case formulations

Attached you can find information about person I would like to use for paper. So your task would be to add this information according to outline plus add more info where necessary, while comparing to the sample paper. Let me know if you can work on it.

CASE FORMULATIONS AND PRESENTATIONS:

  1. Who this person is to you?-friend
  2. How you gonna get information?-interview
  3. What at this point you are formulating? There were a few main areas of concern for the client.These were a lack of support from his family, his inability to accept his experience of unpleasant and sad emotions, and his not understanding of broken family connections.He has a strong attachment to the family, and has an inability to let go of his past relationship.

Outline:

Presenting problem:

  • Describe in terms of behaviors, thoughts, and physiological response.-DETAILED
  • Exact number of incidences in day, amount of hair pulled, etc. Details in the behavior and put into objective terms Where, what, how (many), with who (not why!).
  • Also discuss current triggers context (environment), situational (create hierarchy), behavior cues, thought cues).

History of Presenting Problem:

Only information relevant to presenting problem. Onset and course of illness. When problem started, how , under what condition problem started.

Relevant factors to presenting problem (Development):

Information relevant to the development of the problem. Here you are answering HOW.

Here you are looking at learning theory.

Associated and Maintaining variables:

Here you are answering why does it continue.

How reinforced, etc.

Formulation of the chief complaint:

A summary of the above information describing how it developed, how it is experienced, how it is maintained in a succinct paragraph.

Strengths-resources:

What factors will enhance the efficacy of CBT.

Weaknesses-interferences with treatment:

What factors will interfere with the efficacy of CBT.

Eg, Compliance, physical factors, etc.

Treatment goals:

What you hope to accomplish in measurable factors.

Treatment procedures:

including why they are chosen. Be specific about how to proceed.

How monitored:

Be specific on how you plan to monitor the progress of the treatment and how the tools were chosen.

Sample:

Presenting problem: Pt is a 59 year-old Caucasian female hospitalized for bizarre and paranoid behavior. Specifically, she stopped eating, appeared to be responding to auditory hallucinations, and responded with rage to her family. Just prior to the hospitalization, she left her apartment and drove from Houston to New Orleans to see her son without telling any of her relatives, including her son. She was missing for three days and was found by local police of a small town in Texas after she abandoned her car. She denied any psychotic symptoms when asked directly, but she reported bizarre experiences. For example, she stated that she had died and was resurrected four times. In addition, she reported hearing voices “once in a while” giving her instructions, but believes that they are coming from external sources. It should be noted that during the interview, she frequently mumbled, as if responding to voices, and sometimes laughed during these mumbling episodes.

In addition to these difficulties, Pt has a history of being raped in a car while she was in Belgium 23 years earlier (when she was 36 years old). During the rape, she reported disassociating, and therefore, remembers much details immediately before and shortly after the rape, but little about the actual rape. Shortly after the rape, she developed intense fears. Currently, these fears are triggered by being alone with strange men, being in a car with a male, and being in a reclined position (e.g., in a dentist chair) when a male is near. In addition, about once a month, she hears voices commanding her to perform an action in order to avoid a rape like experience to which she responds with great fear. For example, a voice commanded her to get off the couch or “something gooey” would get in her hair. She reports being chronically on edge and easily startled by sudden noises and continues to have intrusive memories of the rape almost every day. These memories cause her to be agitated and fearful, and she experiences increased heart rate and nausea. She attempts to avoid these thoughts and avoids being alone with males. She experiences little connection with others and reports being irritable for most the day. She reported that the rape has changed her life and that she cannot feel normal feelings anymore. It is for these symptoms related to the rape that she requested therapy.

