Journal of Abnormal Psychology 1987, Vol. 96, No. 3,270-272 Copyright 1987 by the American Psychological Association, Inc. 0021-843X/87/$00.75 SHORT REPORTS Cultural Factors Considered in Selected Diagnostic Criteria and Interview Schedules Steven Lopez and Joseph A. Nunez University of Southern California Researchers have argued that diagnostic criteria and interview schedules inadequately reflect cul- tural influences in the definition and expression of psychopathology. In this study 11 widely used diagnostic criteria and interview schedules for schizophrenia, affective disorders, and personality disorders were examined to assess the extent to which they refer to cultural factors. The results indicated that 8 of 11 instruments referred to cultural influences in psychopathology at least once. The consideration of cultural factors, however, was primarily limited to the identification of delu- sions and hallucinations in schizophrenia. Very few cultural references were made in the diagnostic instruments of affective and personality disorders. The clinical implications of these findings are discussed with respect to the evaluation of cultural minority group members residing in the United States. Specific recommendations are offered to increase the attention given to culture in diagnostic instruments and to increase our understanding of how culture influences psychopathology. This study assesses the extent to which frequently used diag- nostic criteria and interview schedules consider cultural factors in the identification of schizophrenic, affective, and personality disorders. Although some authors have discussed how selected diagnostic instruments fail to address cultural influences (Alar- con, 1983; Egeland, Hostetter, & Eshleman, 1983; Klerman, Vaillant, Spitzer, & Michaels, 1984; Swartz, Ben-Arie, & Teg- gin, 1985), none have systematically looked at the extent to which a wide range of diagnostic instruments address the role of culture in psychopathology. Such an examination should re- flect the relative importance given to culture in the classification of mental disorders. Schizophrenic and affective disorders were chosen because much of the cross-cultural psychopathology research concerns these two diagnostic categories (Draguns, 1980, 1984; Klein- man & Good, 1985; Marsella, 1980). Personality disorders were selected because of the recent attention given to their cultural nature (Alarcon, 1983; Klerman et al., 1984). Moreover, sub- jects in current investigations of these disorders are at times drawn from cultural minority groups, including Blacks (Robins et al., 1984), Hispanics (Karno et al., 1987), and the Amish (Egeland et al., 1983). Given the use of these instruments with cultural minority groups as well as with international popula- tions, questions of cross-cultural validity are raised. Method Instruments The diagnostic criteria and structured interview schedules selected for this study were the following: the Diagnostic and Statistical Manual of Mental Disorders (DSM-IH; American Psychiatric Association, 1980), the Feighner Criteria (Feighner et al., 1972), the Flexible WHO (Carpenter, Strauss, & Bartko, 1973), the New Haven Schizophrenic Index (NHSI; Astrachan et al., 1972), the Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1977), Taylor and Abrams (1975), the Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981), Present State Examination (PSE; Wing, Cooper, & Sar- torius, 1974), the Schedule for Affective Disorders and Schizophrenia (SADS; Spitzer & Endicott, 1978), the Structured Clinical Interview for RW-///(SCID; Spitzer & Williams, 1984), and the Structured Inter- view for DSM-II1 Personality Disorders (SIDP; Stangl, Pfohl, & Zim- merman, 1983). We chose these instruments because they are among the most frequently used in the study of schizophrenia, major affective disorders, and personality disorders. The International Classification of Diseases: Clinical Modification (U.S. Department of Health and Hu- man Services, 1980) was considered for review, but we decided to ex- clude it because it is based on a classification scheme that offers no spe- cific criteria for mental disorders. Self-report measures were also ex- cluded because of their large number and because they frequently do not have explicit diagnostic criteria. Including such measures would have gone beyond the desired focus of this investigation. This study was completed while Steven Lopez was a recipient of a Ford