Fig. 13.1 Broad informational domains or levels covering ill health and positive health in the Person-centered Integrative Diagnosis model
Person-centered integrative diagnosis: Bases, models, and guides
Juan E. Mezzich and Ihsan M. Salloum
The international and institutional development of person-centered psychiatry and medicine has made compelling the development of a diagnostic approach relevant to this new perspective in medicine and health. And the methodological unfolding of diagnostic schemas over recent decades provides some of the tools for the conceptualization and design of a suitable diagnostic approach for person-centered medicine. The next sections briefly describe the bases for a person-centered integrative diagnostic model and the subsequent practical guides that are emerging.
Highlighted here as major bases for Person-centered Integrative Diagnosis is the development of person-centered medicine and new comprehensive diagnostic methodology.
The first bases preceding and supporting the development of Person-centered Integrative Diagnosis are the coalescing initiatives for person-centered medicine and health. Historical roots for person-centered care can be found in major Eastern civilizations, particularly Chinese and Ayurvedic, which are still alive and practiced today as traditional medicine. 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 (Patwardhan et al. 2005). 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” (Christodoulou 1987). This position was enriched by Aristotle, the philosopher and naturalist par excellence (Ierodiakonou 2011), and by Hippocrates, who brought theory, emotion, and individuality into the practice of medicine and delineated its ethical and person-centered foundations (Jouanna 1999).
Such broad and enlightened concept of health (full well-being and not only the absence of disease) has been incorporated into WHO’s (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 doctor–patient relationship, and commoditization of medicine (Heath 2005).
In response, proposals for re-prioritizing medicine 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. The World Psychiatric Association, which was born from the articulation of science and humanism (Garrabe and Hoff 2011), established at its 2005 General Assembly an Institutional Program on Psychiatry for the Person (Mezzich 2007; Christodoulou et al. 2008).
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 (Mezzich 2011a). The process and impact of the Geneva Conferences led to the emergence of the International Network (recently renamed College) of Person-centered Medicine (INPCM, ICPCM) (Mezzich, Snaedal, et al. 2009; Mezzich 2011b). The ICPCM launched the International Journal of Person-Centered Medicine in collaboration with the University of Buckingham Press (Miles and Mezzich 2011). It is promoting research and scholarship on person-centered medicine across the world.
The unfolding of the core concept of person-centered medicine is taking several forms. One is that it represents a medicine of the person (of the totality of the person’s health), for the person (aimed at promoting the person’s total health and well-being and facilitating the fulfillment of his/her life project), by the person (with health professionals extending themselves as full persons professionally competent and with high ethical aspirations), and with the person (collaborating respectfully and in an empowering manner with all persons involved) (Mezzich, Snaedal, et al. 2010). Another form, through a broad international consultation project aimed at elucidating the key concepts underlying person-centered medicine, encompasses ethical commitment, holistic scope, cultural sensitivity, relationship focus, individualized treatment, common ground for diagnosis and care, people-centered systems of care, and person-centered health education and research (Mezzich et al. 2013).
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) to also involve understanding of what is going in the body and mind of the person who presents for care. Understanding an individual’s clinical condition also requires a broader assessment of his/her 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 (Canguilhem 1991), this encompassing perspective must incorporate a thorough diagnosis of health. There are indeed compelling reasons, in consistency with WHO’s definition of health, for including health-promoting or salutogenic factors (Antonovsky 1987) and positive health (Mezzich 2005) under comprehensive diagnosis. 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 (Amering 2010).
In connection with the more encompassing model, 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 (Robins and Guze 1978). Recently, clinical utility has been proposed as an additional indication of the value of diagnosis for clinical care (Kendell and Jablensky 2003). Schaffner (2009) has delineated further the epistemology of these two forms of diagnostic validity under the terms of etiopathogenic and clinical validities. Emphasizing the significance of the latter, experienced clinicians have suggested that treatment planning is the most important purpose of diagnosis (Adams and Grieder 2005).
Concerning the architecture of diagnostic formulations, there has been a progressive development of diagnostic schemas with increasing levels of informational richness to support treatment planning. These schemas 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 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 (Banzato et al. 2009). Multiaxial diagnostic formulations are key components of most recent diagnostic systems including ICD-10 (World Health Organization 1996, 1997), DSM-IV (American Psychiatric Association 1994), GLADP (APAL 2004), GC-3 (Otero 1998), the French Classification for Child and Adolescent Mental Disorders (Mises et al. 2002), and the Chinese Classification of Mental Disorders (Chinese Society of Psychiatry 2001). Of note, a multiaxial schema was not included in DSM-5 (American Psychiatric Association 2013), despite that an APA Committee established to evaluate DSM multiaxial systems documented their usefulness (Mezzich et al. 2005).
Another approach to comprehensive diagnosis is that composed of 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 (Mezzich et al. 2003). 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 here have been discussed in a WPA Psychiatry for the Person volume (Salloum and Mezzich 2009).
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 (Mezzich, Snaedal, et al. 2009; Mezzich 2011b). The PID model integrates science and humanism to obtain, as previously mentioned with regard to person-centered medicine in general, a diagnosis of the person (of the totality of the person’s health, both its ill and positive aspects), by the person, for the person, and with the person (Mezzich et al. 2010). This diagnostic perspective goes beyond the restricted concepts of nosological and differential diagnoses on which conventional diagnostic systems are based—such as the WHO’s International Classification of Disease and the American Psychiatric Association’s Diagnostic and Statistical Manuals. The development of the PID diagnostic model was informed by the methodological considerations summarized in the preceding section.