History of Presenting Problem: Pt returned to the United States a month following the rape. It was upon her return that she remembered experiencing the intrusive memories that led to intense fear. Other symptoms soon developed and intensified. Pt soon began avoiding others, especially males, and refused to “go on dates.” In addition, after having an episode of intense anxiety after the dentist put the chair in a reclined position, she avoided all visits to the doctors. She reported having nightmares, of the rape, as well, which led to fear and avoidant behavior of sleep. It was around this time that she reported first hearing the voices speaking to her and giving her bizarre warnings. Her symptoms remained steady for several years, with some increasing in intensity, duration, and frequency. At this time, she began supportive psychotherapy with a female directed at alleviating these symptoms. She reported some symptoms reduction, such as an elimination of her nightmares and reduced tension, but she continued to avoid males, and experienced intrusive memories and subsequent intense anxiety. Her psychotic experiences apparently also increased and she was hospitalized for the first time at the age of 46. She was given antipsychotic medication, which reduced her anxiety as well as the disorganized behavior and hallucinations. Following this, she obtained a job caring for an elderly man. She worked on and off at various “care” positions. Due to the side effects of the medication she frequently discontinued them. After several months without the medication, her psychotic symptoms would worsen and she would be hospitalized and put back on the antipsychotic medications. Including her current hospitalization, she has been hospitalized four times. She reported that even while on the antipsychotic medication, her memories of the rape caused intense fear, but the memories were less frequent. She also continued to avoid being alone with most males, but could manage the fear when the males were people she knew. After 23 years, Pt still reports being bothered by intense fear and avoidant behavior related to the experience of being raped.

Relevant factors to presenting problem (Development): Little history of her family is known and she denies any family history of illness. According to the patient, she was raised in a “strict Christian” home. Her “relationship with God” was very important to her and she often “evangelized” to people who would listen prior to the rape. In fact, she stated that she entered the stranger’s (rapist’s) car in Belgium because she thought it would be “an opportunity to talk to him about God.” When it was discussed how being a Christian influenced her rape experience, she stated that she could not get angry with the rapist. Specifically, she reported more guilt about the consequence to the man after he was arrested. Clear self-blame was also apparent as she searched for her own behavior that led to the rape.

In addition to these cognitions, Pt also stated that her upbringing made “sex” a taboo topic to discuss. “Sex is only to be experienced with a husband.” The idea of “being violated” was hard for her to accept, and indeed, at times (and because she does not remember the actual rape), she questions whether she actually was penetrated.

A recent physical examination found her to have high blood pressure that was being treated with medication. Nothing else was remarkable in her past or current medical history.

Associated and Maintaining variables: Pt’s avoidance is the most outstanding maintaining variable. This avoidance presents itself in many forms. She avoids certain situations (e.g., taxi cabs, being with unfamiliar males) that maintains her fear, as well as subsequent avoidance of certain activities and places. Her avoidance of thinking about the rape and lack of memory of the rape inhibit her ability to process the experience and further reinforce her fear of the thoughts. Also, her response to the “voices” leads her to avoidant behavior. For example, when the voice warned her to get off the couch or “something gooey will get in (her) hair,” she immediately got up and left the room.

In addition, her subsequent beliefs that “the world is unsafe” and that she “cannot trust herself” further maintain the fear and hopelessness that she experiences. These overriding schemata influence her behavior and responses to the environment.

She is frequently tense and on edge. This keeps her sensitive to anxiety provoking thoughts and experiences. This physiological state maintains fear cognitions and behaviors.

No secondary gains are evident at this time. Pt is receiving assistance for her thought disorder; therefore these symptoms of trauma are not reinforced as a source of financial support. Her brother provides her with the same support regardless of these symptoms and no apparent benefits for these symptoms are evident. Pt, however, might prefer to be identified as someone suffering from a trauma rather than from a thought disorder. No exaggeration of trauma related symptoms are evident.

Formulation of the chief complaint: Pt is a 59 year-old Caucasian female entering therapy for her symptoms related to a traumatic event. She experiences intrusive memories of a rape that trigger intense anxiety, in addition to several other trauma related symptoms. Her religious upbringing and prior experiences helped establish schemas about the world and her safety. Specifically, prior schemas were: “bad things happen to bad people,” “women are at least partially to blame when they are raped,” “someone who is raped is a ‘dirty person,’” and “the world is a safe place”. The traumatic experience of a rape challenged these beliefs. In turn, these beliefs were activated and applied to her, causing a strong sense of anxiety (The world is unsafe, people are unpredictable and can harm you, I cannot control what can happen to me) and depression (I must be a bad person to be raped). These thoughts are maintained by her selective attention and sensitivity to evidence that supports these thoughts. Her psychotic symptoms also reinforce her belief that she cannot take care of herself and that she cannot even trust her own judgment.In addition to these cognitions, her avoidance maintains her anxiety. She avoids thinking about the rape so that when she is reminded of it, the intense anxiety occurs. Her avoidance of situations also maintains the current level of anxiety.

