Demystifying the Psychiatric Case Formulation

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Jeerson Journal of Psychiatry
Volume 10 |Issue 2 Article 4
June 1992
Demystifying the Psychiatric Case Formulation
Len Sperry, M.D., Ph.D.
Medical College of Wisconsin, Milwaukee, Wisconsin
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Recommended Citation
Sperry, M.D., Ph.D., Len (1992) "Demystifying the Psychiatric Case Formulation," Jeerson Journal of Psychiatry: Vol. 10 : Iss. 2 ,
Article 4.
DOI: h?ps://doi.org/10.29046/JJP.010.2.002
Available at: h?p://jdc.je;erson.edu/je=psychiatry/vol10/iss2/4

Demystifying the Psychiatric Case
Formulation
Len Sperry, Ph.D., M.D.
Abs t
ract
Until recently
case
formulation was an ethe
rea
l art, in that there was 110 standard,
agreed-upon format for co
nce
ptualizing and writing formulations. However, the in
crea
sing
emphasis on accountability in psychiatric ca
re,
the trend toward theoretical i
ntegration
, and the
diJIicul
ty trainees experie
nce
in mastering formulation skills highlight the
nee
d for a standard
format. The descriptive, etiological and
treatm
ent-progno
stic
co
mponents
qf
a formulation are
discussed as a standardformat for
co
nce
ptualizing and writing
case
formulations. Four written
formulationsaredescribedin t
erm
sofcontent, struct ureand process to illustrate thisformat.
Th
e psychi
atri
c fo
rmul
ati
on is th e clinician 's
com
pass guid
ing
trea
tm
ent.
It
sho uld acc ura te ly refle ct th e p at ient a nd hi s o r h
er
p
att
ern of
functioni
ng as well as
th e pr ecipit
ant
s, pr edi sposin g a nd pe rp
etu
atin
g fac
tors,
an d
prognosis
,while also
b
ein
g cle
ar
, conc ise
and
clinicall y useful. Yet , th e a rt
of
case
fo
rmu
la
tion
has been too
ofte n shro ude d in a m ystical a
ura
. L
ar
gely
thi
s is
because
the re
has
been no
s
ta
n
da
rd, ag
ree
d-upo n f
or
m at for conce p tua liz ing a fo rmu la t ion,
and
se
ldom
has it
been wri
tte
n or r
equir
ed as
par
t of a
case
record or do
cum
en
ta tion ( I).
Traditionall
y,
devel
opin
g th e sk ill o f f
ormu
l
atin
g
cases
ha s be en r eleg at ed t o indiv
idua
l
sup
ervision
and
case
conferences
durin
g psychi
atri
c residency tr
aini
ng (2) . U
nfortuna
tely, the
p
erf
orm
ance of rec
ent
gra dua te s in f
ormul
atin
g
case
ma
ter
ial on
ora
l
psychiatr
y
b
oard
ex am ina tions su gge st s th ese s kills may b e in ad eq ua te. A r ece nt poll for th e
B
riti
sh eq uiva len t of th e ABP N o ra l e
xa
mina tion f
ound
th
at
87 percen t
of
examin
er
s
m
ention
ed th e ca nd i
da
tes'
inability to
pr
es
ent
a co
here
n t for mu la tio n as th e ch ief
reason for fai
ling
th e e
xa
m (3) .
Tod
ay, th e sh ift
toward
bri
ef
er and m
or
e cost-effec tive psychi at ric t
rea
tm
ent,
as
well as
the
tr
end
tow
ard
th
eor
et ical
int
e
gr
ation
has re
sult
ed in c
ha
nges
in
our
und
erstanding
and
uti
li
zation
of
case
formu
lati
ons.
Th
e value and necessity
of
succinct, well-con c
ept
ua
lized ,
writt
en case
formu
l
ation
has been recogni zed
and
is
r
apid
ly be
com
ing a requiremen t f
or
psych
iatri
c eva l
ua
tions, di sch arge s
ummar
ies,
and
prior
authoriza tions for
tr
e
atm
ent
in
both
public and private sec
tors
(2).
Thus
, it
bec
om
es
imp
erativ
e th at psychi
atr
y
tr
ain
ing pro
gr
ams f
or
mally
an
d
more
syst
emati
-
cally facilitat e th e le
arnin
g and ac qu isitio n o f th e skill
of
case
form
u
lation
. A
s
ta
n
da
rdized
formul
ation
f
orm
at could g
rea
tly aid in developi ng
and
refining
thi
s
essen tial skill.
Thi
s p
ap
er bri efly d esc ribes th e co m pone nts
of
a
case
formu
lat ion an d
sug
gest s a
12

DEMYSTIFYING TH E PSYCHIATRIC CASE FORMULATION 13
s
ta
n
da
rd f
ormat
f
or
conce p tua lizing a nd wr iting cas e fo
rm
ulations.
Four
writt
en case
f
ormul
ati
on repo
rt
s f
or
a single
case
are
th
en
pres
ent
ed.
