To complete a case study, you must first find a case

Diagnostic Worksheet Patient’s name/ age: Give full name and age Summary of Pertinent Case Features Presenting Problem: What did the patient report was the issue when coming to therapy? Did anyone bring the patient or require/ recommend that he come? If so, why? What are the issues in the patient’s life and how would he like them addressed? Does the patient have a goal in mind? Do not list a diagnosis in this area. This should be the most detailed section. Me dical History: List any past or current major medical problems (past surgeries, stroke, diabetes, etc.) If there is none, write, “none noted.” History of Mental Illness: List the patient’s and/ or family’s history of mental illness. If there is none, write , “none noted.” History of substance use/ addiction: List substances that the patient is currently using and/ or addicted to, as well as frequency and amount of use. If currently not using, describe patient’s history of past use or abuse, or lack thereof. If the patient does not currently use alcohol or drugs, and has no history of doing so, write “none noted.” Stressors in past year: What is currently causing stress in this patient’s life? Symptoms of the disorder do not constitute stressors. You may choos e to be specific (“Patient’s wife has threatened to leave him due to his having an affair with an ex -girlfriend.”) or general (“Marital problems”). Of course, the more specific descriptions give a better overall picture. Consider stressors in all areas of life: social support, occupational, educational, legal, financial, grief, interpersonal conflict, etc. Safety assessment: Address suicidal and homicidal ideation. Address any issues that may present danger (eg. Violence, neglect of children, inability to care for one’s self, etc.) If the patient has no current suicidal/ homicidal thoughts or behaviors, write, “denies suicidal/ homicidal ideation.” Appearance/ behavior: Discuss how the patient looks (appearance) and how he is acting (behavior). Suggestions include addressing hygiene (well -groomed, unkempt, lacking hygiene, etc.), dress (disheveled, well -dressed, wrinkled clothing, etc.), overall impression (cooperative, polite, demanding, guarded, etc.) Thought Processes: Make note of any unusual thought pro cesses (delusional, obsessive, paranoid, etc.) or note if thoughts are coherent/ logical. Using good/ fair/ poor as indicators, address both quality of insight (ability to understand self) and judgment (ability to make appropriate decisions). Mood/ Affect: Mood refers to the patient’s emotional expression via their words and affect refers to emotional expression via action (facial expressions, etc.) Address both. Note if mood and affect seem contradictory (incongruent mood/ affect). Intellectual Functioning : Assess their intelligence (high/ average/ low). Intelligence is unchanged by symptoms of a disorder, level of consciousness, education level, or age. It is generally safe to assume average intellect unless you have legitimate reason to believe that the p atient is above or below average. Orientation: Patient can be oriented to person (“Who are you?”), place (“Where are you?”), time (“What is today?”) and situation (“Why are we here?”) If patient is oriented to all, note “Oriented X4.” If one or more areas are missing, note which areas patient is oriented to or is not oriented to. Final Diagnoses List each diagnosis on a new line. Make sure the diagnosis you give is a DSM -5 diagnosis. List ONLY the diagnosis (singular) or diagnoses (plural) here. No explana tion is necessary. Justification for the diagnoses should be clear in the worksheet items above. Be sure to fill in every blank. Include an APA style reference for the source at the end of the worksheet. Diagnostic Works heet Patient’s name/ age: Bob, age 22 Summ ary of Pertinent Case Features Presenting Problem: Patient states he has been visited by aliens from outer space. He states that they are trying to steal his recently deceased mother’s collection of rare depression glass through telekinesis , moving the glass out the window with molecular displacement . Pati ent also states he was fired from his job with Jack in the Box because the aliens appeared to him while he was working the drive thru and demanded he leave immediately or they would destroy the restaurant. He was picked up by police last night after a neig hbor called in a complaint that the patient was in his backyard, yelling loudly at the sky. Patient presents with his sister, Ann , who lives in the same home and was present when the police arrived. Medical History: Patient ’s sister reports he had three surgeries to correct a he art condition as a child. No other significant history noted. History of Mental Illness: Patient states he was depressed as a teenager. Patien t’s sist er states that their father committed suicide 15 years ago . No records could be obtained. History of substance use / addiction: Patient reports recreational use of alcohol since high school, t hree beers or fewer per week. Denies illicit drug use. Patient is not currently under the influence. Stressors in past year: Recent death of mother (two months ago). Loss of job last week and sub sequent financial problems . Lack of social support. Safety assessment: Patient denies suicidal or homicidal ideation. Patient does not have a history of violence. Appearance/ behavior: Patient is disheveled, unkempt, lacking hygiene. Patient was inter mittently cooperative, alternately answering questions and becoming agitated. Responding to unseen stimuli (yelling, waving fist at sky, etc.) Thought Processes: Paranoid, delusional, incoheren t. Poor judgment, fair insight. Mood/ Affect: Agitated, hostile at times toward unseen stimuli. Angry, impatient. Intellectual Functioning: Normal Orientation: Oriented to person/ place, not to time or situation. (Oriented x2) Patient believes he is currently in the middle of a nightmare. Final Diagnoses Schizophrenia Reference Smith, A. (2013). Case studies in abnormal psychology. New York: Pearson.

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