case formulation

Case formulation: A simplified example continues

My final post on case formulation illustrates the slightly simplified case study that I presented here.
I will be simplifying his presentation again today, to make sure this post isn’t too enormous!

Firstly, we identify the relatively stable phenomena:

  • Pain-related anxiety and avoidance
  • Work disability
  • Depression
  • Pain behaviours

Selected biophysical contributing factors:

  • Initial scaphoid fracture
  • Complex regional pain syndrome type i
  • Reduced range of movement and strength
  • Central sensitisation (more…)

Case formulation: A simplified example

Over the past few days I’ve been posting about case formulation. While I’ve presented the abductive theory of method (ATOM) which is a process of inferring from phenomena to underlying causal mechanisms, it’s not the only way to develop a formulation.  I posted on some of the other ways formulations can be developed, and today I’m going to describe a simplified formulation to show how it can work in practice. Don’t forget that when I write about patients I make sure details that can identify the individual are changed – or I describe a composite of several patients.

Robert is a 39 year old previously self-employed electrician who sustained a fracture of a his nondominant hand when he fell from a ladder two years ago.  This fracture developed into a complex regional pain disorder type i which had been slowly resolving with the use of medication, functional restoration (graded daily use of the hand), and mirrorbox therapy.  Robert presented for pain management assessment when his progress plateaued, and he became increasingly distressed.

He was assessed in a three-part comprehensive pain assessment in which he was seen by a pain management medical specialist, a functional assessor and a psychosocial assessor.  He completed a set of questionnaires prior to the assessment which were used to ‘flag’ areas for closer investigation.  Information was made available from the referrer (the GP), the case manager (clinical notes from the orthopaedic surgeon and initial physiotherapy treatment provider), and an initial workplace assessment which provided details of his work demands.

The medical assessment consists of reviewing his previous medical history, a full musculoskeletal examination, general ‘systems’ examination, current and past medications used for pain management, and pain specific examination.  The purpose is to identify whether all the appropriate investigations have been completed, the appropriate medical treatments have been pursued, and the medication regime is rationalised. (more…)

Case formulation – the next few steps

Over the past few days I’ve been writing about case formulation because in pain management, it’s rare to find only one single causal factor that is influencing either the pain or the disability. Most times we are looking at many factors coming from all three areas of the biopsychosocial model.

In each person, the relationships between and combinations of these factors will be unique. And that’s the value of a case formulation as opposed to a diagnosis, which is more like ‘shorthand’ for a group of symptoms that go together and are supposedly linked by a causal mechanism (in the case of non-mental health problems).

After identifying stable phenomena (symptoms that are present over time and in different places), the next step is to identify the underlying biopsychosocial causal factors that produce the phenomena we see, and the relationships between these factors as they interact. (more…)

Some readings!

Here are a couple of readings on case formulation…

Enjoy ’em!

This one is a chapter from a book ‘Cognitive Behavioural Therapy in Mental Health Care’, this chapter is written by Alec Grant, Jem Mills, Ronan Mulhern and Nigel Short, and discusses cognitive behavioural case formulation as a method for strengthening the therapeutic relationship, as well as describing some of the models used in cognitive behavioural therapy for mental health.

This paper is written by Eoin Stephens, from PCI College & Centre for Sexual Addictions.  It discusses some of the pro’s and con’s of the approach. (more…)

Case Formulation – a diagram illustrating the first stage

This is an illustration of the first step of case formulation – identifying patterns from the data collected, using a range of ways to obtain the information so that it can be relied upon for both accuracy and to cover the range of possible features of the person’s presentation. (more…)

Case formulation: Abductive reasoning applied
Before moving on any further with the ATOM (abductive theory of method) as used in case formulation, I need to define what is data and what is phenomenon. Haig defines data as individual pieces of information, often unique to the person or situation, whereas phenomenon are patterns amongst those pieces of data that form distinctive features.

