Download the cultural formulation: a method for assessing cultural factors

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Psychiatric Quarterly, Vol. 73, No. 4, Winter 2002 (°
THE CULTURAL FORMULATION: A METHOD
FOR ASSESSING CULTURAL FACTORS
AFFECTING THE CLINICAL ENCOUNTER
Roberto Lewis-Fernández, M.D.
and Naelys Dı́az, M.S.W.
The growing cultural pluralism of US society requires clinicians to examine the
impact of cultural factors on psychiatric illness, including on symptom presentation and help-seeking behavior. In order to render an accurate diagnosis across
cultural boundaries and formulate treatment plans acceptable to the patient,
clinicians need a systematic method for eliciting and evaluating cultural information in the clinical encounter. This article describes one such method, the
Cultural Formulation model, expanding on the guidelines published in DSM-IV.
It consists of five components, assessing cultural identity, cultural explanations
of the illness, cultural factors related to the psychosocial environment and levels of functioning, cultural elements of the clinician–patient relationship, and
the overall impact of culture on diagnosis and care. We present a brief historical overview of the model and use a case scenario to illustrate each of its
Roberto Lewis-Fernández, M.D., is an Assistant Professor of Clinical Psychiatry at
Columbia University, a Lecturer on Social Medicine at Harvard University, and is the
Director of the Hispanic Treatment Program at NY State Psychiatric Institute, New
York, NY.
Naelys Dı́az, M.S.W., is a Doctoral Candidate in Social Work at Fordham University.
Address correspondence to Roberto Lewis-Fernández, M.D., New York State Psychiatric Institute, Unit 69, 1051 Riverside Drive, New York, NY 10032; e-mail: rlewis@
nyspi.cpmc.columbia.edu.
271
C 2002 Human Sciences Press, Inc.
0033-2720/02/1200-0271/0 °
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components and the substantial effect on illness course and treatment outcome
of implementing the model in clinical practice.
KEY WORDS: cultural formulation; diagnostic assessment; cultural psychiatry; popular
syndromes; Latinos.
As rising immigration causes industrialized societies to become even
more culturally pluralistic and organized mental health services in developing nations face the challenge of distributing care more broadly,
psychiatrists will increasingly come in contact with a larger diversity
of social groups (1). The evaluation of patients from disparate ethnocultural backgrounds requires clinicians to assess the impact of cultural factors on all aspects of psychiatric illness, including symptom
presentation and help-seeking behavior. In order to render an accurate
diagnosis across cultural boundaries and formulate treatment plans
acceptable to the patient and oftentimes the family, clinicians need a
method for eliciting and evaluating cultural information during the
clinical encounter.
Standardizing the assessment method is particularly important in order to avoid systematic misjudgments of which the clinician is often unaware. An example of this is the apparent clinician bias that results in
a higher rate of misdiagnosis of paranoid schizophrenia among African
American and Latino patients suffering from bipolar disorder or depression with psychotic features, compared to non-Latino Whites (2,3).
In one key study, misdiagnosis by race was found to be related to
“information variance,” differences in the amount of information the
predominantly White clinicians obtained from African American as opposed to White patients, rather than race-specific discrepancies in the
way diagnostic criteria were applied (“criterion variance”) (4). This suggests that standardizing the process of clinical information-gathering
would reduce misdiagnosis.
Using a systematic method for assessing cultural contributions to
illness presentation would also help the clinician diagnose culturally
patterned experiences of illness that are distinct from mainstream psychiatric diagnostic criteria. Many societies around the world have developed folk mental health classification systems that are distinct from
US psychiatric nosology (5,6). Patients from these societies and cultural
backgrounds often express distress and psychopathology less in accord with US diagnostic categories than with their popular syndromes.
The translation between popular and professional nosologies is often
complicated. Neurasthenia, for example, originally a US professional
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diagnosis that is no longer included in the DSM system but is retained
in ICD-10, is the most prevalent current (12-month) disorder among
Chinese Americans in Los Angeles County (7). For US psychiatrists,
however, it presents a diagnostic challenge, due to its partial overlap
with multiple diagnostic categories, including mood, anxiety, and somatoform disorders (7,8).
Ataque de nervios (attacks of nerves), on which we will focus later
in this article, is another example of a popular category that presents
diagnostic challenges for US psychiatrists. This Latino syndrome is
characterized by paroxysms of intense emotionality, acute anxiety
symptoms, and loss of control, often associated with dissociative experiences and occasionally with other- or self-directed aggressive behaviors (9). It constitutes the second most prevalent psychopathological
syndrome in Puerto Rico and has a complex relationship with psychiatric diagnoses (10). Mainly associated with mood and anxiety disorders, it also can occur in conjunction with dissociative disorders (11)
and in individuals with impulse control, somatoform, or psychotic disorders. The existence of these popular syndromes and the need for a
case-by-case translation into DSM-IV categories underscores the risks
of not obtaining sufficient cultural information as part of the diagnostic
assessment.
In order to deliver care that is culturally valid, therefore, clinicians
need a method that systematically allows them to take culture into
account when conducting a clinical evaluation. One such method that
has been operationalized in recent years is the Cultural Formulation
(CF) model. The CF model supplements the biopsychosocial approach
by highlighting the effect of culture on the patient’s symptomatology,
explanatory models of illness, help-seeking preferences, and outcome
expectations (12–15). It is described in Appendix I of DSM-IV (16) and
is recommended for implementation during the assessment phase of
every clinical relationship.
The CF model is especially necessary when the clinician and the patient do not share the same cultural background, since it is then that
particular attention to cultural features can be most helpful in orienting the clinical intervention. It is important to remember, however, that
even persons sharing the same race or ethnicity can differ in their cultural backgrounds, as race and ethnic groups are culturally heterogenous (12,17). Implementation of the CF model when there is no ethnic
difference between patients and clinicians can still elicit very useful information about culturally based values, norms, and behaviors—such
as about alternative health practices, physiological interpretations, or
religious beliefs—that may otherwise go unnoticed because the clinician
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assumes that the patient is “just like me.” In addition, the CF model
should not be construed for use mainly between majority clinicians and
minority patients. Given the growing ethno-cultural pluralism of psychiatric residency programs in the US (including a high proportion of
International Medical Graduates), the existence of cultural differences
is becoming perhaps just as likely between majority patients and their
clinicians.
This article will present the Cultural Formulation model. The first
part of the discussion will give a brief historical overview of the model
and its components. The second part will consist of a case scenario that
will illustrate the purpose of each section of the model and its usefulness
in psychiatry and mental health in general.
