Francis G. Lu

Toward a more culturally sensitive DSM-IV. Psychoreligious and psychospiritual problems

In theory, research, and practice, mental health professionals have tended to ignore or pathologize the religious and spiritual dimensions of life. This represents a type of cultural insensitivity toward individuals who have religious and spiritual experiences in both Western and non-Western cultures. After documenting the “religiosity gap” between clinicians and patients, the authors review the role of theory, inadequate training, and biological primacy in fostering psychiatrys insensitivity. A new Z Code (formerly V Code) diagnostic category is proposed for DSM-IV: psychoreligious or psychospiritual problem. Examples of psychoreligious problems include loss or questioning of a firmly held faith, and conversion to a new faith. Examples of psychospiritual problems include near-death experiences and mystical experiences. Both types of problems are defined, and differential diagnostic issues are discussed. This new diagnostic category would: a) improve diagnostic assessments when religious and spiritual issues are involved; b) reduce iatrogenic harm from misdiagnosis of psychoreligious and psychospiritual problems; c) improve treatment of such problems by stimulating clinical research; and d) encourage clinical training centers to address the religious and spiritual dimensions of human existence.

Religious or spiritual problem. A culturally sensitive diagnostic category in the DSM-IV.

A new diagnostic category entitled religious or spiritual problem has been included in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) under Other Conditions That May Be a Focus of Clinical Attention. Along with several other changes, this category contributes significantly to the greater cultural sensitivity incorporated into DSM-IV. The authors review the approval process, including the changes that were made in both the proposed new category and the former V Code section of DSM-III-R. In addition, the definition, assessment methods, types, and clinical significance of religious and spiritual problems are clarified, along with the differential diagnostic issues raised by the definitional changes in the former V Code section. Finally, clinical issues involving cultural sensitivity and the implications for future research are addressed. The new category could help to promote a new relationship between psychiatry and the fields of religion and spirituality that will benefit both mental health professionals and those who seek their assistance.

From Spiritual Emergency to Spiritual Problem: the Transpersonal Roots of the New DSM-IV Category:

Religious or Spiritual Problem is a new diagnostic category (Code V62.89) in the 1994 Diagnostic and Statistical Manual of Mental Disorders. Although the acceptance of this new category was based on a proposal documenting the extensive literature on the frequent occurrence of religious and spiritual issues in clinical practice, the impetus for the proposal came from transpersonal clinicians whose initial focus was on spiritual emergencies-forms of distress associated with spiritual practices and experiences. The proposal grew out of the work of the Spiritual Emergence Network to increase the competence of mental health professionals in sensitivity to such spiritual issues. This article describes the rationale for this new category, the history of the proposal, transpersonal perspectives on spiritual emergency, types of religious and spiritual problems, differential diagnostic issues, psychotherapeutic approaches, and the likely increase in number of persons seeking therapy for spiritual problems. It also presents the preliminary findings from a database of religious and spiritual problems.

DSM-III-R disorders in Vietnamese refugees : prevalence and correlates

This studys purpose was a) to determine the prevalence of DSM-III-R disorders in newly arrived ethnic Vietnamese and ethnic Chinese refugees from Vietnam and b) to determine the correlates of DSM-III-R disorders. A Vietnamese-speaking psychiatrist administered translated sections of the Structured Clinical Interview for DSM-III-R to 201 Vietnamese new arrivals undergoing mandatory health screening. Overall, 18.4% had one or more current disorders: 8.5% had adjustment disorder and 5.5% had major depression. Ethnic Vietnamese, compared with ethnic Chinese, had significantly (p < .05) higher rates of current posttraumatic stress disorder and generalized anxiety disorder. Ethnic differences in psychopathology were largely explained by the fact that ethnic Vietnamese refugees had experienced more traumatic events and separation from family. After adjusting for ethnicity, refugees who reported traumatic events, refugees who were married, and veterans were significantly (p < .05) more likely to have one or more psychiatric disorders.

Culture and Psychiatric Evaluation: Operationalizing Cultural Formulation for DSM-5

The Outline for Cultural Formulation (OCF) introduced with DSM-IV provided a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning. However, use of the OCF has been inconsistent, raising questions about the need for guidance on implementation, training, and application in diverse settings. To address this need, DSM-5 introduced a cultural formulation interview (CFI) that operationalizes the process of data collection for the OCF. The CFI includes patient and informant versions and 12 supplementary modules addressing specific domains of the OCF. This article summarizes the literature reviews and analyses of experience with the OCF conducted by the DSM-5 Cross-Cultural Issues Subgroup (DCCIS) that informed the development of the CFI. We review the history and contents of the DSM-IV OCF, its use in training programs, and previous attempts to render it operational through questionnaires, protocols, and semi-structured interview formats. Results of research based on the OCF are discussed. For each domain of the OCF, we summarize findings from the DCCIS that led to content revision and operationalization in the CFI. The conclusion discusses training and implementation issues essential to service delivery.

