Case History

Introduction

          “A record of information relating to a person’s psychological or medical condition. Used as an aid to diagnosis and treatment, a case history usually contains test results, interviews, professional evaluations, and sociological, occupational, and educational data. Also called patient history” (APA). It is a type of structured interview designed to elicit the in-depth client’s details. The case history draws a sketch of current status as well as the underlying causes that led to the development of psychological disorder.

 

Basics of Case History

1.      Personal information gathering stage

2.      Referral stage – The following information is collected.

          (i)       Referred by whom,

          (ii)      The symptoms experienced

          (iii)     Details about how these symptoms started, and           progressed

          (iv)     Duration of symptoms

          (v)      Faced any difficulty in developmental years,

          (vi)     Details of schooling and the education

3.      Medical history – Information about the

medical history, if any, is gathered.

4.      Orientation stage – Information about the person’s interest and attitude towards life, political affiliations and religious belief system are gathered.

5.      Mental Status Examination stage – In this client’s appearance, behaviour, talking style, mood, thoughts and perception are observed to asses MSE.

 

Case History Taking

1.      Identification data – Initially the details

about demographic information such as name, age, gender, residential address, education, occupation, marital status are taken in detail.

2.      Problem explained by

                    (a)      Client

                    (b)      Informant (Person who accompanied client)

                    (c)      Others (family members, friends or colleagues)

          (i)       Duration of the problem

          (ii)      Intensity of the problem

3.      Personal History

          (i)       Birth and Development

          (ii)      School history

          (iii)     Medical history

          (iii)     Social history

          (iv)     Emotional development 

          (v)      Premorbid personality

          (vi)     Occupation history

          (vii)    Physical relations history

 

4.      Social history

          (i)       Family constellation

          (ii)      Socio-economic status

          (iii)     Relationship with parents

          (iv)     Interpersonal relationships

Mental Status Examination (MSE)

          This is done after the completion of history taking. The MSE is used to obtain information about the client’s level of functioning and self-presentation. More often conducted during the initial interview, the MSE can be helpful for organising objective (observations of clients) and subjective (data provided by clients) information to use in diagnosis and treatment. Then he reaches a tentative diagnosis on the basis of the information that is provided by the client and the informant.

          (i)      Behaviour: The behaviour of the client, if it is age appropriate or       not. How does the client behave with the examiner? What is his attitude        towards the examiner? These are all the points that are included under this heading.

          (ii)     Thoughts: The thoughts are significant in two important ways. One   is assessment of these will tell us more about the personality of the person.        Second and very important is that it will also tell us if the person has any       disorder of thoughts.

          (iii)    Speech: This is related to the quality of speech of the client. The    volume tone and other things are good parameters of the speech quality.

          (iv)    Perception: These are related to all the five senses of the person.        Questions regarding this tell us if the person has any illusion or    hallucination. This will tell us about the intensity of the problem the client          is facing.

Higher Mental Processes

Intelligence: This is the key factor. It helps the client to understand his own problem. If the person is aware about his surroundings and what is his general level of knowledge is the indication intelligence. If there is any indication of low sub normality then a particular test may be administered to assess the intelligence.

          (i)      Memory: This is also important aspect of intelligence. But this is at      the same time an indication of the brain functioning. Disturbance of this         is an indication.

         (ii)     Attention: This is one more indication of the brain functioning of       the person. Disturbances of attention may be an indication of some          problem at brain level functioning.

          (iii)    Concentration: As mentioned above attention and concentration        are related to each other. If the attention can be sustained it is called as concentration.

          (iv)    Insight: This means the person understands of his state. Whether      he has any understanding of his illness or not.

 

Psychological Examination

          The information about the psychological test that has been used administered for the assessment needs to be mentioned. This is helpful in quick understanding of the results.

(i)      Diagnosis: This is the final understanding about the client. With the help of the case history and the Mental Status Examination the client is diagnosed.

(ii)     Prognosis: This gives clear understanding about the chances of recovery. Considering pro-and-cons decides the probability of recovery of problem.

 

Purpose

(i)       Exact diagnosis

(ii)      Design and development of intervention

(iii)     Planning of therapy

(iv)     Administration of intervention

 

References:

1.       http://egyankosh.ac.in/bitstream/123456789/50991/1/Unit-2.pdf

2.       पांडेय, जगदानंद. (1956). असामान्य मनोविज्ञान. पटना: ग्रंथमाला प्रकाशन           कार्यालय।

3.       https://dictionary.apa.org/case-history.

 

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