HISTORICAL OVERVIEW AND COMPONENTS OF THE
CULTURAL FORMULATION MODEL
The contemporary version of the CF model dates from the process of
preparing DSM-IV. Due in part to criticisms of insensitivity to cultural
issues in DSM-III and DSM-III-R, the National Institute of Mental
Health supported the creation in 1991 of a Group on Culture and Diagnosis. The main goal of this Group was to advise the DSM-IV Task
Force on how to make culture more central to the Manual. One of the
ways proposed by the Group was the development of a standard method
for applying a cultural perspective to the clinical evaluation (15,18).
Early efforts focused on supplementing the five existing axes with a
sixth or “Cultural Axis.” However, this approach was soon abandoned as
too limiting, since at best it would only permit the use of a restricted list
of socio-cultural labels which would be of little clinical significance (14).
The Group aimed for a more thorough re-thinking by the clinician of
the patient’s cultural picture and how it affects all five axes, as well as
clinical elements not contemplated by the multi-axial structure, such
as help-seeking expectations, family and community views of the illness and its outcome, and institutional pressures on the clinical encounter. A key aim of the Group was to operationalize a method that,
while standardized, still allowed for an individualized assessment of
cultural factors (15). This was based on the perspective that a person’s
cultural background is affected by the intersection of multiple social
influences—including those due to gender, class, race, sexual orientation, etc.—and therefore would need to be described in individual rather
than solely collective terms in order to avoid stereotyping (12).
The Group settled on a narrative format that follows a standard set
of components. These are listed in Table 1. Every patient would have
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TABLE 1
Components of the Cultural Formulation
Cultural formulation
section
Cultural identity of the
individual
Cultural explanations
of the individual’s
illness
Cultural factors
related to psychosocial
environment and
levels of functioning
Cultural elements of the
relationship between
the individual and
the clinician
Overall cultural
assessment for
diagnosis and care
Subheading
• Individual’s ethnic or cultural reference
group(s)
• Degree of involvement with both the culture
of origin and the host culture (for immigrants
and ethnic minorities)
• Language abilities, use, and preference
(including multilingualism)
• Predominant idioms of distress through
which symptoms or the need for social
support are communicated
• Meaning and perceived severity of the
individual’s symptoms in relation to norms of
the cultural reference group(s)
• Local illness categories used by the
individual’s family and community to identify
the condition
• Perceived causes and explanatory models that
the individual and the reference group(s) use
to explain the illness
• Current preferences for and past experiences
with professional and popular sources of care
• Culturally relevant interpretations of social
stressors, available social supports, and levels
of functioning and disability
• Stresses in the local social environment
• Role of religion and kin networks in providing
emotional, instrumental, and informational
support
• Individual differences in culture and social
status between the individual and the
clinician
• Problems that these differences may cause in
diagnosis and treatment (e.g. difficulties in
eliciting symptoms and understanding their
cultural significance, in determining whether
a behavior is normal or pathological, etc.)
• Discussion of how cultural considerations
specifically influence comprehensive
diagnosis and care
Note. Summarized from DSM-IV, pp. 843–844.
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his/her cultural background described in a brief text that incorporates
each of the listed elements. This Cultural Formulation is based on prior
work on the “mini clinical ethnography,” which sets out a brief anthropological assessment of the cultural factors that are immediately relevant
to the clinical situation (19,20).
In selecting a narrative model, the Group was consciously endorsing the growing importance of the study of narrative in anthropology
and other social sciences, as well as echoing a tradition within mental
health assessment: the psychodynamic formulation (14). In medicine
in general, the use of narrative accounts of illness goes beyond diagnostic typologies to claim a different “truth” in the creation of a humanized account of suffering from the patient’s perspective that encompasses a greater view of the social world than the purely diagnostic
evaluation (19). The use of this technique can also account for the role
that health institutions and practitioners have on the evolution of the
person’s illness and his/her perception and interpretation of it (21,22).
This allows a reflexive stance on the clinician-patient interaction, in
which the role of the practitioner in shaping the process of evaluation,
including what is reported by the patient and what is perceived by the
clinician, can be “painted back in.”
An outline of the Cultural Formulation was prepared and submitted
to the DSM-IV Task Force. In addition, a field test was performed on
patients from four US ethnic minorities: African American, American
Indian, Asian American, and Latino. The results revealed that the CF
model could be successfully applied to patients from different cultural
backgrounds. An edited version of the proposed text was published in
Appendix I of DSM-IV (15).
As a result of its publication in DSM-IV, the Cultural Formulation
has begun to form part of the curricula of US psychiatry residency
programs. Since 1996, the CF model has been the subject of a regular
section on clinical case studies in Culture, Medicine and Psychiatry (14),
of whom the senior author is the section editor, and of a yearly course at
the Annual Meeting of the American Psychiatric Association. In 2001,
the Cultural Psychiatry Committee of the Group for the Advancement
of Psychiatry published a book on the CF model that includes a number
of case examples (12).
CULTURAL FORMULATION OF A CLINICAL CASE
The second part of this article summarizes a case study of an actual
patient (23) that illustrates the purpose of each of the components
of the Cultural Formulation and the impact on treatment outcome of
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implementing this model in clinical practice. In particular, the case
highlights some of the diagnostic complexities involved in assessing
patients reporting nervios (nerves) and ataques de nervios (attacks of
nerves), prevalent popular syndromes among Latinos. A brief summary
of the clinical history is followed by the cultural formulation of the case.
Informed consent was obtained from the patient for description of this
clinical material.
Clinical History
A 49 year-old widowed Puerto Rican woman presented to an outpatient
Latino Mental Health Clinic in New England after a 3-year history of
prolonged hospitalizations due to recurrent major depressive disorder
with diagnosed psychotic features and chronic impulsive suicidality.
Except for brief periods of partial recovery lasting less then 2 weeks,
the patient reported several years of chronic sadness, anhedonia, tearfulness, psychomotor retardation, suicidality, guilty ruminations, decreased sleep and appetite, interest, energy, and concentration. She
also suffered from restlessness, “nervousness,” trembling, increased
startle, anguish, and severe headaches. Patient’s “psychotic” diagnosis
was due to the following during her affective decompensations: hearing
her name called when alone, glimpsing a darting shadow, and “feeling”
someone behind her. Despite past traumas (physical abuse, husband’s
murder) she denied many of the symptoms of posttraumatic stress disorder. There was no history of substance abuse. Her first episode of
major depression dated from age 32 and had recurred at least once
before the current episode.
Patient was born in rural Puerto Rico and had a 5th grade education.
Her father developed alcoholism while working as a seasonal agricultural migrant in the United States and was verbally abusive and physically threatening to the patient’s mother when intoxicated. The patient
denied witnessing overt physical or sexual abuse or being the object
of childhood trauma, but did complain of her mother’s cold distance.
