By Lisa Pryor
When psychiatry is in the news, so often it is for
With such a focus on diagnosis and classification, you would be forgiven for thinking that psychiatry is a profession devoted merely to sorting and labeling humans. This is highlighted by the common description of the Diagnostic and Statistical Manual of Mental Disorders — the thick volume published by the American Psychiatric Association listing the various diseases of the mind — as the “bible” of psychiatry.
In reality, the D.S.M., the abbreviation by which it is commonly known, is more like a dictionary than a bible. It is an explanation of the human mind no more than a dictionary is an explanation of literature.
There is another psychiatry concept that gets less of an airing in public but that could be more helpful for understanding how many psychiatrists think about the mind — and how any of us can think about mental suffering. This concept is the psychiatric formulation.
If a diagnosis is a label, a formulation is more like a story. In a few sentences, a formulation gathers up all the biological, psychological and social factors that have led to a person becoming unwell and considers how these factors interconnect. In doing so, it provides clues to the pathway out of suffering.
This story might take into account the individual’s genetic predisposition for mental illness, attachment to a primary caregiver as a child, developmental trauma, intellectual functioning, economic circumstances, illicit drug use or complications created by physical illness, such as thyroid disease or chronic pain.
As you may have noticed, these factors are not located solely within the brain, nor are they solely located within the individual.
For me, a medical doctor training to be a psychiatrist, the formulation is a reminder that however far our understanding of the brain advances, in terms of its myriad receptors and neurotransmitters, this organ never exists in a vacuum.
The brain exists within a human body, which in turn exists within a family, a culture, a society, an economy. When factors outside the brain contribute to mental illness, then the solutions to those problems may also exist outside the brain. Indeed, some of the most valuable mental health interventions we have might be preventive. I am thinking here of measures to reduce poverty and child abuse, for example.
Let’s consider an example of a formulation. The diagnosis “major depressive disorder” may not tell you much about a person, but consider a formulation for an individual, which might go something like this: “Forty-six-year-old single mother of two presents with a three-month history of depressive symptoms including low mood, insomnia and poor appetite (with weight loss). Her condition was precipitated by psychosocial stressors, including unstable housing and credit-card debt since the breakdown of her marriage eight months ago. This is on a background of an introverted and passive temperament and a childhood in which her parents encouraged dependency, and this was followed by a marriage in which her husband had complete control of finances. There is a strong family history of depression; her mother and maternal grandfather were hospitalized for this condition. Protective factors include a strong network of friends and a willingness to engage with therapy.”
Obviously people who all have the same diagnosis of “major depressive disorder” can have different formulations. The combination of predisposing, precipitating, perpetuating and protective factors will be different for everyone. If a diagnosis is a stamp, a formulation is more like a fingerprint, unique to each individual.
In the hypothetical example above, treatment may not be limited to medication; it might include a suite of other interventions. Long-term psychotherapy to help build confidence and a sense of self-efficacy might be one element, as would other measures that on the face of it might not seem to be within the realm of psychiatric treatment. For example, it would make sense to provide assistance for obtaining safe and affordable housing if unstable living arrangements helped cause spiraling feelings of hopelessness. Similarly, helping the person find a course to learn budgeting skills or get a job might be beneficial.
If you have come to believe from what you have read that psychiatry is the study of the isolated and disembodied brain, you might be surprised to learn how important this component of the psychiatric process is and how long it has been around.
One of the early key proponents of this biopsychosocial model of mental illness was George L. Engel, an internist and psychiatrist who practiced in Rochester, N.Y., for most of his career, starting in the 1940s. Working with both physical and psychiatric illness, he was well placed to consider the relationship between the mind and the body, between emotions and disease.
He set out his ideas succinctly in 1977 in a landmark article in the journal Science. In this essay, Engel articulated why psychiatry should not be drawn too far into the medical model of disease, and why, in fact, medicine itself would do well to look beyond this model, which he suggested did not fully account for mental illness or physical illness, for schizophrenia or even diabetes.
The biopsychosocial formulation dovetails nicely with more recent developments in mental health, such as trauma-informed care, a model developed for patients who have suffered traumatic experiences such as abuse and assault. The goal is to avoid traumatizing them again in offering the very services meant to help them. Often this approach is summarized as moving from thinking, “What is wrong with you?” to considering, “What happened to you?” Like the formulation, a label is reframed as a story.
The biopsychosocial formulation also offers much to all of us, when we think about our own well-being and mental health, the factors leading to our own flourishing, or its opposite.
None of us are static objects, we have histories and stories, we change over time. Who we are today is influenced by the sum of the things that have happened to us along the way, but how things are today is not how they are always destined to be.
So when something is wrong we would do well to ask not just, “What is my diagnosis?” but instead, “What is my formulation?”
Lisa Pryor, a medical doctor, is the author, most recently, of “A Small Book About Drugs” and a contributing opinion writer.
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