formulation: putting the diagnosis into a therapeutic context and treatment plan

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  • C L I N I C A L P E R S P E C T I V E S Associate Editor: Michael S. Jellinek, M.D.

    Formulation: Putting the Diagnosis Into a TherapeuticContext and Treatment Plan


    What we observe is not nature itself but nature exposed to our methodof questioning (p. 58).

    W. Heisenberg

    Currently there are two competing methods for evalu-ating and diagnosing children with psychiatric disor-ders. There are marked differences between them. Oneis represented by the DSM-IVderived structured in-terview and is symptom based; the other is the tradi-tional open-ended interview, sometimes using play orprojective materials. The first is quantitative and seeksaccuracy; the second is more qualitative and seeksmeaning. Each has its own advantages and disadvan-tages. Together they represent the science and the art ofchild and adolescent psychiatry. The science of thestructured interview is built on reliability, evidencedbased, and tested by well-accepted research methods,although some question the clinical validity and com-prehensiveness of a symptom-based system that doesnot address underlying psychopathology. The tradi-tional open-ended interview is more subjective, hard toquantify, difficult to reproduce reliably, and heavilydependent on clinical judgment. Some argue that itssubjectivity is inevitably hit or miss and can never serveas the basis for a scientific medical specialty.This drift toward bifurcation rather than integration

    has been noted in the general psychiatry literature byGabbard and Kay (2001) in their article Fate of In-tegrated Treatment: What Happened to the Biopsy-chosocial Psychiatrist? They expressed concern thatgeneral psychiatry was moving away from comprehen-sive formulation and integrated treatment. They won-

    dered, for example, whether too narrow a focus wouldresult in limiting the impact of a therapeutic re-lationship that otherwise might improve the patientsadherence to medication and add to the overall im-provement. The child psychiatric literature has oftenneglected the integrated use of the biopsychosocialmodel. Our fields research on evaluation is supportiveof structured interviews used to assess symptoms anddiagnosis. However, much of this work has been definingdiagnosis and prevalence rather than focusing on for-mulation or the integration of biopsychosocial factors.Over the past decade, multiple pressures on our field

    have encouraged the use of a more reliable structuredapproach for diagnostic evaluation, often leading tomultiple diagnoses that are then prioritized. Currentmanaged care contracts offer higher rates of paymentfor time spent on psychopharmacology and scrutinizetime for evaluation and therapy. Many child psychia-trists, researchers, and pharmaceutical companies sup-port a symptom-based, structured approach as not justmore reliable but more succinct and accurate in itsability to define a treatment plan. Yet, many experi-enced clinicians and training directors have continuedto use the open-ended approach, using a broader rangeof evaluation and interventions than suggested by thesymptom-based approach. The effect of each methodon the frequency of medication use is unknown. Some,however, wonder whether the more focused, symptom-based approach results in more use of medications (Jell-inek, 2003; Zito et al., 2003). Of course, withoutexternal validation, one cannot know the correct fre-quency. In any case, the modern clinician needs toknow both methods and find the best way to combinefeatures of both with his or her own personal/profes-sional style.After gathering data using either or both methods, a

    formulation is necessary to sift, prioritize, and integratedata for treatment planning. We need to understandhow this patient and family came to be as we see them

    Accepted January 12, 2004.Dr. Jellinek is with the Child Psychiatry Service, Massachusetts General

    Hospital, the Newton Wellesley Hospital, and Harvard Medical School; Dr.McDermott is the former editor of the Journal of the American Academy ofChild and Adolescent Psychiatry and Professor Emeritus of the Department ofPsychiatry at the University of Hawaii School of Medicine.

    0890-8567/04/430709132004 by the American Academy of Childand Adolescent Psychiatry.