Foundation postdoctoral fellowship. During this time he was affiliated with the Spanish Speaking Psychosocial Clinic, Neuropsychi- atric Institute, University of California, Los Angeles. Correspondence concerning this article should be addressed to Steven Lopez, Department of Psychology, University of Southern California, Los Angeles, California 90089-1061. Procedure Joseph A. Nunez carefully read the diagnostic criteria and structured interview schedules and identified the instruments' direct references to possible cultural influences in judging the presence of symptomatology regarding schizophrenic, affective, and personality disorders. In addi- tion, introductory comments about the perceived role of culture in psy- chopathology were noted. For the present study, culture generally refers to the distinctive body of customs, beliefs, and institutions characteris- 270 SHORT REPORTS 271 tic of a racial, ethnic, religious, or national group. Social factors (socio- economic status) and patient variables (sexual orientation, age) are also important in the diagnosis of mental disorders and could be included in a broad definition of culture. For this investigation, however, these factors were not considered to be cultural in nature unless the authors of a given instrument referred to them as cultural (e.g., Taylor & Abrams, 1975). In general, we attempted to identify the instruments' perspective regarding how cultural factors should be considered in the identification and diagnosis of psychopathology. Reliability Check To assess the reliability of the rater's judgments, an advanced under- graduate psychology student, blind to the study's purpose, was in- structed to carefully read the instruments and available instructions and to identify the direct cultural references. The two raters concurred on 29 of 34 cultural references (85%). Except for DSM-lII, the following pairs of ratings were based on the entire set of criteria or interview schedule: DSM-IH (American Psychiatric Association, 1980, pp. 1-35, 181-194, 205-224, 305-330) (1:2), Feighner Criteria (0:0), Flexible WHO (0:1), NHSI (1:1), RDC (3:3), Taylor and Abrams (1:1), DIS (0: 0), PSE (18:20), SADS (4:5), SCID (1:1), and SIDP (0:0). This level of interrater agreement was judged adequate for this research. Results Overall, the selected diagnostic instruments minimally rec- ognized how cultural factors can influence the expression and definition of schizophrenic, affective, and personality disorders. Of the six sets of diagnostic criteria, the RDC makes three cul- tural references, the Feighner Criteria makes none, and the re- maining four sets of criteria (DSM-IH, Flexible WHO, NHSI, and Taylor and Abrams) make only one cultural reference each. The review of interview schedules revealed similar findings; the PSE and SADS refer to cultural factors on six and five occa- sions, the SCID refers to culture only once, and the DIS and SIDP fail to acknowledge cultural influences altogether. Con- sidering the sets of diagnostic criteria and interview schedules as a group, 8 of the 11 instruments consider culture at some level. However, the number of references are very few relative to the total number of symptoms designated for a particular disorder. An examination of the diagnostic criteria and interview schedules by disorder revealed the type of cultural references made. In the diagnosis of schizophrenia, 6 of the 10 diagnostic instruments (DSM-III, NHSI, PSE, RDC, SADS, and SCID) that offer criteria for the disorder contain some reference to cul- ture and its potential role in properly identifying delusions and hallucinations. The main point of these cultural references is that diagnosticians should make sure that the patient's particu- lar belief or perceptual experience is not shared by other mem- bers of his or her cultural group. The RDC and its companion structured interview (SADS) also point out cultural factors that should be taken into account when assessing formal thought disorder. Interviewers are cautioned that some speech or think- ing patterns considered to be representative of thought disorder could be representative of normal speech or thinking for some groups. With respect to the 7 diagnostic instruments that have criteria for affective disorders, only the RDC, SADS, and SCID refer to possible cultural influences. The cultural basis of hallu- cinations and delusions is again mentioned here. In addition, RDC and SADS indicate that bereavement