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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