Formulation #1

A diagnosis highlights commonality between patients, while a formulation is about finding the unique story for this patient.

It begins with a good summary statement about the patient. We want to answer the question,
"Why did this patient present, with this problem, in this particular way, at this time?"

The skill to practice is including all relevant and important information, while culling extraneous information.

For example...

Grant* is a 33 year old man, never married, who lives with his parents and younger sister in Granville*, Sydney. He has presented with police, to Emergency, after an argument with his mother where he pushed her. He has not left the house for two years, because of fears about what people will say about him and because he has rituals that prolong showering to the point where he has not been able to do it for four weeks.

to be continued...

* Indicates identifiers that I have invented/changed.

Skills in Psychiatry - Formulation

I am going on a journey. I'm on my way to the place where good formulations get made. I've started reading about formulation as a skill and I'm going to get practicing. I'm just realising that there's a hole in my exam armour, that needs repairing...

I'll be writing some postcards on the way.

PS. This is what I just posted a couple of weeks ago...

Is Freud right?

Ali quotes from Alain de Botton's book, Kiss and Tell, as follows

And even Freud, who one might have expected to cherish hopes for human understanding and communication, told an interviewer at the end of his life that he really had nothing to complain about:

‘I have lived over seventy years. I had enough to eat. I enjoyed many things. Once or twice I met a human being who almost understood me. What more can I ask?’

Can we ask more of this life? I just want to say no... and yes.

The kids had started to call me Dad...

I thought about family and how it's constructed after hearing a patient say this one day. He had ended his brief relationship with a woman and his regret was expressed in the statement about the children starting to accept him into the household.

The word pitiful keeps coming to mind, not because I despise what he is saying, but because I pity his fear. The subtext of what he told me was that the child calling him dad had actually provoked fear in him and then he had left the relationship. Either he did not want to take on that role in the family (or at least not yet) or he was afraid of failing if he stepped into it.

I think we ignore the transience of family in our current culture. I do not generally talk of classes of people, but I think there is a group (or perhaps) class of people, in Australia, who operate in a very matriarchal fashion. Family units are made up of a woman with one or some children, and men transiently move in and out of families. Relationships begin explosively and intensely, bringing new partners quickly to assume to male role, which children link with dad. Men relate to children because of their connection with a child's mother rather than because of a distinct and precious connection with the child.

With time, this can develop to be more balanced and the male can become and effective 'father' in the family. However it can be really difficult for a man, in this dynamic, not to feel like an interloper who must compete with the kids for the woman's attention or love. I am not arguing that blended families are bad, only that they can promote unhealthy dynamics when they begin so quickly and reactively. We also see the effects of uncertainty about male members of the household and where they fit, later on when teenage sons have difficulty in behaviour and discipline. This is not always the result, but I'm postulating that the insecurity of the male position in this style of family would influence how a maturing male will relate within that family.

What do you think?

Is she playing with my mind?

What is a mind?

The brain is a physical organ of the body, a collection of neural networks, but is the mind just the brain? Are thoughts just electrical impulses down nerve cells? As people test and examine the brain in part or as a whole, its complexity is becoming more and more apparent. To persist with the idea that the physical brain cannot carry out all the functions of the mind is becoming more difficult.

Yet each mind is different. If brain structure is so clearly uniform in many ways, how can minds have such individual prints? My mind encapsulates my self. I cannot separate who I am from the processes of my mind.

This question (Is she playing with my mind?) finds its key in the self. When someone asks if their mind is being played with, they are ultimately questioning whether someone is playing with their self. Is she playing with ME? No wonder the question is so deep and desperate. It is founded on a real sense of invasion and being controlled.

The person who asks this question, feels out of control. They cannot change what is happening to them and are desperately seeking stability. It indicates an external locus of control (that is the sense of my life being controlled and affected by events and people outside myself) which puts this person at greater risk of a depressive illness.

And the question is asked because reassurance must come from outside the self to be believable. He cannot trust himself to be able to read the situation, let alone control it. Providing reassurance (an answer) can be counter-productive for the questioner because it reinforces the sense of being ineffective and powerless, that he so clearly has.

Responding to questions

I am going to post a series prompted by the questions and statements I hear, mainly at work, but some will be interesting ones I hear in other places. The thread of similarity will be the ideas about mental health that each prompt raises.

There will be post here, from a psychiatric perspective and a linked post on my personal blog which will be framed more, (need I say), personally.

Selling my soul

If a drug company buys the lunch does that mean we've sold out? Maah. Undecided.

If the lunch comes with a medication spruik by a top 6 Master-Chef Contestant then is the sell-out worth it?

Possibly.

Alvin has a PhD in biochemistry and comes from the science dept. of Astra-Zeneca. As a science bloke he can talk about off-label prescribing (research into using a medication for an illness not covered in its current PBS + or - TGA indications). Our friendly (and lunch-bearing) sales rep is not supposed to talk off-label.

So Alvin gave a teuously linked talk about anxiety and being on Master Chef. He recommended taking a little S-----l XR to cope with performance anxiety on the show.

I hope he was joking....

Seriously, the impact of drug company involvement and visits are subtle. I hope I don't prescribe on the basis of who talked medication with me last or who made me feel good. But the evidence, discussed here, and reported here, is that I do. Drug companies spend money this way because it works.

We have a lunch to get registrars together. People come if there is food, and we want them there to give an opportunity for support and feedback in a stressful job. I am trying to think of some ways to get food there but not be unduly influenced.