1. Formulation Fernanda Garcia-Costas Child and Adolescent Consultant Psychiatrist Plym Bridge House Fernanda.garcia-costas@nhs.net

2. Includes: Diagnostic features Differential diagnosis Aetiological factors: – Predisposing (increase vulnerability) – Precipitating (trigger onset of disorder) – Perpetuating (maintain symptoms after precipitants have disappeared) – Protective factors Prognosis

3. Aetiology: BIOLOGICALPSYCHOLOGICALSOCIAL PRED PPT PERP

4. Biological Predisposing: – Obstetric complications – Genetic loading – Head injuries – Drug and alcohol misuse – Physical illness – Gender – Cognition

5. Biological Precipitant: – Non compliance – Drug and alcohol – Physical illness – Head injury

6. Biological Perpetuating: – In addition to the irreversible genetic loading and obstetric damage – Continued non compliance – Drug and alcohol – Physical illness

7. Psychological Predisposing: – Inadequate parenting and early trauma/attachment Poor self-esteem Poor impulse control Difficulties with relationships Dysfunctional beliefs – Evidence of maladaptive behaviour Drug and alcohol Excessive/no relationships Offending behaviour.

8. Psychological Precipitant: – Trauma (real or imagined) reignites dysfunctional beliefs from previous similar experiences – Specific psychological mechanisms adopted: Depression: denial, turning against one self Paranoia: projection, splitting OCD: isolation, magical thinking/undoing Phobia: displacement

9. Psychological Perpetuating: – Continued ingrained maladaptive thoughts and behaviour.

10. Social Predisposing: – Poverty – Divorce/parental discord – Overcrowding – Unemployment – Isolation – Any cause of stress: finances

11. Social Precipitant: – Life event: new birth in the family, moving house/school.

12. Social Perpetuating: – Decreased functioning which exacerbates or causes any of the above plus others.

13. Prognosis Short term: current episode – Good or poor depending on likelihood of remission. – Determined by the natural history of the disease (episodic/chronic) and the past psychiatric history. Long term: Likelihood/frequency of recurrence – Dependent on: Natural history Past psychiatric history Bio/Psycho/Social components of the aetiology.