The first of two assessment tasks in Adult Psychopathology is a written report containing an assessment, a formulation and a treatment plan. You will use your knowledge of and skills in: assessment and diagnosis of common adult mental disorders; formulation; treatment planning and; reviewing the relevant treatment literature. Part (a) will be in the form of a clinical report containing assessment,formulation and treatment plan, part (b) will be in the form of a literature review. The task is detailed below, case material will be supplied separately.
Referencing: APA 7 th for second section
Clinical report (part a maximum 1500 words) This section must be structured as a clinical report containing the following sections:
Client Details Section
Date of birth:
Date(s) of assessment:
Reason for referral:
Methods of assessment:
History of presenting problem:
A bio psychosocial formulation which integrates predisposing, precipitating
perpetuating and protective factors.
Diagnosis according to DSM-5 with principal diagnosis(es) identified, sub types and specifiers mentioned along with any differential diagnoses discussed and co-occurring diagnoses. Any symptoms that don’t meet case level but will be the focus of treatment should also be identified.
Details of any further assessment strategies you would take to clarify provisional or differential diagnoses.
1.A set of biological, psychological and social recommendations including any interdisciplinary work that is necessary.
2.An outline of how you will explain the diagnosis and its cognitive, behavioural, emotional and physiological (including neuro biological) components.
3.An outline of how you will explain the treatment including how the psychological treatment will be combined with any pharmacological treatment that might be prescribed.
4.An outline of 6-10 treatment sessions for the disorder(s) you have diagnosed which includes procedures for any symptom monitoring during treatment and at the conclusion of treatment.
Clinical report (part b maximum 1500 words) This section must be structured like a literature review and cover the following areas with referencing:
- A discussion of the conditions(s) you have diagnosed, the main treatments available and if you wish, an alternative formulation.
- Consideration of why you have chosen the treatment (s) for this client.
- A review of the evidence there is to support the treatment you have chosen
FIRST ASSESSMENT TASK CASE MATERIAL
Siu Ling was referred to you by the GP she saw at the large bulk billing medical clinic (Dr. Richard Youseff) that she has attended since moving to Melbourne for study five years ago. Richard supplied limited information in the referral letter but noted that Siu Ling usually saw a female GP when she could but who was on leave at the moment. Records showed she was always punctual and well-presented but whilst cooperative, was usually reserved and more so lately. She has been treated for painful, heavy bleeding during her periods and iron deficiency using pain medication but there is no
note of misuse or illicit substance use. Siu Ling had been referred to a psychologist a psychologist two years ago after the breakup of her first sustained relationship with a young man in her course, there is no record of her attending the psychologist though. She is a 26-year-old (DOB: 03/04/1996) engineering student at a Melbourne university where she is doing her final year of engineering this year after COVID disrupted her
study last year and she had to repeat some subjects in 2019.
Siu Ling feels she has coped well with studying from home, has always been proud of her academic achievements and thinks her family has been too. She was disappointed at having to repeat some subject in 2019 then during lock down in Melbourne she couldn’t visit her family and didn’t see many people socially as she lived on her own in a small apartment. She has been worrying more than usual about returning to face to face lectures and tutorials after the mid-semester break. She misses her family who have
told her she has seemed down and less confident since the breakup. She misses her father in particular and worries about the family’s capacity to support her financially. Siu Lin recently left a job interview abruptly after feeling faint, unsteady and short of breath,after this she decided to seek some help in an attempt to ‘make things better’.
Sui Ling was born in Perth, where her mother and two younger siblings live, her father has been unable to return to Australia after visiting his elderly parents in China last year.She thinks her mother had depression after her surgery and her father had a heart attack eighteen months ago. When asked about how things were when she was growing up, Siu Ling says she got on OK with everyone in her family though they had no extended family nearby. School work was easy and she had a small group of friends that she tagged along with but did what she could to avoid the spotlight as a teenager. She is sure about her gender identity and sexual orientation but recalls usually feeling uncomfortable at parties or informal social gatherings. She worried mainly about what others would think of her at events and on one occasion had to leave the party quickly with shortness of breath and heart palpitations and increased sweating. She had
sometimes felt nervous about leaving home to go to school as a child and during year seven she had about a month where she didn’t go to school at all whilst here mother was home recovering from surgery after cancer.
At university, she has focussed mainly on her studies and had group of friends who were mainly international students but most had to return home midway through last year leaving her with limited support.
Richard’s letter notes that Siu Ling reported feeling down for ‘a long time’ despite reasonable appetite and physical health. She also acknowledged trouble staying asleep, concentrating and difficulty making decisions but he doesn’t ask how long these had been a problem. With restrictions gradually lifting over the last six months, she sees her few friends in their homes but has avoided almost all other social situations and doing her shopping late at night. Siu Lin assured Richard that she would never harm herself despite her distress. He administered the K 10 and got a score of 28 and suggested she see you as well as considering taking an anti-depressant to help with her worry.
At interview, Sui Lin appeared hesitant and perplexed though cooperative and adequately oriented to place and time. She paused to consider questions before responding and was vigilant for cues from the examiner but thought stream was logical.Thought content involved distortions about self-worth, scrutiny of others in social settings and loss, affect was mildly restricted, she appeared tired but showed some insight and good judgement.