Case history structure
An introduction is necessary to establish the focus of your case and provide orientation to your reader. It should consist of a few clear and concise opening statements, which typically include information on:
Current living situation
Example: Julie, a 35-year-old single accountant who lives with her partner. Julie was referred by her family doctor because she was experiencing symptoms of happiness, optimism, and good health that have started to cause her distress and interfere with her daily functioning.
2. Presenting Problem
This should be a detailed account of the client’s central problem that you have already identified in your opening statement. Put details about the problem and related symptoms in a chronological order, as this will help with the clarity of your writing. Comment on the impact of the disorder on the client’s life including work, social relations, and self-care.
Example: Approximately 3 months ago Julie began to notice that her life was satisfying and fulfilling. At work she was attentive, curious, and responsible which started causing significant problems with her co-workers. Julie began to pay a lot of attention to her friends, asking them about their lives, rather than complaining about her own, and complementing them on their appearance and behavior. One night she brought home a beautiful bouquet of flowers for her girlfriend Latonya and cooked a gourmet dinner. Latonya was so concerned about this abrupt shift in mood and behavior that she called Julie’s family doctor who suggested that proceed immediately to the emergency room. They immediately started her on a dose of the mood reducer Ruinex and referred her to this clinic.
3. History of Problem and Related Psychological Problems and Treatment
In this section you will build a picture of the pattern of disorder and related symptoms (chronicity, severity, coping strategies, crisis triggers, etc.). You should include previous outpatient treatment and admissions, any suicide attempts, drug and alcohol use, and a description of how the client functions between episodes of symptoms.
Example: Julie described multiple episodes of acute joy for which she has needed to seek treatment. Her first episode occurred when she was approximately 8-years old. Julie had spent the day at the park with her father. On the way home, they stopped at an ice cream shop where Julie was told she order a regular size cone instead of the “kiddie” size she was used to. Julie noticed feelings of excitement and overall happiness that grew in intensity as the night wore on. Her parents were extremely concerned when Julie awoke the next morning in a cheerful mood and they brought her in to see a pediatrician. She was diagnosed with Joy Disorder and immediately started on a trial of Ruinex. Within approximately 4 weeks her symptoms dissipated. However, Julie experienced another episode when she was 17 that appears to be triggered by her college acceptance letter from Suffolk. Julie tried to “self-medicate” by drinking milkshakes in her room without her parent’s knowledge. One day they came home from work and found her extremely content. They rushed to the hospital where she was admitted for a 2-week stay. Although Ruinex caused her to be slightly less happy, it did not sufficiently decrease her optimistic attitude or kind nature. Thus, Julie was referred for outpatient psychotherapy. Since that time, Julie has had approximately 10 additional episodes, although each has been successfully treated with a combination of Ruinex and therapy. She has also tried to make lifestyle changes to manage her symptoms. For example, she switched her college major from psychology to accounting and she even considered transferring out of Suffolk. She and her partner also went to couples therapy to work on their communication style. Julie mastered the eye roll and she can be sarcastic at times, but she also frequently slips into her old habit of being kind, caring, and compassionate.
4. Cultural Identity and Family History
This section should include: The client’s cultural identity and information about which aspects are most salient to him or her, Parents and siblings, nature of the relationships between family members, any family tensions and stresses and family models of coping, and family history of psychological disorders (incl. drug/alcohol abuse, suicide attempts)
Julie identifies as a Korean-American, gay, female. Although she was brought up Presbyterian, she does not currently consider herself a “spiritual person”. Her parents emigrated from South Korea in 1970, but the family is still close with their extended family members living in South Korea. Julie also considers herself a part of her parents strong social network which consists of many other Korean American families who are part of their church.
Julie also has one younger brother with whom she continues to have a close relationship.
Growing up Julie’s family was upper middle class and they were comfortable and had “everything they needed”.
Although neither of Julie’s parent’s have ever been diagnosed with a psychological disorder, there is a history of Joy in the family. Julie’s maternal grandmother was joyful for most of her adult life and Julie has one aunt who was hospitalized for Amusement Disorder. Julie’s brother has periods of contentment, but has been able to keep them under control with the help of therapy.
5. Personal History
This section should include: developmental history (anything notable about childhood and adolescence), education and occupation history, relationship history (romantic partners), social (including current support network), and any notable medical, legal, or trauma history. Most of these sections will be brief unless there was a particular problem, notable event.
Julie met all of her development milestones as expected. Her parents are self-employed, small business owners (they own a local specialty toy store). Julie describes her early childhood development and upbringing as “normal”. When probed, she disclosed that her parents treated she and her brother with love and respect. They enjoyed reading and playing games together and her parents supported and encouraged Julie to pursue her interests. This family history likely contributed to the development of Julia’s chronic Joy Disorder.
During adolescence, Julie became more dependent on her peer group. Most of her friends were honors students and active on student council. They would frequently have fun with each other, hanging out, doing volunteer work, and studying. When Julie turned 16 she and her friends started going out for milkshakes on the weekend. Julie made sure her parents knew where she was at all times and that lead to increased trust in the relationship.
