Download - A Culture of Diagnostics – Professional knowledge and cultural contexts Oslo Akershus University
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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
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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
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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)
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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
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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
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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
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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
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Outline for a Cultural Formulation in DSM-IV, Appendix I
”mini-ethnographic”, narrative assessment (Lewis-Fernández, 1996).
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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
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Outline for Cultural Formulation in DSM-5
Included in Section IIIEmerging Measures and Models
pp. 749-757Cultural Formulation Interview (CFI)
CFI –Informant versionSupplementary Modules
http://www.psychiatry.org/practice/dsm/dsm5/online-
assessment-measures#Cultural
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The Cultural Formulation Interview
• 16 questionsAny 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
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The Cultural Formulation Interview
Cultural definition of the problem
1. What brings you here today?
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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
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Supplementary modules
1. Explanatory Model 2. Level of Functioning 3. Social Network 4. Psychosocial Stressors 5. Spirituality, Religion, and Moral Traditions 6. Cultural Identity
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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
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Interview guide – contextualising the CF
• Research on the CF in DSM-IV
• Interview guide
Bäärnhielm, Scarpinati Rosso, 2009Scarpinati Rosso, Bäärnhielm, 2012
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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?
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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
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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
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Preliminary diagnosis• Adjustment Disorder with Depressed
Mood 309.0 (?) • Depressed mood?• Is distress a reaction to a demanding
social and family situation?
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CULTURAL DEFINITION OF THE PROBLEM
1. What brings you here today?
Swedish: Vad har du för besvär?Norwegian: Hva slags plager har du?
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Affaf responds by talking about:
Tired, worried, brooding, lacks energyFurther details of how complicated the divorce situation was Struggles with herself to take care of her son Often sits alone in a dark roomHas grown to like the darkness of the Swedish winter - mirrors her mood
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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.
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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
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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?
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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 familyShe is afraid of the family
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The CFI Supplementary Module 11. Immigrants and refugees
Aims to explore:Experiences of migration and resettlement
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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)
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• 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
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Asks the interviewer ”Why do I sometimes think about
dying?”
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Clinical benefits of the CFI in this case
• identifying a depressed mood • evaluating severity and impairment• identifying personal resources &
symptoms of PTSDDiagnosis was revised to: Major Depressive Disorder, single episode, Moderate, 296.22PTSD 309.81
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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 moodrevised diagnostic evaluation
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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
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Canadian study on the CFI (DSM-IV) – psychotic patients
• Misdiagnosis for psychotic patients occurred with patients from all ethnocultural groups, especially recently settled immigrants.
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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.
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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.
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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
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The Swedish context • The inclusion of the CFI in DSM makes
this type of mini-ethnographic work and research socially acceptable within Swedish psychiatry
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The Swedish context
• In a situation of constant cut backs of costs
• Increasingly more manualised /standardised psychiatric care