Academic journal article Indian Journal of Psychiatry

Diagnostic Formulation

Academic journal article Indian Journal of Psychiatry

Diagnostic Formulation

Article excerpt

Byline: K. Kuruvilla, Anju. Kuruvilla

Writing a 'Diagnostic Formulation' is a skill expected of candidates in the post-graduate examinations in psychiatry in most universities in India. However there is ambiguity regarding what the term means and how it should be written. This article is an attempt to provide some guidelines on this topic.


One of the great attractions of psychiatry is the considerable scope for disagreement-on every aspect including diagnosis, aetiology, treatment and the very nature of psychiatric disorders. It is presumably because of this that the process of formulation has evolved-a process by which the features of an individual case can be discussed and evaluated to consider a series of possibilities, which will guide the management. This seems to be an admirably flexible way to deal with the complexities and uncertainties of psychiatric diagnosis[sup] [1] and so has become a skill, which is given great importance in the qualifying examinations in psychiatry in many countries.

What is a Diagnostic Formulation ?

In a survey, examiners of the Royal College of Psychiatrists were asked to give their opinion on why candidates fail the membership clinical examinations. About 87% opined that the major cause of failure was 'poor diagnostic formulation'. Issues like 'lack of factual knowledge' (40%) and 'lack of clinical experience' (26%) were rated a distant 2[sup] nd and 3[sup] rd .[sup] [2]

There is however disagreement about what the term 'formulation' implies and what it includes. Psychiatrists at various levels of seniority working in a teaching hospital were asked to list what should be included in a diagnostic formulation.[sup] [3] The results are shown in [Table 1].

The following three points are striking-firstly, differential diagnosis is preferred to single diagnosis as seniority increases. Secondly, psychodynamics was considered important by only one-third of respondents-least of all by juniors-perhaps because they understood the term as related to psychoanalytic concepts. The authors however had used the term to refer to 'psychological and emotional factors surrounding the patient'. Thirdly, physical examination was not given importance by any group.

A similar survey was conducted with examiners of MRCPsych Part II clinical exam.[sup] [4] The results showed that even among examiners, there is no consensus on what a formulation should contain [Table 2].

There are conspicuous differences in the opinion of the examiners as compared to that of the prospective candidates with respect to the important components of a diagnostic formulation [Table 3].

When there are significant discrepancies between the examiner's expectations and the candidate's assumptions regarding the importance of items like mental status, differential diagnoses, investigations etc., in a diagnostic formulation, the candidate's performance will very likely be viewed as 'poor' by the examiner. Lack of consensus on many aspects of the diagnostic formulation also leads to comments like -'this is a summary, not a formulation', 'the formulation does not include management', 'give us your formulation in two minutes, please'. Such comments are not only anxiety provoking for the candidate but also reflect an unnecessarily rigid point of view. Instead, it is more appropriate to provide flexible guidelines on formulation for examiners and candidates, in order to facilitate a discussion about the patient and his problems, which after all, is the purpose of a clinical examination.

What are the Guidelines on Diagnostic Formulation ?

The Institute of Psychiatry guidelines[sup] [5] to candidates on eliciting and recording clinical information, refers to an 'Initial Formulation' and defines it as 'a doctor's assessment of the case rather than a re-statement of facts. Its length, layout and emphasis will vary considerably from one patient to another. …

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