Case Study

Case Study Assignment: overview, instructions and grading rubric

The purpose of this assignment is for you to practice applying what you are learning about mental health diagnoses, the diagnostic process, and infusing counseling principles into diagnosis. Accordingly, you will analyze ONE case and engage in the diagnostic process for the assigned case. Arriving at the correct diagnosis is not necessarily the key in this assignment; rather, the process of thinking through each case is what this assignment is about. To that end, be thorough in your analysis of the case.

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Please see the detailed Grading Rubric for this assignment in the Appendix at end of this document. The Grading Rubric can also be found in the Appendix at the end of the Course Syllabus.
Analyze the case provided by your Professor in Canvas in an 8-page (minimum) paper. You do not need a cover page or references, and strict adherence to APA style is not necessary. You can also use first person language as needed. Your paper should have sections that address the following topics (minimum 1 double-spaced page per section):
• Relevant symptoms: What psychological, emotional, social, or biological/physiological symptoms do you observe while listening to the case? In this section, don’t just list symptoms; you need to cluster symptoms according to DSM-5 disorder criteria (think criterion A for various disorders). Also make sure to be specific; for example, “anxiety” and “feeling anxious” are not symptoms, but feeling on edge, worrying, shaking, etc. might be. Finally, discuss any relevant cultural considerations/issues that could be impacting the case.
• Substance/medical etiology: Discuss any relevant substances, medications, or medical conditions that could explain the symptoms from the previous section. If possible, rule out any substance/medication-related or medical diagnoses and clearly explain why you would rule them out. If these diagnoses cannot be ruled out, justify why this is the case.
• Stressors/Clinical History: Identify any potential stressors that occurred in relation to symptomology; if there are any, do they explain the symptoms and why/why not? Discuss the timeline of symptoms to the extent possible, including when the symptoms began, how long they last, and the frequency at which they come and go. Note that timelines may vary for different sets of symptoms. If there are gaps in the clinical history, note them as well.
• Diagnostic impression: Offer a DSM-5 diagnosis (you can offer more than 1), including DSM-5 code numbers, relevant subtypes and/or specifiers. Also include the ICD code numbers and the impact of utilizing the DSM version compared to the ICD version on billing and epidemiological disease monitoring. Clearly justify your diagnoses by linking the symptoms to the DSM-5 criteria and to the clinical history. Make sure to address clinically significant distress and/or functional impairment caused by symptoms for each diagnosis offered.
• Rule Outs and Differential Diagnosis: What are potential competing mental health diagnoses for this client that you can definitely rule out based on what you observed? What are potential mental health diagnoses for this client that you cannot yet rule out, but would need to rule out if you continued working with this client? Make sure to justify both in the context of the symptoms you listed and what remains missing from the clinical picture.
• Case conceptualization: How is it that this person came to have these particular problems? What prevention efforts might have mitigated these problems? Where are these problems stemming from (e.g., intrapsychic issues, early relationships, learned behaviors, faulty cognitions)? What cultural factors are relevant to this person’s problems? What ethical and legal considerations specific to clinical mental health counseling might be at play here? What are this person’s strengths? You are encouraged to utilize counseling theory to inform this section.
• Treatment recommendations: What type of intervention/treatment would you implement with the client? What crisis intervention models would have been helpful and when? If you were working with this client, what would be your treatment goals be? Which counseling theories would you draw upon to help this client? Why? Would the person benefit from psychotropic medications? Why or why not?
• Prevention, Crisis Intervention, and Medication Approaches: What prevention, crisis intervention AND medication strategies would you think would be useful for this client and pertinent to the diagnosis and client’s symptoms?
• Personal reactions: What are your personal reactions to this case? What was it like for you to try to diagnose this case? What was easy for you and what was more of a struggle with this case study? Moving forward, what can you do to get stronger with diagnosis?

