PSYCB3102 2023 Case Study Report Guidelines

Assignment Overview
The aim of this exercise is to allow you to apply theoretical knowledge to practice. Your
assignment will be structured as authentically as possible to provide you with real world
experience writing clinical reports that link behaviours, thinking patterns and emotions to
DSM-5 diagnostic criteria, aetiology and treatment options.

Due Date: Monday May 8th, 4pm (Week 10)

Length: 2,500 words maximum +/- 10 %
Weighting: 50% of course mark
Submission: Electronically via Moodle submission link (see Assessments page)

Instructions
Students will select ONE case study presented in this document to write about. Each case
study will feature a specific mental disorder. Students will be required to:
1. Identify the clinically significant symptoms based on the DSM-5 criteria and make a
principal diagnosis.
2. Identify the possible aetiology of the disorder.
3. Suggest evidence-based treatment plans.

Report Structure
Each report should use the following structure:
Section 1: DSM-5 Principal Diagnosis (25%)
Which disorder (according to the DSM-5 criteria) does the client’s presenting symptoms most
closely align with? In this section, identify what you think are clinical symptoms and link
these with the criteria for one disorder.
You must make specific reference to the relevant diagnostic criteria (this includes listing the
criteria). For example, “…the client meets Criterion A, symptoms 1, 2, 4, and 5”. Listing the
criteria word-for-word will not be included in the word count.
When identifying each symptom, be specific about how that symptom has been presented in
the case.
Note: There may be symptoms that the client presents with, that do not necessarily fit with
the diagnostic criteria for the disorder that can be diagnosed (principal diagnosis). Only
symptoms reflecting the principal diagnosis should be discussed here.
Section 2: Formulation (35%)
In this section, you will discuss possible predisposing factors (i.e., aetiology). There are likely
biological, psychological, social, and sociocultural factors involved in the development of the
client’s disorder. Drawing from information in the case study and research on the aetiology of
the disorder:
1. Draw from the bio-psycho-social model, and briefly outline one potential factor from
each sphere of the model (i.e. biological, psychological, social and sociocultural
factors) as possible aetiology of the disorder.
2. Use peer-reviewed research to display evidence that the factors chosen are linked to
the aetiology of the disorder (i.e., employ an evidence-base that highlights how/why
these variables are likely to influence the development of the disorder).
Section 3: Rationale for Treatment Plan/Treatment Options (30%)
There are likely numerous treatments available for the disorder presented in the case study.
Given your interpretation of the client’s presenting issues, your proposed diagnosis, and the
aetiological factors identified by you, choose TWO possible treatment strategies that would
suit your client. Use peer-reviewed literature and provide a rationale for choosing each
treatment, including evidence for how and why the treatment works and why it would be
appropriate in this situation.
Note: Your treatment plan should be in alignment with your diagnosis and the identified
aetiological factors. The client DOES NOT have to be referred for psychological treatment
only. E.g., You can refer your clients for family therapy, couples therapy, etc if the conditions
surrounding the development of the client’s disorder suggest the need.

