Ms. Smith is a 32-year-old, biracial female of average height and petite frame. She appeared her stated age, arrived at the evaluation agitated and dressed in clothes that may have been slept in. She was polite and cooperative at one moment and then sarcastic or argumentative the next during the evaluation. Ms. Smith is left-handed. When challenged she would response with explosive anger, then retrack with an apology and body language that expressed guilt or remorse. Attention and concentration were slightly impaired. Ms. Smith’s thought processes were connected, while logic applied to decision making was not always coherent. Ms. Smith’s eye contact during the evaluation was dependent on her mood.
Regarding her motor functioning, there are no apparent abnormalities. No evidence of impaired vision or hearing was present during this evaluation. Ms. Smith did not demonstrate any difficulties with speech and appeared to demonstrate the ability to both understand and express the English language without notable exceptions. The content of her thought was occasionally tangential, moving off topic to the discussion of Frank, or to make personal inquiries directed at getting to know Dr. Liam. Her preoccupation with being abandoned does not appear to reflect paranoid thinking. Her affect shifts rapid, contingent on topic of the discussion. She did not report hallucinations or delusions. Ms. Smith’s gait and pace reflected shifts in mood throughout the session. She did express suicidal but not homicidal ideation.
STEP 2: Draft a Case Conceptualization
Apply cumulative knowledge from this course and others (i.e., abnormal psychology) to diagnosis Ms. Smith, support your diagnosis with evidence from the case and recommend further assessment and treatment options. Your paper should consist of the following sections:
Title Page
Part I: Reason for Referral
What was the reason for the referral?
What sources of data do you have and need?
Part II: Background Summary
Family/Social, (supports) Include ethnic/racial/cultural
Medical/ developmental
Educational/occupational (hobbies)
Behavioral observations
Part III: Assessment Data
Assessment:
1. In addition to a good diagnostic interview, what assessment tools would you recommend using to aid in giving an accurate diagnosis and developing a treatment plan?
Part IV: Tentative Diagnosis
Select a diagnosis using the DSM-5
Defend which diagnosis/diagnoses are possible using specific examples from the case.
Part V: Treatment Recommendations
Consider which treatment would be the ethical choice (community, group, referral to a forensic psychologist, psychiatrist, physician or for a neuropsychology evaluation).
Provide one or two Evidence Based Treatment recommendation for the diagnosis given. Be sure to cite the source that helped you to determine the best Evidence Based Treatment for this diagnosis.
Part VI: Considerations
Clearly present your analysis of developmental, sociocultural, and ethical considerations that contribute to the diagnosis and treatment recommendations made.
1. Developmental Considerations
2. Sociocultural Considerations
3. Ethical Considerations
Part VII: Conclusion
Conclude with a summary of your findings.
Part VIII: References
Your paper should be 6 pages in length. Use APA style headings and subheadings, double-spacing, an appropriate serif or sans serif font (e.g., Times Roman 12-point; Arial 11-point; Calibri 11-point), one-inch margins (left, right, top, and bottom), page numbering, and logical flow from topic to topic. Write with clarity, paying attention to spelling, grammar, and syntax.
