The Five P’s of Case Formulation
(Macneil et al., 2012)
• Presenting problem
– What is the client’s problem list?
– What are DSM diagnoses?
• Predisposing factors
– Over the person’s lifetime, what factors contributed to the development
of the problem?
– Think biopsychosocial
• Precipitants
– Why now?
– What are triggers or events that exacerbated the problem?
• Perpetuating factors
– What factors are likely to maintain the problem?
– Are there issues that the problem will worsen, if not addressed
• Protective/positive factors
– What are client strengths that can be drawn upon?
– Are there any social supports or community resources ?
Diagnostic criteria
– Disorder-specific criteria set (Presenting Problem)
– Subtypes and specifiers (Presenting Problem)
• Explanatory text information
– Diagnostic features (Presenting Problem)
– Associated features (Presenting Problem)
– Prevalence (Presenting Problem)
– Development and course (Predisposing, Perpetuating and
Protective Factors)
– Risk and prognostic factors (Predisposing, Perpetuating
Protective Factors)
– Culture-related diagnostic issues (5 P’s)
– Gender-related diagnostic issues (5 P’s)
– Suicide risk (Presenting Problem)
– Functional consequences (Perpetuating Factors)
– Differential diagnosis (Presenting Problem)
– Comorbidity (Presenting Problem and Perpetuating Factors)
Case of Helen
Helen was fired from her job one month ag because she started making numerous mistakes and had trouble concentrating. About three months ago she started feeling “down“ after a break-up with a man she had been dating for a few months. She has trouble falling asleep and has noticed a significant decline in her appetite. She feels like a failure and believes that no one will want to hire her again. She has thoughts of committing suicide but admits, “I could never do it.” The only thing that seems to help is when she participates in a bible-reading group every Tuesday night. She explains, “During that time I’m more like my old self and at least that night I can sleep.” She also reports that her mood improves when she visits her friends. However, she reports such low energy throughout the day that she is unable to schedule a job interview. She had a similar episode about two years ago after she was laid off from her former job. She reports that it took four months before she began feeling “normal” again and positive about herself. Her history indicates that her mother had severe depression and was hospitalized on several occasions when Helen was young. She describes her as “negative” and often absent in her youth. However, Helen always did well in school and had an active social life. Her work history has been very consistent up to her lay off.
Diagnostic Work-Up
• DSM-5 measures:
– Level 1(positive for depression, sleep problems and avoiding certain events)
– PHQ-9, Score = 20 (Severe)
– WHODAS 2.0
• General Disability Score = 85 (2.36; Mild)
• Subscale: Life activities = 14 (3.5; Moderate)
• Subscale: Participation in Society = 28 ( 3.5;
Moderate)
• Differential diagnosis: What are the possibilities?
• Diagnostic Impression:
296.33 Major Depressive Disorder, recurrent, severe severity
V62.29 Other Problems related to employment
Case Formulation
• Why is she so depressed?
– Predisposing factors?
– Precipitating factors?
– Perpetuating factors?
– Positive or protective factors?
• How does the diagnosis and case
formulation inform your treatment plan?
Guide to Case Formulation
1. State the problem or diagnostic impression.
2. State the precipitant
3. Describe critical predisposing factors
4. Include a statement about perpetuating or maintaining factors
5. Highlight protective and positive qualities
Write a Case Formulation
Helen presents with……(1) which appears
to be precipitated by…..(2). Factors that
seem to have predisposed her to depression
include….(3). The current problem is
maintained by….(4). However, her
protective and positive factors include….(5).
From Formulation to Treatment
• How does the formulation inform the treatment plan?
– Best practices for this disorder?
– Which types of interventions will address the predisposing, precipitating and perpetuating
factors?
– How do you ensure that diversity factors are considered?
– How do you tailor treatments so that they are more strength-based?
