1. A Culture of Diagnostics – Professional knowledge and cultural contexts Oslo Akershus University The Cultural Formulation – an attempt to introduce cultural awareness to clinical psychiatric diagnosing Sofie Bäärnhielm, MD, PhD

2. Outline of presentation Discuss the Cultural Formulation (CF) The Swedish context Clinical challenges Our interest in the CF in DSM-IV and 5 A case presentation

3. Some facts about Sweden 15.1% born in another country 19.1% including two parents born abroad Main country of origin Finland 166 723 Iraq 125 499 (2011)

4. Mental health care in Sweden Meet refugees and immigrants - from all over the world A variety in expressions of distress A variety in expectations of help and treatment

5. Mental health care in Sweden Much epidemiological data on inequalities in health Poor adaption of the health and mental health care system to cultural diversity Mental health care is working in a context of increasing social segregation

6. Example of a multicultural suburban area Rinkeby 89.3% foreign born background At the top of all ill health, disability and poor income index lists….. …… but not regarding alcohol consumption

8. Clinical challenges - my experiences Difficult to understand patients’ expressions of distress Difficult to make meaningful diagnostic evaluations Sometimes able to help patients sometimes not – random To summarize: our way of working is not good enough

9. Outline for a Cultural Formulation in DSM-IV, Appendix I ”mini-ethnographic”, narrative assessment (Lewis-Fernández, 1996).

10. Outline for Cultural Formulation in DSM-5 The CF in DSM-IV, culture related to: Identity Conceptualization of distress Psychosocial stressors and cultural features of vulnerability and resilience Features of the relationship between the individual and the clinician Overall assessment

11. Outline for Cultural Formulation in DSM-5 Included in Section III Emerging Measures and Models pp. 749-757 Cultural Formulation Interview (CFI) CFI –Informant version Supplementary Modules http://www.psychiatry.org/practice/dsm/dsm5/online- assessment-measures#Cultural

12. The Cultural Formulation Interview 16 questions Any patient, any setting, especially: cases of social and cultural differences difficulties evaluating symptoms difficulties evaluating severity and impairment disagreement over course of care limited engagement in treatment

13. The Cultural Formulation Interview Cultural definition of the problem 1. What brings you here today?

14. The Cultural Formulation Interview Cultural definition of the problem 1.What brings you here today? invites further information and probing of: - the patient’s view - the patient’s illness understanding - cultural and contextual factors

15. Supplementary modules 1. Explanatory Model 2. Level of Functioning 3. Social Network 4. Psychosocial Stressors 5. Spirituality, Religion, and Moral Traditions 6. Cultural Identity

16. Supplementary modules 7. Coping and Help-Seeking 8. Patient–Clinician Relationship 9. School-Age Children and Adolescents 10. Older Adults 11. Immigrants and Refugees 12. Caregivers On the Web

17. Interview guide – contextualising the CF Research on the CF in DSM-IV Interview guide Bäärnhielm, Scarpinati Rosso, 2009 Scarpinati Rosso, Bäärnhielm, 2012

18. A case: background information - some details changed to protect confidentiality Affaf 28-year-old women from Iraq, a 3- year-old son Referred from primary care to a psychiatric outpatient clinic Depression?

19. Psychiatric interview Conducted using a female Arabic interpreter Came to Sweden to marry a man she did not know Her GP has prescribed anti-depressive medication – she has not followed the prescription

20. Psychiatric interview Social problems: no work, no network, divorced, little money, rejected by her family in Iraq, isolates herself, does not understand Swedish Complicated family situation – her family in Iraq do not accept her divorce She says that she feels hopeless Denies trauma and PTSD symptoms

21. Preliminary diagnosis Adjustment Disorder with Depressed Mood 309.0 (?) Depressed mood? Is distress a reaction to a demanding social and family situation?

22. CULTURAL DEFINITION OF THE PROBLEM 1. What brings you here today? Swedish: Vad har du för besvär? Norwegian: Hva slags plager har du?

