Custom «Case Formulation» Essay Paper Sample

Case Formulation

The psychiatric analysis includes Jason Gratski, who is a 31-year-old Caucasian divorced male. Jason divorced his wife six years ago.

Admission of the patient followed his request about wanting to stay clean and off marijuana. Jason complained of cough and sore throat, which made him lose voice. He tried to quit using marijuana, but a friend informed him about another type of marijuana, synthetic marijuana. Jason started using this substance on March 13 2011, and he has developed substance dependence over the marijuana. He has made three attempts of quitting substance use in the previous days without success. The patient reported the attempts to detoxify himself from synthetic marijuana. He was extremely depressed with suicidal thoughts. The patient reports that he has experienced problems with sleeping because, since March 2011, he has hardly slept for about two hours a night. He keeps waking up every 15 minutes to inhale the synthetic marijuana because sometimes he feels as on an acid drip. The patient has experienced decreased appetite. He reports a history of control issues and mood swings, but he denies any acting out or physical violence. The patient reports a history of child abuse by his stepfather at the age of 6-7 years, which left him emotionally scarred. Even if he has not had inpatient hospitalization, he has received different antidepressant medications such as Effexor and Paxil, Wellbutrin and Prozac from a primary care. The patient experienced negative effects with Effexor and Paxil, and the Prozac proved to be ineffective in the treatment of depression. He cannot recollect why the physician stopped to administer Wellbutrin.

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The patient reports to have started using marijuana when he was 13 years old. Therefore, he has used marijuana for more than 16 years since he started. In March, he put an effort to stop depending on marijuana and he had started using synthetic marijuana. It was unfortunate that he has become more dependent on the synthetic marijuana, which costs him more than 350 dollars every week. It has become impossible for the patient to stop using synthetic marijuana. Most recently, he tried to stop using the synthetic marijuana for about 24 hours, which led to severe physical psychological symptoms. The withdrawal symptoms included sweating, palpations, inability to sleep, tremors, increased depression, unable to eat, nightmares, and cough. This necessitated for admission in a health institution for medical attention, and he felt that stopping the use of the synthetic marijuana would hurt his health. The patient last used synthetic marijuana on December 8 2011. The patient has been attending NA and AA meetings, but has not attended for the past few days.

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The patient reports to have a history of atrial fibrillation, and events at ages 21, 23, 26, and 28. Currently, the patient is neither on any medication nor on treatment for the atrial fibrillation. The patient states that a physician offered to insert a pacemaker into his cardiac muscles, but he refused the offer. Through the cardiogram, it was evident that the patient’s sinus rhythm was normal on admission. The patient has a history of Charcot-Marie-Tooth disease (CMT), which is a progressive neuropathic muscular atrophy. He reports to have had six surgeries on his foot when he was 13 years old.

The patient has a family history of anxiety with his grandmother, mother, and aunt.

The patient reports that he is a loner because he divorced his wife six years ago. However, he has 6-years-old and 8-years-old daughters who he has no contact with, which is evident from the statement that he spoke with them during the last Christmas. Since the patient is a loner, he does not let people into his residential place, and says that he does not have a support system. The patient states that even his own daughters and siblings did not call him during his birthday that was on 22nd.  He has a brother and three sisters, with whom he states that he does not have contact. The patient states that he is the eldest son in his family because all the other siblings are ten years younger than he is. He reports to have attained an eleventh grade education. The patient has a full-time job regarding fishing. In 2008, the government imprisoned the patient for six months for child support. The patient has never worked as military personnel. His stepfather emotionally and physically abused him when he was 6-7 years of age. The patient tried to disclose the incidents to his mother, but she failed to believe him. He states that this situation has led to the formation of a long-lasting emotional scar for him.

