Cultural concepts of distress and assessment

CULTURAL CONCEPTS OF DISTRESS AND ASSESSMENT

1. Cultural Concepts of Distress and Assessment

2. Cultural assessments in psychiatry have evolved in tandem with changing definitions of culture throughout time, especially within anthropology. In 1904, Emil Kraepelin sailed to Java, Indonesia, and investigated symptom manifestations in 100 European, 100 indigenous, and 25 Chinese patients at the Buitenzorg mental hospital.

3. Kraepelin found that psychotic Javanese patients experienced fewer visual and auditory hallucinations and crystallized delusions than European patients, leading him to conclude that the Javanese mind was more primitive than the European mind

4. Cultural psychiatry has documented wide variations in the experience and expression of mental distress around the world. Historically, these variations were often characterized in terms of “culture-bound syndromes”—distinctive patterns of co-occurring symptoms and signs that were assumed to be rooted in or “bound” to local features of culture and context.

5. The clear implication was that Western psychiatric categories were not culture-bound, but rather universal, and that proper characterization would disclose a simple mapping of non Western syndromes onto the categories of international nosology

6. The attribution of “boundedness” emerged early in the history of cultural psychiatry in colonialist contexts in which observers had limited understanding of local cultures. Hence, there was a strong tendency to exaggerate difference, generate stereotypes, and “exoticize” the Other.

7. The foreign observers believed that the communities had been socially isolated and, therefore, saw the patterns of distress as unique and locality bound. Considering the massive migrations and cultural diffusions that have occurred throughout human history, this assumption of boundedness has rarely been tenable.

8. For example, in the 1950s, Raymond Prince described a Nigerian culture-bound syndrome of “brain fag” characterized by feelings of mental fatigue, difficulty concentrating, heat in the head, and other somatic symptoms. Brain fag was found among students who were the first in their families.

9. However, recent historical evidence shows that “brain fag” was commonly described in England in the late 1800s and, presumably, traveled to Nigeria as part of the colonial system to be adopted as a local mode of expressing distress.

10. Cross-cultural mental health researchers have introduced several terms to refer to and describe culture-specific forms of expressing and diagnosing emotional distress, including cultural syndromes, popular or folk illness categories, idioms of distress, and illness explanations or attributions. The need for multiple terms reflects the complexity of the ways in which people experience, understand, and communicate distress.

11. Anthropologists use the term folk illness to refer to local illness categories that are based on particular systems of medicine or broader cultural ontologies, independently of whether they are organized as discrete syndromes or not. A related term is popular illness category, which simply reflects the fact that these are labels or constructs used by lay people.

12. However the term “folk” tends to connote less affluent and formally educated sectors of society and ignores the fact that these categories are used in complex medical systems. Hence DSM-5 uses the more general term cultural concepts of distress to encompass folk illnesses, cultural syndromes, idioms of distress and causal explanations.

13. Y E A R E V E N T S 1893 W . G i l m o r e E l l i s - r e p o r t ed a m o k w h i c h w a s o bs e r v e d a m o n g t h e M a l a y s . 7 1897 W . G i l m o r e E l l i s - r e p o r t ed l at a h an d d e s c r i b e d it a s a m e n t a l ma l ad y o f t h e M a l a y s . 8 1908 W i l l i a m F le t c h er - f u r t h er e l ab o r a t ed o n l at a h an d d e s c r i b ed i t s r e l a t i o n t o c r i me . 9 1910 M us g r a ve a n d S i s o n – r e p o r t ed t h e p h e n om e n o n o f ‘ m i m ic p s y c h o s is’ w h i c h w a s s i m i l a r t o l at ah . I t w a s c a l l ed m a l i - m a li b y t h e l o c a l p e op le o f P h i l i p p i n e s w h e r e it w a s o b s e r v e d . 10 1913 A . A . B r i l l - r e p o r t ed p i b l o k t o (Ar c t ic h y s t e r i a ) , obs e r v e d a m on g t h e I nu it c o m m u n i t y o f G r e e n l a n d , d u r i n g R ob e r t E . P e a r y ’ s v i s i t s . 11 1933 R e v. J o h n M . C o op er - r e po r t ed ‘ w i t iko ps y c hos i s ’ . H e c l a i m ed t h a t it ‘ t y p i c a l l y’ e x i s t ed am o n g t h e C r e e , w h o w e r e m e mb e r s o f t h e A l g o n qu i a n Ind i a n s , l i vi n g in n o r t h e r n C an a d a . 12 1934 v a n W u l f f t e n P a l t h e - r e p o r t ed k o r o a s a n u n us u a l f o r m o f an x ie t y n e u r os i s . 13

