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INTRODUCTION |
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As medicine and psychiatry are both science and art, clinical diagnosis involves knowledge, skills and attitudes that demand the best of our scientific, humanistic and ethical talents and aspirations. The philosopher and historian of medicine Pedro Lain-Entralgo (1982) cogently argues that diagnosis is more than just identifying a disorder (nosological diagnosis) and more than distinguishing one disorder from another (differential diagnosis); it is in fact understanding thoroughly what goes on in the mind and the body of the person who presents for care. This understanding must be considered in the context of the history and culture of each patient to be meaningful.
Recent decades have witnessed considerable advances in the methodology of psychiatric diagnosis. These have included a more systematic and reliable description of disorders, and multi-axial schemas for addressing the frequent plurality of the patient's clinical problems and their biopsychosocial contextualisation. On the other hand, compelling arguments have been made about the need to enhance the validity of these diagnostic formulations by attending to symbols and meanings that are pertinent to the identity and perspectives of individual patients (Tasman, 2000). Furthermore, in the increasingly multicultural world in which we live, it is essential to strive for an effective integration of universalism (which facilitates professional communication across centres and continents) and local realities and needs (which address the uniqueness of the patient in his or her particular context).
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THE IGDA PROJECT |
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Also reflective of the relevant work of the WPA classification section on international psychiatric classification and diagnosis are two conferences over the past two decades during which African, Chinese, Egyptian, French, Japanese, Latin American, Russian, Scandinavian, South Asian and United States perspectives were presented and discussed (Okasha, 1988; Mezzich et al, 1994).
Another important root of the IGDA project was the International Survey on Diagnostic Assessment Procedures conducted by the WPA Section on Classification and Diagnostic Assessment in the early 1990s, which revealed a widely perceived need for more comprehensive diagnostic approaches, culturally informed and generated in a truly international manner (Mezzich, 1993). (Influenced by the results of this international survey, the Section on Classification and Diagnostic Assessment decided in 1994 to start work on the IGDA project. The first meeting for this purpose took place in the Bavarian town of Kaufbeuren, in Germany. Since then, meetings have been held in Canada, China, France, Germany, Mexico, Turkey and the USA.)
The workgroup for this project is composed of experts representing several theoretical approaches and fields of psychiatry. As a group, they cover all continents, consistent with the diversity of the Section membership. The names of the workgroup members and advisors are listed at the beginning of this supplement. In 1997, the Executive Committee of the WPA adopted the project as a WPA Educational Programme. Later, the project received some central institutional funding to facilitate its completion.
Distinctive features and components
Fundamental to the IGDA project is the assessment of the psychiatric
patient as a whole person, rather than just as a carrier of disease. This
assumes in the clinician the exercise of scientific competence, humanistic
concern and ethical aspirations. Another essential feature is the coverage of
all key areas of information (biological, psychological and social) pertinent
to describing the patients' disorders, dysfunctions and problems, as well as
their positive aspects or assets. A third important feature involves basing
the diagnostic assessment on the interactive engagement of the clinician, the
patient and the patient's family, leading to a joint understanding of the
patient's clinical condition and a joint assumption and monitoring of the
treatment plan. Fourth, IGDA uses ICD10 for the first three axes of its
multi-axial formulation (classification of mental and general medical
disorders, disabilities and contextual factors). Alternatively, regional
adaptations of ICD10, such as DSMIV, the Chinese
CCMD2R, the Cuban GC3 or the Latin American GLDP, may be
used for this purpose.
Additionally, it is important to point out the need for scientific objectivity and evidence-based procedures in the diagnostic assessment process, as well as intuition and clinical wisdom, in order to enhance the descriptive validity and therapeutic usefulness of the diagnostic formulation. Furthermore, it is critical for the effectiveness of the diagnostic enterprise to use a culturally informed framework, both for the development of new diagnostic models and procedures as well as for conducting a competent clinical evaluation of every patient.
The main products of the IGDA project include the following:
Contents of this supplement
This supplement presents concisely the 100 IGDA guidelines, along with
explanatory diagrams and tables, and recommended reading lists. This material
is organised into ten parts, covering conceptual bases, interviewing and
information sources, symptom and supplementary assessments, comprehensive
diagnostic formulation, treatment planning and chart organisation. A final
part sets out an illustrative clinical case.
These guidelines are offered as recommendations for both in-patient and out-patient care, and for both child and adult psychiatry. The manner of their application should be informed by local realities and needs. The guidelines are presented here in a deliberately compact form, deferring for the support book a detailed presentation of their implications and adaptations to different clinical situations.
Part 1 (IGDA Workgroup, WPA, 2003a, this suppl.) offers a conceptual framework for the whole diagnostic process, including historical, cultural and clinical perspectives, definitions of core constructs and procedures and their overall articulation for enhancing clinical care.
