CASE

HISTORY NOTES

1.Case summary
- Descriptive

Example: The patient is currently pursuing masters in Management. He has been facing financial
problems from his childhood as he was raised by his mother singlehandedly. Even though his
maternal uncle supports them financially, he had to avail an educational loan. He was a studious,
career aspirant with a clear vision about the future which all changed last month. He had been
involved in a romantic relationship which dissolved because of the negative response from the
girl’s side of the family. They weren’t okay with the relationship because of the financial status of
the patient. He is unable to concentrate, focus on job interviews which brings conflict with his
family.

2.Demographic details
A. Identifying information
- Descriptive or Table format

Example: D is a 20 years old young boy who is pursuing his college. He is a religious Christian who is
born and brought up in Bengaluru. His parents hail from a village in Tamil Nadu and therefore his
mother tongue is Tamil. However, years of exposure have also resulted in him learning Kannada and
English. The client lost his father who was an electrician, in early 2018.Now his mother works in an
office as the sole earning member to meet the needs of the family. He belongs to the lower middle
class background economically.

Name K.D
Age 14 years
Gender Female
Race/Religion Hindu
Socio-economic Status Upper middle class
th
Education 9 standard
Living Situation Resides with parents and younger brother
Occupation Student
Informant Self
Referral None

B. Informant – self or others
i. Adequacy (state or quality)
ii. Reliability (quality of being trustworthy)
iii. Consistency (steadiness/ stability)
iv. Corroborativeness (confirm/ give support to)

3.Presenting problems
- Descriptive
- Note the presenting complaint in a chronological order and state the client directly
- Note the duration of the present complaint
- Frequency of the occurrence

Example: “I met a guy through a dating app called Meet24. We used to talk and I’ve met him
once and that day, he tried to hug me and kiss me. I also hugged and kissed him back. I felt guilty
for doing that and told him to stop talking to me. Then, he blackmailed me saying he’ll send our
chat to my mom and told me to send him my ‘pics’. Then I sent him my pics, blocked him and
deleted the app. I don’t know what to do now”


4.Chief complaints
- Descriptive

Example: She is feeling guilty about everything that happened and is scared if he’ll send the
pictures to her mother’s number. She is also not able to move one from A. She reported she is
‘feeling that it’s better to die’. Such thoughts to end her life occur when she is sitting alone or trying
to study. There is constant ‘worry’ about these problems may affect her academics. She also
reported that she has trouble going to sleep sometimes and takes about 1 or 2 hours to fall asleep.

5. Brief history of the presenting problems
- Descriptive. Describe each area of complaint preferably with a detailed example
• When did it start?
• What are the thoughts, feelings, and observable behaviour related to it?
• Where and when does it occur most/least?
• How much does it interfere with the client’s daily functioning?
• What previous solutions/plans have been tried for the problem and what
were the results?
• What made the client decide to seek help at this time? (Or if referred,
what influenced the referring party?)


I. 3Ps
A. Precipitating factor – Triggering or specific event
The particular factor, usually a traumatic or stressful experience that is the
immediate cause of a mental disorder

B. Predisposing factor – Genetic factors or life events
Refers to a factor that increases the probability that a mental disorder or hereditary
characteristic will develop

C. Perpetuating factor – factors that maintain the problem
To make continuous, persisting and prolonging the psychopathology



II. OCP
Onset
• Abrupt - sudden or unexpected
• Acute - severe intense, generally <48 hours
• Sub acute - recent onset, generally 2weeks
• Gradual - slow by degree, few weeks to months
Course
• Continuous – ongoing symptoms with no intervening periods of normalcy
• Fluctuating (raising& falling) – periodic exacerbations of continuous illness
• Episodic (series of separate part of events) – discrete symptomatic periods
with intervening periods of normalcy
Progress – Forward or onward movement towards a destination
• Improving – giving moral or intellectual
• Deteriorating – become progressively worse
• Stable – lacking movement, action or change

6.Identifying the needed data
•Details on the premorbid personality of the patient
•Information about the psychiatric history of the patient
•Data on the type of parenting and the attachment styles associated
with the client
• Details regarding the reason for his parent’s separation
• Reaction and response of the patient towards the absence of his
father
• Details regarding the attachment he had with his partner in the
romantic relationship
A.Biological functioning
- Sleep: Unchanged, Increased or Decreased
- Appetite: Unchanged, Increased or Decreased
- Energy: Unchanged, Increased or Decreased
- Sexual life

B.Psychosocial history
Psychosocial factors refers to social situations, relationships and pressures that have
psychological effects. For example, business completion, rapid technological change, work
deadliness, changes in roles and status of women. i.e., factors that maintain the problem
- Social and Developmental history
- Family, Marital and Sexual history
- Education and Job history

