Proposed DSM-5 Cultural Formulation guidelines: A report from the SSPC

Last week saw the annual meeting of the Society for the Study of Psychiatry and Culture (SSPC) in New York City. SSPC’s mission includes “furthering research, clinical care and education in cultural aspects of mental health and illness,” and although somewhat small includes some of the most prominent thinkers in the world of psychiatry and culture. These are the people who go beyond simplistic cultural diatheses (e.g., individualism versus collectivism), incorporating multidimensional frameworks that include political factors as well as ethnicity and race.

Among the livelier presentations was a report by Roberto Lewis-Fernandez, Neil Aggarwal (both at Columbia), Laurence Kirmayer (McGill), and Renato Alarcón (Mayo Clinic and Universidad Peruana Cayetano Heredia) on much needed updates to the Cultural Formulation guidelines in the upcoming DSM-5. The DSM — Diagnostic and Statistical Manual — is the American Psychiatric Association’s official guidebook to human psychopathology, and the current version, DSM-IV-TR, is largely accepted as the last word on mental health problems in psychiatry, psychology, social work, and related disciplines. Cultural Formulation guidelines are suggestions for how clinicians should conceptualize the role of culture in patients’ mental health problems. The guidelines appeared first in the pages of the DSM-IV (1994), but, along with a short and messy list of “Culture-Bound Syndromes,” were placed in the back of the book where few practitioners would ever find them.

This time around there is a widespread effort to place the Cultural Formulation front and center in the DSM-5. Drs. Lewis-Fernandez and Aggarwal reported on a tool designed to make cultural formulation quicker and easier, the Cultural Formulation Interview, or CFI. The CFI is meant to be administered during patients’ initial assessment, and consists of 14 questions. Many of these questions are just good clinical practice. For instance, the first question is, “What problems or concerns bring you to the clinic?” Although there are hints at what might be considered culture by question three (“People often understand their problems in their own way, which may be similar or different from how doctors explain the problem. How would you describe your problem to someone else?”), it’s not until the seventh question that culture is explicitly mentioned: ”Is there anything about your background, for example your culture, race, ethnicity, religion or geographical origin that is causing problems for you in your current life situation?”

The point of framing the questions this way  is to not make a big deal of culture while at the same time getting a good person-centered assessment that considers culture as important to how patients view their problems. This is meant to avoid the stereotyping that considering culture often leads to in situations in which clinician and patient differ on some cultural dimension. The CFI seems to provide space for individuals to define their problems as they see fit — i.e., to make explicit their own explanatory models — and then relate this to how others within their social networks (including family members and those that don’t share their culture) may see their problems.

My favorite exchange came after one audience member looked over the CFI and asked, “For whom would these questions not be relevant?”

Dr. Lewis-Fernandez replied: “Yes, exactly.”

The CFI is currently undergoing field trials. Read more about the proposed DSM-5 Cultural Formulation and the CFI, and express your opinion as to whether it should be emphasized (or not, I suppose), by following this link to the DSM-5 commentary website. Common sense needs advocates.

On a related note: If you haven’t read it yet, Allen Frances’ Op-Ed in Saturday’s New York Times, provocatively titled Diagnosing the DSM, is worth it. In it Dr. Frances, one of the architects of the DSM-IV, argues strongly that the DSM-5 development process should be untethered from professional psychiatry in order to build a better product. A teaser:

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.

Two press pieces on the science (and anti-science) of PTSD in the military

The past weekend saw two articles in the popular press concerning PTSD among U.S. soldiers that are worth a read. First, the Seattle Times reported that the Army’s new PTSD screening guidelines fault the established screening tests designed to root out PTSD fakers. Why would anyone fake PTSD? The Army pays an average of $1.5 million in disability benefits per soldier (over his/her lifetime) with PTSD. It is estimated that 22 percent of returning soldiers have PTSD. The difference between those who have it and those who may be faking is no small chunk of change.

