Cultural Formulation (DSM-5 Section III) and Glossary of Cultural Concepts of Distress (DSM-5 Appendix)

A 22-year-old man from Zimbabwe presents to a clinic with a complaint of anx- iety and pain in his chest. He tells the clinician that the cause of his symptoms is kufungisisa, or "thinking too much." Which of the following statements about kufungisisa is true? a. In cultures in which kufungisisa is a shared concept, thinking a lot about troubling issues is considered to be a helpful way of dealing with them. b. The term kufungisisa is used as both a cultural explanation and a cultural idiom of distress. c. Kufungisisa involves concerns about bodily deformity. d. Kufungisisa is related to schizophrenia. E. B and C.

The term kufungisisa is used as both a cultural explanation and a cultural idiom of distress. Explanation: The term kufungisisa refers to both a cultural explanation and a cultural idiom of distress. It is believed to be caused by thinking too much, which is considered to be damaging to the mind and body. Because kufungisisa is associated with ruminations, it is possible that the concept of "thinking too much" refers to a cultural experience related to ruminations. It is not especially associated with schizophrenia.

A 19-year-old man presents to the clinic complaining of headaches, irritability, emotional lability, and difficulty concentrating. He is accompanied by his mother, who tells you that her son has had nervios since childhood. Which of the following statements about nervios is false? a. Unlike ataque de nervios, which is a syndrome, nervios is a cultural idiom of distress implying a state of vulnerability to stressful experiences. b. The term nervios is used only when the individual has serious loss of functionality or intense symptoms. c. Nervios can manifest with emotional symptoms, somatic disturbances, and an inability to function. d. Nervios can be related to both trait characteristics of an individual and episodic psychiatric symptoms such as depression and dissociative episodes. e. Nervios is a common term used by Latinos in the United States and Latin America.

The term nervios is used only when the individual has serious loss of functionality or intense symptoms. Explanation: Nervios is a cultural idiom of distress used by Latinos in the United States and Latin America to describe an individual with a general state of vulnerability to stressful experiences and difficult life circumstances. The symptoms of nervios range from very minor distress to severe incapacitation. Research studies indicate that individuals so labeled within the culture can manifest both characteristic trait features and discrete episodic symptoms.

The DSM-5 Cultural Formulation Interview (CFI) is intended not only as an adjunct to diagnosis but also as a holistic clinical approach to the patient. Which of the following clinician communications would be consistent with the spirit of the CFI? a. "I want you to understand the medical approach to depression, so we can clarify any misunderstandings you may have." b. "You need not worry, I have worked with many Latino patients who have been depressed, and I know how Latinos think about this." c. "There is no need to feel ashamed—depression is an illness, like asthma, and it affects everybody in a similar way." d. "How does your family view your illness?" e. "The most important thing is to take medication regularly, and the depression will go away, just as an infection would disappear with antibiotics."

"How does your family view your illness?" Explanation: The CFI is a brief semistructured interview for systematically assessing cultural factors in the clinical encounter that may be used with any individual. The CFI focuses on the individual's experience and the social contexts of the clinical problem. As illustrated by the clinician communication in option D, the CFI follows a person-centered approach to cultural assessment by eliciting information from the individual about his or her own views and those of others in his or her social network. This approach is designed to avoid stereotyping, in that each individual's cultural knowledge affects how he or she interprets illness experience and guides how he or she seeks help. Because the CFI concerns the individual's personal views, there are no right or wrong answers to these questions. The clinician communications in options A, B, C, and E involve imposing of the clinician's perspective onto the patient, who may have a very different con- text. Furthermore, some of these communications suggest—incorrectly—that all members of a group or of a diagnostic category have the same experience, as well as the same interpretation of the meaning of that experience.

Which of the following statements about ataque de nervios is false? a. Ataque is a cultural syndrome as well as a cultural idiom of distress. b. Ataque is related to panic disorder, other specified or unspecified dissociative disorder, conversion disorder (functional neurological symptom disorder), and other specified or unspecified trauma-and stressor-related disorder. c. Ataque is most often associated with withdrawn and reserved behaviors and limited interaction. d. Ataque often involves a sense of being out of control. e. Community studies have found ataque to be associated with suicidal ideation, disability, and outpatient psychiatric service utilization.

Ataque is most often associated with withdrawn and reserved behaviors and limited interaction. Explanation: Ataque is often experienced with intense and outwardly expressed emotional upset representing a sense of being out of control, rather than withdrawn quiet internalization. Ataque is both a cultural syndrome (i.e., the cultures in which it occurs recognize it as a distinct syndrome) and a broader idiom of distress (i.e., the term ataque de nervios may also be used within the culture as a dimensional description of experienced distress rather than a defined syndromal category). Although no one-to-one correlation with a DSM-5 diagnosis exists, ataque de nervios is related to panic disorder, other specified or unspecified dissociative disorder, conversion disorder, and other specified or unspecified trauma- and stressor-related disorder, among others. Epidemiological research has established its association with suicidal ideation, disability, and outpatient psychiatric service utilization.