Using DSM-5 in
Case Formulation
Gary G. Gintner, Ph.D., LPC
Louisiana State University
gintner@lsu.edu
Case Formulation
• Case formulation is a core clinical skill
that links assessment information and
treatment planning
• It is a hypothesis about the mechanisms
that cause and maintain the problem
• It answers the question, “Why is this
person, having this type of problem, now?”
DSM-5 Informed
Case Formulation Process
Assessment
•DSM-5 Enhancements
•DSM-5 Organization
•DSM-5 Background
information
Case
Formulation
• DSM-5 Criteria Sets
•DSM-5 Background
Information
Treatment
Planning
•Best practice
guidelines are often
tied to a diagnosis
• DSM-5 measures to
monitor progress
Fundamental Changes in DSM-5
Dimensional
Approach
• The conundrum with
categories
• Dimensional
concepts:
• Spectrum Disorders
• Severity ratings
• Dimensional
assessment tools
Lifespan
Perspective
• Lifespan perspective
is infused throughout
the manual
• More attention to
developmental
differences in
presentation
New Organization
• Data-informed
reorganization
• Proximity reflects
similarity
DSM-5’s Single Axis System
• There is one diagnostic axis on which all
of the following can be coded:
– All mental disorders (formerly on Axis I and
II)
– Other Conditions that May be the Focus of
Treatment (V-codes; formerly Axis I)
– Medical disorders (formerly Axis III)
DSM-5 Tools and Enhancements
• Clinical rating scales
•
WHODAS 2.0
• Cultural Formulation
Interview
Clinical Rating Scales
• Rationale for adding:
– Measurement-informed care
– Dimensional assessment of severity
– Assessment of broad range of symptoms
– Adjunct to clinical evaluation
• Types
–
Cross-Cutting Symptom Measures
– Disorder-Specific Severity Measures
– Disability Measures (WHODAS 2.0)
– Personality Inventories
– Early Development and Home Background Form
Link to Online Assessment
Measures
• Assessment measures can be freely used
by clinicians for use with clients
• They can be downloaded at:
http://www.psychiatry.org/practice/dsm/
dsm5/online-assessment-measures
or
www.dsm5.org DSM-5 Online Measures x
DSM-5 Online Measures x
DSM-5 Online Measures x
DSM-5 Online Measures x
Cross-Cutting Symptom Measures
• Assesses symptoms across the major
domains of psychopathology
• Two types:
– Level 1
– Level 2
• Versions
– Adult self-report
– Parent/guardian-rated version (for children 6-17)
– Youth self-report (11-17)
Level 1 Cross-Cutting
Symptom Measure
• Description: Adult version measures 13 domains
of symptoms DSM-5 level1 assessment
• Rate each item:
– How much or how often “you have you been
bothered by…in the past two weeks.”
– 5-point rating scale from 4 (severe, nearly everyday)
to 0 (none or not at all)
• Scoring: Rating of 2 or higher (Mild, several days)
should be followed up by further clinical
assessment. On items for suicidal ideation,
psychosis and substance use, a rating of 1 (Slight)
or higher should be used.
