5 Engel’s Model (summary) Biological changes in disease are not always reciprocated in illnessPresence/absence of disease does not necessarily shed light on the meaning of symptomsPsychosocial determinants of illness are of fundamental importance in assessment and symptom expressionThe sick role/illness behaviour is not necessarily associated with diseaseSuccess (or failure) of biological treatments is influenced by psychosocial factors (&vice-versa)Dr/P relationship influences outcomesPatients are profoundly influenced by the way in which they are studied (&vice-versa)
6 Translation of the BPS model to clinical practice Relationship between mental/physical aspects of healthPaying “lip service” to participatory relationshipSelf-awarenessCultivation of trustEmpathic curiosityRecognising biasUsing informed intuitionCommunicating clinical evidence
7 Clinical FormulationA map to help us understand the terrain of an individuals narrativeAn attempt to explain why a person is experiencing symptoms in a particular way at a particular point in time.Moving beyond description into explanation
8 Models and RealityDon’t mistake models for reality!
10 The Four P ModelAn attempt to provide an explanatory overview of a presenting problem / problemsNot based in any one psychiatric / psychological modelEvidence basedForces you to consider relevant factors
11 Predisposing FactorsThings that make the person vulnerable to developing the current presentationExamples could include:Early trauma (e.g. abuse, bullying, parental separation).Physical health problems.Family history of mental ill health.Think – What happened in the past?
12 Precipitating Factors ‘The Final Straw”Things that happened in the person’s life that seemed to trigger an episode of illnessExamples could includea bereavementloss of a job orother significant life change.drug useThink – What was the final straw?
13 Perpetuating FactorsThings that seem to be keeping the person in their current state of distress.Examples includepervasive negative thinking.lack of a close confiding relationshiplack of adherence to medicationThink – Why are they not getting better?
14 Protective FactorsThings which seem to help keep the person well and which need to be strengthened in order to decrease the likelihood of the problem reoccurringExamples includea strong relationship,a particular skill in a specific areaa psychological feature such as a good sense of humourThink – What are their strengths? What’s good in their life?
15 Iatrogenic FactorsIatrogenic factors relate to treatments that worsen the patient’s conditionThese are not part of the formulation but can have a massive impact on treatment.Tend to be associated with drug treatment but all treatments are potentially iatrogenic.
16 The Four P Model Iatrogenic Protective Predisposing Precipitating ‘Symptoms’Perpetuating
17 Putting it together: An integrative aetiological formulation NB : First we need a collaborative understanding of the presenting complaint!BiologicalPsychologicalSocialPredisposingPrecipitatingPerpetuatingProtectiveIatrogenic
18 Management Biological Psychological Social Short term Medium term Long term