In part because of pressure by Senator Patty Murray (D-Washington) to investigate screening at the Madigan Army Medical Center (in Tacoma, Washington), the Army Surgeon General has issued new guidelines that criticize the use of the Minnesota Multiphasic Personality Inventory — or, MMPI, as most psychologists know it. The MMPI is one of the most venerated of psychological screening questionnaires, holding up pretty well in over 60+ years of research (it has been revised several times, most recently in 2008). At issue in this case is the MMPI’s “lie scale,” which has been shown to detect malingerers of various stripes in multiple studies.

According the the Seattle Times, the Army’s new policy ”specifically discounts tests used to determine whether soldiers are faking symptoms of post-traumatic stress disorder. It says that poor test results do not constitute malingering.” Technically this is true; malingering scale scores on any normed test like the MMPI are associated with higher or lower probabilities of malingering, and not absolute certainty. Still, by throwing out the best tool they have to detect whether soldiers are malingering or not, what the Army really seems to be doing is trying to avoid appearing callous by relying on scientific methods.

Ironically, the same guidelines include empirically-based treatment improvements regarding medication:

The document found “no benefit” from the use of Xanax, Librium, Valium and other drugs known as benzodiazepines in the treatment of PTSD among combat veterans. Moreover, use of those drugs can cause harm, the Surgeon General’s Office said. The drugs may increase fear and anxiety responses in these patients. And, once prescribed, they “can be very difficult, if not impossible, to discontinue,” due to significant withdrawal symptoms compounded by PTSD, the document states.

Score one for research on meds, zero for research on screening questionnaires (or maybe: psychiatrists one, psychologists zero).

The second article of note wasn’t a report, but an editorial. Writing in the New York Times’ Sunday Review, Weill Cornell Psychiatrist Richard Friedman builds the case that one possible reason for the increase in cases of PTSD among returning soldiers from Afghanistan and Iraq is an increase in stimulants prescribed to them on the battlefield. With the help of the Freedom of Information Act, Dr. Friedman found that military spending on stimulants increased 1,000 percent over five years.

Stimulants do much more than keep troops awake. They can also strengthen learning. By causing the direct release of norepinephrine — a close chemical relative of adrenaline — in the brain, stimulants facilitate memory formation. Not surprisingly, emotionally arousing experiences — both positive and negative — also cause a surge of norepinephrine, which helps to create vivid, long-lasting memories. That’s why we tend to remember events that stir our feelings and learn best when we are a little anxious.

Since PTSD is basically a pathological form of learning known as fear conditioning, stimulants could plausibly increase the risk of getting the disorder.

Dr. Friedman goes on to explain the neurochemistry behind the proposed interaction of stimulants and trauma, review new research showing ameliorative effects of beta-blockers, and (appropriately) call for more transparency and more research on the topic.

More evidence that measuring local concepts of distress matters

The latest issue of Psychological Assessment includes an article by University of Pennsylvania postdoctoral research fellow (and soon to be Manhattan College Assistant Professor) Nuwan Jayawickreme that provides support for the use of locally developed distress measures in post-disaster settings that are beyond the cultural boundaries of Western psychology’s usually realm. Are Culturally Specific Measures of Trauma-Related Anxiety and Depression Needed? The Case of Sri Lanka provides empirical evidence suggesting that once locally-developed measures of posttraumatic distress are administered, administering measures of PTSD and depression (as defined by DSM-IV) does not provide any more useful information vis-a-vis an individual’s impairment of day-to-day functioning.

Developing psychological distress measures in non-Western disaster zones has been on the agenda of many in the disaster mental health field for over a decade now. The essential problem is that conceptualizations of mental health problems and the way that different people from different cultures express their distress vary widely. So, when mental health professionals need to assess individuals to see if they need treatment, they need a measure (questionnaire, survey, or some other standard measurement tool) that is sensitive to that population. How  are such tools to be developed? Jayawickreme explains:

Identifying such idioms first need to use ethnographic methods to understand how the social world interacts with the individual’s physical and psychological processes. Such ethnographic studies usually involve an in-depth examination of a specific culture’s conceptualization of a particular experience. Once the concepts and the idioms used by the community in question have been identified, questionnaires or inventories can be developed to assess these concepts, which are then validated using iterative statistical and field testing methods

And that’s what he did. And then he administered this measure, called the Penn/RESIST/Peradeniya War Problems Questionnaire (PRP-WPQ), the PTSD Symptom Scale (or PSS, a standard PTSD scale developed by trauma treatment luminary – and Jayawickreme advisor – Edna Foa) and the Beck Depression Inventory (the BDI, a standard measure of depression) to 197 Tamil Sri Lankans living in the war torn northern and eastern parts of the island. And then he looked at the incremental ability of the PTSD Symptom Scale and the Beck Depression Inventory to predict a measure of functional impairment.