Patient married at 16 and had 6 children, one of whom died of pneumonia at 3 months of age. Husband also developed alcohol problems
and became physically and emotionally abusive towards her. After an
escalation of his abuse, patient ended the marriage by migrating to the
Eastern United States at age 31 with the man who became her second
husband. She left four of her children behind with relatives, a decision
that resulted in her parents’ rejection. Five years later she returned to
Puerto Rico after the murder of her second husband in a street fight.
The son who had migrated with her to the US entered a residential
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drug abuse program 11 years later, at which point she migrated to a
different East Coast city at age 47 to be near her oldest son from whom
she felt estranged. Her conflicts with this son and her other children
precipitated her inpatient admissions.
Inpatient psychotherapy, antidepressants, and antipsychotics only
produced minor improvement of her depression and suicidality and no
change in her psychotic symptoms. After discharge to the outpatient
Latino Clinic, her psychotic symptoms were reassessed as normative
Puerto Rican spiritual expressions of demoralization and her molindone
was discontinued. While still on phenelzine during evaluation for family
therapy, the patient suffered an ataque de nervios in the midst of an
argument with her son. During the ataque, which was characterized by
dissociative symptoms (depersonalization, “numbness”), she attempted
an impulsive overdose with phenelzine. She required ICU treatment
and a brief in-patient stay, and was taken off all psychiatric medications.
Intensive psychotherapeutic management was instituted, initially including individual, family, and group modalities. Improved family relations resulted in marked decrease in symptoms. Outpatient assessment
and psychotherapy revealed patient’s longstanding characterological
symptoms and she received a diagnosis of Borderline Personality Disorder. She reduced her participation in treatment after a few months,
preferring weekly supportive psychotherapy and monthly psychiatric
visits. These latter acted as a kind of supervision of her clinical picture, since medications were not prescribed. Patient was followed off
medications for 8 years without recurrence of major depression or suicidality. She did develop periodic exacerbations of depressive, anxiety,
dissociative, and somatization symptoms that did not meet specified diagnostic criteria. Though she continued to perceive “shadows” and hear
her name called when alone, these experiences produced only temporary concern. There was never any evidence of formal thought disorder
nor loss of generalized reality orientation [Summarized from (23)].
Cultural Formulation
Cultural Identity
The section on Cultural Identity serves as an introduction to the rest of
the Cultural Formulation. Its purpose is to identify for each patient the
particular mix of socio-cultural influences that has patterned his/her
individual cultural world. As stated earlier, cultures are experienced
differently by different members according to subgroup characteristics such as gender, class, religion, race, and sexual orientation, among
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other factors. This section of the formulation collects information on
how these various social factors impact the person’s cultural environment in order to prevent overly general or stereotypical interpretations
of cultural influence (13). This section also permits assessment of the
person’s own sense of his/her ethno-cultural identity, particularly in
respect to other alternative identities; this takes on particular significance in settings of rapid cultural change or ethnic conflict, or among
migrants or persons of multicultural heritage. At the conclusion of this
section, the formulation writer should have a sense of how the person
fits against a specific cultural background. This serves as a prelude to
understanding how his/her individual experience of the illness and its
meanings and outcomes fit within that cultural context, which is the
topic of the rest of the CF model (12).
The following subsections are included within the general section on
Cultural Identity. For the purpose of illustrating its content, each subsection begins with one key question regarding the case under discussion that summarizes the subsection topic. We will follow this format
for every subsection throughout the article.
Reference Group. Within her overall group (Puerto Rican culture),
which particular cultural subgroups form the relevant context for assessing this person?
A key influence on this patient’s cultural background is her status
as a rural person with limited formal education who migrated twice
to the US for a total of 13 years’ residence as part of the “circular”
pattern of Puerto Rican migration that intensified in the 1960’s and
70’s. The “circularity” of this migratory stream consists of recurrent
“back and forth” moves between Puerto Rico and usually the East Coast
of the United States in search of better economic and health care opportunities and in order to reestablish family and cultural links (24).
Like many of these migrants, she was only mildly acculturated despite
this extended stay, given her periodic returns to her culture of origin
and the barriers to integration into the US mainstream for persons
of her ethnic, class, and educational background caused by chronic
unemployment and limited housing options outside of encapsulated
Latino neighborhoods (25). Her self-identity remained that of an Island Puerto Rican, despite her migratory experience. In effect, this
patient had retained most of the traditional views of illness from her
rural background despite several years of residence in US urban
settings.
In this subsection it is also important to understand the patient’s migratory process in the context of her former experience in Puerto Rico
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and the reasons for her migration (13). Because her initial migration occurred in order to escape her husband’s physical abuse, and involved a
prolonged separation from her children, this person’s migratory process
is akin in some respects to that of a refugee, an unusual status among
low-income Puerto Rican migrants, who are usually motivated by economic reasons. Some of her subsequent psychiatric symptoms, such as
her acute alienation, guilt, and suicidality, can be better understood
against this unusual migratory context.
Language. Does the patient have access to more than one language
for expressing her illness-related experiences and obtaining care, and if
so, which language predominates?
Language assessment is an important element of the CF model because language identifies and codifies a person’s experience, which can
be distorted in the process of translation. In the case of multilingual
individuals, the use of a secondary language may limit the ability to obtain an accurate history and reach a valid diagnosis, since emotionality
and cognition may be expressed differently in different languages. For
example, an individual may appear more or less pathological depending
on the language of the evaluation (26).
This patient used Spanish predominantly in all her daily interactions. Her use of English was very rare and her fluency poor. This constitutes another sign of her limited participation in non-Latino US society.
Although the in-patient unit employed interpreters regularly in the
care of the patient, it is likely that some of the limitations in their clinical assessment were related to difficulties in bridging the language gap,
resulting in relatively shallow interpretations of her experience. For example, the cultural connotations for the Spanish terms that the patient
used to express her distress, such as nervios (nerves), ataques (attacks),
and celajes (glimpses or shadows, understood by the staff as visual hallucinations), appear to have been lost or distorted during the translation
process.
Cultural Factors in Development. Are there features of the patient’s
childhood development that should be placed in a specific cultural context in order to be properly understood?
Locating childhood development within a cultural context can help
clarify the contribution of environmental factors to personality characteristics (12). Experience is made meaningful and incorporated as enduring personal attributes partly in response to its perceived normality
and collective interpretation. Factors that influence personality development and that vary across cultures include, among others: gender
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roles, relational characteristics within the family and roles within the
family constellation, socialization experiences, and social valuation of
emotional expression (27,28).
