Ebook Clinical manual of cultural psychiatry (2/E): Part 1

Clinical Manual of
Cultural Psychiatry
Second Edition


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Clinical Manual of
Cultural Psychiatry
Second Edition
Edited by

Russell F. Lim, M.D., M.Ed.

Washington, DC
London, England


Note: The authors have worked to ensure that all information in this book is accurate
at the time of publication and consistent with general psychiatric and medical
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medical research and practice continue to advance, however, therapeutic standards
may change. Moreover, specific situations may require a specific therapeutic response
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involved in their care or the care of a member of their family.
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Library of Congress Cataloging-in-Publication Data
Clinical manual of cultural psychiatry / edited by Russell F. Lim.—Second edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58562-439-3 (pbk. : alk. paper)
I. Lim, Russell F., 1961– editor.
[DNLM: 1. Mental Disorders—ethnology. 2. Community Psychiatry. 3. CrossCultural Comparison. WM 31]
RC454
616.89—dc23
2014012210
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.

Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
Francis G. Lu, M.D.

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . xxix
Video Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxi
www.appi.org/Lim

1 Assessment of Culturally Diverse Individuals:
Introduction and Foundations . . . . . . . . . . . . . . . . 1
Hendry Ton, M.D., M.S. and Russell F. Lim, M.D., M.Ed.
Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Critical Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Outline for Cultural Formulation . . . . . . . . . . . . . . . . . . . . . 6
Cultural Formulation Interview . . . . . . . . . . . . . . . . . . . . . . 7
Historical Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2 Applying the DSM-5 Outline for Cultural
Formulation and the Cultural Formulation
Interview: A Resident’s/Early Career
Psychiatrist’s Perspective . . . . . . . . . . . . . . . . . . 43
Angel Caraballo, M.D., Jennifer Robin Lee, M.D., and
Russell F. Lim, M.D., M.Ed.
Cultural Identity of the Individual . . . . . . . . . . . . . . . . . . . 46

Cultural Concepts of Distress . . . . . . . . . . . . . . . . . . . . . . 56


Psychosocial Stressors and Cultural Features of
Vulnerability and Resilience . . . . . . . . . . . . . . . . . . . . . . 60
Cultural Features of the Relationship Between
the Individual and the Clinician. . . . . . . . . . . . . . . . . . . . 68
Overall Cultural Assessment . . . . . . . . . . . . . . . . . . . . . . 72
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

3 Issues in the Assessment and Treatment of
African American Patients . . . . . . . . . . . . . . . . . . 77
Tracee Burroughs-Gardner, M.D., Annelle B. Primm, M.D., M.P.H.,
William B. Lawson, M.D., Ph.D., and Deborah Cohen, M.B.A.
Historical Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Current Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Applying the Updated DSM-5 Outline for
Cultural Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

4 Issues in the Assessment and Treatment of
Asian American Patients . . . . . . . . . . . . . . . . . . 127
Nang Du, M.D. and Russell F. Lim, M.D., M.Ed.
Overview of the Asian American Population . . . . . . . . . 128
Immigration Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Assessment and Therapeutic Techniques:
Using the DSM-5 Outline for Cultural Formulation
and the Cultural Formulation Interview
With Asian Americans . . . . . . . . . . . . . . . . . . . . . . . . . 134

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

5 Issues in the Assessment and Treatment of
Latino Patients . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Amaro J. Laria, Ph.D. and Roberto Lewis-Fernández, M.D.
Social Demographics and History of
U.S. Migration Patterns . . . . . . . . . . . . . . . . . . . . . . . . 184


Applying the DSM-5 Outline for Cultural Formulation. . . 196
Overall Cultural Formulation. . . . . . . . . . . . . . . . . . . . . . 235
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

6 Issues in the Assessment and Treatment of
American Indian and Alaska Native Patients . . 251
Candace M. Fleming, Ph.D. and Russell F. Lim, M.D., M.Ed.
Current Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Historical Issues That Relate to Mental Health. . . . . . . . 255
Mental Health Needs and Service System Issues . . . . . 258
Applying the DSM-5 Outline for Cultural Formulation. . . 260
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

