DIMENSIONS OF THE DIAGNOSTIC FORMULATION
The diagnostic formulation summarizes and integrates the biopsychosocial, developmental, and temporal axes. The biopsychosocial axis refers to multiple systems, from molecular to socio-cultural, that interact constantly and are manifest in current objective behavior and subjective experience. The developmental axis is applied to different levels of the biopsychosocial axis in order to determine whether each level is developmentally normal, delayed, advanced, or deviant. The temporal axis refers to the ontogenesis of the individual from his or her origins to the present and beyond.
Current functioning is the expression of multiple biopsychosocial levels within the patient, as he or she interacts with the physical, family, socio-cultural, occupational, and economic environment. In order to evaluate present functioning, the clinician examines the levels and systems described in Table 12–1.
Table 12–1The Biopsychosocial Axis ||Download (.pdf) Table 12–1 The Biopsychosocial Axis
|Level ||Systems Assessed |
|Physical level ||Periph eral organ systems |
| ||Immune system |
| ||Autonomic system |
| ||Neuroendocrine system |
| ||Sensorimotor system |
|Psychological level ||Information-processing system |
| ||Communication systems |
| ||Social competence |
| ||Internal working models of the self and others |
| ||Unconscious conflicts, ego defenses, and coping style |
| ||Patterns of psychopathology |
|Social level ||Physical environment |
| ||Family system (nuclear and extended) |
| ||Socio-cultural systems (peers, adults, school) |
Each level of the biopsychosocial axis can be assessed with regard to what would be expected for that age. Some of these assessments (e.g., height, weight, head circumference) are very accurate. For others (e.g., intelligence), although a number of assessment instruments are available, existing measures represent a composite of skills potentially affected by extraneous factors (e.g., social class, motivation). For still others (e.g., ego defenses, working models of attachment), measurement techniques are relatively crude and the norms subjective.
Nevertheless, during interviewing and mental status examination, the clinician will scan the levels shown in Table 12–2 for delay, precocity, or deviation from the normal and, when appropriate, order formal special investigations.
Table 12–2The Developmental Axis ||Download (.pdf) Table 12–2 The Developmental Axis
|Level ||Systems Assessed ||Assessment Method |
|Physical level ||Peripheral organ systems (e.g., height, weight, head circumference) ||Growth charts |
| ||Sensorimotor system ||Developmental assessment, neuropsychological testing |
|Psychological level ||Information processing ||Intelligence testing, special testing for memory and other cognitive functions, educational attainment testing, neuropsychological testing |
| ||Communication ||Speech and language assessment, neuropsychological testing |
| ||Social competence ||Behavioral observation, psychological testing |
| ||Internal working models ||Interviewing, personality testing |
| ||Conflicts, defenses, coping style ||Interviewing, behavioral observation, personality testing |
| ||Symptom patterns ||Interviewing, checklists, structured interviews |
|Social level ||Family system, peer relations, school functioning ||Family interviews, observations, checklists |
All individuals have come from somewhere, exist where they are now, and ...