the cultural formulation: a method for assessing cultural factors

Psychiatric Quarterly, Vol. 73, No. 4, Winter 2002 ( C○ 2002) 

THE CULTURAL FORMULATION: A METHOD 

FOR ASSESSING CULTURAL FACTORS 

AFFECTING THE CLINICAL ENCOUNTER 

Roberto Lewis-Fernández, M.D. 

and Naelys Díaz, M.S.W. 

The growing cultural pluralism of US society requires clinicians to examine the 

impact of cultural factors on psychiatric illness, including on symptom presentation 

and help-seeking behavior. In order to render an accurate diagnosis across 

cultural boundaries and formulate treatment plans acceptable to the patient, 

clinicians need a systematic method for eliciting and evaluating cultural information 

in the clinical encounter. This article describes one such method, the 

Cultural Formulation model, expanding on the guidelines published in DSM-IV. 

It consists of five components, assessing cultural identity, cultural explanations 

of the illness, cultural factors related to the psychosocial environment and levels 

of functioning, cultural elements of the clinician–patient relationship, and 

the overall impact of culture on diagnosis and care. We present a brief historical 

overview of the model and use a case scenario to illustrate each of its 

Roberto Lewis-Fernández, M.D., is an Assistant Professor of Clinical Psychiatry at 

Columbia University, a Lecturer on Social Medicine at Harvard University, and is the 

Director of the Hispanic Treatment Program at NY State Psychiatric Institute, New 

York, NY. 

Naelys Díaz, M.S.W., is a Doctoral Candidate in Social Work at Fordham University. 

Address correspondence to Roberto Lewis-Fernández, M.D., New York State Psychiatric 

Institute, Unit 69, 1051 Riverside Drive, New York, NY 10032; e-mail: rlewis@ 

nyspi.cpmc.columbia.edu. 

271 

0033-2720/02/1200-0271/0 C○ 2002 Human Sciences Press, Inc.

272 PSYCHIATRIC QUARTERLY 

components and the substantial effect on illness course and treatment outcome 

of implementing the model in clinical practice. 

KEY WORDS: cultural formulation; diagnostic assessment; cultural psychiatry; popular 

syndromes; Latinos. 

As rising immigration causes industrialized societies to become even 

more culturally pluralistic and organized mental health services in developing 

nations face the challenge of distributing care more broadly, 

psychiatrists will increasingly come in contact with a larger diversity 

of social groups (1). The evaluation of patients from disparate ethnocultural 

backgrounds requires clinicians to assess the impact of cultural 

factors on all aspects of psychiatric illness, including symptom 

presentation and help-seeking behavior. In order to render an accurate 

diagnosis across cultural boundaries and formulate treatment plans 

acceptable to the patient and oftentimes the family, clinicians need a 

method for eliciting and evaluating cultural information during the 

clinical encounter. 

Standardizing the assessment method is particularly important in order 

to avoid systematic misjudgments of which the clinician is often unaware. 

An example of this is the apparent clinician bias that results in 

a higher rate of misdiagnosis of paranoid schizophrenia among African 

American and Latino patients suffering from bipolar disorder or depression 

with psychotic features, compared to non-Latino Whites (2,3). 

In one key study, misdiagnosis by race was found to be related to 

“information variance,” differences in the amount of information the 

predominantly White clinicians obtained from African American as opposed 

to White patients, rather than race-specific discrepancies in the 

way diagnostic criteria were applied (“criterion variance”) (4). This suggests 

that standardizing the process of clinical information-gathering 

would reduce misdiagnosis. 

Using a systematic method for assessing cultural contributions to 

illness presentation would also help the clinician diagnose culturally 

patterned experiences of illness that are distinct from mainstream psychiatric 

diagnostic criteria. Many societies around the world have developed 

folk mental health classification systems that are distinct from 

US psychiatric nosology (5,6). Patients from these societies and cultural 

backgrounds often express distress and psychopathology less in accord 

with US diagnostic categories than with their popular syndromes. 

The translation between popular and professional nosologies is often 

complicated. Neurasthenia, for example, originally a US professional

ROBERTO LEWIS-FERNÁNDEZ AND NAELYS DÍAZ 273 

diagnosis that is no longer included in the DSM system but is retained 

in ICD-10, is the most prevalent current (12-month) disorder among 

Chinese Americans in Los Angeles County (7). For US psychiatrists, 

however, it presents a diagnostic challenge, due to its partial overlap 

with multiple diagnostic categories, including mood, anxiety, and somatoform 

disorders (7,8). 

Ataque de nervios (attacks of nerves), on which we will focus later 

in this article, is another example of a popular category that presents 

diagnostic challenges for US psychiatrists. This Latino syndrome is 

characterized by paroxysms of intense emotionality, acute anxiety 

symptoms, and loss of control, often associated with dissociative experiences 

and occasionally with other- or self-directed aggressive behaviors 

(9). It constitutes the second most prevalent psychopathological 

syndrome in Puerto Rico and has a complex relationship with psychiatric 

diagnoses (10). Mainly associated with mood and anxiety disorders, 

it also can occur in conjunction with dissociative disorders (11) 

and in individuals with impulse control, somatoform, or psychotic disorders. 

The existence of these popular syndromes and the need for a 

case-by-case translation into DSM-IV categories underscores the risks 

of not obtaining sufficient cultural information as part of the diagnostic 

assessment. 

In order to deliver care that is culturally valid, therefore, clinicians 

need a method that systematically allows them to take culture into 

account when conducting a clinical evaluation. One such method that 

has been operationalized in recent years is the Cultural Formulation 

(CF) model. The CF model supplements the biopsychosocial approach 

by highlighting the effect of culture on the patient’s symptomatology, 

explanatory models of illness, help-seeking preferences, and outcome 

expectations (12–15). It is described in Appendix I of DSM-IV (16) and 

is recommended for implementation during the assessment phase of 

every clinical relationship. 

The CF model is especially necessary when the clinician and the patient 

do not share the same cultural background, since it is then that 

particular attention to cultural features can be most helpful in orienting 

the clinical intervention. It is important to remember, however, that 

even persons sharing the same race or ethnicity can differ in their cultural 

backgrounds, as race and ethnic groups are culturally heterogenous 

(12,17). Implementation of the CF model when there is no ethnic 

difference between patients and clinicians can still elicit very useful information 

about culturally based values, norms, and behaviors—such 

as about alternative health practices, physiological interpretations, or 

religious beliefs—that may otherwise go unnoticed because the clinician


assumes that the patient is “just like me.” In addition, the CF model 

should not be construed for use mainly between majority clinicians and 

minority patients. Given the growing ethno-cultural pluralism of psychiatric 

residency programs in the US (including a high proportion of 

International Medical Graduates), the existence of cultural differences 

is becoming perhaps just as likely between majority patients and their 

clinicians. 

This article will present the Cultural Formulation model. The first 

part of the discussion will give a brief historical overview of the model 

and its components. The second part will consist of a case scenario that 

will illustrate the purpose of each section of the model and its usefulness 

in psychiatry and mental health in general. 

