Abstract
Mental health practitioners in the United States often use two classification systems for mental disorders, namely, the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5). A critical issue when diagnosing people with mental disorders is to ensure that cultural variables do not potentially explain the presentation of symptoms. A fundamental difference between the two classification systems is that the ICD is mute regarding the need to consider such variables in this context of diagnosing people with mental disorders, whereas the DSM-5 does alert mental health practitioners that they should not make a diagnosis in this context without considering the cultural variables potentially affecting the assessment and diagnosis of such disorders. This difference between the two classification systems is illustrated with a sample of mental disorders in both systems.
Introduction
Mental health practitioners in the United States generally use the International Classification of Diseases (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) to guide their clinical diagnostic practice involving mental disorders in children, adolescents, and adults (APA, 2013; Centers for Disease Control and Prevention [CDC], 2009; World Health Organization [WHO], 2016a).
The ICD-10 discusses mental disorders in chapter 5, and three variants of this classification system are available. The first variant is the ICD-10 Clinical Descriptions and Diagnostic Guidelines (ICD/CDDG-10), which is recommended for general clinical, educational, and service use. The second variant is the ICD-10 Diagnostic Criteria for Research (ICD/DCR-10), which is recommended for research purposes. The ICD/CDDG-10 and the ICD/DCR-10 are both available from WHO (2016a). The third variant of the ICD-10 is suitable for use by coders or clerical workers, but it is not recommended for mental health practitioners (CDC, 2016; WHO, 2016b). This article emphasizes the ICD/CDDG-10 because it is the ICD-10 variant that mental health practitioners are expected to use to diagnose mental disorders in all WHO countries, including the United States.
A clinical modified (CM) version of the ICD-10 was developed by the CDC, which is known as the ICD-10-CM. This CDC version of the ICD-10 is required for diagnosing physical and mental disorders and reimbursement of medical and mental health services in the United States (Besser & Bufka, 2015; CDC, 2014, 2015, 2016; Clay, 2013, 2014; Reed, 2010). Nordal (2014) and Paniagua (2011, 2016), however, suggested that all versions of the ICD-10 and the ICD-10-CM are appropriate systems for billing purposes but not for diagnosing mental disorders.
A section (Z codes) is included in the ICD-10 (WHO, 2010, 2016a) and in the ICD-10-CM (CDC, 2015; Centers for Medicare and Medicaid Services, 2015), which encourages physicians and mental health practitioners to pay attention to patients’ prior exposures to potential health hazards associated with socioeconomic and psychosocial circumstances. These Z codes resemble the “other conditions that may be a focus of clinical attention” in the DSM-5 (see the V codes in APA, 2013, pp. 715-727). In the DSM-5, ICD-10, and ICD-10-CM, such conditions (i.e., Z codes or V codes) are not diagnostic categories, but variables that may affect the assessment and diagnosis of mental disorders. In the case of the ICD-10 and ICD-10-CM, such variables should also be considered in the assessment and diagnosis of physical diseases. Table 1 shows examples of Z codes in the ICD-10 and ICD-10-CM, with their respective domain (e.g., Z55: problems related to education and literacy) and examples (e.g., illiteracy or low-level literacy). The Z61 section in Table 1 is not included in the ICD-10-CM. When applicable, in Table 1, the corresponding DSM-5 V code is included after the dash (/; e.g., Z55/V62.3).
ICD-10 Health Hazards (Z/V codes) Related to Socioeconomic and Psychosocial Circumstances.
Source. Adapted from World Health Organization (2010).
Note. ICD-10 = International Classification of Diseases.
Cultural Variations and Culture-Bound Syndromes
A significant contribution in the DSM-5, in the ICD-10, and in the ICD-10-CM is to alert mental health practitioners about potential health hazards associated with socioeconomic and psychosocial circumstances, which may be the focus of clinical attention during the assessment and diagnosis of mental disorders (see Table 1). The DSM-5, however, goes further in that it also alerts clinicians that they should consider cultural variables prior to diagnosing the patient with a given DSM-5 mental disorder (e.g., culture-bound syndromes, see APA, 2013; Paniagua, 2014), and provides culturally specific guidelines “for assessing information about cultural features of an individual’s mental health problem and how it relates to a social and cultural context and history” (APA, 2013, p. 749). In the DSM-5, these guidelines are included in three areas. First, the DSM-5 includes a section dealing with culture-related diagnostic issues across most mental disorders in the DSM-5. Second, the cultural formulation “provides a framework for assessing information about cultural features of an individual’s mental health problem and how it relates to a social and cultural context and history” (APA, 2013, p. 749). Third, the cultural formulation interview is a new section in the DSM-5 “that clinicians may use to obtain information during a mental health assessment about the impact of culture on key aspects of an individual’s clinical presentation and care” (APA, 2013, p. 750). These three areas are missed in all variants of the ICD-10 and in the ICD-10-CM.
It should be noted that the ICD/CDDG-10 (see WHO, 2016a) includes a brief section titled “culture-specific disorders,” and informs mental health practitioners that “the need for a separate category for disorders such as latah, amok, koro, and a variety of other possible culture-specific disorder [see Box 1] has been expressed less often in recent years” (p. 19, emphasis added). This is a misleading suggestion because it means that mental health practitioners should not be concerned about screening for potential culture-specific disorders because the need to consider such disorders in clinical practice has decreased in recent years. The opposite, however, is the truth: attention to “culture-specific disorders” (ICD) or “cultural concepts of distress” (in the DSM-5, see APA, 2013, pp. 833-837), or “culture-related syndromes” or “culture-bound syndromes” (see Paniagua, 2014, pp. 206-211), is currently a fundamental diagnostic issue in clinical practice with culturally diverse patients (e.g., African American, Asian, Latino/a/Hispanic patients, etc.) diagnosed with mental disorders with the ICD or the DSM-5.
