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CLINICAL CASE STUDY
OK, as promised this is the Clinical Case Study. This is actually a very simple
assignment and typically, if you follow directions, you would do very well. Read the
directions from the Syllabus (which I have included here for your convenience) and
follow the format I give you in the bottom of this page. Basically you need 3 pages; the
first one with title, name etc; the second one with an outline (see below) and the third
one is the one you will expand a little more, and that’s it! EASY, relax and you will do
just fine.
Please follow this direction because when I have to grade dozens of these assignments,
in addition to over a hundred papers THE FORMAT makes it easier for me to read and
understand; if I have problems tracking you, that will not be good for your grade J
For additional help as you try to decide what disorder you are contemplating, you just
need to consider everything up to week 8 (Personality Disorders) and the chapter in
schizophrenia, which as you would see it is unlikely J. I know you will do very well.
CLINICAL CASE STUDY
As per your Syllabus:
This is a new feature for this class. Towards the end of the semester, I would give
you a clinical scenario and I will like for you to write a 2-3 page summary of your
assessment, diagnosis and treatment recommendation. This needs to include the
following:
1. The methods and strategies you would use in order to perform the initial
assessment. In other words, I want to know how you arrived to the diagnosis
and what processes you used.
2. Which diagnoses would you consider? You should have a primary diagnosis,
but perhaps there may be other possible diagnoses you may want to rule/out
or consider.
3. 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”.
4. What is your treatment plan? Nothing extensive here but it has to make sense.
Don’t just put things in there to make sure you cover all bases. Not all patients
need MRIs!
5. 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 very useful
in order to reach a diagnosis and develop a treatment plan? For example, the
patient with depression has complained primarily of fatigue, mild dizziness
and difficulties concentrating. Perhaps you may want to rule out a medical
condition (anemia) and you may want to have this patient be medically
evaluated.
This is not a difficult task, but requires a little thinking from your part. As long as
you are “in the ball park” for the diagnosis, you will be fine. The important point
is that I need you to show me you know how to do the assessment, followed by a
diagnosis, good case formulation and a reasonable treatment plan. Don’t write
more than 3 pages (about 1000-1200 words). You will have this task towards the
end of the semester (see schedule below) and it will be worth a total of 10 points.
As with any other assignments, this is your own work, not a team effort. Sharing
or copying another student’s work will result in a failing grade for the class.
This is the format I would like for all to follow, again PLEASE follow directions.
This should not be a difficult assignment. I am not looking for a “perfect” diagnosis or
treatment plan. Basically, if you are in the “Ball –Park” you are good!
The point is that I would like for you to show me HOW YOU ARE APPLYING THE
KNOWLEDGE YOU ARE OBTAINING IN CLASS. Like always, if you wait for the last
minute, you may not be able to do the work you are capable of doing.
ESSENTIALLY YOU WILL BE TURNING IN THREE PAGES.
THE FIRST PAGE HAS YOUR NAME AND TITLE.
THE SECOND PAGE YOU WILL WRITE BRIEF DESCRIPTION OF FIVE
TOPICS: METHODS, DIAGNOSIS, CASE FORMULATION, TREATMENT PLAN AND
ADDITIONAL INFORMATION YOU MAY WANT TO KNOW.
THE THIRD PAGE YOU WILL EXPAND ON THE TOPICS ABOVE.
OK, here is the format.
On the FIRST PAGE:
Title of the Assignment and your name (Title Page/ first page).
EXAMPLE:
Clinical Case Assignment
Mr. John Doe
On the SECOND PAGE , I would like for you to LIST your answers to the 5
topics above. This means a short summary for each five topics like this:
EXAMPLE:
First topic: 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.
Second Topic: Diagnosis: Here you will put your primary diagnosis for example:
Generalized Anxiety Disorder.
In addition, I would like you to add any other Diagnoses to consider:
Panic Disorder, Simple Phobia, etc.
The Third Topic is the Case Formulation: (I want a couple of 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”.
The Fourth Topic is the 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:
1. Relaxation Training
2. Insight-oriented Therapy
3. SSRI’s
Fifth and Final TOPIC: 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:
1. Medical history
2. Drug screen.
3. Interview family members
ON THE THIRD 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. 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
Turn it in ON THE DUE DATE, AND YOU ARE DONE!
Ok here is the Clinical Case:
Clarisse is a 26 years 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 of 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 hate 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.
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.
…
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