Concepts underlying the procedures of assessment The separation of form from content and from effects on activities

In psychiatric practice more than in other medical disciplines, the key items of information that allow the identification of signs and symptoms of psychiatric disorders are often embedded in a mixture of complaints about disturbed personal and social relationships, together with descriptions of problems to do with work, housing, and money. These complaints and problems may be a contributing cause or a result of the symptoms of psychiatric disorders, or they may simply exist in parallel with the symptoms. A preliminary sorting out into overall categories of information is therefore essential.

The distinction between the form and the content of the symptoms is particularly important, together with the differentiation of both of these from their effects upon the functioning of the patient (function is used here in a general sense as applying to all activities, in contrast to the specific meaning given to it in the classification of disablements). This differentiation is discussed in ChapterJ .9, so only a brief mention is needed here.

The presenting complaint of the patient is often the interference with functions, but enquiry about the reasons for this should then reveal the contents of the patient's thoughts and feelings. The form of the symptoms (i.e. the technical term, such as phobia or delusion used to identify a recurring pattern of experience or behaviour known to be important) allows the identification of the psychiatric disorder. Knowledge of the effects on functions is essential for decisions about the management of patient and family, and is an important aspect of the severity of the disorder.

This sorting into different types of information often implies a conflict of priorities during the interview. The clinician must be seen to acknowledge the concerns and distress of the patient, but also must ask questions that will allow the identification of symptoms; and the concept of a symptom (having both form and content) is probably not shared by the patient and family. Learning to balance this conflict of interest is an essential part of clinical training, and has been well recognized by previous generations of descriptive psychiatrists, including Jaspers. (4) The separation of the social effects of a symptom from the symptom itself is also a necessary part of the assessment process. Further comments on this and related issues have been made by Post(5) and, influenced to some extent by a psychodynamic background, by McHugh and Slavney.(6)

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