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A standardized case history format for clinical psychology and psychiatry

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Article · January 2015

DOI: 10.5958/2320-6233.2015.00015.2

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International Journal of Psychology and Psychiatry Vol. 3 No. 2 2015

DOI:10.5958/2320-6233.2015.00015.2

6.A STANDARDIZED CASE HISTORY FORMAT FOR CLINICAL PSYCHOLOGY AND

PSYCHIATRY PROFESSIONALS
Dr. Gopal Chandra Mahakud
Assistant Professor
Department of Applied Psychology, University Of Delhi South Campus, New Delhi

Abstract

A case study method is one of the old and widely used method in clinical psychology
and psychiatry to gathor the information from the patient. In this regard it is imprtnat
to say that, although taking hstory of the patient is important, but still in India, no two
clinicians have been using a similar type of case histry formate. Therefore the present
case hirtoy method developed bu the researcher will serve a standardized case history
format for the psychologist and psychiatrist, especially in India to collect the
information in more scientific way from the patients related to different psychological
and psychiatric disorders.

Key words: Psychology, Psychiatry, Standardized Case History format, Inter-rater

Reliability, Content Validity

INTRODUCTION

Collection of information through case history method is still more popular among the
researchers, especially for the researchers working in qualitative research. Different case history
forms have been used in different organizational sector for collection of information accordingly. In
this regard it is important to say that the uses of case history forms in clinical settings are quite
important especially for clinical psychologists and psychiatrists. In this regard, researchers1-2 stated
that a ‘case study’ is a research method that involves an up-close, in-depth, and detailed examination
of a subject of study (the case), in relation to the contextual conditions. Many people in the history of
clinical psychology used case history for the collection of information and completed their study
successfully. For example, Freud3, in his first research in clinical psychology collected information
from 80 cases and analyzed to find out different psycho dynamic and psychoanalytic principles
related to different mental disorders. Similarly, Watson, and Rayner4, the experiment of little Alberta
is one of the best examples of case study as an effective method of technique for data collection.
From the history and till date case study method is one of the most effective technique for the
collection of information especially in clinical psychology and psychiatry.

Besides the field of clinical psychology and psychiatry, now days case study is one of the
commonly used qualitative technique in most of the field of social sciences. Therefore it is called that
case study as a method of diagnosis of the positive relationship of any past event with the present
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International Journal of Psychology and Psychiatry Vol. 3 No. 2 2015

DOI:10.5958/2320-6233.2015.00015.2

behavior. As a case history is based on retrospective information, Goffman5 affirmed that, the
development and origin of many psychological problems can be analyzed by ordering the historical
information according to its development systematically. Therefore, it can be said that Case History
supposedly a literal presentation of the historical facts that serves to legitimate official explanations,
as it appears to have the authority of an authentic life history. Further Lofland6, stated that the
method of data collection using case history functions as a special history related to the present
problem behavior of the patient. In other words, it can be said that it's one of the methods of data
collection using biography of the Clinet to the present malevolence characteristics related to the past
threats.

REVIEW OF LITERATURE: The history of research conducted using case history is quite
a long. The first use of case history in the field of psychology was originated in clinical psychology
by Sigmund Freud3, where he conducted the case history of 80 clients suffering different mental
disorders. Interestingly, the entire psychoanalytic theory of Sigmund Freud is based on these 80 case
studies. Similarly, another important and renowned case study of little Alberta by J. B Watson4
emphasized the importance of case history in the field of psychology, especially in clinical and health
psychology and psychiatry. Many studies7-8 even today has been conducted by psychologists and
psychiatric using the case history method. Emphasizing the importance of case history in sociology,
Whan9, stated that case histories share patients inner and suppressed, though which was in the
shadow of the straight world. The statement is quite similar to the Freudian principle of the
unconscious where proposed that, different abnormal and irrational behaviors are suppressed in the
unconscious level of mind. Further, Sigmund Freud stated that, the conflict between these
unconscious suppressed behaviors is the reason for the abnormal behavior of human being. The
usage of case history taking is more common and important I the field of criminal and forensic
psychology.

Many researchers published a series of case history in the field of criminal and forensic
psychology. In the field of criminal and forensic psychology, symptoms/traits related to criminal
behavior, forensic assessment, or treatment many researchers prefer case history as a better
technique. For example Murphy10, in his study, analyzed the case history of an individual with an
autistic spectrum disorder and its relation to his violent behavior. Similarly, Mart and Connelly11,
analyzed a case of postictal aggression resulting in criminal charges. They stated that seizures and
their concomitant behaviors, are the result might lead to criminal acts of the individual. One other
case history related to the mental disorders and criminal behavior was studied by Mart & Connelly11.
The forensic case history of Mart & Connelly11 concluded that criminal behaviors are related to the
mental state of the individual at the time of the crime.

