Asian Journal of Psychiatry 7 (2014) 8991

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

DSM-5 and culture: The need to move towards a shared model of care
within a more equal patientphysician partnership
K.S. Jacob
Christian Medical College, Vellore 632002, India

A R T I C L E I N F O

A B S T R A C T

Keywords:
DSM-5
Culture
Mental disorders

The universal models employed by psychiatry de-emphasise the role of context and culture. Despite
highlighting the impact of culture on psychiatric diagnosis and management in the Diagnostic and
Statistical Manual of Mental Disorders-5, most of the changes suggested remain in the introduction and
appendices of the manual. Nevertheless, clinical and biological heterogeneity within phenomenological
categories mandates the need to individualise care. However, social and cultural context, patient beliefs
about causation, impact, treatment and outcome expectations are never systematically elicited, as they
were not essential to diagnosis and classification. Patient experience and narratives are trivialised and
the biomedical model is considered universal and transcendental. The need to elicit patient perspectives,
evaluate local reality, assess culture, educate patients about possible interventions, and negotiate a
shared plan of management between patient and clinician is cardinal for success. The biopsychosocial
model, which operates within a paternalistic physician-patient relationship, needs to move towards a
shared approach, within a more equal patient-clinician partnership.
! 2013 Elsevier B.V. All rights reserved.

1. DSM-5 and culture

The introduction acknowledges the role of culture in defining
norms for mental disorders. It considers the impact of local
systems of knowledge, concepts, rules, and practices. It recognizes
that culture influences the boundaries between normality and
pathology, tolerance to specific symptoms and behaviours,
vulnerability, suffering, help seeking, treatment adherence and
stigma; cultural explanations affect clinical presentations, perceptions about causation, and outcome.
DSM-5 now highlights cultural concepts (APA, 2013) that have
much greater clinical utility than the culture-bound syndromes
mentioned in previous editions. It recognizes specific cultural
idioms of distress (e.g. kufungisisa), which are often used to
communicate a wide range of suffering and concerns. It also
records cultural syndromes (e.g. Dhat syndrome, Khyal cap, Shenjing
shuairuo, Taijin kyofusho), a cluster of co-occurring, invariant
symptoms found in specific cultural groups and contexts.
DSM-5 concedes that these explanations are examples of
cultural ways of understanding illness experience and the clinical
encounter (APA, 2013). The cultural formulation framework and
interview include a systematic assessment of cultural identity,
concepts of distress, stressors, vulnerability, resilience and also
places the relationship between the patient and the clinician
within their cultural contexts. The shift from exotic and rare

E-mail address: ksjacob@cmcvellore.ac.in.

1876-2018/$ see front matter ! 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ajp.2013.11.012

culture-bound syndromes seen in circumscribed contexts to an

emphasis on cultural formulation for all patients with all DSM-5
disorders acknowledges the fact that concepts of distress,
perceptions, coping, supports, help seeking, and identity are
locally and culturally shaped.
The section on culture in DSM-5 (APA, 2013) argues that all
identified mental disorders started out as cultural syndromes. It
cites depression as an idiom of distress, which is now reflected in
many DSM-5 categories of depression. It acknowledges that there
is no one-to-one correspondence between cultural concepts and
DSM categories. It admits that many cultural categories may apply
to wide range of severity of distress including those, which meet
sub-threshold criteria. It argues that cultural concepts can change
with time, in response to local and global influences. It warns of
that the inability to obtain relevant cultural information can lead to
misdiagnosis, misjudgement of severity, and is pertinent in the
assessment of risk, resilience and outcome. It underscores the fact
that cultural information will improve rapport, clinical engagement and therapeutic efficacy, psycho-education and treatment
adherence. It notes cultural data can aid in epidemiology and in
research.
The DSM-5 criteria and texts for specific disorders also include
information on cultural variations in prevalence, symptomatology,
and associated clinical issues and regional concepts (APA, 2013).
The manual also has codes for conditions that are a focus of clinical
attention including acculturation problems, parentchild relationship difficulties, religious and spiritual conflicts. The glossary
provides examples of cultural concepts of distress that illustrate

