The Environment and Mental Health: A Guide for Clinicians

Mental Health Conditions
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Despite some differences between theoretical orientations, some key themes exist around the content of formulations, with one of the more popular recent approaches utilizing the 'Five Ps'. These are:. Presenting problem. This goes beyond diagnosis to include what the person and clinician identify as difficulties, how the person's life is affected, and when a particular difficulty should be targeted for intervention.

For example, while a person may meet criteria for the diagnosis of borderline personality disorder, presenting difficulties may include not being able to maintain employment, erratic friendships, and physical health complications resulting from self-harm.

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Specifying such difficulties can allow for a more focused intervention. Predisposing factors. This comprises identifying possible biological contributors for example, organic brain injury and birth difficulties , genetic vulnerabilities including family history of mental health difficulties , environmental factors such as socio-economic status, trauma, or attachment history and psychological or personality factors including core beliefs or personality factors which may put a person at risk of developing a specific mental health difficulty.

Precipitating factors. This can include significant events preceding the onset of the disorder, such as substance use, or interpersonal, legal, occupational, physical, or financial stressors. Perpetuating factors. This comprises factors which maintain the current difficulties.

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These can include ongoing substance use, repeating behavioral patterns including avoidance or safety behaviors in anxiety disorders, or withdrawal in depressive disorders , biological patterns such as insomnia in mania, and insomnia or hypersomnia in depression or cognitive patterns such as attentional biases, memory biases, or hypervigilance. This involves identifying strengths or supports that may mitigate the impact of the disorder. These can include social support, skills, interests, and some personal characteristics.

Kuyken et al. We would add that identification of protective factors also creates increased optimism in both the clinician and patient and contributes to a positive therapeutic relationship. Importantly, formulations should be flexible, and should incorporate new information as it emerges. As Persons [ 6 ] noted, ' Despite numerous strengths, some caution is required when using a formulation-based approach.

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Chadwick et al. This study highlights the importance of developing collaborative formulations within a strong therapeutic relationship and at a reasonable pace. We would also suggest that similar risks exist when discussing diagnoses with patients. It is also notable that the formulation undertaken in this study did not include identifying participants' strengths or protective factors.

It may be, therefore, that had protective factors and strengths been included, the outcome could have been better. Notably, research on the impact of formulation on outcome is still somewhat limited, and questions remain regarding inter-rater reliability [ 4 , 13 ]. However, training and therapist experience have consistently been found to impact on the quality of formulations for clinicians working with either cognitive behavioral or psychodynamic frameworks [ 14 ].

When done well, formulation provides an opportunity for a shared understanding of a person's difficulties, and can offer a way of answering the classic questions of 'why this person? Importantly, it can also provide a rationale and shared agenda for what to target and in what order.

Perspective ARTICLE

While there may be some risks involved in formulation, if done sensitively, collaboratively, and accounting for strengths, we suggest it can be a clinical tool with the potential to provide considerably better outcomes than diagnosis alone. A challenge is the integration of a formulation-based management plan with categorical diagnosis and the current evidence base to provide a broad-based clinical understanding and an individualized therapeutic strategy.

Aveline M: The advantages of formulation over categorical diagnosis in explorative psychotherapy and psychodynamic management. Eur J Psychother Couns Health. Kendell R, Jablensky A: Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry. However, the principles of care outlined in the guidelines are applicable in mental health settings. In addition, the RANZCP notes that practitioners need to comply with relevant legislative requirements, including mental health legislation and medical treatment decision-making legislation.

Recognising and reducing alcohol-related harm position statement 87, November Professional practice guidelines. The contribution to practice of psychiatrists who have a personal experience of mental illness position statement 85, November Acknowledging and learning from past mental health practices position statement 84, March Recovery and the Psychiatrist position statement 86, March Children of parents with mental illness position statement 56, March PDs are placed earlier in the proposed ICD classification structure than in DSM-5 where they are one of the last chapters to reflect their more developmental sequence.

Finally, mental and behavioral syndromes due to particular types of diseases or disorders are organized differently in ICD than in DSM-5 because of differences in the way that the two classifications handle primary and secondary disorders. Several categories have been recommended for inclusion in the ICD that were considered but not included in the DSM-5 , such as olfactory reference disorder Stein et al. Conversely, DSM-5 contains several categories that have not been recommended for inclusion in ICD , such as disruptive mood dysregulation disorder Evans et al.

The origins of ICD and DSM as public-health-focused classification systems account for some of the characteristics that have contributed to subsequent problems in classifying mental disorders. Several characteristics of both ICD and DSM that stem largely from these structural requirements have received criticism.

First, disorders can be represented in one and only one place, but the basis for assigning certain disorders to particular places in either system is arbitrary and not fully consistent with all available evidence. For example, in both systems, major depression and GAD are classified in different places, even though they are highly comorbid and the genetic contribution to these disorders is essentially identical Kendler, , p. Both DSM-5 and ICD modified this structural requirement and cross-listed a few disorders so that the systems would better reflect the complexity of mental-disorder diagnosis.

For example, DSM-5 placed schizotypal PD and antisocial PD with the other PDs; moreover, it also placed schizotypal PD with other schizophrenia-spectrum disorders and antisocial PD with its required childhood precursor, conduct disorder. Second, categorical systems are ideal when the entities being classified are taxa i.

