756165

research-article20182018
SGOXXX10.1177/2158244018756165SAGE OpenPaniagua

Article

SAGE Open

ICD-10 Versus DSM-5 on Cultural Issues

January-March 2018: 1­–14
© The Author(s) 2018
DOI: 10.1177/2158244018756165
https://doi.org/10.1177/2158244018756165
journals.sagepub.com/home/sgo

Freddy A. Paniagua1

Abstract
Mental health practitioners in the United States often use two classification systems for mental disorders, namely, the
International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5). A
critical issue when diagnosing people with mental disorders is to ensure that cultural variables do not potentially explain the
presentation of symptoms. A fundamental difference between the two classification systems is that the ICD is mute regarding
the need to consider such variables in this context of diagnosing people with mental disorders, whereas the DSM-5 does alert
mental health practitioners that they should not make a diagnosis in this context without considering the cultural variables
potentially affecting the assessment and diagnosis of such disorders. This difference between the two classification systems is
illustrated with a sample of mental disorders in both systems.

Keywords
ICD-10, DSM-5, genetics, cultural variables, mental disorders

Introduction Reed, 2010). Nordal (2014) and Paniagua (2011, 2016),

Mental health practitioners in the United States generally use
the International Classification of Diseases (ICD-10) and the
Diagnostic and Statistical Manual of Mental Disorders (5th
ed.; DSM-5; American Psychiatric Association [APA], 2013)
to guide their clinical diagnostic practice involving mental
disorders in children, adolescents, and adults (APA, 2013;
Centers for Disease Control and Prevention [CDC], 2009;
World Health Organization [WHO], 2016a).
The ICD-10 discusses mental disorders in chapter 5, and
three variants of this classification system are available. The
first variant is the ICD-10 Clinical Descriptions and
Diagnostic Guidelines (ICD/CDDG-10), which is recom-
mended for general clinical, educational, and service use.
The second variant is the ICD-10 Diagnostic Criteria for
Research (ICD/DCR-10), which is recommended for
research purposes. The ICD/CDDG-10 and the ICD/DCR-10
are both available from WHO (2016a). The third variant of
the ICD-10 is suitable for use by coders or clerical workers,
but it is not recommended for mental health practitioners
(CDC, 2016; WHO, 2016b). This article emphasizes the
ICD/CDDG-10 because it is the ICD-10 variant that mental
health practitioners are expected to use to diagnose mental
disorders in all WHO countries, including the United States.
A clinical modified (CM) version of the ICD-10 was
developed by the CDC, which is known as the ICD-10-CM.
This CDC version of the ICD-10 is required for diagnosing
physical and mental disorders and reimbursement of medical
and mental health services in the United States (Besser &
Bufka, 2015; CDC, 2014, 2015, 2016; Clay, 2013, 2014;
however, suggested that all versions of the ICD-10 and the
ICD-10-CM are appropriate systems for billing purposes but
not for diagnosing mental disorders.
A section (Z codes) is included in the ICD-10 (WHO,
2010, 2016a) and in the ICD-10-CM (CDC, 2015; Centers
for Medicare and Medicaid Services, 2015), which encour-
ages physicians and mental health practitioners to pay atten-
tion to patients’ prior exposures to potential health hazards
associated with socioeconomic and psychosocial circum-
stances. These Z codes resemble the “other conditions that
may be a focus of clinical attention” in the DSM-5 (see the V
codes in APA, 2013, pp. 715-727). In the DSM-5, ICD-10,
and ICD-10-CM, such conditions (i.e., Z codes or V codes)
are not diagnostic categories, but variables that may affect
the assessment and diagnosis of mental disorders. In the case
of the ICD-10 and ICD-10-CM, such variables should also
be considered in the assessment and diagnosis of physical
diseases. Table 1 shows examples of Z codes in the ICD-10
and ICD-10-CM, with their respective domain (e.g., Z55:
problems related to education and literacy) and examples
(e.g., illiteracy or low-level literacy). The Z61 section in
Table 1 is not included in the ICD-10-CM. When applicable,
in Table 1, the corresponding DSM-5 V code is included after
the dash (/; e.g., Z55/V62.3).
1
The University of Texas Medical Branch at Galveston, USA
Corresponding Author:
Freddy A. Paniagua, The University of Texas Medical Branch at Galveston,
University Boulevard, Galveston, TX 7555, USA.
Email: faguapan@aol.com

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2 SAGE Open

Table 1.  ICD-10 Health Hazards (Z/V codes) Related to Socioeconomic and Psychosocial Circumstances.

Z Code/V Code Domain

Z55/V62.3 Problems related to education and literacy: Illiteracy, low-level literacy, underachievement
Z56/V62.29 Problems related to employment and unemployment: Unemployment, threat of job loss, stressful work
schedule, and discord with boss and coworker
Z57 Occupational exposure to risk factors: Exposure to noise, radiation, dust, toxic agents, extreme
temperature, vibration
Z58 Problems related to physical environment: Air pollution, soil pollution
Z59/V60.0, V60.1, V60.89 Problems related to housing and economic circumstances: Homeless, inadequate housing, discord with
neighbor, lodgers, and landlord
Z60/V62.89, V60.3 Problems related to social environment: Adjustment to retirement, empty nest syndrome, living home
Z60.3/V62.4 Acculturation difficulty: Migration, social transplantation (adjustment to a new culture), social exclusion
and rejection, target or perceived discrimination and persecution
Z61/V61.21, V15.41 Problems related to negative life events in childhood: Alleged sexual abuse of child by person within
primary support group (e.g., parents) or by person outside primary support group; past history of
physical abuse in childhood
Z62/V61.20, V61.8 Other problems related to upbringing: Inadequate parental supervision and control, parental
overprotection; placing the child in an orphanage or group home
Z63/V61.10, V61.03 Other problems related to primary support group, including family circumstances: Problems in
relationship with spouse or partner, disruption of family by separation or divorce, high expressed
emotional level within the family
Z64 Problems related to certain psychosocial circumstances: Unwanted pregnancy, accepting physical and
psychological interventions known to be hazardous and harmful
Z65/V62.5, V62.22 Problems related to other psychosocial circumstances: Conviction in civil and criminal proceedings
without imprisonment, imprisonment and other incarceration, problems related to release from
prison, problems related to other legal circumstances, exposure to disaster, war, and other hostilities

Source. Adapted from World Health Organization (2010).

Note. ICD-10 = International Classification of Diseases.