7.Past illness and treatment
• Associated Disturbance: Enquiry should also be made of impairment in other areas
of functioning. These include disturbances in sleep, appetite, weight, sexual life,
social life and occupational functioning. The specific nature of the disturbance and
the degree of disability should be recorded.
 • Personal hygiene: Personal hygiene the patient has to be recorded, especially lapses
in maintaining good personal hygiene. Clinical conditions of the patient
• It should also include whether there were any significant psychiatric or medical illness
present, whether any treatment received for the same, type of treatment, length of
treatment, treatment place, outcome of treatment and reasons for termination,
prescription of drugs
• Social cultural influences like traditional methods of healing using Ayurveda,
homeopathy, Unani, pooja, etc.
• Negative history: certain historical details must be routinely enquired into, to rule
out an organic etiology. These include: history of trauma, fever, headache, vomiting,
confusion, disorientation, memory disturbance, history of physical illnesses like
hypertension / diabetes and history of substances abuse. Seizures while these details
are important regardless of the nature of presentation, they are particularly
important in the elderly.


8.Present illness and treatment
• Treatment received for present illness, what type and by whom? Outcome
• Current medications.
• Date of last physical examination and results.

9.Premorbid personality
-Personality of patients consists of those habitual attitudes and patterns of behavior which
characterize an individual.
-Personality sometimes changes after the onset of an illness.
-Get a description of the personality before the onset of the illness.
-Aim to build up a picture of the individual, not a type. Enquire with respect to the following
areas.

A. Attitude to others in social, family and sexual relationships
• Ability to trust others
• Make and sustain relationships / Anxious or secure
• Leader or follower / Participation, responsibility,
• Capacity to make decisions / Dominant or submissive,
• Friendly or emotionally cold,
• Evidence of any jealously, suspiciousness, guardness etc.
• Evidence of difficulty in role taking – gender, sexual, familial parental and
work.
• Certain adaptive qualities like respecting, obedient optimistic, adjustive, warm,
outgoing, empathy manifested.

B. Attitude to self
• Egocentric (thinking only of oneself ) / Selfish, indulgent (broad minded),
dramatizing
• Critical, deprecatory (expressing disaaproval),
• Over concerned, self conscious,
 • Satisfaction, or dissatisfaction with work
• Narcissism, pathological levels of increased self esteem, self absorption
(combine),
• Attitudes towards health and bodily functions.
• Attitudes to past achievements and failures, and to the future.

C. Moral and religious attitudes and standards
• Evidence of rigidity or compliance
• Permissiveness or over conscientiousness,
• Conformity, or rebellion (compliance with standards, rules, or laws).
• Enquire specifically about religious beliefs, ability to cope up.

D. Mood
• Enquire about stability of mood,
• Mood swings
• Anxious
• Irritable
• Worrying or tense
• Whether lively or gloomy.
• Ability to express and control feelings of anger, anxiety, or depression.

E. Fantasy life
• Enquire about content of day dreams and dreams amount of time spent in
day dreaming
• Wishful thinking

F. Reaction pattern to stress
• Ability to tolerate frustration, losses,
• Disappointments and circumstances arousing anger, anxiety or depression.
• Evidence for the excessive use of particular defense mechanism such as
denial, rationalization, projection, etc.

G. Biological functions and habits
• Eating
• Sleeping
• Excretory functions


10.Insight
-Diagnostic summary





11.Provisional diagnosis – DSM IV axis
Case Conceptualisation
Example:
The case manager’s own assessment of the case rather than a restatement of the facts.
Its length, layout and emphasis will vary considerably from one patient to the other. It
should always include a discussion of the diagnosis, of the etiological factors which sees
important, a plan of management and an estimate of the prognosis, regardless of the
uncertainty or complexity of the case, a provisional diagnosis, should always be
specified using the ICD. A complete physical examination is mandatory for each patient.
The DSM-IV organises each psychiatric diagnosis into five dimensions (axes) relating to
different aspects of disorder or disability:

Axis and disorder classification

A. Axis I: All diagnostic categories except mental retardation and personality
disorder
B. Axis II: Personality disorders and mental retardation (although developmental
disorders, such as Autism, were coded on Axis II in the previous edition, these
disorders are now included on Axis I)
C. Axis III: General medical condition; acute medical conditions and physical
disorders
D. Axis IV: Psychosocial and environmental factors contributing to the disorder
E. Axis V: Global Assessment of Functioning or Children's Global Assessment Scale
for children and teens under the age of 18