Other Requirements
Structure and formatting
1. Your assignment should be prepared as a Word document and written in prose. We
recommend using subheadings for each of the sections described above.
2. Use double-spacing, with 1” margins on all sides, and use a font that is highly
readable such as 12-point serif font (e.g., Times New Roman).
Referencing
1. In-text citations and the reference list should be formatted according to the APA 7th
ed.
2. In line with the best practice of evidence-based practitioners, students are required to
analyse and synthesise literature in their case study reports. Students are required to
cite a minimum of SIX academic references.
Marking Guide
Please see the marking guide at the end of this document. Your final grade will be calculated
by summing marks across the different sections of the report. Your final mark will be
presented as a % out of 100.
 CASE STUDY ONE
Buddy King is a 28-year-old married Aboriginal man with two daughters (aged 10
months and 5 years). He works as a manager in the local food store. Buddy was referred by
his family doctor after his wife had called the doctor to express concern over her observations
that her husband was becoming increasingly depressed. Over the prior 2 to 3 months, Buddy's
symptoms of depression had escalated notably. These symptoms included sustained
depressed mood and lack of energy, difficulties concentrating, decreased interest and
withdrawal from the activities he usually enjoyed, pessimistic views and rumination about the
future, and sleep disturbances (i.e., awakening in the morning several hours before he
intended). More recently, Buddy had experienced a decrease in his interest in sexual relations
with his wife, and occasionally he had thoughts about committing suicide.
Despite the escalation in his symptoms of depression, Buddy was hesitant to see a
therapist due to his fear of being labelled as "mentally ill" or "weak." However, these
symptoms were beginning to interfere with his work, social life, and marriage. Buddy had
previously been very energetic and devoted to his work. He now found it difficult to get up in
the morning to go to the office. Furthermore, he had been an avid athlete, but recently
discontinued nearly all his athletic activities. Based on these factors, Buddy reluctantly
agreed to set up an initial appointment with you.
Clinical History
Buddy's decision to agree to make this appointment was also influenced by his
experiences at University. Buddy tells you that when he was in his final year of Sport and
Exercise Science at a University in Sydney, he experienced symptoms of depression. During
this time, Buddy was under a great deal of stress from his family (his parents were upset that
he was taking too long to complete his degree and that he was neglecting his family
responsibilities), and his strong concerns about what he would do for a career after
graduation. However, unlike Buddy's more recent experiences, these symptoms of depression
were followed a few days later by more dramatic symptoms. Specifically, Buddy had
experienced symptoms of abnormally and persistently elevated mood, grandiose and
persecutory delusions, hyperactivity, and a substantially decreased need for sleep. During this
period, he experienced a marked increase in sexual desire and was also arrested for
trespassing.
During this episode, Buddy's university performance diminished greatly, and he often
skipped classes altogether. Although he had previously been a sensible drinker (he only drank
socially at university parties), Buddy engaged in several alcohol and marijuana binges. He
started failing at University and chose to complete his degree at another university. He was
shunned by his friends (who did not understand why Buddy had suddenly started acting in a
manner so out of character), and his family was very disturbed by the onset of these serious
manic symptoms. There were numerous family conflicts and heated discussions between
Buddy and his parents. Buddy eventually completed his degree and having been unable to
find a job in the area of his degree, decided to work in retail food. During his first year after
university, Buddy met the woman he eventually married, and he settled into working.
However, Buddy has continued to have brief periods of depression from time to time, none of
them long or severe enough to cause Buddy to obtain treatment, although his wife had often
urged him to do so. Had it not been for his wife's urgings, Buddy may have never agreed to
the initial appointment.
Buddy was born and raised in a very small outback community. His father was in the
tourism industry, heading up a very successful Aboriginal tour company promoting authentic
cultural experiences across the state. His father had successfully incorporated all of his
children in the family business except Buddy who was determined to live a different life in
the city. Buddy is the youngest of five children; he often struggled with the competition with
his older brothers. He stated that he often felt that he had to "go the extra mile" to measure up
to his older brothers in his parents' eyes. Their ties to the country and to the community in
which they live remain very strong whereas Buddy admits to often feeling somewhat
disconnected and lost. Buddy described himself as being hyper-conscientious and driven
during his childhood years, a characteristic that he attributed to wanting to break free from his
family environment. He also recalled being perfectionistic in high school and in the sporting
arena (he played on the football team and was a gifted athlete) and to some degree in his
schoolwork.
Buddy's family had various members with mood disorders and a history of
intergenerational trauma. His mother had recurring bouts of depression that had been treated
with antidepressant medications. Buddy's maternal grandmother, paternal uncle (both