Cultural Variations and Culture-Bound
Syndromes
A significant contribution in the DSM-5, in the ICD-10, and in
the ICD-10-CM is to alert mental health practitioners about
potential health hazards associated with socioeconomic and
psychosocial circumstances, which may be the focus of clini-
cal attention during the assessment and diagnosis of mental
disorders (see Table 1). The DSM-5, however, goes further in
that it also alerts clinicians that they should consider cultural
variables prior to diagnosing the patient with a given DSM-5
mental disorder (e.g., culture-bound syndromes, see APA,
2013; Paniagua, 2014), and provides culturally specific guide-
lines “for assessing information about cultural features of an
individual’s mental health problem and how it relates to a
social and cultural context and history” (APA, 2013, p. 749).
In the DSM-5, these guidelines are included in three areas.
First, the DSM-5 includes a section dealing with culture-
related diagnostic issues across most mental disorders in the
DSM-5. Second, the cultural formulation “provides a frame-
work for assessing information about cultural features of an
individual’s mental health problem and how it relates to a
social and cultural context and history” (APA, 2013, p. 749).
Third, the cultural formulation interview is a new section in
the DSM-5 “that clinicians may use to obtain information dur-
ing a mental health assessment about the impact of culture on
key aspects of an individual’s clinical presentation and care”
(APA, 2013, p. 750). These three areas are missed in all vari-
ants of the ICD-10 and in the ICD-10-CM.
It should be noted that the ICD/CDDG-10 (see WHO,
2016a) includes a brief section titled “culture-specific dis-
orders,” and informs mental health practitioners that “the
need for a separate category for disorders such as latah,
amok, koro, and a variety of other possible culture-specific
disorder [see Box 1] has been expressed less often in recent
years” (p. 19, emphasis added). This is a misleading sug-
gestion because it means that mental health practitioners
should not be concerned about screening for potential cul-
ture-specific disorders because the need to consider such
disorders in clinical practice has decreased in recent years.
The opposite, however, is the truth: attention to “culture-
specific disorders” (ICD) or “cultural concepts of distress”
(in the DSM-5, see APA, 2013, pp. 833-837), or “culture-
related syndromes” or “culture-bound syndromes” (see
Paniagua, 2014, pp. 206-211), is currently a fundamental
diagnostic issue in clinical practice with culturally diverse
patients (e.g., African American, Asian, Latino/a/Hispanic
patients, etc.) diagnosed with mental disorders with the
ICD or the DSM-5.
For example, Leong and Kalibatseva (2016) alerted men-
tal health practitioners that if they provide clinical services to
Asian American patients, it is important to carefully screen
Paniagua 3

Box 1.  Examples of Culture-Bound Syndromes in the Mental Health Literature.

Syndrome Definition
Ataque de nervios Among Hispanics, “out-of-consciousness state resulting from evil spirits . . . [and also] often
associated with stressful events (e.g., death of a loved one)” (Paniagua, 2001, p. 21), with symptoms
of “attacks of crying, trembling, uncontrollable shouting, physical or verbal aggression” (p. 21)
Amok “Outbursts of violent and aggressive or homicide behavior directed at people and objects” (Paniagua,
2014, p. 206), among clients from Malaysia, Laos, Philippines, Polynesia, Papua New Guinea, and
Puerto Rico
Dhat “Extreme anxiety associated with a sense of weakness, exhaustion, and the discharge of semen”
(Paniagua, 2014, p. 206), among clients from China, India, and Sri Lanka
Ghost sickness “Weakness, dizziness resulting from the action of witches and evil forces” (Paniagua, 2014, p. 206),
among American Indian clients
Hwa-byung Reports of “pain in the upper abdomen, fear of death, tiredness resulting from the imbalance
between reality and anger” (Paniagua, 2014, p. 206). Generally experienced by Asian clients
Koro “A man’s desire to grasp his penis resulting from the fear that it will retract into his body and cause
death” (Paniagua, 2014, p. 206). Reported among clients from Asian countries
Latah “A sudden fright resulting in imitative behaviors that appear beyond control, including imitation of
movements and speech; the individual often follows commands to do things outside his or her wish
. . . [such as] verbal repetition of obscenities” (Paniagua, 2001, p. 22). Generally reported among
clients from Malaysia and Indonesia
Mal de ojo/evil eye Excessive admiration and attention can result in mental health and physical problems in others.
“Children are particularly at risk . . . [with] sleeping problems, crying without an apparent reason,
vomiting, fear, and diarrhea” (Paniagua, 2014, p. 207). Reported in some Arabic and Hispanic
cultures
Mal puesto, hex, root work, “Unnatural diseases and death resulting from the power of people who use evil spirits” (Paniagua,
voodoo death 2001, p. 22). Reported by African American and Latino/Hispanic clients
Pibloktog “Excitement, coma, and convulsive seizures resembling an abrupt dissociative episode, often
associated with amnesia, withdrawal, irritability, and irrational behaviors such as breaking furniture,
eating feces, and verbalization of obscenities” (Paniagua, 2014, p. 207), among clients from the
Arctic and sub-Arctic Eskimo or Inuit communities
Taijin Kyofusho Feeling guilty “about embarrassing others . . . resulting from the feeling that appearance, odor, facial
expressions [e.g., eye contact]) are offensive to other people” Paniagua, 2014, p. 207), among Asians
Susto, Espanto, Pasmo, Sadness, lack of motivation, “tiredness, weakness resulting from frightening and startling experiences”
Miedo Paniagua, 2014, p. 207), among Latino/Hispanic clients