Further, a treatment based case study was conducted by Barnao, Robertson, and Ward12
indepth discussion of how the Good-Lives-Model approach to offender rehabilitation was applied to
three forensic patients. In their study, they begin by outlining the model and then illustrating the
approach in terms of case conceptualization and treatment for three different individuals involved in
different criminal activities and finally, they use the case examples to embark upon a discussion of
the model and how it relates to the treatment of forensic patients and criminal offenders.

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DOI:10.5958/2320-6233.2015.00015.2

Besides that in the field of psychiatry, and clinical psychology, the application of the case
study is more common. In this regard from the study of Bleuler13, who had examined 130 late onset
cases of Schizophrenia stated that all schizophrenic disorders begin between ages 40 and 60, and
onset after age 60 is negligible. Further Post14 classified patients having paranoid symptoms show
their symptoms of paranoid schizophrenia after the age of 50 years such as hallucinosis,
schizophreniform syndrome and schizophrenic syndrome. In India, Jena15, conducted 10 case studies
on children with different type of learning disabilities. From these case studies the, researcher found
the important causes of different types of learning disabilities such as reading disabilities, writing
disabilities, and mathematical disabilities. Mahakud and Jena16, also conducted two cases of children
with reading disabilities. After finding a detailed underlying cause of reading disabilities, they found
that, children with reading disabilities are poor in their cognitive processing abilities. Further,
Kishore17 conducted a case study on children with Autism spectrum disorders and found the causes
and etiology of Autism and provided intervention successfully. Onyeizugbo18, conducted a case
study adult with stuttering problem where, the researcher found the detailed problem related to
stuttering problem and provided simplified regulated breathing treatment.

NEED OF THE CASE HISTORY FORM: Although, in clinical and psychological, health sector,
many professionals have been using, case history form to find out the in depth information related to
different psychological and psychiatric problems, but still, in India, no two professional in a clinical
setting, a standardized case history form they have been using. Therefore, the ore sent study was
intended to develop a standardized case history form to avail in depth information in the field of
clinical psychology and psychiatry.

METHODOLOGY:
Objective: To Standardized Case History Format for Clinical Psychology and Psychiatry
Professionals

Sample: A total of 20 cases suffering different psychological problems such as, learning disabilities,
reading disabilities, depression, Schizophrenic disorders, and autism spectrum disorders were
participated in the present study from different psychiatric and psychological clinics from the New
Delhi municipality region, India.

Material: To develop the standardized case history form, the researcher, prepared a case history
form studying more than 20 review of literature based on case studies. More than 50 cases were
critically evaluated and then present the case study form Develop (Annexure-1). Besides that, paper,
pencil and other relevant materials were also used for the collection of information to make the
present case history form standardized.

Preparation: Before preparation of the present case history form, the researcher, critically analyzed
a total of 50 cases conducted by different psychologist and psychiatrist, Then the content of the
present case history form development, The content of the present case history form also based on
some of the researchers19-22. From the analysis of the format of case history form, Yin19 stated that,
the case study design must have five components: the research question(s), its propositions, its unit(s)
of analysis, a determination of how the data are linked to the propositions and criteria to interpret the
findings. Yin19 also affirmed that operationally defining the component of analysis of case studies,
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International Journal of Psychology and Psychiatry Vol. 3 No. 2 2015

DOI:10.5958/2320-6233.2015.00015.2

assists with replication and efforts at case comparison. Similarly Stake20 emphasized that the number
and type of case studies depend upon the purpose of the inquiry such as an instrumental case study is
used to provide insight into an issue; an intrinsic case study is undertaken to gain a deeper
understanding of the case; and the collective case study is the study of a number of cases in order to
inquire into a particular phenomenon. Guba and Lincoln21 describe a case study ‘types’.These types
are factual, interpretative and evaluative. Each case study must outline the purpose, then depending
on the type of case study and the actions proposed by the researcher. For example, research
undertaken to describe men’s experience of living with chronic coronary heart disease (CHD) could
be placed in both factual and interpretative categories23. Finally, it can be concluded that, the
researcher’s actions should include recording, constructing, presenting, and producing a chronicle, a
profile or facts. Besides that the case study should be included, construction, synthesization and
clarification. Following the above mentioned criteria, the present case history form prepared and
studies.

Procedure: After the, development of the format of the case history form used in the present study,
the researcher collected a data from 20 cases suffering different psychological and psychiatric
problems. After collection of information, for the standardization, the researcher used Interrater
reliability to find out the usability of the case history form in the field of clinical psychology and
psychiatry.

Scoring and Data Analysis: For the standardization of the case history form, the researcher used
interrater reliability. A total of five Clinical psychologist was employed for the rating of the
information for inter-rated reliability correlation and coefficient. The professional (raters) were
instructed to give numbers to the qualitative information collected using the present case history
form. Finally, the data were naluysedusing Sprearman’s Product movement correlation. Besides that,
the test –retest reliability also used for the standardization of the present case history form.

