CASE ANALYSIS REPORT & TREATMENT PLAN 1
I. CLIENT DEMOGRAPHIC CHARACTERISTICS
Name
Age
Sex
: Arthur
: 22
: Male
II. PRESENTATION OF SIGNS AND SYMPTOMS AND DIAGNOSIS
295.90 (F20.9)
Schizophrenia (a,b,c)
295.70 (F25.1)
catatonia associated with schizophrenia
V62.82 (Z63.4)
Uncomplicated Bereavement
Severity is at most 1-month duration. This must be measured using Clinician-Rated
Dimensions of Psychosis Symptom Severity
A. Presenting problem
DSM 5 CRITERIA
REMARKS
PRESENTATION
Delusions and disorganized speech are
present of the time period during 1-month
period.
MET
he now talked about saving
all the starving children in the
world with his “secret plan.”
 speaking strangely
Negative symptoms
MET
Onset disturbance, level of function is
affected in major areas of one’s life which is
achieved lower prior to the onset.
MET
Continuous signs of disturbance is persisting
for at least 6 months including prodromal
and residual periods. Negative symptoms or
two more listed in Criterion A is attenuated
form.
MET
Other psychotic features ruled out because
mood episodes occurred in active-phase
MET
dramatic changes in emotion,
often crying and acting
apprehensive
laid off from his job a few
days before because of
cutbacks
and
hadn’t
communicated with any of
his family members for
several days
stopped wearing socks and
underwear and, despite the
extremely cold weather,
wouldn’t wear a jacket when
he went outdoors.
revealed more details of his
plan
Arthur’s handwriting had
deteriorated, and he had
written notes instead of the
usual check information
demeanor changed to one of
extreme concern and he
symptoms and present in minor times in
total duration and residual period of illness.
spoke nonstop about his plans
walked out during the session
and disappeared for 2 days
and was found walking in
streets like nothing happened.
Continuous: symptoms fulfilling the DSC of the disorder are remaining for the majority of the illness
course, with subthreshold symptom periods being very brief to the overall course.
B. Predisposing factors
1.
2.
3.
4.
5.
father’s death years ago
regrets from unachieved educational attainment
shift on work environment
idealistic
more to others than the self
C. Precipitating factors
1.
2.
3.
father’s death years ago
Attain extremities without practicality
No social communication for 7 days
D. Perpetuating factors
1. carrying several spiral notebooks that he claimed contained his scheme
2. changes in emotion, often crying and acting apprehensive
3. little to no sleep
4. distress caused by present symptoms
5. helplessness from relationship and family
E. Protective/positive factors
1.
2.
3.
family seek professional help
the client is participative
support from family is acquired
III. DIFFERENTIAL DIAGNOSIS
DISORDER
Major depressive or
bipolar disorder with
psychotic or catatonic
features
Schizoaffective
Delusional disorder
Obsessive-compulsive
disorder and body
dysmorphic
Other mental disorders
associated with a
psychotic episode
Schizophreniform
METHOD FOR CRITERIA FOR EXCLUSION
Depends on temporal relationship in mood disturbance and psychosis.
Delusions occur excessively during major depressive or manic episode; it is
depressive or bipolar disorder with psychotic features.
Requires manic episode occur concurrently with active-phase symptoms.
Mood symptoms is also present in total duration of active symptoms
Client has absence of the other symptoms for DD.
OCD-BD present absent insight where prominent obsessions, compulsive
actions, hoarding and repetitive behaviors is present. The client was not seen
to have this kind of symptoms.
Schizophrenia has psychotic episode but not brought or attributed by
physiological effects of substance or drug use. Some minor neurocognitive
disorder has present with psychotic symptoms but would have temporal
relationship in onset cognitive changes consistent with those disorders.
Shorter duration compared to Schizophrenia specified in Criteria C, that
disorder and brief
psychotic disorder
required 6 months of occurring symptoms. In BPD, it occurs at least a day but
never exceeds in a month.
IV. CASE CONCEPTUALIZATION (Theory based)

Mustafa 1990- Kisii tribal doctors listen to patients to find location of their noises in their heads, get drunk,
take a piece of scalp in the skull to hear the voices.

