1. Formulation
Dr Adebowale TO
NPH, ARO

2. THE PURPOSE OF THE FORMULATION
The formulation is the method used to integrate all the clinical data that are required in order to treat the patient and evaluate the outcome:
it is not a case summary.

3. Diagnosis v Formulation
A diagnosis involves a 'nomothetic‘ process.
This means that all cases included within the identified category have one or more properties in common.
By contrast the formulation is an 'ideographic' process (paints a picture of the individual').
Identifies the unique characteristics of each patient's case which are needed for the process of management.
We advance knowledge about diseases through normothetic processes but we use ideographic methods to understand and study the individual.

4. THE FORMAT OF THE FORMULATION
Demographic data
Clinically relevant demographic information: name, age, occupation, and marital status.
Descriptive formulation
Required information are chiefly derived from the history of presenting complaints, the mental state, and physical examinations which are necessary and sufficient for the syndrome diagnosis.
Describe the nature of onset, for example acute or insidious;
the total duration, and course of the present-illness;
Then list the main phenomena (that is symptoms and signs) that characterize the disorder.
try to be selective by emphasising the phenomena that are most important, either because of their greater diagnostic specificity or because of their predominance in severity or duration.
Avoid long lists of minor or transient symptoms and negative findings with no diagnostic significance.
Mrs Ade is a forty-five-year-old married housewife. Three weeks ago, following the death of her mother, she experienced an acute onset of an illness characterized by depressed mood, anhedonia, poor sleep, early morning waking, poor appetite and weight loss, poor libido, and constipation. She has had intermittent left chest pain. On examination she shows mild retardation of movement and speech, weeps frequently, and appears depressed. Her thought content is focused on the death of her mother and she has the delusion that she is responsible for her mother's death. Physical examination reveals recent and older bruising.

5. Differential diagnosis
List in order of probability all diagnoses that should be considered, and include any disorders that you will wish to investigate.
These will usually be syndrome diagnoses based on the descriptive formulation above.
Give the evidence for and against each diagnosis that you consider. Include any current physical illness which may account for some or all of the phenomena.
If you think a condition is worth investigating then you should include it in your differential diagnosis; if it's not worth mentioning don't bother to investigate it.
Remember that in addition to the primary diagnosis you may need to consider a supplementary diagnosis, for example alcoholism in a patient presenting with delirium, or a personality disorder in a patient with an anxiety state.
1. Depressive illness: Morbid grief reaction (preferred diagnosis). The symptoms and signs are essentially those of a depressive illness, with depressed mood, depressive thought content; and neuro-vegetative features. This has developed in the setting of bereavement and the content of abnormal beliefs and perceptions is limited to the bereavement.
2. Manic depressive disorder in view of the psychotic symptoms it is necessary to consider the possibility that this is a depressive episode in a bipolar affective disorder. However there is no evidence of manic episodes in the past.
3. Angina pectoris: the distribution of chest pain is more characteristic of anxiety than of myocardial insufficiency, but this possibility will have to be investigated before it can be excluded.

6. Aetiology The aim here is to answer these questions:
why has this particular patient developed this particular illness at this particular time?
Identify various factors that have contributed to the aetiology of the illness, as evident mainly from the family and personal histories, the history of previous illness, and the pre-morbid personality.
Organise them systematically into predisposing, precipitating and perpetuating groups & biological, social and psychological categories.
Predisposing factors include a family history of depressive illness in her mother, the death of her father during her childhood, and marked pre-morbid obsessional and dependent traits. The illness has been precipitated by the illness and subsequent death of her mother and her inability to face the ambivalent nature of that relationship.

7. Investigations
List all investigations that are required to support your preferred diagnosis and to rule out the alternatives, and also any that you think are required to improve your understanding of the aetiology.
Give reasons for investigations if they are not self­evident.
Include the need for, and sources of additional information as well as social and psychological investigations.
Learn to plan investigations systematically.
Investigations should include contacting her general practitioner to find out more about her past history of mental illness and review of her mother's hospital records. She also
requires physical examination, chest X-ray, and an ECG. It will be important to observe her mood state through the day, sleep, and appetite, and to keep a weight chart. Insight­oriented psychotherapy may help to determine the aspects of her bereavement that have determined morbid grief.

8. Treatment Outline the treatment plan that you. wish to follow.
This should stem logically from your discussion of the aetiology as well as from the diagnosis.
Consider each stage of management in turn: immediate, short term and long term plans, starting with the preliminary arrangements / setting, and finishing with the possible need for prophylaxis:
Treatment: It is preferable initially to provide treatment on an in-patient basis in view of the severity of Mrs Woods's depression and self-neglect, and this should be on a voluntary basis. If the physical investigations confirm that there is no evidence of cardiac disease she should be told of this and the ways in which psychological factors can give rise to chest symptoms should be explained. If the depressive symptoms persist in hospital following a few days' observation she should then be started on a tricyclic antidepressant drug with sedating properties, e.g. Amitryptyline, increasing to a full dose of 150 mgm at night after a few days. If no improvement occurs within two to three weeks it may then be necessary to consider ECT She should be encouraged to attend occupational therapy in order to maintain social and occupational skills. Psychotherapy should initially be supportive and, although some insights may be obtained, it should not be interpretive - at least until her depressive symptoms are much improved. It is too early to predict how much help she will need to adjust to her mother's death in the longer term.

9. Prognosis
What is the expected outcome of management of this illness episode, both with regard to the symptoms and also subsequent function, e.g. self-care and return to the community.
Consider the risk of subsequent relapse.
Give your reasons for these predictions.
Prognosis: Mrs Woods is likely to make a complete recovery from her present illness because it is an affective disorder (and these generally result in recovery); it had an acute onset and a specific precipitant; she has a supportive husband and no material hardship. The prominence of neuro-vegetative symptoms suggests a good response to tricyclic antidepressant drugs. However, she is likely to have some continuing difficulty in adjusting to her mother's death. She is constitutionally predisposed to suffer from depressive illness and is likely to suffer further episodes in the future, particularly when she experiences bereavement or other loss.

10. The Use of formulation
In the formulation the clinical data are used to set up hypotheses concerning the diagnosis and aetiology of the case.
The investigations, and the response of the illness to treatment, provide the method for testing them.
By observing the outcome of investigations and management we are able to discover whether our initial hypotheses were correct, but we can do so only if we recorded them in the formulation.
If our hypotheses are not supported, for example the patient has failed to improve with the planned treatment, then we have to review the accuracy of the original data.
This will require reappraisal of the history and mental state and possibly further investigations.