HISTORICAL OVERVIEW AND COMPONENTS OF THE 

CULTURAL FORMULATION MODEL 

The contemporary version of the CF model dates from the process of 

preparing DSM-IV. Due in part to criticisms of insensitivity to cultural 

issues in DSM-III and DSM-III-R, the National Institute of Mental 

Health supported the creation in 1991 of a Group on Culture and Diagnosis. 

The main goal of this Group was to advise the DSM-IV Task 

Force on how to make culture more central to the Manual. One of the 

ways proposed by the Group was the development of a standard method 

for applying a cultural perspective to the clinical evaluation (15,18). 

Early efforts focused on supplementing the five existing axes with a 

sixth or “Cultural Axis.” However, this approach was soon abandoned as 

too limiting, since at best it would only permit the use of a restricted list 

of socio-cultural labels which would be of little clinical significance (14). 

The Group aimed for a more thorough re-thinking by the clinician of 

the patient’s cultural picture and how it affects all five axes, as well as 

clinical elements not contemplated by the multi-axial structure, such 

as help-seeking expectations, family and community views of the illness 

and its outcome, and institutional pressures on the clinical encounter. 

A key aim of the Group was to operationalize a method that, 

while standardized, still allowed for an individualized assessment of 

cultural factors (15). This was based on the perspective that a person’s 

cultural background is affected by the intersection of multiple social 

influences—including those due to gender, class, race, sexual orientation, 

etc.—and therefore would need to be described in individual rather 

than solely collective terms in order to avoid stereotyping (12). 

The Group settled on a narrative format that follows a standard set 

of components. These are listed in Table 1. Every patient would have


TABLE 1 

Components of the Cultural Formulation 

Cultural formulation 

section 

Cultural identity of the 

individual 

Cultural explanations 

of the individual’s 

illness 

Cultural factors 

related to psychosocial 

environment and 

levels of functioning 

Cultural elements of the 

relationship between 

the individual and 

the clinician 

Overall cultural 

assessment for 

diagnosis and care 

Subheading 

• Individual’s ethnic or cultural reference 

group(s) 

• Degree of involvement with both the culture 

of origin and the host culture (for immigrants 

and ethnic minorities) 

• Language abilities, use, and preference 

(including multilingualism) 

• Predominant idioms of distress through 

which symptoms or the need for social 

support are communicated 

• Meaning and perceived severity of the 

individual’s symptoms in relation to norms of 

the cultural reference group(s) 

• Local illness categories used by the 

individual’s family and community to identify 

the condition 

• Perceived causes and explanatory models that 

the individual and the reference group(s) use 

to explain the illness 

• Current preferences for and past experiences 

with professional and popular sources of care 

• Culturally relevant interpretations of social 

stressors, available social supports, and levels 

of functioning and disability 

• Stresses in the local social environment 

• Role of religion and kin networks in providing 

emotional, instrumental, and informational 

support 

• Individual differences in culture and social 

status between the individual and the 

clinician 

• Problems that these differences may cause in 

diagnosis and treatment (e.g. difficulties in 

eliciting symptoms and understanding their 

cultural significance, in determining whether 

a behavior is normal or pathological, etc.) 

• Discussion of how cultural considerations 

specifically influence comprehensive 

diagnosis and care 

Note. Summarized from DSM-IV, pp. 843–844.


his/her cultural background described in a brief text that incorporates 

each of the listed elements. This Cultural Formulation is based on prior 

work on the “mini clinical ethnography,” which sets out a brief anthropological 

assessment of the cultural factors that are immediately relevant 

to the clinical situation (19,20). 

In selecting a narrative model, the Group was consciously endorsing 

the growing importance of the study of narrative in anthropology 

and other social sciences, as well as echoing a tradition within mental 

health assessment: the psychodynamic formulation (14). In medicine 

in general, the use of narrative accounts of illness goes beyond diagnostic 

typologies to claim a different “truth” in the creation of a humanized 

account of suffering from the patient’s perspective that encompasses 

a greater view of the social world than the purely diagnostic 

evaluation (19). The use of this technique can also account for the role 

that health institutions and practitioners have on the evolution of the 

person’s illness and his/her perception and interpretation of it (21,22). 

This allows a reflexive stance on the clinician-patient interaction, in 

which the role of the practitioner in shaping the process of evaluation, 

including what is reported by the patient and what is perceived by the 

clinician, can be “painted back in.” 

An outline of the Cultural Formulation was prepared and submitted 

to the DSM-IV Task Force. In addition, a field test was performed on 

patients from four US ethnic minorities: African American, American 

Indian, Asian American, and Latino. The results revealed that the CF 

model could be successfully applied to patients from different cultural 

backgrounds. An edited version of the proposed text was published in 

Appendix I of DSM-IV (15). 

As a result of its publication in DSM-IV, the Cultural Formulation 

has begun to form part of the curricula of US psychiatry residency 

programs. Since 1996, the CF model has been the subject of a regular 

section on clinical case studies in Culture, Medicine and Psychiatry (14), 

of whom the senior author is the section editor, and of a yearly course at 

the Annual Meeting of the American Psychiatric Association. In 2001, 

the Cultural Psychiatry Committee of the Group for the Advancement 

of Psychiatry published a book on the CF model that includes a number 

of case examples (12). 

CULTURAL FORMULATION OF A CLINICAL CASE 

The second part of this article summarizes a case study of an actual 

patient (23) that illustrates the purpose of each of the components 

of the Cultural Formulation and the impact on treatment outcome of


implementing this model in clinical practice. In particular, the case 

highlights some of the diagnostic complexities involved in assessing 

patients reporting nervios (nerves) and ataques de nervios (attacks of 

nerves), prevalent popular syndromes among Latinos. A brief summary 

of the clinical history is followed by the cultural formulation of the case. 

Informed consent was obtained from the patient for description of this 

clinical material. 

Clinical History 

A 49 year-old widowed Puerto Rican woman presented to an outpatient 

Latino Mental Health Clinic in New England after a 3-year history of 

prolonged hospitalizations due to recurrent major depressive disorder 

with diagnosed psychotic features and chronic impulsive suicidality. 

Except for brief periods of partial recovery lasting less then 2 weeks, 

the patient reported several years of chronic sadness, anhedonia, tearfulness, 

psychomotor retardation, suicidality, guilty ruminations, decreased 

sleep and appetite, interest, energy, and concentration. She 

also suffered from restlessness, “nervousness,” trembling, increased 

startle, anguish, and severe headaches. Patient’s “psychotic” diagnosis 

was due to the following during her affective decompensations: hearing 

her name called when alone, glimpsing a darting shadow, and “feeling” 

someone behind her. Despite past traumas (physical abuse, husband’s 

murder) she denied many of the symptoms of posttraumatic stress disorder. 

There was no history of substance abuse. Her first episode of 

major depression dated from age 32 and had recurred at least once 

before the current episode. 

Patient was born in rural Puerto Rico and had a 5th grade education. 

Her father developed alcoholism while working as a seasonal agricultural 

migrant in the United States and was verbally abusive and physically 

threatening to the patient’s mother when intoxicated. The patient 

denied witnessing overt physical or sexual abuse or being the object 

of childhood trauma, but did complain of her mother’s cold distance. 

