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Case History Sample
Psychology (Christ (Deemed To Be University))
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lOMoARcPSD|4978814
Case History - 5
Demographics
Name: Mr. S.S.
SES: Lower Middle Class
Informant: Mr. S.S. (Client) and Father
Age: 24 yrs
Sex: Male
Occupation: Shop Owner/Manager
Complaints and their Duration
• Sadness (occasionally): Acute onset and episodic course.
• Guilt: Acute onset and gradual course.
• Anger: Gradual Onset and Continuous course
History of Present Illness
The client reported that he was guilty of causing problems at home and in his
neighborhood. Furthermore, he was guilty of causing monetary problems at home due to alcohol
abuse and betrayal by a close friend. He stated that he had severe anger problems post
consumption of alcohol. There would be complete memory loss of the events occurring after
consumption of alcohol following prolonged duration of sleep. Furthermore, he stated extreme
levels of aggression after consumption of alcohol. His father stated that the client would break
objects at home and become physically aggressive causing severe problems to the members of
the family. Feelings of extreme sadness and low mood were reported by the clients on multiple
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occasions. There was gradual increase in anger after prolonged consumption of alcohol over a
period of time. He had never lived away from his family and his time at the rehabilitation center
caused him severe emotional discomfort. Lastly, the client reported severe anger towards his
brothers for no significant reasons. the sleep attacks first occurred two years ago in 2017 and
disappeared for the upcoming years.
Past History
The client had no major medical pattern reported. However, the client reported Alcohol
Abuse over the past few years. He stated that he started drinking with his friends and there was
gradual increase in consumption. In the following years, he experienced swollen knots in his
throat and had made multiple visits to the doctor for this purpose. Lastly, he stated that he had
suffered from pain in his liver and kidneys in the past. However, after consumption of
medication provided by the doctor, the pain had subsided. The client’s father reported excessive
consumption of benzodiazepines over a period of two years. Follow up visits with the doctor
were discontinued by the client resulting in continuous consumption of the medication.
Family History
The client reported that he is very close to his family which includes his father, mother
and an elder sister. He lived with his family in his home town and assisted his father at his shop.
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His father was strictly focused on handling the shop and would rarely take a holiday until there
was an emergency. He reported that his father used to consume alcohol in the past but had quit
consumption 15-18 years ago after a ‘kidney-stone’ operation. His mother was a home maker
and took care of all the necessities at home. His sister was close to him and helped him in various
situations emotionally and mentally. He stated that his father was the leader in his family
followed by his mother and sister. Communication within the family was open across each
member and decisions were taken in unison by his parents. Lastly, he stated that his uncle was
seriously involved in the decisions made within the family. He had immense respect for all the
members within the family but seemed distant from his uncle.
Personal History
Birth and Early Development: FT-NVD with immediate birth cry and achieved all
developmental milestones within normal limits.
Behaviour during Childhood: Normal childhood with love and support from the family
members. No significant psychiatric/behavioural problems reported.
Physical Illness during Childhood: None reported.
Educational History: The client reported normal schooling until 7th Standard and
discontinuation post 8th Standard.
Menstrual History: Not Applicable
Sexual History: None Reported.
Marital History: None.
Use and abuse of alcohol, tobacco and drugs: Use of Alcohol multiple times in a week
and use of Benzodiazepines on a daily basis reported.
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Premorbid Personality
The client displays severe negative attitude towards self marked by extreme levels of
guilt and sadness. Moderate moral and religious attitudes are reflected in the upbringing of the
client and his faith in god. His mood is generally tense and anxious due to his habits and
experiences mood swings occasionally.
His leisure activities include watching movies and listening to songs. He spends most of
his leisure time with his small circle of friends. He spent a sufficient amount of time (usually 2-3
hours) day dreaming. Lastly, his reaction pattern to stress involved excessive use of defense
mechanisms such as denial. He wouldn’t analyze the situation and would start drinking due to
the various problems that evolved in his day to day life.
Mental Status Examination (MSE)
General Behavior: Normal gait, adequate eye contact and normal behavioral
functioning.
Psychomotor Activity: Average level of activity.
Talk: Relevant, Spontaneous speech with normal tone, pitch and rate.
Thought: Normal stream and form, no possession/ abnormal content.
Mood: Extreme levels of sadness, guilt and mild lability of mood as reported.
Perception: No hallucinations, delusions.
Cognitive Functions
Attention and concentration: Normal.
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Orientation: Well oriented.
Memory: Immediate, recent and remote memory reported to be normal.
General Information: Adequate knowledge of general information.
Intelligence: Average.
Abstractibility: Average.
Judgement: Sound judgment about personal, social and test situations.
Insight: Present.
Case Formulation
Thus, the client has psychoactive substance use disorder. No other past/family history of
physical/psychological disorders present. This reflects a diagnosis of F10.F1x.21 – Mental and
Behavioural disorders due to use of Alcohol as per the ICD 10. Pharmacological treatment along
with individual psychotherapy is recommended.
Co-morbidity – F13.F1x.00 – Mental and Behavioural disorders due to use of sedatives
and hypnotics – Uncomplicated.
