formulation is a time honoured term which unfortunately serves more to obscure and mystify than to enlighten the clinical process in psychiatry. It originated in a time when much less was known about the aetiology of mental disorders, and most hypotheses were derived from arcane theories more akin to alchemy than science. Hence the common phrase "the art of formulation". It tends to separate rather than link psychiatry with the rest of medicine and should properly be abandoned, but is retained for reasons of sentimentality and conventional usage.
The best way to de-mystify and understand the art of formulation is to break it down into logical component parts which have clinical utility.
The three traditional elements of clinical management in all clinical disciplines are assessment, diagnosis, and treatment.
The pschyiatric formulation is no more than an expansion of the second element (diagnosis) reflecting the particular perspectives of psychiatry.
The formulation summarises, synthesises, and hypothesises about information drawn from the assessment, and in turn informs clinical treatment.
The key elements of the psychiatric formulation are:
The summary should be of greater or lesser complexity depending on the model of presentation employed. Where the formulation immediately follows a detailed presentation of clinical data, it should be quite brief, merely re-orientating the listener to the salient features of the case, often just the key demographics and major features of diagnosis, dangerousness, and disability.
Where there is no prior detailed presentation of clinical data the summary should present sufficient relevant information to support the diagnostic and aetiological components of the formulation,
The diagnostic formulation must logically come before the aetiological formulation because it makes no sense to hypothesise about something before stating what that something is.
The term "diagnostic formulation" is preferable to diagnosis, because it emphasises that matters of clinical concern about which the clinician proposes aetiological hypotheses and targets of intervention include much more than just diagnostic category assigment, though this is usually an important component. The diagnostic formulation is most broadly a structured typification of the patient's problems, usually including statements about:
Dangerousness should be separately mentioned becuase if crosses conventional diagnostic categories and is the first focus of intervention.
Disability should be separately mentioned as well becuase it also crosses conventional diagnostic categories and is a target of longer term interventions.
The aetiological formulation is a set of explanatory hypotheses regarding the diagnostic formulation.
The aetiological formulation ought logically to address all components of the diagnostic formulation, but conventionally focuses on the illness, the episode, and the person, ignoring dangerousness and disability. With greater attention to risk management and rehabilitation this is likely to change. Already the concept of risk formulation has entered the clinicial lexixon.
Aetiological hypotheses commonly concern linkages between various "factors" derived from the assessment and diagnostic formulation, and between the present and the past. This is sometimes taken by inexperienced students and poor candidates to propose anything adverse in the past as an antecedent to problems in the present.
The safest and best aetiological hypotheses are those which are supported by research evidence or at the very least by a substantial body of expert opinion, such as psychoanalytic insights, which may not lend themselves so readily to objective verification. Speculation should be left to last or avoided completely. The formulation is not the place to make it up as you go along.
It is common to consider biological, psychological and social factors, operating in a predisposing, precipitating or perpetuating (and sometimes protective) manner on the elements of the diagnostic formulation.
Common biological factors are genetic inheritance, acquired illnesses, drugs and toxins.
Common psychological factors are personality vulnerabilities and strengths related to early life experiences and recent life events.
Common social factors are culture, gender, class, political and economic circumstances.
Copyright (c) Robert Shields 2004
Date created: 3 April 2004
Last modified: 3 April 2004
Email: Rob Shields