Grading Rubric for Case Study Assignment (Maximum: 20 points)

Met (2) Marginal (1) Not Met (0)
Relevant symptoms
[CMHC 5. C. 2. d. ] Identifies the most relevant symptoms and cultural factors pertaining to disorders present. Identifies many relevant symptoms and cultural factors pertaining to the disorder, but also includes several non-relevant symptoms. Identifies few or no relevant symptoms or cultural factors pertaining to present disorders.
Substance/Medical Etiology
[CMHC 5. C. 2. B] Discusses the most relevant substances, medications, and/or medical conditions and justifies any rule outs. Discusses some relevant substances, medications, and/or medical conditions, but also includes some non-relevant ones as well OR contains minor inaccuracies in justification of rule outs. Discusses few or no relevant substances, medications, and/or medical conditions OR contains major inaccuracies in justification or rule outs OR no discussion of rule outs.
Stressors/Clinical History
[CMHC 5. C. 2. d.
CMHC 5. C. 2. b
CMHC 5. C. 2. g
CMHC 5. C. 2. j.] Identifies relevant stressors (if any) and their relation to symptoms AND provides an in-depth discussion of clinical history. Identifies some relevant stressors (if any) but also includes non-relevant ones OR does not link stressors to symptoms OR offers a brief discussion of clinical history. Identifies stressors (if any) that bear no resemblance to the correct ones OR offers not discussion of clinical history.
Diagnostic impression
[CMHC 5. C. 2. d. ] Identifies correct diagnoses including DSM-5 and ICD code numbers, relevant subtypes and/or specifiers, along with justification. Identifies correct diagnoses, but not code numbers OR relevant subtypes and/or specifiers OR identifies diagnoses that are close to the correct ones. Identifies diagnoses that bear no resemblance to the correct ones.
Rule Outs and Differential Diagnoses
[CMHC 5. C. 2. d.
CMHC 5. C. 2. b
CMHC 5. C. 2. g] Identifies other disorders that are the “chief rivals” of the correct diagnosis/ disorder AND clearly justifies why disorders can/cannot be ruled out. Identifies other disorders that are much less likely to rival the correct diagnosis/disorder OR does not clearly justify why disorders can/cannot be ruled out. Identifies other disorders that are not at all likely to rival the correct diagnosis/disorder OR does not justify why disorders can/cannot be ruled out.
Case Conceptualization
[CMHC 5. C. 2. b
CMHC 5. C. 2. g
CMHC 5. C. 2. j. ] Provides a clear, theory-based discussion of symptoms, prevention, cultural, and strengths-based factors. Provides a theory-based discussion of symptoms, prevention, cultural, and strengths-based factors with minor inaccuracies. Does not discuss symptoms, prevention, culture, or client strengths OR does not integrate counseling theory or integrates theory incorrectly.
Treatment recommendation
[CMHC 5. C. 2. l. ] Identifies clear, ethically informed, treatment interventions, goals, and theory-based approaches that are reasonably connected to the diagnoses and symptoms. Identifies treatment interventions, goals, and theory-based approaches that are tentatively connected to the diagnoses and symptoms. Identifies treatment interventions, goals, and theory-based approaches that are not at all connected to the diagnoses and symptoms OR does not identify interventions, goals, or theory-based approaches.
Prevention, Crisis Intervention, and Medication Approaches
[CMHC 5. C. 2. l.
2. F. 5. m. ] Identifies clear prevention, crisis intervention, and medication strategies that are reasonably connected to the diagnoses and symptoms. Identifies prevention, crisis intervention, and medication strategies that are tentatively connected to the diagnoses and symptoms. Identifies prevention, crisis intervention, and medication strategies that are not at all connected to the diagnoses and symptoms OR does not identify prevention, crisis intervention, and medication strategies.
Personal reactions Applies the case to their own professional development, identifies personal strengths and limitations related to counseling diagnosis. Offers remarks regarding impression of the case, but does not incorporate these details into their own professional development. Does not address their own professional development or reactions to the case.
Grammar/
Quality of writing Offers a concise yet thorough analysis of the case. Writing is free from grammatical errors. Offers an application of the case OR writing contains some grammatical errors. Summarizes but does not analyze the case OR writing contains multiple grammatical errors.