In this case, the patient’s childhood contacts were limited to her extended kin group, given the rural isolation of her family compound and
her early school termination. This may have intensified the negative
impact on her personality development of her father’s disruptive and
abusive behavior and her mother’s affective distance despite the stated
absence of witnessed or experienced physical or sexual abuse during
childhood. These personality patterns were probably also reinforced
by later adult episodes of physical abuse and traumatic loss. Another
sociocultural feature of the patient’s early socialization that appears
to have influenced her later symptomatology relates to her role as a
parentified child who was removed from elementary school in order to
help raise her younger siblings. Though not an uncommon practice in
the patient’s cultural reference group, this seems to have determined a
particularly important element in her self-perception, as evidenced by
her lifelong nickname within the family which refers to this maternal
function. The loss of this culturally established role, through separation and subsequent estrangement from her children, was the main
cause of the patient’s affective decompensation. The partial resumption of this role through family therapy marked the beginning of her
improvement.
Involvement with Culture of Origin and Host Culture. How does understanding a migrant like this patient in the context of her culture of
origin separately from the host culture reveal something about her as a
person and about her migration experience?
This subsection is primarily relevant to migrants. Its purpose is to
compare the individual’s involvement with the culture of origin, on the
one hand, to his/her involvement with the host culture, on the other.
By evaluating each attachment independently, the clinician can avoid
a zero-sum model of acculturation, which mistakenly assumes that as
a person becomes more fluent in the new culture, he/she necessarily
becomes disconnected from his/her culture of origin (29). Instead, contemporary acculturation models understand that, in a world where multiculturality and geographical displacement are becoming increasingly
prevalent, multiple combinations of involvement are possible, such as
the alternative of developing a deep connection to both cultural environments (30). Finally, by establishing the migrant’s relative cultural
attachments, the person’s cultural identity is rounded out, setting the
stage for the other topics of the CF model.
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This patient was predominantly connected to her culture of origin
and had limited contact with the host culture. She lived in a mainly
Latino neighborhood and traveled frequently to Puerto Rico, where
she kept in close contact with several siblings; she had few friends,
mostly Latinas, apart from her family. She was, however, able to maneuver some aspects of United States urban life well, such as obtaining elderly subsidized housing (though only in her 50’s) and disability
benefits.
Cultural Explanations of the Illness
The heart of the Cultural Formulation is this second section, which
examines the cultural factors that affect the experience and interpretation of illness, as understood by the patient, the family, and the social
network. These cultural factors exert a deeper influence than just covering over an unchanging reality with curious cultural explanations.
They instead help to create the illness experience by affecting cognitive, bodily, and interpersonal aspects of disease, including by helping
to shape symptom presentations, perceived etiologies, severity attributions, treatment choices, and outcome expectations (6,31). In particular, explicit cultural analysis is required for accurate assessment of
the severity of the presenting problems, since patients’ attributions of
severity are acutely impacted by cultural interpretations. Finally, adherence to clinicians’ recommendations may be compromised without
careful attention to patients’ cultural views of treatment. In this respect, it may also be necessary to account for the views of key relatives
or members of the larger social network (32).
Idioms of Distress and Local Illness Categories. How do cultural factors affect the way this person experiences and understands her distress,
including the specific shape of the presenting symptoms and the way
they are clustered?
Cross-cultural research reveals the existence of multiple overall perspectives on distress—ways in which to experience, understand, and
describe it—that are so comprehensive that they seem akin to different languages of suffering rather than specific syndromes. The term
“idioms of distress” is used to denote these different languages of experience (33). Examples of idioms are: the tendency to somatize suffering,
or to psychologize it; experiencing interpersonal problems or physical
illness as forms of possession; attributing illness to the impact of suffering on the anatomical “nerves”; or describing distress in terms of “fate,”
or as a kind of “spiritual test” (16).
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In addition to these general forms, cultures have also evolved more
specific illness categories or syndromes, assembled according to alternative systems of causation. The organizing principle can be a relatively invariant collections of symptoms, a perceived common etiology,
or a shared response to treatment (5). One of the essential tasks of a
Cultural Formulation is to discover the idioms of distress and the illness categories that are evoked by the patient’s presentation. Often
the patient is not fully conscious of the categories he/she is referencing, and yet may be acutely aware of the dissonance between his/her
understandings and those of the clinician.
In this case, the patient’s illness was described by herself and her community as nervios (nerves) and ataques de nervios (attacks of nerves).
Patient’s view of her nervios was typical of many traditional Puerto
Ricans, for whom it is an idiom of distress describing a vulnerability to
experiencing symptoms of depression, anxiety, dissociation, somatization and rarely psychosis or poor impulse control given interpersonal
frustrations (34). The idiom is held together conceptually by the cultural understanding that all its presentations reflect an “alteration,”
acquired or inherited, of the nervous system, and specifically of the
anatomical nerves. The patient had suffered from all the symptoms
of nervios except psychosis. Her acute fit-like exacerbations of nervios
are known as ataques de nervios, and were characterized by paroxysms of anxiety, rage, dissociation, and impulsive suicidality followed
by depression and exhaustion in response to acute interpersonal conflicts (9,11). In this patient’s case, nervios and ataques were associated
with her character pathology, but many Puerto Ricans suffer from similar folk syndromes without showing characterological deficits, though
the exact relationship between these clinical conditions has not been
ascertained.
Another critical aspect of her nervios was the high frequency and
distressing nature of the culturally specific perceptual distortions she
reported (hearing voices, feeling presences, seeing shadows [known as
celajes; glimpses]). These experiences are very prevalent among Puerto
Ricans with and without nervios, but sufferers of ataques are markedly
more distressed by them (35). They probably represent culturally patterned signs of anxiety or emotional distress determined by a person’s
dissociative capacity. In the patient’s case, these experiences were mistaken for psychotic symptoms by her inpatient clinicians. As such, discussion of these symptoms in the Cultural Formulation straddles this
subsection and the next, as they constitute culturally specific idioms of
distress whose interpretation can affect the perceived severity of the
presenting complaints.
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Meaning and Severity of Symptoms in Relation to Cultural Norms.
How does taking her cultural background into account affect the level
of pathology suggested by her presenting symptoms and their meaning
as a form of communication in her interpersonal context?
This subsection is devoted to a careful assessment of the level of
severity implied by the person’s symptoms, as well as to discussion of
the role of the illness as a form of interpersonal communication that is
interpreted by others in the social network. It is essential that cultural
norms be considered when assessing the clinical severity of specific behaviors, so as to avoid two erroneous extremes: overpathologizing what
is normative in a cultural group, or ascribing to normal behavior what is
considered pathological in that culture (13,36). Whether what is at issue is the normal degree of individuation of an 18 year-old in relation to
his/her parents, or the potential delusionality of a person who ascribes
his/her symptoms to a supernatural etiology, some knowledge of local
behavioral norms is essential to the process of diagnosis. The fact that
different subgroups within a larger cultural setting may interpret these
behaviors differently complicates the process of assessment and forces
an individualized evaluation of cultural factors in each case.