14. 1948 G i l l i n - el a bo r a t ed o n m a g i c a l f r i g h t . 17 1957 C a n no n - r e po r t ed o n ‘ v o o d oo ’ d e a t h . 18 1959 F e rn á nd e z - M a r i a n - r e po r t e d a P u e r t o R i c a n s y n d r o m e. I t w a s l a t er d e s c r i b e d a s a t aqu e s d e n e r v i o s b y G u a r n a cc i a , R ub i o - S t i p e c , & C an i n o in 1 989 . 19 1960 R a y m o n d P r i n c e - r e po r t ed t h e ‘b r a i n f a g ’ s y n d r om e am o n g N i g e r i a n s t ud e n t s . 20 1962 T . A . L a m b o - d e s c r i b ed t h e ph e no m e n o n o f ma l i g n an t a n x ie t y in Afr i c a . 21 1964 R u b el - r e p o r t ed t h e ph e n o m e n o n o f s u s t o w h i c h w a s o b s e r v e d a m on g H i sp a n ic A m e r i c a n s . 22 1966 H s ien R i n – p r e s e n t e d a c a s e o f f r i g ophob i a . I t w a s a n e x c e s s ive f e a r o f c a t c h i n g c o ld s e e n in T a i w a n . 23 1974 K asa h a r a d e s c r i b ed ‘a n t h r o p hob i a ’ in J a p a n . 24 1975 B u r t o n - B r a d ley in P a p u a N ew G u i n ea r e p o r t ed ‘ c a r g o c u l t ’ . 25 1976 S u w a n le r t r e p o r t ed a v a r ie t y o f s p i r it p oss e ss i o n n am e d ph i i po b in T ha i l a n d . 26 1976 I n A us t r a l i a , a m on g a bo r i g i n e s J o h n C a w t e r e po r t e d m a l g r i ( t e r r i t o r i a l a n x ie t y ) . 27 1977 L ee r e p o r t e d a n a n g er s y n d r om e n am e d h w ab y un g p r e v a le n t a m o n g K o r e a n s . 28

15. atypical, culture bound, psychogenic psychosis’(Yap, 1962) culture-bound, reactive syndromes’(Yap, 1967) culture-bound syndromes’(Yap, 1969) culture-related specific psychiatric syndromes’ (Tseng & McDermott, 1981) culture-related specific syndromes’ (Tseng, 2001) culture specific disorders’ (ICD-10, WHO, 1992) culture-related syndromes’ (Jilek, 2000) cultural concepts of distress’ (DSM-5, APA, 2013)

16. Four key features of cultural concepts were described in DSM -5:  The correspondence between any cultural concept and a diagnostic entity is more probably one-to-many and in either direction. ii) The severity denoted by cultural concepts may range from symptoms that do not meet DSM criteria of any disorder to conditions fulfilling diagnostic criteria. iii) The same cultural term may denote multiple cultural concepts. iv) As a response to global and local influences, they may change over time.

17.   C U L T U R A L C O N CE P T S TY P E R E L AT E D C O N D I T IO N S I N D S M - 5 1. A t aqu e d e n e r vi o s S y n d r om e or Id i o m o f d i s t r e s s P a n ic d i s o r d e r , pan ic a tt a c k, c on v e r s i o n d i so r d e r , o t h e r sp e c i f ied o r u n sp e c i f i e d d i sso c i a t ive d i s o r d e r , i n t e rm i tt e n t e x p l o s ive d i s o r d e r , o t h er s p e c i f ied o r u n sp e c i f i e d t r au m a a n d s t r e s s o r - r el a t ed d i so r d er o t h e r sp e c i f ied o r u n sp e c i f i e d an x ie t y d i s o r d e r , 2. Dha t s y n d r o m e C u l t u r a l E x p l a na t i o n P e rs i s t e n t d e p r e s s ive d i s o r d er ( d y s t h y m i a ) , ma j o r d e p r e s s ive d i s o r d e r , g e n e r a l i z ed a n x ie t y d i s o r d e r , i l l n e s s a n x ie t y d i so r d e r , so m a t ic s y m p t o m d i so r d e r , e a r ly ( p r e m a t u r e) e j a c u l a t i o n , e r e c t i l e d i s o r d e r , o t h er sp e c i f ied o r un s p e c i f ied s e x u a l d y s f un c t i o n , a c a d e m ic p r o b le m . 3. K h y a l c a p S y n d r om e P an ic d i s o r d e r , p a n ic a tt a c k, g e n e ra l i z e d an x ie t y d i so r d e r , a g o r a p h ob i a , i l l n e s s a n x ie t y d i s o r d e r , pos tt r a u m a t ic s t r e s s d i s o r d e r .