Examples of Culture-Bound Syndromes in the Mental Health Literature.
For example, Leong and Kalibatseva (2016) alerted mental health practitioners that if they provide clinical services to Asian American patients, it is important to carefully screen for the potential contribution of Hwa-byung (see Box 1), which is considered a culture-bound syndrome resembling somatic symptom disorder in the DSM-5 (APA, 2013) or somatization disorder in the ICD-10 (WHO, 2016a). In the specific case of Korean patients, Leong and Kalibatseva (2016) observed that
because of the Korean culture’s esteem of restraint, suppression of verbal aggression, and avoidance of confrontation, Hwa-byung is a unique Korean culture-bound syndrome in which suppressed emotions reflecting anger, disappointment, sadness, misery, hostility, grudges, and unfulfilled dreams or expectations manifest themselves physically. (p. 62)
Examples of physical symptoms during the experiencing of that culture-bound syndrome among Korean patients include heart problems, poor appetite, problems with the urinary track, and vomiting blood. Despite these findings from Leong and Kalibatseva (2016), clinicians should not automatically conclude that all Korean patients would report symptoms suggesting the Hwa-byung culture-bound syndrome. The same point applies in the case of additional culture-bound syndromes (see Box 1) across other culturally diverse patients.
It is also important to observe that a careful screening regarding how the DSM-5 (APA, 2013) treats cultural issues suggests a distinction between culture-specific disorders, cultural concepts of distress, or culture-related syndromes and cultural variations (see Paniagua, 2014, for an extensive discussion with emphasis on this distinction). Although the DSM-5 (APA, 2013) recognizes the need to consider culture-bound syndromes across some mental disorders (e.g., taijin kyofusho in the case of social anxiety disorder, see APA, 2013, and Box 1), the DSM-5 generally emphasizes cultural variations across most disorders. All variants of the ICD, however, are mute in both contexts.
Paniagua (2014) proposed the difference between culture-related syndromes and cultural variations in the following terms: “Culture-bound syndromes [or culture-specific disorders, culture-related syndromes, cultural concepts of distress] are ‘locally specific troubling experiences that are limited to certain societies or cultural areas’” (Smart & Smart, 1997, p. 394).
. . . such experiences have specific names within the particular cultures (e.g., ataques de nervios, koro, mal puesto, and susto). Therapists need to be aware that symptoms associated with a given mental disorder may be related to a particular cultural context without being part of a culture-bound syndrome per se. A clinician should conduct an assessment of cultural variations that may be contributing to the client’s symptoms, rather than search for the culture-bound syndrome that may or may not apply to the particular case. (p. 211)
For example, the DSM-5 (APA, 2013) observes that the mental health practitioner assessing the patient for psychotic symptoms may arrive at the wrong diagnosis if this practitioner fails to consider “unfamiliar spiritual explanations [that] may be misunderstood as psychosis” (APA, 2013, p. 759). In this case, “spiritual explanations” function as a cultural variation and not as a culture-bound syndrome. In this context, the DSM-5 alerts clinicians that “in some cultures [e.g., in the Latino/Hispanic and Native American cultures], visual or auditory hallucinations with a religious content (e.g., hearing God’s voice) are a normal part of religious experience” (APA, 2013, p. 103). For example, experiencing “visions” during religious or healing ceremonies among traditional Native Americans can be perceived as symptoms suggesting a psychotic disorder. Similarly, some African Americans and Hispanics “who engage in religious or healing ceremonies may briefly show one or more of the symptoms [suggesting brief psychotic disorder in the DSM-5]” (Paniagua, 2014, p. 238), including hallucinations, catatonic behavior, and disorganized speech.
Another example of cultural variations in the DSM-5 can be found in the diagnosis of learning disorder. The DSM-5 observes that in the case of English-speaking U.S. children and adolescents,
the observable hallmark clinical symptoms of difficulties learning to read is inaccurate and slow reading of single words; in other alphabetical languages that have more direct mapping between sounds and letters (e.g., Spanish, German) and in nonalphabetical languages (e.g., Chinese, Japanese), the hallmark feature is slow but accurate reading. (pp. 72-73, emphasis added)
Therefore, the critical process during the assessment and diagnosis of learning disorder is not to search for a given culture-bound syndrome (because it does not exist in this case), but to identify the particular linguistic cultural variation in the language under consideration.
In the case of alcohol-related disorders, examples of cultural variations to consider when diagnosing people with such disorders include the approval and encouragement of the use of alcohol among some ethnic groups during “religious celebrations (e.g., Jewish and Catholic holidays)” (APA, 2013, p. 498) or during “specific events (e.g., wakes following funeral)” (p. 498). Binge drinking (“drinking more than 5 drinks in a single occasion,” Monteiro, 2007, p. 5) is prevalent among individuals from some Caribbean islands (e.g., Dominican Republic, Puerto Rico), Central American countries (e.g., Costa Rica, El Salvador), and South American countries (e.g., Argentina, Brazil) in which males tend to “compete” on who is able to drink the most. In this case, binge drinking is not an alcohol-related problem but a culturally expected behavior. Below are additional examples of cultural variations in a sample of mental disorders.
Examples of culture-bound syndromes are included in Box 1. For example, the “evil eye” or “mal de ojo” is an excessive admiration and attention that could result in mental (e.g., anxiety, depression) and physical (e.g., vomiting, fever) problems in others. Among patients from Arabic and Hispanic cultures, the belief in “evil eye” or “mal de ojo” might also create the impression of delusional or psychotic ways of thinking (Al-Jassem, 2010; Paniagua, 2014). In these cultural contexts, unfamiliarity with how the particular culture explains apparent psychotic features “may lead clinicians to misjudge the severity of a problem or assign the wrong diagnosis” (APA, 2013, pp. 758-759; see also Fukuyama, Sevig, & Soet, 2008, p. 351).