For example, difficulty getting off to sleep, lack of energy and poor appetite are data; when they’re tied together with tearfulness and feelings of guilt and poor concentration, and occur over the period of at least two weeks and are causing problems in work, home and social life, we can call it part of a pattern that we recognise as depression. Data are the evidence for the underlying phenomenon, they’re visible or reportable, but in themselves are not patterns.

But giving it a name doesn’t mean it’s now a case formulation – we need to sift through other pieces of data and phenomenon to identify relationships between factors to start to create an explanation for how and why it is occurring. This is abductive reasoning and this is also case formulation. It ‘takes us from descriptions of data patterns to one or more plausible explanations of those phenomena. This explanatory move is from presumed effect(s) to underlying causal mechanisms.’ (more…)

An introduction to case formulation

One definition of case formulation is ‘Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions’. What this means is that it is essentially a story not just to describe, but explain, how a person’s problem has developed, and how it is maintained so that treatments can be based on influencing those factors.

There are many different frameworks for case formulation, but several key elements are usually present:

  1. a description of the presenting issues;
  2. the factors that act to create vulnerability or precipitate the problems developing;
  3. factors that may not have been involved in the initial problem developing, but are helping to maintain the problems; and finally,
  4. factors that can help the person cope or act as resources.

To move beyond just describing these factors, a case formulation should describe the relationships between these various factors and the problems that are present – and should reflect not just the visible features of the problem (ie what we can see, or what the person reports that are unique to his or her situation), but also the underlying phenomena or stable, recognisable features that are present. (more…)

Revelation: I’m experimenting on patients!!

Actually, the heading should read ‘I’m experimenting on with patients!

Does that not help?  Sorry, perhaps I should unpack what I mean!

Chronic pain, or actually, chronic disability associated with pain, is multifactorial.  What that means is there are many different factors that influence how and why a person has chronic pain and disability.  It also means that each person is likely to have a different set of factors that is contributing to why they are having this set of problems in this specific situation.

And the implications of this are that it’s highly unlikely that any one single treatment will ‘work’ to ‘fix’ the problem! In fact, the only time we can be certain about our treatments is when the following conditions are met:

  • a reliable and valid diagnosis
  • with a well-defined explanation for the cause of the pain
  • and known patient selection criteria
  • that predict a positive response to treatment
  • with known mechanisms of response

This doesn’t happen often, especially with chronic low back pain – and as a result, we’re probably using a working hypothesis when we’re choosing a treatment.  And guess what? That’s exactly what an experiment is – following a systematic process to establish whether the results support a specific hypothesis.

Oooops.  Are you guilty too? (more…)

One size does not fit all – people with pain are not clones

On a similar theme from my post ‘Pain management can’t be cloned’, I want to post about the need to tailor therapy to suit the person.  Pain management does not follow a recipe – principles yes, protocols … not quite so sure.

What do I mean by this?  Well let’s take two people with back pain that is making it difficult for them to work.  Both have trouble bending forward, sitting, walking and sleeping.  Both are male, mid-30’s, hard workers in manual labouring jobs.  Same date of onset, same reported pain intensity.   Neither man responding very well to NSAIDs with gastric problems and now taking regular paracetamol but no other medications.  ‘Objective’ measures of forward flexion, straight leg raising, lower limb strength are only slightly limited, and neurological testing is normal, and both present with paravertebral spasm, localised tenderness to palpation over L4/5, and localised pain over the central low back.  There are no changes on X-ray, and MRI/CT is not indicated.

Robbie is a surfer in his spare time, hasn’t been surfing recently but has been swimming, and until now had back pain intermittently but had never stopped working.  He comes from a family where pain has been ‘toughed out’, and he expects that this episode will eventually settle too.   He is surprised that his back pain hasn’t settled, but is carrying on with regular walking and intends to return to work as soon as he is able.  His main concern is that he finds during exacerbations of his pain, he has trouble settling his body down – his breathing changes, he feels nauseous, giddy, his heart rate rapidly increases, he becomes sweaty and quite distressed.  He has difficulty getting off to sleep and his sleep is interrupted.  He is typically active when his pain is settled, but then experiences a long period of intense discomfort (boom and bust pattern of activity).  He is quite careful with his movements, and in particular takes care not to move into certain positions that he has found have been associated with pain.

