Academic journal article Indian Journal of Psychiatry

Psychiatric Assessment and the Art and Science of Clinical Medicine

Academic journal article Indian Journal of Psychiatry

Psychiatric Assessment and the Art and Science of Clinical Medicine

Article excerpt

Byline: K. Jacob

The decline of phenomenology was associated with the corresponding rise of operational criteria for psychiatric diagnosis. Detailed and nuanced evaluations were replaced by symptom checklists, the diversity of clinical phenomena reduced to a few "typical symptom" and contexts ignored in favor of symptom criteria. This article highlights some issues related to the art and the science of clinical examination. It includes conceptual models, matching patients with typical typologies, cross-sectional and longitudinal perspectives, symptom checklists and contexts, population characteristics, prevalence and predictive values, demarcation of abnormalities, and the Bayesian approach to diagnosis. The challenge is to rekindle the interest in phenomenology, appreciate the complexity of the task of psychiatric assessment and to teach the principles of clinical examination.

Introduction

The death of phenomenology has been mourned in literature. [sup][1],[2] The decline of phenomenology was associated with the corresponding rise of operational criteria for diagnosis (e.g. Feighner's criteria and Research Diagnostic Criteria), [sup][3],[4] which culminated in the publication and use of the Diagnostic and Statistical Manual III [sup][5] and its later editions III R and IV [sup][6],[7] and the International Classification of Disease-10. [sup][8] The goals for the DSM III project, which represented the then current best efforts included: improving communication between clinicians, increasing the reliability of diagnosis, enhancing training in clinical interviewing and making the system more compatible with international approaches. Unfortunately, the DSM categories became definitive truths, reified and formed the basis of many training programs and health care delivery. The approach substituted authority for enquiry and simplification for subtlety. [sup][1],[2] Detailed and nuanced evaluations were replaced by symptom checklists, the diversity of clinical phenomena reduced to a few "typical symptom" and contexts ignored in favor of symptom criteria. This article discusses some issues related to the art and the science of clinical examination in psychiatry.

Conceptual Models

Diverse theoretical models have been employed to conceptualize psychiatric disorders. [sup][9] The medical model views psychiatric disorders as diseases, supposes a central nervous system etiology and pathogenesis, documents signs and symptom, offers differential diagnoses, recommends somatic therapies and prognosticates about the course and outcome. Psychological, dynamic and analytical models focus on developmental stage and conflicts, emphasize distorted childhood relations, and highlight vulnerability to stress. Cognitive behavioral approaches concentrate on learning, identify maladaptive patterns and reinforcers and recommend retraining. Social models highlight the complex interaction with social systems. The failure of unitary theories and individual models to explain all psychiatric disorders suggests that they are part perceptions and argue for the use of the different conceptual models commonly employed in psychiatry. These models need to be employed simultaneously and in sequence and are complementary and not competitive. While the biopsychosocial model is often recommended, the individual components are difficult to assimilate and hence demand a conscious effort at integration.

The choice of model(s) has a powerful impact on diagnosis and on treatment and are dependent on many factors including: the ideology of the clinician, the availability of expertise, the clinical presentation, the severity of condition and risk, the immediacy of social situation and the social class of the patient. While it was argued that the use of symptom for diagnosis in the DSM operational criteria suggest an atheoretical approach, these strategies are essentially biomedical and fail to recognize the context. …

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