Th
ese r
eport
s reflect the
st
ruc
tu
re,
co nte n t and pr ocess a mo ng th e cu
rre
nt biological, psychodynamic, beh av-
iora
l and biopsy
cho
social orien
ta
tio ns
(4-9)
. A side -by-side compa rative ana lysis
of
th ese r ep
ort
s illu
str
at es th e
utilit
y
of
th e for
ma
t.
TH
E A ATOMY
OF
A CASE FORMULATI
ON
Basicall y, th er e
are
thr
ee co mpo ne n ts of a psych i
atri
c
formu
lation: des
cripti
ve,
etiologica l and
tr
e
atm
ent
-pr
ogn ostic (I). A desc
riptiv
e for
mul
ation is a ph
enom
en
o-
logical s ta te me n t a bou t th e n
atur
e, seve rity a nd pr ecipitan ts
of
an individual's
psychi
atri
c
pr
es
ent
ation
.
It
answe rs th e " W
ha
t h
app
en ed ?" qu est io n.
Whil
e th
er
e are
man y
diff
er
ent
ways to conce pt ualize
thi
s
dat
a, for all practical
purpo
ses, the
des
criptiv
e f
ormulati
on l
end
s its
elf
to DSM-III-R diagno
sti
c cr iteria
and
nosology.
An etiologica l
formul
ati
on
att
empt
s to
off
er
a ra t iona le for t he deve
lopm
ent
and
m
aint
en
an
ce
of
sym ptoms a nd dysfun cti
onal
lif
e p
att
ern
s.
It
is
mor
e expla
na
tory and
lon
gitudin
al in n
atur
e.
Eti
ological fo
rmul
ati
on s a nswe r th e "
Why
did it
happ
en?"
qu e
sti
on.
A
tr
e
atm
ent-pr
ogn osti c fo rm ul
ati
on follows
from
the descr iptive
and
etiological
for mulations a nd serves as a n explicit blu
eprint
gove
rning
tr
eatm
ent
int
erv
enti
ons
and progn osis.
Th
e
tr
e
atm
ent
f
ormul
ati
on addresses th e " W ha t ca n be
don
e about it
and how?" que
sti
on. As in th e o the r two
fun
cti on al typ es
of
formulations
, th
er
e migh t
be
ma
ny ways to
answer
this que
sti
on.
A review
of
recent pu blications
(4-9)
ind
icates
that
case
s
formulat
ed in four
major
or
ie
nta
tions- bio logica l, psyc hody na mic, b
ehavioral
and
biopsy
cho
social-
t
end
to enco m
pass
all th
ree
struc
tura l dimension s: d
escriptiv
e, etiologica l
and
treatment-
prog
nost
ic. P
ar
enth
eticall y,
the
review also
sugg
ests
som
e conve
rge
nce in
co nte n t a mo ng th e va ry
ing
app
roac
hes
.
Convergen
ce
ref
ers
to the e me rgin g simi
lar-
ities
amo
ng d ist inct
or
ie
nta
tio ns r
ath
er th an to a n a
ctua
l inte
gr
ati
on or s
ynth
esis
of
th ese o rie n
ta
tions (10 ).
Th
e
case
of
Mr.
Z. des
crib
es a rel
ati
vely
commo
n psychia
tr
ic pres
entati
on. It is
followed by four psychi
atri
c f
ormul
ati
ons to illus
tr
at
e th e p rocess
of
th e biological ,
psych odyn
am
ic, beh avi
or
al and biopsychosocial or
ien
ta
tions
. Each
formu
lation
is
org a nized in t
hree
sections, design
at
ed I
-III:
Sec
tio n I ref
er
s to the " de scripti
ve"
fun
ction
, II r
ef
er
s to th e
"e
tiolog ical" f unc tio n a nd IIIto th e " t
reatmen
t
-progn
ostic"
fun cti on .
TH E CASE O F MR . Z
Mr.
Z is a 4
0-year
-old bu sin essm an who pr e sent ed wit h com pla ints
of
loss
of
int
er
est in his
jo
b, hobbies, a nd fam ily over a p
er
iod
of
six weeks. He acknowledged
periods of
pro
f
ound
sad ness, red uced ap
peti
te wit h signifi
can
t wei
ght
loss, ins
omn
ia,
fatig ue, and re
curr
ent
thou
ght
s of d ea th , bu t d eni ed su icida l id ea tio n. H e d eni ed
any
pre
cip
i
ta
nts but
did
a
dm
it tha t his ex
pec
ted
job
promo
tion
had
not m
at
eri ali zed .

14 JEFFERSON
JOU
RNAL
OF PSY
CHIA
TRY
Mr.
Z des
cribed
him
s
elf
as
unu
su ally se rio us, co nse rva tive,
and
rel
ativ
ely un able
to express affection. H e also ac knowle
dge
d
tryin
g to be p
er
fect, ne
eding
to be in
con tro l of every socia l sit
ua
tion, and having an excessive
commitm
ent
to w
ork
.
