Case Formulation in Assessment Reports
In clinical practice, case formulations are usually included in reports provided to psychotherapists and psychiatrists. They are usually not included in forensic, educational, and primary physician requested reports. Nevertheless, since psychologists and psychiatrists are our main referral source, case formulations should be included in your reports. Additionally, case formulations are an excellent tool for integrating assessment data and history information and developing a treatment plan, which is likely to be helpful.
The way you formulate the case will depend to a certain degree on your background and theoretical orientation. However, it is a good practice to write the case formulation without using jargon, since you cannot always assume that your reader has the same theoretical background as you. A nice way of writing case formulation, which allows you to avoid repetition, is to write it as your discussion section. On the most basic level, your case formulation should answer the questions of why does this person exhibit these symptoms at this time.
While a case formulation should be firmly based on test and historical data, keep in mind that it is always a theory. Therefore, the quality of your case formulation depends largely on how logical and coherent it is, how well it integrates all available data, and how well it is supported by the data. As is true about any theory, it can be tested by the effectiveness of proposed interventions.
A sample case formulation/discussion section outline.
1)Nature or physical parameters of the client (including heredity, pre-natal and developmental history, physical illnesses, injuries, medications, etc.).
2)Nurture or family and educational environment, traumatic events, social history.
3)Interactions between nurture and nature, producing individual’s coping and defensive style, areas of strength and vulnerability.
4)Current life circumstances and stressors.
5)How do client’s coping and defensive style in combination with circumstances surrounding onset and maintaining current illness produce observed symptoms.
6)What is the appropriate DSM-IV diagnosis justified by this constellation of symptoms.
7)Given all of the above, what would be effective interventions in this case.
A sample case formulation/discussion section.
Discussion and Recommendations:
The results of current assessment indicate that Ms. X’s receptive language and orientation are intact. Her memory, expressive language, attention, concentration, and executive functioning are mildly impaired. Her medical records document a similar pattern of deficits over the past five months. The interview revealed mild retrograde amnesia with typical gradient of better memory for more remote past and worse memory for more recent events. Ms. X’s test results indicate deficits that are quite typical of mild cortical dementia and consistent with the diagnosis of Dementia of Alzheimer’s type, Uncomplicated, With Late Onset.
Ms. X reported depressed mood, crying spells, fitful sleep, loss of interest and pleasure in activities she previously enjoyed and feelings of worthlessness and uselessness. These symptoms fulfill the diagnostic criteria for a mild depressive episode. However, Ms. X’s symptoms correspond to her loss of independence due to her move to a higher level of care and her adjustment difficulties and she is quite aware of this connection. The most appropriate diagnosis is, therefore, Adjustment Disorder With Depressed Mood. Ms. X is currently not amenable to taking medications for her mood, she prefers to change her environment. Some suggestions for behavioral management of her symptoms are offered below. If her symptoms become worse in spite of these interventions, I would suggest a referral to psychiatry and re-evaluation of appropriateness of psychotropic medications.
Ms. X’s attempts to engage the staff and other residents inappropriately, repeating herself and demanding attention, can be explained by her vain attempts to counteract her feelings of worthlessness and helplessness and to feel like she belongs. Her mild, but persistent paranoid ideation is a reflection of her feeling unsatisfied. Because of the significant deficit in executive functioning, Ms. X is easily overwhelmed and confused, which leads to a vicious circle of behaviors. An approximate chain of events may look like this:
(1)Ms. X feels depressed and worthless;
(2)to counteract that she goes to the staff or other residents to be reassured that she is valued;
(3)because of her tendency to become confused, especially in an emotionally vulnerable state, she approaches people inappropriately with impossible demands or repetitive statements about her importance, as in talking about her book;
(4)when people respond to these with denial or lack of interest, she feels more worthless and unvalued;
(5)she tries to reassure herself again, by repeating the same statements or demands;
(6)this irritates people and leads to the same or more irritable responses;
(7)she feels even more worthless and slighted and explains it to herself as the ill will of those around her, leading to mild paranoid ideation and mistrust.
Given this pattern of behavior, the best way to address Ms. X’s complaints and symptoms is to increase her sense of self-worth and being needed. When she approaches the staff, instead of responding to the content of her complaint, it may be more productive to address the underlying need. For example, when she starts following the staff demanding something, she can be told that the staff understands how important it is, and that the person is busy now, but would really appreciate her help with (insert the activity she can help with) or her suggestion about how she can solve the problem. As soon as the staff person will have time, which is going to be at such-and-such point, they will be happy to discuss her request with her.
Ms. X’s cognitive functioning remains in mildly impaired range since her initial MSE upon intake. However, her performance on similar tasks fluctuates a little. The pattern of her performance indicates that emotional factors are currently affecting her concentration and cognition. Ms. X is easily overwhelmed and confused by large amounts of information, especially if she is emotionally involved. Therefore, she is unlikely to understand complex explanations. She will respond better to short, simple sentences and an encouraging, supportive tone of voice. Structure and repetition are also likely to help. For example, her complaints about too many medications can be addressed by providing her with structure to understand them, as in a list of all her medications with the symptoms each of them is supposed to address and the times she is supposed to take them written in big, clear letters because of her visual problems. Her nurse practitioner can discuss this list with her and they both can sign it and place it on her wall or table. After that, the shift nurse can refer her to that list every time she has a question.
Maximizing Ms. X’s independence and sense of self-worth overall should decrease inappropriate attention-seeking behaviors. Volunteer work would be helpful for Ms. X. It would improve her self-esteem and provide an appropriate way of attracting positive attention. Maximum involvement in activities, including religion, physical exercise, entertainment and regular one-to-one support from staff would also serve to improve Ms. X’s adjustment. If she could be involved in helping staff with activities (setting up materials, etc), that would also help.
