Assessment, Diagnosis and Formulation

Dr Jo BillingsUCL Division of Psychiatry

Clinical Mental Health ModuleMSc Clinical Mental Health Sciences / Mental Health Sciences Research

Overview

• What do we need to assess and why?

• How do you do an assessment?

• What is the difference between diagnosis and formulation?

Assessment – what and why?

AssessmentDiagnosis/

Formulation Intervention

What to include?

In small groups, brainstorm things you might want/need to ask when doing an

assessment?

What to include?

• What is the purpose of your assessment?• What setting is assessment taking place in?• How much time do you have?• What do you need to know?• What does the patient need to tell you?

What to include?• What is the problem(s)

– Nature of the problem– Recent example

• How did the problem develop– When did it start– How has it developed

• What caused the problem– Historical factors– Triggers

• What keeps the problem going (maintaining factors)– Biological– Social– Psychological– Environmental– Systemic

The 5 ‘P’s

1. Problems2. Predisposing factors3. Precipitants4. Perpetuating factors5. Protective factors

What to include?

• Risk• Previous treatment• Patient’s goals• Engagement with services/current treatment plan• Motivation to change• When is the problem not a problem• Strengths, resources and resilience

How to do an assessment?

Structured Unstructured

Open

Closed

Open vs closed questions

Open Questions• What has brought you here

today?• Tell me about when you first

noticed your mood was low?• What was your experience

of previous treatment like?

Closed Questions• What impact has this had on

your sleep?• When did you last work?• Have you taken anti-

depressants before?• Did you find your previous

therapy helpful?

How to do an assessment?

How to do an assessment?

“Conversation with a purpose”

Exercise – Role Play - Sam

MHP: Mental health professional working in a primary care mental health service.

Patient: 36 year old woman on maternity leave from her job as a marketing manager, referred by her health worker

Exercise – Role Play - Chris

MHP: Mental health professional working in a community mental health team

Patient: 42 year old man referred by his GP with physical symptoms and low mood. Currently signed off of work.

How to make sense of it?

The determination of which disease or condition is causing a person’s signs and symptoms

The theoretically-based conceptualisation of information obtained from a clinical assessment. It offers a hypothesis, or hypotheses, about the cause and nature of the presenting problems

Formulation

Diagnosis

Diagnosis

• DSM-V, ICD 10• Specific disorder labels i.e.

Major Depressive Disorder, OCD, PTSD

• Relevant research and literature

• Evidence-based interventions

Formulation

• Idiosyncratic • Why does this particular

person have this particular problem at this particular time?

• Helps tailor intervention to specific individual

Diagnosis vs Formulation

Formulation

• What is the problem?• When did it start?• How has it developed?• What earlier life experiences may have predisposed

the patient to developing this problem?• What is keeping the problem going now?• What strengths/resources does the patient have to

overcome the problem?

Formulation - Narrative

Mr Brown is presenting with symptoms consistent with the diagnosis of PTSD following a physical assault last year. It seems that this has triggered further memories of having been bullied at school and confirmed beliefs that he is weak and vulnerable.

Since the assault Mr Brown has been avoiding reminders of the assault, such as watching violent programmes on TV and trying not to talk to anyone about what has happened, which is preventing him from processing his memories of the attack. He has also been avoiding going out on his own or at night, which is preventing him from disconfirming his belief that he is likely to be attacked again.

Mr Brown is very motivated to engage in therapy and has support from his partner and friends. He has been determined to continue to going to work and attending the gym.

Formulation - Diagrammatic

Thoughts

Emotions

Behaviour

Physiology

What I’ve experienced

What that means to me

Current Problems and what keeps

them going

Formulation - Diagrammatic

Memories of Assault

I’m weak and vulnerable

Avoid reminders – don’t process memories or

challenge beliefs

Formulation - Diagrammatic

Vicious circles – inactivity

Vicious circles - Perfectionism

Vicious circles - Performance anxiety

Exercise - Formulation

Review the notes you took from your assessment of Sam/Chris

What do you think the diagnosis is?

Work on a provisional formulation of Sam/Chris’ difficulties

Exercise – Role Play - Sam

MHP: Present your diagnosis and provisional formulation to Sam

Sam: Give MHP feedback on the formulation

Exercise – Role Play - Chris

MHP: Present your diagnosis and provisional formulation to Chris

Chris: Give MHP feedback on the formulation

Questions

Recommended Reading

Aquilino, C. & Warner, J. (2004) A guide to psychiatric examination. PASTEST

Kuyken, Padesky & Dudley (2009) Collaborative Case Conceptualisation. Guilford Press: London

Noble, L. (2007) Written communication. Chapter in Ayers S, Baum A, McManus C, Newman S, Wallston K, Weinman J, West R (Ed.), Cambridge Handbook of Psychology, Health and Medicine Cambridge University Press

Westbrook, D., Kennerly, H. & Kirk, J. (2011) An introduction to Cognitive Behaviour Therapy: Skills and Applications (2nd Edition). Sage.