Diagnosis is one of the most central concepts in psychiatry and medicine: in effect, it defines the field. It describes the whole clinical condition of the patient in a way that is helpful for effective treatment and health promotion. Consequently, it is also a fundamental concept for clinical training and clinical research. Furthermore, it informs the conceptualisation of what a case is and the methodology for its assessment in epidemiology and public health.
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 (Reference Lain-Entralgo1982) 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 (Reference TasmanTasman, 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).
THE IGDA PROJECT
Development
One of the roots of the World Psychiatric Association (WPA) project to develop the International Guidelines for Diagnostic Assessment (IGDA) can be found in the dedicated collaboration between the World Health Organization and WPA, through its Executive Committee and its Section on Classification and Diagnostic Assessment towards the development of the Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD—10) (World Health Organization, 1992; Reference SartoriusSartorius, 1995), the Diagnostic and Statistical Manual of Mental Disorders (4th edn, DSM—IV) (American Psychiatric Association, 1994), recent Chinese classifications of mental disorders (CCMD—2—R, CCMD—3) (Chinese Medical Association, 1995; Reference LeeLee, 1996), the Third Cuban Glossary of Psychiatry (GC—3) (Reference OteroOtero, 2000) and the Latin American Guide for Psychiatric Diagnosis (GLADP) (Reference Berganza, Mezzich, Otero-Ojeda, Mezzich and FabregaBerganza et al, 2001).
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 (Reference Okasha, Mezzich and von CranachOkasha, 1988; Reference Mezzich, Honda and KastrupMezzich 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 (Reference MezzichMezzich, 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 ICD—10 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 ICD—10, such as DSM—IV, the Chinese CCMD—2—R, the Cuban GC—3 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:
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(a) a concise presentation of the international guidelines for diagnostic assessment (this supplement);
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(b) an educational protocol — to organise various educational formats for the presentation of the guidelines to different audiences;
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(c) a support book — to provide literature reviews related to the development of the guidelines to discuss their implications;
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(d) a case book — to present illustratively and heuristically the results of the application of the guidelines to diverse cases from around the world.
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 clinician—patient 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.
AIMS OF THE IGDA
The objectives and contents of the International Guidelines for Diagnostic Assessment are fully consistent with one of the central missions of the World Psychiatric Association, namely to advance scientifically, humanistically and ethically the practice of psychiatry across the world. More specifically, the purpose of the guidelines is to facilitate and structure the conduction of a diagnostic evaluation that is effective for clinical care. This is to be achieved by promoting the clinician's use of both scientific evidence and clinical wisdom, as well as by actively engaging the patient and the family in the process of diagnosis and care. This supplement presents concisely the International Guidelines for Diagnostic Assessment for use by clinicians — young or experienced — across the world. Further information on educational protocols, compiled literature reviews and international patterns on the application of these guidelines will be published in due course.
eLetters
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