International Guidelines for Diagnostic Assessment (IGDA) Real Illustrative Case
Prof. Miguel R. Jorge, M.D. Federal University of São Paulo Brazil
Demographic Identification, Sources of Information and Reasons for Evaluation
History of Psychiatric and General Medical Illnesses Family, Developmental and Social History
Symptoms and Mental Status Evaluation Physical Examination and Supplementary Assessments Comprehensive Diagnostic Formulation
Treatment Plan Format
Demographic Identification and Sources of Information
Ms. A is a 34 year-old Brazilian Muslin woman from Lebanese migrant parents, married, 4 daughters, homemaker, completed high school, born and living in São Paulo, a 17 million people Metropolitan Area. All information gathered with the patient and from a medical statement related to two previous psychiatric hospitalizations.
Reasons for Evaluation
She presents for care to the psychiatry emergency room of an university general hospital where one of her daughters has been attended due to a congenital malformation. As she reports a history of previous persecutory ideas, hearing voices, aggressive behavior and depression, she was referred by the attending psychiatrist to the university Schizophrenia Outpatient Service. After an initial trial she was again referred to the Mood Disorders Outpatient Service.
History of Psychiatric and General Medical Illnesses
Ms. A reports that she was a extremely organized person, detailed, and selfdemanding. After marriage in her late teens, she developed cleaning compulsions. When she was 24 years-old, her third daughter born with ambiguous genitalia and was considered as a boy by her husband’s family. Six months later, the medical staff said that the baby was a XY0 genotyped girl and recommended hormonal treatment and a surgery.
History of Psychiatric and General Medical Illnesses
On the day of the surgery, her husband’s relatives talked to the surgeon and demand him to not change “the baby masculinity” and the surgery was cancelled (at that time). Ms. A presented a nervous breakdown and was hospitalized for 2 months (middle of 1989) with mood exaltation followed by depression, diagnosed as bipolar. After the discharge, her husband took her to her parents’ house in Lebanon. After 1 year there she was hospitalized again but she has no memories since her first nervous breakdown up to 2 years after.
History of Psychiatric and General Medical Illnesses
After almost 3 years in Lebanon she returned to Brazil in full remission. Her third daughter was living with her sister-in-law and her husband’s family didn’t allow her to bring her daughter back home. After a while she got pregnant again and fearing of that the new baby would also born with problems. She needed to be hospitalized again for 2 weeks with depression when she was at a 6-month pregnancy. In August of 1993 she had her 4th daughter.
History of Psychiatric and General Medical Illnesses
Since the first appointment I was attending her in a monthly basis and she remained well even not taking medication regularly. After 4 months she presented complains of nervousness due to lack of money and to problems with her husband and sister-inlaw by demanding to have her 3rd daughter back to her. I refer her to a psychotherapist but she preferred to go to an evangelic church. One month later she was taken to the hospital emergency room and was hospitalized again for 2 months with maniac symptoms and ideas of reference.
History of Psychiatric and General Medical Illnesses
After discharge she returned to my care free of symptoms but sedated (she was taking 2.5 mg of haloperidol bid). Two weeks later haloperidol was decreased to 1.25 mg per day and she has started systemic based psychotherapy. For the last 5 years she remains well but not comfortable to change medication to a mood stabilizer as recommended. GMI: fibromyalgia since 5 years ago.
Family, Developmental and Social History
Ms. A is the 4th daughter of seven children (the last two, boys) and was born at the All Souls’ Day. Her parents migrated from Lebanon around 13 years before. Her father was an austere middle class Muslin man who took very seriously his children studies and religious education. Her mother was a homemaker totally submissive to the husband. Ms. A had a happy childhood but most of her social relations was just to other relatives. She didn’t have any difficulty to adapt to a public elementary school but was just a regular student up to hers teens.
Family, Developmental and Social History
She was a quiet, shy, and introspective girl, and experienced feelings of rejection and affective privation from the family. When Ms. A was 11 years old, her 7 years old daughter died of lung cancer and she got hepatitis, remaining in bed for long time. During this period, her distraction was to read all volumes of the encyclopedia they had at home. She remembers that looks like “the world opened” to her and she became a brilliant student. She also turned more her attention to religion.
Family, Developmental and Social History
Her adolescence was nice but she didn’t have a boyfriend. When she was 17 years old almost finishing the high school - her father suddenly decided to move back to Lebanon because he was concerned about her grandparent and also because he preferred that his daughters do not marry Brazilian men. She didn’t want to go but when she arrived there she became very happy with the opportunity to meet all her parents’ families. They went to live in a small village but she and another sister were placed in an uncle’s house next to a high school.
