Clinical formulation

Summary and formulation do different work

A summary condenses the important facts. A formulation explains how those facts fit together, what remains uncertain and which explanations deserve consideration. It should be anchored in the evidence of the case rather than a generic account of a diagnosis.

Begin with the main clinical problem, its chronology and effect on functioning. Integrate relevant past episodes, physical health, treatment, substance exposure and social circumstances. State which findings support the working interpretation and which do not fit it.

Organize contributors without inventing causes

Predisposing, precipitating, perpetuating and protective factors can organize discussion across biological, psychological and social domains. They are prompts for reasoning, not proof of causation. Distinguish a reported association from an established relationship and avoid a confident causal story when the evidence is incomplete.

A differential should be discriminating. Explain why a plausible alternative is being considered and what additional information would distinguish it. An extensive list of unrelated diagnoses adds little to the formulation.

Make uncertainty useful

Identify missing records, unclear chronology or a finding that needs reassessment. Separate the clinician’s working interpretation from an established diagnosis. Prognosis should consider the individual course and circumstances, with its uncertainty stated, rather than being inferred solely from a disorder name.

A formulation is revised when new evidence arrives. In a teaching discussion, ask which fact would most change the interpretation. The website supplies an educational structure; it does not generate patient-specific diagnoses, treatment changes or safety conclusions.

For your next supervision discussion

Identify the strongest evidence for a working explanation and the strongest evidence against it. What missing information would most alter the formulation, and how would you communicate that uncertainty?