Strengths-resources: Recent assessment revealed that Pt’s cognitive functioning is higher than average, which is especially unique for an inpatient population. Specifically, her Verbal IQ was measured to be 119 (as measured by the WASI) and her immediate and delayed recall of context-relevant verbal (Logic Memory) and non-verbal (Family Pictures) information, as well as her mental manipulation of verbal information (Letter-Number Sequencing) ranged from scaled score of 12 to 15. In addition she is oriented to time and place. This strength in cognitive functioning will assist her in understanding and remembering the CBT formulation and techniques.

In addition, Pt is motivated for treatment and has the support of her group home. The home will provide her transportation to the sessions and provide other support in her therapeutic efforts. In addition, the patient believes that she will benefit from therapy, and has shown behavior that indicates a potential for good compliance (e.g., completing assessment procedures on time and with much thought, arranging her own transportation to the sessions). She reports being enthusiastic and eager to begin therapy.

Despite having somewhat blunted affect, Pt still remains connected with others. She reported being comfortable with the therapist (who is male). This rapport will be essential as treatment begins and details of the rape are elicited.

Pt is enrolled in a socialization program that will focus on improving her job skills. She will be trained on the computer and on greeting guests. This program will also provide opportunities to challenge her cognitions and behaviors (e.g., being alone with unfamiliar males, experiencing competency).

Weaknesses-interferences with treatment: The primary concern is the psychotic experiences in which she reports little insight. These symptoms may interfere with her understanding of the formulation, ability to retain prior knowledge, and engage in the therapy (e.g., challenge her belief). Therapy may be especially difficult during active psychotic phases. This also may make exposure techniques difficult as the intense emotion may trigger a psychotic episode or the habituation to the feared stimuli may be stalled.

As is common with long lasting PTSD symptoms, Pt also is experiencing a high level of depression (33 on the BDI). The depression may also interfere with exposure techniques and cause additional distress.

Treatment goals: The primary goal is to reduce the trauma-related symptoms. Specifically, we aim to increase the time free from intrusive memories of the rape and limit the impact these memories have on Pt. Also, we hope to reduce the level of tension and agitation experienced, and cease the avoidant behavior and increase adaptive behavior. It is expected that, as the trauma related symptoms decrease, her depressive experiences will also decrease as they are highly related to each other. It is also expected that her psychotic symptoms will be less intense and less frequent due to the reduction in the stress caused by the trauma symptoms. This will reduce the amount of stress that can trigger the onset of psychotic symptoms.

Treatment procedures: Pt has strong verbal and memory skills that will likely respond well with efforts to identify her negative schemas and subsequent automatic thoughts. Therefore, efforts to challenge cognitions are highly recommended. She can receive interventions to educate her about the effects of her negative automatic thoughts, how to identify them, and subsequently how to challenge them.

Behavioral intervention can include engaging in positive behaviors to increase positive experiences and teach her the behavioral-feeling connection. Also, engaging in behaviors that challenge her irrational beliefs may be necessary. Exposure should be performed with caution due to her psychotic experiences, as well as depression. However, exposure in the session can include repeated descriptions (written or spoken into a tape recorder) of the rape to access the memory of the rape. The goal here is to help her process the experience emotionally rather than to habituation (due to the psychotic and depressive symptoms). The exposure in the session can monitor Pt’s reaction to the description in order to assist her if the exposure is difficult to manage.

Because of the tension Pt experiences, she might benefit from relaxation training. Efforts can be made to identify a method in which she responds well. Different techniques should be explored during sessions.

How monitored: Every four sessions, Pt can complete the IES, a measure of PTSD symptoms, BDI, a measure of depression, and the PTCI, a measure of distorted cognitions associated with traumatic experiences. This will monitor progress toward the goals of therapy. Every session, Pt can provide a general rating of tension, anxiety related to intrusive memories, and depression to show the progress of subjective experiences. These ratings can be graphed to provide Pt with a picture of her progress in therapy.

As each assignment is assigned, an additional assignment will be to monitor reactions and changes associated with the assignment. For example, Pt can be asked to rate level of depression and happiness before and after engaging in a positive behavior.

 
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