Screening for major depression in Vietnamese refugees: a validation and comparison of two instruments in a health screening population

Objectives: 1) Using standard cutoffs, to determine the accuracy of two Vietnamese-language depression screening instruments for major depression in a nonpsychiatric setting, 2) to examine the utility of other cutoffs, and 3) to compare the instruments’ overall accuracies.Design: 1) A research assistant administered the Vietnamese Depression Scale (VDS) and the Indochinese Hopkins Symptom Checklist Depression Subscale (HSCL-D) to all subjects. 2) The “gold standard” was determined by a native Vietnamese-speaking psychiatrist using a written translation of a standard semistructured clinical interview.Setting: A health screening clinic at a large public hospital.Patients: A convenience sample of 206 newly arrived adult Vietnamese refugees undergoing routine, mandatory health screening.Results: The psychiatrist diagnosed7% of the refugees as having major depression. At standard cutoffs, the VDS had a 64% sensitivity, a 98% specificity, a 75% positive predictive value, and a 97% negative predictive value. Corresponding results for the HSCL-D were 86%, 93%, 48%, and 99%. More than half of the patients who had false-positive results had other clinical disorders. For each instrument, adjusting the cutoff improved sensitivity and positive predictive value. Receiver operating characteristic (ROC) curve analysis showed no difference in accuracy between the two instruments. Each instrument took approximately 5–10 minutes to administer.Conclusions: These instruments accurately identified Vietnamese refugees with major depression and should be of use to clinicians in primary care settings. Standard cutoffs may need to be adjusted in nonpsychiatric settings.

Issues for DSM-V: the role of culture in psychiatric diagnosis.

Renato D. Alarcón, MD, MPH,* Anne E. Becker, MD, PhD, ScM,†‡ Roberto Lewis-Fernández, MD,§¶ Robert C. Like, MD, MS, Prakash Desai, MD,** Edward Foulks, MD, PhD,†† Junius Gonzales, MD, MPH,‡‡ Helena Hansen, MD, PhD,§§ Alex Kopelowicz, MD,¶¶ Francis G. Lu, MD, María A. Oquendo, MD,*** and Annelle Primm, MD, MPH†††‡‡‡ for the Cultural Psychiatry Committee of the Group for the Advancement of Psychiatry

Neuropsychiatric complications of AIDS: a literature review

Acquired immune deficiency syndrome (AIDS) has become a major public health problem with over 12,000 cases and 6,000 deaths reported to date. Although there has been an explosion of knowledge in the virology, immunology and pathology of AIDS, relatively little has been written on the neuropsychiatric aspects. This report reviews the existing literature on the neuropsychiatric complications of AIDS. As many as 40 percent of patients with AIDS have neurologic complications at some point in their illness. These complications include either focal deficits attributable to opportunistic organisms infecting the CNS or diffuse encephalopathy caused by viral infection or lymphoma infiltration. Psychiatric complications include major depression, adjustment disorder with depressed mood, and organic brain syndrome with affective, delusional or demented features. Inpatient and consulting psychiatrists must be alert to these complications of AIDS so as to make accurate diagnoses and deliver appropriate therapy. Further studies, integrating both psychiatric and neurologic perspectives, are needed to better elucidate the neuropsychiatric complications of AIDS and help plan appropriate therapeutic interventions.

Using non-feature films to teach diversity, cultural competence, and the DSM-IV-TR outline for cultural formulation

ObjectiveFeature films have been used for teaching in psychiatry for many years to demonstrate diagnoses, but the use of documentary and instructional films in resident and staff cultural competence training have not been extensively written about in the medical and psychological literature. This article will describe the films that have been used by the authors and suggest methods for their use in cultural competence and diversity training.MethodsA literature search was done using MEDLINE and PsychINFO and the authors were asked to describe their teaching methods.ResultsOne article was found detailing the use of videotapes as a stimulus but not for cultural competence education, and two articles were found documenting the use of The Color of Fear as a stimulus for the discussion of racism. However, many educators use these films all across the country for the purpose of opening discussion about racism.ConclusionDocumentary, instructional, and public service announcements can be useful in teaching culturally competent assessment and treatment.

Culture and Psychiatric Education

Received February 21, 2008; accepted March 26, 2008. Dr. Lim isaffiliated with the Department of Psychiatry and BehavioralSciencesat the University of California Davis School of Medicine; Dr. Lu isaffiliated with the Department of Psychiatry at the UniversityofCali-fornia San Francisco. Address correspondence to Russell F. Lim,M.D., Psychiatry and Behavioral Sciences, UC Davis School ofMedicine, 2230 Stockton Blvd., Sacramento, CA 95817; rflim@ucdavis.edu (e-mail).Copyright 2008 Academic Psychiatry