DSM-5 level1 assessment
DSM-5 level1 assessment
DSM-5 level1 assessment
Level 2 Assessment Measure
• Description: A brief rating scale for a
particular symptom (e.g., anxiety,
depression, substance use)
• Indications: When a Level 1 item is rated
above the cut-off
• Can be readministered periodically to plot
change
• Scoring instructions are available at the site
• DSM-5 Online Measures x
DSM-5 Online Measures x
DSM-5 Online Measures x
DSM-5 Online Measures x
Disorder-Specific Rating Scales
• Description: Disorder-specific rating scales
that correspond to the diagnostic criteria
• Indications: Used to confirm a diagnostic
impression, assess severity, and monitor
progress
• Versions: Adult, Youth and Clinician rated
• DSM-5 Online Measures x
DSM-5 Online Measures x
DSM-5 Online Measures x
DSM-5 Online Measures x
WHODAS 2.0
• Description: A 36-item measure that assesses
disability in adults 18 years and older
• Rating: “How much difficulty have you had
doing the following activities in the past 30
days.” Rated 1 (None) to 5 (Extreme or
cannot do)
• Scoring: Calculate average score for each
domain and overall
• Versions: Adult and proxy-administered
• DSM-5 whodas2selfadministered
DSM-5 whodas2selfadministered
DSM-5 whodas2selfadministered
DSM-5 whodas2selfadministered
Domains on the WHODAS 2.0
1. Understanding and communicating
2. Getting around
3. Self-care
4. Getting along with people
5. Life activities
6. Participation in society
DSM-5 whodas2selfadministered
DSM-5 whodas2selfadministered
DSM-5 whodas2selfadministered
DSM-5 whodas2selfadministered
Cultural Formulation Interview
(CFI)
• Description: A 16-item semistructured
interview to assess the impact of culture on
key aspects of the clinical presentation and
treatment plan
• Indications: Use as part of the initial
assessment with any client but is especially
indicated when there are significant
differences in “cultural, religious or
socioeconomic backgrounds of the clinician
and the individual”(p. 751).
CFI Domains
• Cultural definition of the problem
• Causes of the problem, stressors and
available supports
• Coping efforts and past help-seeking
• Current help-seeking and the clinician-
client relationship DSM-5 Cultural Formulation Interview
DSM-5 Cultural Formulation Interview
DSM-5 Cultural Formulation Interview
DSM-5 Cultural Formulation Interview
Clinical Applications of
DSM-5 Enhancements
• During initial assessment:
– Administer Level 1 Cross-Cutting Symptom
Measure
– Complete intake including social history, mental
status, and diagnostic assessment
– Administer Level 2 measures as needed
– WHODAS 2.0 can be administered as indicated
– Use aspects of the CFI interview throughout
• Follow-up sessions
– Administer disorder-specific measures
– Re-administer periodically to assess progress
DSM-5 and Case Formulation
• Biopsychosocial
model in case
formulation
• The Five P’s of Case
Formulations
• Doing a case
formulation using
DSM-5
Biopsychosocial Model in
Case Formulation
Case
Formulation
Biological
Factors
Psychological
Factors
Sociocultural
Factors
The Five P’s of Case Formulation
(Macneil et al., 2012)
• Presenting problem
– What is the client’s problem list?
– What are DSM diagnoses?
• Predisposing factors
– Over the person’s lifetime, what factors contributed to the development
of the problem?
– Think biopsychosocial
• Precipitants
– Why now?
– What are triggers or events that exacerbated the problem?
• Perpetuating factors
– What factors are likely to maintain the problem?
– Are there issues that the problem will worsen, if not addressed
• Protective/positive factors
– What are client strengths that can be drawn upon?
– Are there any social supports or community resources ?
The Five P’s in DSM-5
• Diagnostic criteria
– Disorder-specific criteria set (Presenting Problem)
– Subtypes and specifiers (Presenting Problem)
• Explanatory text information
– Diagnostic features (Presenting Problem)
– Associated features (Presenting Problem)
– Prevalence (Presenting Problem)
– Development and course (Predisposing, Perpetuating and
Protective Factors)
– Risk and prognostic factors (Predisposing, Perpetuating
Protective Factors)
– Culture-related diagnostic issues (5 P’s)
– Gender-related diagnostic issues (5 P’s)
– Suicide risk (Presenting Problem)
– Functional consequences (Perpetuating Factors)
– Differential diagnosis (Presenting Problem)
– Comorbidity (Presenting Problem and Perpetuating Factors)
Case of Helen
Helen was fired from her job one month ago
because she started making numerous
mistakes and had trouble concentrating.
About three months ago she started feeling
“down“ after a break-up with a man she had
been dating for a few months. She has
trouble falling asleep and has noticed a
significant decline in her appetite. She feels
like a failure and believes that no one will
want to hire her again.
