Good Psychiatry: The First Meeting, Giving Patient Feedback using The Case Formulation

This is the second installment of a series where I describe the care I offer to my patients.

After I have asked all the questions needed for the initial assessment, the next task (in the same appointment if possible) is to come up with my case formulation.

A case formulation is how a mental health professional understands the patient and the patient's symptoms.  It is coming up with the best explanation for what is happening and why.  The importance of doing a good formulation is that it should not only provide a rationale for the diagnosis given, it also lays out conclusions made from all the information gathered in the initial assessment to support the treatment suggestions and to predict treatment response.

Diagnosing a psychiatric illness in North America is based on a text called the Diagnostic and Statistical Manual of Mental Disorders.  It is in its 5th edition and so the text is most commonly referred to as the DSM-5.  To arrive at a diagnosis, a psychiatrist needs to ask a series of questions to see if the patient has "met the criteria" for any given illness.  For example, to have a diagnosis of major depressive disorder, one must have 5 of the 9 symptoms listed in the DSM-5 and the symptoms must last more than 2 weeks.  In my assessments, I run through the diagnostic criteria for 6 to 7 of the most common mental illnesses.  If I think another mental illness is present, I will need to book a follow-up appointment to assess further.  Diagnosing personality disorders, eating disorders, obsessive-compulsive disorders, trauma-and stressor-related disorders and neurodevelopmental disorders are some examples of disorders that require more time.

However, there is far more to someone's mental health than a checklist of symptoms.  And simply having a diagnosis does not provide patients any deeper understanding of their experience and how the illness arose.  This is where other information from a patient's life and psychology come into play.  For example, knowing the impact of early life attachments as well as adverse childhood events can be very helpful in explaining symptoms and patients' difficult emotional experiences.  We know that children develop coping mechanisms to chronic stressful situations that are adaptive when they are young while the trauma is happening.  But these coping mechanisms can outlast their purpose and cause enormous emotional suffering in life later on. 

Other patients may have flawed thinking patterns, even when there is no history of trauma.  Here, an understanding of different cognitive styles and psychological traits can be helpful in explaining how patients may perpetuate their own mental health suffering on an unconscious level.  A common example is people who judge too swiftly that things must either be good or bad with nothing in between.  We call this black and white thinking or all or nothing thinking.  This kind of thinking gets in the way of having relationships, compassion and emotional resilience.  An astute mental health clinician will listen for and pick up on these traits throughout an assessment. 

I use my case formulation to start the conversation with patients about next steps and expectations.  I will tell the patient my provisional diagnosis and how I have come to the diagnosis.  I will highlight different parts of the patient's history and thinking patterns that I believe are important to her presenting problem.  I share my impressions as fully as I can, even if the feedback is unfavorable.  I do this for several reasons:

1) To communicate to patients that I have been listening deeply and am trying to understand them deeply as well. I want patients to know I see them as more than just the illness. They are complete and valued individuals.

2) I want patients to understand what is and is not within their control.  That way, they can better focus their attention on what would increase their chances of recovery and not waste their efforts on things they can not change. 

3) It is a chance for patients to correct me if I have something wrong and to ask questions.

4) The dialogue that follows helps me assess further for the patient's psychological vulnerabilities and strengths. Is the patient capable of increased self-awareness and curiosity? This tells me how a patient may benefit from my involvement and to other treatments like therapy.