LEARNING TASK 5

CASE FORMULATION AND TREATMENT PLAN

I. Case History:

a) Identifying Information:
Name: Thea Angela Cianna Dakay
Age: 21
Sex: Female
Address: 163 BLK 6 Kabisig Floodway San Andres Cainta Rizal
Educational Attainment: Rizal Technological University (B.S. Psychology)

b) Chief Complaint:
Thea wants to be treated because of the worsening of her depression that
started when an unexpected event came into her life, the death of her youngest
brother and her pet dog. it also happened this year. She also said that she had
bad habits such as waking up late because of the sadness she felt until it
reached the point where he could not sleep well.

c) History of Present Illness:

Feb.2022. Thea lost a loved one and that's when the symptoms started saying
that the patient had depression because of the stressful events that went through
her life (always crying, not being able to talk properly, having lack of sleep). It
became even more alarming when he had to go to his class even though she
was in the middle of mourning her situation worsened. Her symptoms included
the following:
a. Emotional symptoms: sadness,lack of interest in almost all activities
b. Cognitive symptoms: difficulty concentrating
c. Behavioral symptoms: crying, social isolation
d. Physiological symptoms: difficulty falling asleep, tiredness

d) Psychiatric History:
Thea's lack of sleep and depression started when her brother died just this year.
Within a month of her brother's hospitalization, she was facing a series of
problems. She tried to distract herself by reading and using her cellphone but it
was not enough to forget the complicated things that had happened in her life.
 She described it as if nothing was changing and as if it was just happening to her
over and over again and she mentioned that she was tired of everything. So far
the client has remained steadfast despite what is happening in her life and she
has been able to continue whatever she thinks reduces the sadness she is
feeling now (for example meeting her friends, venting her grievances with her
sister. and of course reading novels)

e) Medical History:
Thea did not have any medical use that could influence her psychological
functioning.

f) Mental Status Check:

the client is, it's okay to talk, she can answer correctly somehow, it is noticed that
she will show sadness and response and depressed mood.

g) Diagnostic Impression: (With DSM 5 Criteria)

Dysthymia

II. Case Formulation:

a. Precipitants:
The loss of two important things that Thea has kept in her life, has caused
her so much grief that it has led to depression. Because of this, she lost
motivation in everything, including her studies, only negatives were
running through her mind so she was often easily distracted. One of the
worsening of her situation is that her family is facing despite her grief and
her family also needs to understand the problem they are facing as a
family.

b. Theoretical Explanation:
As indicated by the cognition-theoretical explanation, the premise of
every burdensome improvement is addressed essentially by mental
brokenness; the reasoning example of the discouraged patient is
portrayed by consistent mistakes like particular insight, arbitrary
reaching of inferences, embellishments, and so on. Negative,
 oppressive valuable encounters, which manifest themselves as
cognitive schemes, are setting off conditions prompting brokenness by
fostering a bunch of negative insights. The patient encounters these
contemplations as being automatic, obstinate, persevering and
accidental. Such contemplations are consistently about subjects like
sadness and low confidence and furthermore the normal one the self-
destruction. This cognitive problem liable for all psychiatric features of
depression. Discouraged people generally point extremely high and
accept that the world generally forces insurmountable impediments for
them. They will generally make their own deficiencies or low degree of
capacity answerable for undesirable encounters.

III. Treatment Plan:

a. Concerns and Problems:

1. her lack of motivation especially in studying.
2. her loneliness especially in this pandemic she rarely has anyone
to talk to.
3. Depression; especially sadness, crying

b. Treatment Goals:
1. Reduce negative distorted thinking.
2. Find healthier ways to have fun. ( example: change in diet,
practice exercise, and increase socialization)
3. Try relaxation techniques, meditation, and breathing exercises.

c. Intervention/Psychotherapy Procedures:

- Talk therapy where her would be fixing up a specific time

with the counsellor. During these sessions, the counsellor
would try to get into her frame and focus on the things that
bother you and things that bring out the negativity in her.

- Role playing can help Thea to work through different

behaviors in potentially her difficult situations. Playing out
 possible scenarios can lessen fear and can be used for:
practicing social skills and improving communication skills

Cognitive Behavior Therapy or CBT can help her to:

1. learning to manage powerful emotions like anger, fear, or sadness. especially in

her case where grief is more predominant.

2. dealing with grief

3. improving communication skills

Prepared by: Valles, Zherlyn C.