Family, Developmental and Social History
When she was finishing the high school, a war started against Israel and they fled to Syria, where they stayed for 6 months. She became even more religious and when they returned to Lebanon was impossible to return to school – it was destroyed. She met her future husband, a Brazilian Muslim man that was working in Venezuela and then peregrinating to Mecca. After 20 days she married him and traveled to Brazil to be introduced to his parents. Her parents-inlaw were radical Muslims and very rigid people to whom she never feel adapted.
Family, Developmental and Social History
She didn’t got a visa to move to Venezuela, became pregnant and for 6 months lived without her husband in the backyards of her parents-in-law house. She didn’t have contact to anybody else and has no money to deal with. She experienced again feelings of rejection and affective privation even when his husband returned from Venezuela as he was too much submissive to his mother. After the birth of her third daughter a conflict to his husband’s family as described elsewhere was established and she started to present psychiatric problems.
Symptoms and Mental Status Evaluation
Ms. A presents for interview using a long dress and a scarf covering his head. She has no make-up but denotes to care for herself. She is pleasant and collaborative at interaction, initially showing some inhibition but slightly being more talkative as the interview progresses. Her speech is spontaneous and it is more sophisticated than her educational degree indicates.
Symptoms and Mental Status Evaluation
She is alert and oriented to person, time and place. Spontaneous and voluntary attention is normal. Short and long-term memory has no alteration excepted to a 2 years period following the breakdown which implied in her first psychiatric hospitalization at age 25. Her intelligence level looks slightly above average. Judgment and insight is present but some aspects of her behavior looks out of her understanding.
Symptoms and Mental Status Evaluation
Her rate of speech is normal, coherent, and has no delirious ideas. She reports ideas of grandiosity and of self-reference by the time of previous hospitalizations. There were no current or past hallucinations. Affect is full and no mood disturbances are present at the time of current evaluation. Again, she reports periods of depression or mood exaltation preceding previous hospitalizations. No motor activity abnormalities.
Physical Examination and Supplementary Assessments
Physical examination has no alterations and routine laboratory tests present normal results. No image or any other exams were required.
COMPREHENSIVE DIAGNOSTIC FORMULATION
(WPA International Guidelines for Diagnostic Assessment, IGDA) Name: Ms.A Age: 34 Gender: Female Record N°: Date(d/m/y): January, 1999 Occupation: Homemaker
Marital Status: Married
FIRST COMPONENT: STANDARDIZED MULTIAXIAL FORMULATION
Axis I: Clinical Disorders (as classified in ICD-10).
A. Mental Disorders (mental disorders in general, including personality and development disorders): Codes
Bipolar Affective Disorder, currently in remission
B. General Medical Disorders:
F31.7
Codes
Fibromyalgia
Axis II: Disabilities
Areas of Disability 0 1
M79.0
Disability Scale * 2 3 4
5
U
A B C D
Personal Care
X
Occupational (wage earner, student, etc)
With family Social in general
X
X X
(*) 0= None; 1= Minimal; 2 = Moderate; 3 = Substantial; 4 = Severe; 5 = Massive; U = Unknown; according to the intensity and frequency of disabilities recently present.
Axis III: Contextual Factors (Psychosocial problems pertinent to the presentation, course or treatment of the patient’s disorders or
relevant to clinical care, as well as personal problems, such as hazardous, violent, abusive, and suicidal behaviors, that do not amount to a standard disorder).
Problem Areas (Check areas with significant problems and then specify them) Z Codes
x x
1. Family/House: 2. Education/Work: 3. Economic/Legal: 4. Cultural/Environmental: 5. Personal:
Z63 Z55,Z56
x
x x
Z59.6
Z60.3 Z73.1
Axis IV: Quality of Life (To indicate the perceived level of quality of life by the patient, from poor to excellent, mark one of the
10 points on the line below. This level can be determined through an appropriate multidimensional instrument or by direct global rating). Poor
x
1 2 3 4 5 6 7 8
Excellent
0
9
10
COMPREHENSIVE DIAGNOSTIC FORMULATION
(WPA International Guidelines for Diagnostic Assessment, IGDA)
SECOND COMPONENT: IDIOGRAPHIC FORMULATION I. Clinical Problems and their Contextualization (Include disorders and problems, based on the Standardized Multiaxial Formulation, in language shared by the clinician, patient and family, as well as complementary key information, mechanisms and explanations from biological, psychological, social, and cultural perspectives)
Patient is a Brazilian woman born from Lebanese parents. Her father was an open-minded man and she grew up in a quite stimulant and enjoyable environment. Nevertheless, in her late teens, she married to a Muslin man from a very conservative family, when they were living in Lebanon. According to the patient, her main problems started 10 years ago, when she gave birth to her 3rd child (after 2 daughters), who born with ambiguous genitalia. When this child was 6 monthsold, a surgery to define a female phenotype was scheduled but her husband’s family opposed to this gender definition. The patient had a nervous breakdown (diagnosed as bipolar) and was hospitalized, recovering her “memory” 2 years later, with full recovery of her symptomatology. But her 3rd daughter remained in her brother-in-law home and she felt rejected by her husband’s family and observed by her mother-in-law.