Julie was a strong student throughout elementary, middle, and high school, frequently winning academic awards. She was an honors student at Suffolk and belonged to several clubs. After Julie graduated, she began working at EmployeesComeFirst, a big 5 accounting firm in Boston. She has been employed continuously at the same firm for her entire career. Julie is a hard worker who receives frequent promotions and bonuses at work, which also may contribute to her current presenting symptoms.
Although Julie went on casual dates in high school, her first serious romantic relationship was with Latonya, who she met at Suffolk. Julie’s friends and family were thrilled when Julie identified as gay and they immediately welcomed her Black girlfriend into their “circle”. Julie described several instances of strangers seeming “happy for them” when they were out together and being affectionate. Julie described internalizing these overt and subtle messages of support. This love and support may have caused Julie to feel happy and accepted. When those feelings of happiness and acceptance become strong, Julie often drinking milkshakes and sometimes even treats herself to jellybeans.
This section should note if the client meets criteria for a single or comorbid disorders. The diagnosis should be supported with examples. Each of the major criteria should be presented along with client-specific examples.
Julie currently meets diagnostic criteria for Joy Disorder (recurrent). She has had several episodes during which she is joyful, more days than not, for a period of 10 days or longer. While in this mood state, Julie exhibits symptoms of kindness as evidenced by the way she treats her girlfriend and co-workers. For example, Julie frequently complements her co-workers and makes sure they receive credit for their work. She acts lovingly towards LaTonya, cooking her dinner, buying flowers, and offering to give her massages when her neck muscles are tense. During one episode, when LaTonya was traveling for work, Julie did not watch the season finale of Game of Thrones, instead waiting until she could watch it with her girlfriend on Demand. Julie also shows many of the physical symptoms of Joy Disorder. Her posture is relaxed and her face shows signs of frequent smiling. Julie also consistently gets eight hours of sleep a night and has not gained or lost any weight in the past 6 months.
7. Case Conceptualization
In this section of the report, the writer uses a theoretical model (e.g., cognitive behavioral, psychodynamic) to explain the cause (and maintenance) of the client’s psychological problems, drawing from the client’s history. In your assignment, you will also include (and summarize) two research articles that offer support for your conceptualization.
Several factors likely contributed to Julie’s pattern of recurrent Joy Disorder. First, genetics likely played a role in that Julie was born with a biological predisposition toward Happiness Disorders in general. On her maternal side, there is a strong family history for both Joy and Amusement Disorder.
According to Rivera and Lee (2017), there is some evidence that genes play a role in the high level of Niceatonin seen in Happiness Disorders. In this study, a sample of (describe participants)…. were examined using (describe the methods of the study)….. Rivera and Lee found (describe the results)…..It should be noted that (note one or more limitations to the study)…… However, this study still provides preliminary evidence that (describe conclusion)….
Cognitive theory would suggest that Julie’s core beliefs, developed during her childhood, also influence her mood. When Julie was young, because of her parents’ treatment of her, she likely developed beliefs such as “I am loved” and “I don’t have to be perfect”. Julie’s social history confirmed the belief that she was a good person and that she could trust others, which clearly play a role in her joy.
A study by Qadir, Bennett & Lee (2014) has shown that these types of beliefs are quite prevalent among those with Joy Disorder. These researchers conducted an epidemiological study with (describe participants). Each person completed a packet of questionnaires assessing something at certain time points (describe method). Participants with joy disorders were significantly more likely to (describe results). This suggests that….(describe conclusion). However, these results may have been impacted by (describe limitations).
Finally, social-cultural influences likely increased Julie’s risk of developing Joy Disorder. The widespread acceptance of her cultural identity left her feeling secure and comfortable. It is not surprising that her joy increased over time culminating in the episodes she frequently experiences.
8. Treatment Plan
In this section of the report, the writer describes a plan for treatment. This plan should be informed by the causes (e.g., a biological cause may merit biological treatment; cognitive restructuring might positively impact core beliefs, etc.) In your assignment, you will also include (and summarize) two research articles that offer support for your choice of treatment.
Julie could benefit from both psychotherapy and medication. I recommend that she continue with Ruinex, as it is a Niceatonin Inhibitor, and should help with the biological component of her Joy.
Additionally, I would recommend that Julie be seen for 12 session of cognitive-behavioral treatment. In this treatment Julie would learn about that Joy is comprised of thoughts, emotions, and behaviors. I would encourage Julie to monitor her thoughts every time she noticed a feeling of joy arise. In session, I would teach her about cognitive errors (e.g., always seeing the positive, not blaming self or others when problems arise) and use Socratic questions to help her identify them in her thinking (e.g., how do you know LaTonya really loves you? What is the evidence that you are a loveable person? What is the likelihood that your new co-worker is actually a nice person?). Together we will come up with more helpful thoughts like “People can’t be trusted” and “I am probably not a very good person”. More on CBT ……
Several studies have documented the positive effects of CBT on Joy Disorder. Gross, Chadha, & O’Neill (2017) conducted a randomized trial to compare the effects of CBT versus Ruinex on joyful symptoms among participants recently discharged from an inpatient unit (methods, results, limitations, conclusions). Similarly, Jackson & Pipe (2010)…..(methods, results, limitations, conclusions).