Systematic inclusion of culture‐related information in ICD‐11

Abstract

The experience and presentations of mental disorders are affected by culture and the social milieu, not only of patients and families, but also of the individuals and health systems providing care. These cultural views impact what is considered normal or pathological. The salience of cultural considerations has therefore been increasingly reflected in modern classifica­ tion systems. The two dominant classification systems in psychiatry, in their earlier editions, took somewhat different approaches to reflecting cultural influences on diagnosis. The Clinical De­ scriptions and Diagnostic Guidelines (CDDG) for ICD­10 Men­ tal and Behavioural Disorders did not include a classification of culture­specific disorders, but rather noted the presence of cultural variations in expression under broad disorder group­ ings (e.g., somatoform disorder) and in help­seeking and ill­ ness­related behaviour. However, consideration of culture was not systematically incorporated in the manual. In contrast, the DSM­IV incorporated brief descriptions of cultural features under specific disorders, outlined components of a cultural formulation approach, and listed twenty­five “culture­bound syndromes”. The development of the ICD­11 has emphasized the prin­ ciple of global applicability, i.e., the need for the diagnostic guide lines to function well across global regions, countries and lan guages. Reflecting the cultural context in which clinical encoun ters take place is likely to enhance this goal. However, there is an inev itable tension between the incorporation of lo­ cally relevant material and the essential purpose of an interna­ tional classi fication system, which is to reliably convey clinical information across diverse boundaries. Responding to this chal­ lenge requires a pragmatic balance that involves recognizing cultural differenc es where these are clinically im portant with­ out allowing them to detract from the goal of a common global diagnostic language. As a way of including meaningful consideration of culture in the diagnostic process, the World Health Organization (WHO) Department of Mental Health and Substance Abuse constituted a Working Group to develop guidance on cultural considera­ tions for the ICD­11 CDDG, based on the current state of clini­ cally applicable information for individual disorders and/or disorder groupings. The focus was on providing pragmatic, actionable material to assist clinicians in their evaluation of patients using the ICD­11 guidelines and reduce bias in clinical decision­making by facili­ tating diagnostic assessment in a culturally informed manner. Thus, for example, while recognizing that specific idioms relat­ ing to mental illness are always influenced by culture, what the guidance describes are emotions, cognitions or behaviours that are broadly universal and therefore not “culture­bound” in the sense of being unique. The Working Group developed the following set of questions to guide the generation of the material on culture: • Is there evidence that culture exerts a strong influence on the presentation of the disorder? For example, is there nota­ ble cross­cultural variation? Is a mechanism known for how culture might influence the symptoms or presentation of the disorder? • Is there evidence that the prevalence of the disorder is particu­ larly high or low in specific populations? What caveats should be considered in interpreting these data (e.g., misattribution of symptoms by clinicians unfamiliar with cultural expres­ sions of distress)? Is it possible to link prevalence variation to information on mechanisms (e.g., available data suggest­ ing that prevalence of anorexia nervosa is higher in societies where thinness is idealized)? • What are the cultural concepts of distress (idioms, syndromes, explanations/causes) identified in various cultural groups that are related to the disorder?