The Biopsychosocial Formulation Manual

A Guide for Mental Health Professionals

William H. Campbell, Robert M. Rohrbaugh

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135429430
• Edition: 1
• Topic: Medicine
• Subtopic: Clinical Psychology

Based on George Engel's model, The Biopsychosocial Formulation Manual presents ways to help psychiatry residents and students effectively gather and organize patient data to arrive at a complete mental health history in a limited timeframe. While most current models only take one factor into account, Campbell and Rohrbaugh emphasize and analyze three essential components (biological, social, and psychological).

The process of identifying pertinent data for each component of the biopsychosocial formulation is explicated in detail. A separate section outlines how to use the biopsychosocial formulation to generate treatment recommendations. This volume includes a complete package for practicing the biopsychosocial method; this easy-to-use guide includes a data record sheet and downloadable resources to facilitate organization and assessment, appealing to both the psychiatric professional and the trainee.

1

An Overview of the BiopsychoSocial Formulation Model

Many of us have had the experience of observing senior clinicians develop an awe-inspiring formulation after hearing a case presentation. The formulation organizes the patient’s presenting symptoms, facilitates an understanding of the genesis of the difficulties, and enables the development of a comprehensive care management plan for ongoing work with the patient. Many beginning clinicians wonder, “How did they do that?” Although trainees read the standard textbooks and study the Diagnostic and Statistical Manual of Mental Disorders (DSM), the process of organizing the patient data in a meaningful way and marrying it with the theory in an effort to explicate the patient’s difficulties eludes them. There is so much information from the patient and the literature that it is difficult to imagine generating a comprehensive biopsychoSocial Formulation. This manual was written with that purpose in mind.

The BiopsychoSocial Formulation Manual will assist clinicians by providing them with a structured paradigm to follow both in the initial collection and organization of patient data and in the process of crafting the data into a biopsychoSocial Formulation. The manual is not meant to take the place of a comprehensive textbook or the DSM. Students will need to know the symptoms and diagnostic criteria for mental disorders and have an understanding of the biological, psychological, and social theories that pertain to mental illness. We hope that by identifying the range of pertinent data, organizing the data, and providing a framework for analysis of that data, our readers will become more proficient and confident in their ability to develop biopsychoSocial Formulations.

The most efficient way to teach a new model is first to provide the student with a bird’s-eye view, so they can gain the proper perspective, and then to break the model down into its component parts for further study. Our model is comprised of seven sections: Biological Formulation, Psychological Formulation, Social Formulation, Differential Diagnosis, Risk assessment, Biopsychosocial Treatment Plan, and Prognosis. The basic outline of the BiopsychoSocial Formulation Model appears in Figure 1.1. It is our hope that as you use this manual, you will memorize the model so that it will become an internal mental template that you keep in mind as you evaluate all your patients.

Figure 1.1 The BiopsychoSocial Formulation Model.

A careful review of all seven sections will provide you with an overview of the data required to construct a comprehensive biopsychoSocial Formulation. A useful exercise at this point is to ask yourself how much of this data you routinely utilize in your current patient formulations. If you find there are a lot of gaps in your typical formulation, do not be discouraged, you are not alone. The purpose of this manual is to help you develop the skills to collect data and more fully utilize the data you collect.

The process of formulation begins by collecting and organizing patient data from the patient interview and chart review. The BiopsychoSocial Formulation Database Record (see Appendix D) is where you will record, organize, and begin the analysis of the data from your patient interview and chart review.

We will review the two initial steps necessary to devise a comprehensive formulation and then demonstrate how the Database Record will be useful to you in organizing this process:

1.  The first step is to complete your initial patient interview and chart review utilizing a standard format like the one on the Database Record. Many beginning clinicians feel as though they cannot do a formulation until they have many hours of patient interview data. We discourage this notion. A comprehensive formulation can be initiated after the first interview and will help the clinician focus on pertinent areas of the patient’s history in subsequent interviews.

2.  The second step is to begin to organize the symptom data you collected into broad areas of psychopathology. We suggest filtering symptoms into eight categories: mood, anxiety, psychosis, somatic, cognitive, substance, personality, and other. In order to perform this step appropriately, you must know the DSM categories and the symptoms for each of the disorders in each category. Also, be aware that some symptoms may fit into more than one category. Feel free to include symptoms in any of the categories in which they may fit. For example, insomnia may be a mood symptom, an anxiety symptom, or the result of a psychotic disorder (in which the patient stays awake at night because of paranoia) or substance-related disorder. Feel free to be overinclusive at this stage.

