Formulation in psychiatric clinical practice

I found out this week that a book review I had submitted to the British Journal of Psychiatry had been accepted for publication. The review was of a recent book published by Wiley-Blackwell – Psychodynamic Formulation, Deborah Cabaniss. In a piece of shameless self aggrandisement I thought I would write this week a little about what I think of as the role of formulation in modern psychiatric practice, and then include my review of Cabaniss’ book towards the end.

Coincidentally, or with synchronicity – depending on your interpretation, the day before I found out the review was accepted I was listening to the Shrink Rap Radio podcast interview with Nancy McWilliams about her book on Psychoanalytic diagnosis and Personality and reflecting on the parallels between what she was describing and my own thoughts. Another book to add to my somewhat lengthy reading wish list I think…

Classical clinical assessment

Medical assessment follows the classical paradigm, beginning with the recording of the patient’s “History”:

The clinician listens to the patient describing the problem that has brought them for medical attention (referred to as The Presenting Complaint).

The clinician allows the patient to provide their own description and then asks more directed questions based on their interpretation of the history given so far – (expansion into the History of Presenting Complaint).

The clinician continues with directed questioning to elicit relevant past medical experiences. This is the “Past Medical and Surgical History”. A “sieve” approach may be employed now, or later in the consultation, to ensure no significant piece of information is omitted. A classic sieve might be the gnomonic “MJTHREADS”:

  1. Myocardial infarction (heart attack)
  2. Jaundice (liver disease)
  3. Tuberculosis (or other infectious history, e.g. HIV)
  4. Hypertension (high blood pressure)
  5. Rheumatic disease (arthritis etc)
  6. Asthma (or other lung disease)
  7. Diabetes (or other metabolic conditions)
  8. Stroke (or other neurological disorder).
  9. Any current medications – “Drug History” (including any allergic response to previous medications)
  10. Any relevant medical history among family members is explored – “Family History
  11. Exploration of the patient’s social situation eg. – Employment, marital status, housing situation – “Social History

The nature of the assessment and the length of time dedicated to various portions of the history will obviously depend on the clinical scenario.

Having obtained the “history” in which the clinician translates the information provided into “symptoms” and risk factors the assessment moves onto examination, based on the findings from the history. Through physical examination the subjective symptoms reported are corroborated with objective elicited signs – so the patient with appendicitis complains of pain in their stomach (symptom), the examining clinician pushes over the right lower quadrant of the abdomen and elicits a pain response (sign).

Clinical tests – e.g. blood tests may then be requested to back up examination and history findings – for example a chest X-Ray if lung pathology is suspected.

Based on the findings from the history, clinical examination and investigation the clinician reaches a diagnosis and develops a management plan (hopefully through negotiation with the patient).

I have presented this sequence of events in a linear fashion, however, dependent on the clinical scenario it may well be that different events take place at different times – for example asking questions simultaneously with findings elicited from clinical examination.

Another important factor to highlight is that the process of diagnosis does not take place solely at the end of the assessment – instead the clinician considers a broad differential diagnosis and eliminates possible diagnoses through the process above until the (hopefully) correct diagnosis is reached.

Psychiatric clinical assessment

It can be argued that psychiatric assessment follows the same paradigm as other assessments described above. The psychiatrist listens to the story presented (subjective symptoms) and asks directed questions in relation to phenomenology, or psychopathology, to elicit signs through a mental state examination. Rarely investigations may be requested to aid diagnosis. A differential diagnosis is considered and honed down to a final diagnosis – leading to a treatment plan.

However, there are a number of distinctions in psychiatric assessment that I think are crucial. Firstly the line to be drawn between subjective symptoms and objective signs is for me blurred, we as psychopathologists interpret the individual’s phenomenological experience, ultimately we are using our own empathy to interpret the description of events offered. Pathology lies outside our conceptualisations of what is “normal” and it is argued that this represents objectivity, that through our examination of our own psychic experience we develop objective measures. There is a conceit in this approach that I find somewhat disturbing however; what right do I have to describe an experience as normal or pathological?

Second – diagnosis of mental disorder is not directly analogous to diagnosis of medical disorder. I want to say more on this in a future post so this explanation will be brief – however our current definitions of diagnosis (e.g DSM-5) represent a “best guess” not an exact definition.

Third – Treatments in psychiatry are rarely specific to diagnoses. Techniques drawn from psychological interventions can be applied to many different disorders, medications are used in a variety of ways – antipsychotics, for example, are used in the treatment of classical psychosis in Schizophrenia and of both mania and depression in Bipolar disorder. Again, I want to return to this in a future post. Attempts to introduce specificity of approach through tailoring treatments to specific conditions are I, personally, find misleading and, given current uncertainties regarding the nature of psychiatric diagnosis, unwarranted.

Case formulation

How is a case formulation approach different? I want to imply two key distinctions, or questions that need to be answered through case formulation.

