patient case formulation report example

What should be included in a case formulation?

With ongoing consent of the client, it should be used as a guide for treatment planning and clinical decision making. A case formulation should provide a coherent summary and explanation of a client’s symptoms and problems. It should include the following components (Persons, 2008):

Why is case formulation important in the recovery process?

While team formulations of clients’ difficulties enable be important in the recovery process. Moreover, it can help the client and the clinician to make choices about care that maximize the potential usefulness and effectiveness of interv entions. process of collaborative case formulation with the client. supporting them.

What is an informed case formulation?

Case formulation is a core clinical skill that links assessment information and treatment planning It is a hypothesis about the mechanisms that cause and maintain the problem It answers the question, “Why is this person, having this type of problem, now?” DSM-5 Informed Case Formulation Process

How to write a patient case analysis?

Your patient case analysis is an investigation of a medical plight or case. When you present your findings, you have to balance the description of the situation and the detailing of the analyses. You have to illustrate how and why you came to a conclusion by providing the necessary background information.

How do you write a case formulation report?

4 Things to Include in Your Case FormulationSummary of the client's identifying information, referral questions, and timeline of important events or factors in their life. ... Statement of the client's core strengths. ... Statement concerning a client's limitations or weaknesses.

What is a case formulation example?

Formulation in a Nutshell Examples include genetic (i.e. -family history) predisposition for mental illness or prenatal exposure to alcohol. Precipitating factors are typically thought of as stressors or other events (they could be positive or negative) that may be precipitants of the symptoms.

What is included in a case formulation?

We broadly defined a case formulation as a hypothesis about the causes, precipitants, and maintaining influences of a person's psychological, interpersonal, and behavioral problems. The approach views a case formulation as a tool that can help organize complex and contradictory information about a person.

What are the 5 ps In formulation?

What should a formulation comprise? The 'Five P's' approach to formulationPresenting problem. ... Predisposing factors. ... Precipitating factors. ... Perpetuating factors. ... Protective/positive factors.

What is a formulation report?

A formulation is a joint effort between you and the psychologist to summarise your difficulties, to explain why they may be happening and to make sense of them. It may include past difficulties and experiences if these are relevant to the present. It acknowledges your strengths and resources.

How do you write a formulation?

It should always include the following: (1) a discussion on the diagnosis (2) aetiological factors, which seem important, as well as taking into account (3) the patient's life situation and background, with (4) a plan for treatment and (5) an estimate of the prognosis.

What is case formulation in nursing?

• Case formulation is a framework that informs a choice of psychological treatments. and links assessment and treatment phases to guide practitioners and individuals on treatment options.

What is the difference between Case formulation and case conceptualization?

Case conceptualization will be referred to as the explanation for a client's presenting problems. Case formulation will reference the process by which a case conceptualization is developed or formed.

What is formulation CBT?

Formulation enables the therapist to identify where the strong links are between thoughts, feelings, behaviours and physical symptoms, and the specific things that need to change for the patient to feel better.

Is the 5Ps a CBT formulation?

The 5Ps is however commonly associated with the CBT model, in line with Johnstone and Dallos (2014). Therefore, for our example, I will use this Biopsychosocial idea and draw on a range of different underpinning approaches, however coming predominantly from a CBT perspective.

What is a patient case study?

Writing Your Patient Case Study. Since patient case studies are generally descriptive, they are under the a phenomenological principle. This means that subjectivity is entertained and allowed in research design. The medical scenarios are open to the researcher’s interpretation and input of insights.

How do case studies make a difference in the medical arena?

Patient case studies make a difference in the medical arena by reporting clinical interactions that can improve medical practices, suggest new health projects, as well as provide a new research direction. By looking at an event as it exists in the natural setting, case studies shed understanding on a complex medical phenomenon.

What is a case study?

Case studies are a qualitative research method that offers a complete and in-depth look into some of the situations that baffled medical science. They document the cases that escape the ordinary in a hospital that has seen a manifold of plights. They serve as cautionary tales of the intricacy in dealing with human health.

Why do medical practitioners use case studies?

Medical practitioners use case studies to examine a medical condition in the context of a research question. They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. The following are case study samples and guides on case presentation.

Can you generalize a population using one case study?

You cannot generalize a population using one case study. However, multiple case study contains two or more cases under the point of interest can give you a replicated result. When the findings remain true for several cases under this research method, your case study’s results become more reliable.