for the potential contribution of Hwa-byung (see Box 1),
which is considered a culture-bound syndrome resembling
somatic symptom disorder in the DSM-5 (APA, 2013) or
somatization disorder in the ICD-10 (WHO, 2016a). In the
specific case of Korean patients, Leong and Kalibatseva
(2016) observed that
because of the Korean culture’s esteem of restraint, suppression
of verbal aggression, and avoidance of confrontation, Hwa-
byung is a unique Korean culture-bound syndrome in which
suppressed emotions reflecting anger, disappointment, sadness,
misery, hostility, grudges, and unfulfilled dreams or expectations
manifest themselves physically. (p. 62)
Examples of physical symptoms during the experiencing
of that culture-bound syndrome among Korean patients
include heart problems, poor appetite, problems with the
urinary track, and vomiting blood. Despite these findings
from Leong and Kalibatseva (2016), clinicians should not
automatically conclude that all Korean patients would
report symptoms suggesting the Hwa-byung culture-bound
syndrome. The same point applies in the case of additional
culture-bound syndromes (see Box 1) across other cultur-
ally diverse patients.
It is also important to observe that a careful screening regard-
ing how the DSM-5 (APA, 2013) treats cultural issues suggests
a distinction between culture-specific disorders, cultural con-
cepts of distress, or culture-related syndromes and cultural vari-
ations (see Paniagua, 2014, for an extensive discussion with
emphasis on this distinction). Although the DSM-5 (APA, 2013)
recognizes the need to consider culture-bound syndromes across
some mental disorders (e.g., taijin kyofusho in the case of social
anxiety disorder, see APA, 2013, and Box 1), the DSM-5 gener-
ally emphasizes cultural variations across most disorders. All
variants of the ICD, however, are mute in both contexts.
Paniagua (2014) proposed the difference between
culture-related syndromes and cultural variations in the fol-
lowing terms: “Culture-bound syndromes [or culture-spe-
cific disorders, culture-related syndromes, cultural concepts
of distress] are ‘locally specific troubling experiences that
are limited to certain societies or cultural areas’” (Smart &
Smart, 1997, p. 394).
4 SAGE Open
. . . such experiences have specific names within the particular
cultures (e.g., ataques de nervios, koro, mal puesto, and susto).
Therapists need to be aware that symptoms associated with a
given mental disorder may be related to a particular cultural
context without being part of a culture-bound syndrome per se.
A clinician should conduct an assessment of cultural variations
that may be contributing to the client’s symptoms, rather than
search for the culture-bound syndrome that may or may not
apply to the particular case. (p. 211)
For example, the DSM-5 (APA, 2013) observes that the
mental health practitioner assessing the patient for psychotic
symptoms may arrive at the wrong diagnosis if this practitio-
ner fails to consider “unfamiliar spiritual explanations [that]
may be misunderstood as psychosis” (APA, 2013, p. 759). In
this case, “spiritual explanations” function as a cultural vari-
ation and not as a culture-bound syndrome. In this context,
the DSM-5 alerts clinicians that “in some cultures [e.g., in the
Latino/Hispanic and Native American cultures], visual or
auditory hallucinations with a religious content (e.g., hearing
God’s voice) are a normal part of religious experience”
(APA, 2013, p. 103). For example, experiencing “visions”
during religious or healing ceremonies among traditional
Native Americans can be perceived as symptoms suggesting
a psychotic disorder. Similarly, some African Americans and
Hispanics “who engage in religious or healing ceremonies
may briefly show one or more of the symptoms [suggesting
brief psychotic disorder in the DSM-5]” (Paniagua, 2014, p.
238), including hallucinations, catatonic behavior, and disor-
ganized speech.
Another example of cultural variations in the DSM-5 can
be found in the diagnosis of learning disorder. The DSM-5
observes that in the case of English-speaking U.S. children
and adolescents,
the observable hallmark clinical symptoms of difficulties
learning to read is inaccurate and slow reading of single words;
in other alphabetical languages that have more direct mapping
between sounds and letters (e.g., Spanish, German) and in
nonalphabetical languages (e.g., Chinese, Japanese), the
hallmark feature is slow but accurate reading. (pp. 72-73,
emphasis added)
Therefore, the critical process during the assessment and
diagnosis of learning disorder is not to search for a given
culture-bound syndrome (because it does not exist in this
case), but to identify the particular linguistic cultural varia-
tion in the language under consideration.
In the case of alcohol-related disorders, examples of
cultural variations to consider when diagnosing people
with such disorders include the approval and encourage-
ment of the use of alcohol among some ethnic groups dur-
ing “religious celebrations (e.g., Jewish and Catholic
holidays)” (APA, 2013, p. 498) or during “specific events
(e.g., wakes following funeral)” (p. 498). Binge drinking
(“drinking more than 5 drinks in a single occasion,”
Monteiro, 2007, p. 5) is prevalent among individuals from
some Caribbean islands (e.g., Dominican Republic, Puerto
Rico), Central American countries (e.g., Costa Rica, El
Salvador), and South American countries (e.g., Argentina,
Brazil) in which males tend to “compete” on who is able to
drink the most. In this case, binge drinking is not an alco-
hol-related problem but a culturally expected behavior.
Below are additional examples of cultural variations in a
sample of mental disorders.
Examples of culture-bound syndromes are included in
Box 1. For example, the “evil eye” or “mal de ojo” is an
excessive admiration and attention that could result in men-
tal (e.g., anxiety, depression) and physical (e.g., vomiting,
fever) problems in others. Among patients from Arabic and
Hispanic cultures, the belief in “evil eye” or “mal de ojo”
might also create the impression of delusional or psychotic
ways of thinking (Al-Jassem, 2010; Paniagua, 2014). In
these cultural contexts, unfamiliarity with how the particular
culture explains apparent psychotic features “may lead clini-
cians to misjudge the severity of a problem or assign the
wrong diagnosis” (APA, 2013, pp. 758-759; see also
Fukuyama, Sevig, & Soet, 2008, p. 351).
A major difference between all versions of the ICD-10
(e.g., CDC, 2015; WHO, 2016a) and the DSM-5 (APA, 2013)
is that the ICD systems do not alert clinicians about how cul-
tural variables may have an impact on the diagnosis of either
physical diseases or mental disorders (see Alarcón, 2009;
Paniagua, 2001; Paniagua & Yamada, 2013), whereas the
DSM-5 does alert clinicians regarding they should consider
such variables before diagnosing people with mental disor-
ders (Paniagua, 2014). A vast literature exists evidencing that
people can actually be diagnosed with mental disorders
when, in fact, certain cultural variables (e.g., either cultural
variations or culture-bound syndromes, as described above)
are responsible for the presence of symptoms associated with
such disorders (e.g., Leong & Kalibatseva, 2016; Paniagua,