23. Affaf responds by talking about: Tired, worried, brooding, lacks energy Further details of how complicated the divorce situation was Struggles with herself to take care of her son Often sits alone in a dark room Has grown to like the darkness of the Swedish winter - mirrors her mood

24. CULTURAL DEFINITION OF THE PROBLEM 2. How would you describe your problem to your family? She has not told her family about her problems. She does not want them to know. She has told them that she is tired, has become ill, has sleeping problems and that she sometimes cannot eat.

25. CULTURAL PERCEPTION OF CAUSE, CONTEXT AND SUPPORT - CAUSE 4. What do you think are the causes of your [problem]? Her divorce has impaired her relation with her parents and relatives (in Iraq) Feels punished by relatives because she has betrayed her own traditions

26. CULTURAL PERCEPTION OF CAUSE, CONTEXT AND SUPPORT – STRESSORS AND SUPPORT 7. Is there any kind of stress that makes your [PROBLEM] worse, such as difficulties with money, or family problems?

27. Affaf responds by talking about: Her family’s view and says: ”A woman is not allowed to divorce. A women is not allowed to live alone. A women has to endure everything” She feels pressured by the family She is afraid of the family

28. The CFI Supplementary Module 11. Immigrants and refugees Aims to explore: Experiences of migration and resettlement

29. Affaf responds by talking about: Her father arranged the marriage – made migration possible to escape Iraq Knew nothing about Sweden when she arrived Migration – no trauma Returned to Iraq to negotiate with the family about the divorce (did not help)

30. Witnessed bombings People dying, mutilated corpses Recurrent visions of maimed people Avoided situations triggering these memories Going back to Sweden, the Iraqi border was closed Succeeded in returning to Sweden through great creativity and personal strength

31. Asks the interviewer ”Why do I sometimes think about dying?”

32. Clinical benefits of the CFI in this case identifying a depressed mood evaluating severity and impairment identifying personal resources & symptoms of PTSD Diagnosis was revised to: Major Depressive Disorder, single episode, Moderate, 296.22 PTSD 309.81

33. Clinical benefits of the CFI in this case Improved understanding of: context culture and traditions affecting her situation her illness perspective the family’s view identified a depressed mood revised diagnostic evaluation

34. Possible clinical benefits of the CFI Improved understanding of: culture and context in an individualised way frames of normality meaning of symptoms severity & impairment cultural stressors and resilience factors

35. Canadian study on the CFI (DSM-IV) – psychotic patients Misdiagnosis for psychotic patients occurred with patients from all ethnocultural groups, especially recently settled immigrants.

36. After using the CF, 49% of the patients with an intake diagnosis of psychotic disorder were re-diagnosed as non-psychotic and 5 % of the patients with a referral diagnosis of non-psychotic disorder were diagnosed as having a psychotic disorder. Adeponle, A.B., Thombs, B.D., Groleau, D., Jarvis, E., Kirmayer, L.J. (2012). Using the Cultural Formulation to Resolve Uncertainty in Diagnoses of Psychosis Among Ethnoculturally Divers patients. Psychiatric Services, 63(2), 147-153.

37. Swedish study – non psychotic patients Adding the CF to ordinary psychiatric diagnosing led to major revisions of diagnosis for 56% Anxiety disorders, especially PTSD Bäärnhielm, Åberg Wistedt, Scarpinati Rosso (in press) Revising psychiatric diagnostic categorisation of immigrant patients after using the Cultural Formulation in DSM-IV, Transcultural psychiatry.

38. The Outline for a Cultural Formulation May be a method to: - improve cultural awareness in clinical psychiatric diagnosing -gain an insight in patients’ meanings and context related to illness -improve the diagnostic evaluation

39. The Swedish context The inclusion of the CFI in DSM makes this type of mini-ethnographic work and research socially acceptable within Swedish psychiatry

40. The Swedish context In a situation of constant cut backs of costs Increasingly more manualised /standardised psychiatric care

41. Thanks for your attention! sofie.baarnhielm@sll.se