Jayawickreme’s regression analysis showed what some of us have been talking about (and even publishing empirical results on) for a while now: Using measures of psychological distress with local populations that incorporate terms that they can understand is better at getting at the functional impairment due to this distress than using DSM-IV based measures.

The current findings provide support for the notion that sensitive measurement of  psychopathology in non-Western, war affected populations may require the development of instruments that incorporate local idioms of distress. As noted earlier, there are limited resources available for providers of psychosocial aid in non-Western, war-affected countries. Given the considerable needs of such populations, it may seem inappropriate to engage in what appears to be a costly and complicated process to develop measures incorporating local idioms of distress. The current results do indicate that the PSS and the BDI predict functional impairment to a substantial degree. However, the current results also suggest that measures incorporating idioms of distress may improve our ability over and above the established measures to identify those who are functionally impaired because of mental illness and who therefore need assistance.

Recent focus on child soldiers and what the research says

The International Criminal Court (ICC) has made its first ruling, convicting Congolese rebel leader Thomas Lubanga of using children younger than 15 as soldiers. For basic media coverage, see here, here, and here. The conviction if Lubanga is the ICC’s first in its decade of existence, and for those of you interested, the BBC has a decent discussion of the costs, estimated at $900 million, here.

Lubanga could have been accused of any number of war crimes, but the ICC chose to focus on child soldiering (due to the quality of evidence, say prosecutors). The recent Invisible Children anti-Joseph Kony video recently trending on Twitter (no need for a link, I’m sure) chooses to also focus on child soldiering. Clearly this is compelling stuff for the media as well as legal teams, nightmare material for those who love kids and those who fear teenagers. From the sympathetic side we often hear simplistic pronouncements like this one from today’s New York Times:

Social workers say that even if children have enlisted willingly, looking for food, status or protection, they are often still permanently damaged by war-time violence and drugs.

There is, however, a research literature on child soldiers that presents a more nuanced picture. Although certainly former child soldiers suffer higher rates of physical and mental health problems than similar kids, the research suggests that there is more hope for them than is commonly portrayed. The work of Jeannie Annan and Chris Blattman show that there is wide variability in what child soldiering actually entails, and, that former child soldiers – far from being permanently damaged – are more active in peaceful post-conflict political processes than their peers. Theresa Betancourt‘s work shows that symptoms of emotional distress decrease over time among many, and I believe she has plans underway for treatment trials for those with continuing problems. Brandon Kohrt’s work presents (among other things) complex stories of reintegration through film, as well as research articles.

All this is not to say that child soldiering is in some way really not so bad. Making this a cause is indeed appropriate. But there is more to the issue than just crazed violent teenagers and their adult bad guy overlords. Child soldiers become former child soldiers, adults who live lives and can contribute to their societies.

Sacrificing the Violence Against Women Act in order to prevent protecting immigrant women

In recent years, more and more Immigration Courts in the Unites States have been granting political asylum to women who are victims of domestic violence and can’t get protection in their own countries. This is not really news (it was covered in these pages a couple years), but the issue seems to have raised a bit of a ruckus in the hallowed halls of the U.S. Senate recently.

Like most bills, the U.S. Federal Violence Against Women Act of 1994 needs to reauthorized every now and again in order to fund its various activities. Activities the bill funds generally are along the lines of domestic violence prevention programs and provision of forensic “rape kits” to ensure that proper evidence is collected following sexual assaults. During the reauthorization process a few edits can be made. This year’s reauthorization almost didn’t make it out of committee when all Republican Senators on the Judiciary Committee voted to keep it from a vote on the Senate floor. What was the problem? From today’s New York Times Editorial page:

The main sticking points seemed to be language in the bill to ensure that victims are not denied services because they are gay or transgender and a provision that would modestly expand the availability of special visas for undocumented immigrants who are victims of domestic violence .