2014; Sue & Sue, 2003; Tseng & Strelzer, 1997). Box 1
includes examples of culture-bound syndromes in the mental
health literature.
Acculturation in Clinical Contexts
Acculturation difficulty is a factor both the ICD-10 and the
ICD-I0-CM consider among other factors (see Table 1) sum-
marizing problems related to social environment (i.e., Z
codes). All variants of the ICD, however, are mute regarding
explicitly guiding mental health practitioners should con-
sider to rule out (exclude) the process of acculturation as a
potential cultural variation associated with the presentation
of symptoms for mental disorders. The DSM-5 (APA, 2013)
not only includes acculturation (i.e., the V62.4 coordinated
with the Z60.3 code in Table 1), but it also encourages men-
tal health practitioners to consider acculturation during the
cultural formulation of the case when the DSM-5 states that
“For immigrants and racial or ethnic minorities, the degree
Paniagua 5
and kinds of involvement with both the culture of origin and
the host culture or majority culture [i.e., acculturative pro-
cess] should be noted separately” (p. 750).
The construct of acculturation has been defined in many
different ways. For example, Paniagua (2014) defined this
construct “in terms of the degree to which an individual inte-
grates new cultural patterns into his or her original cultural
patterns” (p. 13). Another definition of acculturation is
offered by Buki, Ma, Strom, and Strom (2003): “The concept
of acculturation generally refers to the process by which
immigrants adapt to a new culture” (p. 128). Pumariega et al.
(2013) defined acculturation in terms of a “process of change
in the cultures of 2 or more groups of individuals from differ-
ent cultures resulting from their continuous first-hand con-
tact” (p. 1102). These definitions of acculturation are
particularly important to consider in the case of patients from
Spanish-speaking countries (e.g., Colombia, Cuba,
Dominican Republic, Mexico, Panama, Venezuela, etc.) and
Asian countries (e.g., China, Japan, Philippines, Taiwan,
Vietnam, etc.). The reason why acculturation is more pro-
nounced with these groups is because they are among the
largest immigrant groups in the United States (Leong, Lee, &
Chang, 2008; Paniagua, 2014; Sue & Sue, 2003), which sug-
gests a better chance to encounter patients from these groups
in mental health services, relative to immigrant patients from
other countries (e.g., Africa and Middle East countries). Four
models of acculturation have been investigated in the present
context, namely, assimilation, separation, integration, and
marginalization models (Paniagua, 2014).
When an individual shows significant changes in his or
her behavioral patterns (e.g., style of dressing,) and belief
system (e.g., refusing to follow the native culture’s dating
process, described below), resulting from a long-term asso-
ciation with a new culture (e.g., immigrant children and ado-
lescents into the U.S. culture), one would say that such an
individual is highly acculturated into the new culture. This
individual would generally prefer to be identified with the
dominant or host culture (see APA, 2013) and would refuse
to share the values, behaviors, and/or beliefs of his or her
culture of origin (Ayers et al., 2009). This acculturation pro-
cess corresponds to the assimilation model of acculturation
(see Paniagua, 2014). Immigrants influenced by the assimi-
lation model of acculturation would refuse to listen to native
music (from their country of origin), would not participate in
native forms of dance, would not dress or eat food in the
ways prescribed in the culture of origin, and would not par-
ticipate in social behaviors demanded by the culture or origin
(e.g., the ritual involved in the dating process in some cul-
tures). This model of acculturation process may result in con-
flicts between members of the family who are assimilated to
the dominant or host culture and those who maintain behav-
ioral patterns and the belief system of their native culture.
In the separation model of acculturation (also known as
“enculturation”), the patient would report (e.g., during indi-
vidual psychotherapy sessions) that he or she only values
behaviors and beliefs of his or her native culture. In this
model, the patient (particularly an adolescent) would “main-
tain his or her cultural/ethnic identity, refusing to adapt to or
identify with elements of the host (dominant) culture”
(Paniagua, 2014, p. 19). This model of acculturation may
also lead to conflicts among family members, particularly
when some members are assimilated into the host culture but
others elect to separate from such values and only agree to
accept the behavioral patterns and belief system of the cul-
ture of origin (i.e., the separation model of acculturation).
In the integration model of acculturation, the individual
“displays behaviors and beliefs found in both his or her tradi-
tional culture . . . and the host (dominant) culture. This [indi-
vidual] maintains his or her cultural and/or ethnic identity and
at the same time integrates into his or her identity many val-
ues from the host culture” (Paniagua, 2014, p. 19). This model
of acculturation is also known as “biculturalism” (see Sue &
Sue, 2003, pp. 160-161) and may also lead to conflicts in the
family between the integrated individual and family members
who “reject the idea of mixing elements of their own culture
with elements of the dominant culture [i.e., the separation
model of acculturation]” (Paniagua, 2014, p. 19). When
assessing, diagnosing, and treating immigrant children and
adolescents, it is important to evaluate the nature of such con-
flicts in terms of separation–integration acculturation con-
flicts, which may explain marital problems (e.g., parents
disagree regarding accepting or rejecting the child’s decision
to mix elements from both cultures) and “behavioral prob-
lems” (e.g., conduct disorder, oppositional behaviors, depres-
sion, anxiety) in children and adolescents who have chosen
the integration model of acculturation.
As observed by Paniagua (2014), in the marginalization
model of acculturation, the individual “rejects behaviors and
beliefs associated with both his or her traditional culture and
the host (dominant culture) culture” (p. 20). This model of
acculturation is the one that results in more “symptoms”
associated with a given mental disorder (e.g., conduct prob-
lems, depression) among immigrant children. The child or
adolescent affected by this model of acculturation would be
perceived by parents and relatives (siblings, aunts, uncles)
and friends in school as someone who is “isolated,” “indif-
ferent,” “unfriendly,” or “detached,” suggesting the diagno-
sis of schizoid personality disorder in both the DSM-5 (APA,
2013) and the ICD-10 (WHO, 2010, 2016a).
Acculturation Stress in Clinical
Contexts
During the assessment of each of the above models of accul-
turation in clinical practice, an important construct to assess
is acculturation stress (LaFromboise & Malik, 2016;
Paniagua, 2014). Acculturation stress has been defined in
several different ways. For example, LaFromboise and Malik
(2016) observed that acculturation stress is “a system over-
load associated with navigating differences between two or
6 SAGE Open

