Adjectives and scales: The importance of terminological fine-

tuning in psychiatric reports for officials

Cornelia Wermuth (KULeuven Antwerpen),

Student MA Translation (Vrije Universiteit Brussel)

Rita Temmerman (Vrije Universiteit Brussel)

Marc Lamote M.D. (Sint Pieters Ziekenhuis, Brussel)

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Topic

Omstandig medisch verslag

Rapport médical

circonstancié

Detailed medical report

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Dr. Marc Lamote

Saint Pierre Hospital Brussels

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Background

published by WHO published by APA

(American Psychiatric Association)

Diagnostic classification systems for mental disorders

Based on agreed classification criteria

Applied by different users (clinicians, researchers, health insurances)

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Rationale

Diagnosis making

Diagnosis formulating

Diagnosis reporting

(e.g. to insurances)

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standardized and uniform

format

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Design

System

of

diagnostic categories

Artificial constructs:

result of expert

agreement

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Approach

symptom symptom Validation

of diagnosis

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pre-defined in

categorical systems

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Alternative approach

symptom symptom

Making

of diagnosis

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not pre-defined

result of observed symptoms

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Shortcomings

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unscientific approach

subjective categories

un-homogenous categories

class-class-overlap

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Scheme of mood disorders (DSM)

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Pathoplasticity of mental disorders

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early

timeline

late

mild

severity

severe

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Dimensional diagnosis

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The use of time-related

modifiers (frequency, duration)

Attention deficit hyperactivity disorder (ADHD)

"Persistent pattern of inattention and/or hyperactivity-

impulsivity that interferes with functioning or development"

beginning in childhood, and present across more than one

setting

Specify whether:

314.01 Combined presentation

314.00 Predominantly inattentive presentation

314.01 Predominantly hyperactive/impulsive presentation

Specify if:

In partial remission

Specify current severity:

Mild

Moderate

Severe

The use of degree and severity

modifiers

Master thesis presentation

Case study on the psychiatric emergency ward:

gedwongen opname - mise en observation -

involuntary commitment

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Situation

• Legislation of 1990

• Omstandig medisch verslag/Rapport médical circonstancié/detailed medical report

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Problems

• Lack of guidelines

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Invoegen omstandig medisch verslag

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Problems

• Lack of guidelines

• Terminology doctor <> knowledge magistrate

• Understanding

• Symptoms => diagnosis

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Possible solution

Gliding scales with adjectives as snapshot => use in report

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Methods

• Observation

• Corpus analysis

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And then?

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Thank you.

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