A major difference between all versions of the ICD-10 (e.g., CDC, 2015; WHO, 2016a) and the DSM-5 (APA, 2013) is that the ICD systems do not alert clinicians about how cultural variables may have an impact on the diagnosis of either physical diseases or mental disorders (see Alarcón, 2009; Paniagua, 2001; Paniagua & Yamada, 2013), whereas the DSM-5 does alert clinicians regarding they should consider such variables before diagnosing people with mental disorders (Paniagua, 2014). A vast literature exists evidencing that people can actually be diagnosed with mental disorders when, in fact, certain cultural variables (e.g., either cultural variations or culture-bound syndromes, as described above) are responsible for the presence of symptoms associated with such disorders (e.g., Leong & Kalibatseva, 2016; Paniagua, 2014; Sue & Sue, 2003; Tseng & Strelzer, 1997). Box 1 includes examples of culture-bound syndromes in the mental health literature.
Acculturation in Clinical Contexts
Acculturation difficulty is a factor both the ICD-10 and the ICD-I0-CM consider among other factors (see Table 1) summarizing problems related to social environment (i.e., Z codes). All variants of the ICD, however, are mute regarding explicitly guiding mental health practitioners should consider to rule out (exclude) the process of acculturation as a potential cultural variation associated with the presentation of symptoms for mental disorders. The DSM-5 (APA, 2013) not only includes acculturation (i.e., the V62.4 coordinated with the Z60.3 code in Table 1), but it also encourages mental health practitioners to consider acculturation during the cultural formulation of the case when the DSM-5 states that “For immigrants and racial or ethnic minorities, the degree and kinds of involvement with both the culture of origin and the host culture or majority culture [i.e., acculturative process] should be noted separately” (p. 750).
The construct of acculturation has been defined in many different ways. For example, Paniagua (2014) defined this construct “in terms of the degree to which an individual integrates new cultural patterns into his or her original cultural patterns” (p. 13). Another definition of acculturation is offered by Buki, Ma, Strom, and Strom (2003): “The concept of acculturation generally refers to the process by which immigrants adapt to a new culture” (p. 128). Pumariega et al. (2013) defined acculturation in terms of a “process of change in the cultures of 2 or more groups of individuals from different cultures resulting from their continuous first-hand contact” (p. 1102). These definitions of acculturation are particularly important to consider in the case of patients from Spanish-speaking countries (e.g., Colombia, Cuba, Dominican Republic, Mexico, Panama, Venezuela, etc.) and Asian countries (e.g., China, Japan, Philippines, Taiwan, Vietnam, etc.). The reason why acculturation is more pronounced with these groups is because they are among the largest immigrant groups in the United States (Leong, Lee, & Chang, 2008; Paniagua, 2014; Sue & Sue, 2003), which suggests a better chance to encounter patients from these groups in mental health services, relative to immigrant patients from other countries (e.g., Africa and Middle East countries). Four models of acculturation have been investigated in the present context, namely, assimilation, separation, integration, and marginalization models (Paniagua, 2014).
When an individual shows significant changes in his or her behavioral patterns (e.g., style of dressing,) and belief system (e.g., refusing to follow the native culture’s dating process, described below), resulting from a long-term association with a new culture (e.g., immigrant children and adolescents into the U.S. culture), one would say that such an individual is highly acculturated into the new culture. This individual would generally prefer to be identified with the dominant or host culture (see APA, 2013) and would refuse to share the values, behaviors, and/or beliefs of his or her culture of origin (Ayers et al., 2009). This acculturation process corresponds to the assimilation model of acculturation (see Paniagua, 2014). Immigrants influenced by the assimilation model of acculturation would refuse to listen to native music (from their country of origin), would not participate in native forms of dance, would not dress or eat food in the ways prescribed in the culture of origin, and would not participate in social behaviors demanded by the culture or origin (e.g., the ritual involved in the dating process in some cultures). This model of acculturation process may result in conflicts between members of the family who are assimilated to the dominant or host culture and those who maintain behavioral patterns and the belief system of their native culture.
In the separation model of acculturation (also known as “enculturation”), the patient would report (e.g., during individual psychotherapy sessions) that he or she only values behaviors and beliefs of his or her native culture. In this model, the patient (particularly an adolescent) would “maintain his or her cultural/ethnic identity, refusing to adapt to or identify with elements of the host (dominant) culture” (Paniagua, 2014, p. 19). This model of acculturation may also lead to conflicts among family members, particularly when some members are assimilated into the host culture but others elect to separate from such values and only agree to accept the behavioral patterns and belief system of the culture of origin (i.e., the separation model of acculturation).
In the integration model of acculturation, the individual “displays behaviors and beliefs found in both his or her traditional culture . . . and the host (dominant) culture. This [individual] maintains his or her cultural and/or ethnic identity and at the same time integrates into his or her identity many values from the host culture” (Paniagua, 2014, p. 19). This model of acculturation is also known as “biculturalism” (see Sue & Sue, 2003, pp. 160-161) and may also lead to conflicts in the family between the integrated individual and family members who “reject the idea of mixing elements of their own culture with elements of the dominant culture [i.e., the separation model of acculturation]” (Paniagua, 2014, p. 19). When assessing, diagnosing, and treating immigrant children and adolescents, it is important to evaluate the nature of such conflicts in terms of separation–integration acculturation conflicts, which may explain marital problems (e.g., parents disagree regarding accepting or rejecting the child’s decision to mix elements from both cultures) and “behavioral problems” (e.g., conduct disorder, oppositional behaviors, depression, anxiety) in children and adolescents who have chosen the integration model of acculturation.
