The diagnostic process involves more than simply identifyinga disorder or
distinguishing one disorder from another. Itshould lead to a thorough,
contextualised and interactive understandingof a clinical condition and of
the wholeness of the personwho presents for evaluation and care.
This comprehensive concept of diagnosis is implemented throughthe
articulation of two diagnostic levels. The first is a standardisedmulti-axial
diagnostic formulation, which describes the patient'sillness and clinical
condition through standardised typologiesand scales (see
IGDA Workgroup, WPA, 2003, this
suppl.). Thesecond is an idiographic diagnostic formulation, which
complementsthe standardised formulation with a personalised and flexible
statement.
The preparation of the idiographic formulation starts with therecognition
of the perspectives of the clinician, the patientand (whenever appropriate)
the family, on what is unique, importantand meaningful about the patient. The
formulation sets outthese perspectives and identifies any discrepancies,
permittingtheir resolution and integration into a shared understandingof the
case at hand.
The clinician's perspectives should represent a synthesisingand
integrative effort to identify the essential features ofthe patient's
clinical condition and the biological (e.g. genetic,molecular, toxic),
psychological (e.g. psychodynamic, behavioural,cognitive) and social (e.g.
support, cultural) factors thatare relevant to that condition.
The perspectives of the patient and the family should covertheir
understanding of the clinical condition and its contributoryfactors, the
patient's self-image, assets and strengths, andsense of what is meaningful in
life, as well as their expectationsfor the clinical care process. This
information should be elicitedthrough questions placed strategically
throughout the clinicalinterview, such as: What problem brought you here? How
do youexplain what has happened to you? What is important for youin life?
What do you expect from clinical care? The most importantfactor in eliciting
the patient's and family's perspectivesis the ability to listen well.
Learning to listen requiresdidactic instruction, practice and feedback, as
well as a knowledgeof the patient's cultural background.
Integration of clinician and patient perspectives, essentialfor a
therapeutic alliance, should be based on empathetic rapport,reflecting mutual
respect and interest, and human feeling betweenthe clinician and the patient.
These two people (with the collaborationof the family as needed) should
attempt to reach a joint understanding,to the maximum extent possible, of the
clinical problems andtheir contextualisation, the patient's positive factors,
andexpectations about restoration and promotion of health. Eachof these
elements is outlined below. Finally, clinician, patientand family should
jointly monitor the progress of care andits outcome, and agree on any
adjustments to be made.
The first element of the idiographic formulation is the identificationof
clinical problems and their contextualisation. These includedisorders,
symptoms and problems (based on the standardisedmulti-axial formulation)
described in language shared by theclinician, the patient and the family, as
well as key complementaryinformation and the elucidation of pertinent
mechanisms andcontributory factors, from biological, psychological, social
and cultural perspectives. Important disagreements should benoted and their
resolution addressed.
The second element of the idiographic formulation is the descriptionof the
patient's positive factors. These are factors pertinentto the treatment of
the clinical condition and to health promotion,such as maturity of
personality, skills, talents, social resourcesand supports, and personal and
spiritual aspirations.
The third element of the idiographic formulation outlines expectations
about the restoration and promotion of health. These includespecific
expectations about the types of treatments and theirresults, as well as
aspirations about health status and qualityof life in the foreseeable
future.
The idiographic formulation should be presented in natural orcolloquial
language to maximise the flexibility of its presentation.The length of a
written idiographic formulation could be abouta page
(Fig. 8.1), and that of an oral
presentation about5 minutes. Although this length may be advisable in
general,the formulation may vary from a short statement to a much more
extensive one, depending on the time available, the purposesand format of
clinical care, and other circumstances.
American Psychiatric Association (1995)
Practice guidelines for psychiatric evaluation of adults. American
Journal of Psychiatry, 152
(suppl.), 67-80. DeVries, M.W. (ed.) (1999)The
Experience of Psychopathology: Investigating Mental Disorders in their Natural
Settings. Cambridge: Cambridge University Press. IGDA Workgroup, WPA (2003) IGDA. 7:
Standardised multi-axial diagnostic formulation. British Journal of
Psychiatry, 182 (suppl. 45),
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Psychiatry: From Cultural Category to Personal Experience. New
York: Free Press. Mezzich, J. E., Otero-Ojeda, A. A. & Lee, S.
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Kaplan & Sadock's Comprehensive Textbook of
Psychiatry (eds B. J. Sadock & V. A. Sadock) (7th edn), pp.
839-853. Philadelphia, PA: Lippincott, Williams &
Wilkins. Ross, C A. & Leichner, P. (1986) Canadian
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