Case Formulation and Treatment Plan
The student will be required to provide a DSM-5 diagnosis, a treatment plan and a summary integrating evidence-based literature and justifying the treatment plan the student developed for the client. The student will also cross reference the diagnosis with the DSM 5 and note patient symptoms matching criteria.
AB is aged 22 years Caucasian female divorced with no kid, employed part time, full time med school and cares for her mother who has stroke.
History: AB has no significant past medical history. She was moderately depressed following her mother MI attack 5 years ago and was offered antidepressants but declined them. She was referred for five sessions of counselling, which led to some improvement in her symptoms.
On examination AB complains of feeling ‘stressed’ all the time and constantly worries about ‘anything and everything’. She describes herself as always having been a ‘worrier’ but her anxiety has become much worse in the past 6 months since her mother condition is becoming worse with little improvement, and her school work is overwhelming, and she no longer feels that she can control anything.
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When worried, AB feels tension in her shoulders, stomach and legs, her heart races and sometimes she finds it difficult to breathe. Her sleep is poor with difficulty getting off to sleep due to worrying and frequent wakening. She feels tired and irritable. She does not drink any alcohol.
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