7 Cultural Issues in Women’s Mental Health. . . .

287

Lisa Andermann, M.Phil., M.D., FRCPC and
Kenneth P. Fung, M.D., M.Sc., FRCPC
Women’s Mental Health and the Women’s
Movement: A Brief History . . . . . . . . . . . . . . . . . . . . . . 288
Epidemiology and Psychopathology. . . . . . . . . . . . . . . . 305
Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Developmental Issues in the Woman’s Life Cycle . . . . . 307
DSM-5 Outline for Cultural Formulation . . . . . . . . . . . . . 321
DSM-5 Cultural Formulation Interview . . . . . . . . . . . . . . 331
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
Cultural Assessment of Gender:
Summary of Key Clinical Skills. . . . . . . . . . . . . . . . . . . 332
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

8 Sexual Orientation: Gay Men, Lesbians,
and Bisexuals . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Marshall Forstein, M.D., Jason Lambrese, M.D., and
Tauheed Zaman, M.D.
Disclosure of Sexual Orientation to Providers . . . . . . . . 343
Epidemiology of Homosexuality . . . . . . . . . . . . . . . . . . . 343


Psychiatric Disorders and Suicide in Lesbian, Gay,
and Bisexual People. . . . . . . . . . . . . . . . . . . . . . . . . . . 347
History of Homosexuality . . . . . . . . . . . . . . . . . . . . . . . . 349
Sexual Identity Terminology . . . . . . . . . . . . . . . . . . . . . . 358
Cultural Identity of the Individual:
Development of a Lesbian, Gay, or
Bisexual Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Common Issues for Lesbian, Gay, or Bisexual

People Presenting for Treatment Throughout
the Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

9 Transgender and Gender Nonconforming
Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Dan H. Karasic, M.D.
Transgender Identity Formation . . . . . . . . . . . . . . . . . . . 399
Transition Care and the WPATH Standards
of Care, Version 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Transgender Patients in Health Care Settings . . . . . . . . 402
Case Discussion: Outline for Cultural Formulation. . . . . 405
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409

10 Religious and Spiritual Assessment. . . . . . . . .

411

David M. Gellerman, M.D., Ph.D.
Performing a Spiritual Assessment . . . . . . . . . . . . . . . . 413
Using the Outline for Cultural Formulation to
Organize the Spiritual Assessment . . . . . . . . . . . . . . . 417
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430


11 Ethnopsychopharmacology. . . . . . . . . . . . . . . .

435

David C. Henderson, M.D. and Brenda Vincenzi, M.D.
Introduction to the Pharmacogenetics of
Drug-Metabolizing Enzymes . . . . . . . . . . . . . . . . . . . . 437
Ethnic Variation in Medication Response . . . . . . . . . . . . 437
Pharmacogenetics of Drug-Metabolizing Enzymes . . . . 442
Cytochrome P450 Enzymes and
Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . 454
Importance of Nonpharmacological Factors. . . . . . . . . . 459
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

12 Conclusion: Applying the Updated DSM-5
Outline for Cultural Formulation and
Cultural Formulation Interview . . . . . . . . . . . . . 469
Russell F. Lim, M.D., M.Ed.
Outline for Cultural Formulation . . . . . . . . . . . . . . . . . . . 470
Cultural Formulation Interview . . . . . . . . . . . . . . . . . . . . 473
Final Thoughts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

Appendix 1: DSM-5 Outline for Cultural
Formulation, Cultural Formulation Interview,
and Supplementary Modules . . . . . . . . . . . . . . . 477
Outline for Cultural Formulation . . . . . . . . . . . . . . . . . . . 477
Cultural Formulation Interview (CFI). . . . . . . . . . . . . . . . 479
Cultural Formulation Interview (CFI)—Informant
Version . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487

Supplementary Modules to the Core Cultural
Formulation Interview (CFI) . . . . . . . . . . . . . . . . . . . . . 493

Appendix 2: DSM-5 Glossary of Cultural
Concepts of Distress . . . . . . . . . . . . . . . . . . . . . 519
Ataque de nervios. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Dhat syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521


Khyâl cap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
Kufungisisa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Maladi moun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Nervios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Shenjing shuairuo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
Susto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Taijin kyofusho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532