The suitability of the prospective elements of PID were examined 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 (Salloum and Mezzich 2011). The survey was constructed in consultation with network members and aimed to identify the most important domains to consider in the development of future diagnostic classification for psychiatric disorders; 74 percent of the groups responded. Treatment planning was most frequently chosen as the key purpose of diagnosis. Communication among clinicians and diagnosis as a means to enhance illness understanding were also identified as key. The survey highlighted the areas of information judged important to be covered by psychiatric diagnosis. These included disorders (100 percent), disabilities (74 percent), risk factors (61 percent), experience of illness (58 percent), protective factors (55 percent), and experience of health (52 percent). 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 percent), dimensions (74 percent), and narratives (45 percent). It also revealed that 80 percent of responders preferred that clinicians, patients, and caregivers work together as key players in the diagnostic evaluation process as compared to clinicians working alone (20 percent).
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) (Salloum and Mezzich 2011). In an overwhelming manner, the participants in the three settings indicated that diagnosis should go beyond disease. Participants unanimously responded that diagnosis should cover dysfunctions and a great majority of them (over 83 percent) believed that it is very important to include positive aspects of health. 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 diagnostic categories. Participants also emphasized that diagnosis is a process and not only a formulation, and highlighted the partnership between caregivers and service users as fundamental.
The delineation of the structure of the Person-centered Integrative Diagnosis model (PID) must take into account that diagnosis is both a formulation and a process. The presentation of the fundamental elements of the model include the following three defining conceptual pillars: a) Broad Informational Domains, b) Pluralistic Descriptive Procedures, and c) Partnership for Evaluation.
The PID framework’s first pillar, Broad Informational Domains or Levels, is depicted in Figure 13.1. These domains cover both ill health and positive health along three structural levels: Health Status, Experience of Health, and Contributors to Health.
Fig. 13.1 Broad informational domains or levels covering ill health and positive health in the Person-centered Integrative Diagnosis model
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 would 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) (World Health Organization 2001). The assessment of the well-being aspect of Health Status could be conducted through standard scales such as the WHO QOL Instrument (WHO QOL Group 1994).
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 worldwide experience with the Cultural Formulation (Mezzich, Caracci, et al. 2009). 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 lifestyle factors and related health contributors (Seyer 2012).
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 (Jablensky 2005; Kirmayer 2000). 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 (Adams and Grieder 2005). Additional information on the elements of the PID model can be found in Mezzich, Salloum, et al. (2009).
The diagnostic model prepared and published by the Latin American Psychiatric Association (2012) at the core of the Latin American Guide of Psychiatric Diagnosis, Revised Version (GLADP-VR) (Asociación Psiquiátrica de América Latina 2012) (see Figure 13.2) was built starting with the original GLADP (Guia Latinoamericana de Diagnostico Psiquiatrico) (Asociación Psiquiátrica de América Latina 2004) and largely incorporated the basic elements of the PID. 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 (enriched with health values and expectations) as the third level. Another major difference is of course that while the PID is a theoretical model, the GLADP-VR is a practical guide.
Fig. 13.2 Cover of the Latin American Guide of Psychiatric Diagnosis, Revised Version (GLADP-VR). © Asociación Psiquiátrica de América Latina (APAL).
The key information domains or levels of the GLADP-VR diagnostic schema are now summarized.
The first component of this model corresponds to Health Status. This includes standardized coverage of pathological and positive aspects of health. Utilizing a Personalized Diagnostic Formulation, this 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, including, in addition to standard disease codes, the Z codes for non-disease conditions that require clinical attention.
Next 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 the degree of the person’s well-being, from worst to excellent, by directly marking on the 10-point line displayed on the form or with 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.
The second component of the Personalized Diagnostic Formulation corresponds to Health Contributing Factors. These include Risk Factors as well as Protective and Health Promotion Factors. 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 (Seyer 2012), 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.
The third component of the GLADP-VR Personalized Diagnostic Formulation assesses Experience and Expectations on Health. This is based on the combination of elements of the experientially described Cultural Formulation (Mezzich, Caracci, et al. 2009) and of the patient’s needs and preferences (Fulford et al. 2011). This assessment is obtained through the narrative presentation of the following three points: a) Personal and cultural identity (self-awareness and its potentials and limitations); b) Suffering (its recognition, idioms of distress, and beliefs on illness); and c) Experiences with and expectations for health care (Mezzich 2012).
A renewed Second Edition of the Latin American Guide for Psychiatric Diagnosis (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 2015. Its development would be based on the ongoing experience of implementing, teaching, and studying the GLADP-VR.
There are also plans to develop under the auspices of the International College of Person-Centered Medicine PID practical guides intended for use in general medicine (including psychiatry).
Within the framework of a paradigmatic initiative for person-centered medicine, building on modern diagnostic methodology developments, and expanding the concept of diagnostic validity, a model for PID has been developed. It addresses the diagnosis of a person’s total health through three informational levels (health status, health contributors, and health experience and expectations), the utilization of categories, dimensions, and narratives as descriptive instruments, and the interactive engagement of clinicians, patients, and families in the diagnostic process. This model is broader than ICD and DSM, which are focused on classifying and diagnosing only illness and do not have the other features mentioned earlier. The PID model has been applied recently in the latest version of the Latin American Guide for Psychiatric Diagnosis (GLADP-VR) published by the Latin American Psychiatric Association. The model is also being engaged in the preparation of other practical guides for general medical diagnosis under the auspices of the International College of Person-Centered Medicine.
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