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CLINICAL SYNTHESIS   |    
DSM-IV Outline for Cultural Formulation: Bringing Culture Into the Clinical Encounter
Francis G. Lu, M.D.
FOCUS 2006;4:9-10.
View Author and Article Information

CME Financial Disclosure
Francis G. Lu, M.D., Department of Psychiatry, University of California, San Francisco.

No disclosure of financial interests or affiliations to report.

Copyright 2006 American Psychiatric Association

In 1994 APA published DSM-IV, which included an Outline for Cultural Formulation to provide a concise method of incorporating cultural issues into the diagnostic process. The Outline had been proposed by the National Institute of Mental Health Workgroup on Culture, Diagnosis, and Care, which was initiated by Delores L. Parron, Ph.D., Director of the Office of Special Populations, and chaired by Juan E. Mezzich, M.D., Ph.D., a member of the APA Task Force on DSM-IV. The Outline was published as part of Appendix I along with a Glossary of Culture-Bound Syndromes. The Outline remained relatively obscure for several years—no doubt largely because of its location deep in the appendix section of DSM-IV—but that has begun to change. A search of the PubMed and PsycINFO databases for "DSM-IV Outline for Cultural Formulation" from 1994 to 2005 yielded 10 unduplicated citations (110) for articles that describe the Outline or illustrate its use with one to four cases.

In the 2001 revision of the Accreditation Council for Graduate Medical Education program requirements for psychiatry (11), residency training programs were required to include experiences in "integrative case formulation that includes neurobiological, phenomenological, psychological, and sociocultural issues involved in diagnosis and management of cases presented" (p. 27). This description of the clinical formulation has been incorporated into the Outline in the Practice Guideline for the Psychiatric Evaluation of Adults, 2nd edition (12) (see next article). The Outline "provides a systematic method of considering and incorporating sociocultural issues into the clinical formulation." In other words, the use of the Outline ensures that we put cultural issues on the radar screen, thereby enriching our biopsychosocial understanding of our patients, broadening our differential diagnoses, and improving our treatment planning.

This inclusion is very timely, coming after the release of the Surgeon General’s report Mental Health: Culture, Race, and Ethnicity (13), which documented mental health disparities for racial and ethnic minority groups and challenged the mental health professions to reduce those disparities through culturally competent clinical care, training, and research. APA’s strategic plan to reduce disparities focused on these areas as well (14). The Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education have added accreditation standards involving cultural competence, and teaching the use of the Outline can help institutions meet these standards.

This issue of FOCUS joins a small but growing body of work that helps clinicians, educators, and trainees bring culture into the clinical encounter. Several teaching tools are available that explicate both the content and process of using the Outline. First, the Cultural Psychiatry Committee of the Group for the Advancement of Psychiatry published a monograph on the Outline and illustrated its use in six clinical cases (15). Second, Harriet Koskoff, a filmmaker, created a 58-minute training videotape/DVD (16) with 23 multicultural, multidisciplinary mental health professionals commenting on the five sections of the Outline. Third, approximately 17 clinical cases demonstrating the use of the Outline have been published in the quarterly journal Culture, Medicine, and Psychiatry since 1995, including a number of excellent teaching cases (1720). Finally, the Clinical Manual of Cultural Psychiatry (21) represents the collected wisdom from 10 years of teaching an APA annual meeting course on the use of the Outline with patients from minority racial/ethnic groups; it includes an appendix with a detailed inventory of specific approaches and questions clinicians can use to obtain information for each of the five components of the Outline.

Christensen M: Diagnostic criteria in clinical settings: DSM-IV and cultural competence. Am Indian Alsk Native Ment Health Res  2000; 10:52—66
 
Dillard DA, Manson SM: Assessing and treating American Indians and Alaska Natives, in Handbook of Multicultural Mental Health. Edited by Cuéllar I, Paniagua FA. San Diego, Academic Press,  2000, pp 225—248
 
Harper G: Cultural influences on diagnosis. Child Adolesc Psychiatr Clin North Am  2001; 10:711—728
 
Hinman C: Multicultural considerations in the delivery of play therapy services. Int J Play Ther  2003; 12:107—122
[CrossRef]
 
House AE: DSM-IV Diagnosis in the Schools, 2nd ed. New York, Guilford,  2002
 
Lu F, Lim R, Mezzich J: Issues in the assessment and diagnosis of culturally diverse individuals, in American Psychiatric Press Review of Psychiatry, vol 14. Edited by Oldham J, Riba M. Washington, DC, American Psychiatric Press,  1995
 
Mezzich JE, Kirmayer LJ, Kleinman A, Fabrega H Jr, Parron DL, Good BJ, Lin K-M, Manson SM: The place of culture in DSM-IV. J Nerv Ment Dis  1999; 187:457—464
[CrossRef] | [PubMed]
 
Novins DK, Bechtold DW, Sack WH, Thompson J, Carter DR, Manson SM: The DSM-IV Outline for Cultural Formulation: a critical demonstration with American Indian children. J Am Acad Child Adolesc Psychiatry  1997; 36:1244—1251
[CrossRef] | [PubMed]
 
Paniagua FA: Culture-bound syndromes, cultural variations, and psychopathology, in Handbook of Multicultural Mental Health. Edited by Cuéllar I, Paniagua FA. San Diego, Academic Press,  2000, pp 139—169
 
Takeuchi J: Treatment of a biracial child with schizophreniform disorder: cultural formulation. Cultur Divers Ethnic Minor Psychol  2000; 6:93—101
[CrossRef] | [PubMed]
 