As observed by Paniagua (2014), in the marginalization model of acculturation, the individual “rejects behaviors and beliefs associated with both his or her traditional culture and the host (dominant culture) culture” (p. 20). This model of acculturation is the one that results in more “symptoms” associated with a given mental disorder (e.g., conduct problems, depression) among immigrant children. The child or adolescent affected by this model of acculturation would be perceived by parents and relatives (siblings, aunts, uncles) and friends in school as someone who is “isolated,” “indifferent,” “unfriendly,” or “detached,” suggesting the diagnosis of schizoid personality disorder in both the DSM-5 (APA, 2013) and the ICD-10 (WHO, 2010, 2016a).
Acculturation Stress in Clinical Contexts
During the assessment of each of the above models of acculturation in clinical practice, an important construct to assess is acculturation stress (LaFromboise & Malik, 2016; Paniagua, 2014). Acculturation stress has been defined in several different ways. For example, LaFromboise and Malik (2016) observed that acculturation stress is “a system overload associated with navigating differences between two or more cultures” (p. 226). In another source (Paniagua, 2014), acculturation stress is defined “in terms of those situations where an individual perceives his or her norms, values, behaviors, and beliefs are in conflict with the new cultural environment” (p. 21).
The struggle to deal with different models of acculturation (e.g., the case of separation–integration conflicts discussed above) can lead to acculturation stress with symptoms resembling some mental disorders in the ICD-10 and the DSM-5 (e.g., adjustment disorders, major depressive disorders [MDDs]). For example, LaFromboise and Malik (2016) reviewed the literature on acculturation stress experienced by American Indian/Alaska Native (AI/AN) children and adolescents and found that “suicide rates [resulting from severe symptoms of depression] were positively associated with acculturation stress and negatively associated with traditional integration [model of acculturation] in 18 AI/NA tribes” (p. 227). In addition, children and adolescents from East and Southeast Asian countries are more at risk to be vulnerable to acculturation stress and the development of mental disorders (Kim & Partk, 2008).
Furthermore, higher levels of acculturation stress are generally experienced by individuals exposed to the marginalized model of acculturation, whereas lower levels of acculturation stress are generally observed among individuals associated with the assimilation model of acculturation (Paniagua, 2014).
If acculturation stress is a critical variable during the process of assessing and diagnosing people with mental disorders, the mental health practitioner is expected to use reliable and valid psychological tests to appropriately assess this construct, rather than using his or her imagination. For example, the Riverside Acculturation Stress Inventory (RASI) emphasizes “five domains, namely, language skills, work, intercultural relationships, discrimination, and cultural composition of the community” (Paniagua, 2014, p. 22; see also Benet-Martinez & Haritatos, 2005). A review of general acculturation scales can be found in Paniagua (2014). Below are examples of mental disorders in the DSM-5 that illustrate the role of acculturation and other cultural variations during the assessment and diagnosis of such disorders, but without clinical cultural considerations in all variants of the ICD.
Conduct and Oppositional Defiant Disorders
The ICD-10 and the CD-10-CM encourage clinicians to consider war and other hostilities (see Z65, in Table 1) as psychosocial and/or cultural circumstances potentially associated with both physical diseases and mental disorders. This observation particularly applies during the diagnosis of conduct disorder in children and adolescents. The DSM-5 (APA, 2013) is very specific in this context when it asserts, after the description of diagnostic criteria for this disorder, that
conduct disorder diagnosis may at times be potentially misapplied to individuals in settings where patterns of disruptive behavior are viewed as near normative (e.g., in very threatening, high-crime areas or war zones). Therefore, the context [i.e., the cultural variation] in which the undesirable behaviors have occurred should be considered. (p. 474, emphasis added)
During the diagnosis of oppositional defiant disorder, the need to consider the potential impact of acculturation is a key cultural variable mental health practitioner should consider avoiding while diagnosing children and adolescents with this disorder (Paniagua, 2010). The assimilation model of acculturation is particularly associated with the potential development of oppositional defiant symptoms. For example, traditional (less acculturated) Latino/Hispanic parents believe that the “dating process” should include not only their son or daughter and the girlfriend or boyfriend but also parents or caregivers and other relatives (e.g., aunts, grandmother, etc.). A highly acculturated Latina/Hispanic female adolescent who refuses to follow this belief system may strongly disagree with her parents regarding who should be involved in that dating process. When Latino/Hispanic parents bring that adolescent to the clinic for evaluation of her “symptoms” (i.e., refusing to do what her parents ask her to do), clinicians without training associated with the impact of the assimilation model of acculturation on immigrant children and adolescents would erroneously diagnose that adolescent with “oppositional defiant disorder” (see APA, 2013, pp. 462-466). That adolescent, however, is not mentally ill but displaying behaviors and beliefs that compete with the low level of acculturation in her parents. That is, different levels of acculturation are what explain the child–parent relational problems or conflicts and not that mental disorder (Paniagua, 2014; Sue & Sue, 2003).
The clinician’s failure to appreciate the above assimilation process of acculturation would result in placing that adolescent in intensive outpatient psychiatry treatment with emphasis on individual psychotherapy (to learn what “intra-psychic” feelings lead to oppositional behaviors toward parents), family therapy (to help the adolescent and her parents to “communicate better”), and the use of psychotropic medications (to help that adolescent to “relax” when under stress resulting from parents’ demands to value only the norms and beliefs of the Latino/Hispanic culture). Because that adolescent is erroneously diagnosed with a mental disorder (i.e., oppositional defiant disorder), the wrong treatment plan would be implemented with emphasis on individual psychotherapy, family therapy, and medication. In this case, however, a culturally appropriate treatment approach is termed “cultural reframing” (Ho, 1992) in which “the demands or expectations made by both [the adolescent and her parents are] are analyzed in relation to the cultural values that constituted the background for the demands” (Ho, 1992, p. 153). Therefore, instead of emphasizing the above traditional treatment modalities, the clinician would use cultural refraining strategies with emphasis on how different levels of acculturation among family members are responsible for that adolescent’s “symptoms.” During this cultural reframing strategy, parents would learn that their daughter is not actually “oppositional” but only behaving according to a process of acculturation she has already assimilated after several years residing in the United States in which that dating process generally only involves the adolescent and his or her girlfriend or boyfriend (and sometimes friends), but not parents or relatives.
