Idiographic formulations, symbols, narratives, context and meaning

To locate the place of idiographic, narrative formulations in a psychiatric nosology and to address the problems stemming from the absence of such formulations in ICD-10 and DSM-IV, the author begins with a review of the stated goals of DSM-IV: that it should serve clinical, research, educational and information-management purposes. He argues that there is a conflict between the clinical and research goals of both manuals and that, with their emphasis on categorical diagnoses, criteria sets and statistical reliability, they serve the purposes of the biomedically oriented researcher better than those of the clinician. The latter is focused on the individual patient and tends in his diagnostic assessment toward a narrative fleshing out of the particulars of the patient's life and personality. Clinicians do not work with tight criteria sets but rather with a prototypal or ideal-type approach, and they emphasize individual histories, psychodynamic formulations and other kinds of idiographic accounts. If a psychiatric nosology is to serve as a clinically useful instrument, it will have to allow for such formulations. The author then offers a description and definition of idiographic, narrative formulations, along with remarks on the conceptual background to this approach. He concludes by highlighting the work of the workgroup of the World Psychiatric Association in developing a section of their International Guidelines for Diagnostic Assessment entitled 'Idiographic (personalised) Diagnostic Formulation'.