18. 4. K u f un g i s i s a Id i o m o f d i s t r e s s & C u l t u r a l e x p l a n a t i o n P e rs i s t e n t d e p r e s s ive d i s o r d er ( d y s t h y m i a ) , ma j o r d e p r e s s ive d i s o r d e r , g e n e r a l i z ed a n x ie t y d i so r d e r , o b s e ss i v e- c o m pu l s ive d i s o r d e r , p o s tt r a u ma t ic s t r e s s d i s o r d e r , p e rs i s t e n t c omp l e x b e r e a v e m e n t d i s o r d e r . 5. M a l a d i m o u n C u l t u r a l e x p l a na t i o n S c h i z o p h r e n i a w i t h p a r ano i d f e a t u r e s ; D el u s i o n a l d i so r d e r , p e rs e c u t o r y t y p e . 6. N e r vi o s Id i o m o f d i s t r e s s P e rs i s t e n t d e p r e s s ive d i s o r d er ( d y s t h y m i a ) , ma j o r d e p r e s s ive d i s o r d e r , s o c i a l a n x ie t y d i so r d e r , g e n e r a l i z e d a n x ie t y d i so r d e r , so m a t ic s y m p t o m d i s o r d e r , o t h er sp e c i f ied o r u n sp e c i f i e d d i s s o c i a t ive d i s o r d e r , s c h i z o p h r e n i a .

19. 7. S h e n j i n g s h ua i r u o S y n d r om e P e rs i s t e n t d e p r e s s ive d i s o r d er ( d y s t h y m i a ) , ma j o r d e p r e s s ive d i s o r d e r , g e n e r a l i z e d a n x ie t y d i so r d e r , s o c i a l a n x ie t y d i so r d e r , so m a t ic s y m p t o m d i so r d e r , p o s tt r a u m a t ic s t r e s s d i so r d e r , sp e c i f ic p h ob i a . 8. S us t o C u l t u r a l e x p l a na t i o n M a j o r d e p r e ss ive d i s o r d e r , so m a t ic s y m p t o m d i s o r d e r s , pos tt r a u m a t ic s t r e s s d i s o r d e r , o t h er sp e c i f i e d o r u n sp e c i f i e d t r au m a a n d s t r e s s o r - r el a t ed d i s o r d e r . 9. T a i j in ky o f u s h o S y n d r om e S o c i a l a n x ie t y d i s o r d e r , d el u s i o n a l d i so r d e r , b od y d y s m o r ph ic d i s o r d e r , obs e ss iv e - c o m pu l s ive d i s o r d e r , o l f a c t o r y r e f e r e n c e s y n d r o m e .

20. In an attempt to organize and classify the various culture -bound syndromes, several systems were proposed by different authors. The important among them are enlisted below: 1. Subgrouping by cardinal systems   2. Subgrouping by taxons 3. Subgrouping by relationship to culture

21. 1. SUBGROUPING BY CARDINAL SYSTEMS   Pow Meng Yap (1967) was of the view that these syndromes are regional variations of universal psychiatric disorders, produced by the influence of local beliefs, social structure and values in the clinical presentation. He believed that all attempts to classify illnesses should be based on etiology, but there was insufficient knowledge to give an aetiological classification of the culture-bound syndromes. So he attempted to do the categorization by identifying the cardinal symptom of the prototypical case or primary emotional state.

22. i ) Primary fear reactions – included latah , malignant anxiety, psychogenic or magical death. ii) Morbid rage reaction – amok. iii) Specific culture-imposed nosophobia - koro iv) Trance dissociation - windigo psychosis

23. 2. SUBGROUPING BY TAXONS This was proposed by Ronald C. Simons and Charles C. Hughes in 1985. They were having the opinion that phenomenological similarity was present between various culture related syndromes across diverse cultural settings. The concept of ‘taxon’ was borrowed from biology to refer to a category that arranges a group of objects based on a common factor. Thus categorization of these syndromes into various subgroups was done with each subgroup defined by a common factor.