Accreditation Council for Graduate Medical Education: Program Requirements for Residency Training in Psychiatry. Chicago, Accreditation Council for Graduate Medical Education, November 12,  2004. Available at
 
American Psychiatric Association: Practice Guideline for the Psychiatric Evaluation of Adults, 2nd ed. Washington, DC, American Psychiatric Association, in press
 
Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services,  2001
 
American Psychiatric Association: Steering Committee to Reduce Disparities in Access to Psychiatric Care: Final Report. Washington, DC, American Psychiatric Association,  2004
 
Group for the Advancement of Psychiatry: Cultural Assessment in Clinical Psychiatry. Washington, DC, American Psychiatric Publishing,  2002
 
Koskoff H: The Culture of Emotions (video). Boston, Fanlight Productions,  2002
 
Yongmi Yi K: Shinbyung (divine illness) in a Korean woman. Cult Med Psychiatry  2000; 24:471—486
[CrossRef] | [PubMed]
 
Yeung AS, Chang DF: Adjustment disorder: intergenerational conflict in a Chinese immigrant family. Cult Med Psychiatry  2002; 26:509—525
[CrossRef] | [PubMed]
 
LeVine P, Matsuda Y: Reformulation of diagnosis with attention to cultural dynamics: case of a Japanese woman hospitalized in Melbourne, Australia. Cult Med Psychiatry  2003; 27:221—243
[CrossRef] | [PubMed]
 
Shore JH, Manson SM: The American Indian veteran and posttraumatic stress disorder: a telehealth assessment and formulation. Cult Med Psychiatry  2004; 28:231—243
[CrossRef]  | [PubMed]
 
Lim R (ed): Clinical Manual of Cultural Psychiatry. Washington, DC, American Psychiatric Publishing, in press
 
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References

Christensen M: Diagnostic criteria in clinical settings: DSM-IV and cultural competence. Am Indian Alsk Native Ment Health Res  2000; 10:52—66
 
Dillard DA, Manson SM: Assessing and treating American Indians and Alaska Natives, in Handbook of Multicultural Mental Health. Edited by Cuéllar I, Paniagua FA. San Diego, Academic Press,  2000, pp 225—248
 
Harper G: Cultural influences on diagnosis. Child Adolesc Psychiatr Clin North Am  2001; 10:711—728
 
Hinman C: Multicultural considerations in the delivery of play therapy services. Int J Play Ther  2003; 12:107—122
[CrossRef]
 
House AE: DSM-IV Diagnosis in the Schools, 2nd ed. New York, Guilford,  2002
 
Lu F, Lim R, Mezzich J: Issues in the assessment and diagnosis of culturally diverse individuals, in American Psychiatric Press Review of Psychiatry, vol 14. Edited by Oldham J, Riba M. Washington, DC, American Psychiatric Press,  1995
 
Mezzich JE, Kirmayer LJ, Kleinman A, Fabrega H Jr, Parron DL, Good BJ, Lin K-M, Manson SM: The place of culture in DSM-IV. J Nerv Ment Dis  1999; 187:457—464
[CrossRef] | [PubMed]
 
Novins DK, Bechtold DW, Sack WH, Thompson J, Carter DR, Manson SM: The DSM-IV Outline for Cultural Formulation: a critical demonstration with American Indian children. J Am Acad Child Adolesc Psychiatry  1997; 36:1244—1251
[CrossRef] | [PubMed]
 
Paniagua FA: Culture-bound syndromes, cultural variations, and psychopathology, in Handbook of Multicultural Mental Health. Edited by Cuéllar I, Paniagua FA. San Diego, Academic Press,  2000, pp 139—169
 
Takeuchi J: Treatment of a biracial child with schizophreniform disorder: cultural formulation. Cultur Divers Ethnic Minor Psychol  2000; 6:93—101
[CrossRef] | [PubMed]
 
Accreditation Council for Graduate Medical Education: Program Requirements for Residency Training in Psychiatry. Chicago, Accreditation Council for Graduate Medical Education, November 12,  2004. Available at
 
American Psychiatric Association: Practice Guideline for the Psychiatric Evaluation of Adults, 2nd ed. Washington, DC, American Psychiatric Association, in press
 
Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services,  2001
 
American Psychiatric Association: Steering Committee to Reduce Disparities in Access to Psychiatric Care: Final Report. Washington, DC, American Psychiatric Association,  2004
 
Group for the Advancement of Psychiatry: Cultural Assessment in Clinical Psychiatry. Washington, DC, American Psychiatric Publishing,  2002
 
Koskoff H: The Culture of Emotions (video). Boston, Fanlight Productions,  2002
 
Yongmi Yi K: Shinbyung (divine illness) in a Korean woman. Cult Med Psychiatry  2000; 24:471—486
[CrossRef] | [PubMed]
 
Yeung AS, Chang DF: Adjustment disorder: intergenerational conflict in a Chinese immigrant family. Cult Med Psychiatry  2002; 26:509—525
[CrossRef] | [PubMed]
 
LeVine P, Matsuda Y: Reformulation of diagnosis with attention to cultural dynamics: case of a Japanese woman hospitalized in Melbourne, Australia. Cult Med Psychiatry  2003; 27:221—243
[CrossRef] | [PubMed]
 
Shore JH, Manson SM: The American Indian veteran and posttraumatic stress disorder: a telehealth assessment and formulation. Cult Med Psychiatry  2004; 28:231—243
[CrossRef]  | [PubMed]
 
Lim R (ed): Clinical Manual of Cultural Psychiatry. Washington, DC, American Psychiatric Publishing, in press
 
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