Appendix 3: Cultural Formulations of
Case Examples Seen in the Videos. . . . . . . . . . 535
Russell F. Lim, M.D., M.Ed. and Hendry Ton, M.D., M.S.
Chapter 2: Vietnamese American Case—
Mr. Tran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Chapter 3: African American Case—Mr. Jones . . . . . . . 539
Chapter 4: Asian American Case—Mr. Chen. . . . . . . . . 542
Chapter 5: Latino Case—Mrs. Santiago. . . . . . . . . . . . . 546
Chapter 7: White Euro-American Case—
Ms. Diamond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Francis G. Lu, M.D.

Books . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Journals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Web Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565


List of Tables
Table 1–1
Table 1–2

Essential components of culture . . . . . . . . . . . . . . 5
DSM-IV-TR and DSM-5 Outline for Cultural
Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Table 1–3
Cultural Formulation Interview . . . . . . . . . . . . . . 10
Table 1–4
Cultural identity . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Table 1–5
Migration history . . . . . . . . . . . . . . . . . . . . . . . . . 15
Table 1–6
Cultural identity: advantages of assessment . . . . 16
Table 1–7
Conflicting explanatory models . . . . . . . . . . . . . . 21
Table 1–8
Kleinman’s eight questions . . . . . . . . . . . . . . . . . 23
Table 1–9
Cultural influences on transference and
countertransference. . . . . . . . . . . . . . . . . . . . . . . 27
Table 1–10 Competency criteria for interpreters . . . . . . . . . . 32

Table 2–1
Useful mnemonics for cultural formulation . . . . . 47
Table 2–2
Culture-bound syndromes (cultural
concepts of distress) in Asia . . . . . . . . . . . . . . . . 61
Table 2–3
Culture-bound syndromes (cultural
concepts of distress) in Latin America. . . . . . . . . 62
Table 2–4
Culture-bound syndromes (cultural
concepts of distress) in industrialized
countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Table 2–5
Culture-bound syndromes (cultural
concepts of distress) in Africa and the
Caribbean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Table 2–6
Culture-bound syndromes (cultural concepts of
distress) among Native Americans . . . . . . . . . . . 65
Table 3–1
DSM-IV-TR Outline for
Cultural Formulation (OCF) and
updated DSM-5 OCF. . . . . . . . . . . . . . . . . . . . . . 94
Table 3–2
Critique of therapist and skills . . . . . . . . . . . . . . 112
Table 4–1
Major Asian American groups
in the 2010 U.S. Census . . . . . . . . . . . . . . . . . . 129
Table 4–2
Cultural concepts of distress . . . . . . . . . . . . . . 142

Table 4–3
Table 4–4
Table 4–5
Table 4–6
Table 5–1

Table 6–1
Table 6–2
Table 6–3
Table 6–4
Table 6–5

Table 6–6

Table 6–7
Table 7–1

Table 7–2

Table 7–3

Table 8–1

Religious philosophies. . . . . . . . . . . . . . . . . . . . 144
Alternative beliefs and healing strategies . . . . . 148
Common Asian American beliefs
about medications and strategies . . . . . . . . . . . 156
Ten tips for psychotherapy

with Asian Americans . . . . . . . . . . . . . . . . . . . . 170
Educational status, financial status,
and employment status
of non-Hispanic whites and Hispanics
in the United States, 2012 . . . . . . . . . . . . . . . . . 186
Preparing to see a Native patient . . . . . . . . . . . 259
Native American patient’s
expectations of a non-Native healer . . . . . . . . . 274
Native American patient’s
expectations of an indigenous healer . . . . . . . . 275
Native American patients’
desired characteristics of therapists . . . . . . . . . 276
Developing trust between
Indian and Native patients
and their therapists . . . . . . . . . . . . . . . . . . . . . . 277
Building effective therapeutic
relationships between Indian
and Native patients and therapists . . . . . . . . . . 278
Suggestions for working
with Native American patients . . . . . . . . . . . . . . 279
Practical guide to culturally competent
assessment on gender issues:
identifying data/history of present illness
and psychiatric history . . . . . . . . . . . . . . . . . . . 292
Practical guide to culturally competent
assessment on gender issues: mental status
examination . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Practical guide to culturally competent
assessment on gender issues: assessment of
personal history . . . . . . . . . . . . . . . . . . . . . . . . 312

