Making a Mental Health Diagnosis

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Introduction

 

 

Making a Diagnosis

Symptoms alone do not define illness and do not require treatment. Rather diagnostic criteria are required to help make a diagnosis and let others know what is going on. If there is no functional impairment, there is no illness.

 

Mental illness is difficult to define. What is considered abnormal varies with time and across cultures, being shaped by social conventions. The DSM-IV-TR is a categorical approach to mental health conditions, leading to increased research studies but also generating much controversy surrounding.

DSM is a categorical judgement placing a patient in a box at this specific time. However, patients are dynamic; labels need not be permanent.

 

 

Formulation

Formulation is a diagram outlining the current issues, and interrelations between an individual's biological, psychological, and social factors. For each category, there are predisposing, precipitating, perpetuating, and protecting factors.

Case formulation is the integration of therapeutic connection, diagnosis, and treatment, representing the process of identifying a patient's psychic signs and symptoms and understanding them in the context of heredity, upbringing, and life events. Formulation ties together emotional, behavioural, and cognitive responses to life and leads to an appropriate treatment plan based on this information. Formulations develop over time, with further interactions, insights, and with healing.

It ties together theory and a patient's real story.

 

During formulation, a person's history and resulting psychic structure are defined in order to effectively frame their current siutation.

It involves the ABC's: affect, behaviours, and cognition.

The mental health assessment, namely the psychiatric history, identifies symptoms and past demographics, but often goes no further. Formulation extends this data to a fuller understanding of cause and moves into the art of healing.

 

 

Models of Formulation

Different practitioners have different definitions and models of formulation, though each encompasses descriptions of a patient's situation, prescriptions for therapeutic pathways, and predictions of outcome (Sim, Gwee, and Bateman, 2005).

 

A formulation from a CBT perspective will likely focus on a problem list, core beliefs, precipitants and activating situations, origins, a working hypothesis, a treatment plan, and predicted obstacles to treatment. Alternatively, a dynamic psychotherapy approach would also include a description of psychodynamic factors, core psychodynamic ego states and transactions, and model of self psychology.

 

 

 

 

 

Effective Formulation

An effective formulation captures the essence of a patient's situation, providing a theoretical basis for it rooted in emotions, cognitions, and choices rooted in past experiences.

 

Formulation is often poorly taught due to misconceptions about their being time-consuming and useful only in long-term cases, although neither are true.

 

Formulations should be written down as a record and to organize thoughts.

There is a balance between being overly simplistic and complex, as well as relying too much on either observation or hypothesis. Movement in either direction will hinder effective understanding of a patient.

 

Effective formulations have the following characteristics (Sim, Gwee, and Bateman, 2005):

Integrative: Identification and summarization of symptoms and origins, especially for complex cases, can help narrow focus on key components.

Explanatory: Formulation allows insight into the history of a patient's views and responses to self and others, as well as providing a framework for understanding interactions between biology and psychology through a developmental lens.

Prescriptive: Understanding a patient's past and present guides future treatment choices with some certainty, especially as various emotions and behaviours emerge during therapy and threaten second-guessing.

Predictive: Formulation assists with prognosis and assessment of treatment success.

Compassionate: A greater understanding by the therapist allows greater empathy, including during acting out, nonadherence to homework plans, or other patient resistance.

 

Formulation must also be done in a cultually-sensitive manner in order to ensure a patient feels, and is, understood.

 

 

Can be structural, gathered from interview and analysis of responses.

Can be functional, gathered from the interview itself and other interactions by observing patient ABC's.

Formulation can depend on the specfic psychotherapy used.

 

 

 

Observe words, tone of voice, body language,

Observe in interactions (reciprocal roles) and identify examples of health/unhealth

 

 

Syndrome

A syndrome is a central feature with typical associated symptoms. Fear is the central feature of anxiety, while sadness is the central feature of depression. Mental health diagnoses are therefore patterns..

There should be no difficulty with multiplicity of diagnoses (co-morbidities).

Important question: are things that look the same, the same?

 

Duration

Minimum duration is important - feeling down for one day is very common and should not be too concerning.

 

Disability and Distress

Disability and distress are also very very important.

 

DSM Axes

 

What is occurring is sometimes unclear: use a working diagnosis, but make a differential. You may occasionally need to defer and observe over time.

 

DSM-V is in process as our thoughts evolve.

 

The DSM-IV is supposed to be a-theoretical. A criteria: what people need to have

Diagnostic criteria help with treatment and management, follow-up and evaluation of treatments, easier communication among health care providers, counseling of risk.

 

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Resources and References

Sim K, Gwee KP, Bateman A. 2005. Case formulation in psychotherapy: revitalizing its usefulness as a clinical tool. Acad Psychiatry. 29(3):289-92.

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