Management plan and formulation
Management plan
The management plan is a comprehensive plan of action that starts with the differential diagnosis and investigations necessary to reach a firm diagnosis, and progresses through immediate, short- and long-term treatments. Physical, psychological and social interventions should be considered in every case.
Differential diagnosis
The differential diagnosis is a list of possible diagnoses drawn up after taking a full history and performing both mental state and physical examinations. It is helpful to consider each of the following categories for patients presenting with psychiatric symptoms:
Functional mental illness. These are psychiatric illnesses occurring without a physical cause (p. 7).
Personality disorder. This may be the primary diagnosis, or occur concurrently with another disorder.
Mental retardation. This may result in presentation with emotional or behavioural abnormalities. Both functional and organic mental illnesses occur more frequently in people with mental retardation.
Medical disorder. There may be a coincident medical disorder which, although not directly causing the mental illness, may have an impact on its presentation and response to treatment.The correct diagnosis may be glaringly obvious, but in most cases there will be three or four realistic alternative differential diagnoses, with one favourite. There will often be more than one correct diagnosis present at the same time (Fig. 1).
Investigations
The purpose of investigations is to reach a firm diagnosis by confirming or excluding each differential diagnosis in turn. It is not acceptable to do ‘routine investigations’ without adequate justification for each. All investigations have a cost, either financial or in terms of discomfort or side-effects for the patient, or clinicians’ time.
Investigations should start with information gathering from psychiatric and medical case notes and the GP. Relatives or friends may be interviewed with the patient’s consent. If possible, the patient should not be present at these interviews in order to give the informant an opportunity to speak freely. They should be asked for their view of the patient’s problems, and may be able to clarify or confirm aspects of the history you are uncertain about. It is helpful to engage the family at an early stage as they may have an important role in the later management of the patient. Psychological and physical investigations may be helpful if abnormalities are found in routine cognitive testing or physical examination (Fig. 2).
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