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DIAGNOSIS, WRITING UP, AND CONCLUSIONS I now discuss how the final diagnosis
is arrived at in reports, as based on the information to hand from the assessment process.
TRANSPARENCY Generally speaking, psychiatrists now write their reports in the knowledge
that sooner or later, they will be seen by the patient if they wish to do so, becauase of the Data Protection Act.
(There is provision under the Act for information to be withheld if it is likely to be "harmful"; however, this seems rarely to be used. My limited experience is that patients can become so agitated to see reports if they are withheld, that they are more likely to suffer "harm" by the withholding, than by seeing the report, warts and all.)
It is therefore vital
to make sure that factual content is correct, that opinion can be substantiated
and that the language is professional and moderate.
Personal comments which do not add to the report can be a source of needless
distress all round, and should therefore be avoided.
PERSPECTIVE is vital. I think it is very helpful if the examiner remains
in clinical practice; practitioners who have retired from the messy but fulfilling
business of seeing real patients for clinical care in the NHS may quickly
lose touch.
As well as technical
skill and qualifications, experience and common sense are very important. MOVING TOWARDS A CONCLUSION Let us consider the position when the psychiatrist has finished gathering
the following information:
- history at interview
- mental state examination, including rating scales if used
- physical examination and investigations
- views of informant (if available)
- medical notes & previous reports
- employment records
- any other information including surveillance
SUMMARY AND OPINION In the light of all the above, the psychiatrist
will then be in a position to summarise the salient features in a few key paragraphs.
The summary may well be the part that the reader of the report will turn to
first, so it should be long enough to include the key features (ìstandaloneî).
But it should not be too long, repeating large sections of the main
body of the report unnecessarily.
SHOW YOUR WORKING Just as in a school maths exercise, it
is necessary not only to give your conclusions, but also to show how you have
arrived at them.
A sound exposition of the arguments leading up to the conclusion will help
the lay reader, even if the matter is obvious to the medical mind.
It helps to show oneís reasoning by referring back to key points by
paragraph numbers, for example: ìI now set out my conclusions, referring
by paragraph numbers thus 1 to show my reasoning.î
Then, having marshalled oneís arguments, one is in a position to proceed
to a diagnosis. As indicated elsewhere, this should be accompanied
by the appropriate numerical code from the DSM or ICD.
HANG ON A MINUTE- IS THERE A DIAGNOSIS AT ALL? Before we
get to the stage of considering possible diagnoses, however, it is important
to remember that not every patient seen will immediately attract a psychiatric
diagnosis. (If they did, there would perhaps be less point in seeking the opinion
of a psychiatrist at all.)
This lack of an immediate diagnosis could be for various reasons:
- Incomplete information: for example, the GP notes are not
to hand. In this case, a provisional report could be issued, but the psychiatrist
will need to ask for full information.
If he expresses an opinion based on partial information, he will need to make
it clear that this is a provisional opinion only.
Inexperienced experts have sometimes been induced to express strong opinions
on the basis of comparatively little information, only to be placed in difficulty when further information
(e.g. video) becomes available...
- Inconsistent information Sometimes, the picture is inconsistent:
it fails to "hang together". An example would be a patient with
prolonged inability to work, reportedly due to "depression"; yet
the clinical assessment is of mild depression only, and difficult to reconcile
with the severe disability presented.
In such cases, it may be wiser for the psychiatrist to refrain from making
a diagnosis at all, and explain his inability to explain the overall picture.
After all, no scientist can explain every observed phenomenon in his field.
- For example, one could say that ìthere were features suggestive of a
depressive illness, but due to certain inconsistencies in the records, a clear
diagnosis cannot be reached at this stage.î Medically speaking, this
may be the reality of the situation, though some lawyers might be dissatisfied
with the lack of a clear ìbottom lineî in such a report.
- The patient had a diagnosable condition, but it got better If
there was apparently a condition which has resolved by the time of the interview,
this should still be recorded in the report in some way, for example ìDiagnosis:
F40 Phobic Anxiety Disorder (formerly). No
current diagnosisî. The dates of onset and resolution should
be given as far as possible, though obviously such a retrospective opinion
cannot be exact.
- Symptoms evident but below threshold for diagnosis. Emotional
distress, for example following an adverse event such as bereavement or relationship
breakdown, is part of the human condition. Self-evidently, most such distress
is not a medical phenomenon, and does not count as a psychiatric diagnosis.