The separation model of acculturation may also explain symptoms of conduct and oppositional defiant disorders. For example, because of economic reasons, some immigrant parents come to the United States without their children. After several years residing in this country, immigrant parents then bring them to this country. Several months after the arrival of a child, some parents may become very concerned about “sudden” behavioral changes in their child. During the first visit to the clinic, parents then report that their child “refuses to follow parents’ directions at home, is very argumentative, and often stays out at night without parents’ permission.” During the face-to-face clinical interview with that adolescent, the mental health practitioner may find out that this adolescent recently immigrated to the United State and that he is being affected by the separation model of acculturation, whereas his parents are very well acculturated to the American society (via the assimilation model of acculturation). If the mental health practitioner evaluating this adolescent fails to carefully assess the potential impact of the separation model of acculturation on the presentation of symptoms, that practitioner would likely diagnose that adolescent with either “oppositional defiant disorder” or “conduct disorder” (see APA, 2013, pp. 462-469 and pp. 469-470, respectively). In this case, the conflict between the two acculturation models in the family is what potentially explains the adolescent’s oppositional or conduct problems and not the actual presence of DSM-5 diagnostic criteria for either oppositional defiant disorder or conduct disorder. In other words, in this example, the recently immigrated adolescent elected to maintain elements from his original culture, which resulted in conflicts or constant arguments between that adolescent (affected by the separation model of acculturation) and his parents (affected by the assimilation model of acculturation). In this situation, during family therapy sessions, the mental health practitioner’s task should be to avoid taking sides with any of these models of acculturation but to provide a counseling process with emphasis on participants’ understanding of their disagreement resulting from these two conflicting models of acculturation (i.e., assimilation vs. separation model of acculturation).
Children and adolescents struggling with the impact of the integration process of acculturation may also show behaviors considered by parents as examples of “conduct problems” and “oppositional acts.” In this process of acculturation, the child would decide under which condition or environmental context (e.g., family reunion, birthday parties, etc.) he or she agrees to show behavioral patterns reflecting his or her own culture or the dominant (host) culture. For example, the child may sometimes agree to eat foods from his or her native country, but in other instances the child would agree to eat only foods from the host culture. If parents disagree with their child’s decision to mix elements of his or her own culture with elements of the dominant culture, this situation may result in parents reporting that their child is “very oppositional” or that the child “has severe conduct problems.” As observed above, this situation may result in the child experiencing the acculturation stress phenomenon described earlier.
If the child is diagnosed with either conduct disorder or oppositional defiant disorder and parents also report that the child is having problems accepting behavioral patterns from either the native culture or the host culture, the best guess is that the child is experiencing the marginalization acculturation process. In this situation, the mental health practitioner may erroneously diagnose the child with schizoid personality disorder if parents report that the child is perceived by them and others as “isolated,” “indifferent,” “unfriendly,” and “detached” (see APA, 2013, pp. 655-656).
Dependent Personality Disorder
If a Latina/Hispanic female client/patient seeking mental health services reports to the mental health practitioner she is having problems making decision without excessive amount of advice from her husband, is not able to express her disagreement to her husband regarding how things should be handled at home (e.g., the discipline of their children, how to spend their money, or when and where to take a family vacation, etc.), and that these situations resulted in fear of abandonment and a sense of incompetence regarding not being able to care for herself, that mental health practitioner would probably conclude that this patient is experiencing symptoms associated with dependent personality disorder. The DSM-5 alerts mental health practitioners they should consider “dependent behavior . . . characteristic of [this disorder] only when it is clearly in excess of the individual’s cultural norms” (APA, 2013, p. 677). For example, two cultural variables the clinician should assess in that example are machismo and marianismo (Paniagua, 2014; Sue & Sue, 2003). Among many Latina/Hispanic families, machismo is a cultural value in which the Latino/Hispanic man expects Latina/Hispanic women to be obedient, dependent, and submissive. If that Latina/Hispanic woman displays behaviors expected by the Latino/Hispanic man, one would say that she is influenced by the cultural value of marianismo, which is highly rewarded by other members in the Latina/Hispanic community. If the clinician does not have a good understanding regarding the role of machismo and marianismo in the development of symptoms resembling dependent personality disorder, the woman in this example would likely be erroneously diagnosed with dependent personality disorder.
Although the constructs of machismo and marianismo have generally been associated with the Latina/Hispanic community (Paniagua, 2014; Sue & Sue, 2003), similar cultural values can be found in other societies where women are expected to accept such values in their social interactions with others. For example, in most Muslim societies, women are also expected to be submissive, obedient, and possessed by their husband (Al-Mateen & Afzal, 2004). This culturally sanctioned belief has its root in the Glorious Qur’an. For example, in the Glorious Qur’an, Surah 4, Verse 3, Muslim men are allowed to
marry from among . . . women two or three, or four; but if you have reason to fear that you might not be able to treat them with equal fairness, then [only] one-or [from among] those whom you rightfully possess. This will make it more likely that you will not deviate from the right course [or will not do injustice]. (Asad, 2003, pp. 117-118)
This is not a case of polygamy because in this verse of the Glorious Qur’an, Muslim women are expected to be obedient and submissive to the decision of the Muslim man to have multiple wives. Furthermore, despite the fact that this is a case of machismo versus marianismo in the Muslim societies, this situation would not meet DSM-5 diagnostic requirements for dependent personality disorder because polygamy is a cultural value accepted by Muslim men and women who strictly follow that verse in the Glorious Qur’an.
