OUTLINE OF A CASE STUDY REPORT

I. Identifying Information
A.
B.
C.
D.
E.
F.
G.

Name of the Client

Sex
Age
Civil Status
Educational Attainment
Religion
Date of the Evaluation

Imelda Castillo
Female
29
Single
Roman Catholic
March 9, 2012

II. Reason/s for Referral

III. Assessment Procedures

A. Testing Behavior
B. Psychological Tests Administered
House-Tree-Person
Hand Test
Purdue Non-Language Test
16 Personality Factors
Sacks Sentence Completion Test
C. Mental Status Examination
1. General Description
Note appearance, gait, dress, grooming neat or unkempt), posture,
gestures, facial expression. Does patient appear older or younger than
stated age?
Strategies: Introduce yourself and direct patient to take a seat. In the
hospital, bring your chair to bedside; do not sit on the bed.
a. appearance
facial features- May brace, walang wire- brackets lang
daw, aquiline nose, protruding eyes, mataas iyong hairline,
manoo, manipis ang kilay
grooming- lagging nakatali iyong buhok , not bad breath,
poor hygiene when it comes to taking a bath but is
particularly clean when it comes to neck, face, and
forearms
posture- slightly slouch when walking and in taking the test

clothing, jewelries, styling- always wear trousers at least 2

inches below the knee, no jewelry
facial appearance- average pleasant countenance
eye movements and eye contact- sustain eye contact
during normal conversations but when taking an exam, she
stares at the ceiling
degree of friendliness- friendly but moody at times
scar formation and tattoos- lacerations inside forearm, scar
that might be accounted for mosquito bites or pimple marks
looks younger/older than stated age- younger
height, weight and body shape- height, her hips are broad,
large thighs, weight is normal for her age,
mobility- all right, no catatonic or excitatory movements, no
odd gestures

Suggestions: Unkempt sand disheveled in organic or medical

disorder, pinpoint pupils in narcotic addiction; withdrawal and stooped
posture in depression

b. motor behavior:
Note the Level of activity psychomotor agitation or psychomotor
retardation tics, tremors, automatisms, mannerisms, grimacing,
stereotypes, negativism, apraxia, echopraxia, waxy flexibility;

gait when in a good mood, she skips but in a bad mood,

drags her feet
firmness and strength of handshake- normal grasp
handshake but most of the time she doesnt want to be
touched because she feels that her hands are dirty
involuntary/abnormal movements- none
purposefulness of movements- she sometimes
unconsciously swings her foot back and forth
degrees of agitation- severe when the place is crowded
and noisy, or every time she would suspect that others are
talking about her

Strategy: Ask: You may ask about obvious mannerisms. E.g. I notice
that your hand still shakes; can you tell me about that?
Suggestions: fixed posturing, odd behavior in schizophrenia.
Hyperactive with stimulant (cocaine) abuse and in mania.
Psychomotor retardation in depression; tremors with anxiety. Eye
contact is normally made approximately half the time during interview.

c. speech
rate of speech- normal
spontaneity of verbalization- natural
volume- average volume but becomes louder whenever
she talks about her traumatic experiences
speech defects- none
Whether speech is: Slow, fast, pressured, garrulous, spontaneous,
taciturn, stammering, stuttering, slurring, and staccato. Pitch,
articulation, aphasia, coprolalia, echolalia, incoherent, logorrhea, mute,
paucity, stilted.
Strategies: Ask patient to say Methodist Episcopalian to test
dysarthia

Suggestions: manic patients show pressured speech; paucity of

speech in depression; uneven or slurred speech in organic illness.

d. attitudes
how the client relates to the therapist (friendly and
cooperative only to people whom she is comfortable with,
demanding, guarded, defensive, shy whenever she jokes
around because she reported feeling ridiculed, suspicious
to most people especially toward males
Strategies: Comment about attitude. You seem irritable about
something; is that an accurate observation?
Suggestions: suspiciousness in paranoia; seductive in hysteria;
apathetic in medical illness or dementia
2. Emotions
a. mood (steady or sustained emotional state)
how deeply it is felt, length of time it prevails, how much it
fluctuates. e.g. happy, gloomy, tense, ecstatic, hopeless,
resentful, sad, bashful, elated, euphoric, apathetic,
anhedonic, fearful, suicidal, grandiose, nihilistic, panicky,
enraged, depressed
anger inflicted to herself evident in lacerating her arms with pointed
objects on hand whenever she feels distressed, in a good mood most
of the time,