  1. Why is this person presenting in this manner and at this time?
  2. What support, or treatment, can we offer that will best meet the needs described?

These questions could be answered through the classical approach described above but I think that an important distinction needs to be drawn. The case formulation then focusses not only on describing the current presentation, but also on obtaining a feel for the person’s previous experiences and finally attempting to establish relevant links between past and current experience. The final formulation will present the information in a narrative linking past to present to current distress. Diagnosis may play a role in this formulation, but not necessarily as the headline finding. Treatment plans should flow naturally from the formulation and should, as past experiences have been considered, be more easy to negotiate with the client.

There are various models of case formulation, perhaps the most famous being a “BioPsychoSocial” approach to assessment in which predisposing, precipitating and perpetuating factors for current difficulties are identified and divided into Biological, Psychological and Social headings.

For me however the most important difference between what I am trying to describe and the classical paradigm relates to fragmentation. The medical assessment seeks to divide the relevant information from the irrelevant and to reach a diagnosis and treatment plan. This can be appropriate in certain circumstances – for example in accident and emergency. The difficulty I believe is that the approach is essentially clinician centred, with effort being made to extract information through a framework of use to the clinician. For many people a consultation with a clinician may be one of the most frightening experiences they will have, representing a fear of the unknown that has led to them seeking help. The medical approach can lead to objectification of the individual, a process that may be distressing in its own right. People present their experiences as narrative and our interpretation of them should, I believe, also be in narrative.

I think this is particularly important to psychiatric practice, however I also believe there is a strong argument for its application throughout medical practice. There is a counterargument that case formulation simply represents “good history taking” that experienced clinicians will complete naturally. I think there is a further distinction to be drawn and I feel that the shift of emphasis away from diagnosis to individual priorities is probably worth highlighting.

Book review

Psychodynamic Formulation – Deborah Cabaniss et al. Wiley-Blackwell, March 2013

This short book offers a brief overview of a psychodynamic approach to clinical case formulation.1 The book is divided into five sections in which, following an introduction and overview, each of the components of the framework is introduced, with a final section covering the application of the formulation to clinical scenarios outside of a typical individual therapy setting. The formulation framework is broken down into an initial description of the patient’s difficulties, the exploration of the personal and developmental history and finally efforts to link past experiences to current difficulties through the use of theories of attachment and object-relations amongst others. This overview of psychodynamic theories of development and defence against trauma will be of value to psychiatric trainees with topics reviewed and presented in a concise manner. The final chapters, exploring the application of the formulation in emergency settings or psychopharmacology consultations are perhaps the most useful however.

Although written in the United States this book is of relevance to the practicing psychiatrist in the UK as well given the on-going debates surrounding efficacy and the place of depth psychotherapies in modern clinical practice.2,3 The role of formulation informing clinical practice and treatment has also recently been represented in the popular press with the publication of a series of explorations by the psychoanalytic therapist and thinker, Darian Leader.4,5 These books have been well received, attracting supportive reviews by prominent figures such as Hilary Mantel, and, along with the spirited debate generated by two recent critiques of psychiatric practice, indicate that the public appetite for debate around the role of psychiatry in society has not diminished.6,7

While this book by Cabaniss and colleagues can do little to address the on-going debate, providing no new evidence or arguments either way, it does provide a clear, succinct summary of psychodynamic theory and demonstrates, through the use of illustrative clinical vignettes, the application of the described framework. While psychiatrists practicing in the UK may be jealous of the occasional recommendation for twice weekly therapy over a three year period the closing chapters illustrating the application of psychodynamic formulation in the acute care setting are informative, and support a series of recent articles on similar topics recently published in Advances in Psychiatric treatment.8,9

References
1 Cabaniss D, Cherry S, Douglas C, Graver R, Schwartz A. Psychodynamic Formulation.Wiley-Blackwell, 2013.
2 Fonagy P, Lemma A. Does psychoanalysis have a valuable place in modern mentalhealth services? Yes. BMJ 2012; 344: e1211.
3 Milrod B. The gordian knot of clinical research in anxiety disorders: some answers, morequestions. Am J Psychiatry 2013; 170: 703–6.
4 Leader D. What is Madness. Penguin, 2012.
5 Leader D. Stricly Bipolar. Penguin, 2013.
6 Davies J. Cracked: Why Psychiatry is Doing More Harm Than Good. Icon Books, 2013.

7 Burns T. Our Necessary Shadow: The Nature and Meaning of Psychiatry. Penguin, 2013.

8 Martindale B, Summers A. The psychodynamics of psychosis. Advances in Psychiatric Treatment 2013; 19: 124–31.

9 Summers A, Martindale B. Using psychodynamic principles in formulation in everyday practice. Advances in Psychiatric Treatment 2013.

Conclusions

As usual I’m sure that turned into more of a rant than I intended. Still. Any comments please?

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One thought on “Formulation in psychiatric clinical practice

  1. Pingback: Reflections on… Diagnosis | shrinking thoughts

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