Problems with Diagnosis and Formulation.

In the previous blog, I described some of the issues with treatment in conventional psychiatry. In this blog, I’ll discuss some of the issues with diagnosis and formulation that may contribute to the issues we see in treatment.

The DSM describes Concepts, not Causes.

The process of diagnosis involves capturing how a presentation is similar to the general population. This is crucial because, theoretically, a presentation should align with an underlying disease process. A disease process is hallmarked by the disease tetrad, which includes the syndrome, pathophysiology, epidemiology, and etiology of the disease. The Diagnostic and Statistical Manual of Mental Disorders (DSM) became the primary tool for psychiatric diagnosis in 1980 in its third edition. This tool was developed out of public health interest in the incidence and prevalence of disease and to eliminate conflict among those with varying theoretical perspectives regarding the etiology of psychiatric illness (McHugh & Slavney, 2012). As a tool devoid of etiologic considerations, the DSM provided a unification of psychiatric providers under a common language of categorical diagnostic labeling. It was left to the individual psychiatric provider to determine the etiology of the patient’s illness. Several have proposed alternatives to the DSM to recapture the disease tetrad, such as the Research Domain Criteria (RDoC), Hierarchical Taxonomy of Psychopathology (HiTOP), and Psychodynamic Diagnostic Manual (PDM).

“The DSM is like a field guide for amateur birders to identify bird calls”

- Paul McHugh

In contrast to the process of diagnosis, formulation is a method of capturing elements of a psychiatric illness unique to the individual (Owen, 2023). With formulation, the hope is that the clinician will be able to synthesize these elements to identify underlying causes. The authors of the DSM-III designed a multi-axial system that would more holistically capture an individual’s experiences. The multi-axial system included clinical disorders (axis I), personality disorders (axis II), general medical conditions (axis III), psychosocial and environmental problems (axis IV), and the global assessment of functioning (axis V) (APA, 1980). This system initially eclipsed the biopsychosocial model by George Engel, who proposed his model in 1977 for similar purposes. The multi-axial system was ultimately abandoned in the DSM-5 due to several concerns, including a lack of validity and reliability (APA, 2013; First, 2010). Stepping into the light was the biopsychosocial model. This model was proposed to capture the biological, psychological, and social aspects of psychiatric illness by capturing each domain's four P’s (predisposing, precipitating, perpetuating, and protecting factors). This formulation model is now widely taught in academic programs worldwide but is poorly utilized in the clinical practice setting (Tavakoli, 2009). One noteworthy alternative to the biopsychosocial model is the Perspectives of Psychiatry approach developed by Paul McHugh and Phillip Slavney in 1986 and taught at Johns Hopkins University. This model encourages considering four perspectives (disease, dimension, behaviors, and life story) for each symptomatic presentation (McHugh & Slavney, 1998; Peters et al., 2012). Unlike the biopsychosocial model, the perspectives model provides treatment guidance rather than just functioning as an assessment model. However, both systems tend to overly compartmentalize experiences and can be stigmatizing (Pescosolido et al., 2010).

“Your beliefs become your thoughts. Your thoughts become your words. Your words become your actions. Your actions become your habits. Your habits become your values. Your values become your destiny.” - Mahatma Gandhi

The problems of our current diagnostic and formulation systems are reflected in clinical outcomes (see the previous blog). The inability to accurately navigate the heterogeneous expression of psychiatric illness contributes to misdiagnosis and poor agreement among clinicians and corresponding inefficacious and intolerable treatment options (Newson et al., 2021; Paris, 2015). Humans are complex systems sensitive to internal and external environmental conditions. When working with complexity, we need a holistic approach that accounts for the dynamic whole while simultaneously appreciating the nature of parts and the interconnected nature of internal and external systems. Accounting for the various contextually-based perturbations that influence the sensitive whole is crucial so long as it does not sacrifice our appreciation for the whole system. Such a system would more effectively navigate heterogeneity and guide personalized treatment initiatives.

For a more comprehensive analysis of the diagnostic and formulation process…

I’ll dive into the Integrative Psychiatry Matrix (IPM) in the next blog. This mid-range theoretical model brings the abstract phenomenon of holism into the domain of clinical practice to guide actionable steps to achieve mental health and wellness.

References.

American Psychiatric Association (APA). (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd Ed.).

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

First, M. B. (2010). Paradigm shifts and the development of the diagnostic and statistical manual of mental disorders: Past experiences and future aspirations. The Canadian Journal of Psychiatry, 55, 692–700.

McHugh, P. R. & Slavney, P. R. (2012). Mental Illness – Comprehensive Evaluation or Checklist?. New England Journal of Medicine. 366(20): 1853–1855.

McHugh, P. R. & Slavney, P. R. (1998). The perspectives of psychiatry (2nd ed.).

Newson, J. J., Pastukh, V., & Thiagarajan, T. C. (2021). Poor separation of clinical symptom profiles by DSM-5 disorder criteria. Frontiers of Psychiatry, 12, 1-17.

Owen, G. (2023). What is formulation in psychiatry? Psychological Medicine, 53(5), 1700–1707. doi:10.1017/S0033291723000016

Paris, J. (2015). Psychosocial factors in the personality disorders: A biopsychosocial perspective. Canadian Journal of Psychiatry, 60(6), 284-287.

Pescosolido, B. A., Martin, J. K., Long, J. S., Medina, T. R., Phelan, J. C., & Link, B. G. (2010). "A disease like any other"? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. The American Journal of Psychiatry, 167(11), 1321-1330.

Peters, M. E., Taylor, J., Lyketsos, C. G., & Chisolm, M. S. (2012). Beyond the DSM: the perspectives of psychiatry approach to patients. The primary care companion for CNS disorders, 14(1), PCC.11m01233. https://doi.org/10.4088/PCC.11m01233

Tavakoli H. R. (2009). A closer evaluation of current methods in psychiatric assessments: a challenge for the biopsychosocial model. Psychiatry (Edgmont (Pa. : Township)), 6(2), 25–30.