Diagnostic assessment is the process of appraising a patient'scondition.
It involves effectively engaging the patient inorder to obtain accurate
information relevant to understandinghealth problems (mental and general
medical disorders), theircontext (psychosocial and environmental problems)
and theirimpact on adaptive functioning and participation in society
(disablements). A comprehensive diagnostic formulation representsa summary of
the clinician's judgement about the overall conditionof the patient, obtained
as much as possible with the latter'scollaboration. The main purpose of
diagnosis is to serve asthe basis for clinical care. Further objectives
include tocommunicate concisely and reliably information on health problems,
to understand their biopsychosocial pathogenesis and the interactionof
internal and contextual factors, to enhance training andresearch, and
last but not least to informa collaborative process of care aimed at
the restoration andpromotion of health, functioning and quality of life
(Fig. 1.1).
A mental disorder is conceived in these guidelines as a recognisableset of
clinical symptoms and behaviours associated in the majorityof cases with
suffering, psychic disharmony, and interferencewith adaptive functioning and
participation in social life.This concept is incorporated in standard
classifications ofmental disorders, such as the chapter on mental and
behaviouraldisorders of the World Health Organization's International
Classification of Diseases and Related Health Problems (ICD10)and
other international classifications based upon it.
Other concepts integral to a comprehensive diagnostic formulationinclude
the following.
General medical conditions health problems that arenot classified
as mental or behavioural disorders. Generalmedical conditions may have
emotional components, and mentaldisorders may have somatic elements.
Disabilities limitations or problems in adaptive functioning.Such
limitationsoccur in self-care, interpersonal functioning,occupational
performance and participation in society.
Psychosocial andenvironmental problems contextual factorsor
situationsaffecting the emergence or course of illnessand requiring clinical
attention and intervention.
A comprehensive diagnostic formulation and its theoretical framework,like
all human constructs, are products of their time and circumstances.Therefore,
the clinician should be aware that they reflecthistorical developments,
cultural factors, ethical norms, andclinical and epidemiological requirements
at a particular moment.
The psychiatric interview is the single most important partof the
diagnostic evaluation process. It affords the meansto establish rapport and
to elucidate clinical data by listeningto and questioning the patient, and
observing the patient'sbehaviour. The interview is the main source of
informationon the course of the condition: the patient's personality,
biography and adaptive functioning, and environmental and psychosocial
stressors. It is also the basis of the idiographic (personalised)evaluation
of the patient. The interview is conducted accordingto professionally
accepted rules and ethical standards, andrequires appropriate training.
The clinician must consider other sources of information besidesthe
clinical interview. This is essential in circumstancesthat prevent the
patient from providing information. Recordsof previous hospitalisations and
out-patient treatment areusually important to consult. Other sources such as
relatives,friends, neighbours and police should be consulted whenever
appropriate, with the patient's consent and assuring confidentialityin the
use of such information, as far as possible.
All patients presenting for psychiatric care should receivea comprehensive
evaluation of symptoms and mental state. Abasic physical evaluation is
advisable, including if necessarya physical examination. All
psychopathological terms shouldbe used in a reliable and comparable way, and
all areas ofpsychopathology should be described in a systematic and
standardisedmanner. Supplementary assessment procedures are further sources
of information, ranging from specialised physical evaluation,laboratory tests
and imaging procedures to structured or standardisedinstruments for the
assessment of the clinical condition. Theclinician should be familiar with
them and with the prerequisitesfor their use.
The diagnostic process involves more than identifying a disorder.Positive
aspects of health, such as personal and social assetsand quality of life,
should also be described. The diagnosisitself should combine a nomothetic or
standardised diagnosticformulation (e.g. ICD-10, DSM-IV) with an idiographic
(personalised)diagnostic formulation reflecting the uniqueness of the
patient'spersonal experience. At the nomothetic level, a multi-axial
diagnostic formulation is recommended. For the idiographic formulation,an
integration of the perspectives of the clinician, patientand family should be
presented in natural language.
The main objective of diagnosis is patient care. A care planshould be
prepared on the basis of both the multi-axial formulationof the patient's
condition (taking into account clinical disorderspresent, disablements,
contextual factors and quality of life)and the idiographic diagnostic
formulation (e.g. the patient'sneeds and expectations, cultural factors and
economic and therapeuticresources). The programme of care should include
additionaldiagnostic studies and specific therapeutic interventions. Evolving
longitudinal observations should lead to periodic updating ofthe
comprehensive diagnostic formulation.
A record of information documenting the comprehensive diagnosticassessment
should be kept in every individual patient's chart.This information should be
presented in an organised formatwhich includes narrative components.
Barron, J. W. (ed.) (1998)Making
Diagnosis Meaningful. Washington, DC: American Psychological
Association. Mezzich, J. E., Kleinman, A., Fabrega, H., et al (eds)
(1996)Culture and Psychiatric Diagnosis: A
DSMIV Perspective. Washington, DC: American Psychiatric
Press. Misés, R., Fortineau, J., Jeammet, P., et al
(1988) Classification Français des troubles mentaux de
l'enfant et de l'adolescent [French classification of mental disorders of
children and adolescents]. Psychiatrie de L'Enfant,
31, 61-134. Sadler, J. Z., Wiggins, O. P. & Schwartz, M. A.
(1994)Philosophical Perspectives on Psychiatric
Diagnostic Classification. Baltimore, MD: Johns Hopkins
University Press. Zheng, Y. P., Lin, K. M., Zhao, J. P., et al
(1994) Comparative study of diagnostic systems: Chinese
Classification of Mental Disorders, 2nd ed. versus DSMIIIR.
Comprehensive Psychiatry,
35,
441-449.[Medline]