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Dr. Alex Raben: [00:00:00] Hello listeners, this is Alex here. Welcome back to PsychED! For the month of July instead of one episode, you'll be getting five. That's because we're going to be doing a special mini-series in which we cover clinical skills in Psychiatry. So in the past, we've tended to cover specific disorders or illnesses, but these five episodes will focus on approaches and competencies that will help you in your training in psychiatry. We hope that you will enjoy!
Dr. Aarti Rana: [00:00:38] Thank you and welcome to PsychED, an educational Psychiatry Podcast for Medical Learners by Medical Learners. Thank you for joining us today in our mini-series on psychiatric clinical skills. In this particular episode today, we're going to be discussing something called the biopsychosocial formulation. This is one of those conceptual structures we use in psychiatry to bring together our biological, psychological and social models of understanding and treating psychiatric illness. Your host today are myself Dr. Aarti Rana, a second-year resident at the University of Toronto. Dr. Chen, I'll let you introduce yourself.
Dr. Lucy Chen: [00:01:17] Hey there! I'm Dr. Lucy Chen. I'm a PGY4 for psychiatry resident at the University of Toronto.
Dr. Aarti Rana: [00:01:22] And we're sitting here today in the west end of the city at Saint Joseph's Health Care Centre, joined by Dr. Erin Carter, who will be interviewing today about the biopsychosocial model. Dr. Carter happens to be my current supervisor on my rotation and is an acute care psychiatrist. Dr. Carter, I'll let you introduce yourself and your background and expertise.
Dr. Erin Carter: [00:01:42] Thank you so much for having me today. I'm Dr. Erin Carter. I'm a psychiatrist at Saint Joseph's Health Centre in the west end of Toronto. I work as an inpatient psychiatrist, so I see people with acute mental illness who've been admitted to the hospital. I work with a lot of residents. I'm interested in education, and I carry a full patient load here but primarily in the inpatient setting.
Dr. Aarti Rana: [00:02:07] I thought we could divide our discussion today into three parts. The first part, really about understanding what the biopsychosocial formulation is, kind of the who, what, when, where, why of it. The second part, the how. So the tricks and trades of actually doing formulation. And then the third will hopefully get to a sample formulation in real time. We're going to put you in the hot seat, Dr. Carter.
Dr. Erin Carter: [00:02:31] Sounds good.
Dr. Aarti Rana: [00:02:33] So let's begin. What exactly is a biopsychosocial formulation for someone who's never heard that term before?
Dr. Erin Carter: [00:02:39] Well, if you're just starting out learning about psychiatry and training in psychiatry, biopsychosocial formulation is something that we do when we are really trying to understand who a patient is and why they look the way they look in front of us on any given day. And it's kind of a living entity. It's something that changes over time depending on what's going on in their life. But it's something that we use when we communicate with each other. And also just when we think to ourselves as clinicians about what has brought this person to where they are. I would encourage learners to to think about the word formulation. So, it's about making something. It's about building something. So when you do this, you're drawing on the areas of biology, psychology and sociology, and then also culture of the patient before you. You're building on these areas and you're trying to build something, and what you're trying to build is an understanding.
Dr. Aarti Rana: [00:03:39] So, Dr. Carter, I kind of get that conceptually, but what does that actually look like? So if you're building something, it's not with popsicle sticks, right? Can you tell us what's the actual components of a biopsychosocial formulation? Like if you were to look at one, what would it look like?
Dr. Erin Carter: [00:03:53] Well, I guess you want to bring it to life. You want to think of a person in front of you, and they are a living, breathing entity and you're trying to capture them at a moment in time. So what it would look like is if you want to start with biology, you would look at what are the aspects of biology that have contributed to who this person is. So is this somebody who has had any sort of biological stressor or even a biological advantage, something that's happened to them in the distant past during the time that they were in utero or in their childhood, their teen years, or who they are now in front of you, what's happening biologically with them genetically? Think about those sort of physical things. So, that's one area then you want to look at psychologically. And I'm going to just start right at the beginning and say that everybody seems to have trouble at the beginning distinguishing between the differences between psychology and sociology. So I would really encourage you to think of psychology as the factors for the patient that are happening internally inside their head, inside their mind, who they are on the inside. Whereas sociological factors, the sociology of it is what's happening outside of them externally. So for example, psychologically, are they somebody who has intelligence or are they somebody that struggles with intelligence? Or another example would be, are they somebody who is psychologically minded? You know, they think about things a lot emotionally, cognitively they reflect on things or are they somebody that doesn't have any sort of sort of psychological minded approach to life? And then sociologically, like I said, those are external things. Do they have housing, do they have finances? Are they in a relationship? So things that affect who they are right now based on what's going on outside of them. And more recently, we've added a fourth dimension, which is we think about culture. Is that something that has influenced who is standing before you right now?
Dr. Aarti Rana: [00:05:54] That's really helpful. So in summary, a bio component of the formulation is things that have happened to someone's body. So that could include neurologically, developmentally, for example, socially sound. Sorry, let's go back to psychologically. Are things inside the person? Use the examples of their cognitive ways of thinking and then social would be things between them and others or between them and their environment, and that would include culture.
Dr. Erin Carter: [00:06:27] I think that's very fair.
Dr. Aarti Rana: [00:06:28] Okay, that's very helpful. And you'd also mention when you said we're formulating who the person is right now, what do you mean by that? So not just who the person is, but why right now? What's the importance there?
Dr. Erin Carter: [00:06:42] Well, I think when you start out in your training, in psychology, formulating someone is something that you fear often as a learner. It's a pretty big task to bring all these factors together, and it's something that can create anxiety and fear in new learners. But I think over time it becomes something that you love. And it's probably a big part of the reason why you chose psychiatry, because you're actually really interested in all the pieces that come together to make a person who they are. That's all that formulation is. And so inevitably that's a dynamic thing. I mean, that changes over time. The person that you were when you were seven or eight years old and the things that were influencing you, I'm sure we're really different than the person you were when you were in third year university or the person that you are today. They can be really affected by all sorts of different things inside of you, outside of you, biological things. They will all change what you see really on any given day. And so I would encourage people to sort of settle that anxiety or that fear about formulation and really embrace it as an exciting way to look at a person and an exciting way to inform how you're going to understand them and how you're going to help them, and to know that it's dynamic, to know that it's it's going to change and that it's your opinion as someone expresses their thoughts about formulation. It's an opinion. It's not a fact. It's just what I think is happening and what I think I'm seeing. And so, again, inevitably that's going to change over time.
