The place of culture in DSM-IV

J Nerv Ment Dis. 1999 Aug;187(8):457-64. doi: 10.1097/00005053-199908000-00001.


This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

Publication types

  • Review

MeSH terms

  • Culture*
  • Forecasting
  • Humans
  • Manuals as Topic
  • Mental Disorders / classification*
  • Mental Disorders / diagnosis*
  • Mental Disorders / ethnology
  • Outcome and Process Assessment, Health Care
  • Practice Guidelines as Topic
  • Psychiatric Status Rating Scales / standards
  • Psychometrics / standards
  • Psychometrics / trends
  • Reproducibility of Results
  • Terminology as Topic*