During the diagnosis of dependent personality disorder, the mental health practitioner should also consider the impact of acculturation on the presentation of symptoms. For example, if in a marital relationship, the Latina/Hispanic wife reports during family therapy sessions that she does not want to continue doing everything her husband asks her to do and that she is “tired depending on him for everything in her life,” this report would suggest that the wife is experiencing the assimilation process of acculturation after several years residing in the host country (e.g., the United States) where women are expected to be more “independent” from their husbands. This situation would compete with the belief system of the husband regarding how his wife “should behave” in their marital relationship. In this example, the husband’s belief system is under the influence of the separation model of acculturation (i.e., the husband only values behaviors and beliefs of his native culture, including the cultural machismo–marianismo demarcation), whereas the wife’s belief system is under the control of the assimilation model of acculturation.
Separation Anxiety Disorder of Childhood
Mental health practitioners should not diagnose children from cultures that reward interdependence among family members with separation anxiety disorder. The DSM-5 (see APA, 2013) is very explicit, alerting clinicians to avoid mistakenly diagnosing children with this disorder under that particular cultural context.
For example, some Asian families value the “obligation to family, conformity, obedience, and subordination to authority” (Leong et al., 2008, p. 114). If an Asian child moves away from this culturally accepted value, the resulting outcome could be the development of symptoms resembling separation anxiety disorder. Similar cultural values have been reported among Latina/Hispanic families (Delgado-Romero, Galván, Hunter, & Torres, 2008), “and strong adherence to such values may also result in symptoms resembling separation anxiety disorder among some Hispanics” (Paniagua, 2014, p. 243). In the case of Muslim families, clinicians should avoid diagnosing Muslim children and adolescents with separation anxiety disorder if they consider the following note from Al-Mateen and Afzal (2004): “attachment to the mother beyond normal Western developmental expectations is considered normal [among Muslim families]” (p. 190). In addition, recent immigrant families are generally less acculturated to social norms of the United States and more prone to reward their children and adolescents for not moving away from their relatives and parents, which may result in the development of symptoms associated with separation anxiety disorder (Sue & Sue, 2003).
Social Phobia/Social Anxiety Disorder
Social demands in certain cultures can result in symptoms resembling social phobia (in the ICD-10 and ICD-10-CM) or social anxiety disorder (in the DSM-5). For example, mental health practitioners from Japan and Korea sometimes report about clients who tend to avoid social situations because they are very afraid of making “other people uncomfortable” (APA, 2013, p. 245). These clients often believe that their facial expression, body odor, and eye contact can be offensive to others. As observed above, this situation is a culture-bound syndrome known in the Japanese culture as taijin kyofusho (see APA, 2013, and Box 1), which the clinician should carefully assess to avoid diagnosing the client/patient with social phobia.
Selective/Elective Mutism
The ICD (WHO, 2010, 2016a, 2016b) and the DSM-5 (APA, 2013) provide general guidelines for diagnosing people with selective (ICD) or elective (DSM-5) mutism. The DSM-5, however, also includes a section alerting mental health practitioners about the need to consider “cultural-related issues” (p. 186) during the diagnosis of mutism in children, adolescents, and adults. The DSM-5 observes that “children in families who have immigrated to a country where a different language is spoken may refuse to speak the new language because of lack of knowledge of the language” (p. 196) and not because the child is actually experiencing symptoms of elective/selective mutism. So, if a recently immigrated Asian, Latina/Hispanic, or Muslim family in the United Sates brings the child to the attention of a mental health practitioner because “the teacher is concerned our child is not talking in the classroom,” this practitioner should first assess the potential cultural variable associated with “symptoms” of mutism (e.g., language barriers) before diagnosing the child with mutism using either the ICD or the DSM-5 system.
Somatization/Somatic Symptom Disorder
The somatization disorder (WHO, 2016a) or somatic symptom disorder (APA, 2013) is another example in which both diagnostic systems differ in terms of the need to consider cultural variables as potential explanations of symptoms. The DSM-5 (APA, 2013) observes that symptoms for this disorder “are prominent in various ‘culture-bound syndromes’” (p. 313) including susto and ataques de nervios (see APA, 2013, p. 83 and p. 835, and Box 1, for a definition of these terms). Chaplin (1997) observed that the mental health practitioner would expect more reports about symptoms for this disorder from Asian and Latino/a/Hispanic patients, in comparison with White patients residing in the United States. Maffini and Wong (2014) made a similar observation regarding this mental disorder, but in the specific case of Asian American patients. In addition, Paniagua (2014) observes that
regarding the type of symptoms [for this disorder] African and South Asian clients generally report more symptoms of burning hands and feet as well as nondelusional experiences of worms in the head or ants crawling under the skin compared to clients from North America. (p. 253)
Mood (Affective) Disorders/Depressive Disorders
The ICD-10 (WHO, 2016a) includes a section dealing with “mood [affective] disorders with several variants, namely, manic episode, bipolar disorder, depressive episode, recurrent depressive disorder, persistent mood [affective] disorder, other mood [affective] disorders, and unspecified mood [affective] disorder.” The DSM-5 (APA, 2013, pp. 155-188) includes a chapter dealing with “depressive disorders” that includes some variants of mood (affective) disorders in the ICD-10. For reasons unexplained in the DSM-5, cultural variables discussed only the case of the following depressive disorders: MDD (depressive episode in the ICD-10) and premenstrual dysphoric disorder (PMDD; not included in the ICD-10).
