This study evaluated the use of the Outline for Cultural Formulation (OCF) from the DSM-IV in the diagnosis of immigrants and refugee patients at an outpatient psychiatric clinic in Sweden. Using the OCF in conjunction with standard diagnostic procedures led to major revisions of diagnoses for 56.5% of patients. Anxiety disorders, especially PTSD, constitute the disorder group in which the most changes were made. In order to understand how information from the OCF interview led clinicians to revise diagnoses, data from clinical discussions were analysed through qualitative content analysis. This revealed four major themes related to the reevaluation, and at times confirmation, of given clinical psychiatric diagnoses: new information; expression of distress in emotional language; expression of distress in relation to life experiences; and improved understanding of the patient’s suffering. The findings suggest that the OCF may be useful for: (a) formulating culture in relation to illness experiences, (b) contextualising diagnostic categorisation, and (c) improving overall understanding of the patient that may facilitate individualised planning of treatment and therapy.
AdeponleA. B.ThombsB. D.GroleauD.JarvisE.KirmayerL. J. (2012) Using the cultural formulation to resolve uncertainty in diagnoses of psychosis among ethnoculturally diverse patients. Psychiatric Services63(2): 147–153.
2.
AlarcónR. D.BellC. C.KirmayerL. J.LinK.-H.ÜstünB.WisnerK. L. (2002) Beyond the funhouse mirrors. In: KupferD. J.FirstM. B.RegierD. A. (eds) A research agenda for DSM-V, Washington, DC: American Psychiatric Association, pp. 219–281.
3.
AlbinB.HjelmK.EkbergJ.ElmståhlS. (2006) Higher mortality and different pattern of causes of death among foreign-born compared to native Swedes 1970–1999. Journal of Immigrant and Minority Health8(2): 101–113.
4.
Al SaffarS.BorgåP.HällströmT. (2002) Long-term consequences of unrecognised PTSD in general outpatient psychiatry. Social Psychiatry and Psychiatric Epidemiology37: 580–585.
5.
Al SaffarS.BorgåP.WicksS.HallströmT. (2004) The influence of the patients’ ethnicity, socio-demographic conditions and strain on psychiatric diagnosis given at an outpatient clinic. Nordic Journal of Psychiatry8: 421–427.
6.
Al SaffarS.BorgåP.LawokoS.EdmanG.HellströmT. (2004) The significance of addressing trauma in outpatient psychiatry. Nordic Journal of Psychiatry58: 305–312.
7.
American Psychiatric Association (2005) Diagnostic and statistical manual of mental disorder, (4th ed., Text Rev. Washington, DC: American Psychiatric Association.
8.
BäärnhielmS. (2012) The meaning of pain: A cultural formulation with a Syrian born woman in Sweden. Transcultural Psychiatry49(1): 105–120.
9.
BäärnhielmS.Scarpinati RossoM. (2009) The cultural formulation: A model to combine nosology and patients’ life context in psychiatric diagnostic practice. Transcultural Psychiatry46(3): 406–428.
10.
BäärnhielmS.Scarpinati RossoM.PattyiL. (2007) Kultur, kontext och psykiatrisk diagnostik. Manual för intervju enligt kulturformuleringen i DSM-IV [Culture, context and psychiatric diagnosis. Interview manual according DSM-IV], Stockholm, Sweden: Transkulturellt Centrum, Stockholms läns landsting.
11.
Bayard-BurfieldL. (1999) Migration and mental health: Epidemiological studies of immigrants in Sweden (doctoral dissertation), Malmö, Sweden: Department of Community Medicine Malmö University Hospital Lund University.
12.
BhuiK.BhugraD.GoldbergD.SauerJ.TyleeA. (2004) Assessing the prevalence of depression in Punjabi and English primary care attenders: The role of culture, physical illness and somatic symptoms. Transcultural Psychiatry41(3): 307–322.
13.
BorraR. (2011) Depressive Turkish women in the Netherlands: A qualitative study of idioms of distress. Transcultural Psychiatry48(5): 660–674.
14.
Cantor-GraaeE.ZolkowskaK.McNeilF. (2005) Increased risk of psychotic disorder among immigrants in Malmö: A 3-year first-contact study. Psychological Medicine35: 1155–1163.
15.
FirstM. B.SpitzerR. L.GibbonM.WilliamsJ. B. W. (1996) Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV), Washington, DC: American Psychiatric Press.
16.
GeertzC. (1973) The interpretation of cultures: Selected essays, New York, NY: Basic Books.
17.
