Clinical Case Study

a. 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.
b. 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.
c. 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”.
d. 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.
e. 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.
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.
EXAMPLE: Clinical Case Assignment
Ms. Jane Doe
The SECOND thing you would do: On the second page, I would like for you to LIST your answers to the 5 topics above. This means short summary for each five topics like this::
EXAMPLE:
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, MRI, etc.

2. 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.
3 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”.
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
b. Insight-oriented Therapy
c. 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:
a. Medical history
b. Drug screen.
c. Interview family members
The Third thing you would do:
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.
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 says things got better and eventually went to college and graduated from a nursing program.
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 “get 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 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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