Where same-sex relationships are legal . . . . . 357


Table 8–2
Table 8–3
Table 8–4

Table 10–1
Table 11–1
Table 11–2

Table 11–3
Table 11–4
Table 11–5
Table 11–6
Table 11–7

Dimensions of sexual, social,
and psychological orientation . . . . . . . . . . . . . . 360
Cass’s six stages of sexual identity
development . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Questions from the
Cultural Formulation Interview (CFI) and
supplementary modules for lesbian, gay, and
bisexual patients . . . . . . . . . . . . . . . . . . . . . . . . 384
Mnemonics for a spiritual assessment . . . . . . . 416
Ethnicity and atypical antipsychotics . . . . . . . . . 443
Summary: major human cytochrome P450
(CYP450) enzymes and their psychotropic
substrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444

Cytochrome P450 (CYP450) isoenzymes,
inhibitors, and inducers . . . . . . . . . . . . . . . . . . . 446
Cytochrome P450 (CYP450)
2D6 metabolic rates. . . . . . . . . . . . . . . . . . . . . . 448
Herb–cytochrome P450 (CYP450)
drug interactions . . . . . . . . . . . . . . . . . . . . . . . . 458
Herbal medications and
cytochrome P450 (CYP450) enzymes . . . . . . . 459
Five tips for working with
ethnic minority patients . . . . . . . . . . . . . . . . . . . 461


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List of Figures
Figure 1–1

The therapeutic triad model. . . . . . . . . . . . . . . . . 31

Figure 3–1

Use of mental health services
by race/ethnicity. . . . . . . . . . . . . . . . . . . . . . . . . . 90

Figure 3–2

Non-M.D. service use by race. . . . . . . . . . . . . . . 91

Figure 11–1 Factors affecting drug metabolism. . . . . . . . . . . 436

Figure 11–2 Haloperidol metabolism
by route and ethnicity. . . . . . . . . . . . . . . . . . . . . 440
Figure 11–3 Cytochrome P450 (CYP450)
2D6 poor metabolizers (PM) and
slow metabolizers (SM). . . . . . . . . . . . . . . . . . . 449
Figure 11–4 Cytochrome P450 (CYP450)
2D6 ultrarapid metabolizers. . . . . . . . . . . . . . . . 451
Figure 11–5 Cytochrome P450 (CYP450) 2C19 activity
and half-life of diazepam
in Chinese patients. . . . . . . . . . . . . . . . . . . . . . . 454
Figure 11–6 Nifedipine side effects and corn. . . . . . . . . . . . . 456


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Contributors
Lisa Andermann, M.Phil., M.D., FRCPC
Assistant Professor, Equity, Gender and Populations Division, Department of
Psychiatry, University of Toronto and Mount Sinai Hospital, Toronto, Ontario, Canada?
Tracee Burroughs-Gardner, M.D.
CEO/Medical Director, Urban Behavioral Associates, Baltimore, Maryland
Angel Caraballo, M.D.
Assistant Clinical Professor of Psychiatry, Columbia University, New York,
New York
Deborah Cohen, M.B.A.
Research Project Manager, American Psychiatric Association, Arlington, Virginia
Nang Du, M.D.
Clinical Professor of Psychiatry, University of California, San Francisco, California; Medical Chief, San Mateo North County BHRS Services, Daly City,
California