Patient married at 16 and had 6 children, one of whom died of pneumonia 

at 3 months of age. Husband also developed alcohol problems 

and became physically and emotionally abusive towards her. After an 

escalation of his abuse, patient ended the marriage by migrating to the 

Eastern United States at age 31 with the man who became her second 

husband. She left four of her children behind with relatives, a decision 

that resulted in her parents’ rejection. Five years later she returned to 

Puerto Rico after the murder of her second husband in a street fight. 

The son who had migrated with her to the US entered a residential


drug abuse program 11 years later, at which point she migrated to a 

different East Coast city at age 47 to be near her oldest son from whom 

she felt estranged. Her conflicts with this son and her other children 

precipitated her inpatient admissions. 

Inpatient psychotherapy, antidepressants, and antipsychotics only 

produced minor improvement of her depression and suicidality and no 

change in her psychotic symptoms. After discharge to the outpatient 

Latino Clinic, her psychotic symptoms were reassessed as normative 

Puerto Rican spiritual expressions of demoralization and her molindone 

was discontinued. While still on phenelzine during evaluation for family 

therapy, the patient suffered an ataque de nervios in the midst of an 

argument with her son. During the ataque, which was characterized by 

dissociative symptoms (depersonalization, “numbness”), she attempted 

an impulsive overdose with phenelzine. She required ICU treatment 

and a brief in-patient stay, and was taken off all psychiatric medications. 

Intensive psychotherapeutic management was instituted, initially including 

individual, family, and group modalities. Improved family relations 

resulted in marked decrease in symptoms. Outpatient assessment 

and psychotherapy revealed patient’s longstanding characterological 

symptoms and she received a diagnosis of Borderline Personality Disorder. 

She reduced her participation in treatment after a few months, 

preferring weekly supportive psychotherapy and monthly psychiatric 

visits. These latter acted as a kind of supervision of her clinical picture, 

since medications were not prescribed. Patient was followed off 

medications for 8 years without recurrence of major depression or suicidality. 

She did develop periodic exacerbations of depressive, anxiety, 

dissociative, and somatization symptoms that did not meet specified diagnostic 

criteria. Though she continued to perceive “shadows” and hear 

her name called when alone, these experiences produced only temporary 

concern. There was never any evidence of formal thought disorder 

nor loss of generalized reality orientation [Summarized from (23)]. 

Cultural Formulation 

Cultural Identity 

The section on Cultural Identity serves as an introduction to the rest of 

the Cultural Formulation. Its purpose is to identify for each patient the 

particular mix of socio-cultural influences that has patterned his/her 

individual cultural world. As stated earlier, cultures are experienced 

differently by different members according to subgroup characteristics 

such as gender, class, religion, race, and sexual orientation, among


other factors. This section of the formulation collects information on 

how these various social factors impact the person’s cultural environment 

in order to prevent overly general or stereotypical interpretations 

of cultural influence (13). This section also permits assessment of the 

person’s own sense of his/her ethno-cultural identity, particularly in 

respect to other alternative identities; this takes on particular significance 

in settings of rapid cultural change or ethnic conflict, or among 

migrants or persons of multicultural heritage. At the conclusion of this 

section, the formulation writer should have a sense of how the person 

fits against a specific cultural background. This serves as a prelude to 

understanding how his/her individual experience of the illness and its 

meanings and outcomes fit within that cultural context, which is the 

topic of the rest of the CF model (12). 

The following subsections are included within the general section on 

Cultural Identity. For the purpose of illustrating its content, each subsection 

begins with one key question regarding the case under discussion 

that summarizes the subsection topic. We will follow this format 

for every subsection throughout the article. 

Reference Group. Within her overall group (Puerto Rican culture), 

which particular cultural subgroups form the relevant context for assessing 

this person? 

A key influence on this patient’s cultural background is her status 

as a rural person with limited formal education who migrated twice 

to the US for a total of 13 years’ residence as part of the “circular” 

pattern of Puerto Rican migration that intensified in the 1960’s and 

70’s. The “circularity” of this migratory stream consists of recurrent 

“back and forth” moves between Puerto Rico and usually the East Coast 

of the United States in search of better economic and health care opportunities 

and in order to reestablish family and cultural links (24). 

Like many of these migrants, she was only mildly acculturated despite 

this extended stay, given her periodic returns to her culture of origin 

and the barriers to integration into the US mainstream for persons 

of her ethnic, class, and educational background caused by chronic 

unemployment and limited housing options outside of encapsulated 

Latino neighborhoods (25). Her self-identity remained that of an Island 

Puerto Rican, despite her migratory experience. In effect, this 

patient had retained most of the traditional views of illness from her 

rural background despite several years of residence in US urban 

settings. 

In this subsection it is also important to understand the patient’s migratory 

process in the context of her former experience in Puerto Rico


and the reasons for her migration (13). Because her initial migration occurred 

in order to escape her husband’s physical abuse, and involved a 

prolonged separation from her children, this person’s migratory process 

is akin in some respects to that of a refugee, an unusual status among 

low-income Puerto Rican migrants, who are usually motivated by economic 

reasons. Some of her subsequent psychiatric symptoms, such as 

her acute alienation, guilt, and suicidality, can be better understood 

against this unusual migratory context. 

Language. Does the patient have access to more than one language 

for expressing her illness-related experiences and obtaining care, and if 

so, which language predominates? 

Language assessment is an important element of the CF model because 

language identifies and codifies a person’s experience, which can 

be distorted in the process of translation. In the case of multilingual 

individuals, the use of a secondary language may limit the ability to obtain 

an accurate history and reach a valid diagnosis, since emotionality 

and cognition may be expressed differently in different languages. For 

example, an individual may appear more or less pathological depending 

on the language of the evaluation (26). 

This patient used Spanish predominantly in all her daily interactions. 

Her use of English was very rare and her fluency poor. This constitutes 

another sign of her limited participation in non-Latino US society. 

Although the in-patient unit employed interpreters regularly in the 

care of the patient, it is likely that some of the limitations in their clinical 

assessment were related to difficulties in bridging the language gap, 

resulting in relatively shallow interpretations of her experience. For example, 

the cultural connotations for the Spanish terms that the patient 

used to express her distress, such as nervios (nerves), ataques (attacks), 

and celajes (glimpses or shadows, understood by the staff as visual hallucinations), 

appear to have been lost or distorted during the translation 

process. 

Cultural Factors in Development. Are there features of the patient’s 

childhood development that should be placed in a specific cultural context 

in order to be properly understood? 

Locating childhood development within a cultural context can help 

clarify the contribution of environmental factors to personality characteristics 

(12). Experience is made meaningful and incorporated as enduring 

personal attributes partly in response to its perceived normality 

and collective interpretation. Factors that influence personality development 

and that vary across cultures include, among others: gender


roles, relational characteristics within the family and roles within the 

family constellation, socialization experiences, and social valuation of 

emotional expression (27,28). 