Slotema et al. – intervention may modestly improve auditory hallucinations, delusions that effects in a
month.

Scoriels et al.- research found that Modafinil is a substance that is a cognitive enhancer with low potential
abuse. This drug may improve emotion processing in schizophrenic patients.

Kopelowicz 2009- adapting treatments to make culturally relevant including family relatives in social skills
training is essential for effectiveness in treatment process.

Psychosocial interventions are now used not only to treat schizophrenia but take compliance by helping
patient communicate frequently to better understand them by professionals.
V. SUGGESTED CONFIRMATORY ASSESSMENT TOOLS

Tools like Clinician-Rated Dimensions of Psychosis Symptom Severity and Measurement and Treatment
Research to Improve Cognition in Schizophrenia (MATRICS) will be used to identify the client’s well being
from the first session and what interventions can be used in the disorder.
VI. TREATMENT PLAN
PHASE 1: INITIAL PHASE
GOAL: seek family appointment to start collecting previous observations of client
Specific Phase
Objectives
Ask family
background and
recent events that
might affect the
client
What are observed
from the past few
weeks and
educate family
members about
the disorder to
manage and
reduce stress and
tension at home
Intervention/
Activity
Interview
Persons
Involved
Family
members
Duration
First
session
-
Know key points from
background
Family
psychoeducation
Family
members/
client
First
session
-
Gain knowledge and
predict diagnosis of the
client that needs to be
assessed first
PHASE 2: WORKING PHASE
Outcomes
GOAL: Using Intergrative treatment approach to further investigate and direct the client’s concerns
Specific Phase
Objectives
Provide support in
the
community
with
small
caseloads for care
providers, services
in
community
setting rather than
clinical in at least
24
hours
assessment
Provide sufficient
support to sustain
the person and
keep the
meaningful job
Intervention/
Activity
Assertive
community
treatment
Persons
Involved
Client
and
psychologist
Duration
Outcomes
2-3 hours
in a week
Help
client
better
his
communication skills and develop
cognitive thinking from outside
perspective
Supportive
employment
care givers and
family members
3 times a
week
This creates strategies in active
participation and process
positive emotions, thoughts and
feelings in the things being done.
PHASE 3: TERMINATION PHASE
GOAL: To establish and evaluate the client’s improvement from the recent treatment process conducted
in duration of weeks.
Specific Phase
Objectives
Provide effective
use of medication
and
establish
positive
coping
styles
when
symptoms reoccur
Collects data and
evaluate
observations from
the initial phase
until termination
phase.
Intervention/
Activity
Illness
management and
recovery
Persons
Involved
Other
clinicians,
client,
and
psychologist
Duration
Outcomes
1
hour
after
working
phases
To develop knowledge with
regards to the boundaries of
substance use.
Followtreatment
Client
and
psychologist
30
minutes
Know improvement and gain
insight on how to handle
symptoms.
up
INDICATORS/ MEASURES OF PROGRESS (Assessment tools)
Psychiatric evaluation must be conducted during termination phase to check mental status if
similar conditions are still frequently seen. This also includes a discussion with the family and personal
history.
PROGNOSIS:
Approximately 5%-6% of individuals with schizophrenia die due to suicide. Other risk factors can
highly affect period of psychotic episode or hospital charge. About 20 percent schizophrenia patients on
medication relapse within a year after successful treatment of acute episode. Dr. Duckworth said that
people who experience schizophrenia depends on how willing they are to be cured. It was also seen that
with successful schizophrenia treatment involves family support, community engagement with a positive
social interaction fully influence the individual experiencing schizophrenia. A combination of medical
