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PSY 708 Example
Case Formulation & Treatment Plan [parts abbreviated]
Identifying Information
Name: Dennis Holt
Gender: Male
Date of Birth: 3/22/80
Counselor: Adam Volungis, PhD, LMHC
Age: 33 years
Date: 4/9/13
Reason for Referral
Dennis Holt is a divorced, 33-year-old male… …and successful salesman. He is currently in a
long-term relationship of four years… He was persuaded by his girlfriend to seek help after his
most recent panic attack…
Problem List (include cognitive, emotional, behavioral, and physiological components, when appropriate)
1. Panic attacks: Since the age of 24 Dennis has been having multiple unexpected panic attacks
in a variety of contexts (e.g., dinner theater, driving, mall)…
2. Worry over… : Dennis constantly thinks/worries about having another panic attack… He
tries to avoid rush hour traffic and when he does drive in heavy traffic he favors the right lane in
order to pull over to the side of the road if he “has an attack”…
3. ………..: Dennis reports being extremely tense and anxious between panic attacks… …Also,
he has difficulty relaxing…
4. Highly self-conscious: Dennis is very self-conscious or overly concerned that other people
are negatively evaluating him…
5. …: …As his fears of being in crowded places have increased more and more each year,
Dennis finds himself …
6. …: …Thus, Dennis has a greater propensity to flee situations that…
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PSY 708 Example
DSM Diagnosis
Axis I:
300.02, Generalized Anxiety Disorder (primary)
300.23, Social Phobia, Generalized
R/O Panic Disorder w/ Agoraphobia
Axis II:
V71.09, No Diagnosis
Axis III: 564.1, Irritable Bowel (colon) Syndrome (past diagnosis)
Axis IV: Problems related to the social environment – limited and restricted social interactions
Axis V:
65 (current)
Nomothetic Formulation of Primary Diagnosis
See readings and lecture notes for a nomothetic formulation of diagnosis. Also see Persons and
Tompkins (2006, pp. 292 & 307).
Idiographic Components of Formulation
Mechanisms (Schemas)
Cognitive: …Do not let any weaknesses show. Constantly focuses his thought… fear of
social evaluation. Also consistently thinks/worries about future…
Emotional: Experiencing frustration/overwhelmed over not achieving perfection (i.e.,
showing weakness…
Behavioral: …Also continually avoids crowded places or other places where…
Biological/Physiological: Experiences a variety of generalized anxiety symptoms (e.g.,
constantly feeling “wound up and on edge” and unable to sleep)…
Origins of the Mechanisms (Schemas): Although Dennis got along well with his mother, his
father was a very demanding perfectionist who held very high expectations for Dennis… core
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PSY 708 Example
beliefs… Dennis was a very shy child and even after putting effort into interacting with other
people…
Precipitants of the Current Problems: … seek help both in the past and present are his
occasional panic attacks (about 2-3 a year). His most recent panic attack… His generalized
anxiety and social phobia seem to be his primary problems… …primarily situations in which
Dennis is under some form of social evaluation; especially in crowds of people or with
individuals he does not know well… …Other areas of evaluation… His most recent activating
situation is when he…
Strengths and Assets
He is one of the most successful salespersons in his firm… …has a good social support network
of friends… …in a current stable relationship… …has made previous attempts to decrease his
anxiety (e.g., transcendental meditation… recorded a personal tape to reassure and encourage
himself).
Sociocultural Factors
See lecture notes and Persons and Tompkins (2006, pp. 296-297).
Case Formulation of Dennis’ Presenting Problems
Dennis was an only child of two parents and very shy while growing up… During this time
Dennis also had to deal with his “demanding perfectionist” father who h... Thus, no matter how
hard he tried.... This in many ways could possibly explain why Dennis puts great effort into
everything he does and has such high… At this point in his live Dennis had developed a strong
cognitive schema where one must be… Emotionally, his schema consists of getting frustrated
and overwhelmed very easily… …and behaviorally his schema is too avoid any threatening
situation or… physiologically…
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PSY 708 Example
Over the years this maladaptive schemata has evolved and has been “reinforced”
cognitively, emotionally, and behaviorally through his continued experiences… It is rational to
speculate that his continued social apprehension eventually reached its “climax” when he... In
other words, Dennis’ biological and psychological vulnerability to stressful life events resulted
in… as a “false alarm”… …eventually became generalized to a variety of contexts…
Currently, his cognitive schema focuses on what other people may think of him …
Emotionally, he is experiencing... Behaviorally, he is experiencing… …continued avoidance
of… may be difficult. These negative schemata have decreased the quality of his life
including…
Treatment Plan
Goals (Measures)
1. Decrease concern of having future … (measured via a log of the specific context when
a concern for a… along with the associated thoughts and physical symptoms).
2. Reduce frequency, intensity, and duration of… symptoms… (measured vi …).
3. Gradually decrease his preoccupation with social evaluation and increase… (measured
via an… along with the associated context and thoughts).
4. Increase acceptance of… …being imperfect and focus on own positive
qualities/traits… (measured via a log of…).
5…
Modality: Individual cognitive-behavioral therapy.
Frequency: Weekly.
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PSY 708 Example
Interventions
1. Explain the treatment rationale: Describe a comprehensive rationale for…
2. Administer the ….: Considering the plethora of anxiety symptoms that Dennis is
suffering from it would be best to administer…. More importantly this will help in the process
of obtaining specific cognitive and behavioral information needed for developing a treatment
program.
3. Education about… / early cue detection: Before going any further it is best to educate
Dennis about how the body can react physiologically…
4. …: Providing Dennis this training will prove especially helpful when he is ready for “in
vivo”…
5. Cognitive Restructuring: This will be implemented in order to help change Dennis’
maladaptive schemata and help him integrate more appropriate coping strategies…
6. …: Although Dennis’ primary diagnosis is… Dennis will first create a hierarchy of…
7. …: Having Dennis continue many of these techniques outside of the therapist’s
office....
Obstacles:
1. Difficulty…: Due to Dennis’ past history of avoiding...
2. …: May be a problem if early success is not shown and constant…
3. Fear of…: Dennis’ fear of social evaluation may make it difficult..