In this case, the patient’s childhood contacts were limited to her extended 

kin group, given the rural isolation of her family compound and 

her early school termination. This may have intensified the negative 

impact on her personality development of her father’s disruptive and 

abusive behavior and her mother’s affective distance despite the stated 

absence of witnessed or experienced physical or sexual abuse during 

childhood. These personality patterns were probably also reinforced 

by later adult episodes of physical abuse and traumatic loss. Another 

sociocultural feature of the patient’s early socialization that appears 

to have influenced her later symptomatology relates to her role as a 

parentified child who was removed from elementary school in order to 

help raise her younger siblings. Though not an uncommon practice in 

the patient’s cultural reference group, this seems to have determined a 

particularly important element in her self-perception, as evidenced by 

her lifelong nickname within the family which refers to this maternal 

function. The loss of this culturally established role, through separation 

and subsequent estrangement from her children, was the main 

cause of the patient’s affective decompensation. The partial resumption 

of this role through family therapy marked the beginning of her 

improvement. 

Involvement with Culture of Origin and Host Culture. How does understanding 

a migrant like this patient in the context of her culture of 

origin separately from the host culture reveal something about her as a 

person and about her migration experience? 

This subsection is primarily relevant to migrants. Its purpose is to 

compare the individual’s involvement with the culture of origin, on the 

one hand, to his/her involvement with the host culture, on the other. 

By evaluating each attachment independently, the clinician can avoid 

a zero-sum model of acculturation, which mistakenly assumes that as 

a person becomes more fluent in the new culture, he/she necessarily 

becomes disconnected from his/her culture of origin (29). Instead, contemporary 

acculturation models understand that, in a world where multiculturality 

and geographical displacement are becoming increasingly 

prevalent, multiple combinations of involvement are possible, such as 

the alternative of developing a deep connection to both cultural environments 

(30). Finally, by establishing the migrant’s relative cultural 

attachments, the person’s cultural identity is rounded out, setting the 

stage for the other topics of the CF model.


This patient was predominantly connected to her culture of origin 

and had limited contact with the host culture. She lived in a mainly 

Latino neighborhood and traveled frequently to Puerto Rico, where 

she kept in close contact with several siblings; she had few friends, 

mostly Latinas, apart from her family. She was, however, able to maneuver 

some aspects of United States urban life well, such as obtaining 

elderly subsidized housing (though only in her 50’s) and disability 

benefits. 

Cultural Explanations of the Illness 

The heart of the Cultural Formulation is this second section, which 

examines the cultural factors that affect the experience and interpretation 

of illness, as understood by the patient, the family, and the social 

network. These cultural factors exert a deeper influence than just covering 

over an unchanging reality with curious cultural explanations. 

They instead help to create the illness experience by affecting cognitive, 

bodily, and interpersonal aspects of disease, including by helping 

to shape symptom presentations, perceived etiologies, severity attributions, 

treatment choices, and outcome expectations (6,31). In particular, 

explicit cultural analysis is required for accurate assessment of 

the severity of the presenting problems, since patients’ attributions of 

severity are acutely impacted by cultural interpretations. Finally, adherence 

to clinicians’ recommendations may be compromised without 

careful attention to patients’ cultural views of treatment. In this respect, 

it may also be necessary to account for the views of key relatives 

or members of the larger social network (32). 

Idioms of Distress and Local Illness Categories. How do cultural factors 

affect the way this person experiences and understands her distress, 

including the specific shape of the presenting symptoms and the way 

they are clustered? 

Cross-cultural research reveals the existence of multiple overall perspectives 

on distress—ways in which to experience, understand, and 

describe it—that are so comprehensive that they seem akin to different 

languages of suffering rather than specific syndromes. The term 

“idioms of distress” is used to denote these different languages of experience 

(33). Examples of idioms are: the tendency to somatize suffering, 

or to psychologize it; experiencing interpersonal problems or physical 

illness as forms of possession; attributing illness to the impact of suffering 

on the anatomical “nerves”; or describing distress in terms of “fate,” 

or as a kind of “spiritual test” (16).


In addition to these general forms, cultures have also evolved more 

specific illness categories or syndromes, assembled according to alternative 

systems of causation. The organizing principle can be a relatively 

invariant collections of symptoms, a perceived common etiology, 

or a shared response to treatment (5). One of the essential tasks of a 

Cultural Formulation is to discover the idioms of distress and the illness 

categories that are evoked by the patient’s presentation. Often 

the patient is not fully conscious of the categories he/she is referencing, 

and yet may be acutely aware of the dissonance between his/her 

understandings and those of the clinician. 

In this case, the patient’s illness was described by herself and her community 

as nervios (nerves) and ataques de nervios (attacks of nerves). 

Patient’s view of her nervios was typical of many traditional Puerto 

Ricans, for whom it is an idiom of distress describing a vulnerability to 

experiencing symptoms of depression, anxiety, dissociation, somatization 

and rarely psychosis or poor impulse control given interpersonal 

frustrations (34). The idiom is held together conceptually by the cultural 

understanding that all its presentations reflect an “alteration,” 

acquired or inherited, of the nervous system, and specifically of the 

anatomical nerves. The patient had suffered from all the symptoms 

of nervios except psychosis. Her acute fit-like exacerbations of nervios 

are known as ataques de nervios, and were characterized by paroxysms 

of anxiety, rage, dissociation, and impulsive suicidality followed 

by depression and exhaustion in response to acute interpersonal conflicts 

(9,11). In this patient’s case, nervios and ataques were associated 

with her character pathology, but many Puerto Ricans suffer from similar 

folk syndromes without showing characterological deficits, though 

the exact relationship between these clinical conditions has not been 

ascertained. 

Another critical aspect of her nervios was the high frequency and 

distressing nature of the culturally specific perceptual distortions she 

reported (hearing voices, feeling presences, seeing shadows [known as 

celajes; glimpses]). These experiences are very prevalent among Puerto 

Ricans with and without nervios, but sufferers of ataques are markedly 

more distressed by them (35). They probably represent culturally patterned 

signs of anxiety or emotional distress determined by a person’s 

dissociative capacity. In the patient’s case, these experiences were mistaken 

for psychotic symptoms by her inpatient clinicians. As such, discussion 

of these symptoms in the Cultural Formulation straddles this 

subsection and the next, as they constitute culturally specific idioms of 

distress whose interpretation can affect the perceived severity of the 

presenting complaints.


Meaning and Severity of Symptoms in Relation to Cultural Norms. 

How does taking her cultural background into account affect the level 

of pathology suggested by her presenting symptoms and their meaning 

as a form of communication in her interpersonal context? 

This subsection is devoted to a careful assessment of the level of 

severity implied by the person’s symptoms, as well as to discussion of 

the role of the illness as a form of interpersonal communication that is 

interpreted by others in the social network. It is essential that cultural 

norms be considered when assessing the clinical severity of specific behaviors, 

so as to avoid two erroneous extremes: overpathologizing what 

is normative in a cultural group, or ascribing to normal behavior what is 

considered pathological in that culture (13,36). Whether what is at issue 

is the normal degree of individuation of an 18 year-old in relation to 

his/her parents, or the potential delusionality of a person who ascribes 

his/her symptoms to a supernatural etiology, some knowledge of local 

behavioral norms is essential to the process of diagnosis. The fact that 

different subgroups within a larger cultural setting may interpret these 

behaviors differently complicates the process of assessment and forces 

an individualized evaluation of cultural factors in each case. 

