Clinical Case History

1. Present Status:
This should be a detailed account of the patient's central problem. Put details about the
problem and related symptoms in a chronological order, as this will help with the clarity
of your writing.
I. Behaviour:
Therapist should notice clients behaviour and what is the point of view of the
client regarding his problem; major issues the client is facing.
II. Adaptation in life:
Clients life style; how the client is interacting with his surroundings?
Clients relationships with peers, family and colleagues.
III. Motivation:
Does the client came by his own will or somebody else motivated him to visit the
therapist? Is he or she is concerned with his mental health;
What are the chances that the client will do what the therapist will ask him to
do?
IV. Appearance of the Client in Clinic:
How the client appears? Is client well dressed; posture of the client and how the
client sits in front of the therapist.

2. Manifestation of Personality:
The overt behaviour of the client, Clinician observers how the client talks, walks, or
behaves with others.

I. Biological Factors:
What is the posture of the client? How does the client perceive himself and
others?
II. Temperament:
Physical posture depicts the abnormalities and diseases temperament.
III. Personality Traits:
What are the personality traits of the client? How the client describes himself
and the others?
 IV. Description of the Client:
How the client describes himself; what are his views regarding himself.
V. Interpersonal Communication:
What is clients interpersonal behaviour? Does the client show aggressive
behaviour?

3. Personality Dynamics:

I. Motives:
Dynamics means motives and efforts. Personality dynamics suggests us the
clients motives and what the client wants to achieve, his aims and goals, worth
and desires. What are his feelings towards life?
II. Affects:
The affects are the feelings or emotions client faces during his mental illness.
It can be anger, guilt, regret, shame, etc.
III. Social Values:
It suggests the moral values of the client, the ideologies, values, attitudes,
flexibility of the client.
IV. Ego Identity:
The living environment of the client also affects his personality, is the client living
in crowded environment?
What are the personal interests of the client; likes and dislikes?
What is the personal satisfaction level?
V. Defence and Coping Mechanism:
How the clients handle any stressful situation in his life?
What are the problems he faces in handling any novel situation?
VI. Thought Organization:
What is the cognition level of the client?
Is there any problem in his cognition?
What is the perception of the client; and perception about his life and his mental
problems?
Perception
Interpretation
Organization
Judgement
 VII. Intelligence Level, Abilities, Capabilities.
What is the clients intelligence level? Does he have enough knowledge about his
surroundings? What are the abilities and capabilities of the client?
VIII. Self-concept, Self Identity:
What does client think about himself?
Does the client know his worth and value?

4. Social Determination and Current Life Situation:

The diverse and often conflicting bits of information about the individual's personality
traits, behaviour patterns, environmental demands, and so on, must then be integrated
into a consistent and meaningful picture. Knowledge of the patient's strengths and
resources is important.

I. Social Grouping/ Social Participation.

Clinician is supposed to know how the client interacts with others. Is the client is
social or asocial, aloof or joyful.
II. Family:
Clinician must know whether the client is living in joint family or nuclear family
or the family structure of the client and the interfamily relationships.
III. Education and Work:
Clients educational level is also an important factor in understanding his mental
illness. Workplace also affects the clients nature.
IV. Social Ideology:
It is also important to assess the social context in which the individual operates.
What kinds of environmental demands are typically placed on the person, and
what supports or special stressors exist in his or her life situation?

5. Major Stress and Coping Potential:

How does the person characteristically respond to other people?
Are there excesses in behaviour present, such as eating or drinking too much?
Are there notable deficits, for example, in social skills?
How appropriate is the person's behaviour?
Is the person manifesting behaviour that is plainly unresponsive or uncooperative?
 Excesses, deficits, and appropriateness are key dimensions to be noted if the clinician is
to understand the particular disorder that has brought the individual to the clinic or
hospital.

6. Personality Development:
I. Early Life Development:
Clients birth; was there any complication during his birth?
How the upbringing of the client is done?
Did the client achieved his milestones in normal age or there was any problem
during milestones?
II. Peer Group:
Is the client so self-absorbed that intimate relationships are not possible? Is the
person able to accept help from others?
III. Parents:
What are the relations of the client with his parents?
Is the client an ignored child?
IV. Experiences:
General life experiences of the client
V. Challenges:
How does the client cope with the situations and challenges.

7. Formulation of the Case:

I. Synthetic Interpretation of Personality:

It is important to have an adequate classification of the presenting problem for a
number of reasons. In many cases, a formal diagnosis is necessary before
insurance claims can be filed.
II. Overall Diagnostic Impression:
It is essential to know the range of diagnostic problems that are represented
among the patient or client population and for which treatment facilities need to
be available.
III. Specific Dysfunction:
If most patients at a facility have been diagnosed as having personality disorders
for example, then the staffing, physical environment, and treatment facilities
should be arranged accordingly. Thus the nature of the difficulty needs to be
understood as clearly as possible.
 8. Recommendations:

I. Desired Outcomes:
Clinician will provide the client with necessary instructions and should tell the client
regarding future treatment plans and what therapeutic interventions will be applied.
II. Possible Interventions:
Environmental and Social Change:
Interventions can be applied on the environment of the client as well. Therapist
can suggest client to change his environment or social circle.
Psychotherapy:
Therapies which the therapist will apply on the client regarding his major stress.
Therapeutic Interventions:
Therapist will take a note that whether the client must be admitted in hospital
and what medications should be given to the client.
III. Course of Future Life:
Clinician cannot leave the client abruptly, after the treatment, clinician is supposed to
keep a check and balance on the condition of the client that whether the symptoms of
client have increased or decreased.