Andrew is a motorcyclist and is continuing with recreational motorcycling despite having had what he calls ‘grumbling’ back pain for most of his adult life.  His back pain hasn’t really settled completely, and this episode has got him quite worried because it is more intense than ever before.  His family are becoming quite irritated with the ongoing saga of his back – and want him to ‘get on with it’.  He has stopped walking, going to the gym and doesn’t like swimming.  He stays fit by using an exercycle, but doesn’t enjoy it.  His main concern is his lack of energy, and his increasing need for sleep. He does have trouble getting off to sleep on occasion, and goes to bed quite early because he is fatigued, but wakes regularly through the night and about an hour earlier than he would really like to.  He has even had an occasional afternoon nap.  He doesn’t really avoid movements that increase his pain – but has reduced his overall activity level because of his fatigue.  He notices that he has gained weight because he is not doing very much.

Sound familiar?  Clients like both of these men often attend pain management centres – and often they receive exactly the same treatment.  Lots of ‘core stability’, fitness training, daily scheduling, relaxation training and a graded return to work programme.   And these probably help in some way… but let’s take a closer look at what might be a more targeted and individualised strategy.

Robbie may have pain-related anxiety and avoidance. He describes increased physiological arousal and has learned that certain movements are best avoided.  He’s not deactivated or unfit – his cardiovascular fitness as measured by a 3-minute step test has remained high.  Treatment should probably focus on helping him develop skills to manage his physiological arousal (eg biofeedback, relaxation training, cognitive behavioural therapy to help identify automatic thoughts and replace with more helpful thoughts and behaviours), alongside graded exposure to those movements and activities that he finds concerning.   Sleep management would focus on strategies to improve sleep hygiene, reduction of unhelpful rumination as he goes off to sleep, and possibly sleep restriction.  A graded return to work would have a greater chance of success if he develops strategies to work to quota, and addresses his automatic thoughts and beliefs about needing to get everything done very fast (and very well).  He can probably return to work quite quickly once he has overcome his concerns about activities such as lifting and bending.

Andrew on the other hand, has lost fitness and lacks energy to increase his activity level.  He is assessed as being depressed and is treated with a combination of both antidepressant medication and cognitive therapy for this.  His family need to be brought into his treatment and it would help if he developed ways of communicating with them.  He needs to develop a daily activity plan with a schedule for both active and pleasurable activities.  Because he normally attends the gym and walks, his programme needs to be developed around this – swimming or hydrotherapy probably won’t be helpful.  He may need some help with ‘efficient’ ways for relaxing through the day, but doesn’t have the need for specific methods to reduce physiological arousal that Robbie does.  He may need to have a similar programme of sleep hygiene and sleep restriction, but because worry isn’t a problem for him, he may not need to focus on ways to address this before sleep.  His ‘pacing’ will need to focus on gradual increases in activity – and increases set by his fitness level.  Graded return to work will need to be progressed according to his cardiovascular fitness and fatigue/depression levels rather than avoided activities.

In effect, the two men have quite different treatment programmes despite experiencing very similar functional limitations.   This is why it’s so important to assess their presentation very carefully and develop hypotheses about what might be perpetuating their problems.  Any ‘protocol’ should ensure that the following principles are followed:

  • good assessment
  • generation of a number of competing hypotheses about cause and maintenance of the problems
  • interventions designed to confirm or disconfirm the hypotheses or based on a confirmed hypothesis
  • pre and post as well as follow-up outcome measures

A protocol may be less effective when it specifies the content of each session or the processes used to facilitate learning.  People learn at different rates, have different learning styles, varying automatic thoughts and underlying beliefs and attitudes, and live in different environments.

Health professionals have skills in applying concepts to specific situations.  This is why people are professionals, not computers or robots.

Sorry I don’t have any references for this post – unusual for me!  If you’ve got some – or any comments – let me know! And if you’ve been provoked by this post and don’t want to miss any others – use the RSS feed above, and subscribe!