Diagnosis, Clinical Formulation and Treatment

Diagnosis:

There are different aspects to the notion of diagnosis. First is, diagnosis is a descriptive catalogue of signs and symptoms. Signs are things that the clinician can observe. And symptoms are the things that are reported by the client’s subjective experience. Second, the diagnostic impression is a combination of the professional’s education training and experience. Just note that the descriptive database constantly changes based on new perspectives discoveries and interpretations replacing old notions. But that doesn’t mean that all of the old notions are no longer valid. For example, there have been the ideas of phrenology, Freud, Jung, humanists, cognitive behavioral and now we are seeing the influence of the neuroscientists. These are merely different perspectives or lenses through which to view the human condition. A recognized reference source for diagnosis is “Kaplan and Sadock’s Synopsis of Psychiatry.”

Clinical formulation:

Clinical formulation is basically asking what are the important dynamics and supporting factors that are driving the signs and symptoms, i.e. clinical presentation. Simply, why is this happening? Based on the clinician’s theoretical perspective, e.g., are they a Freudian or neuro scientist, etc. their clinical formulation will be focused on different aspects. It can be quite confusing when a professional is talking about the evolutionary, environmental, social biology influences or the cognitive mental constructs that are embedded in a person’s cultural, social, economic, class experience and what about the socio-biologists? WTH is a person talking about. When this is confusing, focus on the clinician’s premise or first principle thinking. To get some clarification, simply ask the clinician to explain their theoretical orientation in an understandable and common- sense manner. The reason is if you don’t understand; it’s difficult to take part in the treatment and likely won’t do it because it doesn’t make sense to you. The underlying point is it is your life. Get informed, do your own research, use your discernment and remember you are a sovereign being trying to make sense of your life.

Etiology means what is cause and subsequent other supporting factors that result in the signs and symptoms of the clinical presentation, i.e., the client’s complaint and reason for MH services. The whole question of what is causing and supporting the clinical presentation is the process of investigation. Think of this investigation of trying to fit five pieces of the clinical profile jigsaw puzzle (as noted in the above video). Relative to the idea of the wellness spectrum https://lovechangegrow.com/what-is-mental-health/.

A profile includes a review of historical events, medical conditions, psychological dynamics, social/relationship, vocational and education and financial aspects. The current relevant medical factors such as medical conditions, genetic factors, pain, drug and alcohol and laboratory results such as infections, pregnancy, hormones, etc. And the mental statics exam, which is a current snapshot of their state of mind, thoughts and mental processing and orientation to their situation, insight and judgement. These are the general jigsaw pieces a clinician uses to put together a clinical profile.

The important part of the clinical profile is called the clinical formulation. Clinical formulation is basically the asking of why is this clinical presentation happening now? And thus the clinical formulation, often gives clue to general treatment direction and frequently to specific interventions or approaches.

Treatment:

Remember, treatment primarily stems from the clinician’s education training and experience, which includes their theoretical orientation. The other influence that underlies treatment is the diagnosis. In the past few of decades, there has been the development of treatment protocols. The idea of treatment protocols is based upon the desire for standardization. We can see this push for standardization with the establishment of the clinical tools of the diagnostic statistical manual (DSM) which is a descriptive classification of mental disorders. And the International Classification of Diseases, revision 10 (ICD-10) is a tool of matching (coding) a diagnosis to a treatment procedure/protocols. The research tools of statistical meta-analysis of data, attempts to figure out what are the “best practices or most efficient treatments” relative to the diagnostic condition. Just be aware that the idea of “best practices” is based on a statistical model and may or may not apply to an individual’s circumstances or presentation. Also, there are institutional, marketing, and funding influences that are enmeshed in the “best practice or most efficient (less costly) treatments.” For instance, diagnosis “coded” to treatment have become almost a prescriptive protocol via insurance and lawsuits. Which is the standard of practice of getting authorization or pre-approval from insurance companies to ensure payment of the treatment. Also the DSM is a clinical short hand tool used between clinicians when communicating with other professionals.

A hands-on reference for a client and/or family member is to look at the “manual for inpatient psychiatric nursing care plans.” They are organize by types of behaviors and provide straightforward, supportive task-oriented interventions and will note the clinical rationale for the intervention. These manuals are a great resource for understanding treatment rationales and approaches. And can provide ideas for families in their day-to-day support of loved ones. It can give clues to understand why an inpatient or outpatient clinician may make specific treatments recommendations.

Remember, in treatment there are three general treatment prongs or pathways in MH. The first one is medications but the central issue for the client is their “quality of life” taking medications versus not taking the medications. Ideally, the client is fully aware (informed consent) of the risks, benefits and side effects of the medications. The second one is counseling, which can entail both insight therapy and life skills management. And last is having a wellness routine that works well in the client’s day-to-day life.