Helen Continued
She has thoughts of committing suicide but
admits, “I could never do it.” The only thing
that seems to help is when she participates in a
bible-reading group every Tuesday night. She
explains, “During that time I’m more like my
old self and at least that night I can sleep.” She
also reports that her mood improves when she
visits her friends. However, she reports such
low energy throughout the day that she is
unable to schedule a job interview.
Helen Continued
She had a similar episode about two years ago
after she was laid off from her former job. She
reports that it took four months before she began
feeling “normal” again and positive about herself.
Her history indicates that her mother had severe
depression and was hospitalized on several
occasions when Helen was young. She describes
her as “negative” and often absent in her youth.
However, Helen always did well in school and had
an active social life. Her work history has been
very consistent up to her lay off.
Diagnostic Work-Up
• DSM-5 measures:
– Level 1(positive for depression, sleep problems and
avoiding certain events)
– PHQ-9, Score = 20 (Severe)
– WHODAS 2.0
• General Disability Score = 85 (2.36; Mild)
• Subscale: Life activities = 14 (3.5; Moderate)
• Subscale: Participation in Society = 28 ( 3.5;
Moderate)
• Differential diagnosis: What are the possibilities?
• Diagnostic Impression:
296.33 Major Depressive Disorder, recurrent, severe
severity
V62.29 Other Problems related to employment
Case Formulation
• Why is she so depressed?
– Predisposing factors?
– Precipitating factors?
– Perpetuating factors?
– Positive or protective factors?
• How does the diagnosis and case
formulation inform your treatment plan?
Guide to Case Formulation
1. State the problem or diagnostic
impression.
2. State the precipitant
3. Describe critical predisposing factors
4. Include a statement about perpetuating
or maintaining factors
5. Highlight protective and positive
qualities
Write a Case Formulation
Helen presents with……(1) which appears
to be precipitated by…..(2). Factors that
seem to have predisposed her to depression
include….(3). The current problem is
maintained by….(4). However, her
protective and positive factors include….(5).
From Formulation to Treatment
• How does the formulation inform the
treatment plan?
– Best practices for this disorder?
– Which types of interventions will address the
predisposing, precipitating and perpetuating
factors?
– How do you ensure that diversity factors are
considered?
– How do you tailor treatments so that they are
more strength-based?
Final Thoughts…
• Begin using DSM-5
enhancements
• DSM-5 can help you
identify the five P’s
• Case formulation is a
skill and has been tied
to better outcome
References
American Psychiatric Association. (2014). Online assessment measures. Retrieved from
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures.
American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington DC: American Psychiatric Association.
American Psychiatric Association. (2010). Practice guidelines for the treatment of major
depressive disorder, third edition [Supplement]. American Journal of Psychiatry. 167(10).
doi:10.1176/appi.books.9780890423387.654001
Craighead, W. E., Miklowitz, D. J, & Craighead, L. W. (2013). Psychopathology: History, diagnosis,
and empirical Foundations. Hoboken, NJ: Wiley.
Frank, R. I., & Davidson, J. (2014). The transdiagnostic road map to case formulation and
treatment planning. Oakland, CA: New Harbinger Publications.
Gintner, G. G. (In press). DSM-5 conceptual changes: Innovations, limitations and clinical
implications. The Professional Counselor.
Gintner, G. G. (2008). Treatment planning guidelines for children and adolescents. In R.R. Erk
(Eds.), Counseling treatments for children and adolescents with DSM-IV-TR mental disorders
(pp.344-380). Upper Saddle River, NJ: Prentice Hall Publishing.
Macneil, C. A., Hasty, K., K, Conus, P., & Berk, M. (2012). Is diagnosis enough to guide treatment
interventions in mental health? Using case formulation in clinical practice. BMC Medicine,
10, 111. doi:10.1186/1741-7015-10-111
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