Total Points:
Met (2) Marginal (1) Not Met (0)
Relevant symptoms
[CMHC 5. C. 2. d. ] Identifies the most relevant symptoms and cultural factors pertaining to disorders present. Identifies many relevant symptoms and cultural factors pertaining to the disorder, but also includes several non-relevant symptoms. Identifies few or no relevant symptoms or cultural factors pertaining to present disorders.
Substance/Medical Etiology
[CMHC 5. C. 2. B] Discusses the most relevant substances, medications, and/or medical conditions and justifies any rule outs. Discusses some relevant substances, medications, and/or medical conditions, but also includes some non-relevant ones as well OR contains minor inaccuracies in justification of rule outs. Discusses few or no relevant substances, medications, and/or medical conditions OR contains major inaccuracies in justification or rule outs OR no discussion of rule outs.
Stressors/Clinical History
[CMHC 5. C. 2. d.
CMHC 5. C. 2. b
CMHC 5. C. 2. g
CMHC 5. C. 2. j.] Identifies relevant stressors (if any) and their relation to symptoms AND provides an in-depth discussion of clinical history. Identifies some relevant stressors (if any) but also includes non-relevant ones OR does not link stressors to symptoms OR offers a brief discussion of clinical history. Identifies stressors (if any) that bear no resemblance to the correct ones OR offers not discussion of clinical history.
Diagnostic impression
[CMHC 5. C. 2. d. ] Identifies correct diagnoses including DSM-5 and ICD code numbers, relevant subtypes and/or specifiers, along with justification. Identifies correct diagnoses, but not code numbers OR relevant subtypes and/or specifiers OR identifies diagnoses that are close to the correct ones. Identifies diagnoses that bear no resemblance to the correct ones.
Rule Outs and Differential Diagnoses
[CMHC 5. C. 2. d.
CMHC 5. C. 2. b
CMHC 5. C. 2. g] Identifies other disorders that are the “chief rivals” of the correct diagnosis/ disorder AND clearly justifies why disorders can/cannot be ruled out. Identifies other disorders that are much less likely to rival the correct diagnosis/disorder OR does not clearly justify why disorders can/cannot be ruled out. Identifies other disorders that are not at all likely to rival the correct diagnosis/disorder OR does not justify why disorders can/cannot be ruled out.
Case Conceptualization
[CMHC 5. C. 2. b
CMHC 5. C. 2. g
CMHC 5. C. 2. j. ] Provides a clear, theory-based discussion of symptoms, prevention, cultural, and strengths-based factors. Provides a theory-based discussion of symptoms, prevention, cultural, and strengths-based factors with minor inaccuracies. Does not discuss symptoms, prevention, culture, or client strengths OR does not integrate counseling theory or integrates theory incorrectly.
Treatment recommendation
[CMHC 5. C. 2. l. ] Identifies clear, ethically informed, treatment interventions, goals, and theory-based approaches that are reasonably connected to the diagnoses and symptoms. Identifies treatment interventions, goals, and theory-based approaches that are tentatively connected to the diagnoses and symptoms. Identifies treatment interventions, goals, and theory-based approaches that are not at all connected to the diagnoses and symptoms OR does not identify interventions, goals, or theory-based approaches.
Prevention, Crisis Intervention, and Medication Approaches
[CMHC 5. C. 2. l.
2. F. 5. m. ] Identifies clear prevention, crisis intervention, and medication strategies that are reasonably connected to the diagnoses and symptoms. Identifies prevention, crisis intervention, and medication strategies that are tentatively connected to the diagnoses and symptoms. Identifies prevention, crisis intervention, and medication strategies that are not at all connected to the diagnoses and symptoms OR does not identify prevention, crisis intervention, and medication strategies.
Personal reactions Applies the case to their own professional development, identifies personal strengths and limitations related to counseling diagnosis. Offers remarks regarding impression of the case, but does not incorporate these details into their own professional development. Does not address their own professional development or reactions to the case.
Grammar/
Quality of writing Offers a concise yet thorough analysis of the case. Writing is free from grammatical errors. Offers an application of the case OR writing contains some grammatical errors. Summarizes but does not analyze the case OR writing contains multiple grammatical errors.

Total Points:

Note: although strict adherence to APA style is not required, the grading rubric does include evaluation of quality of writing.

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