Download pdf - How to Write a Case History

8/7/2019 How to Write a Case History

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useful in planning reatment and measuring its impact as well as in predictingoutcome.The Global Assessment of Functioning (GAF) scale can be used to quantifythislevel of functioning. The GAF scale was developed specifically to ratepsychological, 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 diagnosisusing the 5 axes is given in table 1.

EXAMPLEAxis I: psychiatric diagnosis (es) include major depression, first episode,moderate severity and panic disorder with agoraphobiaAxis II: developmental diagnoses of infancy or childhood. Diagnosis deferredon axis 2Axis III: physical diseases including epilepsy, headaches, bronchitisAxis IV: psychological stress factors affecting the patient including divorce,

death of mother 15Years agoAxis V: global functioning of the patient, moderate to poor with aGAF score of 75Table1. Psychiatric diagnosis using the 5 axes

4). Intervention (Treatment/Managementa) Biological/Pharmacological (Examples ECT, Drugs etc.)b1). Behavioural / Cognitive-Behavioral ApproachExplain how a cognitive-behavioral therapist would approach treatment. Offerbackground 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 duringtreatment. The second section of your paper will focus on the interventionused to help the client.b2). Psychoanalytic ApproachDescribe how a psychoanalytic therapist would view the client's problem.Provide some background on the psychoanalytic approach and cite relevantreferences. Explain how psychoanalytic therapy would be used to treat theclient, how the client would respond to therapy and the effectiveness of thistreatment approach..b3). Humanistic ApproachDescribe a humanistic approach that could be used to treat your client.Provide information on the type of treatment you chose, the client's reactionto the treatment and the end result of this approach. Explain why thetreatment was successful or unsuccessful.b4)Counseling of client/family membersType of counseling, (Individual, Couple, Group, etc)

5)Social/ Environmental Modification/Rehabilitation Measure:
http://psychology.about.com/od/psychotherapy/a/cbt.htmhttp://psychology.about.com/od/historyofpsychology/a/psychodynamic.htmhttp://psychology.about.com/od/pindex/f/psychoanalytic-therapy.htmhttp://psychology.about.com/od/historyofpsychology/a/hist_humanistic.htmhttp://psychology.about.com/od/psychotherapy/a/cbt.htmhttp://psychology.about.com/od/historyofpsychology/a/psychodynamic.htmhttp://psychology.about.com/od/pindex/f/psychoanalytic-therapy.htmhttp://psychology.about.com/od/historyofpsychology/a/hist_humanistic.htm


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

Prepared By Professor Madya Dr.

Elizabeth DanielSUMMARY

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'ssymptoms 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


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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, Jacobsons Deep relaxation

therapy, etc

3) Social/Community/ Rehabilitation/Changing or modifying the

Environment

Prepared By Professor Madya Dr.

Elizabeth Daniel