Giovanni CartaM.BernalM.HardoyM. C.Haro-AbadJ. M. (2005) The “Report on Mental Health in Europe” working group: Review. Migration and mental health in Europe (the state of the mental health in Europe working group: Appendix I). Clinical Practice and Epidemiology in Mental Health1: 1–16. doi:10.1186/1745-0179-1-13.
18.
GoodB. J. (1996) Culture and DSM-IV: Diagnosis, knowledge and power. Culture, Medicine and Psychiatry20(2): 127–132.
19.
GoodB.DelVecchio GoodM.-J.MoradiR. (1985) The interpretation of Iranian depressive illness and dysphoric affect. In: KleinmanA.GoodB. (eds) Culture and depression. Studies in the anthropology and cross-cultural psychiatry of affect and disorder, Berkeley: University of California Press, pp. 369–428.
20.
HaasenC.YagdiranO.MassR.KrauszM. (2000) Potential for misdiagnosis among Turkish migrants with psychotic disorders: A clinical controlled study in Germany. Acta Psychiatrica Scandinavica101: 125–129.
21.
HaasenC.YagdiranO.MassR.KrauszM. (2001) Schizophrenic disorders among Turkish migrants in Germany. Psychopathology34: 2003–2008.
22.
HollanderA.-C.BruceD.EkbergJ.BurströmB.BorellC.EkbladS. (2012) Longitudinal study of mortality among refugees in Sweden. International Journal of Epidemiology41(4): 1153–1161.
23.
HorwitzA. V. (2002) Creating mental illness, Chicago, IL: University of Chicago Press.
24.
JohnsonH.ThompsonA. (2008) The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of trauma of war and torture: A review. Clinical Psychological Review28: 36–47.
25.
KinzieD. (2007) PTSD among traumatized refugees. In: KirmayerL. J.LemelsonR.BaradM. (eds) Understanding trauma: Integrating biological, clinical, and cultural perspectives, New York, NY: Cambridge University Press.
26.
KirmayerL. J. (2001) Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of Clinical Psychiatry62(Suppl. 13): 22–28.
27.
KirmayerL. J. (2003) Failures of imagination: The refugee’s narrative in psychiatry. Anthropology & Medicine10(2): 167–185.
28.
KirmayerL. J.GroleauD.GuzderJ.BlakeC.JarvisG. E. (2003) Cultural consultation: A model of health service for multicultural societies. Canadian Journal of Psychiatry48(3): 145–153.
29.
KirmayerL. J.ThombsB. D.JurcikT.JarvisG. E.GuzderJ. (2008) Use of an expanded version of the DSM-IV outline for cultural formulation on a cultural consultation service. Psychiatric Services59(6): 683–686.
30.
KleinmanA. (2005) How is culture important for DSM-IV? In: MezzichJ.KleinmanA.FabregaH.ParronD. (eds) Culture & psychiatric diagnosis: A DSM-IV perspective, Washington, DC: American Psychiatric Press, pp. 15–25.
31.
KleinmanA.BensonP. (2006) Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS-Medicine3(10): 1673–1676.
32.
KrippendorffK. (2004) Content analysis: An introduction to its methodology, (2nd ed. Thousand Oaks, CA: Sage.
33.
LeãoS. T.SundquistJ.FrankG.JohanssonL.-M.JohanssonS.-E.SundquistK. (2006) Incidence of schizophrenia or other psychoses in first- and second-generation immigrants. A national cohort study. The Journal of Nervous and Mental Disease194(1): 27–33.
34.
Lewis-FernándezR. (1996) Cultural formulation of psychiatric diagnosis. Case No. 02. Diagnosis and treatment of nervios and ataques in a female Puerto Rican migrant. Culture, Medicine & Psychiatry20(2): 155–163.
35.
Lewis-FernándezR. (2009) The cultural formulation. Transcultural Psychiatry46(3): 379–382.
36.
Lewis-FernándezR.DiazN. (2002) The Cultural Formulation: A method for assessing cultural factors affecting the clinical encounter. Psychiatric Quarterly73(4): 271–295.
37.
Lewis-FernándezR.HintonD. E.LariaA. J.PatterssonE.HofmanS. G.CraskeM. G.LiaoB. (2010) Culture and the anxiety disorders: Recommendations for DSM-V. Depression and Anxiety27: 212–229.
38.
MansonS. M. (2005) Culture and DSM-IV: Implications for the diagnosis of mood and anxiety disorders. In: MezzichI. J.KleinmanA.FabregaH.ParronD. (eds) Culture & psychiatric diagnosis: A DSM-IV perspective, Washington, DC: American Psychiatric Press, pp. 99–113.
39.