Dr. Aarti Rana: [00:08:08] I think have a pretty good understanding now of the what a formulation. Dr. Chen, do you have any questions about the formulation?
Dr. Lucy Chen: [00:08:15] Yeah. And I guess, like, where does formulation happen, where our residents are going to be formulating sometimes where clerks are going to be formulating, I guess how we can prepare learners for the environments where they're going to be might be expected to formulate.
Dr. Erin Carter: [00:08:29] Well, in a concrete sense formulation, you know, geographically happens any place where you're coming into contact with a patient. So it's important and particularly when you're meeting a new patient or when a patient appears to be changing a little bit that you're working with over time. So you're going to formulate in the emergency room, when you see people there, you're going to formulate in the clinic, you might have a patient that you're following for psychotherapy over a period of a few years. And you're going to formulate and reformulate over time as you get to know them better. And as they change and grow and evolve, you're going to formulate during exams when you have to communicate with your supervisors and with your examiners about your understanding of patients. So I guess that's the concrete answer. But again, I can't resist adding that in a less concrete way. The place of formulation is happening is inside your mind, and it's the exciting place where you are mulling and thinking about what you bring to this case, your understanding of this patient. So it's happening in your mind.
Dr. Lucy Chen: [00:09:28] Yeah, well, I guess there's mulling sort of process maybe kind of transitions us nicely into part two, which is understanding the mechanics of formulation, basically the how of doing a formulation, presenting it and using it effectively. So I guess before we begin an interview, how can we set ourselves up for success? What's a really good approach to organising the information that we're going to be collecting from the patient?
Dr. Erin Carter: [00:09:53] Well, I'm going to give you the advice that I would give to a new learner, to a clinical clerk, a med student or a first year resident. But I'll be honest with you, it's the same advice that I would give when you're right at the end of your residency, preparing for your exams. The way to set yourself up for success in formulation is to really do an organised interview with your patient. So I think that people become familiar with what's known as the psychiatric interview. It has different categories. It starts with identifying information and and it goes from there. And, and these are categories that you really want to own, you really want to master these categories. And if you are able to master an organised interview, a psychiatric interview with your patient, if you can do that in an organised manner, you will have all the pieces of information you need to formulate well.
Dr. Lucy Chen: [00:10:42] I guess taking us through what that is, identifying information, kind of a chief complaint, what brought them in to hospital or to the emergency department were brought them in for a psychiatric consultation. The history of presenting illness, sort of the context and sort of a symptom screen, their past psychiatric history, their past medical history, the medications that they're currently taking, the medications that they've tried allergies to medication or other sorts of allergies, family history.
Dr. Aarti Rana: [00:11:10] And substances.
Dr. Lucy Chen: [00:11:13] Substances. So kind of it sort of gets ingrained over the course of time, which.
Dr. Erin Carter: [00:11:19] A really good there you were on a run you had you don't even have any paper in front of you did very well with those.
Dr. Aarti Rana: [00:11:23] And it shows how hard it is to be organised about all of those things. Right. In a systematic way.
Dr. Lucy Chen: [00:11:28] Yeah. And I guess finally just to add to that list is also sort of the past personal history or the developmental history and the relational history to help us get that information for a comprehensive formulation. So how do we elicit that salient information, the most important information needed to formulate? How do we get that out of the patient?
Dr. Erin Carter: [00:11:48] Well, that's kind of a difficult question to unpack. I think there are several pieces to that question, and I'm going to try to give you an answer that's not too lengthy. But I think that, first of all, for again, for new learners, what you need to really think about is the categories of the interview that you just laid out quite nicely. I would really encourage learners to attempt to set goals for themselves to gain mastery over each of those categories. And so, for example, the first category you may gain mastery over is identifying information, you know, and that's where you find out the person, their name, their age, what they like to be called, what their relationship status is, you know, these kind of very factual pieces of information. And that once you've memorised that, the approach to that category where you don't have to look at a piece of paper to know the questions you want to ask, then you have mastery over that category. So that may be the first one. The next one you may have mastery over is later in the interview, the mental status examination. That's something you do over and over again and again. You want to get mastery of that. There are some categories that are easier to master than others, and there are some that are challenging. Long after you've finished residency and your staff, you're still struggling to master them. I would say that some of the most challenging categories to master are the history of the presenting illness and the personal history. And inevitably, these are also two of the ripest categories for gaining salient information for formulation. So that's okay. You may never have mastery of them because they are particularly dynamic for the patient.
Dr. Erin Carter: [00:13:17] The history of the presenting illness, which is what's brought them before you like what's really been happening in the past few weeks of the past few months. It's very challenging to get that information in an organised way and you just get better and better at it through practice and observation. Once you're able to do that and get kind of a tight, concise history of the presenting illness, I think you have a lot of salient information for formulating, particularly what were the precipitates of this illness event, this particular presentation, and also what may be perpetuating it, what's causing it to continue? And then I think the personal history, that's a different category that you're getting later in the interview that is going to really help you have an understanding of the predisposing characteristics. So again, you're trying to build up. Why does this person look the way they look today in front of me and it matters what was happening in their childhood or even maybe what was happening in utero. So, a lot of the personal history questions that come towards the end of the interview, do not lose time. Do not lose all of your time before you get to that section, because it's really going to help you to build your understanding of what shaped this person into who they are. So you are going to get salient information from all over. I guess if I had to pick three categories, I'd want the HPI, the personal history and the psychiatric history. And I feel like I could take a pretty good stab at a formulation if I had those three categories. Get them all, but make sure you get those three.
Dr. Lucy Chen: [00:14:46] But if we were to really kind of simplify an approach to an HPI categories like symptom collection, how can we best sort of comprehensively sort of summarise in HPI for young learners.
Dr. Erin Carter: [00:14:59] I think I'm going making eyes at your colleague now because I think you're cheating. I think this is a different podcast approach to HPI. But anyway, let's see, I'll give it a stop. So you're asking me really how do you get a tight HPI? That's sort of the question. I think, to be honest with you. That is the enduring question throughout residency is and I find as a teacher working together with learners, with residents, that is something that people struggle to master. And there are so many things that go into to getting a tight HPI. And as I say, I think people continue to struggle with it at times, even as a staff person after residency. But I think that for a learner who's starting, what I would encourage people to do is to really start out with an open-ended question at the beginning of your HPI. You really want to ask the person something that gives them a chance to talk, that gives them a chance to show you who they are and what's concerning them right now. So an obvious open-ended question would be to say to your the patient in front of you "Can you help me to understand what's brought you here today to the emergency room" or to the clinic or wherever they are. Can you help me to understand, what do you think has brought you here? What's happened? What's brought you here? And then hopefully they're going to tell you a story. Hopefully they're going to give you their story. And I think that your job then for the HPI is really just to work together with them to to enable them to tell you their story.
