Case study 2 – choose any related disorder covered in modules 7-12
For each study, you are to imagine you are an intake therapist doing an initial assessment of a disorder. You can make up your client and the details, or if you work in the mental health field, you can use a real person / case IF you change the name and all information or details which may threaten confidentiality. DO NOT use a family or friend and attempt to diagnose them. You are not qualified to do so, and this can cause issues in your relationship and view of such a person. A fictitious person is suggested. Your study MUST BE ORIGINAL. YOU must write it in its entirety. You may NOT find one on the internet or other source and use it for your assignment. To do so will be considered academic dishonesty!
Each case should be submitted as a Word document. It is not expected that your case studies will be of the level of a professional case study, but should be thorough and detailed as would be expected of an upper level student in psychology. It need not be in complete APA format (except references if used), but should be neat, orderly, and include your name in the file name.
Each case should include the following:
CASE SUMMARY – This should include at least the following three things:
· Information on the client such as demographic information, career, education, or other life situations
· Purpose of the visit / Reason client is presenting
· Current executive functioning (may include social, family, occupational, or other circumstances affected or not affected by the symptoms)
Include the client’s background and demographic information, especially things which may be important to diagnosis and treatment. Typically, this would read something such as “The client is a 30 year old male who presents with complaints of….. S/he reports current ability to work without impairment and…..” This section will likely be 1-3 paragraphs. One of the key features of this section is that you include the details that would lead you to your diagnosis. A person who knows the diagnosis should be able to read this section and identify the symptoms and circumstances leading to the diagnosis, as well as a guide for treatment.
CLINICAL HISTORY – Include any prior treatment, history of symptoms, any medical conditions that could be relevant, and other clinical information. If the symptoms are new and there doesn’t appear to be any relevant previous history, state that there is no prior treatment, client is in good health, never been treated for any condition, etc. This supports the diagnosis, but also helps rule out other etiologies of the symptoms such as medical problems. This may or may not repeat some information in the case summary.
INITIAL DIAGNOSIS– Include your initial diagnosis of the condition using the DSM-5 terminology, and list the ICD-10 code. Also, cite the corresponding page in your DSM for the diagnosis. Be sure your information supports (leads you to) the diagnosis using your DSM-5. The diagnostic features and associated features in your DSM will be helpful with this as well. For example, if a criteria states the client must have at least 3 symptoms, lasting for six months or more, and your information only shows 2 for six months and 1 for one month, it would not meet the diagnostic criteria. Again, you are making up the case and symptoms, so you can “make” them have the disorder. You wouldn’t do that if you were evaluating an actual person and case of course. Just be sure the details you give of the case in the case summary support the diagnosis correctly. You should also identify the subtype if applicable. Your DSM will be helpful in all these areas.
DIFFERENTIAL DIAGNOSIS / RULE-OUT- A differential diagnosis has sometimes been called “rule out” diagnoses. These are other diagnoses that may fit the symptom which should be ruled out to support the initial diagnosis, and be sure there aren’t other etiologies of the symptoms. You will often have similar mental disorders to include here, but many of these will be possible “medical” explanations as well. For example, if your client is having tremors and has recently experienced a head trauma, along with other symptoms, you may diagnose him with _________________. However, they could be explained, for example, by drug use. Perhaps the man’s accident could have been caused due to drug use, and repeated use may be contributing to the tremors. You would want to rule out drug abuse as a contributing factor to your diagnosis. Your DSM will include differential diagnoses to consider with each disorder.
TREATMENT SUGGESTIONS / PROGNOSIS – You should give just a brief suggestion / typical treatment and prognosis here. Again, your DSM will be helpful with this, but this is the section where you may want to use your textbook or other sources to determine what treatment efforts may be appropriate, and what prognostic concerns there may be in the treatment process. Because this is an initial diagnosis, this section need not be lengthy. You are not mapping out the entire treatment process. You are only giving an initial suggestion as to the direction to take.
If you want, you can use the guideline / template for your case study on the following page (delete the instructions above if you use the template).
Case Study 1/2
Assessing therapist: ________[your name]_______________________ Intake date: _____________
Client’s name: __[make it up]_______________ Preferred call name: _________________________
DOB: __________ Age: ________
Does client present voluntarily: ____yes ____ no ____ court ordered
ICD-10 CODE: _____________________________
DIFFERENTIAL DIAGNOSIS / RULE-OUT:
TREATMENT SUGGESTIONS / PROGNOSIS: