|Year : 2016 | Volume
| Issue : 3 | Page : 188-195
Values and context in person-centered diagnosis
Juan E Mezzich M.D., Ph.D
Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York; Editor in Chief, International Journal of Person Centered Medicine; Former President, World Psychiatric Association
|Date of Web Publication||3-Nov-2016|
Juan E Mezzich
Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, Fifth Ave and 100th St, Box 1093, New York NY, USA
Source of Support: None, Conflict of Interest: None
A sound and effective approach to psychiatry and medicine should prioritize the whole person. This implies an ethical commitment to the person behind the patient, and attention to the biological, psychological, social, cultural, and spiritual bases of illness and positive health. As part of this comprehensive approach, attention to values and context are required for an adequate diagnostic informational base and optimal planning of care. A model for person-centered and contextualized diagnosis of mental health has been developed under the name of Person-centered Integrative Diagnosis (PID) within the framework of person-centered psychiatry and medicine. It engages recent and evolving methodological approaches, which are addressed to enhancei the reliability and validity of diagnostic systems. Among the cardinal features of the PID model, are the diagnosis of a person’s whole health (both ill and positive health), considering diagnosis as both a formulation and an interactive process among clinicians, patients and families, and the use of categories, dimensions, and narratives as descriptive tools. Its multilevel informational structure encompasses health status, health contributors, and health experience and values. On the above bases, the PID contrasts with conventional diagnostic systems such as the DSM and ICD illness-classification models. Representing an application of the PID model, the GLADP-VR, a Latin American Guide of Psychiatric Diagnosis (using ICD-10 categories and codes of illness) has been recently published by the Latin American Psychiatric Association for the use of health professionals in the region. This paper identifies the thrusts and elements of the PID model, which represent attention to values and context. This includes ethical commitment through concern for the person's dignity, complexity, uniqueness and autonomy, and incorporation of the cross-sectional and historical context as well as the values, expectations, and preferences of the person presenting for care.
Keywords: Contributory factors, disabilities, health experience and values,health status, illness, person-centered integrative diagnosis (PID), person-centered psychiatry and medicine, positive health
|How to cite this article:|
Mezzich JE. Values and context in person-centered diagnosis. Indian J Soc Psychiatry 2016;32:188-95
| Introduction|| |
An ethical and contextualized PID model is inscribed within the framework of Person Centered Medicine and Healthcare. This represents a distinctive departure from the more conventional (and prevalent) disease-centered medical model, a departure that is predicated on both humanistic and scientific grounds.
This paper attempts to:
- Summarize the meaning and scope of Person Centered Psychiatry and Medicine.
- Describe the conceptual and procedural bases and the structure of the PID model developed by the International College of Person Centered Medicine.
- Present the first official guide for person-centered diagnosis (the GLADP-VR: Guía Latinoamericana de Diagnóstico Psiquiátrico - version revised) recently published by the Latin American Psychiatric Association and which implements the PID model.
- Elucidate the manner and places through which the PID model attends to the person's context and values.
Epitomizing deep concern for context, the Spanish philosopher Jose Ortega y Gasset (1914) said: Yo soy yo y mi circunstancia, y si no la salvo a ella no me salvo yo (I am I and my circumstance, and if I do not take care of it, I do not take care of myself). This concern has been also addressed in connection to person centered medicine.
The concept of Person-centered Psychiatry and Medicine
The eastern civilizations, particularly Chinese and Ayurvedic, which are still alive and practiced today as traditional medicine, represent the earliest historical roots for person-centered care. Both of them articulate a comprehensive and harmonious framework of health and life, and promote a highly personalized approach for the treatment of specific diseases and the enhancement of quality of life. In the West, the need for holism in medicine has been strongly advocated by ancient Greek philosophers and physicians. Socrates and Plato taught that “if the whole is not well it is impossible for the part to be well”. This position was enriched by Aristotle, the philosopher and naturalist par excellence and by Hippocrates, who brought theory, emotion and individuality into the practice of medicine, and delineated its ethical and person-centered foundations. Prehispanic American medicine vision was holistic and integrative in context and in beliefs, and was consistent with concepts of medicine and health in the earliest Asian and Hellenic civilizations. Such broad and enlightened concept of health (full well-being and not only the absence of disease) has been incorporated into the World Health Organization’s (WHO-1946) definition of health. This notion has maintained its vitality throughout the vicissitudes of contemporary health care.