Dr. Erin Carter: [00:16:28] And you have to recognise that it might not be easy for them to tell you their story. They may find it difficult because of the actual diagnosis that they have, maybe they're psychotic or having symptoms that cause them to be disorganised in the way they think or the way they express themselves. So if you ask them an open ended question like that and they're struggling to answer it, that struggle that you're witnessing, rather than being frustrated by it, you can use that for information. You can say to yourself, well, he's really having trouble organising a timeline, what does that mean? Well, it means something. It means something to me. It may be about his diagnosis, so it's actually helpful. Or maybe he's having trouble expressing his story because he's a super quiet, shy guy. Or maybe in his culture, you don't talk about yourself. You don't tell stories. So, whatever's happening with that first open-ended question is giving you enormous clues as to who this person is. And that's what formulating is about. So all of that, to go back and say that, I would start with an open-ended question and let's see what they do with that open-ended question. Let's see. And then you go to work. Your job is to help them tell their story. So you may help them through guiding the way they're answering your questions. And sometimes they may need closed ended questions, questions following that, because they've got so much to say. You may need to help them become concise or they may be able to you know, you may be able to guide them just through body gestures or through listening.
Dr. Aarti Rana: [00:17:59] Dr. Carter, you just gave us a really excellent example of what you described as formulation. You started to hypothesise about what you were observing and you included formulation like language. There you said, maybe this is I'm witnessing this because this person is having difficulty organising themselves. So you're talking psychologically inside? Or psychologically, they're maybe shy person, something about their personality. So I thought that was really interesting.
Dr. Erin Carter: [00:18:26] It's true. We went through the sort of categories there. We considered, you know, a biological reason. Maybe they're having psychosis. But then there are also could be a psychological reason or a sociological reason or a cultural reason. You're already getting hints. And I think it's important that, you know, you are able to be open to what they give you because the patients are giving you clues and telling you about who they are with everything that they say, with the things that they don't say, with the struggle they have in expressing themselves, they're telling you things. And it's your job to sort of settle yourself and calm yourself so that you can see it.
Dr. Aarti Rana: [00:19:09] So for our listeners, there's there's two pearls, one of which I learnt from you actually about the HPI. One is to share it like a movie. And so I imagine going back to my supervisor later and being able to explain what happened, like a movie, and that helps me figure out what questions am I still missing, whether it's questions about the timeline, questions about stressors or inciting factors. What am I missing from the movie that I'm going to be able to ask about now? And the other one is, I think this has taken me my whole second year of psychiatry to learn, which is when I ask that open-ended question, to actually wait a while and and let the answer emerge, it's very tempting, especially with time limits, to ask the open-ended question, but ultimately treat it like a closed-ended question by interrupting quickly.
Dr. Erin Carter: [00:19:55] I think that's very true. The HPI, you're right at the beginning of your interview, so you've asked them the identifying information and you've gotten clues from them during the identifying information. You already have a sense in those first 2 minutes when you've asked identifying information, questions, whether this person's going to be a talker or whether they're going to be hard to get information out if they're already giving you clues. But regardless of what they give you, that HPI is at the beginning. You've got some time. And, I would look at that open-ended question and I would I would be very willing myself to let any patient tell me whatever it is they want to tell me for about anywhere from about 3 to 5 minutes, I'm going to sort of play around with the idea of openendedness. And then at the end of that three or 5 minutes, I don't care how early you are in your training. I bet you have some ideas. I bet you have some ideas about what's going on with this person and then you're off to the races, you've got some ideas and I would say, go with that. So now you've kind of given them that first few minutes of openendedness, which also hopefully you're building some rapport with them. They're getting a sense that you're there to listen to them, but then you do need to move on and get focussed because it is a great danger to lose control of the interview. I mean, the interview is a collaborative process, so I don't always like that phrase of controlling the interview or losing control. But there's a tipping point at which you need to help the patient. You need to work together with them to collaboratively provide the information that you need to work with. So, you do need to get a hold of the interview I would say after somewhere in the 2 to 5 minute range, you need to start to get focussed on the kind of questions you want to ask.
Dr. Lucy Chen: [00:21:36] And I guess in the past personal history, what sort of information are we listening to contribute to that bio psychosocial understanding of the of the patient?
Dr. Erin Carter: [00:21:44] So getting towards the end of the interview, usually when you're doing the personal history, we always called it the social history where I trained. So that's coming at the end of the interview. And I think that at this point, you think of your categories, you've got your biological category, your psychological category, your sociological category, your cultural category. Well, the last three, I think you're really need some of the personal history to get that. You want to understand how this person experiences the world inside themselves and how they experience their interactions with the world. And you want to have an understanding of how that formed over time. So that's the personal history. You want to go back in time, hopefully to a time before they were having symptoms, before they were unwell. So you really want to get a picture of what did this person look like when they were little, when they were, you know, pre-school or when they were starting school and when they were interacting with teachers and friends? I mean, you know, think about yourself. Think about who you are and how did those things shape you? How did your parents shape you? How did your teachers shape you? Did you have a good experience in school or was school a nightmare for you? Was it a terrible place to be? And how did it shape how you feel about yourself and how you feel about the world? And as you approach adulthood from those experiences, how did it shape the ways in which you're going to be able or not able to get your needs met and how are you going to do that? And so that's why personal history is really important.
Dr. Erin Carter: [00:23:21] So I'm really but I'm asking simple questions. I mean, those sound like complicated ideas, but I'm really just asking people: I want to ask you a few questions about yourself, can you tell me where you were born? Can you tell me who raised you? Did you move when you were a kid growing up or he always in the same apartment or house? Did you have siblings? W when they say who raised them, it wasn't always a parent. Sometimes it's a grandparent or sometimes it's someone completely outside of the family. And you might ask them about that person. You know, you might ask them if you had to pick a couple of adjectives to describe your grandmother who raised you. What adjectives would you use? And you're going to learn a lot about how they were shaped. So you're kind of wanting to generate a bit of a conversation with them again. And this is also an area where you may be asking them questions about whether or not they had traumatic experiences in their childhood. So you need to connect with them. They need to feel some connection with you. They need to feel that you're interested in what you're asking because you're going to ask them some personal questions that may be about their identity, their sense of who they are, their sexuality, their abuse history. So, you need to maybe put your pencil down and make eye contact and connect with them because you're asking them to share a personal history, emphasis on personal.