Mr.
Zindi
cat
ed th at hi s
ma
rr
iage
had be
en
worsen
ing
for several yea rs and
des
crib
ed his wife as fli
ght
y, ove
remo
tio
na
l an d h elpless un
der
str
ess.
For
the past,
severa l
yea
rs she had be
en
angry, dist
ant
, and had declined to be invo lved s
exu
ally
with
him
. Since th e o nse t o f his sym p to
ma
tology, however, she
had
b
een
soli cit ous
and obviously conce
rne
d.
Th
e Z's have two childre n, a boy, 12,
and
agirl, 10, who
ap
peare
d to be d
oin
g we ll a t schoo l a nd h
om
e.
Mr. Z described his f
amil
y of origin as very poor. His fa th
er
des
ert
ed his m ot her
whe n the p
ati
ent
was 12
yea
rs of
age
and, as th e oldest child, he
had
to tak e
co nside ra ble r esp onsibility f
or
you
nge
r siblings, as we ll as to work
part
-tim
e while
a
tte
nding scho ol. He kn ew th
at
his
mat
ern
al g ra nd fat he r h ad
com
m
itt
ed sui cid e and
th
at
two m
at
ern
al uncles w
er
e alcoholics. A p
at
ern
al uncle had died in
prison
aft
er
a
long period of
antis
ocial behavior.
Physical , l
abor
at
or
y, and n
eurolo
gical studies w
er
e negative.
Axis I 296.22 M
ajor
D
epr
ession , sing le episode
Axi s II 30 1.40
Obs
essive-C
ompul
sive P
er
son
alit
y Disorder
Axis III No relev
ant
curre n t ph ysical dis
ord
er
Axis IV 3; Mod
er
at
e st ress
with
ma
rit
al discord
Axis V GAF now 50; past 12
mon
ths 69
BIOLOGICAL FORMULATION
I.
Th
is is
the
first psychia
tr
ic
consu
lta
tion
for a 40 year old
marri
ed male. He
presen ts with a six-wee k history
of
profound
sadness,
w
eight
loss, decr eased appe tite,
a nhe do nia a nd rec
urr
en
t d
epr
essive dis
ord
er and
suicida
l threat.
Fur
th
er
inf
orm
a-
tion is need ed abou t mood reactivity, the na
tur
e
of
th e
insomnia
,
diurnal
vari
ati
on,
excessive gui lt, psyc homo
tor
agi
ta
tion
or re
tar
da
tion,
mela
ncho lic
sympt
oms, hope-
lessness, and t houg hts of de
ath.
Alt
houg
h scree
ning
physical
and
n
eurologi
cal exa ms
a nd lab orat ory eva l
ua
tio ns
wer
e neg
ativ
e, insidi ous m edical conditions, d
epr
esso-
genic medi c
ati
ons, an d
dru
g a nd alco ho l ab use m ust a ll be ru led
out.
Con
curr
ent
st ressors an d
ava
ila ble su ppo rt sys te ms n eed t o b e ca re fully asses sed sin ce s uch
reso
urces can r
edu
ce th e i
mp
act
of
pot ent ial stressors.
II.
Mr.
Z's positive fa m ily hist
or
y of suici
de,
alco hol ism
and
sociop
athy
has
ge ne tica lly
pr
edisposed him to an affec tive dis
ord
er.
Th
ough
job,
marital,
and
family
s
tressors
have been identified, it is
ju
st as likely th at they
ar
e a r
esult
r
ath
er
than a
cause
of
the d
ep
ressive sym
pto
ms. Assu ming the re is
not
oc
cult
or subclinica l medi cal
cond ition, pr
escr
ibed
med
i
cat
ion,
or
alcoho l
and
dr
ug use th
at
is etiologic and that
mela ncho lic fea t
ures
are
pres
ent, t he diagnosis
of
Maj
or
De pression, single episode is
established . Given Mr.
Z's
cur
rent
cogn
itiv e s tyle, a hei gh ten ed risk for s uicide is
pr es
ent.
III.If suffi
cien
t
fam
ily
support
for Mr. Z's care
out
side a structured environment
cannot
be
assur
ed,
inpat
ient
hosp
ita
l
ization
is r
ecomm
end
ed.
A het
er
ocyclic an tide -

DEMYSTIFYING THE PSYCHIATRIC CASE FORMULA
TION
15
pr
essant-rath
er
than
a
MAOI
or
psy
choth
erap
y-would
be th e
treatm
ent
of
choice,
mon
i
tor
ed by a psy
chiatrist
well-
experi
en
ced w
ith
psy
choph
arm
acology. If th e insom-
nia
was
of
th e
init
ial typ e, a
mor
e s
edating
drug
like
imip
ra
min
e,
trazado
ne or
maprot
iline wou ld be
tri
ed first.