Should you look into all possible explanations for a medical condition?

You should look into all of the possible explanations for the medical condition at hand. If a plight can be explained by more than one reason , then you have to look into the less obvious but similarly compelling explanations. Make your case study as informative as possible.

Is a clinical interaction report valid for generalization?

Since it documents stand-out clinical interactions where a single person or a few number of people are a party of, the findings may not be valid for generalization for a wider population.

How to develop a case formulation?

To develop a strong case formulation, the following steps are recommended (Persons, 2008): 1 Conduct a thorough assessment to determine the presence of specific diagnoses, symptoms, and problems. It’s important to create a list of all of the client’s presenting symptoms and problems in various areas and life domains (i.e., panic attacks, excessive worry, low mood, poor academic performance, relationship difficulties). 2 Develop an initial case formulation based on tentative or “working” hypotheses about:#N#Factors that predisposed the client to develop the symptoms and problems#N#Factors that precipitated the most recent episode#N#Maintaining factors#N#Protective factors 3 Set up experiments to test out the initial case formulation. The results of these tests will confirm or disprove hypotheses about factors that cause or maintain the client’s symptoms and problems. For example, a therapist may use a thought record to test out whether a client’s procrastination stems from perfectionistic beliefs, which may reveal that procrastination or difficulty initiating tasks is instead due to thoughts of hopelessness. The case formulation should be revised based on the results. 4 The case formulation should continue to be tested and revised throughout treatment with the goal of targeting mechanisms involved in the onset and maintenance of the client’s symptoms and problems. With ongoing consent of the client, it should be used as a guide for treatment planning and clinical decision making.

Why is case formulation important?

A case formulation is an invaluable tool for highlighting how a client’s problems and symptoms are related. It aids the therapist in accurately identifying and targeting underlying psychological mechanisms with increased efficiency, leading to improved therapeutic outcomes

Why do therapists use thought records?

For example, a therapist may use a thought record to test out whether a client’s procrastination stems from perfectionistic beliefs, which may reveal that procrastination or difficulty initiating tasks is instead due to thoughts of hopelessness. The case formulation should be revised based on the results.

What is collaborative formulation?

collaborative formulation process that may encourage a sense of self-agency that is likely to. be important in the recovery process. Moreover, it can help the client and the clinician to make.

What is the combination of clinical psychology and research training?

Objectives: The combination of clinical psychologists' therapeutic expertise and research training means that they are in an ideal position to be conducting high-quality research projects. However, despite these skills and the documented benefits of research to services and service users, research activity in practice remains low. This article aims to give an overview of the advantages of, and difficulties in conducting research in clinical practice. Method: We reviewed the relevant literature on barriers to research and reflected on our clinical and research experiences in a range of contexts to offer practical recommendations. Results: We considered factors involved in the planning, sourcing support, implementation, and dissemination phases of research, and outline suggestions to improve the feasibility of research projects in post-qualification roles. Conclusions: We suggest that research leadership is particularly important within clinical psychology to ensure the profession's continued visibility and influence within health settings. Practitioner points: Clinical implications Emerging evidence suggests that clinical settings that foster research are associated with better patient outcomes. Suggestions to increase the feasibility of research projects in clinical settings are detailed. Limitations The present recommendations are drawn from the authors' practical experience and may need adaptation to individual practitioners' settings. This study does not attempt to assess the efficacy of the strategies suggested.

Is formulation a part of therapy?

Formulation is widely considered a critical component of psychological therapies, and is thought to have a number of benefits both for the therapeutic process and the client directly. However, the evidence base supporting formulation and its possible interventive capacity is limited, and there is little empirical evidence exploring how clients perceive formulation as part of therapy. Work with the client described in this single case report provided an opportunity to explore the use of formulation as intervention and evaluate ways in which it may or may not prove helpful by interviewing the client directly about her experience of the process. Implications for further research on the use and outcomes of formulation are discussed.

What is the cross sectional view of a case?

Thecross-sectional view of the case formulation includes observations of thepredominant cognitions, emotions, behaviors (and physiological reactions ifrelevant) that the patient demonstrates in the “here and now” (or demonstratedprior to making substantive gains in therapy). Typically the cross-sectional viewfocuses more on the surface cognitions (ie., automatic thoughts) that areidentified earlier in therapy than underlying schemas, core beliefs, orassumptions that are the centerpiece of thelongitudinal view described below.