Dr. Lucy Chen: [00:24:34] So, after an interview, we have collated a lot of raw data. So what's the best way to sort of organise all of that data and maybe also be an opportunity to delineate the difference between synthesising and summarising information?
Dr. Erin Carter: [00:24:48] Okay. You have a way of asking me questions that are very complicated. You're asking me stacked questions.
Dr. Lucy Chen: [00:24:58] I'm reading your questions.
Dr. Erin Carter: [00:25:01] Okay. Let's see what we can do with that. So I guess we talked previously about where you will find yourself, like where are you when you're formulating? So I mean, realistically for learners, you're probably going to be formulating for your supervisor or you're going to be formulating for an examiner. But but in time when those that stage of life is over and you're practising, you're going to be formulating for yourself. You're going to be formulating to be able to share and talk with colleagues, and you're going to be formulating for the patient or maybe for their families so that you can talk with them about what you think. So you need to have an approach to be able to do that. But I think in your early years, a lot of times you're going to be formulating for your supervisor realistically or for an examination. So I would encourage you at that point in time to create a grid. There is a grid that is used for formulation that everybody knows about as they begin to move through residency. And it's called the formulation grid. And so this is where we need TV instead of radio. But on the left hand column, going down the grid. Let's actually let's start at the top, going across the top, you're creating a few columns.
Dr. Erin Carter: [00:26:08] So the first column is the biological column. So you usually write bio, and then the next column is psycho for psychological. Next column is social for sociological. And then the last column is cultural. So you're making those four columns, so that they can run down your page vertically. Then horizontally. this is where the grid part comes in. On the left side of your page, you're going to really create a bit of a timeline over time because we want to know what's happened to this person, for example, psychologically over time or biologically over time. So biologically, we want to know if something happened in utero, we want to know if something happened biologically in their childhood or their teen years. We want to know what's happening now. So you're going to create a timeline down the left side of the column. You're going to start and it's referred to as the four P's. So the first P is predisposing. So what were the predisposing things biologically, psychologically, sociologically and culturally that contributed to this person's presentation today? So I guess an example would be in the biological column. Predisposing would be if this person's mother consumed a lot of alcohol during the pregnancy, that's a biological factor that may very well be affecting who this person is today.
Dr. Erin Carter: [00:27:25] So, that's just an example. Then the next timeline, the next category after predisposing is precipitating. So, you're looking for a precipitant and it's a precipitant to this episode of illness. And the reason I sort of stress that out with my words is because most psychiatric illnesses are chronic in nature. Let's take a person who has a major depressive disorder. They may have bouts of episodes of depression over time, and they may have times when they're not depressed. And if they come and see me when they're 65 years old and they're depressed, I am going to formulate them based on this episode of depression. So, I'm really going to be focusing on what's happening with this particular episode, and that's why it's important to have a category that's called precipitating in the timeline, because I want to know what factors biological, psychological, etc. I want to know which factors precipitated this episode. So precipitants for the 65 year old with depression might be the fact that they were forced to retire from their workplace. And that sorry, that wouldn't be biological. That would be an external thing. So, that would be a social factor. But a biological factor might be that they had a new diagnosis, something physical had happened to them.
Dr. Erin Carter: [00:28:44] They've just been diagnosed with stage one breast cancer. And that may biologically be contributing to their mood. So, precipitating is the second. category on the left side. The third P is perpetuating. So what is perpetuating this person's current episode of depression? So it may be perpetuated by the fact that this 65-year-old with new breast cancer diagnosis, who's being forced to retire, is also, let's say, perpetuating is that she's really struggling with sleep. She's got this long standing struggle with sleep, but that's making things worse for her. It's perpetuating things. And then the the final category, my favourite category is the P that stands for Protective. So we don't like to just look at the things that are creating the illness state. We want to look at whether they have any protective factors in any of the biological, psychological, in any of these categories. So that's the fourth one. So you're going to create this grid and then you're going to take the information that you got from the interview and you're going to plug it into this grid because it's really going to help you organise your thoughts.
Dr. Lucy Chen: [00:30:00] And then I suppose like this grid really helps us with summarising having like a general sort of overview of all the raw content that we were kind of collating.
Dr. Erin Carter: [00:30:09] That was the second part of your question. You wanted to know the difference between summarising and synthesising. Let's assume that you are going to present your case and your formulation to your supervisor or to an examiner, your supervisor probably knows a bit about this patient already. And the examiners that you're presenting to, they just watched you interview this person. So, they also know a lot about this patient. So, one of the sort of pitfalls I think early in training is that people really just provide a summary instead of a synthesis. So, they really just kind of regurgitate the information that the patient gave them. They say it in the same order. They use the same language. They just they just tell the person what they heard. But over time, I want you to sort of raise the bar for yourself. I want you to sort of set some learning goals for yourself, which is the ability to distil the information that you've been given into something meaningful. I could just repeat to you all of the things that the patient has told me in the interview, or I could hear them, what the patient said, I could think about them, I could think about how they're connected to each other and the meaning they might have. And I could re-organise them into a more concise and meaningful piece of information before I share it with my examiner or my supervisor or my colleague or even the patient, because I don't want to just tell them what I heard. I want to tell them what I think. So synthesis. I like to think of it as distilling. I like to think of it like you put a whole bunch of information into a cup and you distil it at the bottom. And what comes out is this concentrated, thoughtful, connected idea that relates to each other. And that's what you're being paid for. That's the really fun part, is to think about the meaning and to come up with opinions and ideas and to share them.
Dr. Lucy Chen: [00:32:02] And maybe before we get to an example, synthesis of a formulation, how would we use formulation? How do we make use of it for management plan and make sense of it?
