November 9, 2006

Suicide Note Revisited: Formulation

Previously, I had written an (what I thought to be outstanding) article about suicide documentation.  The main point was a refocusing of the note away from Objective and towards Assessment.  It now occurs to me that what I was really trying to get at is the lost art of writing a psychiatric formualtion of a patient.

The reason we don't do formulations anymore-- they're not even taught in most residencies, certainly not in mine or now to the residents I supervise-- is because it's not clear what the formulation is supposed to do.  Doctors get overwhelmed by the psychodynamics of it and can't seethe practical utility.  Someone brought them twenty ingredients but didn't tell them what they were cooking. 

A formulation is different than a diagnosis or description of the patient.  The formulation seeks to convey the relevant parts of a patient so that you can predict how a patient might behave in future circumstances.   By way of example, a formulation is similar to a "profile" in crime movies.  When they say things like, "he's going to want to tie the women with piano wires, because he's a schizophrenic who was forced to sleep in a tuba..." that's a formulation (sort of-- you get the idea.)

The formulation helps prediction by linking the various aspects-- seemingly unrelated, perhaps-- of a patient's existence.  It's the stuff you know is relevant, but DSM and standard psychiatry have no room for.  What does it mean if I tell you an inpatient brought with her fuzzy bunny slippers?  That's goes in the formulation.  A statement such as, "the strong family history of bipolar disorder,  along with his chronic alcohol abuse and prior suicide attempts, and the pending divorce and custody battle, and his recent apostasis from Catholicism put him at higher risk for suicide" is the type of sentence I want in the Assessment-- and it is precisely a short example of a "biopsychosocial" formulation. 

Note the importance of having all factors together, as opposed to individually.  It sets up the logic; it lets the reader know, immediately and obviously, what you were thinking.   This is very different than writing in one part of the note, "Fam Hx: strong bipolar;" and in another part of the note, "Chronic alcohol abuse;  history of multiple suicide attempts;" and in another place, "patient divorcing, and custody trial is next month."  Putting it that way, in the classic H&P format, forces the reader to have to infer.   Put in a biopsychosocial formulation, and the reader gets it instantly without even reading the rest of the H&P.  That's what you want.

Interestingly, the term "biopsychosocial" was coined by George Engel, psychoanalyst(?), who in 1977 made the startling observation, "The dominant model of disease today is biomedical, and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness."

[It] would seem that psychiatry would do well to emulate its sister medical disciplines by finally embracing once and for all the medical model of disease.  But I do not accept such a premise.  Rather, I contend that all medicine is in crisis, and, further, that medicine's crisis derives from the same basic fault as psychiatry's, namely, adherence to a model of disease no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry.

Plus ca change...

Engel, like others, had understood that somatic symptoms such as pain, weakness, etc, and autonomic symptoms such as reflux, tachycardia, etc could be symbolic expressions of emotion or conflict.   How could the Objective portion of a note ever explain why you discharged a person with acute bilateral leg paralysis?  It can't-- but a biopsychosocial formualtion can.

As per Engel, the main question such a biopsychosocial model seeks to answer is why some patients experience an "illness" while others experience a "problem of living."  Importantly, the patient himself doesn't often know: the patient defines it as an illness recursively by whether or not he "needs" a doctor, and not by an actual understanding of what's wrong with him.  It's the doctor's job to decide whether it is actually an illness or a life problem, and then properly re-educate and re-train the patient.

Note that in my post about suicide documentation, the hypothetical patient was not malingering.  He believed he needed to be hospitalized because he was suicidal.  But when you discharge such a patient from the ER, you are thinking that the person will not die-- the suicidality is an expression of something else.  This is Engel's dichotomy.  The patient thinks one thing, you think another-- it's your job to explain to the patient what's really going on, AND explain to the reader why you did what you did. 

Typically, formulations are taught, in my opinion, backwards, so students "don't get it."   You're taught to start with what's going on now, then describe what historical factors that made the patient who he is  (including genetics, upbringing, social stressors, meds, etc),; then psychodynamic explanations, and then your proposed treatment and how you predict the patient will respond.   I think it is easier to go backwards.  First, decide what you think is going to happen in the future (will commit suicide, won't relapse, is a mania risk, etc) and then explain what it is about his past and present that makes you think this.  In this way, you're writing the formulation with a purpose.


"Joe came to the ER for suicidality after he got drunk after getting divorce papers.

Joe takes rejection very hard, and characteristically when the rejection is new, he doesn't spend time to think things through.  He exhibits poor judgment (give examples here or in Objective), is impulsive (examples), and also does things which further reduce his judgment and raise his impulsivity (like get drunk.)

Joe has several narcisissitic features . For example, importantly, his suicidality is directed at his ex-wife.  The point of the attempt is that she find out, that she know he is feeling hurt.  If it was guaranteed that she would never find out, he would not attempt suicide because it would have lost its meaning.  He needs her, or at least someone, to acknowledge his pain, and see him as the person he is trying to portray.   As we talked,  I made it clear that I did see he was hurt, and I understood the rejection--how it not only was a loss of a wife, but also a hint that he himself was unworthy of her.  We discussed that she was entitled to leave him, but that she could not deterine his value."


etc, etc.  You see how even without an Objective portion, the narrative in the Assessment is quite clear. The reader understands what you were seeing and thinking.