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K.S. Jacob / Asian Journal of Psychiatry 7 (2014) 8991

the value and relevance of cultural information for clinical

diagnosis and the interrelationships between cultural syndromes,
idioms of distress and causal explanations.
The DSM-5 also provides for a Cultural Formulation Framework
and Interview, which is semi-structured and allows for a
systematic assessment of cultural issues. It explores cultural
identity, concepts of distress, stressors, vulnerability, resilience
and the clinicianpatient relationship within their cultural
contexts.
2. Comment
Traditional psychiatric categories and subdivisions are often
ideological, based on Euro-American thought. Psychiatry has come
a long way from viewing exotic cultural presentations as variants
of the Euro-American norm to acknowledging that culture affects
many aspects of mental disorders. Culturally driven criterion
modification and notes on diagnosis allow for a culture sensitive
assessment. Many issues emphasized by cross-cultural psychiatry
find a place, albeit primarily in the introduction and appendices of
the manual. Cultural purists will argue that the failure of inclusion
of cultural criteria in diagnosis means that there is still a long way
to go for culture to be accepted as a central part of mental
disorders, their presentation and management.
Nevertheless, DSM-5, its phenomenological clinical criteria and
the biomedical model of mental disorders, have received mixed
reviews. Biologists have argued against using the DSM-5 as the
gold standard because of the inherent heterogeneity of clinical
categories (Insel, 2013). Others have argued that by failing to
consider the context and psychosocial adversity, the DSM-5
medicalizes normal human distress (Jacob, 2013). They suggest
that despite its technical language, operational criteria and
elaborate classification, psychiatry does not have the predictive
power of hard science (Jacob et al., 2013). Without tissue diagnosis,
psychiatric categorization (disease/disorder/distress) remains an
interpretation of the patients illness.
Despite a huge amount of research, the mechanisms of
biological causation have turned out to be oversimplification,
premature and incorrect interpretations of neuroscience data.
Psychiatric categories have reached their limit even within the
current limits of observation. DSM-5 accepts that the goal of
achieving diagnostic homogeneity by diagnostic subtyping no
longer appears sensible.
Cultural psychiatry, on the other hand, has always argued that
the universal categories espoused by the DSM are inappropriate
and needed to be rooted in the local context and culture. It
suggested that there is a category fallacy with the imposition of
Euro-American thought on non-western cultures (Kleinman,
1980). The lack of one-to-one correspondence between cultural
concepts, syndromes and idioms of distress on the one hand, and
psychiatric diagnosis on the other, also argue for heterogeneity
within categories. Nevertheless, clinical criteria, whether based on
western-international diagnosis and classification or on regional
conceptualizations will result in heterogeneous categorizations
(Jacob, 1999). Introducing clinical descriptors based on cultural
attributes into diagnostic criteria will not overcome the problems
of heterogeneity within clinical diagnostic categories.
Biomedical approaches, despite the pretence of their atheoretical nature, play out many dichotomies: subjective vs. objective,
nature vs. nurture; mind vs. body, biological vs. psychological,
disease vs. illness, form vs. content, public vs. private, etc. (Jacob
et al., 2013). These oppositions are not just distinctions but implicit
hierarchies with objective valued over subjective, biological over
psychological, disease over illness, etc. Framing issues within such
value laden structural dichotomies distracts us from the task of
trying to understand the complex interaction, interdependence