Dr. Erin Carter: [00:32:14] So, really the question is why like why are we formulating people? Well, it's important to understand them. And academically it's interesting for us, we like to understand them. But really the real purpose is to guide how we are going to help this person. You know, this person's come before you and potentially in quite a bit of distress, maybe even in danger and they're telling you their story. And now it's your job. It's why you became the doctor that you became. It's your job to help them. And so formulating is the building together and the taking the Plato and forming it into a new shape of understanding that will guide your treatment plan. So, when you have a treatment plan for the person in front of you, there's probably some very acute things you need to do, some things you need to do right away. And that would be what we would consider your short-term management of this patient in front of you. And then there is also a medium-term management and there's a long-term management. You know, you're thinking of the long game also how you can help them. And so once you've got your formulation done, the work is largely done because you have figured out what needs to be addressed for this person.
Dr. Erin Carter: [00:33:26] In each of the domains we listed, you're not only going to help them with pills. I mean, if it was that easy, you wouldn't need to be in school for so long and everybody could do it. You could just say, this person has a diagnosis of whatever and that equals this pill, and you'd give it to them. But it's not like that. We are looking at a much more complicated understanding of them and by the time you've got that understanding, that formulation, then you should have some ideas about how to help them biologically. So there's the, you know, the pill piece or maybe some sort of intervention like ECT or rTMS. It should help you guide you biologically, but also it's going to help guide you psychologically. What do we need to do for this person in terms of therapy? And what are they going to respond to? Like, what do we know about who they are? Are they going to be open to therapy? And if so, what kind are they going to have trouble with? How to make connections with people, including their therapists? You know, we're going to think about those things so we know how to deliver the therapy or the approach that we're taking.
Dr. Erin Carter: [00:34:28] And then socially, does this person have some very real things that need help from a social worker or from someone you know that can help them in the community? Because they don't have a safe place to live right now or because they have no money or, you know, some serious determinants of their mental health that need to be addressed that are practical external factors. And if you skip the cultural piece, you might be missing a lot as well, because that may really inform how you're going to help this person. If you just crank off a script, a prescription for this person, and you have no idea of what that means to them or whether they're going to take it or whether in their culture that's something that they're comfortable with. Unless you understand those pieces, then you're only satisfying yourself in your own mind, you're not actually in a concrete way helping your patient. So, once you do the formulation, much of the work is done and it will really guide you in what you need to do for them in each of those categories.
Dr. Aarti Rana: [00:35:22] Thank you, Doctor Carter. In summary, for the "how" of formulation, it sounds like before you do the interview, being very well organised is quite important and you identify the three areas of the interview that you think are kind of high yield for formulating. You identified the HPI, the personal past, personal history or social history. Past psychiatric history. And then in addition, we talked in detail about the HPI in particular and why that's so important and also takes so long to master. We also talked about what you might do after the interview in terms of organising all of the details you've gathered from the various sections of the interview, in terms of building a biopsychosocial grid with across the top the bio, psychosocial and cultural aspects or factors you're identifying throughout the interview and along the side of the grid, the predisposing, precipitating, prolonging, protective and perpetuating.
Dr. Lucy Chen: [00:36:37] Guess they are synonyms.
Dr. Aarti Rana: [00:36:38] Well, sometimes people actually do that "prolonging" as well.
Dr. Erin Carter: [00:36:45] The predisposing is number one.
Dr. Aarti Rana: [00:36:49] So, this is why you need to do this again and again. And actually draw out the grid too.
Dr. Erin Carter: [00:36:53] What predisposes you to illness? What precipitated this episode? What's perpetuating or prolonging this episode? I like perpetuating Doctor Rana likes "prolonging". And then lastly, what is protective for this individual?
Dr. Aarti Rana: [00:37:06] Yes. And then finally, an aspect of "why we do the formulation" in general is really to ultimately inform our management plan.
Dr. Erin Carter: [00:37:15] Yes.
Dr. Aarti Rana: [00:37:16] Okay. So moving on to part three, which is our practice case. Dr. Carter, I'd like you to imagine that Dr. Chen and I are clinical clerks. We are in the emergency department. We have just gone and assessed a patient for the first time. And we don't really understand this formulation business. So, you've suggested to us that we do the interview and present the interview to you and that you will teach by example by formulating this patient. So. I'll present the case and then Dr. Chen will ask some follow up questions. This is a 40-year-old male who's presenting to the emergency department with his wife. He lives with her and his two children aged two and four. He is self-employed as a real estate agent. He completed a college diploma in accounting. His chief complaint right now is my mood is going up and down all the time and I'm really stressed. His history presenting illness, things started about one month ago. He abruptly asked his wife for a divorce after he confessed to her that he had been having an affair for several weeks. At the time, he states, he was making a lot of rash decisions in his life. He had launched a new business. He'd made new investments. He was really on a roll financially, and he started to engage in a relationship with a person he'd met. In the last two weeks, he's really been despairing about what happened about a month ago in his life. He has been abandoned by his business partner. He's lost a lot of money that he invested.
Dr. Aarti Rana: [00:38:43] He feels very guilty about having this affair and also potentially breaking up his family. His symptoms one month ago included reduced sleep 3 to 5 hours nightly, he was really increasing his activities around his investments and his real estate business. He experienced flight of ideas. His energy was high. He described himself as impulsive with respect to financial decisions alcohol, drugs and sex. And he says his mood was all over the place then. Currently, he said, his mood is still all over the place, but mostly he's feeling quite despairing and low. He says his energy and concentration now are very poor. He's eating a lot in all the time. He's gained about £10, actually, just in the last three weeks. His sleep is still quite poor and for the first time he developed passive suicidal thoughts or thoughts that he doesn't want to live anymore. Life would be better or easier if he wasn't living, but he doesn't want to do anything about that. He's not planning to take any action to end his life. And the fact that he's having these thoughts is very disturbing for him. He has no symptoms of psychosis. He does have long-standing history with difficulty falling asleep. And his review of symptoms was otherwise unremarkable. In terms of his substance use, he has no history of tobacco use, he has been someone who's occasionally had difficulty with cocaine use. He'll use cocaine at parties several times a year and has a history as a teenager and in his early twenties of having periods of high amount of cocaine use and other stimulant use. Most recently, he used cocaine around a month ago, he said he went on a binge for about a week around the time all of these things started. He denies any marijuana use. He drinks a glass of wine nightly. In the last few weeks, he's been drinking a lot more, maybe three glasses a night. In terms of a psychiatric history, he had one major depressive episode after college when he had difficulty finding his first job. That coincided with heavy substance use again at that time stimulant use. Three months ago, he was diagnosed with anxiety, just difficulty handling all the stressors of work and two kids at home. And, because of his sleep difficulties and at that time his physician started him on Venlafaxine, which was titrated up to 75 milligrams. He said it started working within a week. It felt great, he had no side effects. He has no history of self-harm, behaviour or any attempted suicides. He's never had any suicidal ideation before now. In terms of his family psychiatric history, there was depression on the maternal side with mom and grandmother, and he has a sister with anxiety. His medical and surgical history are unremarkable. His doesn't have any allergies. He's only on the on Venlafaxine 75 milligrams for the last three months, though he admits over the last month he hasn't really been taking it as much since the cocaine use and the affair. In terms of his personal history, he grew up in Toronto with a single mom, he didn't really describe his relationship with his dad, who left the family when he was five years old.