In the case of MDD, the DSM-5 alerts mental health practitioners to pay attention to the way patients from some cultures mask symptoms of depression by expressing them in somatic terms (see APA, 2013). For example, 16 years prior to the publication of the DSM-5, Young (1997) summarized cultural variable in the manifestation of symptoms of depression and observed that “whereas the depressed European or American patient is likely to present with complaints of psychological problems [e.g., separation or divorce, see Paniagua, 2017], the depressed Asian patient is more likely to present with somatic complaints” (p. 38). Examples of such somatic complaints Asian patients may report during the initial (intake) interview include being very tired most of the day, weakness, or a feeling of “imbalance.” Paniagua (2014) observed that some patients from Middle Eastern countries and American Indian tribes often avoid reporting symptoms suggesting depression by masking such symptoms with reports about heart problems (without physical/medical evidence to confirm such problems) or feeling “heartbroken,” respectively. In addition, some patients from the Latino//Hispanic community tend to avoid reporting symptoms of depression and instead elect to explain their mood problems in terms of recently experiencing the ataques de nervios culture-bound syndrome (see Box 1).
In the case of PMDD, the DSM-5 (APA, 2013) observes that this disorder “is not a culture-bound syndrome” (p. 173) because it “has been observed in individuals in the United States, Europe, Indian, and Asian” (p. 173). This disorder, however, may be associated with some cultural variations. For example, Paniagua (2014) reviewed the literature in this context and found that women who report racial/ethnic and gender discrimination during the initial clinical interview are most likely to report symptoms for PMDD, “in comparison to women without experiences of discrimination” (Paniagua, 2014, p. 242). Paniagua (2014) also found that “foreign-born women and immigrants who arrived in the United States after age 6 were less likely to have PMDD, compared to U.S.-born women and immigrants who arrived before age 6” (p. 242). The original research on this specific topic can be found in Pilver, Desai, Kasl, and Levy (2011).
Psychotic Disorders
In the Clinical Descriptions and Diagnostic Guidelines (ICD/CDDG-10; see WHO, 2016a), the ICD-10 includes an extensive discussion with emphasis on schizophrenia, schizotypal disorder (schizotypal personality disorder in the DSM-5, see APA, 2013, pp. 655-659), delusional disorder, and schizoaffective disorder. In the DSM-5, a similar discussion is included in the chapter titled “Schizophrenia Spectrum and Other Psychotic Disorders,” which includes delusional disorders, brief psychotic disorders, schizophreniform disorder, schizophrenia, and schizoaffective disorder (see APA, 2013, pp. 87-110). With the exception of schizophreniform disorder, in the DSM-5, mental health practitioners are explicitly encouraged to pay attention to cultural variables during the diagnosis of these psychotic disorders (see Castillo, 1997; Kirmayer, Young, & Hayton, 1995; Paniagua, 2014).
In the case of delusional disorder, the DSM-5 observes that “an individual’s cultural and religious background must be taken into account in evaluating the possible presence of delusional disorder” (APA, 2013, p. 93). For example, Latino/Hispanic males who believe in the separation model of acculturation (described above) and are also influenced by the cultural belief of machismo (i.e., the traditional Latino/Hispanic males’ belief in their dominance over Latina/Hispanic women and perception of women as submissive, obedient, and unassertive, which is a reflection of marianismo) show symptoms suggesting jealous type delusional disorder if they also believe that their wife’s acculturation to the norms and values in the United States suggest that she is unfaithful. Paniagua (2014) observed that “unfamiliarity with the machismo cultural variant might lead to the assumption that the Hispanic husband is experiencing a delusional disorder (jealous type)” (p. 238).
The DSM-5 also alerts mental health practitioners that, to avoid erroneously diagnosing people with brief psychotic disorder, it is important to “distinguish symptoms of brief psychotic disorder from culturally sanctioned response patterns” (APA, 2013, p. 238). For example, symptoms for this disorder (e.g., delusions, hallucinations, disorganized speech) may be showed by some African American, American Indian, and Latino/a/Hispanic individuals “who engage in religious or healing ceremonies” (Paniagua, 2014, p. 239) and briefly display such symptoms during their acts. Castillo (1997) observed that during such ceremonies the individual who is the center of the act shows possession trance behaviors with emphasis on demon or spirit possession resulting in the individual “speaking and performing actions as the spirit or demon, sometimes over a lengthy period of time” (p. 111). These possession trance behaviors are not perceived as abnormal by the audience that observes the act, and such behaviors generally end after the completion of such ceremonies. Castillo (1997) also provided examples of symptoms suggesting a brief psychotic disorder in the case of several culture-bound syndromes, including amok, ataque de nervios, and pibloktog (for a definition of these terms, see APA, 2013, p. 83, and Box 1).
The ICD/CDDG-10 (WHO, 2016a) agrees that, in the group of schizophrenia, schizotypal, and delusional disorders, the ICD discusses in the ICD/CDDG-10, “schizophrenia is the commonest and most important disorder of the group” (p. 78, emphasis added). This classification system, however, does not provide mental health practitioners with cultural guidelines to prevent them from either erroneously diagnosis or misdiagnosis people with schizophrenia. The DSM-5 observes that “in some cultures visual or auditory hallucinations [two key DSM-5 diagnostic criteria in schizophrenia] with a religious content (e.g., hearing God’s voice) are a normal part of religious experience [in some cultures]” (p. 103). An example is the study by Kirmayer et al. (1995), which showed that “in the Nigerian culture, paranoid fears of evil attacks by sprits are part of the local beliefs involving fear of malevolent attacks by evil spirits” (Paniagua, 2014, p. 239). Kirmayer et al. (1995) also observed that such paranoid fears “might be misdiagnosed as symptoms of psychosis [in schizophrenia] by the uninformed clinician” (p. 509).