more cultures” (p. 226). In another source (Paniagua, 2014), conduct disorder diagnosis may at times be potentially
acculturation stress is defined “in terms of those situations misapplied to individuals in settings where patterns of disruptive
where an individual perceives his or her norms, values, behavior are viewed as near normative (e.g., in very threatening,
behaviors, and beliefs are in conflict with the new cultural high-crime areas or war zones). Therefore, the context [i.e., the
cultural variation] in which the undesirable behaviors have
environment” (p. 21).
occurred should be considered. (p. 474, emphasis added)
The struggle to deal with different models of accultura-
tion (e.g., the case of separation–integration conflicts dis-
During the diagnosis of oppositional defiant disorder, the
cussed above) can lead to acculturation stress with symptoms
need to consider the potential impact of acculturation is a
resembling some mental disorders in the ICD-10 and the
key cultural variable mental health practitioner should con-
DSM-5 (e.g., adjustment disorders, major depressive disor-
sider avoiding while diagnosing children and adolescents
ders [MDDs]). For example, LaFromboise and Malik (2016)
with this disorder (Paniagua, 2010). The assimilation model
reviewed the literature on acculturation stress experienced
of acculturation is particularly associated with the potential
by American Indian/Alaska Native (AI/AN) children and
development of oppositional defiant symptoms. For exam-
adolescents and found that “suicide rates [resulting from
ple, traditional (less acculturated) Latino/Hispanic parents
severe symptoms of depression] were positively associated
believe that the “dating process” should include not only
with acculturation stress and negatively associated with tra-
their son or daughter and the girlfriend or boyfriend but also
ditional integration [model of acculturation] in 18 AI/NA
parents or caregivers and other relatives (e.g., aunts, grand-
tribes” (p. 227). In addition, children and adolescents from
mother, etc.). A highly acculturated Latina/Hispanic female
East and Southeast Asian countries are more at risk to be
adolescent who refuses to follow this belief system may
vulnerable to acculturation stress and the development of
strongly disagree with her parents regarding who should be
mental disorders (Kim & Partk, 2008).
involved in that dating process. When Latino/Hispanic par-
Furthermore, higher levels of acculturation stress are gen-
ents bring that adolescent to the clinic for evaluation of her
erally experienced by individuals exposed to the marginal-
“symptoms” (i.e., refusing to do what her parents ask her to
ized model of acculturation, whereas lower levels of
do), clinicians without training associated with the impact of
acculturation stress are generally observed among individu-
the assimilation model of acculturation on immigrant chil-
als associated with the assimilation model of acculturation
dren and adolescents would erroneously diagnose that ado-
(Paniagua, 2014).
lescent with “oppositional defiant disorder” (see APA, 2013,
If acculturation stress is a critical variable during the pro-
pp. 462-466). That adolescent, however, is not mentally ill
cess of assessing and diagnosing people with mental disor-
but displaying behaviors and beliefs that compete with the
ders, the mental health practitioner is expected to use reliable
low level of acculturation in her parents. That is, different
and valid psychological tests to appropriately assess this
levels of acculturation are what explain the child–parent rela-
construct, rather than using his or her imagination. For exam-
tional problems or conflicts and not that mental disorder
ple, the Riverside Acculturation Stress Inventory (RASI)
(Paniagua, 2014; Sue & Sue, 2003).
emphasizes “five domains, namely, language skills, work,
The clinician’s failure to appreciate the above assimila-
intercultural relationships, discrimination, and cultural com-
tion process of acculturation would result in placing that ado-
position of the community” (Paniagua, 2014, p. 22; see also
lescent in intensive outpatient psychiatry treatment with
Benet-Martinez & Haritatos, 2005). A review of general
emphasis on individual psychotherapy (to learn what “intra-
acculturation scales can be found in Paniagua (2014). Below
psychic” feelings lead to oppositional behaviors toward par-
are examples of mental disorders in the DSM-5 that illustrate
ents), family therapy (to help the adolescent and her parents
the role of acculturation and other cultural variations during
to “communicate better”), and the use of psychotropic medi-
the assessment and diagnosis of such disorders, but without cations (to help that adolescent to “relax” when under stress
clinical cultural considerations in all variants of the ICD. resulting from parents’ demands to value only the norms and
beliefs of the Latino/Hispanic culture). Because that adoles-
Conduct and Oppositional Defiant cent is erroneously diagnosed with a mental disorder (i.e.,
oppositional defiant disorder), the wrong treatment plan
Disorders
would be implemented with emphasis on individual psycho-
The ICD-10 and the CD-10-CM encourage clinicians to con- therapy, family therapy, and medication. In this case, how-
sider war and other hostilities (see Z65, in Table 1) as psy- ever, a culturally appropriate treatment approach is termed
chosocial and/or cultural circumstances potentially associated “cultural reframing” (Ho, 1992) in which “the demands or
with both physical diseases and mental disorders. This obser- expectations made by both [the adolescent and her parents
vation particularly applies during the diagnosis of conduct are] are analyzed in relation to the cultural values that consti-
disorder in children and adolescents. The DSM-5 (APA, tuted the background for the demands” (Ho, 1992, p. 153).
2013) is very specific in this context when it asserts, after the Therefore, instead of emphasizing the above traditional treat-
description of diagnostic criteria for this disorder, that ment modalities, the clinician would use cultural refraining
Paniagua 7
strategies with emphasis on how different levels of accultur-
ation among family members are responsible for that adoles-
cent’s “symptoms.” During this cultural reframing strategy,
parents would learn that their daughter is not actually “oppo-
sitional” but only behaving according to a process of accul-
turation she has already assimilated after several years
residing in the United States in which that dating process
generally only involves the adolescent and his or her girl-
friend or boyfriend (and sometimes friends), but not parents
or relatives.
The separation model of acculturation may also explain
symptoms of conduct and oppositional defiant disorders. For
example, because of economic reasons, some immigrant par-
ents come to the United States without their children. After
several years residing in this country, immigrant parents then
bring them to this country. Several months after the arrival of
a child, some parents may become very concerned about
“sudden” behavioral changes in their child. During the first
visit to the clinic, parents then report that their child “refuses
to follow parents’ directions at home, is very argumentative,
and often stays out at night without parents’ permission.”
During the face-to-face clinical interview with that adoles-
cent, the mental health practitioner may find out that this
adolescent recently immigrated to the United State and that
he is being affected by the separation model of acculturation,
whereas his parents are very well acculturated to the
American society (via the assimilation model of accultura-
tion). If the mental health practitioner evaluating this adoles-
cent fails to carefully assess the potential impact of the
separation model of acculturation on the presentation of
symptoms, that practitioner would likely diagnose that ado-
lescent with either “oppositional defiant disorder” or “con-
duct disorder” (see APA, 2013, pp. 462-469 and pp. 469-470,
respectively). In this case, the conflict between the two
acculturation models in the family is what potentially
explains the adolescent’s oppositional or conduct problems
and not the actual presence of DSM-5 diagnostic criteria for
either oppositional defiant disorder or conduct disorder. In
other words, in this example, the recently immigrated ado-
lescent elected to maintain elements from his original cul-
ture, which resulted in conflicts or constant arguments
between that adolescent (affected by the separation model of
acculturation) and his parents (affected by the assimilation
model of acculturation). In this situation, during family ther-
apy sessions, the mental health practitioner’s task should be
to avoid taking sides with any of these models of accultura-
tion but to provide a counseling process with emphasis on
participants’ understanding of their disagreement resulting
from these two conflicting models of acculturation (i.e.,
assimilation vs. separation model of acculturation).
Children and adolescents struggling with the impact of the
integration process of acculturation may also show behaviors
considered by parents as examples of “conduct problems” and
“oppositional acts.” In this process of acculturation, the child
would decide under which condition or environmental context
(e.g., family reunion, birthday parties, etc.) he or she agrees to
show behavioral patterns reflecting his or her own culture or
the dominant (host) culture. For example, the child may some-
times agree to eat foods from his or her native country, but in
other instances the child would agree to eat only foods from
the host culture. If parents disagree with their child’s decision
to mix elements of his or her own culture with elements of the
dominant culture, this situation may result in parents reporting
that their child is “very oppositional” or that the child “has
severe conduct problems.” As observed above, this situation