Modern medicine has brought a number of important advances in the scientific understanding of diseases and the development of valuable technologies for diagnosis and treatment. At the same time, it has led to a hyperbolic, impersonal and dehumanizing focus on disease, over-specialization of medical disciplines, fragmentation of health services, weakening of the clinician-patient relationship, and commoditization of medicine.
In response, proposals for re-prioritizing psychiatry, general medicine and health care as person-centered are emerging, which cover a wide range of concepts, tasks, technologies and practices that aim to put the whole person in context as a center of clinical practice and public health. Among contemporary antecedents of person centered medicine, particularly prominent is the seminal work of Paul Tournier (1940), who wrote Medicine de la Personne in Switzerland. Also important are the contributions of Carl Rogers’ (1961) person-centered approach in education and counseling, which focused on open communication and empowerment in the United States, I.R. Mc Whinney’s (1989) family medicine movement in the UK and Canada, and Irjo Alanen’s (1997) need-adaptive assessment and treatment approach in Finland.
The World Psychiatric Association, which was born from the articulation of science and humanism, established at its 2005 General Assembly an Institutional Program on Psychiatry for the Person., This initiative expanded into general medicine through a series of Geneva Conferences since 2008 in collaboration with the World Medical Association, the World Health Organization, the International Council of Nurses, the International Federation of Social Workers, the International Pharmaceutical Federation, the European Federation of Families of Persons with Mental Illness, and the International Alliance of Patients’ Organizations, among a growing number of other international health institutions. The process and impact of the Geneva conferences led to the emergence of the International Network (now International College) of Person Centered Medicine (INPCM, ICPCM).,
The ICPCM launched in 2011 the International Journal of Person Centered Medicine in collaboration with the University of Buckingham Press. It is promoting research and scholarship on person centered medicine across the world. Since 2012, the impact of the Geneva Conferences has been extended through Geneva Declarations, which includes Person Centered Care for Chronic Diseases, Person Centered Health Research,, Person- and People-centered Integrated Health Care for All,, Person-centered Primary Health Care,, and Person-centered Care through the Life Course.,
To touch base with the field in different areas of the world, a series of annual International Congresses of Person Centered Medicine was initiated in Zagreb, Buenos Aires and London, in November 2013. As in the case of the Geneva Conferences, a Zagreb Declaration on Person Centered Health Professional Education and an accompanying academic paper have been published, as well as a Buenos Aires Declaration on Latin American Perspectives and Person Centered Medicine,, and a London Declaration on Primary Care and Public Health.,
A Model for Person-centered Integrative and Contextualized Diagnosis
Addressing the nature of diagnosis, the eminent historian and philosopher of medicine Lain Entralgo (1982) cogently argued that diagnosis goes beyond identifying a disease (nosological diagnosis), which also involves understanding of what is going on in the body and mind of the person who presents for care. Understanding an individual’s clinical condition also requires a broader assessment of experience and life context. As health may be conceived as a person’s capacity to continue to pursue his or her goals in an ever-challenging world, this encompassing perspective should be incorporated in a thorough diagnosis of health. There are compelling reasons for including health-promoting or salutogenic factors and positive health under comprehensive diagnosis,, bringing it to consistency with WHO’s definition of health. Diagnostic understanding also requires a process of engagement and empowerment that recognizes the agency of patient, family and health professionals participating in a trialogical partnership.
In connection with the above, one should examine the concept of the validity of diagnosis as it denotes its value and usefulness. Traditionally, this validity has been anchored on the faithfulness and accuracy with which a diagnosis reflects and identifies a disorder, its nature, pathophysiology, and other biomedical indicators. Recently, clinical utility has been proposed as an additional indication of the value of diagnosis for clinical care. Schaffner (2009) has delineated further the epistemology of these two forms of diagnostic validity under the terms of etiopathogenic and clinical validities. Pointing out the significance of the latter, experienced clinicians suggest that treatment planning is the most important purpose of diagnosis.
