From complaints to formulation

Figure ! demonstrates how the information contained in the complaints presented by the patient needs to be sorted out into different conceptual categories so that it can form the basis of actions by the various members of the multidisciplinary team.

The top box represents the complaints. Unpleasant symptoms are likely to head the list, but inability to do everyday activities or a description of problems with relationships may well come first. Symptoms that give a clue to disorders, diagnoses, and possible treatments may not be identified without close questioning by someone who knows what to ask about.

The second box indicates that the complaints need to be sorted out into symptoms and impairments (an impairment in this sense is interference with a normal physiological or psychological function, as explained below). Some complaints are both symptoms and impairments: symptoms because it is known that they can contribute towards the recognition of an underlying diagnosis or towards the identification of a disorder, and impairments because they indicate measurable interference with the function of a part of the body or of a particular organ. For instance, inability to remember the time of the day is a symptom (disorientation in time) that may contribute towards a diagnosis of some kind of dementia. It is also an impairment of cognitive functioning that is likely to interfere with the performance of everyday activities such as getting up and going to bed at the correct time, and organizing housework.

The left-hand side of Fig ! represents the progress towards the identification of a disorder and perhaps even an underlying diagnosis. These are important concepts because they may indicate useful treatments and likely eventual outcomes. The right-hand side shows the progression from impairment of functions of parts of the body or organs, through interference with personal and daily activities (called 'disability' in the terms of the ICIDH-1980, (!9,> to interference with participation in social activities ('handicap' in ICIDH-1980).

A clinical assessment is not complete until all the components of both sides of Fig, 1 have been considered. In doing this, the different components and the two pathways of concepts will need to be given widely varying emphasis for different patients, and also for the same patient at different times. For instance, if there is a physical cause for a disturbance of behaviour, an accurate diagnosis of this will lead to the best possible chance of rapid and successful treatment. In contrast, if a disturbance of social behaviour has its origin in personal relationships or has been imposed upon the patient by the social prejudices of others, the correct diagnostic category is unlikely to add much; assessments of social networks and supportive relationships will be key issues.

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