The DSM classification of
mental disorders (see page xxx of the introduction) sets out this diagnostic
threshold: in order to constitute a diagnosis, symptoms should be "not
just an understandable reaction", bearing in mind the person's
culture and circumstances.
This distinction is a daily part of normal clinical practice, though is not
made explicit in the ICD. This reflects the less well-developed nature of this
system as compared with the multiaxial DSM.
Patients who fall into this category sometimes in my experience have been seen
for a previous report by say a GP or orthopaedic surgeon, and have described
some emotional symptoms, or been tearful at this assessment. The initial expert
has not felt competent to assess these, so they have suggested - quite appropriately-
that a psychiatric report should be commissioned.
- The patient never had significant symptoms Occasionally,
patients are referred who seem to have little or nothing in the way of psychiatric
symptomatology.
DIAGNOSING A PSYCHIATRIC CONDITION However, if the patient's account,
and all the other information, is consistent, and the symptoms go beyond an
understandable reaction, then the psychiatrist will go on to give a diagnosis.
The particular mental disorder indicated is diagnosed in fact by a process
of pattern recognition. The
psychiatrist recognises the characteristic patterns of symptoms (complained
of by the patient) and signs (findings of the doctor on examination)
of the disorder in question. These are then compared with the possible diagnoses
available, as described in the ICD or DSM.
ICD10 is available online
in full text; reports should refer to the appropriate section, for example F40
Phobic Anxiety Disorder.
It goes without saying- or should- that the key features of the diagnosis,
as described in the DSM or ICD, must be clearly stated- or the report will
be self-contradictory and vulnerable to adverse criticism.
In other words, it is little use opining that ìthe patient has F45.4
Persistent somatoform pain disorderî if the key features of this condition,
as set out in the ICD, are not spelt out in the report.
DIFFERENTIAL DIAGNOSIS Having indicated the preferred diagnosis,
it is helpful to review other possible diagnoses, and indicate, with reasons,
why they are being rejected in favour of the preferred diagnosis. This process
is sometimes called ìdifferential diagnosis".
This should be very brief if the alternative diagnoses would not change the
report as regards function, causation, treatment or prognosis: in other words,
if it is mainly a question of a slightly different medical label which doesnít
have significant practical implications.
If the alternative to be discussed has major differences in practical effect,
however, for example a difference between a diagnosis on the one hand and no
diagnosis on the other, this should be explored in a level of detail appropriate
to the case.
RANGE OF OPINION There is an obligation on the expert, in
many instructions, to indicate the range of professional opinion on diagnosis
and other matters.
In other words, to indicate what the majority of experts would probably regard
as the likely mainstream opinion of the case, and whether the opinion expressed
is likely to be regarded as within that range. Or, on the other hand, whether
the opinion is probably a minority or even a maverick one.
FUNCTION: DIAGNOSIS ALONE IS NOT ENOUGH Many reports are
good up to the point of diagnosis, but peter out at this point. This is not
sufficient for medicolegal purposes.
The report must continue with a consideration of the effects on function with reasons of any disorder diagnosed.
This should be considered in relation to the patientís personal and
work activities before the accident, broken down into sufficient detail:
CASE EXAMPLE: FUNCTION a travelling salespersonís job might include a number of components:
- Driving
-
Meetings with clients
-
Meetings with manager/ colleagues
-
Using computer
-
Using telephone, etc.
If she has a road traffic accident and develops phobic anxiety related to
driving, then clearly this will impair her ability to do her job overall. However,
only some of the activities involved in doing her job (i.e. driving) are affected.
Being as specific as possible in consideration of function may seem to be
stating the obvious, but does assist in elucidating the medico-legal aspects. FUNCTION: WHO MODEL OF DISABILITY This is an area in which the World Health Organisation has advanced understanding. A personís
- disease or injury (e.g. sprained ankle) may cause
- an impairment, i.e. reduced function (reduced ability to move the leg)
- this may in turn cause a disability, a reduction in the personís mobility
- the reduced mobility may cause a handicap, for example inability to fulfil normal role, e.g. at work
However, the handicap is not predictable from the diagnosis alone.
For example, in the case of a sprained ankle, a person with supportive family and good motivation and resources may still be able to work in a ìwhite collarî job, whereas an isolated person with few resources with exactly the same physical injury may be unable to work in his manual job.
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