Th
e
pati
ent
and
his rel
ati
ves wou ld be educ
ate
d
abo ut th e d
epressiv
e
disorder
, its
prognosis
, a nd th e th
er
ap
euti
c and side effects
of
th e m edi
cation.
This
education would
includ
e a discussion
of
th e a
nti
ci
pat
ed thera-
pe ut ic e ffect, th e es tim ate d
duration
of
tr
eatm
ent
, a nd th e
imp
ort ance
of
compliance
with
medication
and
follow
-up
appointm
ent
s. Sch
edul
ed weekly visits, with pho ne
calls as
need
ed,
wou ld be s et for th e first two
month
s. Sessions would be cha nged to
bimonth
ly
and
th
en
monthl
y,
assumin
g ad
equat
e re
spon
se
and
re solu tion
of
symp-
toms.
In th e
unl
ikely ev
ent
that
only
a
partia
l r
espon
se was ach ieved aft er 4 to 6
weeks ,
drug
plasm
a leve ls wou ld be
drawn
a nd th e do se w
ould
be a
djust
ed. If no
improv
em
ent
in
symptoms
oc
curr
ed ,
triiodothyronin
e, 25 meg / day, would be ad ded .
If
a
noti
c
eab
le r
espons
estill
had
not
oc
curr
ed , a pr ot ocol for
tr
eat m ent-resista nt
d
epression
would be followed . Given
that
Mr.
Z's
mood
di
sord
er
had sufficiently
improv
ed,
th e need for con
curr
ent
psy
choth
erap
ywould be assessed .
Dr
ug
main
te-
nan
ce wou ld continue for
at
le
ast
six m
onth
s afte r a full
rem
ission
of
symptoms
.
Thi
s
wou ld be
at
approximat
ely
50-75
%
of
th e th
erap
euti
c dos e . Su bseque nt ly, the dos age
would be
furth
er
tap
er
ed a nd th en di
scontinu
ed if possible.
PSY
CHODY
NAMIC FORM ULATION
I.
Th
e
pati
ent
is a 40-ye
ar-
old m
arri
ed busin es
sman
who presented for evalua-
tion
and
tr
eatm
ent
afte r b
eing
passed ov
er
for
promotion
about eight weeks
prior
to
evaluation. Sin ce th
en
he
not
es d
ysphori
a, anhed onia, and veg
eta
tive
symptoms
of
d
epr
ession. He al so r
eports
a re
currin
g th
ought
to
run
off and be fre e
of
d
emands
,
and a ni
ghtm
ar
e in whi ch he expe rie nced a
prof
ound
dr
ead of bein g
far
away and lost.
His
fath
er
was describ ed as tyr
anni
cal, critica l, a nd
un
successful as a
bus
inessman,
whil e
moth
er
was ov
erprot
ective
and
intru
sive. She wor ked, a nd thou gh sh e did not
dat
e
or
r
em
arr
y, l
ead
an active social
lif
e afte r h
er
husb
and
a
ban
do ned th e fam ily
wh
en
th
e
pati
ent
was 12.
Mr.
Z
app
e
ars
to meet cri
ter
ia f
or
a diagn osis
of
Major
D
epr
essive
Episod
e.
His
fami
ly
history
is positive for chro nic de
pression
as well as
alcohol d
ep
end
ence, suicide
and
antisocia l beh avi
or
s
ugges
ting the possibility of a
gene t ic pr
edi
sposition
for
major
psy
chopath
ology, s
pec
ifically for uni polar d
epr
es-
sion.
Mr.
Z is in th e l
att
er
stage
of
ad ult
"se
tt li ng d own" o r th e beg inn ing
of
mid-life,
brin
ging
with
it th e p
er
c
epti
on th
at
one has a
limit
ed fut
ure
an d h ighl igh tin g t he
incr
eas
ed
imp
ort
an ce of sta bility
and
pro
gr
ession occu
pat
iona
lly and
endur
ing
intimat
e
and
social r
elation
ship
.
Str
ess
ors
such as m
arit
al and fa mily difficulties as
well as b
ein
g passed over f
or
pr
omoti
on could be not ewor th y na rcissistic injuries
which could
furth
er
pr
edisp
ose Mr. Z tow
ard
clinical d
epr
ession .
II.
Mr.
Z appe ars to
hav
e a central conflict b
etw
een a need to be
perf
ect and in
control, a nd an
und
erlying im age
of
him
s
elf
as w eak ,
imp
erfect , an d lonely. He
reco
gniz
es in
himself
a mi ld de
gr
ee of an g
er
tow
ard
su
per
iors and pe
ers
,
but
has
nev
er
expressed
thi
s. H e
int
ern
alized his m
oth
er'
s ex
pec
tat
ions , bu t h
ar
bors s ubsta n-

16 J EFF ERSON J OURNAL OF PSYCHIATRY
tial ange r a t h
er
ov
er-intrusiv
e d
em
ands
and
push
es asi de th e issu e
of
f
ath
er
. He
fr
equ
entl
y looked for support
from
male teach
ers
but
seld om foun d a m
entor.