RESULT AND STANDARDIZATION: The mean score of information of Rater-1 is (4.86±5.84),

followed by the mean score of information of Rater-2 is (4.86 ±6. 82); the mean score of information
of Rater-3 is (3.71±4.64), the mean score of information of Rater-4 is (3.43±3.76) and the mean score
of of information of Rater-5 is (3.29± 3.01). Table-1 depicts the description of the score of different
Raters.

The standardization scores based content validity and interrater reliability. The present case history
form, followed content validity by critically analyzing more than 50 case histories of 20 literature
studies. The inter-rater reliability correlation score between Rater-1 and Rater-2 is (r=0. 911**),
followed by Rater1- and Rater-3 (r-0.975**); Rater-1 and Rater-4 is (r=0. 713*) and Rater-1 and
Rater-5 is (r=0. 935**). Similarly, the reliability correlation between Rater-2 and Rater-3 is (r=0.
972**) followed by Rater-2, and Rater-4 (r=0. 935**) and between Rater-2- and Rater-5 is (r=0.
736*). The reliability correlation between Rater-3 and Rater-4 is (r=736*) and the reliability
correlation between Rater-3 and Rater-5 is (r=0. 762**). Finally the reliability correlation between
Rater-4 and Rater-5 is 0.743*). Table-2 depicts the inter rater reliability correlation coefficient of
between different Raters.

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DOI:10.5958/2320-6233.2015.00015.2

Table-1: Descriptive Statistics of Information by Different Raters

Raters Mean Std. Deviation

Rater-1 4.86 5.84
Rater-2 4.63 6.82
Rater-3 3.71 4.64
Rater-4 3.43 3.76
Rater-5 3.29 3.01

Table-2: Inter-Rater Correlation of Information

Raters Rater-1 Rater-2 Rater-3 Rater-4 Rater-5

Rater-1 1.00 0.911** 0.975** 0.713** 0.935**
Rater-2 1.00 0.972 0.935 0.736
Rater-3 1.00 0.736 0.762
Rater-4 1.00 0.743
Rater-5 1.00
Note: Significant at α=0. 01

DISCUSSION AND CONCLUSION: Collection of information using case history is a traditional

technique in many branches of social psychology. The importance of case history in clinical setting
for the collection of information is still now an important method of diagnosis. In the field of
psychology, especially in clinical psychology, started with the contribution of Signmund Freud, the
father of modern clinical psychology. Even other theorist such as behaviorists and humanistic
psychologist also emphasized the importance of the case history field of psychology to determine the
in depth information related to any problem behavior of the clients and patients in clinical
psychology and psychiatric center. Although the numbers of case study researches conducted in the
field of clinical psychology and psychiatry, but still there a standard format of the clinical case
history form has not been used in many clinical research and even for collection of information in a
hospital setting, especially in India. Therefore the present case history form will definitely help the
professional working in the field of clinical psychology and psychiatry to collect a standard and in
depth information related to any problem behavior. The result of the present case history based on
content validity and inter-rater reliability indicate high correlation between different Raters (see
Table-2). Finally, it can be concluded that, the present standardized case history form will definitely
help many professional working in the field of psychology, psychiatry and other social science
collect information for their further research and clinical work.

REFERENCES:

1. Mills AJ, Durepos G, Wiebe E. (Eds.). Encyclopedia of case study research (Vol. 2). Sage
Publications. California. 2009: p. xxxi.
2. Yin RK. (2014). Case study research: Design and methods. 5th Edition. Sage Publications.
California. 2014: 5-6.
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DOI:10.5958/2320-6233.2015.00015.2