In addition, illness expressions convey a range of meanings to others
in the social network. Which set of meanings is imputed by the community actually has an impact on the patient’s course, both through interpersonal interactions that promote improvement or pathology and
through concrete levels of assistance or rejection. The cross-cultural
literature on the contribution of expressed emotion to the course of
schizophrenia represents a well-developed example of this issue (37).
In this patient’s case, her symptoms at the time of presentation were
seen by her community to reflect a severe form of nervios because they
could precipitate rage and dissociation ataques with impulsive suicidality and because they had “penetrated deeply,” causing her character
pathology. As opposed to her outpatient clinicians, who saw her character problems as preceding and partly determining her Axis I disorders,
the patient’s social network understood her characterological symptoms
as a consequence of her nervios, rather than as a cause (i.e., a form of
bitterness due to her continued suffering), and thus as a sign of nervios
severity. In another discrepancy between the social network and the
clinical team, the patient’s inpatient clinicians judged her perceptual
distortions to be much more severe than her community, understanding
them as signs of psychosis rather than minor elements of her overall
condition.
Further, the expectation of her interpersonal network was that the
patient actively ward against any worsening of her character pathology
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by “controlling” her needs and desires and focusing on the needs of
others, such as her children. The community thus validated the patient’s understanding that reestablishing positive affective links with
her family would improve the outcome of her nervios. Her achievement
of this goal, as well as her coming off psychiatric medications and preventing further ataques, were considered signs of improvement. The
patient’s children, however, initially rejected the patient’s and the community’s understanding that her character pathology stemmed from
her nervios and ataques, attributing it instead to manipulative ploys
aimed at deflecting their justified anger due to what they perceived as
her neglectful parenting. Therapy helped to bridge these conflicting interpretations, but several of her children always retained the sense that
the patient’s personality conflicts exceeded the norm even for nervios.
Perceived Causes and Explanatory Models. How is her clinical management affected by knowing about her culturally based etiological
attributions, her understandings of pathophysiology, and her hopes and
concerns about the course of the illness?
This subsection focuses on the patient’s views on how the illness
“works”: what caused it; why did it present now and in this way; how is it
affecting the person; what would happen if it was not treated; and what
are the possible outcomes even with treatment? (12,38). This subsection, like the next one on help-seeking to which it is closely linked, is especially important during the process of enlisting the patient’s and the
family’s adherence to the clinician’s recommendations. Patients rarely
pursue treatments for long that run counter to their primary etiological
understandings. Cultural attributions of causation actually vary widely
across societies, from biological to spiritual etiologies, and from drastically individual, internal views to social and even cosmological interpretations (39). Often, there are a mix of attributions, at times partly
or wholly contradictory within one person or across the patient’s social network. Treatment may thus involve negotiating the appearance
of these various perspectives and bringing them into some coherent
strategy (19).
At first, the patient saw her condition fundamentally as a medical
problem caused by an “alteration” of her nervous system due to the
suffering produced by chronically unresolved family conflicts. Primary
among these were the physical abuse by her husband, the parental
rejection, and her separation from several of her children during most
of their childhood, which led to their ongoing anger toward her. This is a
typical traditional Puerto Rican interpretation of the impact of chronic
suffering on the “nerves.” If untreated, the patient feared that she would
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become chronically psychotic (“loca”; crazy), given her limited ability, by
herself, to “control” her symptoms, particularly her anger and grief (40).
Over time, however, medical treatment without family reconciliation
was likewise experienced as insufficient. The traditional link between
nervous ailments and past stressors served the outpatient clinicians as
an entry point for discussing her interpersonal history, including the
conflict with her children. One important function of her caregivers became that of contributing medical authority to the patient’s claims for
filial support. In that sense, the interpersonal element in her system
of etiological attributions grew to supersede the more physiological aspects of her explanatory model. Her ongoing participation in treatment
was attained in large measure by the growing confluence of this model
with that of her providers, who also saw her problematic family relationships as a main cause of her illness. In fact, clinicians’ success in enlisting family support for the patient became proof of their therapeutic
value.
A secondary element of her explanatory model was the notion that
her nervios illness produced a kind of spiritual “weakness,” which led to
the irruption of distressing spiritual visitations, perhaps by deceased
relatives, which were experienced as perceptual distortions. This aspect
of her model was never primary nor fully worked out, yet it initially
disrupted her care, as it led to a diagnosis of psychosis by the inpatient
team. Even when improved, however, the patient remained leery of
these experiences, preferring to pay them minimal attention.
Help-Seeking Experiences and Plans. How does the patient’s cultural identity help explain her past help-seeking choices and expectations about current and future forms of assistance and treatment?
This subsection is closely linked to the previous one, as individuals
usually seek out caregivers who offer assistance in ways that match
their explanatory models (13,19). Patients’ help-seeking choices actually tend to follow “pathways” of care which are partly determined
by psychosocial and cultural forces. One expression of this is the way
cultural perceptions and interpretations of illness affect not only the
decision whether and when to seek formal care (as opposed to being
self-reliant or asking for help from the immediate social network), but
also the type of treatment that is considered to be adequate and effective (41). As with etiological attributions, help-seeking pathways can
also be quite complex, with multiple forms of care being accessed at
once, or in apparently contradictory ways.
During her early bouts of depression, which were acute but brief and
occurred years before the current presentation, the patient did not seek
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ongoing medical care, relying only on rare emergency room visits. At
the time, she felt her life traumas had not yet permanently “altered” her
nervous system, and she relied mostly on her limited social network and
on home remedies, such as herbal teas. Early on during her current presentation, however, having come to see her condition as a physiological
reaction to her interpersonal problems, she sought help first from primary care internists. They in turn referred her to inpatient psychiatric
care, which the patient always understood as being sent to the medical
specialists of the nervous system (“the doctors for nervios”). This was
a fortunate reframing of her treatment, since an alternative and fairly
common interpretation in her cultural group could have been to reject
the psychiatric referral as a sign that the clinicians mistakenly thought
that she was losing her mind. Over time, she accepted some forms of
mental health treatment but refused others, due to a mixture of cultural and personality characteristics. Family therapy, for example, met
her view that an improved relationship with her son would help her recover from her illness, and was enthusiastically accepted. Other forms
of psychotherapy directed more at intrapsychic change, such as group
therapy, met intense resistance. Day hospital care came to be experienced as relatively unfocused and off-the-mark; instead, patient sought
daily visits with her daughter-in-law, where she could re-establish socialization skills with family members. Her view of nervios as a medical
condition never fully disappeared. She felt best protected from relapse
by periodic check-ups with a psychiatrist, even when no medications
were prescribed; the ongoing decision not to medicate reassured her
that her condition remained stable. Interestingly, despite the view that
her perceptual distortions were due to spiritual “weakness,” she never
sought the help of folk healers, saying “I don’t believe in any of that.”
