HOW TO WRITE A CASE HISTORY

1. Background Information
The client's background: Include factors such as age, gender, work, health
status, family mental health history, family and social relationships, drug and
alcohol history, life difficulties, goals and coping skills and weaknesses.
2. Description of the Presenting Problem
In the next section of your case study, you will describe the problem or
symptoms that the client presented with. Describe any physical, emotional or
sensory symptoms reported by the client. Thoughts, feelings, and
perceptions related to the symptoms should also be noted. Any screening or
diagnostic assessments that are used should also be described in detail and
all scores reported.
3. Your Diagnosis
Provide your diagnosis and give the appropriate DSM-IV code. Explain how
you reached your diagnosis, how the clients symptoms fit the diagnostic
criteria for the disorder(s) or any possible difficulties in reaching a diagnosis.
DSM –AXIS
AXIS 1Axis I: Psychiatric diagnosis (es)All psychiatric diagnoses are listed on
Axis I (except for the personality disorders and mental retardation, which are
reported on Axis II). If there is more than one diagnosis, the primary
diagnosis is mentioned first
and then the subsequent co morbid diagnoses.
AXIS 2Axis II: Developmental diagnoses and diagnoses first diagnosed in
infancy or childhood
Diagnoses recorded on Axis II include mental retardation and the personality
disorders. Axis II may also be used to note prominent maladaptive personality
features and defence mechanisms
AXIS 3Axis III: Physical diseases All physical diseases are mentioned here,
whether the disease symptoms are related to the psychiatric disorders or not.
These general medical conditions are
potentially relevant to the understanding or management of the individual’s
mental disorder.
AXIS 4 IV: Psychological stress factors affecting the patient. This includes all
stressors, past and
present, which have an influence on the patient at the time of the evaluation.
These factors may include situations dating from childhood up to the present
day. Possible psychosocial or environmental problems include:
• Negative life events • Environmental difficulties or deficiencies
• Familial or other interpersonal stressors • Inadequate social support or
personal resources
• Problems relating to the context in which a person’s difficulties have
developed.

AXIS 5
Axis V: Global functioning of the patient. This gives a broad evaluation of the
Individual’s ability to cope with their present life situation and can also be
used as a measure of the need for hospital admission. This information is
useful in planning reatment and measuring its impact as well as in predicting
outcome.
The Global Assessment of Functioning (GAF) scale can be used to quantify
this
level of functioning. The GAF scale was developed specifically to rate
psychological, social and occupational functioning (see fact sheet: ‘Rating
mental disorders’ for more information on the GAF and other rating scales).
An example of a psychiatric diagnosis
using the 5 axes is given in table 1.

EXAMPLE
Axis I: psychiatric diagnosis (es) include major depression, first episode,
moderate severity and panic disorder with agoraphobia
Axis II: developmental diagnoses of infancy or childhood. Diagnosis deferred
on axis 2
Axis III: physical diseases including epilepsy, headaches, bronchitis
Axis IV: psychological stress factors affecting the patient including divorce,
death of mother 15
Years ago
Axis V: global functioning of the patient, moderate to poor with a
GAF score of 75
Table1. Psychiatric diagnosis using the 5 axes

4). Intervention (Treatment/Management

a) Biological/Pharmacological (Examples ECT, Drugs etc.)
b1). Behavioural / Cognitive-Behavioral Approach
Explain how a cognitive-behavioral therapist would approach treatment. Offer
background information on cognitive-behavioral therapy and describe the
treatment sessions, client response and outcome of this type of treatment.
Make note of any difficulties or successes encountered by your client during
treatment. The second section of your paper will focus on the intervention
used to help the client.
b2). Psychoanalytic Approach
Describe how a psychoanalytic therapist would view the client's problem.
Provide some background on the psychoanalytic approach and cite relevant
references. Explain how psychoanalytic therapy would be used to treat the
client, how the client would respond to therapy and the effectiveness of this
treatment approach.
.
b3). Humanistic Approach
Describe a humanistic approach that could be used to treat your client.
Provide information on the type of treatment you chose, the client's reaction
to the treatment and the end result of this approach. Explain why the
treatment was successful or unsuccessful.
b4) Counseling of client/family members
Type of counseling, (Individual, Couple, Group, etc)

5) Social/ Environmental Modification/Rehabilitation Measure:

How will you facilitate/help the client to change/ modify the environment?
6) Plan for Follow –Up Measures
How often do you want the client to come on follow -up?
Once a week? Once in 2 weeks?

Prepared By Professor Madya Dr.

Elizabeth Daniel
SUMMARY

A You are required to clearly present the case in an organized

manner, mention the headings under which the matter is
presented: Example, Presenting symptoms, Past history,
Family background, Diagnosis, Treatment etc.
Make sure your information under each of the heading is relevant to
the heading itself.

B When giving the Presenting problem, give all the symptoms in

chronological order clearly presented
EXample :
Since 2 years.......
Since 6 months........
Since 1month........
Now three days ago.......
Mention all facts related to presenting problem and make sure it is
related to the rest of the information presented in the case
study

C It is VERY VERY IMPORTANT to make a Correct DSM diagnosis on

all axes with adequate justification Axis I -5 diagnosis must be
made correctly given Make sure Diagnosis is adequately
justified by matching diagnostic criteria with person's
symptoms or behaviors
D You have to make a Case formulation also Here you will add the
Significant concepts from the theory presented, the appropriate
supporting details from case history presented
At the end Draw out your plan for Management or Treatment
E Mention the BIO_PSYCHOSOCIAL APPROACH TO TREATMENT
1) Biological Role of Medication, Hospitalization, ECT. etc that you
feel is appropriate
2) Psychological Treatments Here. Mention what kind of
Psychological Treatments you think would be necessary for
example Counseling,, Behaviour therapy, play therapy,
Psychotherapy, Cognitive Therapy, Jacobson’s Deep relaxation
therapy, etc
3) Social/Community/ Rehabilitation/Changing or modifying the
Environment

Prepared By Professor Madya Dr.

Elizabeth Daniel