What’s the Best Way to Teach Psychiatric Residents How to Make Case Formulations?

I periodically evaluate junior residents using the new clinical skills exam format and just finished another one. I posted something about this back in January after evaluating another trainee. Again I got a question from another trainee (who I thought did a wonderful job!) about where to get instruction about how to put together case formulations that are not only diagnostic summaries that enable a clinician to make a categorical diagnosis of a psychiatric illness, but allow integrative syntheses of development background to help us understand how patients got to where they are as adults. These evaluations are taking the place of the oral board examinations for certification in Psychiatry. The oral board exams have been the bane of examinees for many years in part because of the extreme anxiety they provoke. Preparing a resident in psychiatry involves a rigorous educational program over 4 to 6 years and they must master a vast amount of content knowledge just to become certified as safe and competent practitioners as defined by regulatory organizations. Elements of the clinical skill exam include interviewing skills, a mental status exam, case presentation, and case formulation.

Case formulation is the most demanding element. There are many references trainees can Google on-line to find. A classic paper often cited is the one by Perry and others[1]. It helps doctors and patients by balancing the focus on both what kind of disease the person has, and what kind of person has the disease. Case formulation is an essential skill which takes years of practice to master and I’m inclined to give a lot of latitude to trainees in their ability to demonstrate it, especially in the first year of residency. Another reason I’m pretty lenient is that I can’t remember ever being taught this skill. I make stabs at it that I’m pretty sure those trained at other institutions might wince at. Anyway, formulations can be used by psychiatrists in every subspecialty, including Psychosomatic Medicine, as the fictionalized examples will demonstrate.

Making useful case formulations can be frustrating for both trainees and experienced clinicians. On the other hand, if it’s not, there’s a good chance that oversimplification is becoming a problem. One pitfall that ironically comes with experience is dashing off a formulation that sounds deep using “psychobabble” but which misses the mark in describing the patient’s problems in the real world. Striking a balance between over inclusiveness and superficiality takes practice. Often, tying the formulation to only one model seems constrictive.

In general, making an integrative synthesis of the relevant factors in a patient’s clinical situation (abstracted from the history) is easier than making an integrative inference about why her problem exists. It helps to look for clues in the form of repetitive themes in a patient’s life which lead to conflicts that are resolved in maladaptive ways. There is no standardized format, and so there may seem to be as many formulation strategies as there are clinicians. Starting with a manageable framework can help. The phrases in bold type are the connectors that guide thinking and writing about the patient and help keep the focus on central issues:

This is a  age, employment status, illness state (acutely v. chronically ill), marital status,male/female, with  psychiatric symptoms list, duration of,  complicated byhead injury, substance abuse, medical syndromes, that we were asked to evaluate because of  consult requestor question.  She meets criteria for Diagnostic and Statistical Manual-IV-TR diagnosis.

Her psychiatric symptoms can be associated with or precipitated by medical diagnoses. They are also known to have familial pattern, affected/exacerbated by drugs, environmental triggers.

The current behavior may have been determined by a developmental background marked by abuse, neglect, conflict in family of origin, maintained longitudinally by pattern of maladaptive management of relationships and situational stressors.  Although cross-sectional exam cannot typically confirm one central conflict, she may have difficulties with independence v. dependence, intimacy v. isolation, generativity v. stagnation.

Typical defenses may include  acting out, denial, reaction formation, etc., which appears to be interfering with medical management, not an issue on the ward, and may be predictive of  chronic noncompliance with therapy, conflict with caregivers, eventual return to adaptive coping, etc.

Although the scaffold looks unwieldy and long, in practice (and with practice) it can be tailored to fit the clinical need. Certain neuropsychiatric problems seen by consultants don’t require any detailed analysis of defenses, e.g., uncomplicated drug-induced deliria in patients without any psychiatric histories. But just because someone does have a complicated psychiatric history doesn’t imply that the formulation must be long and detailed. The goal is always to succinctly summarize the central issues that describe and explain the patient’s current problems so as to guide recommendations for management.

Example case formulations:

  • 44-year-old multiply divorced, alcoholic, unemployed white male without formal psychiatric history, but with acute subsyndromal depressive symptoms without suicidality in the context of recent diagnosis of diabetes mellitus after being hospitalized with diabetic ketoacidosis. His father (who also had diabetes) died of suicide when the patient was 9 years old. Consult triggered by patient refusing to get up to toilet himself, crying, insulting the nurses, yet constantly on his call light. Depression is known to be associated with Diabetes Mellitus and can run in families. He may be conflicted between dependence and independence or struggling with stagnation developmentally, given his social and occupational marginalization. Regression appears to be major defense. Tolerance of nonthreatening behavior and allowing him control over non-essential features of his care may facilitate face-saving return to more adaptive coping with grief. Monitor for development of a more well-defined depressive syndrome; supportive approach with encouragement of affect but engage effective coping by modeling; query into past successful problem solving.
  • 37-year-old divorced white female teacher aide with abrupt onset of medically unexplained slow, garbled speech. Previous psychiatric history notable for one brief hospitalization in her mid-teens after impulsive overdose over a breakup with boyfriend. Temporal association of dysarthria with her discovering her current boyfriend in bed with her teenage daughter (reported by a friend). Her presentation is consistent with conversion reaction. Major conflict is desire to confront boyfriend but fear of rejection and abandonment. Major defense is somatization. Confrontation generally contraindicated; suggest that recovery will be fairly rapid; no invasive procedures or specialist referrals needed and the condition is not dangerous. Quick follow-up in mental health clinic scheduled.
  • 57-year-old disabled man who had a liver transplant and who has polysubstance dependence in remission and longstanding antisocial behavior referred for subsyndromal depression and anxiety along with insomnia. Recently arrested for shoplifting. Also engaging in reckless driving and fistfights, neither of which he’s done in decades either. No organic brain disease identified that could explain the behavior. Possibly struggling with generativity v. stagnation because of chronic unemployment leading to regressive acting out. Refer to psychotherapy, although resistance expected with more acting out and non-adherence.
  • 49-year-old woman with Hepatitis C (HCV) on interferon (IFN) for last 3 months and with gradually increasing symptoms of syndromal depression, personality change with marked irritability, and somatic complaints. Previously diagnosed recurrent depression in the context of Cluster B personality traits complicated by alcoholism and cocaine abuse, now in sustained full remission. Consult triggered by her erupting in the GI clinic at the gastroenterologist’s suggestion that cutting interferon dose might be recommended in light of her psychiatric status. She thinks that this means she’ll get cirrhosis, be denied liver transplant because of her drug history, and be condemned to die of liver failure. She blames doctors for missing the HCV diagnosis for years, yet feels stigmatized by everyone because of the diagnosis, and at the mercy of doctors who control the only effective treatment. Several cognitive distortions could be the issues in her depression including personalization, catastrophizing, control fallacies and blaming. Interferon is also known to be associated with depression and cognitive impairment. Cognitive Behavioral Therapy (CBT) intervention may be influenced by the latter side effect; antidepressants are an effective drug treatment of IFN-induced depression.

I’m sure many psychiatrists out there have favorite references and strategies they use to teach psychiatric residents the important skill of formulations. I’d be thrilled to hear your ideas and would welcome a guest blog post.

1.            Perry, S., A.M. Cooper, and R. Michels, The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application. Focus, 2006. 4(2): p. 297-305.

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