This highlights the intra-ethnic variation in help-seeking pathways,
since many Puerto Ricans seek the assistance of espiritistas and other
spiritual healers at some point during the course of their illness (42).
Cultural Factors Related to Psychosocial Environment
and Levels of Functioning
This section of the CF model allows the clinician to examine how culture
patterns some of the stressors patients are exposed to and their reactions to these situations; the social supports available to them; and the
contexts against which their levels of functioning should be measured.
Among other stressors, this part of the assessment can be used to elicit
patients’ experiences of trauma and how they incorporate these events
into their ongoing interpersonal relationships.
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Social Stressors. How does the patient’s cultural background clarify
the origin and impact of the stressors she experienced?
The main stressor affecting the patient at the time of her presentation
was her estrangement from all of her children, which contradicts traditional values regarding an extended and close family centered around
a matriarch. The patient alternated between feeling that this situation
was unfair and that it was a deserved punishment for abandoning four
of her children in childhood. That decision, which she described as the
hardest of her life, was influenced by several social and cultural factors. These include: the existence at that time of very few nonfamily
supports for abused women in rural Puerto Rico; the emergence of migration as a government-sponsored escape valve for a labor force made
redundant by rapid industrialization; her parents’ lack of support for
marital separation, even in the case of physical abuse; a tradition in
rural Puerto Rico of placing “extra” children in informal foster arrangements with close relatives; and the expectation by some new male sexual partners (the man who became the patient’s second husband) that
they not be expected to maintain non-infant children from a previous
marriage.
Seen over the course of her lifetime, the patient’s stressors were severe, and included the family disruption caused by her father’s alcoholism, her husband’s physical abuse, the death of a child in infancy,
the dispersion of her nuclear family and the consequent discord with
her parents and children, difficulties in acculturation to the US, ethnic discrimination, chronic poverty and unemployment, the murder of
her second husband, and her children’s substance abuse and subsequent loss of child custody. These stressors were considered by the patient and her community to be adequate explanation of her nervios
illness.
Social Supports. How does her cultural identity contribute to the
amount, nature, and quality of her social supports?
As a “circular” migrant who engaged in several migratory cycles and
frequent trips to Puerto Rico, the patient’s supports beyond her son,
daughter-in-law, and caregivers consisted only of community drop-in
centers and a few elderly Latinas. Her lack of supports probably contributed to the length of her hospitalizations, as her fear of going home
seemed to worsen her suicidality whenever discharge was discussed.
Clinicians’ efforts to expand her support system through group therapy membership and psychiatric social clubs were hindered by her
character pathology. Most of the patient’s symptoms, including her suicidal ataques, may be understood as attempts to expand her social
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support network by engaging the attention of family members as well
as professional caregivers. The patient always retained the belief that
in the face of her overwhelming social limitations and the original recalcitrance of her children, only the full expression of her symptomatology
could have produced a positive outcome.
Levels of Functioning and Disability. How does the patient’s cultural
environment affect her level of functioning and degree of impairment?
Prior to her improvement, the patient saw her illness as progressive
and without cure, and feared degeneration into permanent insanity,
consistent with widespread cultural concerns about severe nervios. As
a result of treatment, she came to feel that her nervios had not progressed as far as she had feared, but that she would always remain
permanently vulnerable to relapse if confronted with more stress than
she could handle, especially in her family interactions. She interpreted
the intermittent appearance of anxiety and depressive symptoms as
signs of ongoing nervios illness which entitled her to lifelong subsidized housing and financial support from the government. Her age and
limited formal education, job skills, and English fluency in any case
narrowed her employment opportunities considerably and contributed
to her expectation of government support. Unfortunately, the absence
of organized activities such as work also hindered the development
of a social network beyond her family, which may have helped to decompress the patient’s dependence on a limited number of supportive
contacts.
Cultural Elements of the Clinician–Patient Relationship
This section allows the clinician to consider how his/her own role or
institutional setting has affected the patient’s illness experience, including symptom expression and treatment response. The scientific
emphases on objectivity and material reality sometimes cause psychiatrists to mistake their activity for that of invisible observers, who exert
little effect on the situation observed. On the contrary, much clinical
and ethnographic research has described how patients’ symptom descriptions and etiological attributions are shaped across health care
settings in response to clinicians’ verbal and nonverbal elicitations and
to individual and collective expectations of what the purpose and the
norms are for each kind of setting (38,43). What counts as good and
bad outcomes also varies across therapeutic interactions, depending
on whether the patient and caregiver are focusing on symptoms, longterm morbidity and mortality, psychosocial functioning, interpersonal
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relationships, existential adjustment, ecological integration, or spiritual well-being. The clinical encounter is always a negotiated experience
(44) that in addition echoes a wider system of institutional relationships, such as the organization of health care services, the influence of
third-party review, and pressures brought to bear by employers (22).
The clinical relationship is also impacted by ethno-cultural clashes in
the society at large, requiring clinicians to examine their attitudes toward a patient’s ethnicity and culture and how these impact the therapeutic encounter. This understanding can be helpful not only in terms
of evaluating the role of cultural differences in the interpretation of
patients’ presentations, but also in avoiding biases based on ethnic
stereotypes or other aspects of cultural identity (13). The current section encourages a systematic reflection on these interactions.
In the case of this patient, her psychiatric care prior to her referral
to the outpatient Latino Clinic was hindered by the inpatient unit’s
lack of cultural information on various aspects of her presentation that
have been outlined in this Formulation. In particular, the diagnostic
process was limited by the absence of a culturally normative assessment of the patient’s character structure, which resulted in the overemphasis of her Axis I symptoms and a missed diagnosis of Borderline
Personality Disorder. Likewise, lack of information about the cultural
characteristics of nervios and ataques led to the misinterpretation of
her perceptual distortions as psychotic symptoms, with consequences
for the patient’s psychopharmacological treatment. Finally, the inpatient unit’s reliance on pharmacological rather than psychotherapeutic interventions was not fully consonant with the patient’s treatment
expectations.
The lack of relevant cultural information contrasts with the unit’s
attention to more purely ethnic issues, such as the frequent use of
Spanish interpreters to ensure the patient’s participation in the
milieu, and the focus on “ethnic matching” (45), achieved by assigning a Latino psychiatry resident to her care. The emphasis on ethnicity
alone rather than culture is a problematic characteristic of contemporary US psychiatry that can lead, as in this case, to therapeutic practices
that only go partway toward eliciting the relevant points of difference
in the patient’s presentation and treatment response (46). The use of
Spanish, for example, is absolutely necessary for assessing a nonEnglish speaking Latina such as this patient, but is not sufficient as
a culturally valid intervention; for that, therapeutic approaches based
on cultural information are also required. Ethnic matching does not
guarantee access to this material, since persons from the same ethnic
background can differ in terms of cultural experience and clinicians may
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be influenced less by their culture of origin than by their professional
context.