may result in the child experiencing the acculturation stress
phenomenon described earlier.
If the child is diagnosed with either conduct disorder or
oppositional defiant disorder and parents also report that the
child is having problems accepting behavioral patterns from
either the native culture or the host culture, the best guess is
that the child is experiencing the marginalization accultura-
tion process. In this situation, the mental health practitioner
may erroneously diagnose the child with schizoid personal-
ity disorder if parents report that the child is perceived by
them and others as “isolated,” “indifferent,” “unfriendly,”
and “detached” (see APA, 2013, pp. 655-656).
Dependent Personality Disorder
If a Latina/Hispanic female client/patient seeking mental
health services reports to the mental health practitioner she is
having problems making decision without excessive amount
of advice from her husband, is not able to express her dis-
agreement to her husband regarding how things should be
handled at home (e.g., the discipline of their children, how to
spend their money, or when and where to take a family vaca-
tion, etc.), and that these situations resulted in fear of aban-
donment and a sense of incompetence regarding not being
able to care for herself, that mental health practitioner would
probably conclude that this patient is experiencing symp-
toms associated with dependent personality disorder. The
DSM-5 alerts mental health practitioners they should con-
sider “dependent behavior . . . characteristic of [this disorder]
only when it is clearly in excess of the individual’s cultural
norms” (APA, 2013, p. 677). For example, two cultural vari-
ables the clinician should assess in that example are
machismo and marianismo (Paniagua, 2014; Sue & Sue,
2003). Among many Latina/Hispanic families, machismo is
a cultural value in which the Latino/Hispanic man expects
Latina/Hispanic women to be obedient, dependent, and sub-
missive. If that Latina/Hispanic woman displays behaviors
expected by the Latino/Hispanic man, one would say that she
is influenced by the cultural value of marianismo, which is
highly rewarded by other members in the Latina/Hispanic
community. If the clinician does not have a good understand-
ing regarding the role of machismo and marianismo in the
development of symptoms resembling dependent personality
disorder, the woman in this example would likely be errone-
ously diagnosed with dependent personality disorder.
8 SAGE Open
Although the constructs of machismo and marianismo
have generally been associated with the Latina/Hispanic
community (Paniagua, 2014; Sue & Sue, 2003), similar cul-
tural values can be found in other societies where women are
expected to accept such values in their social interactions
with others. For example, in most Muslim societies, women
are also expected to be submissive, obedient, and possessed
by their husband (Al-Mateen & Afzal, 2004). This culturally
sanctioned belief has its root in the Glorious Qur’an. For
example, in the Glorious Qur’an, Surah 4, Verse 3, Muslim
men are allowed to
marry from among . . . women two or three, or four; but if you
have reason to fear that you might not be able to treat them with
equal fairness, then [only] one-or [from among] those whom
you rightfully possess. This will make it more likely that you
will not deviate from the right course [or will not do injustice].
(Asad, 2003, pp. 117-118)
This is not a case of polygamy because in this verse of the
Glorious Qur’an, Muslim women are expected to be obedi-
ent and submissive to the decision of the Muslim man to
have multiple wives. Furthermore, despite the fact that this is
a case of machismo versus marianismo in the Muslim societ-
ies, this situation would not meet DSM-5 diagnostic require-
ments for dependent personality disorder because polygamy
is a cultural value accepted by Muslim men and women who
strictly follow that verse in the Glorious Qur’an.
During the diagnosis of dependent personality disorder,
the mental health practitioner should also consider the
impact of acculturation on the presentation of symptoms.
For example, if in a marital relationship, the Latina/Hispanic
wife reports during family therapy sessions that she does not
want to continue doing everything her husband asks her to
do and that she is “tired depending on him for everything in
her life,” this report would suggest that the wife is experi-
encing the assimilation process of acculturation after several
years residing in the host country (e.g., the United States)
where women are expected to be more “independent” from
their husbands. This situation would compete with the belief
system of the husband regarding how his wife “should
behave” in their marital relationship. In this example, the
husband’s belief system is under the influence of the separa-
tion model of acculturation (i.e., the husband only values
behaviors and beliefs of his native culture, including the cul-
tural machismo–marianismo demarcation), whereas the
wife’s belief system is under the control of the assimilation
model of acculturation.
Separation Anxiety Disorder of
Childhood
Mental health practitioners should not diagnose children
from cultures that reward interdependence among family
members with separation anxiety disorder. The DSM-5
(see APA, 2013) is very explicit, alerting clinicians to
avoid mistakenly diagnosing children with this disorder
under that particular cultural context.
For example, some Asian families value the “obligation to
family, conformity, obedience, and subordination to author-
ity” (Leong et al., 2008, p. 114). If an Asian child moves
away from this culturally accepted value, the resulting out-
come could be the development of symptoms resembling
separation anxiety disorder. Similar cultural values have
been reported among Latina/Hispanic families (Delgado-
Romero, Galván, Hunter, & Torres, 2008), “and strong
adherence to such values may also result in symptoms resem-
bling separation anxiety disorder among some Hispanics”
(Paniagua, 2014, p. 243). In the case of Muslim families, cli-
nicians should avoid diagnosing Muslim children and ado-
lescents with separation anxiety disorder if they consider the
following note from Al-Mateen and Afzal (2004): “attach-
ment to the mother beyond normal Western developmental
expectations is considered normal [among Muslim fami-
lies]” (p. 190). In addition, recent immigrant families are
generally less acculturated to social norms of the United
States and more prone to reward their children and adoles-
cents for not moving away from their relatives and parents,
which may result in the development of symptoms associ-
ated with separation anxiety disorder (Sue & Sue, 2003).
Social Phobia/Social Anxiety Disorder
Social demands in certain cultures can result in symptoms
resembling social phobia (in the ICD-10 and ICD-10-CM) or
social anxiety disorder (in the DSM-5). For example, mental
health practitioners from Japan and Korea sometimes report
about clients who tend to avoid social situations because they
are very afraid of making “other people uncomfortable”
(APA, 2013, p. 245). These clients often believe that their
facial expression, body odor, and eye contact can be offen-
sive to others. As observed above, this situation is a culture-
bound syndrome known in the Japanese culture as taijin
kyofusho (see APA, 2013, and Box 1), which the clinician
should carefully assess to avoid diagnosing the client/patient
with social phobia.
Selective/Elective Mutism
The ICD (WHO, 2010, 2016a, 2016b) and the DSM-5 (APA,
2013) provide general guidelines for diagnosing people with
selective (ICD) or elective (DSM-5) mutism. The DSM-5,
however, also includes a section alerting mental health prac-
titioners about the need to consider “cultural-related issues”
(p. 186) during the diagnosis of mutism in children, adoles-
cents, and adults. The DSM-5 observes that “children in fam-
ilies who have immigrated to a country where a different
language is spoken may refuse to speak the new language
because of lack of knowledge of the language” (p. 196) and
not because the child is actually experiencing symptoms of
Paniagua 9
elective/selective mutism. So, if a recently immigrated
Asian, Latina/Hispanic, or Muslim family in the United
Sates brings the child to the attention of a mental health prac-
titioner because “the teacher is concerned our child is not
talking in the classroom,” this practitioner should first assess
the potential cultural variable associated with “symptoms” of
mutism (e.g., language barriers) before diagnosing the child
with mutism using either the ICD or the DSM-5 system.
Somatization/Somatic Symptom
Disorder
The somatization disorder (WHO, 2016a) or somatic symp-
tom disorder (APA, 2013) is another example in which both
diagnostic systems differ in terms of the need to consider
cultural variables as potential explanations of symptoms.
The DSM-5 (APA, 2013) observes that symptoms for this
disorder “are prominent in various ‘culture-bound syn-
dromes’” (p. 313) including susto and ataques de nervios
(see APA, 2013, p. 83 and p. 835, and Box 1, for a definition
of these terms). Chaplin (1997) observed that the mental
health practitioner would expect more reports about symp-
toms for this disorder from Asian and Latino/a/Hispanic
patients, in comparison with White patients residing in the
United States. Maffini and Wong (2014) made a similar
observation regarding this mental disorder, but in the specific
case of Asian American patients. In addition, Paniagua
(2014) observes that
regarding the type of symptoms [for this disorder] African and
South Asian clients generally report more symptoms of burning
hands and feet as well as nondelusional experiences of worms in
the head or ants crawling under the skin compared to clients
from North America. (p. 253)
Mood (Affective) Disorders/Depressive
Disorders
The ICD-10 (WHO, 2016a) includes a section dealing with
“mood [affective] disorders with several variants, namely,
manic episode, bipolar disorder, depressive episode, recur-