The DSM-5 Outline of Cultural Formulation is an update of the framework in- troduced in DSM-IV for assessing cultural features of a person's mental health presentation. Which of the following is not a category in the updated framework? a. Cultural identity of the individual. b. Cultural conceptualizations of distress. c. Cultural stressors and cultural features of vulnerability and resilience. d. Cultural preferences in leisure and entertainment choices. e. Cultural features of the relationship between the individual and the clinician.

Cultural preferences in leisure and entertainment choices. Explanation: Although cultural aspects of leisure-time activity may have distal relevance to mental health, it is not a major category of the DSM-5 Outline for Cultural Formulation. Cultural identity of the individual includes aspects of ethnic, racial, linguistic, and cultural factors with which the individual identifies. Cultural conceptualizations of distress involve culturally specific ways of understanding and coping with distress. Cultural stressors and cultural features of vulnerability and resilience involve culturally specific stressors and social support systems and related concepts, as well as culturally bound conceptions of work and disability. Approaches to the patient-physician relationship may vary significantly across different cultures. It is essential to understand these differences if one is to establish a "helping" relationship.

In DSM-5 the term cultural concepts of distress encompasses three main types of concepts. Which of the following options correctly lists these three subtypes? a. Cultural syndromes, cultural idioms of distress, cultural explanations or perceived causes. b. Cultural identity, culture-bound syndromes, cultural bias. c. Cultural boundaries, cultural identity, cultural arts. d. Culturally based sexuality, culture-based faith, cultural causes. e. Culturally recognized etiologies, cultural grievances, cultural healers.

Cultural syndromes, cultural idioms of distress, cultural explanations or perceived causes. Explanation: Cultural concepts of distress refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions. Three main types of cultural concepts may be distinguished. Cultural syndromes are clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communi- ties, or contexts and that are recognized locally as coherent patterns of experience. Cultural idioms of distress are ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns. For exam- ple, everyday talk about "nerves" or "depression" may refer to widely varying forms of suffering without mapping onto a discrete set of symptoms, syndrome, or disorder. Cultural explanations or perceived causes are labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress.

Which of the following statements about dhat syndrome is false? a. It is a cultural syndrome found in South Asia. b. It is related to widespread ideas regarding the harmful effects of loss of semen on sexual as well as general health. c. The central feature of dhat syndrome is distress about loss of semen, to which is attributed diverse symptoms, including fatigue, weakness, and depressive mood. d. The syndrome is most common among young men of lower socioeconomic status. e. The estimated rate of dhat syndrome in men attending general medical clinics in Pakistan is 30%.

Dhat syndrome is a cultural syndrome found in South Asia. Explanation: Despite its name, dhat syndrome is not a discrete syndrome but rather a cultural explanation of distress for patients who attribute diverse symptoms—such as anxiety, fatigue, weakness, weight loss, impotence, other multiple somatic complaints, and depressive mood—to semen loss. The central feature of dhat syndrome is distress about the loss of dhat (semen) in the absence of any identifiable physiological dysfunction. Dhat syndrome is most commonly identified with young men from lower socioeconomic status backgrounds. Research in health care settings has yielded widely varying estimates of the syndrome's prevalence (e.g., 64% of men attending psychiatric clinics in India for sexual complaints; 30% of men attending general medical clinics in Pakistan).

A young Haitian man from a prominent family becomes severely depressed after his first semester of university studies. The family brings the young man to a clinician and states that maladi moun has caused his problem. Which of the following statements about maladi moun is false? a. It is similar to Mediterranean concepts of the "evil eye," in which a person's good fortune is envied by others who in turn cause misfortune to the individual. b. It can present with a wide variety of symptoms, from anxiety to psychosis. c. It is based on a shared social assumption that "rising tides lift all boats." d. It is a Haitian cultural explanation for a diverse set of medical and emotional presentations. e. It is also referred to as "sent sickness."

It is based on a shared social assumption that "rising tides lift all boats." Explanation: The cultural model of maladi moun is based on the idea that one's good fortune, or the flaunting of good fortune, can cause another to have jealous feelings that can be reflected back as actual negative health consequences. It therefore captures a sentiment opposite to that of "rising tides," which may also exist within the culture, as all cultures contain elements of competitive feelings (zero-sum games) and cooperative feelings (win-win games). Maladi moun is a cultural explanation of distress that can present in a wide variety of ways.

Cultural identity of the individual is one of several categories in the DSM-5 Outline for Cultural Formulation. Which of the following is not a feature of cultural identity of the individual? a. Self-defined racial or ethnic reference group. b. For immigrants or minorities, the degree of involvement with both culture of origin and host culture. c. Language abilities and preferences. d. Political party affiliation. e. Sexual orientation.

Political party affiliation. Explanation: Political party affiliation is not generally part of the "cultural identity of the individual" category of the DSM-5 Outline for Cultural Formulation. Self-defined racial and/or ethnic reference group, degree of involvement with one's culture of origin and host culture, language ability and preferences, and sexual orientation are important aspects of identity that inform one's experience of mental health problems and approaches to treatment. Other clinically relevant aspects of identity may include religious affiliation, socioeconomic background, personal and family places of birth and growing up, and migrant status.