24. The startle-matching taxon - included latah and imu . ii) The sleep-paralysis taxon iii) The genital-retraction taxon - koro . iv) The sudden-mass-assault taxon – amok.   v) The running taxon - grisi siknis , pibloktoq and arctic hysteria. vi) The fright-illness taxon – susto . vii) The cannibal-compulsion taxon - windigo psychosis.

25. 3. SUBGROUPING BY RELATIONSHIP TO CULTURE Tseng and McDermott in 1981. The subgrouping of culture related syndromes was done according to how they might be affected by various cultural factors. As the cultural perspective was taken into consideration, this appeared to be a more meaningful approach.

26. i ) Pathogenic effect – cultural factors having causative effect.   ii) Pathoselective effect – cultural factors selects the type and nature of psychopathology. iii) Pathoplastic effect – cultural beliefs contribute to the manifestation of psychopathology. iv) Pathoelaborating effect - certain types of manifestations are elaborated and reinforced by cultural factors. v) Pathofacilitating effect – cultural factors contribute to the frequent occurrence of certain psychopathologies. vi) Pathoreactive effect - the reaction to psychopathology is determined by culture.

27. SYNDROMES IN WHICH CULTURAL FACTORS HAVE PATHOGENIC EFFECTS KORO (Genital-retraction anxiety disorder) Koro was initially considered to be a culture bound syndrome occurring only in the Chinese population, but later in many South and East Asian countries like Singapore, Thailand, Indonesia and India. Koro refers to an episode of intense and sudden anxiety that the penis (in males) or nipples and vulva (in females) will recede into the body, which may possibly lead to death.

28. Dhat syndrome (Semen-loss anxiety) Mostly described in India, this condition was later found to be widely prevalent in Pakistan, Bangladesh, Nepal, China, Sri Lanka (known as prameha disease) and Taiwan. The patients usually present with vague symptoms such as weakness, fatigue, anxiety, loss of appetite, weight loss, guilt, impotence or premature ejaculation , depressive mood etc. They attribute the symptoms to the excessive loss of semen.

29. The chief complaint by the patient is whitish discoloration or turbidity of the urine which he considers as result of passage of semen in urine. It is most commonly observed in young men from lower socio -economic strata. A variant of this can also be found in women, as an excessive concern regarding white vaginal discharge.

30. Frigophobia : This condition is typically found in China, Taiwan and south -east Asia, characterized by ‘morbid fear of catching cold’. Sorcery fear and Voodoo death : ‘Voodoo’ Death was first described by Walter B. Cannon as unexplained and sudden death resulting from a voodoo curse.

31. Malgri (Territorial Anxiety Syndrome) : The term malgri is the name of aborigines inhabiting the Wellesley Islands of the Gulf of Carpentaria in Australia among whom this condition was originally described. First reported by John Cawte in 1976. In this area it is folk belief that if a person enters the sea without washing hands after handling the land food, the spirit guarding that littoral will enter his belly like a bullet and will make that person sick.

32. SYNDROMES IN WHICH CULTURAL FACTORS HAVE PATHOSELECTIVE EFFECTS AMOK : Amok refers to a dissociative episode characterized by an outburst of aggressive, violent or homicidal behaviour directed against people and objects preceded by a period of brooding. Malay mythology describes amok as an involuntary behaviour which is caused by the evil spirit “ hantu belian ”, entering a person's body and making him or her to have violent behaviour without conscious awareness.

33. CARGO CULT SYNDROMES (MILLENNIARY DELUSIONS) : Historically there have been occurrences of ‘crisis cults’ in different countries like Kikuyu maumau in Kenya and the Taiping rebellion in China. They were characterized by many non -logical, magicoreligious endeavors by the members of a native culture taking place when they are exposed to some superior cultures.

