This document provides guidance on psychiatric formulation and management. It discusses conducting a descriptive formulation which provides an integrated summary of the patient's problems, history and examination findings. It also describes creating a dynamic etiological formulation to understand why the patient developed the disorder and potential predisposing, precipitating and perpetuating factors. Differential diagnoses, investigations and a provisional diagnosis using diagnostic criteria are also outlined. Management recommendations include both short and long-term approaches incorporating medical, psychological and social components. The document concludes with discussing prognostic factors for conditions like schizophrenia.

1. Management & Formulation
Dr. Mohammad Hussein
Consultant Psychiatrist

2. History
Personal Data
Source & Reasons
Of Referral
Complain
History Of Present
Illness
Past History
Family History
Personal History
Premorbid
Personality
Examination
Physical
Examination
Neurological
Examination
Mental State
Examination
Formulation
&management
Descriptive
formulation
Dynamic
“etiological”
formulation
Prognosis
Psychiatric sheet
Differential
diagnosis
Investigation
Provisional
diagnosis
Management

3. Formulation

4. Formulation
Descriptive
formulation
Dynamic
formulation

5. Descriptive formulation
 integrated summary and understanding of a particular
patient’s problems.
Descriptive
formulation

6. Descriptive formulation
• Personal Data
• Main features of the presenting complaint.
• Relevant background details
(e.g. past psychiatric history, positive family history).
• Positive findings in the mental state examination and
physical examination.
Descriptive
formulation

7. Dynamic “etiological” formulation
Why has this patient
developed this disorder
at this point in their life?
Dynamic
“etiological”
formulation

8. Dynamic “etiological” formulation
Commonly identified etiological factors:
 Recent stressful life events
 Non-compliance with medications
 Non-engagement with services
 Lack of insight
 Substance misuse
 Co-morbid physical illnesses
 Social isolation
 Poor financial support, lack of employment, housing
 Poor premorbid adjustments
 Previous history of mental illness
 Family history of mental illness
 Recent bereavement (elderly)
 Sensory deprivation (elderly).
Dynamic
“etiological”
formulation

9. Dynamic “etiological” formulation
Predisposing factors
Precipitating factors
Perpetuating factors
Dynamic
“etiological”
formulation
biological psychological
social
Bio
Social
Psycho

10. Dynamic “etiological” formulation
Dynamic
“etiological”
formulation
social
psychological
biological
Predisposing
Precipitating
Perpetuating

11. Dynamic “etiological” formulation
Dynamic
“etiological”
formulation
social
psychological
biological
Predisposing
Precipitating
Perpetuating
Schizophrenia example
Genetic risk
Schizotypal
personality
Urban
Birth
Cannabis misuse
High Expressed
Emotion
Life event
Non Compliance
with medications
Poor insight homelessness

12. Differential
diagnosis

13. Differential diagnosis
organic
substance
Psychotic disorders
Mood disorders
Neurotic disorders
Personality disorders
Differential
diagnosis

14. Investigation

15. Investigation
Physical /
medical
psychological social
Investigation

16. blood
• • Full blood count (FBC)
• • B 12 and folate levels
• • Liver function tests (LFTs)
• • Urea and electrolytes (U&Es)
• • Creatinine
• • Thyroid function tests (TFT)
• • Blood sugar.
Investigation
Physical / medical
urine
Urine drug screen
Infection in elederly
imaging
 Chest x ray
elderly patients and only where examination and
history suggests morbid respiratory and cardiovascular
conditions .
 ECG for specific cases (elderly patients and for
pjlients on high-dose antipsychotics, special
populations with cardiac problems)
 (EEC) - requires justification on the grounds of
Agnostic need
 (CT) - requires justification on the grounds of
diagnostic need
 Magnetic resonance imaging (MR!) - only for
specific cases
 Other investigations as dictated by findings on
physical examination.

17. Investigation
Investigation
psychological
 Psychometric testing/neuropsychological assessment if
you suspect dementia, cognitive impairment, organic
psychiatric illness or learning disability
 Rating scales to establish baselines (mood rating scales,
anxiety and depression rating scales)
 Personality assessment (only for specific cases)
 The following types of self-monitoring can be requested if
appropriate:
• Mood diary
• Eating or drinking diary
• Activities diary.