Part 2 (IGDA Workgroup, WPA, 2003b, this suppl.) focuses on patient interviewing. It is based on the establishment of optimal clinicianpatient engagement, aimed at systematic data-gathering through a fluid and graceful process with a deliberate therapeutic tone. The interviewing process is organised into opening, body and closure phases. Part 3 (IGDA Workgroup, WPA, 2003c, this suppl.) deals with the use of extended sources of information: interviews with relatives, friends and other living informants, and documentary sources. It also attends to the resolution of conflicting information and the protection of confidentiality.
Guidelines for the core characterisation of a psychopathological case are the subject of part 4 (IGDA Workgroup, WPA, 2003d, this suppl.). It organises the assessment of major symptomatological areas and the key components of the mental state examination. Supplementary assessment procedures are reviewed in part 5 (IGDA Workgroup, WPA, 2003e, this suppl.) (concerning psychopathological, neuropsychological and physical aspects) and part 6 (IGDA Workgroup, WPA, 2003f, this suppl.) (concerning functioning social context, cultural framework and quality of life).
One of the most innovative contributions of these guidelines is the creation of a new diagnostic model that combines a standardised multi-axial evaluation with a personalised idiographic one. Personalised interventions call for personalised assessments. The corresponding recommendations concerning the conceptualisation and formulation of a comprehensive diagnostic statement are summarised in parts 7 and 8. Part 7 (IGDA Workgroup, WPA, 2003g, this suppl.) focuses on the standardised multi-axial formulation involving clinical disorders, disabilities, contextual factors and quality of life. Part 8 (IGDA Workgroup, WPA, 2003h, this suppl.) deals with the idiographic (personalised) formulation, which integrates the perspectives of the clinician, the patient and the patient's family into a jointly understood narrative description of clinical problems, the patient's positive factors, and expectations about the restoration and promotion of health. The idiographic formulation might be the most effective way to address the complexity of illness, including its cultural framework.
Part 9 (IGDA Workgroup, WPA, 2003i, this suppl.) outlines the use of the information contained in the diagnostic formulation for treatment planning. This process configures the patient's clinical problems by extracting pertinent elements from both the standardised and the idiographic components of the diagnostic formulation. An intervention package (including appropriate diagnostic studies as well as treatment and health-promoting activities) is then delineated for each of the problems listed. Finally, part 10 (IGDA Workgroup, WPA, 2003j, this suppl.) contains recommendations on organising the clinical chart. This should contain basic demographic identifying data, informational sources and reasons for evaluation, history of psychiatric and general medical illnesses, familial, personal and social history, psychopathological and physical examination, supplementary assessments, comprehensive diagnostic formulation and treatment plan. Chart organising principles that are emphasised include adequate coverage of clinical areas and narrative presentations, along with semi-structured components as needed. The handling of the charts must ensure safe and efficient accessibility, as well as confidentiality.
These ten parts each contain ten guidelines and a recommended reading list, illustrated by a diagram or table where appropriate. The final part (part 11, IGDA Workgroup, WPA, 2003k, this suppl.) exemplifies how the guidelines should be put into practice.
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AIMS OF THE IGDA |
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REFERENCES |
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Berganza, C. E., Mezzich, J. E., Otero-Ojeda, A., et al (2001) The Latin American Guide for Psychiatric Diagnosis: a cultural overview. In Cultural Psychiatry: International Perspectives (eds J. E. Mezzich & H. Fabrega). Psychiatric Clinics of North America. Philadelphia, PA: Saunders.
Chinese Medical Association (1995) Chinese Classification of Mental Disorders (2nd edn, revised). Nanjing: Dong Nan University Press.
IGDA Workgroup, WPA (2003a) IGDA. I:
Conceptual bases historical, cultural and clinical perspectives.
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IGDA Workgroup, WPA (2003b) IGDA. 2:
Interviewing the patient. British Journal of
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Supplementary assessment procedures psychopathological,
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Mezzich, J. E., Honda, Y. & Kastrup, M. (eds) (1994) Psychiatric Diagnosis. A World Perspective. New York: Springer.
Okasha, A. (1988) The Egyptian diagnostic system (DMPI). In International Classification in Psychiatry: Unity and Diversity (eds J. E. Mezzich & M. von Cranach). Cambridge: Cambridge University Press.
Otero, A. A. (ed.) (2000) Tercer Glosario Cubano de Psiquiatría [Third Cuban Glossary of Psychiatry]. Havana: Psychiatric Hospital.
Sartorius, N. (1995) Understanding the ICD10 Classification of Mental Disorders. London: Science Press.
Tasman, A. (2000) Lost in the DSMIV checklist: empathy, meaning and the doctorpatient relationship (presidential address). Proceedings of the 153rd Annual Meeting of the American Psychiatric Association, Chicago, Illinois. Washington, DC: APA.
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World Health Organization (1996) Multiaxial Classification of Child and Adolescent Psychiatric Disorders. Cambridge: Cambridge University Press.
World Health Organization (1997) Multiaxial Presentation of ICD10 for Use in Adult Psychiatry. Cambridge: Cambridge University Press.
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