members of the stolen generation), and oldest brother had also received outpatient treatment
for depression.
 CASE STUDY TWO
Bonnie, a 15-year-old girl, and her parents are attending her first consultation with
you. She states that she gets nervous about everything, particularly things at school and doing
anything new. As an example, she recalls that her mother wanted her to join piano lessons,
but she did not want to because of her “nerves”. Bonnie also tells you that she feels very self-
conscious in a shopping mall and constantly worries about what others might think of her and
the way she looks.
Bonnie is very fearful of things such as eating in public, using public restrooms, being
in crowded places, and meeting new people. She says that she would almost always try to
avoid these situations. Further to this Bonnie tells you that she fears and regularly avoids
daily activities such as speaking up in class, writing on the blackboard, and talking to her
teachers or school principal. Although she was very good at playing the flute, Bonnie says
that she had dropped out of the school band because of her shyness over participating in band
performances. In addition to her nervousness about talking to teachers, she reported that she
feared talking to unfamiliar adults (such as shop assistants). In fact, Bonnie says that she does
not even answer the telephone at home and does not want a mobile phone of her own. She
tells you that she was also very hesitant to use the phone to do such things as ask for
information or order pizza, largely because she does not know these people.
When asked what she feared about such interactions, Bonnie says her fear and
avoidance is related to her worry about possibly saying the wrong thing or not knowing what
to say or do, which would lead others to think badly of her. Quite often, her fear of these
situations is so intense that she has a full-blown panic attack. When this happens, she
experiences an accelerated heart rate, chest discomfort, shortness of breath, hot flashes,
sweating, trembling, dizziness, and difficulty swallowing. Bonnie also says that she suffers
from headaches and stomach-aches when anticipating situations she finds difficult.
You conduct a separate interview with Bonnie’s parents who tell you that her
symptoms were even more severe than what she had indicated. To illustrate this point, they
tell you that even though it is early in the year Bonnie is already worried and having regular
headaches and stomach aches when thinking about beginning the 10th grade next year. They
tell you she is "terrified" in public and has her younger sister do everything for her when they
are out and about.
Her parents note that although Bonnie is attractive, she was usually quite concerned
about her physical appearance. So much so that when she went to parties, Bonnie would
insist on going with a "safe" person (one of her best friends). Her parents also tell you that
she would never initiate any activities, join clubs, invite friends over, or even call friends on
the telephone. They said that the "last straw" had occurred 2 weeks ago when they had a
family gathering at their home with a number of relatives and friends attending. Because of
the large number of people in the house, Bonnie experienced a panic attack and locked
herself in her bedroom for the entire day until the last guests had left.
Clinical History
 Bonnie was the first of two children with a sister two years younger. Bonnie grew up
in a happy, middle-class home until their town was decimated by a flood. Bonnie's father was
a building contractor; her mother worked as a bank teller. Her parents were happily married
and had always been quite supportive of her. In response to Bonnie's shyness, they had
pushed her to socialise more, which seemed to have the opposite effect in that Bonnie would
become even more avoidant. Bonnie's parents reported no history of anxiety problems among
the immediate relatives of the family. Except for typical sibling conflicts, Bonnie got along
quite well with her sister. Despite her shyness, Bonnie had two or three close friends and a
number of "acquaintance" friends. Her parents told the interviewer that Bonnie could always
make friends; she just would never make the first move. Bonnie preferred to spend time with
her close friends with whom she felt safe because they were also extremely shy and had the
same evaluation concerns that Bonnie did. Each day at school, the group ate lunch together
and stayed together, apart from the other students between classes.
Bonnie's grades at school were usually B's and a few C's. Her parents said that Bonnie
achieved these grades with little effort. Interestingly, while Bonnie was often quite fearful of
school, she had not missed many days over the past several school years (in fact, not a single
day of the current school year). Her parents noted that Bonnie always had stomach aches
before school, but she had never asked to stay home.
Although she had always been somewhat shy, Bonnie's shyness increased
dramatically a year before her first contact with the clinic. This increase seemed to be related
to two factors: (1) confrontation with all of the changes associated with entering high school
(e.g., new environment, new classmates, dances, greater demands to speak up in class) and
(2) a breakup with her boyfriend. After breaking up with her boyfriend the previous summer,
Bonnie did not feel like doing anything or going anywhere. Particularly for 2 months during
the past year (after learning that her ex-boyfriend was dating another girl), Bonnie felt very
depressed. During this time, she did not sleep well, felt very fatigued, had problems
concentrating, and felt worthless. Bonnie recalled that, during this time, she frequently
thought and dreamed about her ex-boyfriend. A month or so before her initial evaluation,
Bonnie's mood began to lift. Bonnie told the interviewer that she was beginning to return to
