Diagnosis and Formulation
Diagnostic manuals serve to enhance both inter-rater reliability and communication between clinicians. However, they are not to be used in place of clinical judgment and are not ‘the Bibles of psychiatrists’ as is sometimes suggested by non-clinicians. Indeed, the DSM-IV itself cautions that it should not be used ‘as a cook book’, reflecting concern that, because of its ‘criteria checklist’ approach, it is at risk of this, particularly in a legal context where its form lends itself to lay analysis and unpicking. Hence it is crucial that the legal process does not drag doctors into apparent over-reliance on the classification systems at the expense of clinical judgment. Tat said, if a diagnosis is made, despite insufficient criteria being satisfied in strict DSM terms, or in the more descriptive terms of ICD, then it should still be expressed in terms of one of those classificatory systems, being explicit about which system is being used.
Validity and classification
Te validity of diagnosis in different cultures is mitigated to some extent by the international consensus methods used in agreeing criteria in ICD-10. Tere may, however, be issues relating to the validity of specific instruments (if used) in different cultures. If instruments are translated then the content should be relevant to that culture. Similarly the words, if translated, should have the same meaning. If tools are used that require self-rating based on reading then rates of literacy in different cultures should be borne in mind. Tere is also a need to consider whether a tool will be interpreted similarly in different languages and cultures, and whether it measures the same construct (see also Chapter 5 on psychological testing).
Most clinicians do not have a diagnostic manual in front of them when considering the diagnosis of a patient they have assessed. Tey use their clinical experience and interviewing skills in order to establish the nature, duration and severity of symptoms and make the diagnosis based upon this. Some structured interviewing tools exist for making diagnoses that are predominantly research tools, but they are sometimes used in clinical and medico-legal settings (e.g. SCAN or SCID-II). Training is required if these tools are to be used. Tis also means that doctors should not comment upon the tools applied and interpreted by other experts, unless they have been trained to administer those instruments themselves.
Te following is a summary of some significant difference between classification systems:
ICD-10 (Chapter V) Classification system
Designed for collection of data and includes diagnoses of questionable validity
Diagnosis almost exclusively based on symptoms
Schizotypal disorder described with schizophrenia
Symptoms of schizophrenia must be present for one month
No specific criteria for narcissistic personality disorder
DSM-IV Diagnostic nomenclature
Only contains categories with diagnostic validity
Almost all diagnoses include an impairment in functioning criterion
Schizotypal disorder described with personality disorders
Symptoms of schizophrenia must be present for six months
Specific criteria for narcissistic personality disorder
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