Concerning the architecture of diagnostic formulations, there has been a progressive development of diagnostic schemas with increasing levels of informational richness, particularly, to support treatment planning. These have ranged from a simple, typological single-label diagnosis denoting a symptom, problem, syndrome, or illness to a more complex multiple illness formulation, listing all identified clinical conditions or disorders, including coexisting psychiatric and general medical diseases. Such schemas intend to provide a fuller portrayal of the nosological condition, as well as other aspects of clinical interest such as disabilities, contextual factors, and quality of life, thus attempting to enhance diagnostic understanding, treatment planning and prognostic determination.Multiaxial diagnostic formulations are key components of most recent diagnostic systems including International Classification of Diseases-10th revision,, Diagnostic and Statistical Manual-IVth revision, GuíaLatinoamericana de DiagnósticoPsiquiátrico (GLADP), third Cuban Glossary ofPsychiatry(GC-3) by the Cuban Psychiatric Diagnostic Manual, the French Classification for Child and Adolescent Mental Disorders, and the Chinese Classification of Mental Disorders. Of note, a multiaxial schema was not included in DSM-5, despite that a broad APA Committee was established to evaluate DSM multiaxial systems to document their usefulness.
Another approach to comprehensive diagnosis involves both standardized and idiographic components. One such model is at the core of the International Guidelines for Diagnostic Assessment (IGDA), developed by the World Psychiatric Association. Its standardized multiaxial component includes four axes dealing respectively with clinical disorders, disabilities, contextual factors, and quality of life. Its idiographic and narrative component covers the clinician perspective, perspectives of the patient and family, and integration of the perspectives of all the above. Many of the methodological developments highlighted above have been discussed in a WPA Psychiatry for the Person volume.
Development of the Person-centered Integrative Diagnosis model
Person-centered Integrative Diagnosis (PID), as developed under the auspices of the International College of Person Centered Medicine, is inscribed within a paradigmatic effort to place the whole person at the center of medicine and health care., The PID model articulates science and humanism to obtain a diagnosis of the person (of the totality of the person’s health, both its ill and positive aspects), by the person (with clinicians extending themselves as full human beings, scientifically competent and with high ethical aspirations), for the person (assisting the fulfillment of the person’s health aspirations and life project), and with the person (in respectful and empowering relationship with the person who presents for evaluation and care). This notion of diagnosis goes beyond the more restricted concepts of nosological and differential diagnoses. The development of this diagnostic model was informed by the methodological considerations summarized in the preceding section.
The suitability of the prospective elements of person-centered integrative diagnosis wasexamined through surveys and consultations. Building on its long experience in developing diagnostic models, the World Psychiatric Association (WPA) Section on Classification, Diagnostic Assessment, and Nomenclature conducted a survey among the members of the 43-country Global Network of National Classification and Diagnosis Groups. The survey was constructed in consultation with network members, and aimed at surveying the most important domains to consider in the development of future diagnostic classification for psychiatric disorders. 74 % of the groups responded. Treatment planning, communication among clinicians, and diagnosis as a means to enhance illness understanding were identified as key roles of diagnosis. The survey also highlighted the areas of information judged important to be covered by psychiatric diagnosis. These included disorders (100%), disabilities (74%), risk factors (61%), experience of illness (58%), protective factors (55%), and experience of health (52%). The responses suggested that in addition to the recognized importance of nosological diagnosis, subjective explanatory narratives of illness, and health are also quite valuable. The survey responses also highlighted the importance of utilizing a variety of descriptive tools including categories (81%), dimensions (74%), and narratives (45%). It also revealed that 80% of responders choose clinicians, patients, and carers together as key players in the diagnostic evaluation process as compared to clinicians alone (20%).
A number of focus and discussion groups were organized in 2009 with a variety of health stakeholders (health professionals, patients, family members, and advocates) at international events in Athens (Greece), Uppsala (Sweden), and Timisoara (Romania). In an overwhelming manner, the participants in the three settings considered that diagnosis should go beyond disease. The participants unanimously responded that diagnosis should cover dysfunctions, and a great majority of them felt it is very important to include positive aspects of health. Over 83% of the participants endorsed the inclusion of experience of health as part of diagnosis. Furthermore, there was unanimous agreement on incorporating contributing factors (including risk and protective factors), and on the use of descriptive methods, including dimensions and narratives in addition to conventional categories. The participants also emphasized that diagnosis is a process and not only a formulation, and highlighted the partnership between caregivers and service users as fundamental.
Structure of the Person-centered Integrative Diagnosis model
The delineation of the structure of the PID must take into account that diagnosis is both a formulation and a process. The presentation of the fundamental elements of the model is made here in terms of the following three defining conceptual pillars: a) Broad Informational Domains, b) Pluralistic Descriptive Procedures, and c) Partnership for Diagnostic Evaluation.
The PID framework’s first pillar Broad Informational Domains, is depicted in [Figure 1]. These domains cover both ill health and positive health along three structural levels: Health Status, Experience of Health, and Contributors to Health.
|Figure 1: Key structural levels covering ill health and positive health in the Person-centered Integrative Diagnosis Model|
Click here to view
The broadness of the PID informational domains, including ill and positive health, is intrinsic to holistic person-centered health care. The domain level on Health Status, includes first illnesses or disorders of both mental and physical forms, which correspond to Laín-Entralgo’s (1982)nosological diagnosis. They may be assessed according to the international standard, WHO’s International Classification of Diseases or a pertinent national or regional version or adaptation. Disabilities would be assessed through procedures such as those based on the International Classification of Functioning and Health (ICF). The assessment of the wellbeing aspect of Health Status could be conducted through standard scales such as the WHOQOL Instrument.
The domain level on Experience of Health would appraise the patient’s illness- and health-related values and cultural experiences, possibly with a guided narrative procedure built on world-wide experience with the Cultural Formulation. The third domain level on Contributors to Health would cover a range of intrinsic and extrinsic biological, psychological, and social factors of both risk and protective types. Their assessment may involve a combination of procedures aimed at assessing healthy and unhealthy life-style factors and related health contributors.
The PID model’s second defining pillar, Pluralistic Descriptive Procedures opens up the opportunity to employ categories, dimensions, and narratives for greater flexibility and effectiveness for the evaluation task at hand., The third defining pillar of the PID model is Partnership for Evaluation Such partnership is a fundamental element of person-centered care, and involves the pursuit of engagement, empathy, and empowerment as well as respect for the autonomy and dignity of the consulting person. In fact, it is crucial for achieving shared understanding for diagnosis and shared decision making for treatment planning. Additional information on the elements of the PID model can be found in Mezzich et al (2010).
PID Applications and the Latin American Guide of Psychiatric Diagnosis
An application of the PID model is at the core of the Latin American Guide of Psychiatric Diagnosis, Revised Version (GLADP-VR) [Figure 2]. This Guide represents a revised version of the original GLADP edition. The GLADP-VR incorporates the basic elements of the PID model. The main difference between the PID model and the GLADP-VR schema is that the former has Health Experience as the second informational domain level while the latter has Health Experience as the third level. Furthermore, the GLADP-VR third level is enriched in its content with health values and expectations.
|Figure 2: Cover of the Latin American Guide of Psychiatric Diagnosis, Revised Version (GLADP-VR)|
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The key information domains or levels of the GLADP-VR diagnostic schema are summarized below.
The first component of this model corresponds to Health Status. This includes standardized coverage of both pathological and positive aspects of health. As shown on the GLADP-VR Personalized Diagnostic Formulation, The Health Status component starts with a listing of mental and general medical disorders and other significant clinical conditions. These disorders and conditions are to be coded according to the various chapters of ICD-10, in addition to standard disease codes, the Z codes for non-disease conditions that require clinical attention.
Next in the Health Status component comes the evaluation of Personal Functioning in the areas of personal care, occupational, family, and social activities, each measured with a 10-point scale marked as follows: 0: worst functioning, 2: minimal functioning, 4: marginal functioning, 6: acceptable functioning, 8: substantial functioning, and 10: optimal functioning.
Finally, the Health Status component assesses degree of the person’s well-being, from worst to excellent, by directly marking on the 10-point line displayed on the Formulation Form, with or without the help of an appropriate standardized instrument. This assessment is principally based on the judgment of the person involved, modulated collaboratively with perceptions by the clinicians and family.
Health Contributing Factors
The second component of the GLADP-VR Personalized Diagnostic Formulation corresponds to Health Contributing Factors. These include Risk Factors as well as Protective and Health Promotion Factors. The assessment in each case starts with the identification of relevant factors from the list presented on the form. These factors come from the Health Improvement Card prepared by the World Health Professions Alliance, supplemented by some factors particularly relevant to mental health. It continues with a narrative formulation of additional information about the identified factors and others that could also be elicited.