In addition, illness expressions convey a range of meanings to others 

in the social network. Which set of meanings is imputed by the community 

actually has an impact on the patient’s course, both through interpersonal 

interactions that promote improvement or pathology and 

through concrete levels of assistance or rejection. The cross-cultural 

literature on the contribution of expressed emotion to the course of 

schizophrenia represents a well-developed example of this issue (37). 

In this patient’s case, her symptoms at the time of presentation were 

seen by her community to reflect a severe form of nervios because they 

could precipitate rage and dissociation ataques with impulsive suicidality 

and because they had “penetrated deeply,” causing her character 

pathology. As opposed to her outpatient clinicians, who saw her character 

problems as preceding and partly determining her Axis I disorders, 

the patient’s social network understood her characterological symptoms 

as a consequence of her nervios, rather than as a cause (i.e., a form of 

bitterness due to her continued suffering), and thus as a sign of nervios 

severity. In another discrepancy between the social network and the 

clinical team, the patient’s inpatient clinicians judged her perceptual 

distortions to be much more severe than her community, understanding 

them as signs of psychosis rather than minor elements of her overall 

condition. 

Further, the expectation of her interpersonal network was that the 

patient actively ward against any worsening of her character pathology


by “controlling” her needs and desires and focusing on the needs of 

others, such as her children. The community thus validated the patient’s 

understanding that reestablishing positive affective links with 

her family would improve the outcome of her nervios. Her achievement 

of this goal, as well as her coming off psychiatric medications and preventing 

further ataques, were considered signs of improvement. The 

patient’s children, however, initially rejected the patient’s and the community’s 

understanding that her character pathology stemmed from 

her nervios and ataques, attributing it instead to manipulative ploys 

aimed at deflecting their justified anger due to what they perceived as 

her neglectful parenting. Therapy helped to bridge these conflicting interpretations, 

but several of her children always retained the sense that 

the patient’s personality conflicts exceeded the norm even for nervios. 

Perceived Causes and Explanatory Models. How is her clinical management 

affected by knowing about her culturally based etiological 

attributions, her understandings of pathophysiology, and her hopes and 

concerns about the course of the illness? 

This subsection focuses on the patient’s views on how the illness 

“works”: what caused it; why did it present now and in this way; how is it 

affecting the person; what would happen if it was not treated; and what 

are the possible outcomes even with treatment? (12,38). This subsection, 

like the next one on help-seeking to which it is closely linked, is especially 

important during the process of enlisting the patient’s and the 

family’s adherence to the clinician’s recommendations. Patients rarely 

pursue treatments for long that run counter to their primary etiological 

understandings. Cultural attributions of causation actually vary widely 

across societies, from biological to spiritual etiologies, and from drastically 

individual, internal views to social and even cosmological interpretations 

(39). Often, there are a mix of attributions, at times partly 

or wholly contradictory within one person or across the patient’s social 

network. Treatment may thus involve negotiating the appearance 

of these various perspectives and bringing them into some coherent 

strategy (19). 

At first, the patient saw her condition fundamentally as a medical 

problem caused by an “alteration” of her nervous system due to the 

suffering produced by chronically unresolved family conflicts. Primary 

among these were the physical abuse by her husband, the parental 

rejection, and her separation from several of her children during most 

of their childhood, which led to their ongoing anger toward her. This is a 

typical traditional Puerto Rican interpretation of the impact of chronic 

suffering on the “nerves.” If untreated, the patient feared that she would


become chronically psychotic (“loca”; crazy), given her limited ability, by 

herself, to “control” her symptoms, particularly her anger and grief (40). 

Over time, however, medical treatment without family reconciliation 

was likewise experienced as insufficient. The traditional link between 

nervous ailments and past stressors served the outpatient clinicians as 

an entry point for discussing her interpersonal history, including the 

conflict with her children. One important function of her caregivers became 

that of contributing medical authority to the patient’s claims for 

filial support. In that sense, the interpersonal element in her system 

of etiological attributions grew to supersede the more physiological aspects 

of her explanatory model. Her ongoing participation in treatment 

was attained in large measure by the growing confluence of this model 

with that of her providers, who also saw her problematic family relationships 

as a main cause of her illness. In fact, clinicians’ success in enlisting 

family support for the patient became proof of their therapeutic 

value. 

A secondary element of her explanatory model was the notion that 

her nervios illness produced a kind of spiritual “weakness,” which led to 

the irruption of distressing spiritual visitations, perhaps by deceased 

relatives, which were experienced as perceptual distortions. This aspect 

of her model was never primary nor fully worked out, yet it initially 

disrupted her care, as it led to a diagnosis of psychosis by the inpatient 

team. Even when improved, however, the patient remained leery of 

these experiences, preferring to pay them minimal attention. 

Help-Seeking Experiences and Plans. How does the patient’s cultural 

identity help explain her past help-seeking choices and expectations 

about current and future forms of assistance and treatment? 

This subsection is closely linked to the previous one, as individuals 

usually seek out caregivers who offer assistance in ways that match 

their explanatory models (13,19). Patients’ help-seeking choices actually 

tend to follow “pathways” of care which are partly determined 

by psychosocial and cultural forces. One expression of this is the way 

cultural perceptions and interpretations of illness affect not only the 

decision whether and when to seek formal care (as opposed to being 

self-reliant or asking for help from the immediate social network), but 

also the type of treatment that is considered to be adequate and effective 

(41). As with etiological attributions, help-seeking pathways can 

also be quite complex, with multiple forms of care being accessed at 

once, or in apparently contradictory ways. 

During her early bouts of depression, which were acute but brief and 

occurred years before the current presentation, the patient did not seek


ongoing medical care, relying only on rare emergency room visits. At 

the time, she felt her life traumas had not yet permanently “altered” her 

nervous system, and she relied mostly on her limited social network and 

on home remedies, such as herbal teas. Early on during her current presentation, 

however, having come to see her condition as a physiological 

reaction to her interpersonal problems, she sought help first from primary 

care internists. They in turn referred her to inpatient psychiatric 

care, which the patient always understood as being sent to the medical 

specialists of the nervous system (“the doctors for nervios”). This was 

a fortunate reframing of her treatment, since an alternative and fairly 

common interpretation in her cultural group could have been to reject 

the psychiatric referral as a sign that the clinicians mistakenly thought 

that she was losing her mind. Over time, she accepted some forms of 

mental health treatment but refused others, due to a mixture of cultural 

and personality characteristics. Family therapy, for example, met 

her view that an improved relationship with her son would help her recover 

from her illness, and was enthusiastically accepted. Other forms 

of psychotherapy directed more at intrapsychic change, such as group 

therapy, met intense resistance. Day hospital care came to be experienced 

as relatively unfocused and off-the-mark; instead, patient sought 

daily visits with her daughter-in-law, where she could re-establish socialization 

skills with family members. Her view of nervios as a medical 

condition never fully disappeared. She felt best protected from relapse 

by periodic check-ups with a psychiatrist, even when no medications 

were prescribed; the ongoing decision not to medicate reassured her 

that her condition remained stable. Interestingly, despite the view that 

her perceptual distortions were due to spiritual “weakness,” she never 

sought the help of folk healers, saying “I don’t believe in any of that.” 

