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  • Formulation as Diagnosis:Toward a Post-DSM, Post-Biopsychosocial World
  • G. Scott Waterman (bio)
Keywords

diagnosis, case formulation, Biopsychosocial model

Iappreciate Dr. Bolton’s contribution to the vital and complex question of how best to conceptualize, teach, and practice psychiatry, and am grateful for the opportunity to comment on his thoughtful and provocative paper. Some of what I take to be his premises are not especially controversial: 1) The barrenness of the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic system demands that it be complemented with useful ways of thinking about, communicating about, and treating patients; 2) the Biopsychosocial model, despite its status as ‘part of the ideology of medicine,’ is little used by clinicians; and 3) the Biopsychosocial model carries both practical and conceptual problems that render its replacement as a template for case formulation desirable. Having outlined those points of apparent agreement, I elucidate the problems I see with Dr. Bolton’s scheme and, where applicable, suggest remedies for them.

Dr. Bolton’s explanation of the distinction between diagnosis and case formulation as isomorphic with that between type and token is helpful, but perhaps overdrawn. Clearly the intent of diagnosis is to say something that is both true and useful about patients as individuals. That psychiatric diagnosis accomplishes those goals (to the extent it does) in ways that are often trivial, superficial, and/or unhelpful may reveal more about the shortcomings of our diagnostic system than about the distinction between diagnosis and case formulation. Conversely, case formulation as practiced and taught by Dr. Bolton is predicated on knowledge of ‘types’ that is presumed applicable to individual patients who represent those ‘types.’ Thus, the notion that, for example, an individual patient’s genetic endowment or exposure to violence rendered him vulnerable to the condition with which he now presents is no less an application to the individual of knowledge of the group to which that individual belongs (e.g., people with two ‘val’ alleles of the COMT gene, people who were sexually abused as children, etc.) than is the case with ‘diagnosis.’ One wonders, therefore, whether Dr. Bolton’s mission should be considered that of overhauling (rather than merely complementing) the psychiatric diagnostic system—a mission I would heartily endorse. Such [End Page 211] an overhaul would entail ‘thicker’ descriptions of histories and presentations not only to discern each patient’s uniqueness but also to learn more about—and ultimately take advantage of knowledge of—their commonalities across a far broader range of potentially relevant domains than that tapped by the current diagnostic system (Althoff and Waterman 2011).

To what extent, then, is the 4P model likely to achieve the explanatory and pragmatic goals of such a diagnostic/formulation system? Dr. Bolton makes a convincing case that the structure of the 4P model imparts to learners that humans (and thus their pathologies) are complicated and that information relevant to understanding and helping them covers a wide variety of categories, many of which have not traditionally been foci of medical education and training. Thus, I do not doubt the heuristic value of his scheme—and considering the conceptual mess in which psychiatry finds itself, that is no small matter! I wonder, however, whether our current state of knowledge allows for his template to be filled in with sufficient detail to be of explanatory, prognostic, or therapeutic value for individual patients. How, for example, does the handful of known genetic polymorphisms associated with increased risks of psychopathologies affect diagnosis/formulation today (or will it tomorrow)? How does knowledge that immigration is stressful change the way illness in immigrants is conceptualized or treated relative to native-born patients whose ‘stresses’ have presumably been different but no less pathogenic? Perhaps of greatest practical import, in what ways do “[t]he four questions [based on the 4Ps] in fact elicit ‘actionable’ information . . . [so] the clinician can design comprehensive and effective treatment plans” (Bolton 2014, 182)? Among the myriad problems with the Biopsychosocial model is the unwarranted implication of correspondence between putative causes of illness and components of treatment (a ‘biological’ treatment for a ‘biological’ problem, etc.; Waterman 2006). And even if there is reason to expect that different...

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