treatment in social rehabilitation and support is a great help to support and improve lives of people with
this disorder. With self and other support, an individual can strive to be better and develop good outlook
as time will.
Report prepared by:
Ma. Virginia Jayoma
Phil is a 67-year-old male who reports that his biggest problem is worrying. He worries all of the
time and about “everything under the sun.” For example, he reports equal worry about his wife who is
undergoing treatment for breast cancer and whether he returned his book to the library. He recognizes
that his wife is more important than a book, and is bothered that both cause him similar levels of
worry. Phil is unable to control his worrying. Accompanying this excessive and uncontrollable worry are
difficulty falling asleep, impatience with others, difficulty focusing at work, and significant back and
muscle tension. Phil has had a lifelong problem with worry, recalling that his mother called him a
“worry wart.” His worrying does wax and wane, and worsened when his wife was recently diagnosed
with breast cancer.
CASE ANALYSIS REPORT & TREATMENT PLAN 2
I. CLIENT DEMOGRAPHIC CHARACTERISTICS
Name
Age
Sex
:
:
:
Phil
67 years old
Male
II. PRESENTATION OF SIGNS AND SYMPTOMS AND DIAGNOSIS
300.02(F41.0) Generalized Anxiety Disorder
A. Presenting problem
DSM 5 CRITERIA
REMARKS
PRESENTATION
MET
-
Worries all the time
lifelong problem with
worry
Individual finds difficulty to control the
worry
MET
-
Unable to control his
worrying
Anxiety and worry are associated with three
or more symptoms having more present for
more days than not for the past 6 months
-sleep disturbance
- muscle tension
-difficulty concentrating or mind
going blank
MET
-
Th disturbance is not better explained
inclined by another mental disorder
MET
-
Excessive anxiety and worry, occurring more
days than not at least 6 months
B. Predisposing factors
1.
2.
Undesirable events
simple problems
Accompanying
this
excessive
and
uncontrollable worry are
difficulty falling asleep,
impatience with others,
difficulty focusing at
work, and significant back
and muscle tension.
Both different events
cause him similar levels of
worry.
3.
uninvited thoughts
C. Precipitating factors
4.
5.
6.
sudden circumstances that arise
Analyzing multiple thoughts once in a while
Decision making
D. Perpetuating factors
1.
2.
3.
Decision making
continuous life events
his wife got diagnosed with breast cancer
E. Protective/positive factors
4.
5.
Seek professional help
Has someone to talk to about his constant worries
III. DIFFERENTIAL DIAGNOSIS
DISORDER
Anxiety disorder due to
another
medical
condition
Substance/
medication-induced
anxiety disorder
Social anxiety disorder
Obsessive-compulsive
disorder
Post traumatic stress
disorder
and
adjustment disorder
Depressive, bipolar and
psychotic disorders
METHOD FOR CRITERIA FOR EXCLUSION
Client’s diagnosis is not associated with his anxiety and worry caused by
judgement, based on history, laboratory findings or physical examination to
be inclined with physiological effect of another specific medical condition.
No substance or medication (drugs, caffeine) was judged to be associated
related to the anxiety.
Focused more on upcoming social situations producing anxiety while GAD
worries whether or not he is evaluated.
GAD focuses on upcoming events that creates the worry for the future
situations while OCD has obsessions are inappropriate that take part
intrusively and unwanted thoughts, images and urges are seen.
GAD criteria better explained the current diagnosis rather than PTSD thus
adjustment disorder, anxiety occurs in response with identifiable stressor
within 3 months of onset of stressor and does not persist for more than 6
months.
GAD is a common feature of depressive, bipolar and psychotic disorder but
should not be separately diagnosed if excessive worry has occurred only
during the course of these conditions.
IV. CASE CONCEPTUALIZATION (Theory based)



