studiul de caz conform aaron beck

7/29/2019 Studiul de Caz Conform Aaron Beck

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Appendix A

Case Hist ory, Form ulatio n, and Treatm ent Plan

I. Case Hi sto ry (Suggested # o f wo rds: 750 )

General Instructions: The case histo ry should briefly sum m arize th e m ost im port ant

background info rm ation th at you col lected in evaluating th is patient f or tr eatm ent. Be

succinct in describin g the case hist ory.

A. Ident ifying In form at ion

Provide a ficti t ious nam e to pr ot ect the confident iali ty of pat ient. Use this

ficti t iou s name t hro ughout th e Case Histo ry and Form ulation. Describe patients

age, gender, eth nicity, mari t al stat us, l iving si tuat ion, and occupat ion.

B. Chief Com plaint

Note chief comp laint in pat ient s own wo rds.

C. Hist or y of Pr esen t Il ln ess

Describe pr esent i l lness, including em ot ional, cognitive, behavior al, and

physiological symp to m s. Not e environm ental stresses. Briefly review t reatm ent s

(i f any) that h ave been tried f or t he present i l lness.

D. Past Psych iat ric Hist or y

Briefly sum m arize past psychiat ric hist or y including subst ance abuse.

E. Per so nal an d So cial Hist or y

Briefly summ arize m ost sal ient features of p ersonal and social histo ry. Include

observation s on form ative experiences, tr aumas (if any), suppo rt str uctur e,int erests, and u se of substances.

F. M edical Hist ory

Not e any med ical pro blem s (eg., endocrin e dist urb ances, heart disease, cancer,

chron ic medical i l lnesses, chronic pain) t hat m ay influen ce psychological

fun ctioning or the tr eatm ent pro cess.

G. M e nt al St at us Ob ser vat io ns

List 3-5 of t he m ost salient featu res of t he m ental stat us exam at th e tim e

tr eatm ent began. Include observations on general appearance and mo od. Do not

describe the entire m ental stat us examination.

H. DSM IV Diagnoses

Provid e five Axis DSM IV diagnoses.

I I. Case Formu lat ion (Suggested # o f w ords: 500)

General Instructions: Describe the pr imary featu res of you r case form ulation u sing the

fol lowing out l ine.


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A. Precip it ant s:

Precipitants are large scale event s t hat m ay play a significant ro le in precipitat ing

an episode of i l lness. A typical exam ple is a depressive episode precipit ated b y

m ultiple events, including fai lure to be prom ot ed at w ork, death of a close

fr iend, and mar ital str ain. In som e cases (eg., bipo lar disor der, recurr entdepression w ith str ong biological featu res) there m ay be n o clear psychosocial

precipi tant. If n o psychosocial precipi tant s can be ident i f ied, not e any ot her

featur es of t he patient s histo ry th at m ay help explain the onset of i l lness.

The ter m activating situat ions, used in t he next p art o f t he Case Form ulation,

refers to sm aller scale event s and si tuation s that stim ulate negative m oods or

m aladapt ive bur sts of cognition s and behaviors. For example, the patient w ho is

depressed f ol low ing the precipi tating events described above m ay experience

w orsening of her depr essed m ood w hen shes at w ork, or w hen shes w ith her

husband, or w hen she att ends a class she used t o att end w ith h er fr iend w hodied.

Which precipitants do you hypo th esize played a significant ro le in th e

development of t he pat ient s sympt om s and problem s.

B. Cross-sect i onal view o f cu r ren t cogn i t ions and behav io rs:

The cross-sectional view of th e case form ulation includes observation s of t he

predom inant cognition s, emo tion s, behaviors (and physiological reaction s i f

re levant) th at the pat ient dem onstrates in th e here and now (or demonstrated

prio r t o m aking substant ive gains in t herap y). Typically the cross-section al view

focuses more o n t he surface cognition s (ie., autom atic thou ghts) that areidenti f ied earl ier in th erapy t han un derlying schemas, core bel iefs, or

assum pt ions th at are the centerpiece of the longitudinal view described below .