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The patient is oriented and alert. He dresses himself in casual clothes. He remains cooperative and maintains good eye contact in the course of the interview. He appears well nourished and well developed. Presently, the patient is ambulatory and is not in an acute distress. He keeps complaining of some withdrawal symptoms, which include chills and headaches. He has a characteristic spontaneous speech, whose rhythm, volume, and rate are within normal limits. The patient appears not to have psychomotor agitation or retardation because he has an organized thought process. He denies homicidal or suicidal ideation, and audiovisual hallucinations. Lack of delusions or paranoia as well as the possession of intact cognition and memory justifies that he is right. He has adequate general knowledge, and fair insight and judgment.

The complete blood count (CBC) showed that the patient has a WBC of 11.8. The patient had a negative comprehensive metabolic panel. He also had a troponin level of 0.05. The patient has a negative chest x-ray and a normal sinus rhythm. 

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The patient has full-employment and his physical health appears to be stable. He is aiming at achieving complete rehabilitation and treatment.

DSM-IV-TR Criteria

Once a therapist has performed a thorough assessment of a patient, he or she should make a formal diagnosis of substance dependence. DSM-IV-TR Criteria is extremely significant in the diagnosis of all problems associated with substance dependence. The diagnostic schema works based on groups of physiological effects and behaviors that occur within a specific period. These criteria can enable a therapist to identify possible problems that need intervention to relieve the victim from pain and suffering. Some of the characteristics that the DSM-IV-TR Criteria enable a therapist to identify include:

  1. Tolerance is another substance dependence characteristic, which can make the victim to increase the amount of the substance to bring about a desired effect or intoxication.   
  2. There are unsuccessful efforts or a persistent desire to control or cut down substance use. 
  3.  The victim usually consumes the substance in large quantities and for a longer period than is intended.

These characteristics are very similar to those characteristics that Jason exhibits. Therefore, a therapist can be able to classify Jason as undergoing all his problems because of substance dependence.  Then a therapist identifies all problems that the patient is suffering from, he or she can be able to put the patient on appropriate medication and practices. This will ensure absolute recovery of the patient.

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While using the DSM-IV-TR Criteria, a therapist is supposed to specify whether or not, a victim of substance dependence exhibits evidences of withdrawal or tolerance. A therapist can classify substance dependence as substance dependence with or without physiologic dependence, based on whether or not; there is evidence of withdrawal or tolerance.

The therapist can distribute the characteristics of the patient under five different axes of the DSM-IV-TR. Classification of Jason’s problems of can appear in different axes as follows:

This level of diagnosis represents the most acute substance dependence symptoms that need intervention once a therapist identifies them. Diagnoses under this level are widely recognized and are the most familiar. The symptoms under this level are closely associated with Cannabis dependence, such as depressive disorder, and anxiety. However, there is no evidence of the Jason exhibiting any form of depressive disorder and anxiety.  

This level of diagnosis is for developmental disorders and personality disorders such as mental retardation. These disorders, when present, are likely to bring about the problems in Axis I. For instance, if Jason had a developmental disorder like mental retardation, he could not be able to work; thus, he could be stressed by lack of money for purchasing marijuana and suffer from depression. Because Jason did not exhibit and sign of developmental and personality disorder, there was no diagnosis took place in this axis.

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This level of diagnosis is concerned with neurological or medical conditions that may lead to psychiatric problems. For instance, Jason has the history of atrial fibrillation, which is untreated until the present time. He also has a history of Charcot-Marie-Tooth disease (CMT), which is a progressive neuropathic muscular atrophy. The medical conditions likely influenced Jason’s depressive, suicidal thoughts. 

This level of diagnosis enables a therapist to identify the psychosocial stressors such as divorce, death of a family member, or losing a job, which the client experienced recently. Therefore, the problems can be either environmental or psychosocial in nature. For instance, Jason experienced psychosocial stressors because he divorced his wife. His mother failed to believe about the severe emotional and physical abuse from his stepfather, and this created long-lasting emotional scar in his memory. The psychosocial stressors influenced Jason’s severe stress, cannabis dependence, impaired coping, and perceived support system.

