CASE REPORTS OF CLINICAL PSYCHOLOGY-Ⅱ

Submitted To

Submitted By

Registration number

2019-GCUF-03671

Report submitted in partial fulfillment of

the requirements for the subject.

BACHALOR OF SCIENCE

IN

APPLIED PSYCHOLOGY

DEPARTMENT OF APPLIED PSYCHOLOGY

GOVERNMENT COLLEGE UNIVERSITY FAISALABAD

Table of Content
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Sr. No Title Page No.

1 Case 1 (Psychotic Patient) 1

Appendix
2 Case 2 (Patient of Depression) -
Appendix
3 Case 3 (Patient of Addiction ) -
Appendix
4 Case 4 (Childhood Disorder) -
Appendix
6 References
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Case Report 1
(Psychotic Patient)

Clinical Case Report (Format)

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Bio data

Name: (Initials) xx Age: xx

Father’s Name: (Initials) xx Gender: xx

Date of Birth: xx Examiner: xx

Assessment Dates: xx Case No: xx

Identifying Information

 Personal details (education, marital status, religion, family structure, income, siblings,
birth order, current address, parents’ education and occupations, language etc.)
Reason and Source of Referral

 Who referred (psychiatrist, general physician, clinical psychologist, court etc?)

 What was the purpose of referral?
Presenting Complaints

 Clients’ symptoms, complaints, problems etc. (write client’s verbatim)

Developmental History of the Problem

 History of current & past illness (intensity, severity, duration, and nature of illness)
 Reason of current illness (medical, psychological, social, events / incidences / causes
etc.)
 Risk factors (premorbid functioning, vulnerability, personality etc.)
Background Information

 Developmental History: information regarding developmental millstones e.g., 1st cry,

neck holding, crawling, walking etc., (in case of delay in developmental milestones as
per age norms; give sufficient details)
 Personal History: Client’s daily activities, hobbies, likes and dislikes, free time
activities.
 Family History: Family system, number of family members, any significant
information, family environment, interaction with family members, parental education
and occupation.
 Educational History: Schooling started at what age, school performance, interaction
with teachers and class fellows, favorite subject and games.
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 Social History: No. of friends, mode and frequency of hang-out with friends, client’s
view point about people around, others’ views about the client, any significant
information regarding socialization of the client.
 Occupational History: Duration of work, timing, working hours, relationships,
conflicts, interest in work, success/failure at work, environment etc.
 History of Drug Use/Abuse: (if applicable)
History of Psychiatric/ Medical Illnesses

 Any personal or family history of psychiatric illness, treatment details, effectiveness

of treatment given.
 Any personal or family history of chronic/terminal diseases, treatment and after-
effects of illness.
Psychological Assessment

 Behavioral Observation (i.e., general observation during assessment sessions)

 Interaction, communication, style, body language, participation, involvement,
motivation, resistance, behavior, appearance, hygiene, dressing etc.
 Mental state examination (If necessary)
 Psychological Testing
 Neuropsychological testing (Relevant tests)
 Intelligence testing (Relevant tests)
 Achievement testing (Relevant tests)
 Personality testing (Relevant tests)
 Other testing (If required)
 Medical testing (If necessary)
 Diagnostic testing (Relevant testing with detailed )
 Interpretation of Psychological Tests
 Quantitative and qualitative interpretation of the administered tests
 Provide brief but comprehensive interpretation of all conducted test (test
name, score, standard scores, level, relevant interpretation etc.)
 Informal testing
Case Formulation

Summarize all the contributing predisposing, precipitating, maintaining and protective

factors that lead to the current problem along with strengths and weaknesses of the client.
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Moreover, provide an understanding and psychological explanation of the problem. It should

include:

 Predisposing Factors: (e.g., genetic predisposing factors)

 Precipitating Factors: (e.g., parent’s death, conflict in the family, loss of social
support etc.)
 Maintaining Factors: (factors that may not have been involved initially in the
development of the problem, but help in maintaining the problem, e.g., parental
neglect, problem in school, client’s personal motivation etc.)
 Protective Factors: (factors that can help the client to cope with the problem, e.g.
client’s own easy temperament, family bonding etc.)
Give a comprehensive explanation of course, nature, and severity of psychopathology.

Tentative Diagnosis

 Diagnosis according to DMS-5

Prognosis

 Describe the factors, which make prognosis more better

Summary of the Case

Summarize the client’s problem briefly but comprehensively

Case Management and Treatment Plan (It is necessary only for MS Clinical Psychology)

 Case dynamics, causes and target symptoms

 Target goals
o Short term goals
o Long term goals
 Each session’s agenda
 Initial, middle and follow up phases of treatment
 Sessions detail
 Outcome of psychotherapy/Counseling
 Follow up plan
 Limitations ( dealing with client and achieving short and/or long term management
goals)
Recommendations
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Future suggestions regarding management of the client’s issues and follow up etc.
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Appendix A:
Permission Letter, Test Protocols
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