The place of culture in DSM-IV.
This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.
Mezzich
J E
JE
International Center for Mental Health, Mount Sinai School of Medicine, New York, New York 10029-6574, USA.
Kirmayer
L J
LJ
Kleinman
A
A
Fabrega
H
H
Parron
D L
DL
Good
B J
BJ
Lin
K M
KM
Manson
S M
SM
D003469:Culture; D005544:Forecasting; D006801:Humans; D008370:Manuals as Topic; D001523:Mental Disorders / Q000145:classification* / Q000175:diagnosis* / Q000208:ethnology; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D011569:Psychiatric Status Rating Scales / Q000592:standards; D011594:Psychometrics / Q000592:standards / Q000639:trends; D015203:Reproducibility of Results; D009626:Terminology as Topic