rent depressive disorder, persistent mood [affective] disor-
der, other mood [affective] disorders, and unspecified mood
[affective] disorder.” The DSM-5 (APA, 2013, pp. 155-188)
includes a chapter dealing with “depressive disorders” that
includes some variants of mood (affective) disorders in the
ICD-10. For reasons unexplained in the DSM-5, cultural
variables discussed only the case of the following depressive
disorders: MDD (depressive episode in the ICD-10) and pre-
menstrual dysphoric disorder (PMDD; not included in the
ICD-10).
In the case of MDD, the DSM-5 alerts mental health
practitioners to pay attention to the way patients from some
cultures mask symptoms of depression by expressing them
in somatic terms (see APA, 2013). For example, 16 years
prior to the publication of the DSM-5, Young (1997) sum-
marized cultural variable in the manifestation of symptoms
of depression and observed that “whereas the depressed
European or American patient is likely to present with com-
plaints of psychological problems [e.g., separation or
divorce, see Paniagua, 2017], the depressed Asian patient is
more likely to present with somatic complaints” (p. 38).
Examples of such somatic complaints Asian patients may
report during the initial (intake) interview include being
very tired most of the day, weakness, or a feeling of “imbal-
ance.” Paniagua (2014) observed that some patients from
Middle Eastern countries and American Indian tribes often
avoid reporting symptoms suggesting depression by mask-
ing such symptoms with reports about heart problems
(without physical/medical evidence to confirm such prob-
lems) or feeling “heartbroken,” respectively. In addition,
some patients from the Latino//Hispanic community tend to
avoid reporting symptoms of depression and instead elect
to explain their mood problems in terms of recently experi-
encing the ataques de nervios culture-bound syndrome (see
Box 1).
In the case of PMDD, the DSM-5 (APA, 2013) observes
that this disorder “is not a culture-bound syndrome” (p. 173)
because it “has been observed in individuals in the United
States, Europe, Indian, and Asian” (p. 173). This disorder,
however, may be associated with some cultural variations.
For example, Paniagua (2014) reviewed the literature in this
context and found that women who report racial/ethnic and
gender discrimination during the initial clinical interview are
most likely to report symptoms for PMDD, “in comparison
to women without experiences of discrimination” (Paniagua,
2014, p. 242). Paniagua (2014) also found that “foreign-born
women and immigrants who arrived in the United States
after age 6 were less likely to have PMDD, compared to
U.S.-born women and immigrants who arrived before age 6”
(p. 242). The original research on this specific topic can be
found in Pilver, Desai, Kasl, and Levy (2011).
Psychotic Disorders
In the Clinical Descriptions and Diagnostic Guidelines (ICD/
CDDG-10; see WHO, 2016a), the ICD-10 includes an exten-
sive discussion with emphasis on schizophrenia, schizotypal
disorder (schizotypal personality disorder in the DSM-5, see
APA, 2013, pp. 655-659), delusional disorder, and schizoaf-
fective disorder. In the DSM-5, a similar discussion is
included in the chapter titled “Schizophrenia Spectrum and
Other Psychotic Disorders,” which includes delusional dis-
orders, brief psychotic disorders, schizophreniform disorder,
schizophrenia, and schizoaffective disorder (see APA, 2013,
pp. 87-110). With the exception of schizophreniform disor-
der, in the DSM-5, mental health practitioners are explicitly
encouraged to pay attention to cultural variables during the
diagnosis of these psychotic disorders (see Castillo, 1997;
Kirmayer, Young, & Hayton, 1995; Paniagua, 2014).
10 SAGE Open
In the case of delusional disorder, the DSM-5 observes
that “an individual’s cultural and religious background must
be taken into account in evaluating the possible presence of
delusional disorder” (APA, 2013, p. 93). For example,
Latino/Hispanic males who believe in the separation model
of acculturation (described above) and are also influenced by
the cultural belief of machismo (i.e., the traditional Latino/
Hispanic males’ belief in their dominance over Latina/
Hispanic women and perception of women as submissive,
obedient, and unassertive, which is a reflection of marian-
ismo) show symptoms suggesting jealous type delusional
disorder if they also believe that their wife’s acculturation to
the norms and values in the United States suggest that she is
unfaithful. Paniagua (2014) observed that “unfamiliarity
with the machismo cultural variant might lead to the assump-
tion that the Hispanic husband is experiencing a delusional
disorder (jealous type)” (p. 238).
The DSM-5 also alerts mental health practitioners that, to
avoid erroneously diagnosing people with brief psychotic
disorder, it is important to “distinguish symptoms of brief
psychotic disorder from culturally sanctioned response pat-
terns” (APA, 2013, p. 238). For example, symptoms for this
disorder (e.g., delusions, hallucinations, disorganized
speech) may be showed by some African American,
American Indian, and Latino/a/Hispanic individuals “who
engage in religious or healing ceremonies” (Paniagua, 2014,
p. 239) and briefly display such symptoms during their acts.
Castillo (1997) observed that during such ceremonies the
individual who is the center of the act shows possession
trance behaviors with emphasis on demon or spirit posses-
sion resulting in the individual “speaking and performing
actions as the spirit or demon, sometimes over a lengthy
period of time” (p. 111). These possession trance behaviors
are not perceived as abnormal by the audience that observes
the act, and such behaviors generally end after the comple-
tion of such ceremonies. Castillo (1997) also provided exam-
ples of symptoms suggesting a brief psychotic disorder in the
case of several culture-bound syndromes, including amok,
ataque de nervios, and pibloktog (for a definition of these
terms, see APA, 2013, p. 83, and Box 1).
The ICD/CDDG-10 (WHO, 2016a) agrees that, in the
group of schizophrenia, schizotypal, and delusional disor-
ders, the ICD discusses in the ICD/CDDG-10, “schizophre-
nia is the commonest and most important disorder of the
group” (p. 78, emphasis added). This classification system,
however, does not provide mental health practitioners with
cultural guidelines to prevent them from either erroneously
diagnosis or misdiagnosis people with schizophrenia. The
DSM-5 observes that “in some cultures visual or auditory
hallucinations [two key DSM-5 diagnostic criteria in schizo-
phrenia] with a religious content (e.g., hearing God’s voice)
are a normal part of religious experience [in some cultures]”
(p. 103). An example is the study by Kirmayer et al. (1995),
which showed that “in the Nigerian culture, paranoid fears of
evil attacks by sprits are part of the local beliefs involving
fear of malevolent attacks by evil spirits” (Paniagua, 2014,
p. 239). Kirmayer et al. (1995) also observed that such para-
noid fears “might be misdiagnosed as symptoms of psycho-
sis [in schizophrenia] by the uninformed clinician” (p. 509).
The schizoaffective disorder also receives an extensive
discussion in the ICD-10 (WHO, 2016a), but without a dis-
cussion on cultural variable that mental health practitioners
should consider before diagnosing people with this disorder.
In the DSM-5, however, cultural variables are suggested when
diagnosing the present disorder. In addition, the DSM-5 (APA,
2013) makes a very important point in this context, namely,
that if a “culturally appropriate evaluation” (p. 109) is not
conducted during the assessment of schizoaffective disorder
among clients from the African American and Latina/Hispanic
communities, such patients may be overdiagnosed with
“schizophrenia compared with schizoaffective disorder” (pp.
108-109), which is a less severe psychotic disorder.
An example of symptoms suggesting schizotypal person-
ality disorder include “odd beliefs or magical thinking”
(APA, 2013, p. 655) in the form of “superstitiousness, belief
in clairvoyance, telepathy” (p. 655). Contrary to the lack of
cultural guidelines in all variants of the ICD-10 in the case of
this disorder, the DSM-5 alerts mental health practitioners
that they should not diagnose people with this disorder with-
out assessing perceptual and cognitive distortions “in the
context of the individual’s cultural milieu” (APA, 2013, p.
657). The DSM-5 also observes that “culturally determined
characteristics, particularly those regarding religious beliefs
and rituals, can appear to be schizotypal to the uniformed
outsider” (p. 657). Examples of these culturally sanctioned
characteristics include “voodoo, speaking in tongues, sha-
manism, mind reading, six sense, evil eye, and magical
beliefs related to health and illness” (p. 657). Table 2 should
help busy mental health practitioners to quickly find in the
DSM-5 the particular mental disorder with discussion of cul-
tural variables.
Discussion
A critical clinical issue in the diagnosis of mental disorders is
to rule out the potential impact of cultural variables that may
explain the presentation of symptoms (Alarcón, 2009;
Paniagua, 2014; Zane, Bernal, & Leong, 2016). Despite the
need to recognize this issue in mental health services, in the
case of the ICD, Alarcón (2009) observed that “the fate of the
cultural aspects of psychiatric diagnosis in the ICD is . . .
ambiguous, if not nebulous” (http://onlinelibrary.wiley.com/
doi/10.1002/j.2051-5545.2009.tb00233.x/full). This article
shows examples from the cultural mental health literature to
evidencing Alarcón’s observation. Alarcón (2009) also
observed that despite the fact that the WHO produced a diag-
nostic system to allow commonalities in the diagnosis of
physical and mental disorders across all WHO culturally
diverse countries (e.g., the United States, Asian, Central and
South American countries), the absence of an unambiguous
Paniagua 11