34.     SYNDROMES IN WHICH CULTURAL FACTORS HAVE PATHOPLASTIC EFFECTS TAIJIN KYOFUSHO OR ANTHROPOPHOBIA : Taijin kyofusho is a cultural syndrome characterized by anxiety about interpersonal situations occurring due to the feeling, though t or conviction that the appearance and actions of someone in social interactions are offensive or inadequate to others which leads to the avoidance of such situations

35. BRAIN FAG SYNDROME ARCTIC HYSTERIA or PIBLOKTOQ : Unique hysterical attack occurring in the Eskimo people, characterized by a sudden dissociative episode accompanied by marked excitement which may last as long as 30 minutes.

36. SYNDROMES IN WHICH CULTURAL FACTORS HAVE PATHO ELABORATING EFFECTS LATAH : This term is used to denote the state of highly exaggerated response occurring when an individual is startled or being subjected to a sudden fright. The response is comprised of altered consciousness and a transient dissociated state showing abnormal behaviors. Echolalia, echopraxia, automatic obedience, euphoric mood and verbal outbursts involving erotic words are observed. Following the cessation of the attack subject usually will have amnesia regarding the incident.

37. SYNDROMES IN WHICH CULTURAL FACTORS HAVE PATHO FACILITATING EFFECTS This category is comprised of several psychiatric disorders in which cultural factors have strong influence in determining the prevalence. They do not constitute unique or specific disorders or clinical manifestations . Substance use, alcohol related problems, group suicide and mass hysteria are some examples of this category.

38.   SYNDROMES IN WHICH CULTURAL FACTORS HAVE PATHO REACTIVE EFFECTS ATAQUE DE NERVIOS : This condition is observed typically among the various Latin American cultures, especially in the Hispanic people of Cuba, Puerto Rica and the Dominican Republic. Attacks occur following a stressful event such as death of a relative or marital conflicts. The characteristic symptoms are uncontrollable shouting, trembling, attacks of crying, numbness, heat in chest raising into head and physical or verbal aggression. The attacks usually end rapidly, mostly when others intervene. This condition predominantly affects females.

39. HWABYUNG : Hwabyung is an ‘illness of attribution’. It’s attributed to suppression of anger and observed in women. I n male dominated Korean society, women are often mistreated and they are compelled to suppress their emotions. The accumulated resentment is considered as the core dynamics in development of Hwabyung . The symptoms include fatigue, insomnia, panic, dysphoric affect, fear of impending death, anorexia, indigestion, palpitations, dyspnea, feeling of a mass in the epigastrium and generalized pains and aches.

40. SUSTO : Susto is prevalent among Latinos in United States and people of Mexi co, South America and Central America. The word susto in Spanish means ‘fright’. This term is used to describe chronic complaints which are attributed to the loss of soul caused by a frightening event, including anorexia, agitation , decreased or excessive sleep, mental confusion, lack of motivation , and emotional symptoms such as depression, irritability and anxiety .

41.   C U L T U RE S P EC I F I C D I S O R D E RS SU GG E S T E D I C D - 1 C O D E 1 . A mo k F 68 . 8 O t h er s p e c i f ied d i s o r d e r s o f a du lt p e r s o na l i t y a n d b e h a vi o u r 2 . Dha t / J i r y a n / D ha t u / S h en k ’ u ei / S h e n - k u i F 48 . 8 O t h er s p e c i f ied n e u r o t ic d i s o r d e r s     F 45 . 3 4 S oma t o f o r m au t o n o m ic d y s f un c t i o n o f t h e g e n i t ou r i na r y s y s t em 3 . K o r o / S u k y e on g / J i n j in b e m a r / S u o - y a n g F 48 . 8 O t h er s p e c i f ied n e u r o t ic d i s o r d e r s     F 45 . 3 4 S oma t o f o r m au t o n o m ic d y s f un c t i o n o f t h e g e n i t ou r i na r y s y s t em

42. 4 . L a t a h F 48 . 8 O t h er s p e c i f ied n e u r o t ic d i s o r d e r s     F 44 . 8 8 O t h er s p e c i f ied d i s s o c i a t ive ( c on v e r s i o n ) d i s o r d e r s 5. P i b l o k t o q / Ar c t ic h y s t e r ia F 44 . 7 M i x ed d i s s o c i a t ive ( c on v e r s i on ) d i s o r d e r s     F 44 . 8 8 O t h er s p e c i f ied d i s s o c i a t ive ( c on v e r s i o n ) d i s o r d e r s 6. N e r f i z a / N e r v e s / N e r vi o s / N e v r a F 32 . 1 1 M od e r a t e d e p r e ss i v e e p i s od e w i t h s o ma t ic s y nd r om e     F 48 . N e u r as t h e n ia     F 45 . 1 U nd i f f e r e n t i a t ed so m a t o f o r m d i s o r d e r 7. P a - le n g / F r i g o ph o b ia F 40 . 2 S p e c i f ic p h o b i a s 8 . S us t o / E s p an t o F 45 . 1 U nd i f f e r e n t i a t ed so m a t o f o r m d i s o r d e r     F 48 . 8 O t h er s p e c i f ied n e u r o t ic d i s o r d e r s

