College of Arts and Sciences

Graduate School
Department of Psychology

FULL CASE STUDY REPORT

A Course Requirement on
GC 4009
Internship

Submitted by:
Jason D. Ang, RPm
Student

Submitted to:
Dr. Emmanuel Hernani
Professor
 TABLE OF CONTENTS

I. PERSONAL DATA
II. REASON FOR REFERRAL
III. BACKGROUND INFORMATION
A. Developmental/Family History
B. Educational History
C. Medical History
D. Daily Functioning
IV. PSYCHOLOGICAL ASSESSMENT
A. Pre-test Assessment
i. Initial Test
ii. Further Assessment
iii. Mini-Mental Status Exam
iv. Diagnostic Impression
V. CASE FORMULATION
VI. TREATMENT PLAN
i. Goal
ii. Objectives
iii. Intervetions
iv. Progress Notes
v. Recommendation
VII. POST-TEST ASSESSMENT
VIII. APPENDICES
A. Informed Consent
B. Pre-Test Assessment Tools
C. Post-Test Assessment Tools
I. PERSONAL DATA
Name: Lady L
Address: Bermundo Village, Indahag Cagayan de Oro City
Age: 22 years old
Date of Birth: January 22, 2001
Place of Birth: Cagayan de Oro City
Gender: Female/Girl
Mobile Number: Confidential
Education: BS in Hospitality Management
Occupation: College student
Religion: Roman Catholic
Civil Status: Single
Citizenship: Filipino
Language: Bisaya

II. REASON FOR REFERRAL

She presented herself to participate in this case study because of her current
disposition. She reported that lately, she experienced sudden shaking, palpitations,
hyperventilation, and headaches. These usually takes a minutes, and observed only
when she is too much stressed.

III. BACKGROUND INFORMATION

A. Developmental/Family History
Lady L, is the youngest among in the family. She has an older sister who
had a two year gap with her. They were both girls. Her childhood as what she
describes is a bittersweet ones. She started her schooling at the age of four in a
nearest nursery school. She shares a little details of her childhood but as what
she reported, she is a very active and extroverted person when she was young,
and even participated to different programs in her local community or what they
called “Sitio” and there local parish church. She described their personality of her
older sister as yin-yang, she has the active personality while her older sister is
the reserved one and shy type.
Lady L, describe her teenage years as somewhat low-key rebellious, she
felt inferior towards her older sister because her older sister, is an achiever and
most of the attention of the family and relatives put so much attention to her older
sister than her. She was always compared to her older sister. That is why, she
demanded to enter in a prestigious private institution rather than in a public
school because her older sister enrolled in a science-based public school. Which
she felt, she deserves to be in a private school.
Her parents are both unemployed. So, her older sister now is the one who
supported her financially in her studies in Cebu. She is now in Cebu for her
studies, and now in her graduating year. She is now staying in her Aunt’s family
in Cebu. She describe that she felt awkward, and a bit distant to her aunt
because there family as she described, a very strict and distant with each other.
She feels always that she needs to cautious of her actions because she do not
want to be judged by her aunt’s family or make them offended.

B. Educational history
Lady L, started her schooling when she was 4 in a Childcare Development
Centre, near from her home. She then transferred to a near public school where
she finished her primary education. She describe her educational experienced as
bitter ones, because if her hard-time in reading, she was tagged as slow-learner.
Her family hired a private tutor for her just to catch-up her lessons and able to
aide her difficulties. Compared to her older sister, who is a consistent honour
student in the same school where she is and even graduated valedictorian.
In her secondary education, she really pursue her dream to enroll in a
prestigious private institution instead in a public school just like her older sister
did. Her family, also agreed because of the notion that it will help her in her
learning challenge. Where she describe her social life as supportive and out-
going. She met friends that consider them as confidant and a considered them as
a safe space.
 In her higher education, she decided to leave her town and study at Cebu.
She took up Hospitality Management in one of the prestigious school in Cebu.
She decided to study far from her family because, that is the only thing she thinks
she can prove to her family that she is also capable. Based on her academic
achievements, she showed high grades and become part of the Dean’s Lister.
Though, she decided to stop for about a year and go-back to her hometown due
to the Pandemic Lockdown and Academic challenge that time. Also to pave way
to her older sister who at that time, taking her practicum at Cebu Province. Due
to expensive expenses if both of them are there in Cebu, so she pave the way for
her older sister. Now, she is already taking her internship within the City of Cebu
and next year would be her graduation.