He
ex perie nces a good d eal of s
elf-doubt
,
but
hid es
this
effec tive ly at work. Falling in love
and early m
arriag
e was cl
early
a positive ti
me,
alt ho
ug
h he
often
has
want
ed to
co nt rol th e m
arri
age.
Th
e p
ati
ent'
s d
epr
ession ca n be
und
erst
ood in t
erm
s
of
his und erlying pr
of
ound
dis
appointm
ent
in
him
s
elf
, his fe
ar
of f
ailur
e in his m
oth
er
's eyes,
inabi
lity to ga in
at te n tion
from
th e boss,
and
fe
ar
of
ex pos ure to his
wif
e.
Th
e conflict
betw
een a need
to
prov
e
him
self
and his fea r
of
inad
equ
acy, dep
end
en
cy an d loss
of
control
is cen
tra
l.
Th
e
age
s
of
his c hild re n r
einf
orce a
fant
asy th
at
to leave is a
solution
which he
expe rie nced with his f
ath
er.
Prim
ary d
ef
en
ses in
clud
e re
press
ion, r
egr
ession,
intr
ojec-
tion,
int
elle
ctu
aliz
ation
and isol
ati
on
of
affect.
III.
Int
erv
ention
with
an a nt ide p
ressa
nt m
edi
cation such as f1uox
etin
e is the
pr
ef
e
rr
ed
initial
tr
e
atm
ent.
H oweve r, it ca n b e a n tici pa ted
that
Mr.
Z will expe rience
diffi
cult
y
with
cont rol, d
ep
end
en
ce on medica tion , and acc
eptan
ce
of
his illn ess. He
ma
y b e gua rde d, scr u pu lous, qu e
rul
ous, overco nscie ntious a nd
obstinat
e. He is likely
to bec
om
e di
stru
stful of th e th
er
api st a nd fe
ar
he is cont ro lled,
and
und
erlying
conflicts and
tr
an
sf
er
en
ce
reac
tions will
emerge
as a
part
of
medi
cation
mana
ge-
m
ent.
Th
e p
ati
ent
may
a
tte
mpt to elicit sup
por
t
from
the th
erapi
st espec ia lly if the
th
er
api st is m ale .
Initi
ally, he
may
be ingr
ati
at ing
and
superfica lly co m plia nt, bu t
soon
Mr.
Z may e
ngage
t he th e rapi st in com
petitive
s
tr
ugg
les and
may
well
see
him
as unc
arin
g, as was t he sit
ua
tion wit h his fat
her.
Hence, a deva
luati
on
of
the
t
her
ape ut ic process may develop, wh ere any s
uggest
ions
or
re
comm
end
at
ions by the
the ra pist m ay be me t
with
disd
ain
.
Thu
s, th e th e r
api
st will ne ed to be
attun
ed to the
p
ati
ent
's need for a rel
ati
on
ship
,
and
sim u
ltaneo
us fea r
of
intimacy.
Th
e th
er
ap ist
m ust b e ac t ive wit h th e p
ati
ent
, yet respect b
oth
th e n
ecessary
distan
ce an d
fun
da
me n
ta
l feelings
of
int
ru sion which this
pati
en
t will
exp
eri
ence.
BEHAVIORAL FORMULAT
ION
I. At th e
age
of
40,
Mr.
Z is e xpe rie nc
ing
his first episode
of
major
d
epr
essive
d isord er.
Th
er
e is
pr
obabl e ev ide nce for a n Axis II dia gn osis
of
obsessive-
compul
sive
p
er
son
alit
y disorder.
Mr.
Z has ex pe
rience
d a
pr
of
oun
d c
hang
e in his b
ehavior
over a
six-week period m
anif
est ed by
ma
rkedly r
edu
ced enviro nme ntal
int
er
action
s
with
in a
ra
nge
of social s
tim
uli (job, hobbie s, fa mily), by cog nit ive d istor tions
(sadn
ess, rec
ent
tho ug
hts
of de
ath
), and by a
lte
red physiological behaviors (sleep,
app
etit
e, e ne rgy
level).
Th
e two maj
or
clinical hyp
oth
eses
are
t
ha
t a c
hange
in work sta tus (f
ailur
e to
be
prom
oted) an d a loss of sou rce
of
p
er
son al r
ein
forcement (d ecr eased m
ari
tal
sa tisfaction)
were
su fficie n t t o elicit th e ex
press
ion
of
depressive symptoms.
II. Being passed o
ver
f
or
prom
oti
on and the loss
of
p
ersona
l r
einfor
c
em
en t
a
ppe
ar
to have
pr
ecipi t
at
ed a n umber of negative sc
hemas
.
