Assessment & Formulation

0:00 this talk is about how to organize your thoughts around assessment and formulation and Psychiatry I'll teach you how to do this by separating the assessment into a few different components first assess the diagnosis provide a differential diagnosis in particular highlighting which diagnosis or diagnoses you think are most likely and why you should also list other diagnoses you think are possible and why you think they are more or less likely second complete the formulation I'll go into more depth about this in a bit but for now know that the formulation is meant to answer the question of why is this patient presenting with these symptoms now third assess the treatment What treatments are you recommending for the patient and why remember to think not only about

0:46 medications but also psychological and social interventions finally complete the risk assessment this should include outlining the patient chronic and acute risk factors for self harm as well as protective factors against self harm and conclude with your overall Judgment of whether the patient requires a higher level of care such as hospitalization next let's talk more about the formulation as stated previously the formulation is meant to accomplish the task of answering why is this patient presenting with these symptoms now there are different schools of thought about how to answer this question and I'll explain a few of the more commonly used methods first is the biopsychosocial model this model involves considering biological psychological and social factors

1:31 contributing to the patient's illness such as those listed here second is the four Ps model this model considers four different types of factors that influence the patient's illness predisposing factors are historical factors that increase the patients likelihood to experience mental illness precipitating factors are the more recent or acute circumstances that directly triggered the patient's current episode of mental illness perpetuating factors are those that keep the patient stuck in their current episode finally protective factors are the patient strengths or positive circumstances that suggest a more favorable prognosis third is the perspectives of Psychiatry model this model conceptualizes mental illness through four distinct but overlapping explanatory lenses the disease

2:16 perspective which is the traditional medical model in which disease arises from a specific structural or functional pathology the dimensional perspective in which psychological traits exist on Spectra and extremes of these traits manifest as illness the behavior perspective in which behaviors are shaped by conditioned learning and the life story perspective which views a person's life as a narrative in which past events contribute to present outcomes in illness any of these models are fine as long as you answer that underlying question of why is this patient presenting with these symptoms now to conclude this talk I'll present an example of an assessment using the biopsychosocial model here's the patient's history of present illness now now I'll get into the assessment starting with the diagnosis section most

3:04 likely diagnosis is MDD based on experiencing depressed mood and hedonia and five other symptoms of MDD during the same 2-e period for the formulation section using the biocos social model biologically predisposed to depressive illness based on family history of mood disorders and comorbid medical illness psychologically demonstrates good help-seeking behaviors and coping skills socially recent relationship problems have acutely precipitated suicidal thoughts and housing issues and poor social support perpetuate their symptoms for the treatment section as patient is anti-depressant naive and has coexisting coronary artery disease managed with multiple medications will initiate caline based on its favorable

3:50 tolerability profile and due to its low cyp inhibition finally for the risk assessment section patient is at elevated chronic risk of self harm due to due to diagnosis of a depressive disorder unhoused status and poor social support more acutely elevated risk of self harm due to recent suicidal ideation requires hospitalization for safety and stabilization that's the end of this talk this has been a broad overview of assessment that I hope helps you to organize your thinking but over time feel free to deviate from this structure based on what you feel is most important for a particular patient remember the assessment is perhaps your most important job as a psychiatrist creating an understanding of the patient that incorporates disparate aspects of their life and experience into a

4:35 cohesive story and treatment plan thank you