The BiopsychoSocial Formulation Database Record is divided into seven sections. These include the standard Psychiatric History, a Symptom Filter, a BiopsychoSocial Formulation section, and sections for Differential Diagnosis, Risk assessment, Biopsychosocial Treatment Plan, and Prognosis. The Database Record should be used in the following manner:

1.  Fill in the Psychiatric History section during or shortly after you conduct your interview with the patient. Remember to review the outline ahead of time so you know what data will be needed for a comprehensive biopsychoSocial Formulation.

2.  Sort specific symptoms as they are reported into the appropriate categories in the Symptom filter. Individual symptoms should be listed under as many categories as appropriate.

3.  After the interview has been concluded, it is time to begin the process of analysis. Complete the BiopsychoSocial Formulation section using the data obtained in the first two sections.

Using all the information you elicited, organized, and analyzed, complete the Risk Assessment, Differential Diagnosis, Biopsychosocial Treatment Plan, and Prognosis sections.

Now that you have the bird’s-eye view, including a sense of the first two steps in the formulation process and the structure of the Database Record, you are ready to begin formulating. A detailed review of each of the seven major sections of the BiopsychoSocial Formulation Model is contained in the ensuing chapters.

2

The Biological Formulation

CREATION OF A BIOLOGICAL/DESCRIPTIVE DATABASE

The biological database will draw upon much of the information you collected in your patient interview and chart review. Pertinent information for the Biological Formulation may include the following:

Demographics: Age, race and ethnicity, and gender may influence symptom presentation.

History of present illness: Presenting symptoms analyzed in the Symptom filter will be crucial for establishing a DSM diagnosis.

Past medical history: Physical disorders may cause or exacerbate mental illness.

Medications: Medications may cause or exacerbate mental illness.

Allergies: Rechallenging a patient with a medication, or another medication from the same class, that induced an allergic reaction in the past may result in a life-threatening condition (i.e., anaphylaxis).

Past psychiatric history: This may give clues to the longitudinal course of illness, previous symptoms and diagnoses, and responsiveness to medications.

Substance abuse history: This may be important in establishing comorbid illness or causation of current symptoms.

Family history: This may give clues to genetic predisposition and responsiveness of family members to biological interventions.

Mental status examination: Provides important information on mood, reality testing, and cognitive status.

Physical and neurological examinations: Abnormalities suggest underlying medical or neurological illness that may cause or exacerbate symptoms.

Diagnostic studies: Abnormalities may suggest underlying medical illness that may cause or exacerbate symptoms.

The first step in developing a Biological Formulation is to create a biological/descriptive database. As we discussed in the preceding chapter, the Database Record will assist you in eliciting and organizing the requisite clinical data for your formulation. After completing the Database Record, analysis begins by recording symptoms under one or more of the eight categories in the Symptom filter (Table 2.1).

Table 2.1 The Eight Categories in the Symptom Filter

Mood

Anxiety

Psychotic

Somatic

Cognitive

Substance

Personality

Other

The Symptom filter provides a logical means for organizing the information for presentation. It also serves to preclude the inadvertent omission, or “orphaning,” of essential data. Individual symptoms should be listed under as many categories as appropriate. The Symptom filter is a powerful tool that will also facilitate the development of a differential diagnosis and, by applying the principle of parsimony (i.e., Occam’s razor), a presumptive “working” diagnosis.

CLINICAL PEARLS

Two useful mnemonics may be employed to guide you in eliciting mood symptoms. The first of these, attributed to Gross (Carlat, 1999), is in the form of a prescription for energy capsules for depression (SIG: E-CAPS) and is used to assess the presence or absence of neurovegetative sym...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Introduction
• 1. An Overview of the BiopsychoSocial Formulation Model
• 2. The Biological Formulation
• 3. The Psychological Formulation
• 4. The Social Formulation
• 5. Differential Diagnosis
• 6. Risk Assessment
• 7. The Biopsychosocial Treatment Plan
• 8. Prognosis
• 9. Putting It All Together
• Appendix A. Other Psychodynamic Perspectives*
• Appendix B. Major Ego Functions*
• Appendix C. A Glossary of Psychoanalytic Terms*
• Appendix D. The BiopsychoSocial Formulation Manual Database Record
• References
• Index