This website is intended for use by suitably qualified medical practitioners, who assume full responsibility for the application of any of its content in their clinical practice.  Views and opinions expressed on this website are those of Dr. Hassan and do not necessarily represent those of organizations with which he is affiliated.

©2018-2019 by Islam Hassan, MBChB, MMedSc, MRCP(UK), MRCPsych, FRANZCP, FRCPC, CSCN(EEG).  All rights reserved. 

Neuropsychiatric Formulation Chart

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Neuropsychiatric Formulation Chart

v3.1N (NECSA)

v3.1G (General)

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Rationale

Formulation in psychiatry is more than arriving at a diagnostic label.   A mere diagnostic label is typically insufficient to develop a tailored management plan that takes into account the patient’s unique biopsychosocial presentation.  A formulatory hypothesis, on the other hand, is a more comprehensive understanding of why a particular person presents with certain symptoms at a specific time. 

 

Presentations with psychiatric symptoms in the setting of neurological disorders often pose an exceptional challenge to diagnostic formulation, because of the multitude of potentially contributory factors that need to be considered.

The Neuropsychiatric Formulation Chart* was developed to help negotiate this challenge.  It is a one-page chart which aims to provide a stepwise, intuitive and efficient approach to neuropsychiatric formulation.

  • Hassan I (2019). Formulation in neuropsychiatry: a stepwise approach. Australasian Psychiatry 27: 411-2. 

Stepwise approach

The Neuropsychiatric Formulation Chart begins with the patient’s symptoms, and proceeds to organize data entry and analysis into sequential fields, through a step-by-step process of clinical reasoning, culminating in a formulatory hypothesis that directly informs a tailored management plan. 

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1.  Broad-scope characterization of presenting symptoms.

The broad scope of symptoms considered here, including psychobehavioural as well as cognitive, sensorimotor and other systemic symptoms, protects the clinician from overlooking clues to systemic syndromes or less obvious conditions which may warrant specific treatment.

2. Examination of evidence for potential pathologic mechanisms. 

This is based on information gleaned from history, examination and investigations.  Two versions of the Neuropsychiatric Formulation Chart are available based on whether , for a given patient, the clinician chooses to use the NECSA Classification* – particularly suited to presentations with CNS lesions -  or the general VITAMINS surgical sieve.  The former arose from the author’s clinical practice involving patients with lesional epilepsy.

 

3. Examination for temporal associations between symptoms and

pathologic mechanisms. 

The characterization of temporal relationships is an intermediate step towards the subsequent step of characterization of cause-and-effect relationships, as the former are a requisite for the latter.  Temporal relationships thus deserve special emphasis as they can easily be missed due to the large number of factors which can often be interacting in neuropsychiatric presentations.

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4. Judgment of most likely causative factors. 

Each of the plausible differentials narrowed down from the above steps is examined to estimate its relative likelihood as a causative factor for the patient’s presentation.  In this step, both analytical reasoning (such as consideration of criteria for causation) and heuristic intuition (based on prior anecdotal experience) combine to inform clinical judgment.  

  • Hassan I (2015). The Neuropsychiatric Effects of CNS Structural Abnormalities (NECSA) classification: An aid to differential diagnosis. Australian and New Zealand Journal of Psychiatry 49: 943.