MezzichJ. E. (2013) Culturally informing diagnostic systems. In: BarnowS.BalkirN. (eds) Cultural variations in psychopathology, Göttingen, Germany: Hogrefe, pp. 137–153.
40.
MezzichJ. E.KleinmanA.FabregaH.ParronD. L. (2005) Introduction. In: MezzichJ.KleinmanA.FabregaH.ParronD. (eds) Culture & psychiatric diagnosis: A DSM-IV perspective, Washington, DC: American Psychiatric Press, pp. 123–129.
41.
NorströmE. (2004) I väntan på asyl. Retorik och praktik i svensk flyktingpolitik [Waiting for asylum. Swedish refugee policy – Rhetoric and praxis], Umeå, Sweden: Boréaförlag[Swedish with an English summary].
42.
PattonM. Q. (2002) Qualitative research and evaluation methods, (3rd ed. Thousand Oaks, CA: Sage.
43.
QSR International (2006) NVivo qualitative data analysis software Version 7, Victoria, Australia: QSR International PTY Ltd.
44.
RivasC. (2012) Coding and analysing qualitative data. In: SealeC. (ed.) Researching society and culture, London, UK: Sage, pp. 366–392.
45.
RubinD. C.BerntsenD.BohniM. K. (2008) A memory-based model of posttraumatic stress disorder: Evaluating basic assumptions underlying the PTSD diagnosis. Psychological Review115(4): 985–1011.
46.
Scarpinati RossoM.BäärnhielmS. (2012) The use of Cultural Formulation in Stockholm: A qualitative study on mental illness experiences among migrants. Transcultural Psychiatry49(2): 283–301.
47.
Socialstyrelsen. (2013). Att ha schizofreni och vara utrikesfödd – insjuknande, vård och levnadsförhållanden hos invandrare jämfört med personer födda i Sverige. [Having Schizophrenia and being foreign born – onset of symptoms, health care and living conditions among immigrants compared to people born In Sweden]. http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/19003/2013-2-31.pdf (accessed November 21, 2014).
48.
SundquistJ. (1994) Refugees, labour migrants and psychological distress. A population-based study of 338 Latin-American refugees, 161 south European and 396 Finnish labour migrants, and 996 Swedish age-, sex- and education-matched controls. Social Psychiatry and Psychiatric Epidemiology29(1): 20–24.
49.
SwartzL. (2012) An unruly coming of age: The benefits of discomfort for global health. Transcultural Psychiatry49(3–4): 531–538.
50.
Swedish Integration Board (2006) Pocket facts-statistics on integration, Stockholm, Sweden: The Swedish Integration Board.
51.
TakeuchiJ. (2000) Treatment of a biracial child with schizophreniform disorder: Cultural formulation. Cultural Diversity & Ethnic Minority Psychology6(1): 93–101.
TinghögP. (2009) Migration, stress and mental ill health: Post-migration factors and experiences in the life of the Swedish context, Linköping, Sweden: Linköping University, Department of Medical and Health Sciences.
54.
TrommsdorffG.HeikampT. (2013) Socialization of emotions and emotion regulation in cultural context. In: BarnowS.BalkirN. (eds) Cultural variations in psychopathology, Göttingen, Germany: Hogrefe, pp. 67–92.
55.
WeissmanM. M.BlandR. C.CaninoG. J.FaravelliC.GreenwaldS.HwuH. G.YehE. K. (1997) The cross-national epidemiology of panic disorder. Archives of General Psychiatry54: 305–309.
56.
WestermeyerJ.WahmenholmK. (1989) Assessing the victimized psychiatric patient. Hospital and Community Psychiatry40(3): 245–249.
57.
YadinE.FoaE. (2007) Cognitive behavioural treatments for posttraumatic stress disorder. In: KirmayerL. J.LemelsonR.BaradM. (eds) Understanding trauma. Integrating biological, clinical, and cultural perspectives, New York, NY: Cambridge University Press, pp. 178–193.
58.
ZandiT.HavenaarJ. M.Limburg-OkkenA. G.van EsH.SidaliS.KadriN.KahnR. S. (2008) The need for culture sensitive diagnostic procedures: A study among psychotic patients in Morocco. Social Psychiatry & Psychiatric Epidemiology43(3): 244–250.
59.
ZandiT.HavenaarJ. M.SmitsH.Limburg-OkkenA. G.van EsH.CahnW.van den BrinkW. (2010) First contact incidence of psychotic disorders among native Dutch and Moroccan immigrants in the Netherlands: Influence of diagnostic bias. Schizophrenia Research119: 27–33.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