Borkovec (1994)- emotional processing model which mental imagery are created from somatic and
associated somatic and emotional activation. From the experiences itself, the fear and worry is processed
to successfully employ activity. Worry is an ineffective cognitive attempt to face problems and clear out
threat that triggers somatic and emotional experiences in the duration of fear confrontation.
Turk et al.- GAD individuals usually have emotional hyperarousal or emotions are intense. This has both
positive and negative emotional states.
Roemer and Orsillo (2002, 2005)- acceptance based model where thoughts, feelings are cause to ways a)
negative reacting to internal experiences and b) fusion with internal experiences. Second, fusion in internal
experiences is permanent and thus a defining characteristic of the individual. Third, it creates experiential
avoidance actions like worrying that makes restrictions in engaging social meaningful events.
V. SUGGESTED CONFIRMATORY ASSESSMENT TOOLS


Generalized Anxiety Disorder Assessment (GAD-7)
Hamilton Anxiety Rating Scale
VI. TREATMENT PLAN
PHASE 1: INITIAL PHASE
GOAL: to increase knowledge about Generalized Anxiety Disorder
Specific Phase
Objectives
Describe
vocabulary to
describe GAD
occurring
emotions.
Intervention/
Activity
Discussion type
Persons
Involved
Client
therapist
Duration
Outcomes
First
session
Focus to teach
individuals with
GAD about
importance of
emotions in
decision making
and interpersonal
relationships.
Emotion
education
Client
therapist
First
session
Better
widen
perspectives
correlating GAD and gain
knowledge in observing attitudes
seen.
Resolve unconscious conflicts in
an effort for patients to
understand themselves and their
behaviors.
Promote awareness with various
techniques designed to enhance
understanding and regulation of
their emotions.
PHASE 2: WORKING PHASE
GOAL: Address the concerns and issues regarding GAD
Specific Phase
Objectives
Aims to reveal and
explore
feared
core
emotional
themes
Intervention/
Activity
Experiential
exposure
exercise
Persons
Involved
Client
therapist
Duration
Outcomes
30 mins,
second
session
RCT
therapist
client
20 mins in
second
session
Fully grasp and recognize
emotionally
overwhelming
situations and how to manage
them
Indicate significant reductions in
worry and GAD symptoms of
client.
PHASE 3: TERMINATION PHASE
GOAL: To reduce the risk of reoccurring symptoms for the client’s protection
Specific Phase
Objectives
Further increase
awareness
of
Intervention/
Activity
Writing
assignments
Persons
Involved
Client
therapist
Duration
Outcomes
Own
homes
Adopt coping techniques when
symptoms are at present.
relationship
between behaviors
and values
Decrease harm involving personal
dangers.
INDICATORS/ MEASURES OF PROGRESS (Assessment tools)
3 months follow up will be used after termination of sessions. Evaluation using will be used to
measure progress after each session. Interview will be conducted before termination of session to assess
its condition.
PROGNOSIS:
Generalized Anxiety Disorder is evident among preadolescence until adulthood. This causes
different factors associated by life events and uncontrollable thinking. Most cases, 50% of patients get
treated with improvements within 3-week period while 77% are over 9 months in total.
Report prepared by:
Ma. Virginia Jayoma
Joey was a 12-year-old boy who was referred to mental health care for long-standing anxiety
about losing his parents. He had begun to have anxieties as a young child and had great trouble starting
kindergarten. He had been scared of being away from home for school. He was also briefly bullied in
third grade, which made his anxieties worse.
Joey’s parents noted that he “always seemed to have a new worry.” His most constant fear
revolved around his parents’ safety. He often was fine when both were at work or home, but when they
were in transit or elsewhere, he was afraid that they would die in an accident. When the parents were
late from work or when they tried to go out together, Joey became frantic, constantly calling and texting
them. Joey was mostly concerned about his mother’s safety, and she had gradually reduced her solo
activities to a minimum. She said, it felt like “he would like to follow me into the toilet.” Joey was less
demanding toward his father, who said, “When we comfort him all the time or stay at home, he’ll never
become independent.” He believed his wife had been too soft and over-protective.
Joey’s grades were good. His teachers agreed that he was quiet but had a number of friends and
worked well with other children. They noted that he seemed sensitive to any hint that he was being
picked on.
Joey and his family underwent several months of psychotherapy when Joey was 10 years old.
The father said therapy helped his wife become less overprotective, and Joey’s anxiety seemed to
improve. Joey’s mother had a history of panic disorder, agoraphobia and social anxiety disorder. His
grandmother was described as being as anxious as Joey’s mother.
CASE ANALYSIS REPORT & TREATMENT PLAN 3
I. CLIENT DEMOGRAPHIC CHARACTERISTICS
Name
Age
Sex
:
:
:
Joey
12 years old
Male
II. PRESENTATION OF SIGNS AND SYMPTOMS AND DIAGNOSIS
309.21(F93.0) Separation Anxiety Disorder
C. Presenting problem
DSM 5 CRITERIA
REMARKS
PRESENTATION
MET
-
scared of being away
from home for school
Persistent and excessive worry about losing
major attachment figures caused by harm,
disasters
Persistent and excessive worry about
experiencing untoward event
MET
-
constant fear revolved
around his parents’ safety
MET
-
Fear, anxiety or avoidance is shown lasting 4
weeks
MET
-
When the parents were
late from work or when
they tried to go out
together, Joey became
frantic, constantly calling
and texting them.
begun to have anxieties
as a young child and had
great trouble starting
kindergarten.
briefly bullied in third
grade, which made his
anxieties worse.
His teachers agreed that
he was quiet but had a
number of friends and
worked well with other
children. They noted that
he seemed sensitive to
any hint that he was being
picked on.
Recurrent
excessive
distress
when
anticipating or experiencing separation from
home or attachment figures
-
Disturbances has signs of distress or
impairment in social, academic situations
MET
B. Predisposing factors
6.
7.
8.
Mother has history of panic disorder
Over-protective of parent towards the child since birth
Negative thoughts
-
9.
Attachment issues
C. Precipitating factors
7.
8.
9.
Distance of child from parents
Trauma from bullying
Anxiety attacks
D. Perpetuating factors
6.
7.
Being baby-ed inside the house
Always attached to the mother
E. Protective/positive factors
6.
7.
8.
Parents of the child seek professional help
Has good grades
Cares for family members
III. DIFFERENTIAL DIAGNOSIS
DISORDER
Generalized
anxiety
disorder
Panic disorder
Depressive and bipolar
disorders
Oppositional
disorder
defiant
METHOD FOR CRITERIA FOR EXCLUSION
Anxiety is caused by separation from attachment figures.
SAD anxiety is connected possibly of being away from attachment figures and
worry about untoward event not because of unexpected panic occurrences
Exclusion is depressive and bipolar is from low motivation to connect with
the outside environment while SAD main concern is worry and anxiety from
untoward events.
ODD should be considered when persistent oppositional behavior unrelated
to anticipation or occurrence of separation from attachment figures.
IV. CASE CONCEPTUALIZATION (Theory based)


