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Maidenhead, Berks: Open University Press. The complete guide to medical writing. London: Pharmaceutical Press. Guidebook to better medical writing. Olathe, Kan: Robert L. Health professionals style manual. New York: Springer Pub. Mastering scientific and medical writing: A self-help guide.
Berlin: Springer. Medical writing: A guide for clinicians, educators, and researchers. New York: Springer. Writing clinical research protocols: Ethical considerations. Burlington, MA: Elsevier Academic. Writing for the Health Professions Terryberry, K. Writing for the health professions. Writing skills in practice: A practical guide for health professionals.
London: Jessica Kingsley Publishers.
Stressors might include inadequate social support; living alone; difficulty with acculturation; discrimination; and adjustment to a lifecycle transition, such as retirement. The fourth category is education.
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Stressors might include illiteracy, academic problems, discord with teachers or classmates, and an inadequate school environment. The fifth category is work. Stressors might include unemployment, threat of a job loss, stressful work schedule, difficult work conditions, job dissatisfaction, job change, and discord with the boss or coworkers. The sixth category is housing. Stressors might include homelessness, inadequate housing, an unsafe neighborhood, and discord with neighbors or landlord.
The Social Formulation RT Stressors might include extreme poverty, inadequate finances, and insufficient welfare support. The eighth category is access to health care services. Stressors might include inadequate health-care services, unavailability of transportation to health-care facilities, and inadequate health insurance.
Stressors might include arrest, incarceration, litigation, and being the victim of a crime. The tenth category is other. Stressors might include exposure to disasters, war, or other hostilities; discord with nonfamily caregivers such as a counselor, social worker, or physician; and unavailability of social service agencies. Accordingly, the spiritual assessment is a key component of the social formulation.
The approach to the spiritual assessment is analogous to that of the cultural assessment. The first category is the cultural and spiritual identity of the patient.
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For immigrants and ethnic minorities, note separately the degree of involvement with both the culture of origin and the host culture. Also note language abilities, use, and preference, including multilingualism. Identify the predominant idioms of distress through which symptoms or the need for social support are communicated e. Identify the perceived causes or explanatory models that the patient and reference group use to explain the illness e. Note culturally relevant interpretations of social stressors, available social supports, and levels of functioning and disability.
This would include stresses in the local social environment and the role of religion and kin networks in providing emotional, instrumental, and informational support. Note spiritually relevant interpretations of social stressors, available social supports, and levels of functioning and disability. This includes stresses in the local social environment and the role of spiritual and kin networks in providing emotional, instrumental, and informational support.
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The fourth category is cultural and spiritual elements of the relationship between the patient and the clinician. Indicate differences in culture and social status between the patient and the clinician and problems that these differences may cause in diagnosis and treatment e. Indicate differences in spiritual beliefs between the patient and the clinician and problems that these differences may cause in diagnosis and treatment. The fifth category is the overall cultural and spiritual assessment for diagnosis and treatment.
The formulation concludes with a discussion of how cultural and spiritual considerations specifically influence comprehensive diagnosis and treatment. For example, disparate cultural and spiritual backgrounds in the patient and clinician may impact a number of key variables that will ultimately determine whether treatment is successful. Some of these are listed in Table 4. Table 4.
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Acceptance of diagnosis: How stigmatizing is the acceptance of a mental disorder? Compliance with treatment: What meaning does the recommended treatment have for the patient? Therapeutic alliance: Will the patient be able to trust someone from a different cultural and spiritual background? The differential diagnosis is the RT The importance of developing a comprehensive, but not overly inclusive, differential diagnosis cannot be overemphasized.
Using the Symptom Filter as a guide, work through each of the eight categories, constructing a set of DSM-IV diagnoses based on the symptom profile you constructed. Until you become familiar with the symptom criteria for the DSM-IV disorders, this step will be a laborious process. However, once you become familiar with the symptom profile defining each disorder, this process will be straightforward. You may have a lengthy list of potential disorders at the outset.
After completing your set of possible DSM-IV diagnoses, review the biological, psychological, and social predispositions to assist you in prioritizing the differential diagnosis. For example, the family history may suggest whether one of the diagnoses you are considering is more likely than another. If you suspect there may be a contributing factor, designate this using the appropriate DSM-IV diagnostic criteria i. Your ability to recognize these factors and utilize this knowledge in constructing a differential diagnosis, risk assessment, treatment plan, and prognosis will set you apart from other clinicians.
The time spent is well worth it. Two common errors must be assiduously avoided when developing a differential diagnosis. The first is failing to account for all of the data obtained from the psychiatric Differential Diagnosis RT The second common error is failing to develop as broad a differential diagnosis as the data will support.
Any diagnosis you include in your list must be supported by the data. Study the differential diagnosis sections for the more common mental disorders in DSM-IV and construct a list of possibilities, in decreasing order of probability, after each patient evaluation until it becomes second nature. This is one of the skill sets that differentiate the average clinician from the exceptional one.
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Avoid the frequently strong temptation to prematurely narrow the differential diagnosis by jumping immediately to a presumptive diagnosis. This is one of the most common, and potentially costly for both you and the patient , errors in clinical practice. Do not relax on this one. Therefore, the risk assessment is only considered once the biological, psychological, and social formulations and the differential diagnosis are completed. The risk assessment RT Demographic and other risk factors are useful guides in assessing risk.
However, it is important to remember that these risk factors, by themselves, do not accurately predict risk in a specific patient. That is why clinical judgment is so important.
A final point to keep in mind is that risk factors are not equivalent. For example, two patients may have four risk factors each. However, a depressed woman with a chronic physical illness, no social supports, and a day supply of amitriptyline poses a far greater suicide risk than an elderly widower with a chronic physical illness who lives alone and has no readily available lethal means at his disposal.
Remember that women attempt suicide more often than men, but men complete suicide more often than women. Keep in mind that there is a bimodal distribution of increased risk for suicide in adolescents and the elderly. D — Depression.
However, this refers to any serious mental disorder. P — Previous attempt. Past behavior is always the best predictor of future behavior. Accordingly, a history of attempted suicide is a major risk factor for current suicide. E — Ethanol abuse. This category also includes other substances that cause disinhibition and impaired judgment.
R — Rational thought loss. This refers to any significant cognitive impairment, irrespective of the etiology e. S — Social supports lacking. This refers to limited social supports. O — Organized plan. N — No spouse. A — Availability of lethal means.