Referral to an outpatient clinic with an explicitly cultural focus resulted in a more comprehensive evaluation for the patient, leading to a
process of rediagnosis and to the implementation of psychotherapeutic
interventions more in accord with her expectations, with more successful clinical results.
Overall Cultural Assessment
The final section of the Cultural Formulation summarizes the information in the previous sections, focusing on cultural material that contributes to diagnosis and treatment. The role that cultural features
have played in determining overall illness outcome are particularly
emphasized.
In this case, the overall assessment would mention that the patient’s
cultural identity is that of a rural Puerto Rican migrant with limited
formal education, who speaks Spanish exclusively and has only lived
for limited periods in the US, resulting in minimal acculturation. Her
psychopathology is expressed in the traditional Puerto Rican idioms of
nervios and ataques de nervios. She attributed the origin of these problems and her relapsing course to multiple past stressors and traumas,
and especially to unresolved conflicts with her children resulting from
her prolonged separation from them during childhood. In fact, her clinical condition did not improve until their affective breach was addressed
in family therapy.
The patient’s initial inpatient treatment proved ineffective partly
because of the misattribution of a psychotic label to her perceptual
distortions, which are normative idioms of distress for this cultural
group. Misdiagnosis exposed patient to the potentially toxic effects of
antipsychotic medication and interfered with referral to family therapy. In addition, lack of cultural information also hindered the identification of patient’s underlying Axis II pathology and obscured the
relationship between her character disorder and her persistent Axis I
symptoms, including her chronic suicidality and its exacerbations in
the form of ataques. Pharmacologic treatment of the patient’s refractory depression—dangerous anyway due to her impulsive suicidality—
proved unnecessary once intensive family intervention was underway.
Her remaining intermittent Axis I symptoms led to periodic distress,
warranting NOS diagnoses. But the patient’s primary psychopathology
proved to be characterological, fulfilling criteria for Borderline
Personality Disorder. Like many patients with this disorder, she
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displayed recurrent dysphoria, though in her case she did not meet
strict criteria for Dysthymia. Unlike many Borderline patients, however, her course over the subsequent 8 years was remarkably uneventful
after her initial response to psychotherapy, perhaps reflecting cultural
variation in the treatment outcome of Borderline Personality Disorder.
CONCLUSION
In this article we have presented the Cultural Formulation (CF) model
for clinical assessment, discussing its historical development and its
components as outlined in Appendix I of DSM-IV. We also illustrated
the application of the model with a case scenario of a Puerto Rican
woman suffering from the Latino popular syndromes of nervios and
ataques whose care was markedly improved by the implementation of
a cultural evaluation such as the one outlined.
At a time in which the value of delivering culturally congruent care
is increasingly being recognized and requirements for cultural assessment are being incorporated into treatment guidelines and professional
training curricula, the Cultural Formulation model represents one of
the main existing methods for attaining and implementing a culturally
valid approach to care (12). Regular use of the model teaches clinicians
not only how to elicit culturally relevant clinical material, but also exposes them over time to the content of many cultural perspectives from
diverse patients and their families, thus increasing caregivers’ fund of
cultural knowledge.
The growing cultural pluralism of US society requires that the CF
model become an essential aspect of every clinical training program.
The “long version” of the model, such as the one described in this article, can be taught during clinical supervision as part of comprehensive
patient assessments. This is the format we are using during the outpatient year (PGY-III) at the Adult Psychiatry Residency Program of
Columbia University and NY State Psychiatric Institute. The “short
version” of the model, similar to the Overall Cultural Assessment section of the full Formulation, could then be used for all new evaluations
or comprehensive reassessments of refractory patients once proficiency
in the full CF model is established.
It is also imperative that research be conducted on the effectiveness
of the Cultural Formulation as a method for improving treatment outcomes, including assessment of its cost-benefit ratio. Findings from this
research will help clarify the contribution of the CF model to clinical
care, and prepare the way for its role in DSM-V.
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ACKNOWLEDGMENTS
Dr. Lewis-Fernández was supported by a National Institute of Mental Health (NIMH) Under-represented Minority Research Supplement
(5 R10 MH55165). Ms. Dı́az was supported by NIMH grant T32
MH20074 to the Center for Hispanic Mental Health Research at
Fordham University.
REFERENCES
1. Desjarlais R, Eisenberg L, Good B, Kleinman A: World Mental Health: Problems and
Priorities in Low-Income Countries, New York, Oxford University Press, 1995.
2. Mukherjee S, Shukla S, Woodle J, Rosen AM, Olante S: Misdiagnosis of schizophrenia in bipolar patients: A multiethnic comparison. American Journal of Psychiatry
140:1571–1574, 1983.
3. Strakowski SM, Flaum M, Amador X, Bracha HS, Pandurangi AK, Robinson D, Tohen
M: Racial differences in the diagnosis of psychosis. Schizophrenia Research 21:117–
124, 1996.
4. Strakowski SM, Hawkins JM, Keck PE, McElroy SL, West SA, Bourne ML, Sax KW,
Tugrul MC: The effects of race and information variance on disagreement between
psychiatric emergency service and research diagnoses in first-episode psychosis. Journal of Clinical Psychiatry 58:457–463, 1997.
5. Good BJ, Delvecchio-Good M-J: Toward a meaning-centered analysis of popular
illness categories: “Fright-illness” and “heart distress” in Iran. In: Marsella AJ, White
GM, eds., Cultural Conceptions of Mental Health and Therapy, Dordrecht, D. Reidel,
1982, pp. 141–166.
6. Kleinman A: Rethinking Psychiatry: From Cultural Category to Personal Experience,
New York, The Free Press, 1988.
7. Zheng YP, Lin KM, Takeuchi D, Kuralski KS, Wang YX, Cheung F: An epidemiological study of neurasthenia in Chinese-Americans in Los Angeles. Comprehensive
Psychiatry 38:249–259, 1997.
8. Lee S, Wing Y, Chan C, Lee AM, Lee DTS, Chen CN, Lin KM, Weiss MG: Psychiatric
morbidity and illness experience of primary care patients with chronic fatigue in
Hong Kong. American Journal of Psychiatry 157:380–384, 2000.
9. Guarnaccia PJ, Rivera M, Franco F, Neighbors C: The experiences of ataques de
nervios: Towards an anthropology of emotions in Puerto Rico. Culture, Medicine and
Psychiatry 20:343–367, 1996.
10. Guarnaccia PJ, Canino G, Rubio-Stipec M, Bravo M: The prevalence of ataques de
nervios in the Puerto Rico Disaster Study. Journal of Nervous and Mental Disease
181:157–165, 1993.