What are some examples of precipitating events?

A typical example is a depressive episode precipitated bymultiple events, including failure to be promoted at work, death of a closefriend, and marital strain. In some cases (eg., bipolar disorder, recurrentdepression with strong biological features) there may be no clear psychosocialprecipitant. If no psychosocial precipitants can be identified, note any otherfeatures of the patient’s history that may help explain the onset of illness.

What is case formulation in therapy?

Early in treatment the therapist develops an initial working case formulation that guides initial treatment planning, gives the patient enough information to provide informed consent to treatment, and helps the patient engage in treatment. However, a complete and fully elaborated case formulation typically is available only after treatment has begun and further information is collected, including information from progress moni-toring, described later. In fact, the formulation is a hypothesis and is subject to constant testing and revision as information gathering and treatment go forward.

What is the function of formulation?

The function of the formulation is to guide effective treatment (S. C. Hayes, Nelson, & Jarrett, 1987). A key way the formulation guides treatment is by identifying the targets of treatment, which are generally the mechanisms that the formulation proposes are causing the symptoms. In the case of a formulation like the one above for Jon, which is based on Beck’s cognitive theory, the treatment targets are the schemas, automatic thoughts, and maladaptive behaviors that the cognitive model views as mechanisms causing and maintaining patients’ symptoms. In contrast, a formulation based on Lewinsohn’s behavioral theory (Lewinsohn, Hoberman, & Hautzinger, 1985) identifies deficits in social skills and a dearth of pleasant activities as treatment targets.

What is the purpose of data collection in chapter 9?

Chapter 9 describes this part of therapy in detail. Data collection allows patient and therapist to answer questions like the fol-lowing:

What are the three levels of formulation?

Formulations are developed at three levels: case, disorder or problem, and symptom. The three levels are nested. A case consists of one or more disorders/problems, and a disorder consists of symptoms. Thus, a case-level formulation generally consists of an extrapola-tion or extension of one or more disorder- and symptom-level formulations.

How does a therapist collect data?

The therapist collects data from multiple sources, including the clinical interview, self- report scales, self- monitoring data provided by the patient, structured diagnostic interviews, and reports from the patient’s family members and other treatment providers.

Do patients respond to ESTs?

Many patients do not respond to the ESTs. For example, 40 to 50% of patients who receive CBT for depression in the randomized controlled trials fail to make a full recov-ery by the end of treatment (Westen & Morrison, 2001). The only guidance the ESTs provide in this situation is the suggestion to attempt another EST. However, they do not offer any guidance about which EST is most likely to be helpful.

Background information

Rose grew up in a working class family; however, her mother worked at home as a child-minder due to enduring agoraphobia. Rose’s father also had chronic depression but he “never spoke about it”, giving the impression that the family would not openly discuss their mental health problems.

Resources and strengths

The assessment also explored Rose’s resources and strengths, which included support from her immediate family, some close friends, and “happy-go-lucky” individual characteristics. At times, Rose has been able to experience “better days” or periods when her thoughts appear more positive and solution-focused.

Current Diagnosis

Rose met the criteria for severe depressive disorder with associated anxiety without psychotic features (American Psychiatric Association, 2000), with two key issues of suicidal ideation and relationship difficulties.

Risk Assessment

Rose reported frequent “memory loss”, a feature related to avoidance for traumatic and emotionally challenging memories (REF here), but also connected to the amount of ECT courses she has received throughout life (REF here, e,g NICE). This is an area that needs further assessment.

Formulations

Using the information gathered during assessment and the definition agreed for this paper, Rose’s case was formulated from three different theoretical perspectives as discussed below.

Overview

The metacognitive model was developed by Wells (1995, 1999) and founded in the theory of self-regulation in psychological disorder (Wells & Matthews, 1994, 1996). This model aims to clarify the function of metacognitive evaluation and worry control in the maintenance of pathological worry and anxiety (Fisher & Wells, 2008).

Metacognitive formulation for anxiety and Depression

The metacognitive formulation represents the “here and now” of psychological disorder and is interested in its maintaining factors. The aim is to identify the faulty style of thinking through a person’s meta-beliefs and ruminating style, and address these in therapy (Wells, 2009).