Strategies: How do you feel? How are your spirits? Do you have
thoughts that life is not worth living or that you want to harm yourself?
DO you have plans to take your own life? Do you want to die?
Suggestions: suicidal ideas in 25% of depressives; Elation in Mania
b. Affective expression
Appropriate affect, she sways her foot whenever the topic
seems to distress her and she raises her voice when shes
angry and she wants to justify something she has said that
something which she wants to explain further becomes
repeated several times

Strategies: Observe nonverbal signs of emotions, body movement,

facies, rhythm of voice (prosody)
c. Appropriateness
appropriate
3. Perceptual Disturbances
a. hallucinations
auditory, gustatory hallucination
b. depersonalization and derealization
Strategies: Do you ever see things or hear voices? Do you have
strange experiences as you fall asleep or upon awakening: has the
world changed in any way?
Suggestions: visual hallucinations suggests schizophrenia. Tactile
hallucinations suggest cocainism, delirium tremens (DTs)

4. Thought processes how well a patient formulates, organizes and

expresses his thoughts
a. stream of thought quantity and rate of patients thoughts; usually
she narrates in a repetitive and somewhat unrelated with what the
question/topic is about
goal directedness and continuity of thoughts e.g.
circumstiality, tangentiality, blocking or cessation of
thoughts, loose association unfocused, vague,
perseveration excessive recurrence of a response

marked abnormalities e.g. word salad, neologism,

echolalia

b. thought content NBI

look at its degree of interference with the patients
functioning

delusions persecutory (paranoid), , somatic, sensory, thought

broadcasting, thought insertion, ideas of reference, ideas of unreality, ,
compulsions(repetitive washing of forearm, face), ambivalence,
conflicts, flight of ideas
Strategies: Do you feel people want to harm you? YES
Is anyone trying to influence you? YES
Are there thoughts that you cant get out of your mind? YES
Ask about fantasies and dreams
Suggestions: Are delusions congruent with mood (grandiose
delusions with elated mood) or incongruent? Mood-incongruent
delusions point to schizophrenia. Illusions are common in delirium.
c. Abstract thinking
reflects the capacity to formulate concepts and to
generalize
inability to abstract is known as concreteness which
reflects an earlier childhood development of thought
signaling intellectual impoverishment, cultural deprivation
and cognitive disorders
methods to test this include testing or similarities,
differences and the meaning of proverbs.

Strategies: Ask meaning of proverbs to test abstraction, e.g., People

in glass houses should not throw stones. Concrete answer is glass
breaks. Abstract answers deal with projection, morality, criticism. Ask
similarity between bird and butterfly (both alive), bread and cake (both
food).
Suggestions: loose associations point to schizophrenia; flight of
ideas, to mania; inability to abstract, to schizophrenia, brain damage.

d. education and intelligence

Use of vocabulary- she knows and is fond of using psych terms most
especially the term anxiety, level of education-tertiary (not certain
because on her chart it is written that she has graduated college but
when shes interviewed of her educational attainment, she reports
inconsistently that she has only finished first year college or 2 nd year
college), fund of knowledge- although she never was employed, she
talks as if she has been exposed to the corporate world, she also
answers questions in English whenever she cannot pick the right
Tagalog words
Check educational level to judge results. Rule out mental retardation,
borderline intellectual functioning.

best measured in clinical interviews through the patients use of

vocabulary
level of education of the patient influences the therapists expectations
of the patients level of intelligence

e. concentration patients ability to focus and maintain his/her attention on

a task
Ability to pay attention, distractibility, ability to do simple math.
She can pay attention to questions however she becomes easily
distracted during the course of conversation ie she hears someone
laughing or someone passes by

5. orientation (time, place, person, situation)/sensorium

she is oriented when it comes to place, person and situation
however she does not know the time or month
Strategies: What place is this? What is todays date? Do you know
who I am? Do you know who you are?

