Case Study Module 2:
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 heart beat 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 and 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.
DSM-IV TR diagnosis (see information in the mini lectures on this):
Axis I:
Axis II:
Axis III:
Convert this diagnosis to the single axis DSM 5, 2013 diagnosis here: (Collapse the first three diagnoses in single sentence order and add a Note: Describing stressors and a Note: describing level of impairment. Ex. Panic Disorder, Borderline Personality Disorder, Asthma Note: Stress of loss of job; Note: Moderate impairment in functioning.
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 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. on the proper Axis.
Convert the diagnosis to the single axis DSM 5, 2013 format here –
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, humanistic, behavioral, etc.). Include a peer-reviewed empirical experimental journal article citation to support your case formulation. Also include another peer-reviewed empirical experimental journal article citation to support an evidence-based treatment that is appropriate for the diagnosis you chose.
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