Bowlby- attachment theory, children have to be near their parents for biologically necessary comfort and
support. Secure attachment — knowing that the parent will be available, physically and emotionally
Piaget’s cognitive theory- wide range of changes occurring in the child and how behavior that may be
appropriate at another age.
V. SUGGESTED CONFIRMATORY ASSESSMENT TOOLS
The assessment tool that will be using is the Child and Adolescent Anxiety Assessment.
VI. TREATMENT PLAN
PHASE 1: INITIAL PHASE
GOAL: Diagnostic interviews using assessment of anxiety in children
Specific Phase
Objectives
Educate parent
and child on SAD
Intervention/
Activity
Exposure
to
separation
Persons
Involved
Child
Parent
Duration
Outcomes
Beginning
of
Graduate
exposure
with
separation at school and focus of
and theories why
fear and anxiety
occur and how to
control it
therapist
treatment
contracts.
Duration
Outcomes
Minor
episodes
every
2
weeks
Help child reduce separation from
mother from school and when in
one room.
PHASE 2: WORKING PHASE
GOAL: Address the concerns and issues regarding SAD
Specific Phase
Objectives
Establish
reinforcement
from
different
exposure
of
separation slowly.
Intervention/
Activity
Board games
Verbal praise
Persons
Involved
Child
Parent
therapist
PHASE 3: TERMINATION PHASE
GOAL: To reduce the risk of reoccurring symptoms for the client’s protection
Specific Phase
Objectives
Focuses on home
routines and alone
time inside the
house.
Intervention/
Activity
Home activities
like playing, bike
rides
Persons
Involved
Parent
child
Duration
Outcomes
Sessions 610
Allow separation from time to
time without much attachments
and can move dependently with
minor guidance from guardian.
INDICATORS/ MEASURES OF PROGRESS (Assessment tools)
Severity Measure for Separation Anxiety Disorder will be used to indicate the level of
independency of the child towards attachment figures.
PROGNOSIS:
Most cases are seen among children who develop dependency on people who they want comfort
and support. If this isn’t treated enough, this may lead to various anxiety disorders. If treatment revolves
with the support of his/her family members, most likely children improves at higher rates. Once children
are observed with these symptoms, do not hesitate to seek a health care provider. The earlier a child
seeks help, the more preventions it makes for the child’s development.
Report prepared by:
Ma. Virginia Jayoma