The cross-sectional view should give your conceptual ization of how th e cognitive

m odel appl ied to t his patient early in treatm ent. List up t o th ree current

activating situ ations or m em ories of activating situ ations. Describe the patient s

typical autom atic th ought s, em ot ions, and behaviors (and physiological reaction s

if relevant) in th ese situ ations.

C. Lo n gi t ud in al vi ew o f co gn it i on s an d b eh av io r s:This por t ion of t he case con ceptu alizatio n fo cuses on a longitudinal perspective

of t he patient s cognitive and behavioral functioning. The longitudinal view is

developed ful ly as therapy pro ceeds and t he t herapist uncovers underlying

schem as (core beliefs, rules, assum pt ions) and end ur ing patt ern s of b ehavior

(compensatory strategies).


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W hat are th e patient s key schem as (core b el iefs, rules, or assum pt ions) and

comp ensatory behavioral str ategies? For patient s w hose pre -mo rbid histo ry w as

not significant (eg., a bipolar patient w ith no history o f developm ental issues

th at played a role in generation of m aladaptive assum pt ions or schemas)

indicate t he m ajor bel ief(s) and dysfun ctional behavioral patt erns present o nly

during the current episode. Report developm ental antecedents relevant t o th eorigin or m aintenance of t he pat ients schemas and b ehavioral str ategies, or

off er suppo rt f or your hypo th esis th at th e patient s developm ental histo ry is not

re levant to the current d isorder.

D. St rengt hs and asset s

Describe in a few w or ds t he pat ient s st ren gths and assets (eg., ph ysical health ,

int ell igence, social skil ls, suppor t net w or k, wor k hist ory, et c.).

E. Wo r k in g h yp ot h esi s (su mma ry of co n cep t u al izat i o n)

Briefly sum m arize the pr incipal features of the w orking hypot hesis th at directed

your tr eatment intervent ions. Link your wo rking hypothesis wi t h th e cogni t ive

m odel for t he patient s disorder (s).

I II. Treatm ent Plan (Suggested # o f words: 250)

General Instructions: Describe the prim ary featu res of your t reatm ent plan using the


A. Prob lem list

List any significant prob lems that you and the patient have identi f ied. Usual ly

pro blem s are ident ified in several dom ains (eg., psycholo gical/ psychiat ric

sym pt om s, inter personal, occupatio nal, med ical, financial, hou sing, legal, and

leisure). Problem Lists general ly have 2 to 6 i tem s, som etim es as m any as 8 or 9

i tem s. Briefly describe problem s in a few w ords, or, i f previously described in

det ai l in the HPI, just name t he prob lem here.

B. Treat m ent goals

Indicate t he goals for t reatm ent t hat have been developed col laborat ively wit h

the pat ient.

C. Plan for t reat m ent

W eaving to gether t hese goals, th e case history, and your w orking hypot hesis,

br ief ly state your treatm ent p lan for th is pat ient.

IV. Course o f Treatm ent (Suggested # o f words: 500)

General Instructions: Describe the prim ary featu res of t he course of t reatm ent using th e


A. Therapeut ic Relat io nship


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Detai l the nature and qual i ty of t he ther apeutic relation ship, any prob lems you

encount ered, how you conceptual ized th ese problem s, and ho w you resolved

them.

B. In t ervent ions/ Procedures

Describe three m ajor cognitive t herapy intervent ions you u sed, providing a

rationale that l inks th ese intervent ions w ith t he patient s tr eatm ent goals andyour w orking hypoth esis.

C. Obst acles

Present one example of how you resolved an ob stacle to t herapy. Describe your

conceptual ization of w hy the obstacle arose and not e wh at you did about i t. If

you d id not encount er any significant o bstacles in t his therapy, describe one

exam ple of how you w ere able to capital ize on th e patient s str engths in th e

treatment process.

D. Out com e

Brief ly report on t he outcome of t herapy. I f the treatm ent has not been

comp leted, describe pr ogress to dat e.

studiul de caz conform aaron beck

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