her normal mood, in part because she had started dating another boy. However, her new
boyfriend was just as shy as she was. Her parents expressed some concern that spending a lot
of time with a shy boy would prevent Bonnie from coming out of her shell.
 CASE STUDY THREE
Tiffany Jenkins, a 33 year-old Caucasian woman has sought an appointment with you
as she feels that her eating has been “out of control”. She says that she has had extended
periods where she restricted her food intake drastically, largely due to her negative body
image (i.e., dissatisfaction with her weight and physical appearance) and her poor self-
esteem. Tiffany restricted her food intake because she felt that she weighed too much, a belief
that distressed her greatly. To reinforce the point she tells you that she gauges her value as a
person by her perceptions of her physical appearance and weight. Her efforts at reducing the
amount of food she ate were often rewarded by marked reductions in weight. In fact, as the
result of her most recent period of fasting, Tiffany had lost roughly 27kg (60 pounds).
However, as had always happened in the past, this period of restriction was followed
by a period of binge eating and purging. During a binge, Tiffany typically eats large amounts
of food (often sweets, such as cake, cookies, and ice cream, or starches such as mashed
potatoes) in a short period of time. She says that she is generally totally out of control during
these binges feeling as if she could not stop eating or control the amount of food she was
ingesting. After the binge, she would experience tremendous distress over the prospect of
gaining weight. Consequently, after every binge, Tiffany purged the food by sticking her
finger down her throat to make herself vomit. Nevertheless, because of her binge eating and
changes in her metabolism resulting from her frequent vomiting, Tiffany gained back a lot of
weight that she had lost during a period of food restriction. Now, Tiffany weighed 81kg (180
pounds).
Clinical History
Tiffany was adopted when she was an infant. She consequently grew up as the
youngest child in a family with 2 other children. Her older brother (by 2 years) and older
sister (by 3 years) were the biological children of her adopted parents. Tiffany said that she
never felt close to her adoptive family. Of her family, she was probably closest to her adopted
father, but noted that throughout her life he had placed a great deal of pressure on her to
succeed. She recalled that her focus in her growing years was on excelling in school and
sports, and on pleasing her parents. Tiffany tells you that her relationship with her adopted
mother was very poor. Her adopted mother is an alcoholic who has been treated on several
occasions with little improvement. Tiffany says that she constantly felt "unsupported" by her
mother and claims that she never felt she could confide in her when an issue arose in her life.
However, Tiffany holds the most negative feelings for her siblings, especially for her brother.
Beginning when she was 10 and continuing through her early 20s, Tiffany’s brother
physically abused her, often beating her up in a violent rage for no apparent reason. She says
that her sister used to beat her as well, although less frequently and much less severely than
the beatings that she had suffered at the hands of her brother. From age 13 until she was in
her early 20s, Tiffany was sexually abused by her brother. This brother died in a road
accident five years ago.
In fact, shortly after the sexual abuse began, Tiffany began to experience discomfort
with her body. She began dieting due to rising concerns about her physical appearance and
body shape. Although 10 years had passed since the sexual abuse had ended, Tiffany had
never addressed these issues with her brother before his death. Tiffany tells you that her
father had become aware of the physical abuse when he discovered a dark bruise on the back
of her neck. At this time, when Tiffany was 21 years old, her adoptive father forced her
brother to leave the household, thus ending her many years of physical and sexual abuse. Her
parents were never aware of her sexual abuse until Tiffany was 26 years old.
Tiffany recalled that her parents downplayed the news of sexual assault and said,
"Let's never talk about that again." She said that she grew up wondering what was wrong
with her and how she was responsible for being the recipient of such acts by her brother and
sister. She reported being an obese child and as an adolescent, she was occasionally teased
about her size. Recalling that she felt no control over her environment and of her safety
within the home, one way of coping was to control her weight and shape.
Moreover, Tiffany’s violent childhood led to other significant psychological
difficulties. For example, in her late teens, Tiffany began to have a tremendous problem with
sleeping because she frequently had distressing nightmares about her physical and sexual
abuse. She also reported that for as long as she could remember, she had difficulty trusting
other people (especially men) and handling social relationships. She noted that, during the
past several years, her eating disorder and her recurrent nightmares and flashbacks to
upsetting memories increased in their severity if she established a social relationship with a
male co-worker or classmate. Consequently, she would cut off the friendship in the hopes that
her symptoms would decrease. Tiffany also reported considerable anxiety and some
worsening of her eating disorder symptoms on the infrequent occasions when she developed
an interest in sex. At the time of her admission to the hospital, Tiffany had never had a steady
boyfriend and was living alone in a rented apartment. She says that she had, however,
managed to maintain friendships with two women she had met at school.
 HD D C P N