• Common Axis I disorders include depression, anxiety disorders, bipolar
disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia
nervosa, and schizophrenia.
• Common Axis II disorders include personality disorders: paranoid personality
disorder, schizoid personality disorder, schizotypal personality disorder,
borderline personality disorder, antisocial personality disorder, narcissistic
personality disorder, histrionic personality disorder, avoidant personality
disorder, dependent personality disorder, obsessive-compulsive personality
disorder; and intellectual disabilities.
• Common Axis III disorders include brain injuries and other medical/physical
disorders which may aggravate existing diseases or present symptoms similar
to other disorders. Cardio vascular symptoms, epilepsy






12.Hypothesising the causes
-Inverted pyramid method
-Descriptive

1. Identify and list client concerns

2. Organize concerns into

logical groups

3. Attach groups
to inferred areas
of difficulty

4.
Narrowed
inference

Identify and list concerns
• Presenting problem (behavior, thought, affect, physiology)
• Additional areas of concern- adjustment at school/work, social adjustment
• Family and developmental history
• Thoughts, behaviors and feelings in the session.
• Clinical inquiry (prescription, substance use)
• Psychological assessment

Organizing concerns into logical groups
• Organizing symptoms based on disorders: DSM-IV-TR/DSM-V
• Organizing different aspects of distress/dysfunction into thoughts, feelings,
behaviours and physiology
• Sorting areas of dysfunction based on life situations, life themes, life roles
• Understanding how information about dysfunction shapes the individual’s
experience and

Attach groups inferred areas of difficulty
• Using counsellor’s theoretical orientation to the groups identified.
• Based on client’s needs, past research, counsellor competence

Narrowed inference
• Connecting thoughts, behaviours, feelings into more deeper dynamics


Hypothesising the causes - Coping skills or coping strategies are a set of adaptive tools
that one proactively administers to adapt to a stressful situation. In this case, the
patient who had faced a stressful situation wasn’t able to cope with it. This could be
because of several reasons which can be better explained by Macro-analytic state-
oriented theories given by Lazarus and Folkman. Lazarus and Folkman’s model stated
that successful coping mechanisms depend on the emotional functions related to the
problem. Per the theory, one can find a lot of factors that moderate a person’s
efficiency of coping. Here, in this case, the patient experiences Emotional distancing,
lack of Social support, & Radical acceptance, fails to Strategically solve his problem, &
when confronted with the pressure of the situation he wasn’t able to retaliate back.
This could have been the cause of the emotional distress and associated symptoms that
he is experiencing.

Actual causes – The dissolution of his romantic relationship by itself could trigger his
emotional distress. The break up could bring about diminishing resilience and
optimism. The relationship failure could have brought about low self-esteem and self-
concept. Adding to this, he might have had a poor & unhealthy coping mechanism. On
whole this could have developed as in a snowball effect which could explain his
problems of having trouble concentrating on his studies as well as focus on the future.

Problem identification
• Unhealthy coping skills of the patient
• Low self esteem
• Emotional distress over dissolution of the relationship
• Inferiority over his financial status
• Unable to concentrate on his studies & about his future
• Conflicts in the family

13.Strategies and Intervention
I. RESILIENCE-INFORMED THERAPY:
• Resilience-Informed therapy applies research on resilience to form an
integrative mind-body approach to trauma recovery. This strength-based
treatment model of care includes:
• Relational psychotherapy
• EMDR Therapy (Eye Movement Desensitisation and Reprocessing)
• Somatic Therapy (body-centred psychotherapy)
• Parts Work (Gestalt, Internal Family Systems)
• DBT (Dialectical Behavioural Therapy)
• Mind-body therapies (therapeutic yoga, mindfulness and integrative
healthcare)

II. COGNITIVE BEHAVIOURAL THERAPY:
Cognitive behavioural therapy (CBT) is an ideal approach for tackling low self-
esteem as it is primarily a cognitive (thinking) problem. Thus, it is treated by
restructuring negative, self-critical thinking patterns and by actively directing
your attention to your strengths and qualities. CBT helps one to see the
connection between their thoughts, feelings and behaviour. This helps to alert
the damaging consequences arising from as negative automatic thoughts
(NATs).

III. MINDFULNESS BASED COGNITIVE THERAPY(MBCT):
Mindfulness-based cognitive therapy (MBCT) is an approach to
psychotherapy that uses cognitive Behavioural therapy (CBT) methods in
collaboration with mindfulness meditative practices and similar
psychological strategies. MBCT prioritises learning how to pay attention
or concentrate with purpose, in each moment and most importantly,
without judgment. Through mindfulness, clients can recognise that
holding onto some of these feelings is ineffective and mentally
destructive. MBCT focuses on having individuals recognise and be aware
of their feelings instead of focusing on changing feelings.