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.
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 the 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 the past year: What is currently causing stress in this patient’s life? Symptoms of the disorder do not constitute stressors. You may choose 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.), an overall impression (cooperative, polite, demanding, guarded, etc.)
Thought Processes: Make note of any unusual thought processes (delusional, obsessive, paranoid, etc.) or note if thoughts are coherent/ logical. Using good/ fair/ poor as indicators addresses both qualities 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 affects 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 a legitimate reason to believe that the patient 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 the patient is oriented to all, note “Oriented X4.” If one or more areas are missing, note which areas the patient is oriented to or is not oriented to.
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 explanation 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. Diagnoses
To complete a case study, you must first find a case. Some suggested cases are available under the “Case Studies” link, although you do not have to use one of those. A case can be any person in a news article, fictional or historical character, the person in a book, movie, TV show, etc., or just about anyone whose behaviors can be observed by the general public (note: DO NOT use someone you know personally).
To submit your case study, you will fill out a diagnostic worksheet about your case. Imagine that you are a therapist seeing this character as a client and discern what information you can gather and what would be necessary for diagnosis. If the client is currently deceased, imagine a specific age at which you might have met with them while they were alive. You may have to work off-script or use your imagination a little bit. Where the worksheet requests information that is not available, you may fabricate an answer or embellish upon the information already known, as long as it is consistent with the rest of the case.
Grading is based on your ability to provide necessary information through the completion of the worksheet and to decipher what information is relevant for diagnosis. Directions for diagnostic worksheets can be found below, as well as a sample worksheet. Be sure the worksheet follows the directions and contains sufficient information to justify your diagnosis (singular) or diagnoses (plural). The diagnosis/ diagnoses must be found in the DSM-5.
At the bottom of your diagnostic worksheet, provide a reference (APA style) for the source you used (website, book, movie, etc.) References are provided for the suggested cases; reference on your own if you use another case.
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