Suggestions: delirium or dementia shows clouded or wandering

sensorium. Orientation to person remains intact longer than orientation
to time or place

6. memory

a. remote/long term memory (birthday, schools attended etc.)

she has remote long term memory she vividly remembers a time during
her childhood years when she had a conflict with her cousin,
Strategies: Where were you born? Where did you go to school?
Date of marriage? Birthdays of children? What were last weeks
newspaper headlines?
Suggestions: patients with dementia of the Alzheimers type retain
remote memory longer than recent memory. Hepermnesia is seen in
paranoid personality. Gaps in memory may be localized or filled in with
confabulatory details.

b. immediate/short term memory (recounting what was told 5 minutes after

hearing it and being coached to remember it) e.g. repeat 3 names of
unrelated objects previously told to him/her
Strategies: Ask patient to repeat six digits forward, then backward
(normal response). Ask patient to try to remember three nonrelated
items; test patient after 5 minutes.
Suggestions: loss of memory occurs with organicity, dissociative
disorder, conversion disorder. Anxiety can impair immediate retention
and recent memory. Anterograde memory loss (amnesia) occurs after
taking certain drugs e.g. benzodiazepines.

c. Recent e.g. where were you yesterday? What did you eat at your last
meal?
In organic brain disease, recent memory loss (amnesia) usually
occurs before remote memory loss

7. Impulse Control
verbal and/or behavioral manifestations of the ability to
control the expression of aggressive, hostile, fearful, guilty,
affectionate, or sexual impulses in situations where there
expression is maladaptive

she can manage to control her anxiety through repetitive thinking that
she has to have a control over it however when she feels that she
cannot control it, she would shun people away or shut herself from
others

8. Judgment
patients ability to understand relationships between facts
and to draw conclusions
Strategies: What is the thing to do if you find an envelope in the
street that is sealed, stamped, and addressed?
Suggestions: impaired in organic brain disease, schizophrenia,
borderline intellectual functioning, intoxication.
9. Insight level
Ability to realize whether there is physical or mental problem; denial of
illness, ascribing blame to outside factors, recognizing need for
treatment

patients capacity to be aware and to understand that he or

she has a problem/illness
capacity to review probable cause of the illness, and
recognize the need for treatment

Strategies: Do you think you have a problem? Do you need

treatment? What are your plans for the future?
Suggestions: Impaired in delirium, dementia, frontal lobe syndrome,
psychosis, borderline intellectual functioning.

ORDER OF RECORDING PATIENTS HISTORY

1. Patient Identification personal data
2. Circumstances of referrals
3. chief complaints recorded verbatim; if patient is too disturbed to
verbalize his or her complaints, ask a 3rd party
from patient: kasi nagugulo na sila sa bahay, hindi sila as ease
from informant: bumalik yung dati may kinakausap pero wala naman,
nagmumura at naninira ng gamit as verbalized by her sister
4. history of present illness
- when was the onset of the symptoms

2nd time confinement here @ EHCH 2008

1 yr & 2 months @ Plane View Homecare last March 2010 (Mandaluyong)
highest level of functioning is established
describe how patients problem interfere with his/her highest level of
functioning- easily gets irritable, shes verbally assaultive, physically
assaultive sometimes, mumbling episode, shouting spells, naninira ng
gamit (she allegedly destroyed 2 laptops because she believes that she
has many messages in her social networking site and that the spy
software is up to get her)
document all relevant symptoms presented by the patient
note precipitating factors/stressors at the time the patient became
symptomatic- shes somewhat unproductive becoz she just stayed in their
house, she lives with her mother and sister and her father has another
family, she was a smoker (5-7 stickers per day for 7-8 years)
drinker before
a family psychiatric history is also present in the side of the father- her
half-brother
therapist does not yet confront the patient with his/her findings