Symptoms and Accurately identifies

Omits minimal clinically Omits some clinically Identifies minimal Considerable difficulty
Diagnostic Criteria clinically significant significant symptoms significant symptoms clinically significant identifying clinically
(25%) and/or identifies
symptoms of the client and/or identifies minimal symptoms and/or significant symptoms
minimal issues as
Symptoms are issues as clinically identifies issues as and/or cannot discern
clinically significant
significant that are not clinically significant what is significant and
organised meaningfully that are not
when they are not what is not
into a diagnosis. Symptoms are
Symptoms are
organised into a Some symptoms are Very few or no
Diagnosis is justified organised into a
with detailed reference diagnosis. included, with few symptoms are discussed
diagnosis.
examples
to specific DSM-5 Diagnosis is somewhat Minimal reference and
Diagnosis is justified
criteria justified with adequate Attempted but limited connections to DSM-5
with reference to
reference to DSM-5 reference and criteria are made
specific DSM-5 criteria.
criteria. connections to DSM-5
criteria are made

Formulation All factors addressed All factors addressed All factors addressed All factors addressed in
One or less factors
(35%) and linked to relevant and linked to relevant and, but some may be minimal detail OR
discussed OR
No discussion of
information from the information from the linked to information from
Includes significant aetiology
case study. case study. the case study that is not amounts of irrelevant OR
Most factors are directly relevant and/or
All factors are addressed information. No evidence provided
in significant detail with addressed in significant Some factors are Minimal consideration of
good integration of case detail with good addressed in some detail evidence
study and evidence. integration of case study with some integration of
and evidence. case study and evidence.
Treatment Chosen treatment is Chosen treatments is Chosen treatments are Chosen treatments are Chosen treatments are
planning and specific, well detailed, relevant to the identified relevant to the identified mostly relevant to the not relevant to the
Recommendation justified with evidence, problems, with minor problems, though lack identified problems, but identified problems
(30%) and relevant to the errors justification, some evidence, lack evidence, sufficient
identified problems specifications, and detail specifications, and detail specifications, and detail
Treatment
recommendations are
Treatment Treatment Treatment Treatment not appropriate for the
recommendations are recommendations are recommendations are recommendations are case study
appropriate for the mostly appropriate for somewhat appropriate not all appropriate to the
case study the case study for the case study case study

Expression (5%) None or only superficial One or more errors in Several or consistent Consistent errors in Writing is largely
errors in spelling, the stated criteria but errors in stated criteria stated criteria which incoherent or with
grammar, punctuation, does not distract which somewhat detract detract substantially substantial errors which
and sentence/paragraph substantially from from readability. Some from readability. detract markedly from
construction. Writing is readability. Minimal revision would be Reasonable revision the readability.
concise and precise. revision would be required would be required Substantial revisions
Appropriate formal tone required would be required
and expression is used

APA referencing Work is presented in line Some errors in APA Several errors in APA Only some APA Few or no APA style
(5%) with APA style style guidelines detract style guidelines which guidelines adhered to guidelines adhered to
requirements. Errors are somewhat from overall detract from overall
minimal and do not presentation, but still presentation
detract from overall largely in line with APA
presentation. conventions