Running head: CASE FORMULATION FOR XXX

Case Formulation for XXX

Wan Nada Marhamah binti Wan Abd Razak 1223866

PSYC 4240 Clinical Psychology

Dr. Mimi Iznita binti Mohd. Iqbal

Semester: 1, 2016/2017

Department of Psychology

Kulliyyah of Islamic Revealed Knowledge and Human Sciences

International Islamic University Malaysia (IIUM)

1. Identify the 4Ps (predisposing precipitating, perpetuating, protective) in the case.

a) Predisposing factor is Ct.’s parenting that, taught Ct. to be competitive and everybody is his

competitor. The high expectation of the parents on Ct. also can be the predisposing factor, as he

feels he constantly needs to fulfill his parents’ expectation.

b) Precipitating factor is the upcoming major swimming competition and sleep difficulties.

c) Perpetuating factor is his perception of other people as his adversaries that make him

developed only a few friends.

d) Protective factor is becoming a prankster to hide his loneliness.

2. Prepare a treatment plan for this Ct. Outline the goals of treatment and the weekly

sessions. Please use the document I provided in Italeem as a guide.

Treatment Plan for XXX

Diagnosis

Generalized Anxiety Disorder

Strengths and Weaknesses

Strengths:

Obedience towards parents, athletic and perseverance

Weaknesses:

Lacking in interpersonal skills and having difficulties to self-disclose

Treatment Modality

CPT Code Type Frequency

90806 Individual Psychotherapy Weekly

90847 Family Therapy Monthly

Treatment Approaches:

Cognitive Behavioral Therapy (Applied Relaxation, Cognitive Restructuring and

Breathing Retraining Techniques)

Presenting Problems

Anxiety

Speech problems (will not be directly addressed in psychotherapy at this time)

Treatment Plan

Generalized Anxiety Disorder

Behavioral definition

 Symptoms of motor tension (shakiness, restlessness)

 Symptoms of hypervigilance (sleep-onset insomnia and frequent awakening)

 Irritability (nervousness, dizziness and worrying)

 Speech problems

Long term goals

  Reduce overall level, frequency, and intensity of the anxiety so that daily

functioning is not impaired.

 Resolve the family conflict that is the source of anxiety

 Improve interpersonal communication skills

Short-Term Objectives/Therapeutic interventions

 Appropriate use of relaxation activities

 Train in guided imagery, deep breathing, and progressive muscle relaxation

for anxiety relief and to temper sleep difficulties

 Prescribe practice of relaxation techniques at least twice daily

 Increase daily pleasurable activities

 Exploring the past event that influence the development of anxiety

 Identifying the beliefs or past event that contributed to development of

anxiety

 Assessing what are the signs that can bring the worry feeling

 Using cognitive restructuring to assist in replacing the negative thoughts

with positive thoughts

 Identify the source of conflict in the family

 Help the parents to understand how their expectations to children can make

the children become pressured

 Assist family members to use effective communication skils

 Assist to improve interpersonal skills

 Assist clients to do communication more openly and effectively

  Educate the client in what are the matters that can be self-disclose on and

what are not.

 Guide to improve interpersonal skills by modelling behaviors that can make

client communicate effectively

Prognosis

Prognosis rating of successful achievement of goals: Excellent

Rationale for Prognosis Rating: Client’s perseverance quality make him well motivated

to follow the treatment plan

_______________________ 9th December 2016_____

Wan Nada Marhamah Wan Abd Razak Date

Trainee

________________________ 9th December 2016_____

Dr. Mimi Iznita Mohamed Iqbal Date

Clinical Psychologist
 References

Borkovec, T. D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive-behavioral

therapy in the treatment of generalized anxiety disorder. Journal of consulting and clinical

psychology, 61(4), 611.

Butcher, J. N., Hooley, J. M. & Mineka, S. (2015). Abnormal Psychology. USA: Pearson

Education Limited.

Dugas, M. J., Francis, K., & Bouchard, S. (2009). Cognitive Behavioural Therapy and

Applied Relaxation for Generalized Anxiety Disorder: A Time Series Analysis of Change

in Worry and Somatic Anxiety. Cognitive Behaviour Therapy, 38(1), 29–41.

Trull, T. J., & Prinstein, M. J. (2013). Clinical Psychology. USA: Wadsworth Cengage Learning.