Psychiatric Formulation and the Structural Determinants of Mental Health
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THE LEARNER'S VOICE
Psychiatric Formulation and the Structural Determinants of Mental Health Allison M. Bailey 1 Received: 15 February 2020 / Accepted: 8 September 2020 # Academic Psychiatry 2020
One of my first patients of residency, a high-achieving high school student, presented with debilitating anxiety about multiple topics ranging from academic performance to social acceptance. Her chart history suggested a diagnosis of generalized anxiety disorder. When I met her, I listened carefully to her personal narrative and interpreted each anecdote through the lens of my initial diagnostic theory. Midway through the interview she revealed her concern that her father would get pulled over and shot while driving home from work. This was 2019 in Baltimore City, in the notso-distant wake of the death of Freddie Gray and protest movements around the country surrounding police violence against Black people. I fumbled through the remainder of my patient’s interview, distracted by the realization that my diagnostic reasoning skills might be insufficient to adequately formulate her mental suffering. At my home institution trainees are taught to understand mental suffering through a diagnostic model called the Perspectives of Psychiatry, which was articulated in a 1983 publication by two psychiatrists from Johns Hopkins Hospital [1]. The Perspectives model considers four factors that shape psychiatric presentations: disease, dimension, behavior, and life story. Each factor is associated with a specific therapeutic intervention. Diseases can be diagnosed based on clinical syndromes and treated with medications. Dimensional vulnerabilities or problematic personality traits can be addressed through psychotherapy. Harmful behavioral patterns such as substance use can be interrupted through rehabilitation. Life stories informed by maladaptive interpretations of events and relationships can be rescripted—this approach can help a patient gain a sense of mastery over her circumstances by adopting a new mindset rather than changing the external environment. * Allison M. Bailey [email protected] 1
The Johns Hopkins University School of Medicine, Baltimore, MD, USA
For me, the Perspectives model functions as a system of four complimentary lenses that allows me to view my patients’ narratives in totality. I think about each patient through all four Perspectives, working to understand the relative contribution of each one to an individual’s mental suffering. For my patient with generalized anxiety disorder, I might consider whether she has a disease amenable to medical treatment or anxious dimensional traits amenable to therapy. I might ask whether she is engaging in behaviors that exacerbate anxiety, such as caffeine use. Finally, I might examine her life story for elements related to anxiety such as academic stress and then help her rescript these elements into a more empowering personal narrative. In addition to the Perspectives model, I have access to many other resources such as psychological assessments, laboratory tests, and neuroimag
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