Case:
Jack, a 36-year-old, single Hispanic male truck driver, had been in an accident at work where he witnessed severe injury to two of his coworkers. For a few weeks after that, he was fine but expressed some anxiety over the accident. Two months after the accident he began having nightmares and “flashbacks” seeing vivid images of the accident. He became quite anxious during these intrusive image episodes and hyperventilated, had rapid respiration and heartbeat, and was hypervigilant. He became so afraid another accident would happen at work, that he was unable to function at work due to the anxiety. He would try to avoid reminders of the accident but still, intrusive thoughts about the event popped into his head over and over again. He became exhausted due to the level of constant arousal and at times would feel “numb”. Jack finally went for treatment after being out of work for 4 weeks because of the problem. Prior to this, he had no mental health history. He was intelligent and a B-average student in high school. He had no family psychiatric history. His physical health was excellent.
You should summarize the relevant historical information in the following format:
Presenting problem: Include demographic information first (age, occupation, ethnicity) and then put the clinical information in the client’s “own words”, indicate here in 1 or 2 sentences how you think this person would describe their problem if they were coming to you for treatment.
History of the presenting problem: Write 2-3 sentences here to describe the history of the presenting problem. Present information in chronological order. In the former DSMIV the axes below were used:
DSM-IV TR diagnosis (see information in the mini-lectures on this):
Axis I: (primary clinical psychiatric diagnosis goes here)-
Axis II:(only personality disorders or intellectual impairment goes here if present) –
Axis III: (only medical conditions go here if present) –
Convert this diagnosis to the single-axis DSM 5, 2013 diagnosis see example here: (Collapse the first three diagnoses in single sentence order and add a Note: Describing stressors and a Note: Describing the level of impairment). See this example using another case -Mary had repeated sudden bouts of anxiety and fear of those happening again. She had a long history of being off and on in relationships, difficulty being alone, and had asthma. Since losing her job she became more anxious and had not been functioning at work due to not concentrating well. Ex. DSM-5 Diagnosis – Panic Disorder, Borderline Personality Disorder, Asthma Note: Stress of loss of job; Note: Moderate impairment in functioning.
*DSM-5 Diagnosis (for this case of Jack)- Remove the Axes in the sentence below they are there to guide you.
Put what was on Axis I here:
Note:
put what was on Axis II here:
Note:
put what was on Axis III here:
Justification of diagnoses: Here you should explain why you picked each diagnosis you chose. Specifically, list the symptoms the person has that match up with symptoms required for the diagnosis of the disorder in the DSM-IV. You may also wish to talk about other diagnoses you considered and tell why you eliminated them.* If there is no diagnosis on one of the Axes, write No Diagnosis Axis I or II., etc. for that Axis.
Writing the case formulation:
A case formulation is nothing more than an explanation of how a person’s problems developed according to a particular theory. The formulation should incorporate both significant concepts from the theory and appropriate supporting details from the case history. You must use one (or more) of the major theories discussed in class and in the text (e.g. psychoanalytic, cognitive, humanistic, behavioral, cognitive-behavioral, biological, sociocultural, etc.).1) Include a peer-reviewed empirical experimental journal article citation to support your case formulation. Describe the study supporting the model you used. What was the aim of the study? What was the method? What were the findings? 2) Also include another peer-reviewed empirical experimental journal article citation to support an evidence-based treatment that is appropriate for the diagnosis you chose. Were the statistical methods sound (i.e., for an experimental treatment study did they use an ANOVA or t-test?) Was the sample representative of the larger population? Was the sample size adequate? For example small samples (under 50 are considered small and difficult to generalize from). Was there a control group? Were the participants randomly assigned to the groups?
Citing sources:
Use in-text citations i.e., (Brown, 2020) according to the American Psychological Association (APA) format (Author’s last name, year) in any section that you use a source. At the end please list all references alphabetically (by first author’s last name) in a Reference section at the end of the paper. Make sure that all references cited in the text are cited in the reference section and vice-versa. If you consulted a source but did not use any of that information, do not list it in the reference section.
The “bible” on APA format is the 7th edition of the publication manual published by the American Psychological Association. Please see a sample paper to see how to format an APA-style paper and references here. Or follow the link to the APA Writing Style guide from the Oswego Psychology Department Homepage: First go to the Oswego.edu homepage, then search for Academic Departments, then Psychology Department then APA Writing Style.
American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). Washington, DC: APA.
You are responsible for making sure that both your in-text citations and your references at the end of the paper are done in the required format. If you are not sure, look it up.
Grading:
This assignment is worth 60 points. One point will be deducted for every spelling, punctuation, capitalization, or grammatical error in your report. These points will be deducted from points earned based on the content and organization of your report. Points will be assigned as follows:
Presenting problem
10 points
History of presenting problem
10 points
Correct DSM-IV diagnosis on the first 3 axes with adequate justification AND correct DSM 5, 2013 single-axis diagnosis.
10 points
Case formulation – explain the model or models of the understanding you used to indicate how the disorder came about, how the symptoms are maintained and ideas for evidence-based treatment for the diagnosis you chose. Cite sources in this section.
20 points
All references listed alphabetically by author at the end of the paper in correct APA format. In-text citations in sections above correctly written.
10 points
Total
60 points
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