Health Experiences and Expectations
The third component of the GLADP-VR Personalized Diagnostic Formulation assesses Experience and Expectations on Health. This is based on the combination of elements from the experientially described Cultural Formulation and of patient's needs and preferences. This assessment is obtained through narratives on the following three points:
- Personal and cultural identity (self-awareness and its potentials and limitations),
- Suffering (its recognition, idioms of distress, and beliefs on illness),
- Experiences with and expectations for health care.,
GLADP-VR Diagnostic Formulation Form
A form [Figure 3] has been developed to facilitate the implementation of the GLADP-VR diagnostic formulation. The form offers greater detail on the content and structure of the procedure for this formulation. It includes categorical, dimensional, and narrative elements corresponding to the diagnostic formulation’s three levels: Health Status, Health Contributors, and Health Experience and Expectations. This formulation has resulted from interviews among clinicians, patient and family. The formulation intends to represent their joint understanding of the clinical situation.
|Figure 3: GLADP-VR Person-centered Integrative Diagnosis Formulation Form|
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Other PID Applications
A full Second Edition of the (GLADP-2) is in the works as a priority project of the Diagnosis and Classification Section of the Latin American Psychiatric Association (APAL). For covering mental and general medical disorders, it would be based on the categories and codes of the prospective Eleventh Revision of the International Classification of Diseases (ICD-11), which is expected to be completed around 2017. Its development would be based on the ongoing experience implementing, teaching and evaluating the GLADP-VR.
There are also plans to develop under the auspices of the International College of Person Centered Medicine a PID practical guide intended for use in general medicine.
Presence of Values and Context in Person-centered Diagnosis
In contrast to disease-centered diagnostic systems such as the American Psychiatric Association's (2013), Diagnostic and Statistical Manual, Fifth Edition (DSM-5) and the World Health Organization's(1992), and International Classification of Diseases, Tenth Revision (ICD-10), the PID represents a model for the diagnosis of health (both illness and positive health) aimed at not just identifying diseases present, but also at establishing an informational base for optimal clinical care. This shifts the concept of diagnostic validity from conventional physio-pathology (faithfulness in identifying diseases) to clinical validity (usefulness and helpfulness for planning and conducting care), as articulated by Schaffner (2009) in philosophy of science terms.
Along these lines, the PID represents an ethical commitment in terms of concern for the person's dignity, complexity, uniqueness, and autonomy. This is expressed by the thrust of person-centered medicine and its diagnostic model to address and assess all what is relevant for clinical care, including health status (from illness to disabilities to positive health), contributing factors (risk and protective factors), and health experience and values. And to carry this endeavor with the purpose of ameliorating illness and promoting health and in a manner that is collaborative, empowering and respectful with the presenting patient and family.
More specifically, one can identify various points in the person-centered diagnostic formulation as illustrated in the GLADP-VR form [Figure 3], which ensures that a number of points relevant to the whole person's health, context and values are organized as integral parts of the diagnostic process, and not only as accessory or optional considerations as it usually happens in conventional diagnostic systems. The following are some of these specific points where context and values are addressed in the GLADP-VR formulation:
- Under Health Status, functioning and positive health are pointedly considered. Quality of life is primarily assessed through the patient's self-perception and rating.
- Under Health Contributors, both risk and protective factors (internal and external, biological, psychological and social) are considered.
- Under Health Experience and Values, narrative summaries on personal and cultural identity, suffering (its recognition, idioms of distress, illness beliefs), experiences, and expectations on health care are included.
Furthermore, the procedure for engaging clinicians, patient, and family in the diagnostic process would serve to establish a common ground for joint diagnostic understanding and shared decision-making., This illustrates the usefulness of person-centered diagnosis for articulating science and humanism for optimizing clinical care.
| Conclusions|| |
Person centered psychiatry, medicine, and healthcare represents an emerging approach to refocus the health field from disease to the whole person with strong ethical and clinical effectiveness bases, which is supported by major global institutions in clinical care and public health. The articulation of science and humanism is illustrated by the incorporation in person-centered diagnosis of modern diagnostic methods, cross-sectional and historical contextualization, and attention to the values, expectations and preferences of the patient presenting for care.
| Acknowledgement|| |
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
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