CLINICAL CASE STUDY
I will give you very specific guidelines together with both Case Histories later on the Term. You will turn your assignment with both Case Studies clearly indicating Case#1 and Case #2 in a WORD DOCUMENT. Please follow directions, as the biggest issue I keep having with students is not adhering to guidelines. Briefly, your assignment needs to include the following: The methods and strategies you would use in order 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 very useful in order to reach a diagnosis and develop a treatment plan? This is not a difficult task, but requires a little thinking from your part. The important point is that I need you to show me how you do the assessment, followed by a diagnosis, good case formulation and a reasonable treatment plan. Don’t write more than 3 pages FOR EACH CASE STUDY (about 1000-1200 words for EACH). You will have this task towards the end of the semester (see schedule below) and it will be worth a 10 % of your total grade. 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. 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 FOR EACH CASE STUDY. PLEASE MAKE SURE YOU TURN IN BOTH IN ONE SINGLE WORD DOCUMENT 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. FIRST PAGE: Title of the Assignment and your name (Title Page/ first page). EXAMPLE: Clinical Case Assignment Mr. John Doe SECOND PAGE , I would like for you to LIST your answers to the 5 topics 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: For Example: Generalized Anxiety Disorder. In addition, I would like you to add any other Diagnoses to consider: Panic Disorder, Simple Phobia, etc. Third Topic: 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”. Fourth Topic: 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 Fifth 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: 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 Turn it in ON THE DUE DATE, AND YOU ARE DONE! First 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. 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 a very 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 had quitted his job after suffering a severe stress reaction when his boss ridicule 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.