18. Investigation
Investigation
Collateral history from:
• Partners
• Relatives
• Friends
• Carers
social

19. Provisional
diagnosis

20. diagnosis
Provisional
diagnosis

21. Provisional
diagnosis
ICD 10 Diagnosis for Schizophrenia
G1. Either at least one of the syndromes, symptoms, and signs listed under (1) below, or at least two of the symptoms and signs
listed under (2) should be present for most of the time during an episode of psychotic illness lasting for at least 1 month (or at
some time during most of the days).
1.At least one of the following must be present:
1. thought echo, thought insertion or withdrawal, or thought broadcasting;
2. delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions,
or sensations; delusional perception;
3. hallucinatory voices giving a running commentary on the patient’s behavior, or discussing the patient among
themselves, or other types of hallucinatory voices coming from some part of the body;
4. persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g., being able to
control the weather, or being in communication with aliens from another world).
2.Or at least two of the following:
1. persistent hallucinations in any modality, when occurring every day for at least 1 month, when accompanied by
delusions (which may be fleeting or half-formed) without clear affective content, or when accompanied by persistent
overvalued ideas;
2. neologisms, breaks, or interpolations in the train of thought, resulting in incoherence or irrelevant speech;
3. catatonic behavior, such as excitement, posturing or waxy flexibility, negativism, mutism, and stupor;
4. negative symptoms, such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses (it
must be clear that these are not due to depression or to neuroleptic medication).
G2. Most commonly used exclusion clauses
1.If the patient also meets criteria for manic episode or depressive episode, the criteria listed under G1(1) and GI(2) above must
have been met before the disturbance of mood developed.
2.The disorder is not attributable to organic brain disease or to alcohol- or drug-related intoxication, dependence, or withdrawal.
management

22. diagnosis
Provisional
diagnosis
DSM-5 diagnostic criteria for schizophrenia
A. Two (or more) of the following, each present for a significant portion of time during a one-month period (or less if successfully treated).
At least one of these must be (1), (2), or (3):
1) Delusions. 2) Hallucinations. 3) Disorganized speech (eg, frequent derailment or incoherence).
4) Grossly disorganized or catatonic behavior. 5) Negative symptoms (ie, diminished emotionalexpression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work,
interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This six-month period must include at least 1 month of symptoms (or
less if successfully treated) that meet Criterion A (ie, active-phase symptoms) and may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more
symptoms listed in Criterion A present in an attenuated form (eg, odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major
depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or another
medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of
schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also
present for at least one month (or less if successfully treated).
management

23. Provisional
diagnosis

24. Management
Management
 Short term
 Long term
 Home
 Hospital
 Psychopharmacology
 Psychotherapy
 Psychoeducation
biological psychological
social
management

25. Management
Management
Immediate/short-term management
I. Medical
• Medication
(antipsychotics, antidepressants, mood stabilizers, benzodiazepines
and medications for physical health problems)
• Electroconvulsive therapy (ECT) - if appropriate.
• Nursing
• Nursing assessment involving
• • Observation of behavior
• Monitoring biological functions
• Compliance
management

26. Management
Management
Immediate/short-term management
II. Psychological
• • Advice and structured counselling
• • Psychoeducation for the patient and the family
• • Insight-oriented therapy
• • Supportive psychotherapy
• • Behaviour therapy (child psychiatry, learning disability and selected casts)
• • Drug education/motivational programme (drug and alcohol misuse)
• •- Cognitive behavioural therapy (CBT) - individual and group
• - Family therapy assessment
• - Psychodynamic - individual, group therapy assessment
• - Cognitive analytical therapy (CAT)
• - Dialectical behavioural therapy (DBT)
management

27. Management
Management
Immediate/short-term management
III. Social
• Involve occupational therapists to carry out occupational therapy
assessments including home assessments:
• - To determine activities of daily living skills, level of functioning and to ascertain
the level of support needed
• - To enhance their life skills training, social skills training, problem solving skills
and relaxation techniques
• - To focus on rehabilitation mainly vocational rehabilitation
• involve a social worker and" social services who could help with:
• Community care assessment (needs assessment), assessment of finance“
• Community psychiatric nurse
management

28. Management
Management
Long -term management
Focus on:
Relapse prevention
Rehabilitation
Quality of life Bio
Social
Psycho
management

29. Management
Management
Long -term management
social
psychological
biological
 Self help groups
 Support groups
 Supported
employment
 Individual & group CBT
 Family therapy
 Day hospital
 Continue medications
 Crisis plans 24/7 access
management

30. Prognosis

31. Prognosis
At the end of each clinical
assessment,
review both good and
poor prognostic factors
Prognosis
Schizophrenia
Good prognostic factors
• Acute or abrupt onset
• Late onset of the illness
• Short duration
• Presence of precipitating stressor
• Female sex
• First episode of the illness
• Presence of family history of mood disorder
• Good social support
• No history of co-morbid substance misuse
• Good premorbid personality traits
• Presence of mood symptoms
• Presence of positive symptoms
• Presence of good insight
• Good compliance with treatment.
management

32. Prognosis
At the end of each
clinical
assessment,
review both good
and poor
prognostic factors
Prognosis
Schizophrenia
Poor prognostic factors
• Insidious onset
• Early age of onset
• Chronic course of the illness
• Absence of precipitating stressor
• Male sex
• Past history of similar episodes
• Family history of schizophrenia
• Poor social support Co-morbid substance misuse
• Poor premorbid adjustment
• Absence of mood symptoms
• Presence of negative symptoms Lack of insight
• Poor compliance with treatment Institutionalizatio
or long-term hospitalization Low premorbid IQ
Longer duration of untreated illness.
management

33. ‫يحبذ‬ ‫حسين‬

34. ‫شيفو‬ ‫المعلم‬

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