The schizoaffective disorder also receives an extensive discussion in the ICD-10 (WHO, 2016a), but without a discussion on cultural variable that mental health practitioners should consider before diagnosing people with this disorder. In the DSM-5, however, cultural variables are suggested when diagnosing the present disorder. In addition, the DSM-5 (APA, 2013) makes a very important point in this context, namely, that if a “culturally appropriate evaluation” (p. 109) is not conducted during the assessment of schizoaffective disorder among clients from the African American and Latina/Hispanic communities, such patients may be overdiagnosed with “schizophrenia compared with schizoaffective disorder” (pp. 108-109), which is a less severe psychotic disorder.
An example of symptoms suggesting schizotypal personality disorder include “odd beliefs or magical thinking” (APA, 2013, p. 655) in the form of “superstitiousness, belief in clairvoyance, telepathy” (p. 655). Contrary to the lack of cultural guidelines in all variants of the ICD-10 in the case of this disorder, the DSM-5 alerts mental health practitioners that they should not diagnose people with this disorder without assessing perceptual and cognitive distortions “in the context of the individual’s cultural milieu” (APA, 2013, p. 657). The DSM-5 also observes that “culturally determined characteristics, particularly those regarding religious beliefs and rituals, can appear to be schizotypal to the uniformed outsider” (p. 657). Examples of these culturally sanctioned characteristics include “voodoo, speaking in tongues, shamanism, mind reading, six sense, evil eye, and magical beliefs related to health and illness” (p. 657). Table 2 should help busy mental health practitioners to quickly find in the DSM-5 the particular mental disorder with discussion of cultural variables.
Mental Disorders With Discussion on Cultural Issues in the DSM-5.
Note. DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013).
Discussion
A critical clinical issue in the diagnosis of mental disorders is to rule out the potential impact of cultural variables that may explain the presentation of symptoms (Alarcón, 2009; Paniagua, 2014; Zane, Bernal, & Leong, 2016). Despite the need to recognize this issue in mental health services, in the case of the ICD, Alarcón (2009) observed that “the fate of the cultural aspects of psychiatric diagnosis in the ICD is . . . ambiguous, if not nebulous” (http://onlinelibrary.wiley.com/doi/10.1002/j.2051-5545.2009.tb00233.x/full). This article shows examples from the cultural mental health literature to evidencing Alarcón’s observation. Alarcón (2009) also observed that despite the fact that the WHO produced a diagnostic system to allow commonalities in the diagnosis of physical and mental disorders across all WHO culturally diverse countries (e.g., the United States, Asian, Central and South American countries), the absence of an unambiguous set of cultural guidelines in the ICD system informing clinicians about the need to pay attention to cultural variables before diagnosing people with mental disorders (and physical disorders) is a major deficiency in the ICD system (see Patel, Saraceno, & Kleinman, 2006).
The main message across the selected sample of mental disorders discussed above is that, whereas the DSM-5 includes specific cultural guidelines informing mental health practitioners about the need to consider the role of cultural variables before diagnosing people with mental disorders, this is a message completely missed in all variants of the ICD-10 and in the ICD-10-CM. Examples of such cultural guides in the DSM-5 (APA, 2013) include attention to the role of acculturation difficulty in the manifestation of symptoms for a given mental disorder, as well as the patient’s feelings of social exclusion or rejection, perceived adverse discrimination, and difficulty dealing with religious or spiritual problems that could also affect on the presentation of symptoms.
When comparing all variants of the ICD-10 and the ICD-10-CM systems with the DSM-5, the most relevant cultural discussions in the DSM-5, but missed in such systems, include (a) a glossary of cultural concepts of distress (i.e., culture-bound syndromes, for example, ataques de nervios, dhat, susto. taijin kyofusho, see APA, 2013 and Box 1), (b) the diagnosis and clinical management of the case with emphasis on the cultural formulation (e.g., recognition of the cultural identity of the individual and cultural differences between the client/patient and the mental health practitioner), and (c) guidelines to appropriately conduct the cultural formulation interview with emphasis on the cultural definition of the problem, the cultural perception of cause, context, and support, cultural factors affecting self-coping and past help-seeking behaviors, and cultural factors affecting current help-seeking behaviors (see APA, 2013).
Although the DSM-5 significantly differs from all variants of the ICD system in terms of consideration of cultural variables, the DSM-5 does not cover such variables across all mental disorders. Table 2 shows mental disorders with explicit and/or unambiguous cultural statements in the DSM-5 (APA, 2013). Examples of DSM-5 mental disorders without cultural discussion include narcissistic personality disorder, sexual sadism, and persistent depressive disorder (dysthymia), among many more mental disorders in the DSM-5. Regardless of the fact that the DSM-5 still needs to do more in future revisions of the text in terms of covering 100% of mental disorders in the DSM-5 with discussions on cultural issues, in comparison with all variants of the ICD, the DSM-5 is still superior in alerting mental health practitioners about the need to consider cultural variables (i.e., cultural variations and culture-bound syndromes) during the diagnosis of mental disorders.
Several mental health organizations have published cultural parameters or guidelines mental health practitioners belonging to such organization are expected to consider when providing mental health services to culturally diverse patients (APA, 2016; American Psychological Association, 1993, 2003; DuPree, Bhakta, Patel, & DuPree, 2013; National Association of Social Worker, 2016; National Organizations of Nurse Practitioner Faculties, 2003; Pumariega et al., 2013; Ratts, Sing, Butler, Nassar-McMillan, & McCullough, 2016; U.S. Department of Health and Human Services, 2001). These parameters or guidelines should be particularly considered by mental health practitioners who are demanded to use the ICD-10-CM in the United States if they want to be reimbursed for clinical services (Nordal, 2014; Paniagua, 2016), but in which they are not explicitly informed about the need to assess their patient’s cultural, race, and/or ethnic background before arriving at a diagnosis of mental disorders with emphasis on any variant of the ICD-10.
Footnotes
Acknowledgements
The author thanks Dr. Sandra A. Black for her editorial commentaries during an early draft of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.