8.1
The diagnostic process involves more than simply identifying a disorder or distinguishing one disorder from another. It should lead to a thorough, contextualised and interactive understanding of a clinical condition and of the wholeness of the person who presents for evaluation and care.
8.2
This comprehensive concept of diagnosis is implemented through the articulation of two diagnostic levels. The first is a standardised multi-axial diagnostic formulation, which describes the patient's illness and clinical condition through standardised typologies and scales (see IGDA Workgroup, WPA, 2003, this suppl.). The second is an idiographic diagnostic formulation, which complements the standardised formulation with a personalised and flexible statement.
8.3
The preparation of the idiographic formulation starts with the recognition of the perspectives of the clinician, the patient and (whenever appropriate) the family, on what is unique, important and meaningful about the patient. The formulation sets out these perspectives and identifies any discrepancies, permitting their resolution and integration into a shared understanding of the case at hand.
8.4
The clinician's perspectives should represent a synthesising and integrative effort to identify the essential features of the 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 that are relevant to that condition.
8.5
The perspectives of the patient and the family should cover their understanding of the clinical condition and its contributory factors, the patient's self-image, assets and strengths, and sense of what is meaningful in life, as well as their expectations for the clinical care process. This information should be elicited through questions placed strategically throughout the clinical interview, such as: What problem brought you here? How do you explain what has happened to you? What is important for you in life? What do you expect from clinical care? The most important factor in eliciting the patient's and family's perspectives is the ability to listen well. Learning to listen requires didactic instruction, practice and feedback, as well as a knowledge of the patient's cultural background.
8.6
Integration of clinician and patient perspectives, essential for a therapeutic alliance, should be based on empathetic rapport, reflecting mutual respect and interest, and human feeling between the clinician and the patient. These two people (with the collaboration of the family as needed) should attempt to reach a joint understanding, to the maximum extent possible, of the clinical problems and their contextualisation, the patient's positive factors, and expectations about restoration and promotion of health. Each of these elements is outlined below. Finally, clinician, patient and family should jointly monitor the progress of care and its outcome, and agree on any adjustments to be made.
8.7
The first element of the idiographic formulation is the identification of clinical problems and their contextualisation. These include disorders, symptoms and problems (based on the standardised multi-axial formulation) described in language shared by the clinician, the patient and the family, as well as key complementary information and the elucidation of pertinent mechanisms and contributory factors, from biological, psychological, social and cultural perspectives. Important disagreements should be noted and their resolution addressed.
8.8
The second element of the idiographic formulation is the description of the patient's positive factors. These are factors pertinent to the treatment of the clinical condition and to health promotion, such as maturity of personality, skills, talents, social resources and supports, and personal and spiritual aspirations.
8.9
The third element of the idiographic formulation outlines expectations about the restoration and promotion of health. These include specific expectations about the types of treatments and their results, as well as aspirations about health status and quality of life in the foreseeable future.
8.10
The idiographic formulation should be presented in natural or colloquial language to maximise the flexibility of its presentation. The length of a written idiographic formulation could be about a page (Fig. 8.1), and that of an oral presentation about 5 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 purposes and format of clinical care, and other circumstances.
Fig. 8.1 Blank form for recording the chosen treatment plan. This form may be photocopied free of charge for use in clinical practice.
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