SECTION ONE OF CASE PRESENTATION PAPER

You will turn in two parts of this case presentation at two different due dates. The CASE PRESENTATION PAPER TEMPLATE and the INTAKE & DSM CHECKLIST can be found in the Welcome Module or Files.

The FIRST SECTION of the paper (worth 5% of your grade) is the background information for your subject (everything before the heading “EVALUATION RESULTS” on the template). Create your subject early so you have the subject in-mind throughout the course. I also ask you to do that so you will look ahead at DSM-5 criteria and prime diagnostic thinking.

The SECOND SECTION of the paper os worth 20% of your grade- THE EVALUATION SECTION of the paper is from “EVALUATION RESULTS” on. This section requires more thought and integration of information. YOU ARE ONLY ELIGIBLE TO TURN IN THE EVALUATION SECTION IF YOU RECEIVED A PASSING GRADE FOR SECTION ONE. I ask for this section later so you are formulating and integrating that information as you learn about specific DSM-5 diagnoses. TURN IN YOUR EDITED AND IMPROVED VERSION OF SECTION ONE WITH THE EVALUATION SECTION.

The case presentation paper for this course is modeled after a standard psychodiagnostic clinical assessment (except without testing results). To complete this assignment, you will have to create an imaginary subject that meets the criteria for two DSM-5 disorders. The criteria and background history will have to be consistent with those disorders. Make sure your subject meets sufficient criteria for only your two selected diagnoses. They can have a smattering of other symptoms, but none sufficient to meet a third diagnosis that you do not discuss in the paper.

The length of the paper must be between 10-15 double-spaced pages. An INTAKE & DSM-5 CHECKLIST is included in the FILES folder in Canvas. Use this tool to develop your paper content. Do not turn in the checklist nor cut and paste bulleted items into the paper. If you list DSM criteria in your paper, it must be in paragraph form.

To get started, download the CASE PRESENTATION PAPER template in the FILES folder in Canvas. Keep the headings and fill in that section with relevant subject information Delete highlighted instructions for the final draft of your paper.

If you start early and write a little each week, it will be easily accomplished and well-thought-out. This is a creative exercise. Make your subject interesting and believable. You must persuade me that the subject, in fact, meets the criteria for the diagnoses you select.

Please select no more than TWO DIAGNOSES per the following guidelines:

•DIAGNOSIS 1: Choose a Mood Disorder, Anxiety Disorder, Obsessive-Compulsive Disorder, Childhood Disorder, Psychotic Disorder, or Personality Disorder.

•DIAGNOSIS 2: Choose a Substance Abuse Disorder, Eating Disorder, or Sexual or Gender Identity Disorder.

Remember, you are making up a fake person (do not use someone you know). Keep it simple and have fun with it!

FORMATTING HINTS:

•This is a formal report; do not use bullet lists anywhere except in the recommendation & referrals and treatment plan sections. Write with the voice of a professional clinical psychologist. Only make evaluation conclusions when there is evidence and avoid using slang, clichés, or words that suggest moral judgment (e.g., “good” or “bad).

•Write in complete sentences “The subject reports” NOT “SUBJECT REPORTS”. (I insist you check it with GRAMMARLY before you turn it in).

•Refer to the person in your paper as “the subject” or “Mr. … or Mrs. …”

•Avoid referring to yourself in the report (i.e., don’t’ write “I”). If you must, refer to yourself as “the examiner”.

GRADING RUBRIC:

Grading considerations:

•Are all sections are complete?

•Is the information comprehensive, organized, and clear?

•Are the diagnoses well-evidenced with sufficient criteria?

•Is the summary comprehensive?

•Are the ethnicity and treatment sections creative and comprehensive?

•Are the goals and interventions clear, measurable, and detailed?

•Is the writing style grammatically correct with appropriate formatting – including numbered pages and of sufficient length?

•Is the paper creative and well-integrated?

Make up a letterhead from your fake private practice office. Number your pages.

** Follow the format presented here. Include & label each section. Remove my

notes and highlights in your draft. Keep in mind that you are going to have to

discuss therapy and ethnicity factors in the second part of your paper. Set

yourself up for success by including the factors you will have to address in these

sections within the description of your subject. Be sure to differentiate what your

client reported by using quotes from your subject or write tentative sentences like

“The subject reported that …”

BEFORE YOU TURN YOUR PAPER IN, RUN IT THROUGH GRAMMARLY TO

CORRECT SENTENCE STRUCTURES, MISSPELLINGS, AND

PUNCTUATION.