Many years ago, I was being interviewed for a position as an involuntary treatment or commitment officer. I sat at the end of a conference table where there were 8-10 potential colleagues, the department’s clinical supervisor and the medical director of the emergency services department. They asked two questions.

You are in the ER, there are five persons presenting with psychotic symptoms. One person is bipolar. Another is schizophrenic. One is depressed. The other has drug and alcohol involvement. And the last one, there is uncertainty whether the person is demented or delirious. Using the mental status exam, tell us which is which, what are the general treatment recommendations. And when and why would you detain or commit them?

Next you have five suicidal persons. One who is intoxicated, another is severely/acutely depressed, another who has been in the ER three times this week with suicide thoughts, another who is acutely psychotic and the last one notes that they have a lot on their plate, with stressors of relationship, finances, loss of job, and a history of PTSD. Again, using the mental status exam tell us, which is which, what are the general treatment recommendations and when and why would you detain or commit them?

Both questions are challenging on several levels. They are brilliant questions because they will quickly show your clinical knowledge, experience and will give insight into your thought process, decision-making and triage abilities while under pressure. Subsequently, I’ve used the same interview questions when coordinating emergency services teams. Btw, each question can be easily handled in 5-10 minutes.

The point is in diagnosis and clinical formulation, there is both the content and the process of evaluation. This results in a diagnostic impression and subsequent treatment direction. There is a spectrum of treatment interventions or options. Based on where a person is on the spectrum of severity, ideally you then match the intervention that has a reasonably expectation of benefiting the client.

Pro Tip: Ask the clinician what are the spectrum or range of interventions. Specifically ask them the “what, when, where and how’s” or what should I do when doing poorly. Basically, this develops a safety plan to hang on the refrigerator or near the phone to refer to when things are beginning to fall apart. Similarly, this process is much the same for a mechanic, dentist, plumber or veterinarian… you have their numbers by or in your phone, why would you not call the clinician that knows your situation. By the way, here’s the thing about crisis and suicide hot lines. They are fine for folks that don’t have a clinician. But just note these hotline folks may have little experience and may not know about the resources in your local community. They are a phone bank (sometimes in another state) and sometimes there are only a few qualified professionals overseeing a host of folks answering calls. Also they generally have a low tolerance for risk (anxiety) and have very little training. Thus, their standard response is to go to the ER or call for a police welfare check or they can track a phone call and alert local police for a response. And an interesting side note: In some communities there are discussions of whether a police response is appropriate and if the police even have the capacity and duty to respond to MH cases.

A professional’s ability to diagnose and treat is going to depend on the clinician’s education, training and experience. But it also depends on the symptoms the client is reporting, and how they appear (signs) that can be observed. The mental health professional is looking for the five pieces of information to get a reasonable clinical profile. The five pieces to this clinical jigsaw puzzle are: history and physical (including medications, lab reports, medical conditions, drug and alcohol levels), etc. The person’s psychological dynamic/personality, their social, educational and vocational functioning, their recent and current life situation/stressors and the mental status exam. Often one or two of these jig-saw puzzles can be missing, however a professional can likely fill-in or extrapolated the missing pieces.

As noted earlier, the clinical formulation basically asks why is this presentation happening now? The answer to the question of why gives a good indication of the treatment direction. And subsequently then the clinician pursues the logistical details to engage the client and or access the services. However, each community has a unique system, a range of resources and relationships. The range of resources and the link to these resources are quite fluid and changing which can change from moment to moment. So even though there may be a service or program, the ability, pathway and access to get in that program operates in a highly fluid environment. Given this reality, often the focus is on the goal of accessing the needed service. However the reality of access to the service is a process. At times it’s a logistical and nightmarish labyrinth filled with fear, anxiety, unknowns and competing interest, bias and agendas.

Kaplan and Sadock’s Synopsis of Psychiatry, the Diagnostic Statistical Manual (DSM) and one of the manuals for “psychiatric nursing care” are gold mines of information for individuals and families. Just a few hours of reading the relevant diagnosis, conditions, behavior and treatment will give you an excellent introduction and vastly help in advocating to get services for your needs.

This is a brief look into diagnosis, treatment and access to services. The intent was to offer a bit of insight, some reference sources and some sign post to help you navigate on your journey. Post your comments and questions. I look forward to these because then I can either address them in future post or perhaps in a question-and-answer event. If you have a question, there are probably other folks that have the same or a very similar comment or question. Just comment or send an email.

Blessings

Tim