Candace M. Fleming, Ph.D.
Associate Professor and Director of Training, American Indian and Alaska
Native Programs, Anschutz Medical Campus, University of Colorado Denver,
Aurora, Colorado
Marshall Forstein, M.D.
Associate Professor of Psychiatry, Harvard Medical School; Director, Adult
Psychiatry, Residency Training, Cambridge Hospital, Cambridge Health Alliance, Cambridge, Massachusetts

xvii


xviii Clinical Manual of Cultural Psychiatry, Second Edition

Kenneth P. Fung, M.D., M.Sc., FRCPC
Clinical Director, Asian Initiative in Mental Health, Toronto Western Hospital; Associate Professor, Equity, Gender and Populations Division, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
David M. Gellerman, M.D., Ph.D.
Staff Psychiatrist, Sacramento VA Medical Center, Mather, California; Assistant Clinical Professor, Department of Psychiatry, University of California at
Davis Medical Center, Sacramento, California
David C. Henderson, M.D.
Associate Professor of Psychiatry, Massachusetts General Hospital, Harvard
Medical School; Director, Chester M. Pierce, MD Division of Global Psychiatry and Director, Schizophrenia Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts
Dan H. Karasic, M.D.
Health Sciences Clinical Professor of Psychiatry, UCSF, San Francisco, California
Jason Lambrese, M.D.
Adult Psychiatry Resident, Cambridge Hospital; Clinical Fellow in Psychiatry, Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts
Amaro J. Laria, Ph.D.
Clinical Instructor in Psychology, Department of Psychiatry, Cambridge
Health Alliance/Harvard Medical School, Boston, Massachusetts; Founder
and Director, Boston Behavioral Medicine, Brookline, Massachusetts
William B. Lawson, M.D., Ph.D.

Professor and Chair, Department of Psychiatry, Howard University College of
Medicine, Washington, D.C.


Contributors xix

Jennifer Robin Lee, M.D.
Westport, Connecticut
Roberto Lewis-Fernández, M.D.
Professor of Psychiatry, Columbia University Medical Center; Director, New
York State Center of Excellence for Cultural Competence, New York State
Psychiatric Institute; Director, Hispanic Treatment Program, New York State
Psychiatric Institute, New York, New York
Russell F. Lim, M.D., M.Ed.
Health Sciences Clinical Professor, Department of Psychiatry and Behavioral
Sciences, University of California Davis School of Medicine, Sacramento,
California
Francis G. Lu, M.D.
Luke and Grace Kim Professor in Cultural Psychiatry, Emeritus, Department
of Psychiatry and Behavioral Sciences, University of California Davis School
of Medicine, Sacramento, California
Annelle B. Primm, M.D., M.P.H.
Director, Department of Minority and National Affairs, and Deputy Medical
Director, American Psychiatric Association, Arlington, Virginia
Hendry Ton, M.D., M.S.
Medical Director, Transcultural Wellness Center; Health Sciences Associate
Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California
Brenda Vincenzi, M.D.
Schizophrenia Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts
Tauheed Zaman, M.D.

Adult Psychiatry Resident, Cambridge Hospital; Clinical Fellow in Psychiatry, Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts


xx Clinical Manual of Cultural Psychiatry, Second Edition

Disclosure of Interests
The following contributors to this book have indicated a financial interest in or
other affiliation with a commercial supporter, a manufacturer of a commercial
product, a provider of a commercial service, a nongovernmental organization,
and/or a government agency, as listed below:
William B. Lawson, M.D., Ph.D. Grants: Merck, Inc.; Otsuka Pharmaceutical Development & Commercialization, Inc. Speakers bureau: Reckitt
Benckiser
Roberto Lewis-Fernández, M.D. Grants: National Institute of Mental
Health; Office of Mental Health, State of New York; Columbia University; Eli
Lilly & Co.
The following contributors have indicated that they have no financial interests or other affiliations that represent or could appear to represent a competing interest with their contributions to this book:
Lisa Andermann, M.Phil., M.D., FRCPC, Angel Caraballo, M.D., Nang
Du, M.D., Marshall Forstein, M.D., Kenneth P. Fung, M.D., M.Sc., FRCPC, David M. Gellerman, M.D., Ph.D., David C. Henderson, M.D., Dan
Karasic, M.D., Jason Lambrese, M.D., Amaro J. Laria, Ph.D., Jennifer Robin
Lee, M.D., Russell F. Lim, M.D., M.Ed., Francis G. Lu, M.D., Hendry Ton,
M.D., M.S., Brenda Vincenzi, M.D., Tauheed Zaman, M.D.