11. Lewis-Fernández R, Garrido P, Bennasar M, Parrilla E, Laria AJ, Ma G,
Petkova E: Dissociation, childhood trauma, and ataque de nervios among Puerto
Rican psychiatric outpatients. American Journal of Psychiatry, 159:1603–1605,
2002.
12. Group for the Advancement of Psychiatry Committee on Cultural Psychiatry: Cultural Assessment in Clinical Psychiatry, Washington, D.C., American Psychiatric
Publishing, 2001.
P1: GCP/LCT/GIR
P2: GCR
Psychiatric Quarterly [psaq]
294
ph129-psaq-375280
September 18, 2002
16:15
Style file version June 4th, 2002
PSYCHIATRIC QUARTERLY
13. Lu FG, Lim RF, Mezzich JE: Issues in the assessment and diagnosis of culturally
diverse individuals. In: Oldham JM, Riba MB, eds., Review of Psychiatry, Vol. 14,
Washington, D.C., APA Press, 1995, pp. 477–510.
14. Lewis-Fernández R: Cultural formulation of psychiatric diagnosis. Culture, Medicine
and Psychiatry 20:133–144, 1996.
15. Mezzich JE: Cultural formulation and comprehensive diagnosis: Clinical and research perspectives. Psychiatric Clinics of North America 18:649–657, 1995.
16. American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV), Washington, D.C., 1994.
17. Smedley A: “Race” and the construction of human identity. American Anthropologist
100:690–702, 1999.
18. Alarcón RD: Culture and psychiatric diagnosis: Impact on DSM-IV and ICD-10.
Psychiatric Clinics of North America 18:449–465, 1995.
19. Kleinman A: The Illness Narratives: Suffering, Healing, and the Human Condition,
New York, Basic Books, 1988.
20. Weiss M: Explanatory Model Interview Catalogue (EMIC): Framework for comparative study of illness. Transcultural Psychiatry 34:235–263, 1997.
21. Saris JA: Telling stories: Life histories, illness narratives, and institutional landscapes. Culture, Medicine and Psychiatry 19:39–72, 1995.
22. Mechanic D: The experience and expression of distress: The study of illness behavior and medical utilization. In Mechanic D, ed., Handbook of Health, Health
Care, and the Health Professions, New York, The Free Press, 1983, pp. 591–
607.
23. Lewis-Fernández R: Diagnosis and treatment of nervios and ataques in a female
Puerto Rican migrant. Culture, Medicine and Psychiatry 20:155–163, 1996.
24. Hernández-Cruz J: Migración de retorno o circulación de obreros boricuas? Revista
de Ciencias Sociales 24:81–102, 1985.
25. Rodrı́guez CE: Puerto Ricans: Born in the U.S.A., Boulder, Westview Press, 1991.
26. Oquendo MA: Psychiatric evaluation and psychotherapy in the patient’s second language. Psychiatric Services 47:614–618, 1996.
27. Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and
Conceptual Interactions, New York, Wiley, 1998.
28. Lewis-Fernández R, Kleinman A: Culture, personality, and psychopathology. Journal
of Abnormal Psychology 103:67–71, 1994.
29. Rogler LH, Cortés DE, Malgady RG: Acculturation and mental health status among
Hispanics. American Psychologist 46:585–597, 1991.
30. Marı́n G, Gamba RJ: A new measurement of acculturation for Hispanics: The
Bidimensional Acculturation Scale for Hispanics (BAS). Hispanic Journal of Behavioral Sciences 18:297–316, 1996.
31. Good BJ: Medicine, Rationality, and Experience: An Anthropological Perspective,
Cambridge, Cambridge University Press, 1994.
32. McKinlay JB: Social network influences on morbid episodes and the career of helpseeking. In: Eisenberg L, Kleinman A, eds., The Relevance of Social Science for
Medicine, Dordrecht, D. Reidel, 1981, pp. 77–107.
33. Nichter M: Idioms of distress: Alternatives in the expression of psychosocial
distress: A case study from South India. Culture, Medicine and Psychiatry 5:379–408,
1981.
34. Guarnaccia PJ, Lewis-Fernández R, Rivera M: Towards a Puerto Rican popular nosology: Nervios and ataques de nervios. Culture, Medicine and Psychiatry,
in press.
P1: GCP/LCT/GIR
P2: GCR
Psychiatric Quarterly [psaq]
ph129-psaq-375280
September 18, 2002
ROBERTO LEWIS-FERNÁNDEZ AND NAELYS DÍAZ
16:15
Style file version June 4th, 2002
295
35. Lewis-Fernández R, Canino G, Ramı́rez R, Febo V, Bravo M: Latino perspectives on
mental health in primary care. In: Proceedings of the 49th Institute on Psychiatric
Services, American Psychiatric Association, 1997, p. 142.
36. López SR: Patient variable biases in clinical judgment: Conceptual overview and
methodological considerations. Psychological Bulletin 106:184–203, 1989.
37. Jenkins JH, Karno M: The meaning of expressed emotion: Theoretical issues raised
by cross-cultural research. American Journal of Psychiatry 149:9–21, 1992.
38. Kleinman A: Patients and Healers in the Context of Culture, Berkeley, University of
California Press, 1980.
39. Marsella AJ, White GM: Cultural Conceptions of Mental Health and Therapy,
Dordrecht, D. Reidel, 1982.
40. Lewis-Fernández R: “That was not in me . . . I couldn’t control myself ”: Control, identity, and emotion in Puerto Rican communities [Spanish]. Revista de Ciencias Sociales
4:268–299, 1998.
41. Rogler LH, Cortés DE: Help-seeking pathways: A unifying concept in mental health
care. American Journal of Psychiatry 150:554–561, 1993.
42. Garrison V: Doctor, espiritista or psychiatrist?: Health-seeking behavior in a Puerto
Rican neighborhood of New York City. Medical Anthropology 1:65–191, 1977.
43. Good BJ, Delvecchio-Good M-J: The meaning of symptoms: A cultural hermeneutic
model for clinical practice. In: Eisenberg L, Kleinman A, eds., The Relevance of Social
Science for Medicine, Dordrecht, D. Reidel, 1980, pp. 165–196.
44. Lazare A, Eisenthal S, Wasserman L: The customer approach to patienthood.
Archives of General Psychiatry 32:553–558, 1975.
45. Sue S, Fujino DC, Hu LT, Takeuchi DT, Zane NWS: Community mental health services
for ethnic minority groups: A test of the cultural responsiveness hypothesis. Journal
of Consulting and Clinical Psychology 59:533–540, 1991.
46. Whaley AL: Cultural mistrust: An important psychological construct for diagnosis
and treatment of African Americans. Professional Psychology: Research and Practice
32:555–562, 2001.