PSYCHOLOGICAL EVALUATION

Patient: Jane Doe Examiner: YOUR NAME

DOB: 01/01/01 Dates administered: 1/1/2020

This report may contain sensitive psychological information and is intended as a diagnostic or treatment aid for mental health, health,

legal, or academic professionals. Specific test scores included within it should not be released to the patient under any circumstances,

except by a qualified mental health professional. Patient access to such information may be deemed clinically inappropriate, as

covered by the Patient’s Access to Health Records Act (California Health and Safety Code, Sections 25250 through 25258) and Ethics

Code Standard 2.02 of the American Psychological Association’s Ethical Principles and Code of Conduct.

Reason for Referral

Jane Doe is a 32-year-old Hispanic female who was referred by . . . Mrs. Doe

reports her presenting problems to be . . . These problems have been present

intermittently/chronically since . . . In this section, you are introducing the reader to your

subject. Qualitatively describe the symptoms they are concerned about from the subject’s

point of view (not the referrer). Include a quote of several sentences from the subject in

the words you would expect them to use (subjects don’t use formal psychological terms

and don’t list criteria specifically). Keep this section brief. You can add some

information from a secondary source (referring doctor or relative) if it makes sense. This

is only the introduction (reader should start to get hypothesis from subject complaints

offered here).

Background Information

Background information was gathered from verbal reports provided by Mrs. Jane

Doe, verbal reports provided by her mother (current caretaker of the children), and

Ventura County Human Services records (records may also be from school, previous

psychological testing, police report, etc.). Do not add any other info here other than who

and what records provided info.

CURRENT LIVING/FAMILY SITUATION

Jane Doe lives in a rented house with . . . Complete this section including who

she lives with, ages, and occupations.

DEVELOPMENTAL HISTORY

Use this format replacing appropriate information. The subject’s birth history revealed a

normal, full-term pregnancy. Mrs. XX was XX years old when XX was born, and this

was her second pregnancy. Mrs. XX denied prenatal exposure to nicotine, alcohol,

medications, or street drugs. XX was born by planned c-section due to breech position

after no hours of labor. There was no indication of prenatal distress. XX was nursed for

three months, then formula fed because her mother returned to work. There were no

reported problems with eating, sleeping, or colic as an infant.

In regard to infant and toddler temperament, XX was described as having

“difficult” temperament, “average” sociability, “above average” insistence, and had an

“above average” activity level. Developmental motor and speech milestones were

reportedly reached within normal limits. She was toilet trained at 14 months with no

difficulty.

CHILDHOOD HISTORY

Start with a one- or two-sentence quote about how they described their childhood

overall. Add information about where they grew up, with whom, quotes about their

relationship with each family member, and any other relevant issues (history of abuse,

religion, socioeconomic status, etc.).

ACADEMIC HISTORY

How much school completed by subject? Private or public schooling? Their grades (gpa)

and if they applied little, average, or a lot of effort to obtain their grades. Any other

academic support – GATE, IEP, tutoring, etc.

SOCIAL & BEHAVIORAL HISTORY

How many close friends does the subject have? What do they like to do for fun? Are tehy

satisfied with their social life? Are they currently in an intimate relationship? What is the

quality of that relationship? Have they had prior committed relationships?

OCCUPATIONAL HISTORY

CURRENT AND PREVIOUS

MEDICAL & SUBSTANCE ABUSE HISTORY

Medical history showed no significant acute or chronic illness, brain injuries,

poisoning, or broken bones. Change this info as applicable. Model this section after the

developmental section with appropriate info like current and previous medical conditions

and treatment, meds, surgeries? Substance use? Be specific about types and doses.

PSYCHIATRIC HISTORY

Detail previous treatment or evaluation, psychiatric hospitalizations, & family

psychiatric history of first-degree relatives.

Evaluation Tools and Instruments (you can keep this as is or add to it if you’d like)

Clinical Interview

Physical Complaints Checklist

Review of Records

Self-Rating Symptom Checklist

Mental Status Exam/Behavioral Observations

You can copy and paste this as is, but change information as applies to your case. (It’s

not plagiarism if your professor provides it for you and asks you to cut and paste it.)

Mrs. Doe is a Hispanic female of average height and weight. She was clean, well

groomed, and casually dressed for each testing session. Throughout testing she was

oriented to time, person, place, and situation and was cooperative with euthymic mood

and congruent affect. She spoke with an average tone and pace without abnormal speech

or neologisms. She denied current or past visual or auditory hallucinations or homicidal

or suicidal ideation. There was no evidence of psychotic thought process such as

cognitive slowing, poor thought organization, poverty of content of thought, delusions,

tangentiality, or visual or auditory hallucinations. She appeared to be of average

intelligence without significant memory impairment.

Overall, the subject displayed fair judgment and insight during testing. She appeared to be honest, but guarded and overly concise in her disclosures, demonstrating little affect despite topic of discussion. She voluntarily signed consents for the examiner and made the necessary arrangements in her work schedule to complete several sessions of testing. She was punctual for each appointment.