The Environment and Mental Health: A Guide for Clinicians

Such systems can classify dimension-based entities only by imposing cut points, which may be relatively arbitrary. However, classifying nontaxonic, multidimensional phenomena such as mental disorders, which can overlap in myriad ways, is not straightforward.

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Environmental illness is a concept of growing concern to all health professionals. Patients with problems presumably caused by sick buildings, electromagnetic. The Environment and Mental Health: A Guide for Clinicians edited by Ante Lundberg; Mahwah, New Jersey, Lawrence Erlbaum Associates, , pages.

Third, because each disorder must be classified in one and only one place, there is a tendency to make each entity as distinct as possible, resulting in highly—indeed, overly—specified categories. This issue is manifested in several ways, each of which has associated problems that are among the core criticisms of ICD and DSM. For example, major depression can present with marked anxiety, psychotic features, or both, so to keep these three disorder presentations distinct, a comprehensive categorical system must do one or more of the following:.

Specify exclusion rules e. Create either specified intermediate categories e. For instance, schizoaffective disorder is placed with schizophrenia-spectrum disorders, so it cannot also be placed with mood disorders; conversely, major depression with psychotic features is placed with the mood disorders, so it cannot placed with other psychotic disorders. This approach also results in the proliferation of diagnostic categories, because every important overlap between dimensions then requires the creation of specific diagnostic label.

Resulting diagnoses may misleadingly suggest that the individual has three disorders rather than a single, complex mental disorder. Research literature reviews and meta-analyses have shown that in some domains of psychopathology, a greater percentage of individuals are more accurately characterized as having these types of diagnoses than meet the criteria for any specific disorder in the domain e.

In addition to these various problems, an overarching unintended consequence of overspecification is that it contributes to the reification of disorders. That is, when disorders are highly specified, a natural assumption is that there is an empirical basis for the precision with which they are defined, so they come to be regarded as representing real and distinct natural phenomena.

In turn, thinking about mental disorder in this way obscures the arbitrary nature of and lack of scientific evidence for many distinctions among categories or between disorder and health, as well as inhibits inquiry into their interrelationships and common substrates.

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In summary, despite the many changes and improvements in ICD and DSM-5 from their predecessors and the various differences between them, they both remain categorical classification systems that are fundamentally descriptive in nature, based primarily on self-reported symptoms, clinically observed signs, and a few tests e. The RDoC project was initiated in early in response to this changing landscape, including feedback received in late from researchers in the field as NIMH prepared its new strategic plan.

An experimental approach was deemed necessary, given the still-nascent state of the science of mental disorder and the conceptual and empirical constraints of research based on current classifications. It was apparent that if developments in basic and translational science were to be applied to the science of mental disorder, a long-term approach would be needed.

Such an approach would need to examine psychopathology with reference to behavioral and brain mechanisms rather than in terms of existing disorder categories. It was not that decades or, indeed, centuries of clinical observation and research should be discarded wholesale, but rather that an alternative research framework was needed to understand more fully the basic mechanisms that are disrupted in mental disorders. The RDoC project thus was developed to respond to both of the difficulties that the groups revising DSM-5 encountered: the hitherto predominant reliance on the DSM and ICD diagnostic categories to guide research on the causes and mechanisms of disorder, and the lack of a clear alternative in the face of the failure of this research to support existing diagnostic systems.

Second, the RDoC project was not intended for practical clinical use in the near future. Rather, it provides a framework for research. It does not formally incorporate any current ICD or DSM disorders and, in fact, does not define mental disorder or any specific disorders. It was thought that such a radical departure was needed to create a research framework that could address the problems discussed above in trying to understand, diagnose, and treat mental disorder.

Many behavioral and psychological problems in children and adolescents reflect early stages in the development of later psychopathology, yet there is reluctance to label still-maturing individuals as having a mental disorder. Taken together, these points may explain why reification of mental disorder in younger age groups as opposed to in adults developed more slowly and less strongly. Accordingly, the work of developmental psychopathologists was a rich intellectual source for many aspects of the RDoC project.

For example, as early as the mids, Achenbach had proposed that psychopathology has a hierarchical structure; moreover, such concepts as equifinality the idea that diverse developmental pathways can lead to the same or similar outcomes and multifinality the idea that a given risk factor may result in different outcomes depending on the environment had been used for several decades to understand the development of psychopathology as an outcome of person-environment interactions e. What is new about RDoC is the idea that to understand mental illness in all its complexity, the field needs a research framework that accommodates the study of all causal factors together.

Although it is of course impossible to incorporate all factors in any given study, what the RDoC project hopes to do is break researchers away from studying a few relevant factors in isolation—that is, without consideration of how they fit together with all the other relevant factors. Similarly, given the work of developmental psychopathologists, by the time the RDoC project was being designed, almost all mental illness had come to be regarded as neurodevelopmental—as being affected by, and also affecting, neural structures and processes throughout development.

The RDoC perspective, therefore, is that it is vital to incorporate a neurodevelopmental aspect in research programs, and yet the problems delineated above e. Until recently, it was difficult to investigate what these mechanisms might be. Now, new methods in neuroimaging, behavioral neuroscience, psychometric analyses of behavior, and for examining the effects of various events and social contexts upon behavior and the brain are transforming our understanding of normal and abnormal functioning.