3. Freud S. Mourning and melancholia. Standard edition, 1917; 14(19): 17.

4. Watson JB, Rayner R. Conditioned emotional reactions. Journal of experimental
Psychology, 1920; 3(1): 1.
5. Goffman E. Frame-Analysis, Penguin Books, 1975: p. 559.
6. Lofland J. Deviance and Identity, Prentice-Hall, 1966: p. 150.
7. Bos J, Groenendijk L. The self-marginalization of Wilhelm Stekel: Freudian circles inside
and out. Springer Science & Business Media, 2007.
8. Katz MB.. An occupational neurosis: A psychoanalytic case history of a rabbi. AJS
review, 2010; 34 (01): 1-31.
9. Whan MW. Accounts, Narrative and Case History. The British Journal of Social Work,
1979; 9(4): 489-499.
10. Murphy D. Extreme violence in a man with an autistic spectrum disorder: Assessment and
treatment within high-security psychiatric care. The Journal of Forensic Psychiatry and
Psychology, 2010; 21: 462-477.
11. Mart EG, Connelly AW. An unusual case of epileptic postictal violence: Implications for
criminal responsibility. Psychology Open Access Journal of Forensic, 2010; 2: 49-58.
12. Barnao M, Robertson P, Ward T. Good Lives Model applied to a forensic population.
Psychiatry, Psychology and Law, 2010; 17:202-217.
13. Bleuler M. Late schizophrenic clinical pictures. Fortschr Neurol Psychiatry. 1943; 15:
259-290.
14. Post F. Persistent persecutor States of the elderly. Pergamon, Oxford, 1966.
15. Jena SPK. Case Studies: Assessment and Intervention. Learning Disabilities: Theory to
Practice, Sage India, 2013: 131-175.
16. Mahakud GC. Jena SPK. Effect of Cognitive–Behavioral Intervention for Children with
Reading Disabilities. Learning Community: An International Journal of Education and
Social Development, 2012; 3(1): 89-99
17. Kishore MT. Behavioral Intervention of Compulsive Behavior in Autism. Indian Journal
of Clinical Psychology, 2008; 35 (2): 173-177.
18. Onyeizugbo EU. Simplified Regulating Breathing Treatment for on Adult with Stuttering,
Indian Journal of Clinical Psychology, 2011; 38 (1): 89-94.
19. Yin RK. Case study research: Design and methods (2nd Ed.). Newbury Park, CA: Sage
Publications, 1994.
20. Stake RE. The art of case study research. Thousand Oaks, CA: Sage Publications, 1995.
21. Guba EG, Lincoln YS. Effective evaluation. San Francisco, CA: Jossey-Bass Publishers,
1981.
22. Feigin JR, Orum AM, Sjoberg G. A case for case study. Chapel Hill: The University of
North Carolina Press, 1991.
23. Zucker DM. Using case study methodology in nursing research. The Qualitative Report,
2001; 6(2): http://www.nova.edu/ssss/QR/QR6-2/zucker.html (retrieved on 28-06-2015)

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Appendix-1 (The Case History Form)

CASE HISTRY FORMAT: CLINICAL PSYCHOLOGY/PSYCHIATRY

Profile of Case:
 Name (pseudonym):__________________________________________________________
 Age:__________ Marital status: Married/Unmarried/Single/Divorced/Other
 Occupation:_________________________________________________________________
 Referral details:______________________________________________________________
 Central problem______________________________________________________________
___________________________________________________________________________

History of Presenting Complaint:

 Identify common psychiatric symptoms (e.g. (i.e. depressive, psychotic, anxiety):
___________________________________________________________________________
___________________________________________________________________________
 Comment on the impact of the illness on the patient's life; Consider work, social relations and
self-care:
___________________________________________________________________________
___________________________________________________________________________
 Note details of previous treatment: ______________________________________________
___________________________________________________________________________
 Integrate current problem and psychiatric issues such as patient's psychiatric state and
concurrent medical conditions: _________________________________________________
___________________________________________________________________________
Past Psychiatric History:
 details of previous episodes of illness: ____________________________________________
___________________________________________________________________________
 previous psychiatric admissions/treatment: ________________________________________
___________________________________________________________________________
 outpatient/community treatment: ________________________________________________
___________________________________________________________________________
 suicide attempts/drug and alcohol abuse: ______________________________________
 interval functioning (what is the patient like between episodes/when "well'):
___________________________________________________________________________
___________________________________________________________________________

Medical History:
Current Medical History: __________________________________________________

Record medications (History of Medication and Other medical treatment): ___________

________________________________________________________________________
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DOI:10.5958/2320-6233.2015.00015.2

Family History:
 Parents and siblings, nature of the relationships between family members: ______________
__________________________________________________________________________
 Any family tensions and stresses and family models of coping: _______________________
__________________________________________________________________________
 Family history of psychiatric illness (incl. drug/alcohol abuse, suicide attempts): _________
__________________________________________________________________________

Personal History/Development:
 Early development: __________________________________________________________
__________________________________________________________________________
 Childhood: _________________________________________________________________
___________________________________________________________________________
 School: ____________________________________________________________________
___________________________________________________________________________
 Adolescence: _______________________________________________________________
___________________________________________________________________________
 Occupation: ________________________________________________________________
 Menstrual history: ___________________________________________________________
 Sexual history: ______________________________________________________________
 Marital history: _____________________________________________________________
 Children: __________________________________________________________________
 Social network: _____________________________________________________________
 Habits (Positive): ____________________________________________________________
 Habits (Negative): ___________________________________________________________
 Leisure Timing and Leisure Activity: ____________________________________________
 Forensic history: ____________________________________________________________

Remarks of the Investigator/Clinician: _______________________________________________

_________________________________________________________________________________
_________________________________________________________________________________

Suggested Treatment/Therapy: ______________________________________________________

_________________________________________________________________________________

Signature of Client/patient/Family members Signature of Investigator/Clinician

55

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