C. MEDICAL HISTORY
She had done several cardiovascular test this year due to her chief
complaints of palpitations, sudden shaking, headache, and hyperventilation.
Though the client is hesitant to show her Laboratory results to confirm but her
older sister, whom I asked for confirmation did confirmed that she underwent
several medical exams. Results showed that there are no significant findings in
her tests. She was given prescription to lessen the palpitations and increased
heart rate, which is Carvedilol. Taken only if needed.

D. DAILY FUNCTIONING
For now, Lady L is busy on her thesis and preparation for her internship.
As mentioned, she is living to her Aunt’s family. Where she reported that she
wake up early just to clean the house because she does not want to be called-
out for not doing anything. Despite that she felt unfair because her cousins who
also living the same roof, does not care doing there household choirs even
though they are told by her Aunt. Often she accepted and carried the
responsibility alone because of the thought that she might offended her Aunt and
her family.
She also mentioned that she often not taking her meals at home because
she mentioned that her Aunt’s family have a self-serving behaviours. Does not
 mind of others welfare. So, once she is done with her chores, she leave the
house early and make an excuse that she had a class but the truth is, she will
stay at her classmate turned best friend’s pad and stayed there until her class
time.

IV. PSYCHOLOGICAL TEST

A. PRE-TEST ASSESSMENT - DSM-5 Measures
i. Initial Test: DSM-5 Self-Rated Level 1 Cross-Cutting Symptom
Measure—Adult
Date taken: May 13, 2023
Domains Threshold Remarks
I. DEPRESSION* Greater LEVEL 2—Depression—Adult (PROMIS
Emotional Distress—Depression—Short
Form)
II. ANGER* Greater LEVEL 2—Anger—Adult (PROMIS
Emotional Distress—Anger—Short Form)
III. MANIA Slight
IV. ANXIETY* Greater LEVEL 2—Anxiety—Adult (PROMIS
Emotional Distress—Anxiety—Short Form)
V. SOMATIC Greater LEVEL 2—Somatic Symptom—Adult
SYMPTOMS* (Patient Health Questionnaire 15 Somatic
Symptom Severity [PHQ-15])
VI. SUICIDAL IDEATION None
VII. PSYCHOSIS None
VIII. SLEEP PROBLEMS* Greater LEVEL 2—Sleep Disturbance - Adult
(PROMIS—Sleep Disturbance—Short
Form)
IX. MEMORY None
X. REPETITIVE None
THOUGHTS AND
BEHAVIOUR
XI. DISSOCIATION None
XII. PERSONALITY None
FUNCTIONING
XIII. SUBSTANCE USE None
* Significant Result. For Further Assessment
ii. Further Assessment
MEASUREMENTS USAGE REMARKS
LEVEL 2—Depression—
Depression Moderate
Adult (PROMIS Emotional
 Distress—Depression—
Short Form)
LEVEL 2—Anxiety—Adult
(PROMIS Emotional
Anxiety Moderate
Distress—Anxiety—Short
Form)
LEVEL 2—Sleep
Disturbance - Adult
Sleep Disturbance Moderate
(PROMIS—Sleep
Disturbance—Short Form)

iii. Mental Status Assessment

Lady L was dressed appropriately. In terms of appearance, she
appears to be well-groomed. Her affect is still in sync with her emotions.
She is also very consistent in her thinking and can process questions
very well. Lady L is acutely aware of her surroundings, emotions, and
problems. However, she exhibits agitation while speaking, indicating that
she was anxious during the session. She can't maintain eye contact for
long, so she sometimes diverts it with something very stimulating to her
eyes inside the counselling room. Her posture is slouching, and she is
not sitting comfortably. However, it did not show any significant results.
iv. Diagnostic Impression
F41.1 Generalized Anxiety Disorder
F34.1 Persistent Depressive Disorder, with atypical features, in full
remission, Late onset

