Assessment, Diagnosis and

Formulation
Dr Jo Billings
UCL Division of Psychiatry
Clinical Mental Health Module
MSc Clinical Mental Health Sciences / Mental Health Sciences Research

Overview
What do we need to
assess and why?
How do you do an
assessment?
What is the difference
between diagnosis and
formulation?

Assessment what and why?

Assessment

Diagnosis/
Formulation

Intervention

What to include?

In small groups, brainstorm things you might

want/need to ask when doing an
assessment?

What to include?

What is the purpose of your assessment?

What setting is assessment taking place in?
How much time do you have?
What do you need to know?
What does the patient need to tell you?

What to include?
What is the problem(s)
Nature of the problem
Recent example

How did the problem

develop
When did it start
How has it developed

What caused the

problem
Historical factors
Triggers

What keeps the problem

going (maintaining
factors)

Biological
Social
Psychological
Environmental
Systemic

The 5 Ps
1.
2.
3.
4.
5.

Problems
Predisposing factors
Precipitants
Perpetuating factors
Protective factors

What to include?

Risk
Previous treatment
Patients goals
Engagement with services/current treatment plan
Motivation to change
When is the problem not a problem
Strengths, resources and resilience

How to do an assessment?
Open

Structured

Unstructured

Closed

Open vs closed questions

Open Questions

Closed Questions

What has brought you here

today?
Tell me about when you first
noticed your mood was low?
What was your experience
of previous treatment like?

What impact has this had on

your sleep?
When did you last work?
Have you taken antidepressants before?
Did you find your previous
therapy helpful?

How to do an assessment?

How to do an assessment?

Conversation with a purpose

Exercise Role Play - Sam

MHP: Mental health professional working in a primary
care mental health service.
Patient: 36 year old woman on maternity leave from her
job as a marketing manager, referred by her health
worker

Exercise Role Play - Chris

MHP: Mental health professional working in a
community mental health team
Patient: 42 year old man referred by his GP with physical
symptoms and low mood. Currently signed off of work.

How to make sense of it?

Diagnosis

Formulation

The determination of which disease or

condition is causing a persons signs and
symptoms

The theoretically-based conceptualisation of

information obtained from a clinical
assessment. It offers a hypothesis, or
hypotheses, about the cause and nature of
the presenting problems

Diagnosis vs Formulation
Diagnosis
DSM-V, ICD 10
Specific disorder labels i.e.
Major Depressive Disorder,
OCD, PTSD
Relevant research and
literature
Evidence-based
interventions

Formulation
Idiosyncratic
Why does this particular
person have this particular
problem at this particular
time?
Helps tailor intervention to
specific individual

Formulation
What is the problem?
When did it start?
How has it developed?
What earlier life experiences may have predisposed
the patient to developing this problem?
What is keeping the problem going now?
What strengths/resources does the patient have to
overcome the problem?

Formulation - Narrative
Mr Brown is presenting with symptoms consistent with the diagnosis of PTSD
following a physical assault last year. It seems that this has triggered further
memories of having been bullied at school and confirmed beliefs that he is weak
and vulnerable.
Since the assault Mr Brown has been avoiding reminders of the assault, such as
watching violent programmes on TV and trying not to talk to anyone about what
has happened, which is preventing him from processing his memories of the
attack. He has also been avoiding going out on his own or at night, which is
preventing him from disconfirming his belief that he is likely to be attacked again.
Mr Brown is very motivated to engage in therapy and has support from his partner
and friends. He has been determined to continue to going to work and attending
the gym.

Formulation - Diagrammatic
Thoughts

Emotions

Physiology

Behaviour

Formulation - Diagrammatic
What Ive
experienced

What that
means to me

Current Problems
and what keeps
them going

Formulation - Diagrammatic
Memories of
Assault

Im weak and
vulnerable
Avoid reminders
dont process
memories or
challenge beliefs

Vicious circles inactivity

Vicious circles - Perfectionism

Vicious circles - Performance

anxiety

Exercise - Formulation
Review the notes you took from your assessment of
Sam/Chris
What do you think the diagnosis is?
Work on a provisional formulation of Sam/Chris
difficulties

Exercise Role Play - Sam

MHP: Present your diagnosis and provisional
formulation to Sam
Sam: Give MHP feedback on the formulation

Exercise Role Play - Chris

MHP: Present your diagnosis and provisional
formulation to Chris
Chris: Give MHP feedback on the formulation

Questions

Recommended Reading
Aquilino, C. & Warner, J. (2004) A guide to psychiatric examination. PASTEST
Kuyken, Padesky & Dudley (2009) Collaborative Case Conceptualisation. Guilford
Press: London
Noble, L. (2007) Written communication. Chapter in Ayers S, Baum A, McManus
C, Newman S, Wallston K, Weinman J, West R (Ed.), Cambridge Handbook of
Psychology, Health and Medicine Cambridge University Press
Westbrook, D., Kennerly, H. & Kirk, J. (2011) An introduction to Cognitive
Behaviour Therapy: Skills and Applications (2nd Edition). Sage.