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DCP Occasional Paper 8: Classification, Diagnosis and Datasets: Towards an approach for clinical psychology services and electronic records

DCP Occasional Paper  8: Classification, Diagnosis and Datasets: Towards an approach for clinical psychology services and electronic records

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Quick Overview

This Occasional Paper brings together two original documents. The first was prepared as background for the Division of Clinical Psychology (DCP) Working Group developing a statement on diagnosis and was used by the Working Group to inform the debate. It has been revised for this paper and presents an overview of issues in psychiatric diagnosis and their implications for psychology services. The second is a related document introducing proposals for the development of a clinical psychology model and dataset for electronic clinical records (ECRs) in mental and other health services. These proposals are driven by the perceived need for a system unencumbered by some of the limitations of conventional psychiatric diagnosis systems and are aimed at being relevant to users of psychology services and practitioner psychologists in an NHS context that is itself developing. Some ideas in both parts originate in previous papers by the author (e.g. Berger, 2011), but are extended and updated.





Part 1: Diagnosis and psychiatric diagnosis: An overview of the issues and their implications

  • Diagnosis and psychiatric diagnosis in context
  • Concepts and models
  • Disease, illness, disorder, and 'problems'
  • Medical, biopsychosocial, and psychobiosocial models
  • Categorical vs. Dimensional models
  • Other classification systems
  • Diagnosis
  • Case conceptualisation, transdiagnostic approaches and psychological formulation
  • Other advances
  • The NIMH Research Domain Criteria (RDoC) initiative
  • Clustering models
  • Severity and duration
  • Functional impairment and clinical significance
  • Evaluating diagnostic systems and clinical utility
  • Core issues
  • Implications for clinical psychology

Part 2: Moving towards a model and dataset for clinical psychology services

  • Why a psychology ECR?
  • Introducing other systems
  • Medical and psychiatric diagnoses in clinical psychology
  • Some proposed core requirements for a psychology model
  • Record and dataset considerations
  • Record structure
  • ICF and its structure
  • The NIMH (2012) Research Domain Criteria (RDoC)
  • Transdiagnostic approaches
  • Record components
  • Information capture issues
  • Psychology record development
  • 'Hearing voices' in SNOMED-CT®
  • 'Hearing voices' as a psychological concept

Practicalities: Moving forward



Appendix 1: Psychological formulations in the ECR

Appendix 2: SNOMED-CT®

Appendix 3: Illustration of dataset structure and content

  • Demographics
  • Referral information
  • Main current concerns
  • Previous history of main and other episodes
  • Other concerns
  • Personal circumstances
  • Personal/Self
  • Historical/Developmental
  • Socio-cultural context
  • Tests and related information
  • Assessment meta-information
  • Sealed sections
  • Formulations
  • Interventions
  • Outcomes
  • Follow-up status
  • Reports and other documents
  • Process notes



Additional Information