    DOI: 10.1097/01.chi.0000125090.35109.57


  • now. What initial problems, attempted solutions, andfurther dysfunction necessitated facing a child psychi-atric evaluation and treatment?The biopsychosocial approach to formulation iden-

    tifies three domains to be considered in every evalua-tion: the biological, the psychological, and the social.George Engel, the father of the biopsychosocial ap-proach, believed strongly that this broad approach wasessential to avoid premature closure of our efforts tounderstand the patients needs, tunnel vision, or anoverly narrow approach to treatment: While thebench scientist can with relative impunity single outand isolate for sequential study components of an or-ganized whole, the physician does so at the risk ofneglect of, if not injury to, the object of study, thepatient (Engel, 1980, p. 536). Engel conceptualizedthat a biopsychosocial formulation was an essential linkbetween evaluation and treatment planning.In this Clinical Perspective, we highlight the critical

    importance of a comprehensive and balanced formula-tion and offer an approach to integrate the three in-fluences, biological, psychological, and social, into aclinically meaningful framework for treatment planning.

    Limits of the DSM Symptom-Oriented Approachto Diagnosis

    Patients come to us with symptoms that are causingpersonal suffering and dysfunction in daily life andlimiting their optimal development. However, thesesymptoms are much like words in a dictionary whosemeanings change with the context. Consider the meta-phor in which the meanings of words in our psychi-atric dictionary (the DSM-IV) parallel words orsymptoms found in Websters (1991, OttenheimerPubs, Inc). For example, Websters defines the nounpipe as a tube for making musical sounds; a longtube to convey water or gas. However, a pipe, just likea symptom, has a number of possible meanings de-pending on its context. A pipe can bring us water towash in the morning or cook our food. It melts into thebackground of our lives until it breaks. Then the samepipe can cause disaster in our home, indeed in thewhole neighborhood.The word pipe can have very different meanings in

    different contexts. It can serve as a weapon in some-ones hand or be part of a celebration when played as abagpipe, or, metaphorically, it can be part of a pipedream or a description of intensity, as in piping hot.

    Likewise, the presence of a symptom is only a startingpoint, not sufficient by itself for us to understand thecontext, feeling, or behavior behind it. Is a childs op-positional behavior in school an attempt to cover up alearning disability? Or to re-engage the interest of adivorced father who is starting a new family? Or amaneuver to gain entry as a junior member of a school-based clique or even local gang? Or might it be relatedto an older siblings impending delinquency hearing? Isthat childs punching a peer related to bullying, hyper-activity, or physical abuse at home? Is the child fulfill-ing the family myth of physical dominance,compensating for being viewed as a sissy, or wrestlingwith emerging homosexual feelings? Of course thesesymptoms may reflect a biological vulnerability to frus-tration or anxiety, prodromal to affective disorders, andthus much less related to psychosocial environmentalchallenges. All the variables must be considered to-gether to weigh their influence.There are even more judgments concerning severity

    or impairment that the clinician must make in design-ing a treatment plan. How violent was the childs op-positional behavior? Provoked or unprovoked? Howfrequent? How typical for the particular classroomisthis a problem with the teacher? Or the schooldoes thisreflect a breakdown in the school as a safe place? Or thecommunityare street gangs common or unheard of?Many children come to mind when a comprehensive

    biopsychosocial rather than unidimensional formula-tion was critical to their treatment. One sixth-grade girlbecame quite oppositional and withdrawn at home andat school. Her parents, both mid-life university profes-sors, had very high academic expectations. This girl hadan undiagnosed learning disability (inability to orga-nize thoughts into paragraphs or produce a coherentessay) whose symptoms included feeling dysphoric, in-adequate, and hopelessly trapped. She could not meetthe expectations of sixth grade and was described by allher teachers (except her math and music teachers) as lazy,disobedient, distracted, and withdrawn. The school calledin the parents and wondered whether she should beadmitted to the junior high school. Symptoms quicklyresolved with tutoring, helping parents set reasonableexpectations, and the school seeing her as a hard workerrising to this challenge rather than predelinquent.Another child was a 14-year-old boy who presented

    with symptoms of depression, suicidal ideation, poorschoolwork, and avoidance of his friends, whose par-



  • ents were in the midst of a difficult divorce. The treat-ment plan included antidepressant medication,supportive therapy, tutoring to catch up in school, andappointing a court-ordered guardian ad litem to medi-ate the unending parental discord. His depressivesymptoms gradually improved, and he began to func-tion better, first with peers and then in school. Whichaspect of the treatment plan was most essential? Didthe interventions work in synergy? We do not know.

    The Diagnostic Process



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