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Jeff’s Story

Case Write Up: Jeff’s Story
Description

Demonstrating ability to utilize the biopychosocial model, understand diagnostic criteria, and accurately diagnose presenting problems.
Describe and formulate the case using the biopsychosocial model. For reference please refer to the documents loaded on order for both the case and for the biopsychosocial model. Tell a coherent story about the character with attention to presented relevant history, current problem, cultural factors, and theoretical considerations.
Discuss any cultural factors that may be impacting the individual.
Provide a list of potential diagnoses in DSM-V for which the character has demonstrated at least one symptom.
For each diagnosis for which the character does not meet full diagnostic criteria, describe why that diagnosis is ultimately inaccurate.
Provide a description of how the character meets diagnostic criteria for the disorder with which they are diagnosed using DSM-5 criteria and symptoms.
Provide all relevant diagnoses, citing specific evidence for each.
Make one treatment recommendation from any of the theoretical orientations with which you are familiar.
Please write these case write-ups in an integrated form.
Grading for Case Write-Up_____/10 Writing style, grammar, spelling, APA format (use this resource (http://owl.english.purdue.edu/owl/resource/560/01/ (Links to an external site.)) for APA style as it has the corrections of the second printing of the 6th edition)_____/4 Identifying Information: (provide a brief introduction to the case including age, race, native language, etc.)Reason for Referral: (brief explanation of reason person is being seen now)Chief Complaint: (brief description of problem or symptoms causing difficulty)_____/40 Bio-psychosocial Formulation (biological factors, psychological factors and social factors in an integrated form; be sure to integrate cultural and spiritual factors throughout as relevant). The bio-psychosocial section is about bringing together pieces that you pick up in the case. Look to tell an informed story – bring in data from the case to build a conceptual formulation that makes sense. This integrated formulation connects the dots; it doesn’t just state facts. You should use facts to support your hypotheses/formulation (…as evidenced by…). A formulation explains the biological, psychological, and social vulnerabilities and their impact on the client’s view of self and their world (others). As you think about the case, look to pull together what you know, and what you think is going on for the person physically, symptomatically, and socially. What role do their friends play? What role might their family play? How might the people and stressors in their life come together to impact their symptomology? How might they see themselves in the world and how does that help or hurt them? Look to answer these questions in a coherent narrative and you will be conceptualizing. Also consider protective factors. It’s ok to say you don’t know about something about the case, or that it isn’t yet clear. You can only work off of what information is given. If there is something that you don’t know about the case but would like to, say so, and feel free to speculate within reason making clear your reasons for such speculation. As part of the psychological formulation, include specific theoretical conceptualization for practice. Draw on the theoretical orientation you feel most comfortable with, or the one you think makes sense in the case. How you see the etiology of the diagnosis will set up treatment recommendations as well._____/20 Differential Diagnosis: list and discuss the 2 most important differentials and the rationale for the diagnosis not meeting the differentials. Explain why ultimately the individual does not meet criteria for diagnoses not met in the differential, remember to consider, course, onset, timeframe, subtypes, specifiers, etc.) Be specific and use DSM criteria as rule in and out._____/20 Diagnosis and Coding: List each Diagnosis (diagnose accurately including subtypes, specifiers, and include both the diagnostic and ICD-9 codes) along with Rationale and Evidence for Each Diagnoses: (support your diagnoses using examples from the case and DSM criteria)______/6 Treatment Recommendation: please give 1 treatment recommendation based on your formulation and diagnosis. What would you focus on first in therapy? What is the most salient vulnerability that impacts this client’s functioning? How would you begin to address it?_____/100 points

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