Dr. Aarti Rana: [00:41:59] He has one younger sister who is four years younger than him. He had normal developmental milestones. He reluctantly talked a little bit about witnessing some verbal and physical abuse of his mother by his father when he was quite young, but didn't really want to speak very much to that. He described his mother as being really busy, really engaged and just financially supporting the family. And he doesn't really have any particular fond memories of her or negative memories. And his grades were actually quite poor in school. He struggled with focus, but he managed to graduate on time, and he had some kind of minor difficulties with the law as a teenager, some robbery that was kind of in the context of stimulant use, but none after that. No legal issues after his teenage hood. He describes currently his wife as a real stabilising force in his life. Their relationship has been largely positive until 1 to 2 months ago, and he's really concerned about her judgement and her family judgement. That's what we've focussed mostly on. He says that her family judges him for quote on quote being "white trash" and he feels like he has made a lot of mistakes in his life and he compares that to her life, which has been very different in terms of their upbringing. He's very self conscious about this. He's been very present with raising his children. He says both are healthy and has no concerns there. None of his substance use was around his children at all or ever in the home. And he's done very well financially despite the recent financial losses around $100,000.
Dr. Erin Carter: [00:43:37] Okay, that's a lot of information. Actually, this is deja vu because this is what we do everyday, because I'm supervising you right now. So you're often presenting patients to me just as you just did. Okay, so what next do you want to talk about how to formulate this patient?
Dr. Lucy Chen: [00:43:51] Maybe. First, an approach to synthesising the information, a differential diagnosis, and then maybe a formulation.
Dr. Erin Carter: [00:43:57] Well, I think that's a good point, because it's important when you formulate a person that you are not just formulating in general, you're formulating what is sitting in front of you right now. So and by that, it's usually easiest, you can formulate a particular symptom cluster or you can formulate a diagnosis, you can choose what you want to identify, what you're going to anchor your formulation on. But I would encourage, especially new learners, I would encourage you to try to have a differential diagnosis. So a list of diagnoses that could possibly explain why this person is unwell in the way they currently are. And then I would also encourage you to have a preferred diagnosis. So you've got your list with a few ideas about maybe this person has this, maybe they have that, and then you're going to choose one as your lead. And it might not be right. It just has to be your opinion about what you think they have and you have to be able to defend. It doesn't really matter if it's right or not. It's just your best attempt at saying what you think they have and defending it. So, I would say in this instance that my differential diagnosis so the first thing I would do if I was preparing for an exam or I had to present to my supervisor, I just seen this person in the emergency room or in the exam room, and now I'm alone by myself for a few minutes, getting ready to present to my supervisor or to the examiner.
Dr. Erin Carter: [00:45:17] One of the first things I'm going to think is, what do I think is going on? What do I think this person has? And this presentation is pretty clear that this gentleman has had manic symptoms. So he's had manic symptoms in the context of what actual label, I'm not sure. But I'm pretty sure from this description, he sounds manic. He's spent like he's lost like over $100,000 in the past little while. He's had an affair. He's behaving in ways that are revved up and and not sleeping and maybe a bit grandiose, different than he's been previously. So, he's having a manic episode. In terms of the DSM five, in terms of my differential diagnosis, whether or not I'm going to say that this gentleman has bipolar one disorder with mixed features, or whether or not I'm going to say that this gentleman has substance or medication-induced bipolar disorder, because maybe the cocaine and the alcohol caused it. I'm not really sure. And on my differential diagnosis, I might just be thorough and might also include a stimulant use disorder, and I may include post-traumatic stress disorder, maybe depending on what I got in the interview.
Dr. Erin Carter: [00:46:23] These are all things that this gentleman could have right now. But I got to pick one. So and really the first two are the one I would be struggling between. Does this guy have like a full-blown bipolar one disorder or does this guy have a bipolar picture that's really being caused because he's been using a lot of cocaine lately? I'm going to go with the first one just because. So, I'm going to go with bipolar one disorder with mixed features. I guess to clarify my thinking, the fact that whether it's the cocaine or whether it's the Venlafaxine that the family doctor gave him for anxiety, it does sound as though he may have been having symptoms before that, before his cocaine increased and before his Venlafaxine increased. The reason he went to the family doctor was because he was having increased difficulty sleeping and increased anxiety. So, I might not be right. I just have to be able to defend it. And, I think that's something I can defend. I'm going to go with bipolar one disorder with mixed features. And I'm going to say to my examiner and my supervisor, I'd like to formulate this patient who I believe is currently presenting with bipolar one disorder with mixed features. I would say to them, I'd like to tell you what I know about this gentleman, and then I'm off to the races.
Dr. Erin Carter: [00:47:31] I'm basically basically going to be looking at my grid. Now, here's the trick. When you get a little bit better at it, you're going to try to make as much eye contact as you can with the person that you're talking to. Because I'm telling you my opinion, this is where I'm really telling you what I think about this patient. I'm selling it to you and I want you to buy what I'm selling. I want you to believe what I'm saying because again, I might not be right. It's just my opinion. So the first thing I have to do is I have to sort of I have to summarise the case, but rather than calling it a summary, I'd rather call it a synthesis because I just want to distil it. I don't want to repeat for you everything I just heard. I wanted to distil it and the way that I'm going to distil it, this is just my opinion. This is just me as an individual, how I formulated and how I present. But I'm going to start by telling you the stuff that supports my preferred diagnosis. This gentleman may have given me information, all sorts of information in whatever kind of order he chose to give it to me. But I'm going to synthesize it and give it back to you, the examiner or the supervisor in the order that I think is most important.