Which of the following statements about shenjing shuairuo is false? a. In the Chinese Classification of Mental Disorders, it is defined by a presentation of three out of five symptom clusters. b. One of the psychosocial precipitants is an acute sense of failure. c. It is related to traditional Chinese medicine concepts of depletion of qi (vital energy) and dysregulation of jing (bodily channels that convey vital forces). d. Prominent psychotic symptoms must be present. e. It is believed to be related in some cases to the inability to change a chronically frustrating and distressing situation.

Prominent psychotic symptoms must be present. Explanation: Shenjing shuairuo is a Mandarin Chinese term for a cultural syndrome that integrates conceptual categories of traditional Chinese medicine with the Western diagnosis of neurasthenia. Although well defined, it may not always correspond to DSM-5 disorders. It is believed to be precipitated by a sense of failure or loss of face. This includes situations in which someone feels incapable of changing an undesirable situation in which he or she is involved. Shenjing shuairuo has a proposed mechanism involving standard concepts in Chinese medicine such as qi and jing that involve the distribution of energy through the body.

Which of the following statements about the Cultural Formulation Interview (CFI) is true? a. The CFI tests how well the patient is versed in the cultural heritage from which he or she originates. b. By determining the patient's culture of origin, the CFI helps the clinician predict the patient's attitudes toward the illness concept and the acceptability of treatments. c. The CFI is a carefully formulated, structured interview and should be followed closely to maintain the validity and accuracy of elicited responses. d. The CFI takes a person-centered approach to culture, focusing on an individual's beliefs and attitudes as well as those of others in the patient's social networks. e. Basic demographic information is elicited by the CFI, eliminating the need to obtain it separately.

The CFI takes a person-centered approach to culture, focusing on an individual's beliefs and attitudes as well as those of others in the patient's social networks. Explanation: The DSM-5 CFI is interested in the total experiential context in which an illness/distress experience occurs. This includes the cultural aspect of social networks to which the patient belongs, as well as the patient's personal differences from these norms. The CFI is not focused on how well versed an individual is in his or her culture, but rather the influence of the person's participation in that culture on health. Thus, knowing a patient's cultural membership (which may be one of many memberships) does not justify applying the norms of that one culture to this individual in a stereotyped fashion. The CFI is purposefully a loose set of suggested questions for probing cultural issues and not a formulaic and rigid cultural thermometer. The CFI assumes that basic demographic information is known, so it is best to obtain this information before administering the CFI, as part of the initial data of the psychiatric interview.

Information on cultural concepts to improve the comprehensiveness of clinical assessment is contained in various locations in DSM-5. Which of the following is not one of those locations? a. The Cultural Formulation Interview (CFI) section of the "Cultural Formulation" chapter in Section III. b. The "Glossary of Cultural Concepts of Distress" in the Appendix. c. Culturally relevant information embedded in the DSM-5 criteria and text for specific disorders. d. The Z and V codes in the "Other Conditions That May Be a Focus of Clinical Attention" chapter at the end of Section II. e. The DSM-5 multiaxial diagnostic system.

The DSM-5 multiaxial diagnostic system. Explanation: The importance of culturally relevant assessment is reflected by the ubiquitous presence of cultural contextual data within DSM-5. In addition to the CFI and its supplementary modules, DSM-5 contains a variety of information and tools that may be useful when integrating cultural information in clinical practice. Text and criteria descriptions contain updates of diagnostic research that are culturally relevant, as do the Z and V codes. DSM-5 no longer has a multiaxial approach to diagnosis.

In which of the following clinical situations would the Cultural Formulation Interview (CFI) not be directly useful? a. The clinician and the patient come from very different cultural backgrounds. b. The clinician and patient have a shared belief system regarding the nature of the problem and the appropriate therapeutic approach. c. The patient presents with a symptom complex that is distressing but does not fit any DSM-5 diagnosis. d. The clinician is finding it difficult to get a sense of the severity of the patient's presenting problems. e. The clinician and patient are having trouble agreeing on an approach to treatment.

The clinician and patient have a shared belief system regarding the nature of the problem and the appropriate therapeutic approach. Explanation: When the clinician and patient have a shared belief system regarding the nature of the problem and the appropriate therapeutic approach, there may be less of a need to administer the CFI—not because cultural factors are not playing a role, but because the clinician and patient are embedding these factors in their shared cultural assumptions and are therefore already addressing these issues even without a formal questionnaire. Note that this answer stresses a shared belief system and an agreed-upon approach to the current problem; however, one should not assume a shared belief system just because the patient is from the same ethnic or religious group. People may have multiple group identifications and individualized ways of incorporating these identifications, which is precisely what the CFI explores. Difficulty with problem description, questionable DSM-5 symptom fit, and disagreement on approach to treatment are all major reasons to administer the CFI as a means of clarifying what might be communication difficulties around cultural factors.