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Case Study 2: In Pain
(Adapted from Kring, 2007)
Mark was 38 years old and married with two children. He lived about 50 miles from a large city
in the southwestern U.S. After graduating from high school, Mark went to work for a paper
company that was part of a large multinational conglomerate. Mark’s first job was to move and
load heavy boxes of paper products, and he slowly moved his way up the corporate ladder over
the years. His dedication and long hours of work had recently led to his promotion to section
manager. On one hand, it was what he had been working so hard to achieve: but on the other
hand, he had never been comfortable giving orders to others, and he especially dreaded the staff
meetings he would have to run.
Soon after the promotion, Mark took a break from his paperwork and visited the employees at
the loading dock, many of whom were his friends. For old time’s sake, he helped them load a
few of the heavy paper boxes and in the process felt his lower back become suddenly tight and
rigid. Mark couldn’t walk well after that, and he felt a constant, dull ache in his lower back that
he reported was very uncomfortable. He also experienced tingling sensations and sometimes
shooting pain running down his right leg. Mark’s wife picked him up from work later that day;
they were able to get a walk-in appointment with his primary care doctor, who referred him to an
orthopedist. An MRI helped to determine that Mark was suffering from a herniated disk. The
physician decided on a conservative treatment approach: rest for two weeks and non-steroidal
anti-inflammatory medication (e.g. Aleve) as needed. Surgery would only be considered as a
last resort.
Mark took disability leave from his job while he rested at home. His family was very supportive,
doting on him and even serving his meals in the living room so he could eat while reclining in
his favorite chair. Mark’s recovery went well over the first few days, but then seemed to stall.
He continued to report pain and discomfort in his lower back and leg that prevented him from
walking for too long and even led to him sleeping in his chair at night instead of in his bed. The
next month was filled with physician visits in hopes of pain relief. A subsequent MRI revealed
that Mark’s herniated disk had, in fact, improved, but Mark continued to report daily pain and
discomfort. At 5 weeks post-injury, Mark’s family was clearly experiencing stress related to his
condition, particularly his wife, who frequently had to leave the small business that she ran to
take him to the doctor. Additionally, Mark’s disability leave from work was about to expire; he
could request an extension, but his improved medical reports would not help his case. Since
surgery was not an option, Mark requested stronger painkillers from his physician, but was only
given a supply that he considered too few to control his pain. Mark often found himself very
angry at his situation. He was referred to a health psychologist for pain management.



Guidelines for Writing Case Study Reports
1. Overview
Students will a Case Study about a fictitious client, research etiology and treatments related to the
client’s problem(s), and write a report to describe these findings and to make recommendations for
this individual.
a. Case Reports will be 2-3 written pages in length (2.0 spacing, 12 pt. Times New Roman)
and will contain the following sections:
i. Referral & Presenting Problem
ii. Client Information & Brief History
iii. Case Formulation
1. Biopsychosocial etiology—how did this problem develop?
iv. Treatment Recommendations
1. Which types of treatments might be effective for this person?
2. Which health care provider(s) would be best suited to provide the services
this individual needs?
2. Section Descriptions
a. Referral & Presenting Problem.
Why is the client seeking this testing at this time? (Always refer to the person being
evaluated as the client.) Is he or she self-referred or has the testing been requested by a 3rd
party, e.g., State of Florida in regards to a recent disability claim filed by the client?
b. Client Information & Brief History.
From the Client Intake Form, briefly describe the client’s gender, age, and ethnicity. Note
any historical information might be important, e.g., past treatment for depressed mood.
c. Case Formulation.
This is an important part of the case report. Refer to Taylor (2014), as well 2 other sources,
to formulate an explanation for why the client is presenting with this particular problem(s).
Use the biopsychosocial model of etiology—which biological, psychological, and social
factors may be important in formulating hypotheses to understand this client.
d. Recommendations
Make brief recommendations for this client based on his or her main test results. For
instance, if the client scores very low on a visual spatial task compared to others of similar
age and background, what would you recommend? (In this case, you as the examiner might
recommend that the client follow-up with a neuropsychologist for further evaluation.)
PSY 250 Hybrid / Stasio
e. Report Writing Style.
Please use 12 point Times New Roman font with 2.0 spacing throughout the paper, which
should be about 2-3 pages in length. The student’s name, assignment, and date should
appear at top L to start the document; pages should be numbered. (Title Page is