Dr. Erin Carter: [00:48:36] I just told you that what I think is most important is bipolar one disorder with mixed features. So, hopefully you have some idea of what that looks like in the DSM-5. Hopefully, you have some idea what the language is and you'll have a gaining mastery of that. I'm going to model for you what I would say. I'm going to try to use the language of the DSM so that I can connect with the examiner or the supervisor. I'm going to present this case and tell you a little bit about what I know about this gentleman. This is a gentleman who I believe is presenting with a distinct period of abnormally and persistently elevated mood and abnormally and persistently increased energy for greater than one week. The reason I use that language is because I want them to know my supervisor, my examiner, that I know what the DSM-5 sounds like, also the DSM-4. Then I'm going to move on to the B criteria, which is where I get into the symptoms. I know because I know the DSM, I know that I need at least three.
Dr. Erin Carter: [00:49:37] So ,I'm going to hit those three. I'm going to let them know that this gentleman; he's clearly presenting with decreased sleep with flight of ideas, distractibility, increased goal-directed activities, and some high risk activities in the form of sex and also poor business investments. I might even hit on the negatives just to show them that I really know the DSM. So I may say, there hasn't been any information about whether or not he's had increased talkativeness and whether or not he's had inflated self-esteem or grandiosity. Although, given his behaviours, I think he probably has been grandiose. I'm not going to forget to go on to the C part of the DSM, which is to comment on whether or not it's causing impairment socially or occupationally or educationally and whether or not it could be attributed. His presentation could be attributed to drugs or medications, substances or medication. So don't forget to comment on those. So I am going to comment in my assessment, my presentation of the case that it's difficult to tell whether or not these symptoms are happening independently of the cocaine use and the increased Venlafaxine. That's something I'm going to have to tease out in a future interview. But it certainly is clear to me that this gentleman has caused both social and occupational impairment from his symptoms. By using that kind of language and letting them know in the DSM language, this is what I'm talking about, and then I'm going to quickly sort of synthesize the rest of the information that I was given from the patient in all the different categories of the psychiatric interview, including the next things on my differential diagnosis.
Dr. Erin Carter: [00:51:02] Again, I would be my number two on my differential was substance or medication induced bipolar disorder. So, I would talk about the fact that he had been having symptoms of anxiety and difficulties with sleep and that his family doctor had increased his Venlafaxine, which of course, we all know could have prompted a manic episode, and also that he's been using more cocaine than usual. Hard to know how to tease that out, we'd need some collateral,I would comment on that as well. I may comment on the fact that, you don't need very much to meet criteria for a mild diagnosis of stimulant use disorder if you're using cocaine, you only need two of the symptoms. So, he probably meets criteria for that too. Do I think it's the most like the most responsible presentation for why he's here? No, I think it's the manic stuff. And that's why I'm focusing on that for my presentation of my formulation. And then lastly, I may quickly comment on the PTSD possibility because of his childhood, he witnessed significant persistent abuse of his mother by his father.
Dr. Erin Carter: [00:51:55] Okay, I'm done all of that. At some point we're skipping pieces, but we're moving on to the formulation. So, I'm getting to my chart. I have to make my chart. I mean actually write it out in the minutes that you have. So, when I go to do my chart later in this interview, you're going to ask me if I have any clinical pearls, so I'm just going to tell you them right now. The clinical pearls for the formulation chart, in my opinion, is or are that there are some classic things that exist in each category for almost every individual. So, when you're feeling anxious and you're sort of freezing a little bit, go back to the classics. I would encourage you to sit down with a blank grid and at the bottom of the biological column, choose three things that you can almost always comment on for any individual, and you can comment on them in terms of their presence or their absence because it's relevant, something might be present and causing a problem or it might be absent, and therefore it's a protective factor. For example, for biological, you can always comment on family history and that's a biologically, genetically relevant thing. You can always comment on substance use during their developmental years because that's a factor. It matters, in terms of a predisposing or even a precipitating factor for illness.
Dr. Erin Carter: [00:53:20] So, either they used drugs like cocaine in their teenage years, which is relevant, or they didn't use any drugs and they don't use any drugs. And that's a protective factor, it belongs somewhere else in your chart on your biological column. And thirdly, pain. Pain is a good biological factor you can always address. They either have chronic pain, which matters in terms of predisposing, precipitating and perpetuating, or they are an individual who has no issues with pain, which would be a protective factor. That's just an example. You can choose whatever three you. You could choose things like their physical health, their history of whether or not they've experienced abuse, their sleep history. These would all be things that could go in the biological column for any patient. But, I would encourage you to memorize three, because if you got three, you can always fall back on them for any patient and then for psychological, same thing. Three things you can always comment on. Any person you interviewed, you can comment on their intelligence and that's either going to be protective for them or it's going to be an issue for them that belongs in one of the other three categories. If they have difficulties with intelligence, their attachment history, that's something you'll learn a bit more as you go through your training but whether or not what type, what style of attachment do they have that matters psychologically for all humans. And it's either protective because they have a nice, solid, stable attachment history or they have a disrupted one which many of our patients do.
Dr. Erin Carter: [00:54:44] So, that would be number two. Number three, I might pick psychological mindedness. Is this person somebody who really gets the idea of mental health, mental wellness, mental illness, therapy? How are they going to do with that sort of thing? What are their thoughts about it? That would be a third thing you could comment on, on any individual for social category, housing, money, education. I'm not saying that these are the three in any one category that you have to have, I'm just giving you examples. Housing, money, education, you've either got it or you don't have it. And, it's either protective because you got it or it's a problem because you don't have it. So, figure out where that goes in the grid. Then culturally, again, I think psychological mindedness is an issue in different cultures, what their feelings about psychiatry and mental health are, and it matters. Do they have a lot of supports because they have a tight cultural history either within their extended culture or even just in their family culture? Religion can be a factor for many people, but there can be other things like language barriers, whether the care that they're getting, are they the kind of person that's going to respond to care within their culture from someone who comes from the same culture as them, or do they need to go outside of that culture? So, I think you should have a few classics for each category and then if nothing else happens, you can try to plug those into your grid.
Dr. Erin Carter: [00:56:08] Let's try to do it for this gentleman. Biologically for this gentleman, if I look at the three that I mentioned; family history, substance use and developmental years and pain, you can see that for him, family history is an issue. So biologically, the category that would go in is predisposing. He has a genetic family history of both anxiety and mood in his mother and his sister, so that goes in predisposing. He had substance use in his developmental years, that would also be predisposing. Then also substance use for him carries on into precipitating and perpetuating because he's using increased cocaine and alcohol. It may in fact have been one of the major precipitates for this episode, and it's certainly a perpetuating issue unless he stops it pain. I don't think there was any mention of pain. So it's a great example for how this is something you can use and you can put it in a protective factor.