This highlights the intra-ethnic variation in help-seeking pathways, 

since many Puerto Ricans seek the assistance of espiritistas and other 

spiritual healers at some point during the course of their illness (42). 

Cultural Factors Related to Psychosocial Environment 

and Levels of Functioning 

This section of the CF model allows the clinician to examine how culture 

patterns some of the stressors patients are exposed to and their reactions 

to these situations; the social supports available to them; and the 

contexts against which their levels of functioning should be measured. 

Among other stressors, this part of the assessment can be used to elicit 

patients’ experiences of trauma and how they incorporate these events 

into their ongoing interpersonal relationships.


Social Stressors. How does the patient’s cultural background clarify 

the origin and impact of the stressors she experienced? 

The main stressor affecting the patient at the time of her presentation 

was her estrangement from all of her children, which contradicts traditional 

values regarding an extended and close family centered around 

a matriarch. The patient alternated between feeling that this situation 

was unfair and that it was a deserved punishment for abandoning four 

of her children in childhood. That decision, which she described as the 

hardest of her life, was influenced by several social and cultural factors. 

These include: the existence at that time of very few nonfamily 

supports for abused women in rural Puerto Rico; the emergence of migration 

as a government-sponsored escape valve for a labor force made 

redundant by rapid industrialization; her parents’ lack of support for 

marital separation, even in the case of physical abuse; a tradition in 

rural Puerto Rico of placing “extra” children in informal foster arrangements 

with close relatives; and the expectation by some new male sexual 

partners (the man who became the patient’s second husband) that 

they not be expected to maintain non-infant children from a previous 

marriage. 

Seen over the course of her lifetime, the patient’s stressors were severe, 

and included the family disruption caused by her father’s alcoholism, 

her husband’s physical abuse, the death of a child in infancy, 

the dispersion of her nuclear family and the consequent discord with 

her parents and children, difficulties in acculturation to the US, ethnic 

discrimination, chronic poverty and unemployment, the murder of 

her second husband, and her children’s substance abuse and subsequent 

loss of child custody. These stressors were considered by the patient 

and her community to be adequate explanation of her nervios 

illness. 

Social Supports. How does her cultural identity contribute to the 

amount, nature, and quality of her social supports? 

As a “circular” migrant who engaged in several migratory cycles and 

frequent trips to Puerto Rico, the patient’s supports beyond her son, 

daughter-in-law, and caregivers consisted only of community drop-in 

centers and a few elderly Latinas. Her lack of supports probably contributed 

to the length of her hospitalizations, as her fear of going home 

seemed to worsen her suicidality whenever discharge was discussed. 

Clinicians’ efforts to expand her support system through group therapy 

membership and psychiatric social clubs were hindered by her 

character pathology. Most of the patient’s symptoms, including her suicidal 

ataques, may be understood as attempts to expand her social


support network by engaging the attention of family members as well 

as professional caregivers. The patient always retained the belief that 

in the face of her overwhelming social limitations and the original recalcitrance 

of her children, only the full expression of her symptomatology 

could have produced a positive outcome. 

Levels of Functioning and Disability. How does the patient’s cultural 

environment affect her level of functioning and degree of impairment? 

Prior to her improvement, the patient saw her illness as progressive 

and without cure, and feared degeneration into permanent insanity, 

consistent with widespread cultural concerns about severe nervios. As 

a result of treatment, she came to feel that her nervios had not progressed 

as far as she had feared, but that she would always remain 

permanently vulnerable to relapse if confronted with more stress than 

she could handle, especially in her family interactions. She interpreted 

the intermittent appearance of anxiety and depressive symptoms as 

signs of ongoing nervios illness which entitled her to lifelong subsidized 

housing and financial support from the government. Her age and 

limited formal education, job skills, and English fluency in any case 

narrowed her employment opportunities considerably and contributed 

to her expectation of government support. Unfortunately, the absence 

of organized activities such as work also hindered the development 

of a social network beyond her family, which may have helped to decompress 

the patient’s dependence on a limited number of supportive 

contacts. 

Cultural Elements of the Clinician–Patient Relationship 

This section allows the clinician to consider how his/her own role or 

institutional setting has affected the patient’s illness experience, including 

symptom expression and treatment response. The scientific 

emphases on objectivity and material reality sometimes cause psychiatrists 

to mistake their activity for that of invisible observers, who exert 

little effect on the situation observed. On the contrary, much clinical 

and ethnographic research has described how patients’ symptom descriptions 

and etiological attributions are shaped across health care 

settings in response to clinicians’ verbal and nonverbal elicitations and 

to individual and collective expectations of what the purpose and the 

norms are for each kind of setting (38,43). What counts as good and 

bad outcomes also varies across therapeutic interactions, depending 

on whether the patient and caregiver are focusing on symptoms, longterm 

morbidity and mortality, psychosocial functioning, interpersonal


relationships, existential adjustment, ecological integration, or spiritual 

well-being. The clinical encounter is always a negotiated experience 

(44) that in addition echoes a wider system of institutional relationships, 

such as the organization of health care services, the influence of 

third-party review, and pressures brought to bear by employers (22). 

The clinical relationship is also impacted by ethno-cultural clashes in 

the society at large, requiring clinicians to examine their attitudes toward 

a patient’s ethnicity and culture and how these impact the therapeutic 

encounter. This understanding can be helpful not only in terms 

of evaluating the role of cultural differences in the interpretation of 

patients’ presentations, but also in avoiding biases based on ethnic 

stereotypes or other aspects of cultural identity (13). The current section 

encourages a systematic reflection on these interactions. 

In the case of this patient, her psychiatric care prior to her referral 

to the outpatient Latino Clinic was hindered by the inpatient unit’s 

lack of cultural information on various aspects of her presentation that 

have been outlined in this Formulation. In particular, the diagnostic 

process was limited by the absence of a culturally normative assessment 

of the patient’s character structure, which resulted in the overemphasis 

of her Axis I symptoms and a missed diagnosis of Borderline 

Personality Disorder. Likewise, lack of information about the cultural 

characteristics of nervios and ataques led to the misinterpretation of 

her perceptual distortions as psychotic symptoms, with consequences 

for the patient’s psychopharmacological treatment. Finally, the inpatient 

unit’s reliance on pharmacological rather than psychotherapeutic 

interventions was not fully consonant with the patient’s treatment 

expectations. 