may not represent a depressive disorder if all features of the bereavement are com- monly seen in members of the subject's subcultural group in similar circumstances. In regard to personality disorders, none of the 7 diagnostic instruments makes reference to possible cul- tural influences. Two of the 11 diagnostic instruments (Flexible WHO and PSE) make explicit the assumption that a transcultural descrip- tion of mental disorders can be formulated. Although the au- thors of these instruments indicated that cultural factors can affect nuances in the expression of mental illness, they stated that diagnostic criteria can be used cross-culturally because there are enough common elements across cultures. Discussion Overall, these findings indicate that the lack of attention given to cultural factors in diagnostic instruments goes beyond what has been previously noted for DSM-III (Alarcon, 1983; Kler- man et al., 1984), RDC (Egeland et al., 1983), and the PSE (Swartz et al., 1985). It is fair to say that the currently used sets of diagnostic criteria and interview schedules for schizophrenic, affective, and personality disorders pay little attention to cul- tural factors. Some general recommendations are offered in an attempt to address the limited consideration of culture. At the very least, each set of diagnostic criteria and each interview schedule should have a general statement pointing out that cultural val- ues, beliefs, and practices can influence the definition and ex- pression of psychopathology. The need for such a statement is supported by the growing cross-cultural psychopathology litera- ture (Al-Issa, 1982; Draguns, 1980; Fabrega, 1974, 1982; Kleinman & Good, 1985; Marsella & White, 1982) as well as by the more limited U.S. minority group research (Adebimpe, 1981; Cuellar & Roberts, 1984). The inclusion of this statement should alert diagnosticians and interviewers to seriously con- sider the cultural background of the patient. We also recom- mend that references to cultural factors be made for specific disorders and symptoms, and whenever possible, examples per- taining to specific cultural groups be cited. Comments such as the following might be included in diagnostic instruments: Black patients' depressive symptoms may not be properly iden- tified as depressive in nature (Adebimpe, 1981; Simon, Fleiss, Gurland, Stiller, & Sharpe, 1973), and pressured speech may be inaccurately perceived as thought disorder among the Amish (Egeland et al., 1983). These and related comments may prompt evaluators to be more cautious in applying the available criteria when evaluating these patient groups. In terms of research, we recommend that investigators exam- ine the phenomenology, course, and outcome of the major dis- orders for U.S. minority groups. Cross-cultural studies to date indicate the important role culture plays in the definition and expression of psychopathology. However, we are only just begin- ning to understand how cultural factors influence the psychopa- thology of the major minority groups in the United States— Blacks (Adebimpe, 198 l),Hispanics (Cuellar & Roberts, 1984), Asians (Chin, 1983), and American Indians (Manson, Shore, & Bloom, 1985). In addition, it is important that investigators and clinicians who work with specific cultural groups follow the lead 272 SHORT REPORTS of Egeland and her colleagues in systematically assessing whether available criteria are appropriate. If criteria or inter- view schedules are not appropriate, then ways to modify these instruments should be explored. References Adebimpe, V. R. (1981). Overview: White norms and psychiatric diag- nosis of Black patients. American Journal of Psychiatry, 138, 279- 285. Alarcon, A. D. (1983). A Latin American perspective on DSM-III. American Journal of Psychiatry, 140, 102-105. Al-Issa, I. (1982). (Ed.). Culture andpsychopathology. Baltimore: Uni- versity Park Press. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders ($r& ed.). Washington, DC: Author. Astrachan, B. M., Harrow, M., Adler, D., Brauer, L., Schwartz, A., Schwartz, C, & Tucker, G. (1972). A checklist for the diagnosis of schizophrenia. British Journal of Psychiatry, 121, 529-539. Carpenter, W. X, Strauss, J. S., & Bartko, J. J. (1973). Flexible system for the diagnosis of schizophrenia: Report from the WHO interna- tional pilot study of schizophrenia, Science, 182, 1275-1278. Chin, J. L. (1983). Diagnostic considerations in working with Asian- Americans. American Journal ofOrthopsychiatry, 53, 100-109. Cuellar, I., & Roberts, R. E. (1984). Psychological disorders among Chi- canos. In J. L. Martinez & R. H. Mendoza (Eds.), Chicanopsychology (2nd ed., pp. 133-161). New York: Academic Press. Draguns, J. G. (1980). Psychological disorders of clinical severity. In H. C. Triandis & J. G. Draguns (Eds.), Handbook of cross-cultural psychology: Psychopathology (Vol. 6, pp. 99-174). Boston: Allyn & Bacon. Draguns, J. G. (1984). Assessing mental health disorders across cul- tures. In P. B. Pedersen, N. Sartorius, & A. J. Marsella (Eds.), Mental health services: The cross-cultural context (pp. 31 -58). Beverly Hills, CA: Sage. Egeland, J. A., Hosteller, A. M., & Eshleman, S. K., III. (1983). Amish sludy, III: The impacl of cultural factors on diagnosis of bipolar ill- ness. American Journal of Psychiatry, 140, 67-71. Fabrega, H. (1974). Problems implicit in the cultural and social study of depression. Psychosomatic Medicine, 36, 377-398. Fabrega, H. (1982). Culture and psychiatric illness: Biomedical and eth- nomedical aspects. In A. J. Marsella & G. M. White (Eds.), Cultural conceptions of mental health and therapy (pp. 39-68). Dordrecht, the Netherlands: D. Reidel. Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Winokur, G., & Munoz, R. (1972). Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57-63. Karno, M., Jenkins, J., de la Selva, A., Santana, F, Telles, C., Lopez, S., & Mintz, J. (1987). Expressed emotion and schizophrenic outcome among Mexican-American families. Journal of Nervous and Mental Disease, 175, 143-151. Kleinman, A., & Good, B. (Eds.). (1985). Culture and depression. Berkeley: University of California Press. Klerman, G. L., Vaillant, G. E., Spitzer, R. L., & Michaels, R. (1984). A. debate onDSM-ltt. American Journal of Psychiatry, 140, 102-105. Manson, S. M., Shore, J. H., & Bloom, J. D. (1985). The depressive experience in American Indian communities: A challenge for psychi- atric theory and diagnosis. In A. Kleinman & B. Good (Eds.), Culture and depression (pp. 331-368). Berkeley: University of California Press. Marsella, A. J. (1980). Depressive experience and disorder across cul- tures. In H. C. Triandis & J. G. Draguns (Eds.), Handbook of cross cultural psychology: Psychopathology (Vol. 6, pp. 237-289). Boston: Allyn & Bacon. Marsella, A. J., & White, G. (Eds.). (1982). Cultural conceptions of men- tal health and therapy. Dordrecht, the Netherlands: D. Reidel. Robins, L. N., Helzer, J. E., Croughan, J., & Ratcliff, K. S. (1981). Na- tional Institute of Mental Health: Diagnostic Interview Schedule. Ar- chives of General Psychiatry, 38, 381-389. Robins, L. N., Helzer, J. E., Weissman, M. M., Orvaschel, H., Gruen- berg, E., Burke, J. D., & Regier, D. A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psy- chiatry, 41, 949-958. Simon, R. J., Fleiss, J. L., Gurland, B. J., Stiller, P. R., & Sharpe, L. (1973). Depression and schizophrenia in hospitalized Black and White mental patients. Archives of General Psychiatry, 28, 509-512. Spitzer, R. L., & Endicott, J. (1978). The Schedule for Affective Disor- ders and Schizophrenia (3rd ed.). New \brk: New York State Psychi- atric Institute, Biometrics Research Division. Spitzer, R. L., Endicott, J., & Robins, E. (1977). Research Diagnostic Criteria (3rd ed.). New York: New York State Psychiatric Institute, Biometrics Research Division. Spitzer, R. L., & Williams, J. B. W. (1984). Structured Clinical Interview for DSM-III. New York: New York State Psychiatric Institute, Bio- metrics Research Division. Stangl, D., Pfohl, B., & Zimmerman, M. (1983). A Structured Interview for DSM-III Personality (2nd ed.). Iowa City: University of Iowa Col- lege of Medicine, Department of Psychiatry. Swartz, L., Ben-Arie, O, & Teggin, A. F. (1985). Subcultural delusions and hallucinations: Comments on the Present State Examination in a multi-cultural context. British Journal of Psychiatry, 146, 391-394. Taylor, M. A., & Abrams, R. (1975). A critique of the St. Louis psychiat- ric research criteria for schizophrenia. American Journal of Psychia- try, 132, 1276-1280. U.S. Department of Health and Human Services. (1980). International classification of diseases: Clinical modification (2nd ed.). Washing- ton, DC: Author. Wing, J. K., Cooper, J. E., & Sartorius, N. (1974). The measurement and classification of psychiatric symptoms. London: Cambridge Uni- versity Press. Received December 1,1986 Accepted January 19, 1987 •