The
se
ar
e
ampli
fic
ati
ons
of
preexi st ing l e
arn
ed behavi
or
and cognitive
pa
tterns
(res
tr
i
cted
em otiona l res po n-
sivity,
nega
tive cog ni tive se t , excessive
expec
tatio
ns) as well as an inn
at
e gen
eti
cally
det er mined vu
lne
rab
ility to loss
of
enviro
nmen
ta
l re
infor
cers
(mat
ernal
gr
andf
ath
er

DEMYSTIFYING
THE
PSYCHIATRIC CASE FORMULATIO N 17
comm
itted
suicide)
and
maladaptiv
e
familial
p
att
erns
of
beh avior, possibly secondary
to al
exithym
ia (alcoholism
and
sociopathy
in family m
emb
er
s).
III.
Tr
eatm
ent
pl
annin
gwould incl ude cognitive
strat
egies to recognize
and
diminish
n
egativ
e sch
emas
or cognitions
and
dev
elop
or in cr eas e posi t ive a
ttributions
and
int
eractions
. Relaxation
training
and
distr
a
ction
pro
c
edur
es would be
under-
tak
en to help secure
sound
slee p
and
diminish
ed no
cturn
al
rum
inat ion. T he
centra
l
th
em
e to
treatm
ent
p
lannin
gwould be to h
elp
Mr.
Z ree
stabli
sh co
ntro
lover his own
th ink in g. H om ewor k would be assigne d to r
einfor
ce th ese ac tivities
after
they had
be
en
mod
elled in th e office. Also
included
would be an exercise
reg
ime
nwith daily
quota
s. Sp ecific
hypoth
eses would be fo
rmulat
ed and test ed by having the pa tient
gath
er
and
reco rd
data
(for
exa mple,
improvem
ent
in
mood
following
exerc
ise or the
abi lit y to disru p t no
cturna
l
rumination)
.
The
ma
r
ita
l
situ
ation
would be explored
furth
er
ba sed o n th e o bse rvat ion
tha
t
th e r e
cen
t cha nge in his
wif
e's
r
espons
es is
mor
e likely to r
einf
or
ce helpl essn ess
and
maladaptive
sick role
behav
ior
than
a heal t hy
int
era
ct ion a nd n
orm
al sex life. If
appropria
te,
couples th
erapy
wou ld be
suggest
ed to
modif
y th e se
int
er
acti ons. In view
of
the biologica l
featur
es
of
illn ess,
tr
ea
tment
with
medi c
ation
would be suggested
but
acc
eptan
ce wou ld d ep
end
on th e
pati
ent
's a tt ributions a nd beli
ef
sabout the
appropriat
en ess
of
medic
ation
and it s possible efficacy.
Th
e p
ati
ent
's high
need
for
control
might
well cre ate a reluct an ce to
tak
e
drug
s
althou
gh , if ini t
iate
d,
comp
liance
wou ld
probab
ly be excellen t.
Con
curr
ent
dru
g and beh avi
or
al
tr
ea tment cou ld be
syn
er
gisti
c a nd b en eficial.
Th
e
imm
ediat
e
prognosi
s w
ould
be exce lle nt, b ased on t he fa ct tha t this is a first
episode in an
individual
with
high level s of ac hieve me n t.
Mr.
Z's
perso
na lity sty le will
be conducive to
stron
g collaboration in th
er
apy based on a need to
mast
ery.
The
prognosis for th e
marri
age w
ould
be less cer
ta
in, based on th e wife's possible
pr
efer
ence for h
er
husb
and
in his d
epr
essed sta te .
BIOPSY
CHOSOCIAL
FORM
ULATION
I.
Mr.
Z is a 40-y
ear
-old m
arri
ed
busin
e
ssman
who
se d
epr
essive-like sym ptoms
b
egan
sho
rt ly
aft
er
b
eing
passed over for a
promotion
.
Oth
er
stress
ors
a
ppear
to be
chronic
marita
l
and
s
exu
al
problems
and th e fact
that
his two childre n are nearin g
th e ag e
of
independ ence
and
th e
ag
e when he
exp
eri en ced a significa nt
tr
au ma in his
own life, i.e., the
des
ertion
by his
fath
er
wh
en
he was 12.
Althou
gh th
er
e is a positive
fami
ly history for alc
oho
lism , s uicide
and
sociop
ath
y,
Mr.
Z d
eni
es othe r psychiatric
symptoms
or
tr
eatm
ent
for
hims
elf.
Mr
. Z's
fami
ly hi
stor
y of alcoholism, suicide, a nd
so
ciopathy
mak
es it li kely th at he has a g
en
eti
c
predi
sposition for affective illness. He
appe ars to have
major
conflicts ov
er
dep
end
en cy a nd a uto no my. Bec au se of his ea rlier
ex pe rie nce
with
signific
ant
loss , th e
withdraw
al of a
tte
ntion a nd affection by Mr. Z's
wif
e a nd th e
growin
g ind
ep
end
en
ce of his childre n r
epr
es
ent
significa nt precipitati ng
events.
Mr.