Senators on the Judiciary Committee were evidently willing to sacrifice protections for all women in order to prevent protections for battered undocumented immigrant women. The bill made it through committee, and now it will go to the floor. Think this is over?

Mustering the 60 votes needed to get the bill through the full Senate will not be easy, even though previous reauthorizations were approved by unanimous consent. Recalcitrant Republicans should be made to explain to voters why they refuse to get behind the federal fight against domestic violence and sexual assaults.

Doggy thoughts during wartime: Canine PTSD is (apparently) fit to print.

Back in May I was forwarded an online piece about a Dr. Burghardt and his theory about “canine PTSD” and noted that PTSD conceptual bracket creep had now progressed beyond primates. Now the New York Times sees fit to report on this new canine psychopathology:

Though veterinarians have long diagnosed behavioral problems in animals, the concept of canine PTSD is only about 18 months old, having come into vogue among military veterinarians who have been seeing patterns of troubling behavior among dogs exposed to explosions, gunfire and other combat-related violence in Iraq and Afghanistan.

Here’s how my canine-concerned colleagues conceptualize the disorder:

In each case, Dr. Burghardt theorizes, the dogs were using an object, vehicle or person as a “cue” for some violence they had witnessed. “If you want to put doggy thoughts into their heads,” he said, “the dog is thinking: when I see this kind of individual, things go boom, and I’m distressed.”

See? PTSD. Or maybe just good doggy thinking. Or maybe we’ve seen this before in animals and we want to give it some label that means more to us than what happens when the early behaviorists shocked rats to demonstrate conditioning. Stimulus – response. Cue – stimulus – response. Cue – response.

This is a perfect example of how previously recognized behavioral phenomena are relabeled by popular authorities as psychopathology based on recent cultural historical events. For a quick read on this phenomenon, see Ethan Waters’ Crazy Like Us. Read the New York Times piece on Canine PTSD here.

The HESPER: WHO’s measurement answer to the problem of identifying needs within displaced populations

The World Health Organization recently released the Humanitarian Emergency Settings Perceived Needs Scale (HESPER), a measure that they hope will operationalize the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings and encourage rapid assessment of perceived needs in disaster settings. Longtime disaster mental health and psychosocial researcher Mark van Ommeren was the lead on the project, which means that it was developed with the highest level of rigor given the needs, which include some flexibility. A large advisory group that reads (with a few exceptions) like a who’s who of international disaster mental health and psychosocial intervention provided regular input, and the HESPER was tested in sites as various as Sudan, the UK, Jordan, the Palestinian Territories, Haiti and Nepal. Overall the psychometrics reported look good, particularly given the diversity of locations. There are sections on individual needs and community-level needs on a surprising number of domains, a welcome relief from the unidimensional individual-level norms.

What may be the best thing about the HESPER guide is the presentation. Van Ommeren and company have provided not only the measure and the methods used for development of the measure, but also sections on training local administrators, appropriate sampling, a mock interview transcript that reads true, and even a section on how to present HESPER findings to organizations. Too often I have seen an disaster relief NGO get a measure that may be valid or may not, administer it haphazardly, and then be unsure of how to meaningfully present findings. In addition, there’s an “Other things to consider” section which includes the things that you don’t usually think about but are blatantly obvious on the ground — the dilemma of raised expectations that often come about just by asking about problems, for instance.

And then there’s this:

1.2 WHO MAY USE THE HESPER SCALE?

The HESPER Scale may be used by anybody in its current form for non-commercial purposes. Should you wish to make any modifications to the scale, or translate the scale into another language, you will need to get permission from WHO Press (for contact details, see inside cover page). Currently the HESPER Scale (i.e. Appendix 1 only) is available in English, French, Spanish, Arabic, Nepali, and French / Haitian Creole. Word files of the different HESPER Scale language versions are available upon request.

The WHO provides their measures for free and welcomes further development of these types of rapid assessments.