Foreword

T

he Outline for Cultural Formulation (OCF), first published in DSM-IV
in 1994 and reprinted in DSM-IV-TR (American Psychiatric Association
1994, 2000), provided the starting point for the first edition of the Clinical

Manual of Cultural Psychiatry. That first edition was based on the continuing
medical education courses on the OCF directed by Dr. Russell Lim, first given
at the American Psychiatric Association Annual Meeting in 1996, which have
continued on an annual basis. With the publication of DSM-5 in 2013
(American Psychiatric Association 2013), this second edition is a timely update that incorporates important changes in cultural issues for psychiatric diagnosis, formulation, and treatment planning led by Roberto LewisFernández, M.D., chair of the Cultural Issues Workgroup of the DSM-5 Gender and Cross-Cultural Issues Study Group.
First, as reflected in the new chapters on women’s issues; lesbian, gay, and
bisexual issues; transgender and gender nonconforming patient issues; and religion and spirituality, this second edition embraces the explicit expansion of
the definition of the cultural identity of the individual in the DSM-5 revised
OCF that included this new sentence: “Other clinically relevant aspects of
identity may include religious affiliation, socioeconomic background, personal and family places of birth and growing up, migrant status, and sexual
orientation” (American Psychiatric Association 2013, p. 750). This welcome
addition to the definition of the cultural identity of the individual provides
important dimensions of cultural identity that should be assessed along with
race, ethnicity, language, and migration, which were the focus of the defini-

xxi


xxii Clinical Manual of Cultural Psychiatry, Second Edition

tion in DSM-IV and DSM-IV-TR, to provide a holistic understanding of the
unique cultural identity of the individual seen in the clinical encounter.
The second major revision to the DSM-IV OCF in DSM-5 was the use of
the term cultural conceptualizations of distress instead of the much narrower
term cultural explanations of illness to capture a fuller range of patient experiences of illness, now broadened to include cultural syndromes and idioms of
distress in addition to cultural explanations of illness. This second edition provides important examples so clinicians can recognize these phenomena and
incorporate them correctly in their diagnostic formulation so as to reduce the
chance of misdiagnosing these cultural phenomena as signs and symptoms of
mental disorders.
Third, this second edition thoroughly discusses the use of the Cultural

Formulation Interview (CFI; see Appendix 1), which is entirely new in DSM5 (American Psychiatric Association 2013, pp. 750–757). This major innovation in DSM-5 provides 16 key questions for clinicians to ask patients to
elicit information relevant to the OCF. In addition, there is a second version
for clinicians to use with informants. Finally, in the Assessment Measures section of the online DSM-5, there are 12 supplementary modules to probe in
greater detail on specific areas discovered by using the CFI. These materials
can be accessed at />The last (but not least) innovation in the second edition is online access to
video vignettes that demonstrate parts of a diagnostic interview aimed at obtaining information for the DSM-5 OCF. James Boehnlein, M.D., Professor
of Psychiatry at Oregon Health and Sciences University and past president of
the Society for the Study of Psychiatry and Culture, interviews several simulated patients from diverse cultural backgrounds.
One of the joys of academic psychiatry, despite its many challenges, is the
opportunity to mentor trainees and to see the arc of their career development.
I have been fortunate and grateful to have had this opportunity in my career
with the editor of this book, Russell F. Lim, M.D., who was a psychiatry resident I mentored at the University of California, San Francisco, in the early
1990s, when our collaborative teaching began about the OCF. When published
in 2006, the first edition of this book provided clinicians, trainees, and faculty
the clinical tools to bring culture into the clinical encounter to make more accurate diagnoses and to enhance treatment plans through the use of the OCF


Foreword xxiii

for the four major racial/ethnic minority groups. With this second edition, Dr.
Lim and his colleagues have indeed brought the field of cultural assessment in
clinical psychiatry to a new level of development commensurate with DSM-5,
just 20 years after the publication of the original OCF in DSM-IV.
Francis G. Lu, M.D.

References
American Psychiatric Association: Appendix I: Outline for cultural formulation and
glossary of culture-bound syndromes, in Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994, pp 843–849
American Psychiatric Association: Appendix I: Outline for cultural formulation and

glossary of culture-bound syndromes, in Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, pp 847–903
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC, American Psychiatric Association, 2013


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