COMPREHENSIVE DIAGNOSTIC FORMULATION
(WPA International Guidelines for Diagnostic Assessment, IGDA)
SECOND COMPONENT: IDIOGRAPHIC FORMULATION
I. Clinical Problems and their Contextualization (Include disorders and problems, based on the Standardized Multiaxial Formulation, in
language shared by the clinician, patient and family, as well as complementary key information, mechanisms and explanations from biological, psychological, social, and cultural perspectives)
After 3 years of recovery, she was pregnant again and - at 6 months of pregnancy – she presented another nervous breakdown due to fears of congenital problems in her new baby.She was hospitalized for almost 2 months and some time after discharge she gave birth to another daughter. Since then she is well, taking a small amount of medication and under a systemic based psychotherapy. She feels that her husband is too much submissive to his family, something lazy, and not attentive to her. Despite the fact that she was thinking about divorce some time ago, this is “unthinkable” because of their children. Sometimes she feels downhearted, nervous or irritable, mainly because of her family problems and lack of money. She also occasionally has generalized muscle pain. When she stops medication, she experiences some anxiety and feels too much active; so, she is not comfortable to change to another medication as suggested.
COMPREHENSIVE DIAGNOSTIC FORMULATION
(WPA International Guidelines for Diagnostic Assessment, IGDA) SECOND COMPONENT: IDIOGRAPHIC FORMULATION
II: Positive Factors of the Patient (Include resources pertinent to treatment and health promotion, e.g., maturity of personality, abilities and talents, social supports and resources, and personal and spiritual aspirations).
Since her treatment, Ms. A is aiming to better accept the way his husband is and to keep the family together. She started to study again and was doing some occasional work (teaching English privately and in a school for small children). She feels identified with her cultural roots and has social relations mostly around her mosque community. She didn’t enter college due to their economic situation and her primary objectives are to offer all the conditions she thinks will better prepare her daughters to the future and help her sister-in-law to take care of her third daughter.
COMPREHENSIVE DIAGNOSTIC FORMULATION
(WPA International Guidelines for Diagnostic Assessment, IGDA)
SECOND COMPONENT: IDIOGRAPHIC FORMULATION
III: Expectations on Restoration and Promotion of Health (Include specific expectations on types and outcome of treatment
and aspirations on health status and quality of life for the foreseeable future).
Clinicians and patient agree that her psychiatric condition and fibromyalgia are quite treatable with both medication and psychotherapy. They further agree that adequate attention and care to her marital conflicts, family problems, and socio-occupational situation is likely to improve both her psychological condition and quality of life. Health promotion strategies may also include affirmation of her cultural identity and personal abilities.
TREATMENT PLAN FORMAT
Name: ________________ _________________________________________ Record N°: ________________Date(d/m/y):___________________ Age:________ Gender: M XF Marital Status:__________________ Occupation:___________________________________________________ 34 Clinicians Psychiatrist and a psychotherapist sensitive to cultural matters involved:________________________________________________________________________________________________________________
Ms. A
January 1999
Married
homemaker
Outpatient clinic Setting:__________________________________________________________________________________________________________________
Instructions: Under Clinical Problems list as targets for care key clinical disorders, disabilities, and contextual problems presented in the multiaxial diagnostic formulation, as well as problems noted in the idiographic formulation. Keep the list as simple and short as possible. Consolidate into one encompassing term all those problems that share the same intervention. Interventions should list diagnostic studies as well as treatment and health promotion activities pertinent to each clinical problem. Be as specific as possible in identifying modalities planned, doses and schedules, amounts and time frames, as well as the corresponding responsible clinicians. The space for Observations may be used in a flexible way as needed. Illustratively, it could include target dates for problem resolution, dates of scheduled reassessments, and notes that a problem has been resolved or has become inactive.
Clinical Problems
Interventions
Observations
Clinical Problems 1. Bipolar disorder
Interventions a.Change haloperidol to a mood stabilizer, adjusting dose according to response and side-effects b. Psychotherapy, preferably engaging husband, and considering health promotion strategies focused on strengthening patient’s positive factors
Observations
Re-evaluate in 2 W
Re-evaluate in 3 M
2. Fibromyalgia
a. Prescription of a SSRI b. Referral to the Reumatology Service
a.Improve cultural formulation to better clarify aspects cultural identity and relation to illness and care b. Referral to the General Hospital’s Social and Psychological Services for help with her daughter medical and identity problems
Follow-up
3. Socio-cultural
Follow-up