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This level of psychiatric diagnosis enables a therapist to identify the level of function of the patient on a scale that ranges from zero (0) to 100, where zero is the lowest level of functioning and 100 the topmost level of functioning. The patient’s Global Assessment of Functioning is 35, but the GAF was extremely high in the previous year.  

The patient should receive group and individual therapy, and milieu therapy in order to stabilize his cognition. He will undergo a complete medical, psychiatric, and psychosocial assessment, and interdisciplinary treatment panning. A therapist will keep monitoring the patient for the current psychiatric needs such as the withdrawal symptoms. The therapist will encourage the patient to participate in all milieu and group activities. When the patient becomes stable, the therapist will discharge him and refer him to suitable outpatient follow-up. The therapist will then put the patient on Celexa 10 mg that will undergo daily titrations of 20 mg to address anxiety and mood. The therapist will also start the patient on Tegretol to deal with report of irritability and severe mood swings. A Tegretol level will take place within a period of four days. The patient is likely to undergo treatment for a period not exceeding seven days.    

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Case Formulation

The case formulation is an attempt to bring together a number of important factors and create a summary of the case and its many facets. These factors ought to include pedigree, history, functional status, and resource information about the client.

Chronological age refers to the number of years an individual has lived. This is useful in psychometrics, where it acts as a basis for measuring variables such as intelligence and behavior. Developmental stages refer to an extended period during the process of growth, where behaviors, feelings, and thoughts of an individual do not undergo significant changes. Various developmental theories such as Erikson’s theory, Freud’s theory, and Kohlberg’s theory of development are important in describing the developmental stages for human beings. Erik Erikson provides a description of emotional, psychological, and physical stages of human development, and issues for each stage. Sigmund Freud describes psychosexual stages of human development.











The client’s chronological age is 31 years. Therefore, he belongs to early adulthood, which is the same as the Intimacy versus Isolation stage of Erikson. Because of divorcing his wife, the client belongs to the isolation stage of Erikson’s stages of human development. At this age, the client should look for a satisfying job in order to take care of his family in a fulfilling manner.  

The chronological ages of the client’s siblings are below 21 years because they are 10 years younger than Jason is. Therefore, some of the siblings belong to the stage of adolescence and others in the onset of early adulthood. The tasks they can do include concentrating well in school for academic excellence. This is the time they start intimate relationships as well. The chronological ages for the two daughters are six and eight, which shows that they belong to childhood stage of development. They belong to Piaget’s preoperational stage of human development. At their ages, the daughters can be able to represent objects in terms of symbols.

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Divorce is evident among Jason’s family members. His parents divorced while he was very young. He also divorced his wife two years ago. The chronological ages during the time of divorce ranged between 20-30 years. The divorces occurred when the individuals belonged to early adulthood. Erikson’s stage of human development that represents early adulthood is the intimacy versus isolation. Relationships start with intimacy, and they finally end through isolation. In his early adulthood, the stepfather also severely abused Jason emotionally and physically. Jason developed emotional problems when his mother failed to believe what the stepfather did to him.

The client depends on his full-time employment as a resource for earning income. He spends a lot of money in buying synthetic marijuana, which is an indication that he earns an attractive salary. The client’s support system depends on the clients for its resources because clients pay for services. The government can also fund the support systems and provide appropriate drugs and personnel such as therapists.  

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One of the primary defense mechanisms that the client uses includes the use of marijuana, which enables him to avoid unwanted thoughts. Other defense mechanisms that Jason used include denial. He denies current audiovisual or suicidal hallucinations. Sigmund Freud’s psychoanalytic theory is very significant in addressing the defense mechanisms.

The client should adhere to the therapeutic instructions in order to recover from substance dependence. The defense mechanisms such as substance use and denial are unhealthy s of coping with problems. Important information that the client should understand is that dependence on drugs can deteriorate economic resources of his family. This is evident because the client utilizes about 350 dollars on synthetic marijuana. An individual can lead a comfortable life when he or she does not use any defense mechanism, especially drugs.                 


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