5. Psychiatric History
-ask whether any help was sought by the patient, if yes inquire
about:
who saw the patient
how long was the treatment
nature of the treatment
medications prescribed if any
modality that was helpful e.g. individual, group therapy,
psychopharmacology
reason for discontinuing the treatment
- hospitalizations, therapy, medications
6. alcohol and drug history
drugs used and amounts consumed
method of administration (oral, by sniffling, or by injections)
frequency of use
social setting in which substances are used
reason for using drugs
ask the patient whether he/she has ever considered drug/alcohol
consumption a problem
inquire about complications of drug consumptions (drug overdose, loss
of consciousness, withdrawal effects)
any previous effort to withdraw from use of drugs
previous treatment sought (chemical dependency programs or selfhelp groups_
effects of drug/alcohol consumption on the patients life employment,
social rel, trouble with the law

7. Family History
record a family tree
names and ages of living relatives
names and ages of deceased relatives
organic and psychological illnesses of family members genetic
vulnerabilities
suicidal behavior or death by suicide of relatives
support system
8. Personal History

a. prenatal period
planned or unwanted
toxicological and nutritional status of the mother
medical problems of the mother, including obstetrical
complications
type of prenatal care received
prenatal wishes
parental expectations
whether the child was replacing one lost through
miscarriage or death
how names were selected and whom the child was named
after
fathers role during pregnancy and delivery
delivery problems
defects at birth
obtain it to the extent known by the patient
b. Infancy and Babyhood
Early infant-mother relationship
Feeding problems
Sleep patterns
Developmental milestones
Infantile illnesses
Illnesses of infants caregivers
Who took care of the infant and their particular influences
c. childhood
rel with and influences of caregivers
developmental delays
symptoms of unusual behaviors rocking, head banging,
temper tantrums, bedwetting, separation anxieties, nightmares
toilet training and feeding habits
early sibling relationships, care giving roles of siblings and
sibling rivalries

independent behaviors and capacity

play activities favorite activities, childhood stories and patients
associations with them
earliest memories
school experiences and reaction to first going off to school
academic devt favorite subjects, subjects excelled in/ found
difficulties in
important figures inn school teachers, counselors, friends
illnesses, accidents, medical or surgical events and its influence
on the childs life
possibility of child abuse for children with multiple fractures and
multiple soft-tissue injuries
discipline and types of punishment, including figures who gave
the punishment and its effects of the child
emotional impact of any significant losses/separations
symptoms reflecting emotional distress enuresis, nail biting,
night terrors, excessive masturbation

d. Adolescence
Major body changes and its influence on the individual
Parental, peer and authority relationships and problems
School history, grades and achievements
Interests and activities hobbies, sports, church activities, civic
responsibilities, work
Drug use, eating disorders, periods of depression, alcohol use,
identity problems, suicidal ideation, self mutilation
e. Adulthood
Educational history
Work history
Marital history
Capacities for intimacies, friendships and social networks
Civic responsibilities
Finances
Family relations and children
Vacation habits
Religion
8. Sexual History
Childhood sexual playing experiences
Early life experiences related to sexual abuse
How the patient learned about sex; who was responsible for the
learning
Reactions of parents to patients inquiries about pregnancy or sex
Experiences at puberty menarche (readiness, expectation, meaning
attached to it)

Masturbatory history
Description of sexual experience heterosexual or homosexual; from
kissing to sex
Couples history includes courting, engagement, premarital sexual
activities, marriage, honeymoon, childbearing, child rearing, marital
crises and threats, separations/divorces, traditional or non traditional
rel of couple (married or cohabitation)
Sexual conflicts and sexual dysfunctions
10. medical history
chronic illness leading to frequent medication and treatment
surgical experiences
history of accidents
psychological meaning of illness and interventions : effects on : body
image, fear of invalidism or death, work, play and recreation, family
and social relationships
patients motivation for recovery
patients level of denial
support system