The lack of relevant cultural information contrasts with the unit’s 

attention to more purely ethnic issues, such as the frequent use of 

Spanish interpreters to ensure the patient’s participation in the 

milieu, and the focus on “ethnic matching” (45), achieved by assigning 

a Latino psychiatry resident to her care. The emphasis on ethnicity 

alone rather than culture is a problematic characteristic of contemporary 

US psychiatry that can lead, as in this case, to therapeutic practices 

that only go partway toward eliciting the relevant points of difference 

in the patient’s presentation and treatment response (46). The use of 

Spanish, for example, is absolutely necessary for assessing a non- 

English speaking Latina such as this patient, but is not sufficient as 

a culturally valid intervention; for that, therapeutic approaches based 

on cultural information are also required. Ethnic matching does not 

guarantee access to this material, since persons from the same ethnic 

background can differ in terms of cultural experience and clinicians may


be influenced less by their culture of origin than by their professional 

context. 

Referral to an outpatient clinic with an explicitly cultural focus resulted 

in a more comprehensive evaluation for the patient, leading to a 

process of rediagnosis and to the implementation of psychotherapeutic 

interventions more in accord with her expectations, with more successful 

clinical results. 

Overall Cultural Assessment 

The final section of the Cultural Formulation summarizes the information 

in the previous sections, focusing on cultural material that contributes 

to diagnosis and treatment. The role that cultural features 

have played in determining overall illness outcome are particularly 

emphasized. 

In this case, the overall assessment would mention that the patient’s 

cultural identity is that of a rural Puerto Rican migrant with limited 

formal education, who speaks Spanish exclusively and has only lived 

for limited periods in the US, resulting in minimal acculturation. Her 

psychopathology is expressed in the traditional Puerto Rican idioms of 

nervios and ataques de nervios. She attributed the origin of these problems 

and her relapsing course to multiple past stressors and traumas, 

and especially to unresolved conflicts with her children resulting from 

her prolonged separation from them during childhood. In fact, her clinical 

condition did not improve until their affective breach was addressed 

in family therapy. 

The patient’s initial inpatient treatment proved ineffective partly 

because of the misattribution of a psychotic label to her perceptual 

distortions, which are normative idioms of distress for this cultural 

group. Misdiagnosis exposed patient to the potentially toxic effects of 

antipsychotic medication and interfered with referral to family therapy. 

In addition, lack of cultural information also hindered the identification 

of patient’s underlying Axis II pathology and obscured the 

relationship between her character disorder and her persistent Axis I 

symptoms, including her chronic suicidality and its exacerbations in 

the form of ataques. Pharmacologic treatment of the patient’s refractory 

depression—dangerous anyway due to her impulsive suicidality— 

proved unnecessary once intensive family intervention was underway. 

Her remaining intermittent Axis I symptoms led to periodic distress, 

warranting NOS diagnoses. But the patient’s primary psychopathology 

proved to be characterological, fulfilling criteria for Borderline 

Personality Disorder. Like many patients with this disorder, she


displayed recurrent dysphoria, though in her case she did not meet 

strict criteria for Dysthymia. Unlike many Borderline patients, however, 

her course over the subsequent 8 years was remarkably uneventful 

after her initial response to psychotherapy, perhaps reflecting cultural 

variation in the treatment outcome of Borderline Personality Disorder. 

CONCLUSION 

In this article we have presented the Cultural Formulation (CF) model 

for clinical assessment, discussing its historical development and its 

components as outlined in Appendix I of DSM-IV. We also illustrated 

the application of the model with a case scenario of a Puerto Rican 

woman suffering from the Latino popular syndromes of nervios and 

ataques whose care was markedly improved by the implementation of 

a cultural evaluation such as the one outlined. 

At a time in which the value of delivering culturally congruent care 

is increasingly being recognized and requirements for cultural assessment 

are being incorporated into treatment guidelines and professional 

training curricula, the Cultural Formulation model represents one of 

the main existing methods for attaining and implementing a culturally 

valid approach to care (12). Regular use of the model teaches clinicians 

not only how to elicit culturally relevant clinical material, but also exposes 

them over time to the content of many cultural perspectives from 

diverse patients and their families, thus increasing caregivers’ fund of 

cultural knowledge. 

The growing cultural pluralism of US society requires that the CF 

model become an essential aspect of every clinical training program. 

The “long version” of the model, such as the one described in this article, 

can be taught during clinical supervision as part of comprehensive 

patient assessments. This is the format we are using during the outpatient 

year (PGY-III) at the Adult Psychiatry Residency Program of 

Columbia University and NY State Psychiatric Institute. The “short 

version” of the model, similar to the Overall Cultural Assessment section 

of the full Formulation, could then be used for all new evaluations 

or comprehensive reassessments of refractory patients once proficiency 

in the full CF model is established. 

It is also imperative that research be conducted on the effectiveness 

of the Cultural Formulation as a method for improving treatment outcomes, 

including assessment of its cost-benefit ratio. Findings from this 

research will help clarify the contribution of the CF model to clinical 

care, and prepare the way for its role in DSM-V.


ACKNOWLEDGMENTS 

Dr. Lewis-Fernández was supported by a National Institute of Mental 

Health (NIMH) Under-represented Minority Research Supplement 

(5 R10 MH55165). Ms. Díaz was supported by NIMH grant T32 

MH20074 to the Center for Hispanic Mental Health Research at 

Fordham University. 

REFERENCES 

1. Desjarlais R, Eisenberg L, Good B, Kleinman A: World Mental Health: Problems and 

Priorities in Low-Income Countries, New York, Oxford University Press, 1995. 

2. Mukherjee S, Shukla S, Woodle J, Rosen AM, Olante S: Misdiagnosis of schizophrenia 

in bipolar patients: A multiethnic comparison. American Journal of Psychiatry 

140:1571–1574, 1983. 

3. Strakowski SM, Flaum M, Amador X, Bracha HS, Pandurangi AK, Robinson D, Tohen 

M: Racial differences in the diagnosis of psychosis. Schizophrenia Research 21:117– 

124, 1996. 

4. Strakowski SM, Hawkins JM, Keck PE, McElroy SL, West SA, Bourne ML, Sax KW, 

Tugrul MC: The effects of race and information variance on disagreement between 

psychiatric emergency service and research diagnoses in first-episode psychosis. Journal 

of Clinical Psychiatry 58:457–463, 1997. 

5. Good BJ, Delvecchio-Good M-J: Toward a meaning-centered analysis of popular 

illness categories: “Fright-illness” and “heart distress” in Iran. In: Marsella AJ, White 

GM, eds., Cultural Conceptions of Mental Health and Therapy, Dordrecht, D. Reidel, 

1982, pp. 141–166. 

6. Kleinman A: Rethinking Psychiatry: From Cultural Category to Personal Experience, 

New York, The Free Press, 1988. 

7. Zheng YP, Lin KM, Takeuchi D, Kuralski KS, Wang YX, Cheung F: An epidemiological 

study of neurasthenia in Chinese-Americans in Los Angeles. Comprehensive 

Psychiatry 38:249–259, 1997. 

8. Lee S, Wing Y, Chan C, Lee AM, Lee DTS, Chen CN, Lin KM, Weiss MG: Psychiatric 

morbidity and illness experience of primary care patients with chronic fatigue in 

Hong Kong. American Journal of Psychiatry 157:380–384, 2000. 