Table 2.  Mental Disorders With Discussion on Cultural Issues Table 2. (continued)
in the DSM-5.
Page in the
Page in the Mental disorder DSM-5
Mental disorder DSM-5
Narcolepsy 376
Acute stress disorder 285 Nightmare disorder 406
Alcohol intoxication 498 Opioid use disorder 544
Alcohol use disorder 494 Oppositional defiant disorder 465
Adjustment disorder 288 Obsessive-compulsive disorder 240
Anorexia nervosa 342 Obsessive-compulsive personality disorder 681
Antisocial personality disorder 662 Obstructive sleep apnea hypopnea 381
Attention-deficit hyperactivity disorder (ADHD) 62 Other hallucinogen use disorder 526
Avoidant personality disorder 674 Other (or unknown) substance use disorder 580
Avoidant/restrictive food intake disorder 336 Other (or unknown) substance withdrawal 580
Autism spectrum disorder 57 Panic attacks 216
Binge-eating disorder 352 Panic disorder 211-224
Bipolar I disorder 130 Paranoid personality disorder 651
Bipolar and related disorder due to another 147 Phencyclidine use disorder 522
medical condition Pica 331
Body dysmorphic disorder 245 Posttraumatic Stress Disorder (PTSD) 278
Borderline personality disorder 665-666 Premature dysphoric disorder 173
Brief psychotic disorder 95 Premature (early) ejaculation 445
Bulimia nervosa 348 Psychological factors affecting other medical 323
Caffeine withdrawal 508 condition
Cannabis use disorder 514 Reactive attachment disorder 267
Circadian rhythm sleep-wake disorders 394 Sedative, hypnotic, or anxiolytic use disorder 554
Conduct disorder 474 Selective mutism 196
Conversion disorder 320 Separation anxiety disorder 193
Delayed ejaculation 425 Schizoaffective disorder 108-109
Dependent personality disorder 677 Schizoid personality disorder 657
Depersonalization/derealization disorder 304 Schizophrenia 103
Delusional disorder 93 Schizotypal personality disorder 657
Dissociative amnesia 300 Social anxiety disorder (social phobia) 205-206
Dissociative identity disorder 295 Somatic symptom disorder 313
Developmental coordination disorder 76 Specific learning disorder 72-73
Enuresis 357 Specific phobia 201
Erectile dysfunction 428 Stimulant use disorder 565
Female organic disorder 432 Stereotypic movement disorder 79
Female sexual interest/arousal disorder 435-436 Substance/medication-induced sleep disorder 418
Fetishistic disorder 701 Substance/medication-induced sexual dysfunction 449
Gambling disorder 588 Tic disorders 83
Gender dysphoria 457 Tobacco use disorder 574
General personality disorder 648 Trichotillomania (hair pulling) disorder 253
Generalized anxiety disorder 224
Note. DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (5th ed.;
Genito-pelvic pain/penetration disorder 439 DSM-5; American Psychiatric Association, 2013).
Histrionic personality disorder 668
Hoarding disorder 250
Illness anxiety disorder 317 set of cultural guidelines in the ICD system informing clini-
Inhalant use disorder 536 cians about the need to pay attention to cultural variables
Intellectual disability 39 before diagnosing people with mental disorders (and physi-
Intermittent explosive disorder 468 cal disorders) is a major deficiency in the ICD system (see
Major depressive disorder 166 Patel, Saraceno, & Kleinman, 2006).
Major and mild neurocognitive disorders 609 The main message across the selected sample of mental
Major and mild neurocognitive disorder due to 613 disorders discussed above is that, whereas the DSM-5
Alzheimer’s disease
includes specific cultural guidelines informing mental health
Male hypoactive sexual desire disorder 442
practitioners about the need to consider the role of cultural
(continued) variables before diagnosing people with mental disorders,
12 SAGE Open
this is a message completely missed in all variants of the
ICD-10 and in the ICD-10-CM. Examples of such cultural
guides in the DSM-5 (APA, 2013) include attention to the
role of acculturation difficulty in the manifestation of symp-
toms for a given mental disorder, as well as the patient’s feel-
ings of social exclusion or rejection, perceived adverse
discrimination, and difficulty dealing with religious or spiri-
tual problems that could also affect on the presentation of
symptoms.
When comparing all variants of the ICD-10 and the ICD-
10-CM systems with the DSM-5, the most relevant cultural
discussions in the DSM-5, but missed in such systems,
include (a) a glossary of cultural concepts of distress (i.e.,
culture-bound syndromes, for example, ataques de nervios,
dhat, susto. taijin kyofusho, see APA, 2013 and Box 1), (b)
the diagnosis and clinical management of the case with
emphasis on the cultural formulation (e.g., recognition of the
cultural identity of the individual and cultural differences
between the client/patient and the mental health practitio-
ner), and (c) guidelines to appropriately conduct the cultural
formulation interview with emphasis on the cultural defini-
tion of the problem, the cultural perception of cause, context,
and support, cultural factors affecting self-coping and past
help-seeking behaviors, and cultural factors affecting current
help-seeking behaviors (see APA, 2013).
Although the DSM-5 significantly differs from all vari-
ants of the ICD system in terms of consideration of cultural
variables, the DSM-5 does not cover such variables across all
mental disorders. Table 2 shows mental disorders with
explicit and/or unambiguous cultural statements in the DSM-
5 (APA, 2013). Examples of DSM-5 mental disorders with-
out cultural discussion include narcissistic personality
disorder, sexual sadism, and persistent depressive disorder
(dysthymia), among many more mental disorders in the
DSM-5. Regardless of the fact that the DSM-5 still needs to
do more in future revisions of the text in terms of covering
100% of mental disorders in the DSM-5 with discussions on
cultural issues, in comparison with all variants of the ICD,
the DSM-5 is still superior in alerting mental health practitio-
ners about the need to consider cultural variables (i.e., cul-
tural variations and culture-bound syndromes) during the
diagnosis of mental disorders.
Several mental health organizations have published cul-
tural parameters or guidelines mental health practitioners
belonging to such organization are expected to consider
when providing mental health services to culturally diverse
patients (APA, 2016; American Psychological Association,
1993, 2003; DuPree, Bhakta, Patel, & DuPree, 2013;
National Association of Social Worker, 2016; National
Organizations of Nurse Practitioner Faculties, 2003;
Pumariega et al., 2013; Ratts, Sing, Butler, Nassar-McMillan,
& McCullough, 2016; U.S. Department of Health and
Human Services, 2001). These parameters or guidelines
should be particularly considered by mental health practitio-
ners who are demanded to use the ICD-10-CM in the United
States if they want to be reimbursed for clinical services
(Nordal, 2014; Paniagua, 2016), but in which they are not
explicitly informed about the need to assess their patient’s
cultural, race, and/or ethnic background before arriving at a
diagnosis of mental disorders with emphasis on any variant
of the ICD-10.
Acknowledgments
The author thanks Dr. Sandra A. Black for her editorial commentar-
ies during an early draft of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biography
Freddy A. Paniagua received his PhD from the University of
Kansas, and his postdoctoral degree from Johns Hopkins University
School of Medicine. He is a retired, tenured professor from the
Department of Psychiatry and Behavioral Sciences and currently
adjunct professor, University of Texas Medical Branch (UTMB) at
Galveston.