiatry 2001; Bäärnhielm and Rosso 2009; Groen 2009a; Kirmayer et al 2008; Mezzich et al 2009). Third, the lack of clinician instructions has raised questions about whether it is a separate assessment from the standard interview (Caballero Martínez 2009) and in what service settings it should be conducted (Aggarwal 2012b). Therefore, Cultural Issues Subgroup for the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has revised the OCF into the Cultural Formulation Interview (CFI).…”

“…This framework has been extensively used to understand the dynamics of patient-clinician communication (Simpson et al 1991; Heritage and Maynard 2006; Roter and Hall 2006). Rather than retain the strict focus on clinical decision making, we undertook a separate analysis based on case reports that the OCF has helped clinicians overcome communication barriers to improve patient satisfaction (Caballero Martínez 2009; Groen 2009b). This study is timely since the CFI will be widely disseminated through DSM-5, the latest revision of the psychiatric classification system used most throughout the world (Littlewood 1992).…”