4 Classification and assessment in psychiatry4.3 Clinical assessment

4.3.5.2 Cognitive and behavioural formulation

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Written by Resident Doctor Committee · Published

New in the 2027 syllabus

The College added this topic for exams from January 2027.

Linking thoughts, feelings and actions

A formulation is a shared working explanation of what keeps a problem going. Cognitive and behavioural approaches look at it from different angles.

  • Cognitive formulation looks at how a person interprets events. The interpretation shapes their emotions, bodily responses and behaviour. Those responses then feed back into their beliefs.

  • Automatic thoughts are quick appraisals tied to a particular situation. Assumptions and core beliefs are broader patterns that shape them.

  • Behavioural formulation looks at antecedents (what comes before the behaviour), the behaviour itself and its consequences. It asks what reinforces the behaviour.

The invented example below shows one possible cycle that keeps panic going.

Element

Panic example

Situation

Heart rate rises while climbing stairs

Interpretation

"I am having a heart attack"

Emotion and body

Fear, rapid breathing and more palpitations

Behaviour

Stops, checks pulse and seeks reassurance

Short-term consequence

Anxiety falls for a while

Longer-term consequence

The fear is never tested, and checking becomes more likely

One possible maintaining cycle from the invented example. Relief can reinforce checking while leaving the feared prediction untested; a collaborative formulation does not replace appropriate assessment of physical symptoms. Original illustration drawn in Python for MRCPsychiatrist; see images/ATTRIBUTION.md

Learning processes

  • Classical conditioning: a cue that was once neutral becomes linked to a response because it has been paired with another stimulus.

  • Operant conditioning: behaviour changes because of its consequences. Relief from distress can negatively reinforce avoidance, so avoidance becomes more likely.

  • Negative reinforcement means a behaviour increases because it removes an unpleasant state. It is not punishment.

  • Safety behaviours can stop a person learning that the feared outcome would not have happened without them. Checking the pulse in the panic example is one.

Testing the formulation

  • Collaborative enquiry: ask what the person predicts will happen, and what evidence would support or challenge that prediction.

  • A behavioural experiment tests one specific prediction through a task you agree together. Think about whether the task is actually safe and whether the person is willing to take part.

  • Exposure means approaching feared cues while cutting down avoidance. How you plan it depends on the disorder, the context and the individual formulation.

  • Behavioural activation targets withdrawal and the loss of rewarding activity. The person carries out planned actions, and you review their mood and function.

Limits and adaptation

  • A thought is not false just because it is distressing. Real danger, discrimination or financial hardship may need practical action.

  • Physical symptoms still need appropriate medical assessment. A formulation is no reason to ignore new warning signs.

  • Review the formulation using what happened during treatment, and refine the proposed maintaining cycle. When a prediction fails, revise the formulation rather than blame the person.

Revision material for the MRCPsych examinations. Not clinical guidance, and not for use in patient care.