Values and comprehensive diagnosis.

Abstract

As recognized, but not discussed, by Fulford et al in their paper, there is consonance between attention to values in clinical diagnosis and care and what may be termed the comprehensive diagnostic model. The undeniable importance of values for a science and practice of psychiatry, which Fulford et al are compellingly articulating, is relevant to both the structure and the purposes of comprehensive diagnosis in psychiatry as well as in medicine at large. The emerging comprehensive diagnostic model (1,2) aims at understanding and formulating what is important in the mind, the body and the context of the person who presents for care. This is attempted by addressing the various aspects of ill- and positive- health, by interactively engaging clinicians, patient and family, and by employing categorical, dimensional and narrative descriptive approaches in multilevel schemas. Illustrations of such a comprehensive diagnostic model are at the core of the International Guidelines for Diagnostic Assessment (IGDA) produced by the WPA (3) and the Latin American Guide for Psychiatric Diagnosis (GLADP) produced by the Latin American Psychiatric Association (4). Fulford et al's discussion of values in psychiatric diagnosis focuses on their relevance to classification of mental disorders, which corresponds to Axis I of the ICD-10 mental disorders chapter (5) and Axes I and II of DSM-IV (6). It can be pointed out that values are at least equally relevant to the axes in the above diagnostic systems involving functioning/disabilities and contextual factors (psychosocial environmental and personal problems). Issues of meaning, contextualization, and interpretability are quite germane to these axes. Values are also of substantial importance in the case of Axis IV (quality of life) in IGDA (3) and GLADP (4). It is widely accepted that the assessment of quality of life should be principally based on the own perspectives of the patient or subject of evaluation. The full range of contents involved, from physical well-being to spiritual fulfillment, are to be addressed in such an axis in a personally- and culturallyinformed manner. Attending with such centrality to the person's perspectives attests to and reflects the importance of values for the scientific assessment of a topic increasingly relevant to understanding health and planning health care. The above considerations on values and the assessment of health speak additionally to the ethical exigencies of diagnosis and care (7). The fundamental purposes of comprehensive diagnosis are treatment and health promotion focused on the needs and goals of the patient or consulting person.

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