Case Study Report

 

Use the following format for your paper.

 

I.                     Summary of patient’s problems

 

A.                  Behavioral disturbances

B.                   Psychological disturbances

C.                   Emotional disturbances

D.                  Physiological (somatic) disturbances

 

II.                   Important features of genetic, constitutional, familial, and environmental influences

 

This section can include some of the external stressors which contribute to the client’s problems and/or causes of the problems.  If you see a pattern of this behavior in the family, you may claim that a genetic link is at the root of the problem.  Back up your assertions with what you know about the disorder (does current research support a genetic link for that disorder).

 

You could describe the person’s childhood, how they were raised, their socioeconomic status.  Do not rewrite the entire social history from the case.  Give me the evidence that supports your concerns about the client.

 

This section will give you the material you need to defend your Axis IV and Axis V diagnoses.  So include duration of stressors to help support your GAF score.

 

III.                 Diagnostic classification (5 axis diagnosis)

 

This section of your paper should look like this:

 

Axis I: _______________________________________

Axis II: ______________________________________

Axis III: _____________________________________

Axis IV: _____________________________________

Axis V: ______________________________________

 

No elaboration or explanation is given in this section.  Just the facts.  You would have defended your diagnosis in the preceding sections. 

 

IV.                 Treatment plan

 

In this section you should map out how you would attempt to help the client.  Which symptoms would you attempt to address first and why?  Which specific treatment modality would you use and why?  For example, if you state that psychoanalysis is your treatment of choice, explain why this type of treatment would work with the specific disorder in question. 

 

Remember the biopsychosocial model?  Use this to guide your treatment approach.  Tell me how you would treat each aspect of the problem (biological solutions, psychological solutions, social/environmental solutions).  If the diagnosis you decide upon does not lend itself to all three components, say that and explain why not.  Though you should be able to come up with something for each variable (bio, psycho, and social).

 

V.                   Prognosis and ideas for further assessment

 

It is customary in any psychological report for the clinician to describe how likely the client is to respond positively to the treatment proposed.  What are some obstacles to treatment success?  What are some assets the client possesses that might make success more likely (every client has some positive resources either internal or external, which they can use)?  Finally, what areas are still of concern for you?  What type of further assessment would you recommend to answer any further questions you have?  You can talk about any diagnoses you want to rule out in this section also.

 

 

IF YOU HAVE QUESTIONS ABOUT THE CASE OR THE REPORT ASK ME.   DON’T ASSUME YOU KNOW THE ANSWER, WHEN IN DOUBT ASK!!!   ALSO WORK CLOSELY WITH YOUR GROUP, CONSULT EACH OTHER, AND IF THE GROUP HAS QUESTIONS, ASK ME.