and issues related to mental health and illness. Even the proposed
Research Domain Criteria (NIMH, 2013) underemphasizes the role
of development, environment, and culture and need correction.
Nevertheless, despite the inadequate understanding about the
aetiology and pathophysiology of mental disorders, they have to be
managed in clinical practice. The disadvantages of diagnostic
categorization (e.g. overlap between categories, indistinct boundaries, generation of stereotypes, need to force patients into illfitting categories, need to follow ill-suited treatment protocols,
legal implications of diagnosis) mandate individualized assessments and treatment to optimize care. Consequently, the
Biopsychosocial model (Engel, 1980) soon became standard
perspective in medicine and psychiatry. It attempted to integrate
multiple and interacting components including the psychosocial
dimensions (personal, emotional, family, community, culture,
spirituality) in addition to the biological aspects (disease) of all
patients.
Nevertheless, the difficulties with integrating the diverse and
contradictory strands, which predispose, precipitate and maintain
mental disorders often meant a very superficial and idiosyncratic
approach to its implementation. While the elicitation of psychological and social issues in causation is possible, their management
in practice is much more difficult. Psychotherapeutic strategies
require time and expertise while social interventions are beyond
most psychiatrists. Consequently, the biopsychosocial model is
often praised and yet it is the biomedical model, which is routinely
practiced (Jacob, 2013).
Despite its attempts at patient-centred medicine, psychiatry
continues to be undergirded by the doctor-centred biomedical
model. Social and cultural issues are often on the back burner. In
fact, many issues related to patient beliefs about causation, impact,
treatment and outcome expectations are never systematically
elicited, as they were not essential to diagnosis and classification.
This resulted in a neglect of large swathes of information about the
patients background, concepts, culture and local reality.
Many patients and relatives hold multiple and often contradictory causal explanatory models (Saravanan et al., 2005) and
simultaneously seek interventions from practitioners of modern
and traditional medicine and healing across the globe (Jacob, 1999;
McCabe and Priebe, 2004). Consequently, patients and their
physicians are often on the opposite ends of many divides:
illnessdisease, healingcure, mindbody, and subjective experienceobjective clinical phenomena dichotomies. These distinctions in medicine are also hierarchical with disease, cure, body, and
laboratory results privileged over illness, healing, mind and
subjective symptoms. Patients subjective experiences are translated into universal concepts of structural and functional
dysfunction (disease). Patient experience and narratives are
trivialized and clinical phenomena and results of laboratory
investigations considered universal and transcendental (Jacob,
2012). Their singularity and incommensurability with medical
perspectives are dismissed when universal theoretical formations
are applied to clinical practice. The physicianpatient divide
prevents good communication and impacts on most aspects of
clinical interaction including informed consent procedures.
The biopsychosocial model operated within the paternalistic
medical culture, where psychiatrists decided the diagnostic
formulation and chose management solutions. The universal
models employed by psychiatry deemphasized the role of context
and culture, which encouraged medication-based solutions. The
increasing realization of the importance of the patients context
and culture and its impact on diagnosis and management argues
for the need to upgrade the biopsychosocial model. The need to
elicit patient perspectives, evaluate local reality, assess culture,
educate patients about possible interventions and negotiate a
shared plan of management between patient and clinician is

K.S. Jacob / Asian Journal of Psychiatry 7 (2014) 8991

cardinal for success. The biopsychosocial model, which operated

within a paternalistic physicianpatient relationship, needs to
move towards a shared approach, within a more equal patient
clinician partnership.
Psychiatric diagnosis provides a broad direction and mandates
the need to individualize care. Clinical practice demands a
negotiation of shared model of care and treatment plan between
patient and physician perspectives. The diversity of patients,
problems, beliefs and cultures mandates the need to educate,
match, negotiate and integrate psychiatric and psychological
frameworks and interventions (Jacob and Kuruvilla, 2012).
Individual techniques allow clinicians form and structure to treat
different clinical problems, discuss diverse content, and use it in
varied settings and among people with assorted cultural backgrounds.
Psychiatry, divorced from the cultural and psychosocial
context, with the nave use of universal DSM criteria, reflects
poor clinical practice. Similarly, the unsophisticated use of these
categories in biological research has also proven to be unproductive. The heterogeneity within diagnostic groups and within
cultures, regions and populations demands that clinicians understand local and individual reality, match strategies and choose the
best treatment options from a diverse therapeutic armamentarium. The question is whether the advice on culture suggested in the
DSM-5 will be followed not only in letter but also in its spirit. There
is a need for new synthesis, albeit eclectic, embracing the essence
of contemporary biology and humanism.

91

Conflict of interest
The author does not have any conflict of interest to declare.
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