V. CASE FORMULATION
Lady L presents with a variety of somatic complaints, including palpitations,
hyperventilating, headaches, and body pains, which are accompanied by a depressive
mood for the majority of the day. However, she claims that she is still functional on a
daily basis. These appear to be the result of her current situation. She was separated
from her family and had no choice but to live with her relatives, who are strict and
oppressive to her. Together with the stress of her school's demands and the financial
constraints imposed by her family. Her weak social relationships and family support, as
well as unprocessed emotions from her childhood, appear to have predisposed her to
depressive mood and sudden anxiety attacks. Knowing her precarious health during her
childhood contributes to her complaints. The current problem is maintained by her lack
of strong social support and her continued existence in her current situation. She had
never thought of herself as a confidante. She is also away from her hometown, which is
her safe haven. However, her protective and positive factors include her personality;
she has a strong sense of independence and resilience, which she developed as a
result of being neglected for most of her life. She also mentioned that, even though they
were estranged from each other, she remembered her cousins as someone who always
listened and provided her with great support when she was younger.

VI. TREATMENT PLAN

i. Goal
Lady L must be able to control her unwanted thoughts and false
perceptions over time using the Cognitive-Behavioral Approach. As part of her
short-term goal, she must also be able to handle anxiety attacks with various
breathing and meditation exercises.
ii. Objectives
1. Client must be able to reduce the frequency and intensity of anxiety
symptoms.
2. Client must enhance her ability to identify and challenge negative thought
patterns.
3. Client must develop coping strategies to manage anxiety and prevent
panic attacks.
4. Client must be able to increase her overall well-being and functioning.
iii. Interventions
1. The client will receive psychoeducation on the basics of CBT and its
principles, with an emphasis on the relationship between thoughts,
emotions, and behaviors.
2. The client will be introduced to journaling, in which she will be guided
through the process of identifying and recording negative automatic
thoughts associated with anxiety-provoking situations.
 3. The client will be advised on the Cognitive Restructuring technique. She will
be aided in challenging and reframing her negative thoughts by using
journaling as a foundation.
4. The client will receive a brief workshop on relaxation techniques. She will
be taught various relaxation techniques, such as deep breathing and
progressive muscle relaxation, to assist the client in managing their
physiological symptoms of anxiety.

iv. Progress
Client shows active participation level throughout the entirety of the session,
the client demonstrated an increasing level of comprehension of the CBT principles
as the session progressed. She demonstrated a heightened awareness of the
negative thought patterns that they engaged in; however, it is still evident that she
still has these impediments in terms of making an action to reframe her actions.
However, she reported that the relaxation techniques that were given to her are
helpful, and she reported that there has been improvement in the physical
symptoms that are associated with her anxiety and panic attacks.
After a week of follow-up, the client was still hesitant to accept the reality
and hesitant to reframe her actions; she was willing to acknowledge her negative
thoughts but unwilling to challenge her own behaviour. During this session, the
client was able to report that she continued to experience anxiety and panic attack
symptoms. But significantly different before the application of relaxation
techniques.

v. Recommendation
1. Continue to practice cognitive restructuring techniques and challenge
negative thoughts.
2. Introduce additional coping skills, including mindfulness exercises and
problem-solving techniques.
3. It was recommended that she consult with the guidance counsellor at her
school or any other mental health professional for additional therapy and
 evaluation. It is necessary to provide her with care of a higher quality in
order to address her reservations. And to confirm diagnostic impressions.

V. POST-TEST ASSESSMENT

MEASUREMENTS USAGE REMARKS

LEVEL 2—Depression—
Adult (PROMIS Emotional
Depression Mild
Distress—Depression—
Short Form)
LEVEL 2—Anxiety—Adult
(PROMIS Emotional
Anxiety Moderate
Distress—Anxiety—Short
Form)
LEVEL 2—Sleep
Disturbance - Adult
Sleep Disturbance None
(PROMIS—Sleep
Disturbance—Short Form)

Prepared by:

Jason D. Ang, RPm

MA in Guidance and Counselling
GC 4009
 APPENDIX A
Informed Consent
 APPENDIX B
Pre-Assessment Tools
 APPENDIX C
Post-Assessment Tools