Week One Formulation Tutorial

Vignette: Elise

Elise is a 55 year-old female who has been living in a boarding house in the city for the past three months,
following moving to Queensland from Victoria. She has been receiving the disability support pension for
the past five years. She has no contact with her family, including two adult daughters living with her ex-
husband in Victoria.

She was brought to hospital by the hostel manager because she threatened her roommate at the hostel.
The manager had noticed that she has been keeping more to herself and has been irritable to approach in
the last few weeks. She started working part-time as a cleaner when she first moved to Queensland but
has not done this over the past two months.

On assessment, Elise states that her roommate is part of an “international consortium” that was following
her in Victoria and has now started in Queensland. She first found out about this group around 30 years
ago and “they have made (her) life a living hell” ever since.

Past psychiatric history

Elise reports she has previously been admitted to hospitals in three different states (Victoria, New South
Wales and South Australia). She thinks she has probably had about 10 admissions over the last 20 years.
Her most recent admission was 6 months ago in Victoria, where she was given a diagnosis of delusional
disorder. She states she was case managed after a few weeks in hospital and the case manager told her she
did not need to take medication or see them anymore.

She has previously tried multiple antipsychotics, including depot medication and clozapine. She does not
feel they have been effective and states “but the medication wouldn’t be able to stop the consortium
anyway, so why would I need it”.

Past medical history

Nil

Medication

Nil

Substances

Nil
Personal history

Elise was born in France and moved to South Africa when she was 10 years of age. Her father was in the
Navy and spent most of his time away from home. From an early age, Elise knew that her mother was
unwell with “nerves”, often spending months in hospital. She lived with her aunt during these times and
this arrangement became permanent when Elise was 14 years old when her mother moved into a long
term hospital.

Elise struggled at school and left after completing Grade 10 to work as a seamstress. She was introduced to
her future husband by her aunt at the age of 17 years; they soon and moved to Australia. She spoke
minimal English at this time and found it difficult to make friends or find stable employment.

When Elise became pregnant, her aunt moved out to Australia to assist her to care for the two children.
Elise’s Aunt passed away from ovarian cancer around 1 year ago.

Mental state

Dressed in clean clothing appropriate to the season. Intensely held eye contact with a brittle rapport,
initially engaging well in discussing the “international consortium” but becoming irritable and brief,
minimal answers to questions around her mental health history. She reports her mood as “fine”, denies
any suicidal ideation or perceptual disturbance. She notes she threatened her roommate “only with legal
action” and denies any thoughts to harm them or anyone else, noting “there is nothing you can do about
the consortium, I have tried for 30 years, you can only just move to avoid them”.

Tasks before the tutorial

1. Read this vignette and think about how Elise presents

2. Watch the “Med Student Guide to Formulation” video: Blackboard “Introductory Week”
3. Read the attached 2 articles about formulation

**Tutors: During the tutorial

1. Work together to construct a bio/psycho/social formulation that contains paragraphs on

presentation, precipitation, predisposing, perpetuating, protective factors and a risk assessment.