What are the 7 key variables to keep in mind during formulation?
- culture + ethnicity
- religion
- identity
- age
- children
- elderly
- gender
Explain the summary statement
- succinct + chronological
- key features drawn from case history
- 1-2 paragraphs
- re-state demographics: name, age, marital status, living situation, employment status, income and legal status
- presenting complaints + symptoms organized chronologically
- salient features in the background
Explain the diagnostic formulation
- arrive at primary WORKING diagnosis + rationale for this + consider differentials
- give specific examples of how their sx match DSM criteria
- mental health: disorders, comorbid, differentials you can rule out
- PD/personality traits: comorbidity b/w and within clusters
- medical conditions: may/may not be causally related to mental dx
- psychosocial + environmental stressors: do they contribute sig to the dev and exacerbation of disorders? housing, finance, education, occupation, primary support group, social environment, health care access, legal
What are the 4 key things to consider in a diagnostic formulation?
- mental health
- PD/traits
- medical conditions
- psychosocial factors
What are the steps to accurate diagnosis?
- Is the presenting problem real?
- Is there substance abuse?
- Is there a medical condition?
- Accurate diagnosis!
Explain the etiological formulation
- develop hypotheses to address in therapy
- consider context of sign/sx
- hypothesis about development + maintenance of disorder(s)
- integrate info across bio-psycho-social domains
- allows clinician to draw upon multiple theoretical perspectives
- 3 dimensions: biopsychosocial, developmental, temporal
What biopsychosocial factors do you need to consider?
- biological: genetics, physical medication condition, drugs
- psychological: info processing, attitudes/emotions towards self/others
- social: culture, gender, family structure, economic circumstances, rships to social groups
What are the aspects of an MSE?
- behaviour
- orientation
- talk + thought
- affect
- mood
- insight + judgment
What developmental factors do you need to consider?
- family (genogram)
- age
- job
- support/conflict/isolation
- life hx: infancy, early childhood, primary school, secondary school, training/university, work, relationships
What is the temporal dimension of formulation?
- 4 Ps
- predisposing
- precipitating
- perpetuating
- protective
What disorders may have low insight? Why is this important?
OCD psychosis ED PTSD PD (eg. narcissism) neurocog (eg. ALZ) substance use
- tx non-adherence
- involuntary commitment
- more complicated illness course
- criminaztion
What factors may impact prognosis?
- insight
- comorbidity
- motivation to change
- supports
- duration of sx (chronicity)
What are the different types of formulations?
- CBT
- systematic/family therapy
- psychodynamic therapy
- applied behaviour analysis
- CAT
Why would you use the SCID? What are it’s limitations?
- semi-structured more reliable than self-report
- encourage more thorough + objective approach to ax
- widest coverage of dx
- hierarchical: screen out dx to expedite administration
- high diagnostic reliability
- one-to-one correspondence to DSM-5
LIMITATIONS
- limited depth (only assesses minimal requirements for diagnosis)
- transparency (worded in pathological direction > vulnerable to response biases)
Why might chronic self-harm NOT be an indicator for suicide?
- might be about surviving rather than dying
- way of not feeling (numb, dissociate)
- way to get help or communicate distress to others
- turning in of anger (harm self instead of others)
What things drive self-harm and suicidality?
- hopelessness/loss of will to live
- depression
- grief
- situational distress
- need to reduce emo pain
- wish to communicate distress
- more comorbidities = higher risk of suicide
What things are vital to assess in suicidality?
- impulsivity
- substance use
- plan + intent
- access to means
- hopelessness
- history: attempts, family hx
- strengths: coping skills, personality traits, responses to stress, tolerance of psychological pain
What are the protective factors in suicide?
- marriage
- religion
- children in home
- reasons for living
- social supports
- therapeutic contacts
- psychotropics medications
What are some key protective factors?
- intelligence
- social supports
- physical health
- help-seeking
- access to services
What are some key perpetuating factors?
- ruminative style
- ongoing life stressors
- lack of social support
- avoidance
- substance use
What are the -ve sx of psychosis? What are the thought sx?
- lack of motivation
- asociality
- blunted affect
- poor self-care
- derailment
- word salad
- tangentiality
- clanging (eg. rhyming)
Why are early interventions for psychosis good?
- longer DUP = poorer outcome
- early identification = better outcome
- strain on rships
- interference w psych/social dev
- life disruption
- substance use
- family strain
- cost to community
What are the 3 key things to remember for PDs?
- pathological (outside normal range)
- persistent (5yrs)
- pervasive (across contexts)
What does a typical etiological formulation for psychosis look like? (5 Ps)
PREDISPOSING
- genetics (fam hx)
- lifelong schizoid traits (poor social skills, few friends, slightly delayed motor/cog milestones)
- early neurological insults (childhood head injury or encephalitis, obstetric complications)
- urban birth
- minority groups
- street drug use
- social stressors
PRECIPITATING
- life events
- stress drug use (esp ampehtamine-like drugs)
PERPETUATING
- critical/hostile/over-involved family environment (high expressed emotion)
- street drug use
- poor tx compliance
PROGNOSIS
GOOD: acute onset, early tx, good response to tx, female, good premorbid occupational/social adjustment
BAD: early age onset, insidious onset, poor premorbid adjustment, drug use, -ve sx
RELAPSE: med non-compliance, street drug use, family stress (high EE family), childbirth, life events