9. Guarnaccia PJ, Rivera M, Franco F, Neighbors C: The experiences of ataques de 

nervios: Towards an anthropology of emotions in Puerto Rico. Culture, Medicine and 

Psychiatry 20:343–367, 1996. 

10. Guarnaccia PJ, Canino G, Rubio-Stipec M, Bravo M: The prevalence of ataques de 

nervios in the Puerto Rico Disaster Study. Journal of Nervous and Mental Disease 

181:157–165, 1993. 

11. Lewis-Fernández R, Garrido P, Bennasar M, Parrilla E, Laria AJ, Ma G, 

Petkova E: Dissociation, childhood trauma, and ataque de nervios among Puerto 

Rican psychiatric outpatients. American Journal of Psychiatry, 159:1603–1605, 

2002. 

12. Group for the Advancement of Psychiatry Committee on Cultural Psychiatry: Cultural 

Assessment in Clinical Psychiatry, Washington, D.C., American Psychiatric 

Publishing, 2001.


13. Lu FG, Lim RF, Mezzich JE: Issues in the assessment and diagnosis of culturally 

diverse individuals. In: Oldham JM, Riba MB, eds., Review of Psychiatry, Vol. 14, 

Washington, D.C., APA Press, 1995, pp. 477–510. 

14. Lewis-Fernández R: Cultural formulation of psychiatric diagnosis. Culture, Medicine 

and Psychiatry 20:133–144, 1996. 

15. Mezzich JE: Cultural formulation and comprehensive diagnosis: Clinical and research 

perspectives. Psychiatric Clinics of North America 18:649–657, 1995. 

16. American Psychiatric Association: Diagnostic and Statistical Manual of Mental 

Disorders, Fourth Edition (DSM-IV), Washington, D.C., 1994. 

17. Smedley A: “Race” and the construction of human identity. American Anthropologist 

100:690–702, 1999. 

18. Alarcón RD: Culture and psychiatric diagnosis: Impact on DSM-IV and ICD-10. 

Psychiatric Clinics of North America 18:449–465, 1995. 

19. Kleinman A: The Illness Narratives: Suffering, Healing, and the Human Condition, 

New York, Basic Books, 1988. 

20. Weiss M: Explanatory Model Interview Catalogue (EMIC): Framework for comparative 

study of illness. Transcultural Psychiatry 34:235–263, 1997. 

21. Saris JA: Telling stories: Life histories, illness narratives, and institutional landscapes. 

Culture, Medicine and Psychiatry 19:39–72, 1995. 

22. Mechanic D: The experience and expression of distress: The study of illness behavior 

and medical utilization. In Mechanic D, ed., Handbook of Health, Health 

Care, and the Health Professions, New York, The Free Press, 1983, pp. 591– 

607. 

23. Lewis-Fernández R: Diagnosis and treatment of nervios and ataques in a female 

Puerto Rican migrant. Culture, Medicine and Psychiatry 20:155–163, 1996. 

24. Hernández-Cruz J: Migración de retorno o circulación de obreros boricuas? Revista 

de Ciencias Sociales 24:81–102, 1985. 

25. Rodríguez CE: Puerto Ricans: Born in the U.S.A., Boulder, Westview Press, 1991. 

26. Oquendo MA: Psychiatric evaluation and psychotherapy in the patient’s second language. 

Psychiatric Services 47:614–618, 1996. 

27. Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and 

Conceptual Interactions, New York, Wiley, 1998. 

28. Lewis-Fernández R, Kleinman A: Culture, personality, and psychopathology. Journal 

of Abnormal Psychology 103:67–71, 1994. 

29. Rogler LH, Cortés DE, Malgady RG: Acculturation and mental health status among 

Hispanics. American Psychologist 46:585–597, 1991. 

30. Marín G, Gamba RJ: A new measurement of acculturation for Hispanics: The 

Bidimensional Acculturation Scale for Hispanics (BAS). Hispanic Journal of Behavioral 

Sciences 18:297–316, 1996. 

31. Good BJ: Medicine, Rationality, and Experience: An Anthropological Perspective, 

Cambridge, Cambridge University Press, 1994. 

32. McKinlay JB: Social network influences on morbid episodes and the career of helpseeking. 

In: Eisenberg L, Kleinman A, eds., The Relevance of Social Science for 

Medicine, Dordrecht, D. Reidel, 1981, pp. 77–107. 

33. Nichter M: Idioms of distress: Alternatives in the expression of psychosocial 

distress: A case study from South India. Culture, Medicine and Psychiatry 5:379–408, 

1981. 

34. Guarnaccia PJ, Lewis-Fernández R, Rivera M: Towards a Puerto Rican popular 

nosology: Nervios and ataques de nervios. Culture, Medicine and Psychiatry, 

in press.


35. Lewis-Fernández R, Canino G, Ramírez R, Febo V, Bravo M: Latino perspectives on 

mental health in primary care. In: Proceedings of the 49th Institute on Psychiatric 

Services, American Psychiatric Association, 1997, p. 142. 

36. López SR: Patient variable biases in clinical judgment: Conceptual overview and 

methodological considerations. Psychological Bulletin 106:184–203, 1989. 

37. Jenkins JH, Karno M: The meaning of expressed emotion: Theoretical issues raised 

by cross-cultural research. American Journal of Psychiatry 149:9–21, 1992. 

38. Kleinman A: Patients and Healers in the Context of Culture, Berkeley, University of 

California Press, 1980. 

39. Marsella AJ, White GM: Cultural Conceptions of Mental Health and Therapy, 

Dordrecht, D. Reidel, 1982. 

40. Lewis-Fernández R: “That was not in me ...I couldn’t control myself”: Control, identity, 

and emotion in Puerto Rican communities [Spanish]. Revista de Ciencias Sociales 

4:268–299, 1998. 

41. Rogler LH, Cortés DE: Help-seeking pathways: A unifying concept in mental health 

care. American Journal of Psychiatry 150:554–561, 1993. 

42. Garrison V: Doctor, espiritista or psychiatrist?: Health-seeking behavior in a Puerto 

Rican neighborhood of New York City. Medical Anthropology 1:65–191, 1977. 

43. Good BJ, Delvecchio-Good M-J: The meaning of symptoms: A cultural hermeneutic 

model for clinical practice. In: Eisenberg L, Kleinman A, eds., The Relevance of Social 

Science for Medicine, Dordrecht, D. Reidel, 1980, pp. 165–196. 

44. Lazare A, Eisenthal S, Wasserman L: The customer approach to patienthood. 

Archives of General Psychiatry 32:553–558, 1975. 

45. Sue S, Fujino DC, Hu LT, Takeuchi DT, Zane NWS: Community mental health services 

for ethnic minority groups: A test of the cultural responsiveness hypothesis. Journal 

of Consulting and Clinical Psychology 59:533–540, 1991. 

46. Whaley AL: Cultural mistrust: An important psychological construct for diagnosis 

and treatment of African Americans. Professional Psychology: Research and Practice 

32:555–562, 2001.

the cultural formulation: a method for assessing cultural factors

Create successful ePaper yourself

Delete template?

Save as template?