43. 9 . T a i j in ky o f u s h o / A n t h r op o p h ob i a / S h i n kei s h i t s u F 40 . 1 S o c i a l p h ob i a s     F 40 . 8 O t h er p h o b ic a n x ie t y d i s o r d e r s 1 . U f u f u y an e / S a k a F 44 . 3 Tr an c e a n d p o ss e ss i o n d i so r d e r s     F 44 . 7 M i x ed d i s s o c i a t ive ( c on v e r s i on ) d i s o r d e r s 1 1 . U qa m a i r i n e q F 44 . 8 8 O t h er s p e c i f ied d i s s o c i a t ive ( c on v e r s i o n ) d i s o r d e r s     G 47 . 4 N a r c o le p s y a n d c a t a p le x y ( I n c l ud e s : s le e p p a r a l y s i s ) 1 2 . W i nd i g o ( ? ) F 68 . 8 O t h er s p e c i f ied d i s o r d e r s o f a du lt p e r s o na l i t y a n d Be h a v i o u r

44. John Carr hypothesized that all forms of psychopathology, including the folk illnesses, represent culturally authorized final common behavioral pathways. These are behavioral responses, part of a limited number of behavioral repertoires that individuals use in response to stressful conditions that are common to humanity . Although significantly shaped by culture, these pathways are mediated by universal mechanisms of learning and cognition .

45. To elucidate the relationship between amok and depression, for example, Carr and Peter Vitaliano contended that alternate expressions of distress are culturally determined variants of response to comparable life stress conditions . Then why some respond with aggression, some with depression, and still others cope adaptively to similar aversive events. Culture-specific and idiosyncratic responses to stress result from complex interactions between physiological processes, predisposing personality styles, cognitive processes, and learned problem-solving skills.

46. Ethnographic work reveals that cultural concepts of distress identify socially constructed patterns of interpretation of suffering that serve pragmatic communicative functions. Clarifying these functions requires what Good and Delvecchio Good called a “meaning-​centered medical anthropology” that investigates illness forms from the perspective of semantic networks, the clusters of experiences, words, and interpretations that give rise to particular illness forms as modes of experience and expression . These meaning networks are called “semantic” because they reveal the role of interpretation and communication in shaping reality and may include “personal trauma, life stresses, fears and expectations about the illness . . . the metaphors associated with a disease, the ethnomedical theories, the basic values and conceptual forms, and the care patterns that shape the experience of the illness and the social reactions to the sufferer in a given society.” By taking this contextual approach, the basic organizational principle underlying a particular illness form can be established in order to assess the degree to which it is descriptive, etiological, or expressive of particular concerns.

47. The Explanatory Model Questions were proposed by Kleinman in 1980 as a tool to aid clinicians in interviewing patients about their cultural understandings of their illnesses. This deceptively simple set of eight groups of questions provides a framework for a brief clinical interview that can identify the presence and meaning of a folk illness category. In particular, the first five groups of questions are useful in this regard and include: ► What do you call your problem? What name does it have? ► What do you think has caused your problem? ► Why do you think it started when it did? ► What does your sickness do to you? How does it work? ► How severe is the sickness? Will it have a short or long course ?

48. The DSM-IV Outline for Cultural Formulation

49. The CFI guidelines provide a definition of culture as (1) the values, orientations, knowledge, and practices that individuals derive from membership in diverse social groups (e.g., ethnic groups, faith communities, occupational groups, and veterans groups); (2) aspects of an individual’s background, developmental experiences, and current social contexts that may affect his or her perspective, such as geographical origin, migration, language, religion, sexual orientation, or race/ethnicity; and (3) the influence of family, friends, and other community members (the individual’s social network) on the individual’s illness experience.

50. The DSM-5 Cultural Formulation Interview (CFI)

51. Role of Cultural Identity