Dr. Erin Carter: [00:57:00] You know, you can just throw it in there. This is a gentleman who, unlike many of our patients, he has no issues with pain or chronic pain that's actually protective for him. Then I would jump into the psychological category and I said my three were intelligence attachment, history and psychological mindedness. So, you can think about this guy. He's clearly an intelligent gentleman. He has a very successful, self-employed business, which says several things about him psychologically. He's intelligent, that's protective also that he's able to self-start and to manage himself normally. Again, that's protective of his attachment history, that's probably a concern. This gentleman was abandoned by his father, by his abusive father when he was five years old and his mother is quite distant from him. He doesn't have any positive memories of her in childhood. So, I'd really want to understand more about his attachment history. It would be safe when I do the formulation to start a sentence with something like "I wonder". I wonder because it's just my opinion, right? So, when I'm doing the presentation, I can say: I wonder if the abandonment of this gentleman by his father when he was five, by the witnessed abuse he observed of his mother and also by his mother's emotional distance to him, whether that's affected his attachment.
Dr. Erin Carter: [00:58:16] I wonder what attachment style he might have and how that may have been. Ultimately, a precipitant for him during high stress times with his real-estate business, whether or not it contributed to the fact that he turned to someone he was emotionally not connected to and had an affair with rather than going to his wife, who he has a long-standing relationship with. I wonder if that was a contributor when I jump into the social categories, this gentleman does seem to have stable housing, which is protective, but he's got money problems. He just lost over $100,000 during this manic episode, that's going to be an issue in terms of perpetuating. Then education in the social column, he doesn't have that much education, although he seems to have had enough to do what he needs to do in real-estate. But again, it makes me think back to the psychological column that this gentleman struggled with when he was in school. He may very well have a learning disability or he may have ADHD. He had difficulties in school that were described in the history and that may have contributed to drug use. And the reason he uses cocaine and stimulants. It may also play a role in his psychological sense of himself and why he is so sensitive to the judgement of others, the judgement of his wife's family.
Dr. Erin Carter: [00:59:38] That may matter in terms of what kind of therapy this gentleman needs also. I'd be thinking about it in that column. Culturally, I don't have too much to say about him. He sounds as though he's at least he's male, and I think he might have said he was Caucasian. I can't remember. But then again, it would be protective in the absence of him because the absence of him suffering, racism or gender issues. So, you would plug all of those things in and then you would try to say them out loud to your examiner or to your supervisor. You want to use words like: I wonder if these are connected. I see this gentleman as having predisposing issues in these categories and say what they are. I think maybe what precipitated this event, he's in a very high-stress job, he was using a lot of cocaine, he was having some anxiety and some difficulties going to sleep. So, his family doctor gave him biologically an increase in an antidepressant which may have sent him up into a manic state. Then perpetuating, I'm looking across the columns. This is a guy that when he's in trouble, might not be able to really ask for help because of some of the things that happened in his early childhood, his fear of judgement from others when he's making mistakes.
Dr. Erin Carter: [01:00:49] He might have gotten quite far into the episode before he was able to ask for help because of his psychological background. Again, I'm not saying that's a fact. I'm just I'm saying I wonder, and then and then the fact that he really can't sleep and he's struggling to sleep, inevitably that's perpetuated this situation. I'm jumping around between the categories, but I'm just telling you what I think about what's contributed. Then there's a lot to say about this gentleman. At the end, I would be telling my supervisor or my examiners that I think it's important to mention that this is a gentleman who has a lot of protective factors. He's quite likeable, he's really quite bright. He's able to form relationships psychologically with people, as evidenced by his wife. She comments on him being a great parent. So he's really got a lot to work with positively. Those things tell us also that he may very well be able to engage in therapy, and also he's helped seeking. So, we'll look at whether or not he's comfortable with the medication I'm going to prescribe and whether or not he's going to take it.
Dr. Aarti Rana: [01:01:44] Thank you so much. That really helps paint a very rich picture of him and really interpret his story into a rich picture that could actually be used to relate to him, relate to his family, and also work with him on a management plan.
Dr. Lucy Chen: [01:01:57] Giving us some tools to be able to approach it in a more simplistic fashion that will really be helpful for young learners.
Dr. Erin Carter: [01:02:04] Good. I'm glad to have helped. It's been fun. Thanks, guys.
Dr. Lucy Chen: [01:02:06] Any last impressions or wisdom you'd like to impart on our listening audience?
Dr. Erin Carter: [01:02:11] Two things. Number one, doing a formulation on paper is entirely different than presenting it. You have to practice saying it out loud because it just doesn't sound good the first few times you do it, and that's the same for everybody. I would really encourage you to get in front of the mirror or get together with one of your colleagues and just practice saying it. I mean, formulate each other and then practice saying it out loud because the art is really in the way you synthesize the information. You do not just want to read columns top to bottom or left to right. You want to dance between them and talk about the interplay between those things with phrases like, I really wonder, and you want to show that you are wondering, you want to sell it. Whether you're talking to the patient or your supervisor or your examiner, this is your chance to really say your opinion about why you think the person is like this and you want to sell it. So, make eye contact, say it. Let them know what you're thinking. "You know, I really wonder about this. I think about how this might impact him. I think he's he's really strong in this area. I do think this was an issue." You are using that kind of language. Don't just read it off a page. Say it like you mean it, like it's yours, like you own it and like you're selling it.Good luck.
Dr. Aarti Rana: [01:03:24] Thank you.
Dr. Jordan Bawks: [01:03:28] PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not meant to be representative of either organization. This episode is part of our mini-series on psychiatric skills, which are intended to provide UofT residents with content directly related to the intractable professional activities or EPAs outlined by our program. Since EPAs are designed to capture core professional psychiatric competencies, we trust our listeners outside UofT, will still find the episodes entertaining and educational. This episode was produced and hosted by Aarti Rana and Lucy Chen, audio editing by Jordan Bawks. Our theme song is Working Solutions by All of Music. A special thanks to Dr. Erin Carter for serving as our expert this episode. You can contact us at info@psychedpodcast.com or visit us at psychedpodcast.org. Thank you so much for listening. Catch you next time!