Case Formulation
Created by
Rebecca Thompson
Specialty
Psychologist
Last edited
10/20/2026
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About this template
A structured template for organising a patient’s contributing and protective factors across biological, psychological, and social domains. It supports concise clinical understanding and treatment planning without adding information that was not explicitly provided.
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Case Formulation
Pre-disposing Factors
- Biological: FHx of MDD and GAD (maternal); personal Hx of adolescent panic attacks.
- Psychological: Trait perfectionism, high neuroticism, and early maladaptive schemas of unrelenting standards and failure.
- Social: High-expectation childhood environment with conditional parental regard; bullied during early high school.
Precipitating Factors
- Biological: Acute onset of initial and middle insomnia (averaging 4 hrs/night) following shift-work changes 6 weeks ago.
- Psychological: Perceived loss of control and acute fear of professional failure following a critical performance review.
- Social: Recent restructuring at work resulting in increased workload; breakdown of a 4-year de facto relationship on 12/09/2023.
Perpetuating Factors
- Biological: Chronic sleep deprivation; excessive caffeine intake (5–6 espressos daily) exacerbating physiological hyperarousal; inconsistent adherence to escitalopram (Lexapro®) 10 mg PO daily.
- Psychological: Pervasive rumination, catastrophic thinking regarding career trajectory, and experiential avoidance of workplace triggers.
- Social: Social withdrawal from peer group; living alone following separation; ongoing lack of role clarity and poor supervisory support at work.
Protective Factors
- Biological: Good general physical health; nil Hx of substance or EtOH misuse; regular cardiovascular exercise (running 3x/week).
- Psychological: High psychological mindedness, intact insight, above-average intelligence, and strong motivation to engage in CBT.
- Social: Supportive relationship with older sister (residing locally); financial stability; secure housing.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.