Choose a fictional character from a book, movie, television show, or a famous person on whom you can gather relevant information, such as biography, psychological history, etc.
Do a clinical case study of the person based on the following method:
Please use the following format for your case study. Each section should be numbered with a heading next to it (for example, 1. Indentifying Information should be the first category of your case study. DO NOT write the case study in an essay format. Please make sure case study in double-spaced)
The first section of your paper will present your patient’s current situation. Include identifying data, such as sociodemographic characteristics: age, gender, racial/ethnic characteristics, marital status, religion, employment, socioeconomic status, family composition (including who is living in the home with patient, etc.), housing status, etc.
Description of the Presenting Problem
In the next section of your case study, you will describe the problem or symptoms for which the patient is seeking treatment. Describe any physical, emotional, psychological,or sensory symptoms reported by the patient. Thoughts, feelings, and perceptions related to the symptoms should also be noted. How does the client perceive the problem? What troubling behaviors, thoughts, or feelings are reported? How do they affect the client’s functioning? When did they begin? Because you are not actually able to interview the patient, you can access this information based on what you can find out about their symptoms and behavior, either from interviews and reports on the internet, or through direct observation, such as observing the behaviors and complaints of a character in a movie. For example, “Demi Lovato is seeking treatment at this time to address symptoms of an eating disorder as well as addiction issues. She reports that lately she has been feeling down and stressed out by the obligations of her career,” etc.
Psychosocial history/Background Information
Information describing the patient’s developmental history: who was the patient raised by? How would they describe their childhood? How do they feel about their education? Did they enjoy school? Did they have close friends? Did they get along with their family members? Include educational, social, and occupation history, family relationships, etc. This is the section where you are going to be creating a brief narrative of the patient’s life as best you can. You may not have access to all of this information, but do your best to fill in the blanks. If there are significant gaps in any category, you may note it by stating, “at this time, very little is known about the patient’s early childhood,” etc. Make note of anything about the patient’s history that you feel would be relevant to furthering our understanding of the patient.
The patient’s history of medical and psychiatric treatment and hospitalizations, including out-patient and in-patient treatment/therapy, psychiatric medications, non-psychiatric related illnesses, medications, etc. Is the presenting problem a recurrent episode of a previous problem? If yes, how was the problem handled in the past? Was treatment successful? Why or why not? Include a description of present medical problems and present treatment, including medication. The clinician must be curious about ways in which medical problems may affect the presenting psychological problem. For example, certain medical conditions can affect people’s moods and general levels of arousal. Also, please include any known psychiatric history of family members, especially parents and siblings.
Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual (Links to an external site.) code. Use your textbook to come up with a diagnosis, Google the DSM-V criteria for the diagnosis and see whether or not the patient meets the requirements for the diagnosis, then Google “DSM-V code for (insert name of disorder).” Explain how you reached your diagnosis, how the patient’s symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis. If you are unsure of the diagnosis, please give at least one provisional diagnosis (a provisional diagnosis is one to which the clinician is not yet committed) to narrow down the possible diagnoses. If you cannot decide between 2 different diagnoses, include both diagnoses and provide an explanation for both diagnoses. If the patient has been given a diagnosis in the past that you agree with, include that diagnosis and explain why you think it is accurate by referring to the patient’s current symptoms and behavior.
6. Case Formulation
Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions. What this means is that it is essentially a story not just to describe, but explain, how a person’s problem has developed, and how it is maintained so that treatments can be based on influencing those factors.
Steps to creating a case formulation:
DESCRIBE the primary problems and patterns
REVIEW the developmental history (background information)
LINK the problems and patterns to the history using organizing ideas about
There are many different frameworks for case formulation, but several key elements are usually present:
a description of the presenting issues;
the factors that act to create vulnerability or precipitate the problems developing;
factors that may not have been involved in the initial problem developing, but are helping to maintain the problems; and finally,
factors that can help the person cope or act as resources.
To move beyond just describing these factors, a case formulation should describe the relationships between these various factors and the problems that are present – and should reflect not just the visible features of the problem (i.e., what we can see, or what the person reports that are unique to his or her situation), but also the underlying phenomena or stable, recognizable features that are present.
For a more detailed explanation of case formulation, copy and paste the following link into your browser:
http://www.iuc.hr/IucAdmin/Server/downloads/Cabaniss_Psychodynamic_Formulation.pdf (Links to an external site.)
This section of your case study will focus on the interventions you choose to best help your patient. You should choose a style of therapy based on what you think is best suited to the needs of your patient, NOT based on what type of therapy you prefer. Choose two particular treatment/theoretical approaches.
Some of the possible treatment approaches you might choose to explore include:
Provide some background on the psychoanalytic approach (Links to an external site.) and cite relevant references. Explain how psychoanalytic therapy (Links to an external site.) would be used to treat the patient, how you hope the patient might respond, etc.
Explain how a cognitive-behavioral therapist would approach treatment. Offer background information on cognitive-behavioral therapy (Links to an external site.) and why you think it would be a successful treatment option for the patient.
Describe a humanistic (Links to an external site.) approach that could be used to treat your client, such as client-centered therapy (Links to an external site.). Explain why you believe it would be helpful for the patient.
Although the examples I have provided are all traditional therapeutic approaches, please feel free to include non-traditional approaches as you see fit. Just make sure to explain the approach and explain why/how you think it would be helpful for the patient.
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