Z has conside
ra
ble diffi
cult
y expressing e mo tio ns a nd affec tion . H e is
controlling and p
erf
ecti
oni
sti c. Hi s cog nit ive s tyle is obsessive-compulsive. His
prim
ary d
ef
en
ses
ar
e r
epr
ession ,
regress
ion,
int
roj ecti on , isolat io n o f affect, and
int
elle
ctu
aliz
ation
.
Mr.
Z's sociocultu
ra
l back
ground
has hel ped to instill in him a

18 JEFFERSON JOURNAL OF PSYCHIATRY
basic beli
ef
in
th
e value
of
h
ard
work
, stoicis m a nd se lf- relia nce wit h li
ttl
e dep
en-
den ce on extra-fam ilial
sour
ces
of
su ppor t.
From
a young
age
, he has be en reinforced
to sacrifice
hims
elf
and
to
main
tain
th e rol e
of
provid
er
and
nurtu
rer to oth
ers
who
have d
ep
end
ed
upon
him
f
or
support.
Mr.
Z is also dist
ant
from
his fam ily
of
origin
and
his cu rre n t
lif
e cen te rs aro und his
imm
ediat
e fam ily. His role has
been
as a
provid
er
to a
wif
e
and
childre n wh o have been dep
end
ent
upon hi m. Mr. Z
and
his
wife have
not
be
en
able to
form
a sa tisfac tory m
arit
al coa lition, th ey do few
things
tog
eth
er,
and
th
eir
s
exual
r
elation
ship
has det
erior
at
ed. His wife had
withdrawn
emotionally
and
s
exu
ally
from
him
until
his rec
ent
probl
em
s, whi ch
promot
ed h
er
att
ention
and conce rn .
Mr.
Z
has
be
en
ab le to ad
apt
fairly well ed
uca
t
iona
lly
and
oc
cup
ationall
y,
and
is a succe
ssf
ul busin
essman
. However, he has li
mit
ed social
re
lat
ionships, no clos e fri
end
s,
and
few
indep
end
ent
recr e
ati
onal ac tivities .
II. Mr.
Z's
p
rob
able biological
pr
edisposi
tion
to
aff
ective ins
ta
bility, coupl ed
with
the a
bandonment
by his fat her a nd fa milial
and
socio
cultura
l r
einf
or
c
em
ent
, res
ulted
in the dev
elopment
of
a rigid, obsessive
-comp
ulsive p
er
son
alit
y. His rol e evo lved
into
one
of
stoic,
hard
-wor
king
, self-sac rifice in
the
servi ce
of
ot he rs who
are
dependent
upon
him and a d
enial
of
his own dep
end
en
cy need s.
Whil
e ada pt ive e
ducationa
lly
and
oc
cupationally
, his p
er
sonalit
y st
ruc
ture and
ego
d
ef
en
ses re
sult
ed in an
isolated
lifestyle and th e
inab
ility to acknowled ge his own feelings
or
to rel
at
e to oth
er
s w
ith
w
armth
and affection.
Th
e sy mbo lic a ba ndo nme n t by his w ife a nd ch ildre n
reawak-
ened old d
ep
end
ency conflicts,
thr
eat
en
ed his a
da
ptive ro le in life,
overwhe
lmed his
rigid d
ef
enses, and re
sult
ed in a nxiety, re
gr
ession , and d
epr
ession.
II
I. A
pr
obl
em
list includes I) clinical d
epr
ession ; 2)
mar
i
ta
l
discord
includin
g
se xua l diffi
cult
ies; 3) an obsessive-co mpulsive style; 4) li
mit
ed social
support
syste m
with
fri
ends
; and 5)
limit
ed recr e
ati
onal activities. Initial trea tm ent will include an
an tide p res sa nt
and
sup
por
tive psych
oth
er
ap
y evolving to insigh t-oriented
tr
eatm
ent
as d
epr
essive sympto ms aba
te,
possibly in a
gro
up f
orma
t.
Coup
les
the
rapy
includin
g
work on sex issues co uld also be initi
at
ed afte r sym pto m
ame
lio
ration
.Finally, th e
p
ati
ent
will be a ided in incr easin g his suppor t sys te m a nd rec reat ion al activities.
Since
thi
s is a sing le, discr et e episode of d
ep
ression in a person
with
good
pr
e-morbid
fun
ctioning
, th e pr o
gno
sis for a r
eturn
to a baseline level is good.
It
is
likely
that
Mr
.
Z's
d
epr
essive symptoms will r
espond
to medic
ati
on. His obsess ive
com pulsive per
sona
lity
disorder
and
unm
et dep
end
ency need s
are
longstanding
prob
l
em
s wit h a
mor
e gu
ard
ed
pro
gno
sis th
at
d
ep
end
s on his ability to
engage
in
effec tive psyc
hot
he
rapy
and
to expand and
modif
y his r an ge o f con
tac
ts and ac tivities.
