include the following five points:
The methods and strategies you would use to perform the initial assessment.
Which diagnoses would you consider?
What is your case formulation? That is more comprehensive than just the diagnosis. For example, let’s say you are considering ‘Major Depression” as a Diagnosis. Your case formulation may be something like this: “this patient has suffered significant recent loses in his life, and in the context of possible biological vulnerabilities (ie; history of maternal depression) and limited psychological resources he has developed a depressive condition”. In the case formulation you may also include possible interpersonal, psychoanalytic or existential dynamics if you consider them important.
What is your treatment plan?
What else would you have liked to know about this patient, which was not given to you in the case scenario, and you think it may have been particularly useful in order to reach a diagnosis and develop a treatment plan?
# 1: Methods and Strategies: This means the types of assessments or procedure you would use to get information on the patient.
For example: Interview patient, review record, etc.
#2: Diagnosis: Here you will put your primary diagnosis for example:
For Example: Generalized Anxiety Disorder.
In addition, I would like you to add any other Diagnoses to consider:
Panic Disorder, Simple Phobia, etc.
# 3: Case Formulation: (I want two or three sentences at most).
For Example: “ The patient’s anxiety is present in multiple settings and situations, following a period of intense stress. This anxiety has significantly impacted her social and professional functioning, leading her to seek help”.
# 4: Treatment Plan: Here I want you to list the types of treatment or interventions you would recommend (try to be as specific as possible). Make sure the treatment you recommend are treatments that typically are used for the diagnosis you gave to your patient. In other words, think about it and just don’t throw everything in there:
Example: a. Relaxation Training
Insight-oriented Therapy
SSRI’s
# 5: What Else I would like to know: Here you will add any other information you would like to know about your patient, which may help you to formulate a proper diagnosis and treatment plan.
Example:
Medical history
Drug screen.
Interview family members
THIRD PAGE: On the third and final page, I would like for you to expand on the topics above, telling me for example how you arrived to the diagnosis and what other diagnoses you would consider and why; what is your treatment plan and reasons for it, what else you would like to do or know and/or or any other aspect you think is important for me to know. You may also discuss any particular interpersonal or intra-psychic dynamics pertaining to any of these two cases. Please no more than 4 or 5 paragraphs.
I want you to relax, you are in control in this assignment, you need TO DEDICATE a little time and thought, and you will be fine
First Clinical Case:
Clarisse is a 26 year old white single female, who comes to see you to get help with her “bad mood”. She heard you are “very good Psychologist” and wants to try therapy.
On your initial interview, you observe she is a very attractive female, perhaps too seductively dressed for a doctor’s office. However, she was pleasant and engaging and did not appear in obvious distress.
She tells you she has been “feeling down” for a while. You asked her to be more specific and she says that as long as she can remember, she has been unhappy. When she was teenager she had a tough time, she was rebellious, experimented with drugs, did bad in school, and had multiple sexual partners. She always felt insecure about herself, couldn’t figure out who she was, and felt always very emotional. Her relationship with others was always complicated, as she felt she either loved them or hated them. She says that with time, things got better and eventually went to college and graduated from a nursing program, although her unhappiness and insecurities remained.
She is, however, unhappy. She complaints about men and expressed remorse over her history of “failed relationships”. She tends to idealize men and then despises and hates them. Her anger is a problematic issue with her and often she feels out of control. She explains that things typically start really good, and she often thinks the guy is the “best in the world”, but soon she begins to feel “empty” and develops very strong jealousy feelings, which end up destroying the relationship. She further confesses to you, she “gets crazy when that happens and in a couple of occasions, she has become violent with her boyfriends. She says she has “low self-esteem” and at times she “is not even sure who she is”. This has been going on for years now and she can’t get out of this pattern. She is not eating well and has lost weight, but otherwise, she is active and able to work without problems.
While she does not eat well, she also reported that when she feels stressed out she overeats and then feels guilty and makes new commitments to eat better.
She reported a history of conflict with her parents and rarely talks to them these days. She would like to “feel normal” and be happy, but she does not know how to do so.
Second Clinical Case
Peter is a 40-year-old male who came to the office with complaints of anxiety, sadness, nightmares, and difficulties concentrating. He also reported poor memory, low libido, feelings of guilt, despair, hopelessness and helplessness and occasional suicidal thoughts. In addition, he has difficulties in his marriage. He had been married for 10 years to a woman 15 years his senior. His wife is an attractive woman, who looks younger than her age. For over three years he has been unable to have sexual intimacy with her, but he added he always had sexual difficulties in his marriage to her. Yet, he says he loves her, and she is “the most beautiful woman in the world for him”. He feels very insecure, and compares himself to her wife’s ex-husband who was a successful man and a womanizer. He had quit his job after suffering a severe stress reaction when his boss ridiculed him in front of other managers and told him he would never amount to anything.
His mental status revealed a slightly overweight male superficially pleasant but guarded. He was restless and constantly moved in his seat. His mood was anxious, depressed, and angry and his affect constricted in range. He denied psychotic symptoms and his thinking was linear and goal directed. He reported occasional suicidal thoughts with no plan.
In terms of history, he reported a lonely and difficult childhood. His father was aloof and uninvolved, and his mother was physically and sexually abusive of him. Her sexual seduction and subsequent abuse started during late elementary school and lasted until early adolescence. As soon as he could, he left his home, joined the Marines, and began his adult life. He was able to do well in the military. Upon discharge he went to college, graduating with a business degree and found a job in management. He had a couple of long-term relationships while in college, but never thought about marrying until he met his wife. However, during his first major professional job, a “sadistic, mean boss” drove him to the verge of suicide. He left that job and since then (now 5 years) he has been unable to go back to work. He has difficulties with sleep, overeats, has frequent nightmares, intense startle response, and his anxiety is “over the top”. He has been on various SSRIs medications with only limited success and wants therapy to help him sort out his problems. He often thinks of suicide but knows he would never act on it “because of his wife”.
Case Study # 3
You are the Psychologist on call at a busy regional hospital. You are called late at night to assess an elderly man who was reportedly confused and combative. Drug screen and alcohol levels done at admission were negative. He was brought in by his adult daughter who found him in the kitchen floor crying. There was not a lot of information available when you arrived, but you proceed to do a careful mental status exam. Your exam revealed that he was able to orient himself and knew he was in a hospital. He did not show interest in talking to you, but he was no longer combative or aggressive and he allowed you to finish your assessment. Concentration was fair and verbal recall also fair. Mood was depressed and affect was consistent with mood. His thinking was logical with no evidence for a thought disorder, although you were not too clear about some reported “hallucinations”. His wife had died a few weeks ago and he was claiming he heard her voice at times. He expressed a desire to die and be with his wife. He denied any prior mental illness. Since his wife’s illness and subsequent passing, he had been anxious and depressed. He was not taking any psychotropic medications. As far as you could ascertain from available information, his health was good for his age. However, his Blood Pressure was elevated when he first arrived to the ER, but his heart showed normal rhythm. The ER doctor is not sure what is going on with this patient and asked you for your opinion.