IV. Background of the Client

A. Adaptation in life situations
What are the major tasks in the clients life (work, school, family) and
how well is he functioning? Does he seem to be at or below optimum?
B. Symptomatic Behavior
1. From the clients standpoint, what is troubling him? What are his
presenting symptoms?
2. As viewed by concerned others, family or coworkers, what
deviant or disturbed behaviors does the client show? What
bothers them?
3. From the perspective of the assessing clinician, what evidence
is there pf psychological disturbance? Are there thought
disorders or failure of reality testing? Are negative emotions
overly strong, uncontrollable, or painful? Anxiety? Depression?
Are distressing conflicts visible? Obsessive thoughts? Specific
dysfunctions, e.g., failures of memory, inept problem-solving,
concrete thinking?
C. Motivation for clinical care and preconceptions about mental health
What does the client expect will happen in the clinic? Why did he
come? What is hoped-for outcome? Symptom relief? More effective
functioning? Personality change? Change in distressing external
conditions? What does being a patient mean to him? How does he
view mental illness, mental health? Is he psychologically minded?

D. Appearance and behavior in the clinic

Is he anxious? Guarded? Trusting? Uncooperative and resistant?
V. Social Determinants and Current Life Situation
A. Family
What are the relationships between patient and spouse, parents or
children? How does the present family system work? Is it like or unlike
that of family origin?
B. Education and work
School and work history. Is the client satisfied with his work
achievements, income, and conditions of work? Is leisure available?
How is it used?
C. Social ecology
In what kind of community (physical and social) does the client live? Is
it home or alien? Does he identify his welfare with community goals?
Does he participate in community affairs, work for community
improvement? Is the environment crowded, noisy, safe, and ugly?
Does he commute or live close to work? Are desired facilities
available?
VI. Personality Development
Here the question is How the personality did come to be? the answer
necessarily involves analysis of early life experiences, relationships to significant
others, parents and peers. The critical identifications throughout life and major
learning experiences. The history and sequence of social and interpersonal
influences on the person. Of particular importance is the way in which the patient
coped with successive developmental tasks. What alternatives were available to
the client? How did he withstand new experiences and challenges? Did he hold
to safe and established modes of behavior? Could he take new roles?
VII. Summary of Impressions and Findings (based on the assessment tools
and the personal background of the client)
A. Cognitive Level
1. Current intellectual and cognitive functioning (e.g. ideation,
intelligence, memory, perception )
2. Degree of impairment compared to premorbid level
3. Probable cause of impairment ( by end of this subsection, the
evaluator should know whether the client has a thought
disorder, mental retardation, organicity)
B. Affective and Mood Level
1. Mood, affect at present compare this with premorbid levels

2. Degree of disturbance ( mild, moderate, severe)

3. Chronic VS Acute nature of disturbance
4. Lability how well the person modulate, control affect with
his/her cognitive resources? ( by the end of this subsection, the
evaluator should know whether there is a mood disturbance,
what the clients affects are and how ell controlled his/her
emotions are?
C. Interpersonal- intrapersonal Level
1. Primary interpersonal and intrapersonal conflicts and their
significance
2. Interpersonal and intrapersonal coping strategies (including
major defense)
VIII. Diagnostic Impression
Use the multi-axial system of making diagnosis
IX. Recommendations
A. Desired Outcomes
What qualities pf the client and/or his situation requires change if the
patient is to function in a more effective and comfortable way? What
are his major growth needs which could provide goals for therapeutic
intervention?
B. Possible Interventions
1. Environmental and social. Can the clients life conditions be
change din ways to reduce stress and facilitate growth? For
example, change of home living conditions, taking leave from
school, new job, etc. Can counseling be done with relevant
others, e.g. parents or friends, who might change their impact
on the client? Might new social activities be of benefit, perhaps
in the conjunction with people with similar problems?
2. Psychotherapy. Might psychotherapy be helpful? Of what sort,
with what kind of therapist, for how long, to what goals? Should
it be individual, group, or family? Might other forms of
psychological intervention be useful, instead of or in addition to
psychotherapy; e.g. vocational or educational counseling,
occupational therapy, music, dance or other activities?
3. Other therapeutic interventions. Is hospitalization necessary?
Are drugs required? Which? For what purpose?