Th
e
pro
gno
sis for his m
arri
age is also g ua rde d a nd d ep
end
s upon th e willingness
of
his
wif
e
and
him
self to exam ine th
eir
re
lation
ship
, explore
new
avenu
es
of
int
era
c-
tion, and m
odif
y th
eir
roles. M
arit
al th
er
apy will likely be
requir
ed to ac
comp
lish
these goals.
DISCUSSIO N
Alth
ou gh t he re a re so me di ff
er
ences in
em
phasis in the fo
rmu
lat ions
of
the case
of
Mr.
Z, a side-by-side co
mpariso
n shows
sim
ilarities in structu re , conte nt a nd

DEMYSTIFYING
THE
PSYCHIATRIC CASE FORMU LATION 19
pro
cess
of
th e
four
r
eport
s.
Stru
cturall
y, each ori
ent
ati
on includ es des
cripti
ve,
etiological, and
tr
eatm
ent-progno
stic
fun
ction
s.
An exa mination
of
th e
cont
ent
in
eac
h se
ction
of
th e f
our
ori
entation
s shows
differ
enc
es in emphasis
but
also striking
similariti
es. Each
ori
ent a tion recognizes th e
importan
ce
of
data
in all
thr
ee o f th e biological , psychological , and social sphe res;
arrives
at
a
dia
gnosis com pa tib le
with
DSM-III-R
; ad voca tes
int
ervention
w
ith
medi c
ati
ons as well as
some
type of psy
chother
ap
y; and att
empts
to predi ct th e
possible
out
com
e
of
tr
e
atm
ent.
An
examination
of
pro
cess
of
th e
four
formul
ati
ons likewise shows diff
er
ences in
emp
has
is as well as simil
ariti
es. Ea ch fo
rmul
ati
on moves in
sequ
ence from a
sta te me nt
of
th e p
ertin
ent
d
ata
, to an a
tte
mpt to ex pla in the meaning
of
th e da ta,
a nd finall y to rec
omm
end
specific tre
atm
ent
bas ed up on th at u nd
erstandin
g. Each
formul
ation
a
tte
mpts to id
entif
y sympto ms a nd to
orc
hes
trat
e the ir
tr
eatm
ent
in a
m
ann
er
consis te nt
with
its view of psych op
ath
ology.
Th
e
writt
en case f
ormulati
on is beco
min
g a re qu
irem
ent
in clini cal pr acti ce.
Thi
s p
ap
er
has arg ue d th
at
an effective
case
f
ormul
ation has t
hree
compo
nen
ts:
diagn
osti
c, etiological
and
tr
e
atm
en
t-pr
ogn o
sti
c, and th at
the
litera tu re
(4-
9) sug-
ge st th ese co mpo ne nts a re co m
mon
in the way current biological, psy
chod
ynami
c,
cognitive-behavio
ra
l,
and
biopsy
cho
social f
ormul
ati
ons are co
ncep
t
ua
lized
and
writ-
ten . F inall y, side -by-side co mpa riso n o f th e f
our
Mr.
Z
case
fo rmu la tio ns i
llustrat
e the
utilit
y
of
thi
s
form
at.
It
is hop ed
that
th e
pr
oposed for
mat
will dem
ystif
y case
f
ormulati
ons
and
aid
psychi
atr
y resid
ent
s in co nce pt
ua
lizing an d
writing
mor
e
effective psy
chia
tr
ic
case
fo
rmul
ati
ons.
REFERENC ES
I. S
perry
LT, G
ude
ma n
]E
, Blackwell B,
Faul
k
ner
LR: Psychi
atri
c case f
ormul
ations.
Wa
shin
gt on , DC : A
mer
ican Psychi
atr
ic Press, 1992
2. S
harfs
tein SS, Beigel A (eds):
Th
e new eco
nom
ics and psyc
hiatri
c care . Washington , DC:
Am
eri
can Psychi
atri
c Press, 1985
3. Reveley A: Wh y do ca ndida tes fail th e MRC Psych Pa rt II? Bull of Royal College of
Psychiatrists 1983; 5:5 1
4. R
abk
in]
, Klein D:
Th
e biol ogical th e rapies. I n T r ea tm en t Plan n ing in Psych iat ry. Ed ite d
by Lewi
s]
, Usd in G, W ashingt on , DC,
Ameri
can
Psychiatric Press, pp. 8
9-150
,1 982
5. Pe rry S,
Cooper
AM, Mich els MD:
Th
e psychodynam ic
formu
lation
: Its
purpo
se, st ructure
and clinica l applica tio n. Am ] P sychiat r y 1987; 144:543- 550
6.
Turk
at ID, Wolp e
,]:
Beh avi
or
al for mu lat ion
of
clinical case s in LD. T
ark
at (ed.)
Behavior al
Ca
se Fo rmul a ti ons. New Yo rk: H
arp
er and Row, 1988
7.
Fau
lkn
er
LF, Kinzie
]D
, An gell R, U re n RC , S ha re
]H
: A compre hensive psychiat ric
form ulation mod el
,]
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