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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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DSM-5 Clinical Cases

• Rachel A. Davis , M.D.

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DSM-5 Clinical Cases makes the rather overwhelming DSM-5 much more accessible to mental health clinicians by using clinical examples—the way many clinicians learn best—to illustrate the changes in diagnostic criteria from DSM-IV-TR to DSM-5. More than 100 authors contributed to the 103 case vignettes and discussions in this book. Each case is concise but not oversimplified. The cases range from straightforward and typical to complicated and unusual, providing a nice repertoire of clinical material. The cases are realistic in that many portray scenarios that are complicated by confounding factors or in which not all information needed to make a diagnosis is available. The authors are candid in their discussions of difficulties arriving at the correct diagnoses, and they acknowledge the limitations of DSM-5 when appropriate.

The book is conveniently organized in a manner similar to DSM-5. The 19 chapters in DSM-5 Clinical Cases correspond to the first 19 chapters in section 2 of DSM-5. As in DSM-5, DSM-5 Clinical Cases begins with diagnoses that tend to manifest earlier in life and advances to diagnoses that usually occur later in life. Each chapter begins with a discussion of changes from DSM-IV. These changes are further explored in the cases that follow.

Each case vignette is titled with the presenting problem. The cases are formatted similarly throughout and include history of present illness, collateral information, past psychiatric history, social history, examination, any laboratory findings, any neurocognitive testing, and family history. This is followed by the diagnosis or diagnoses and the case discussion. In the discussions, the authors highlight the key symptoms relevant to DSM-5 criteria. They explore the differential diagnosis and explain their rational for arriving at their selected diagnoses versus others they considered as well. In addition, they discuss complicating factors that make the diagnoses less clear and often mention what additional information they would like to have. Each case is followed by a list of suggested readings.

As an example, case 6.1 is titled Depression. This case describes a 52-year-old man, “Mr. King,” presenting with the chief complaint of depressive symptoms for years, with minimal response to medication trials. The case goes on to describe that Mr. King had many anxieties with related compulsions. For example, he worried about contracting diseases such as HIV and would wash his hands repeatedly with bleach. He was able to function at work as a janitor by using gloves but otherwise lived a mostly isolative life. Examination was positive for a strong odor of bleach, an anxious, constricted affect, and insight that his fears and behaviors were “kinda crazy.” No laboratory findings or neurocognitive testing is mentioned.

The diagnoses given for this case are “OCD, with good or fair insight,” and “major depressive disorder.” The discussants acknowledge that evaluation for OCD can be difficult because most patients are not so forthcoming with their symptoms. DSM-5 definitions of obsessions and compulsions are reviewed, and the changes to the description of obsessions are highlighted: the term urge is used instead of impulse so as to minimize confusion with impulse-control disorders; the term unwanted instead of inappropriate is used; and obsessions are noted to generally (rather than always) cause marked anxiety or distress to reflect the research that not all obsessions result in marked anxiety or distress. The authors review the remaining DSM-5 criteria, that OCD symptoms must cause distress or impairment and must not be attributable to a substance use disorder, a medical condition, or another mental disorder. They discuss the two specifiers: degree of insight and current or past history of a tic disorder. They briefly explore the differential diagnosis, noting the importance of considering anxiety disorders and distinguishing the obsessions of OCD from the ruminations of major depressive disorder. They also point out the importance of looking for comorbid diagnoses, for example, body dysmorphic disorder and hoarding disorder.

This brief case, presented and discussed in less than three pages, leaves the reader with an overall understanding of the diagnostic criteria for OCD, as well as a good sense of the changes in DSM-5.

DSM-5 Clinical Cases is easy to read, interesting, and clinically relevant. It will improve the reader’s ability to apply the DSM-5 diagnostic classification system to real-life practice and highlights many nuances to DSM-5 that one might otherwise miss. This book will serve as a valuable supplementary manual for clinicians across many different stages and settings of practice. It may well be a more practical and efficient way to learn the DSM changes than the DSM-5 itself.

The author reports no financial relationships with commercial interests.

• Cited by None

Psychology Case Study Examples

Experiments are often used to help researchers understand how the human mind works. There have been many famous examples in psychology over the years. Some have shown how phenomena like memory and personality work. Others have been disproven over time. Understanding the study design, data, content, and analytical approach of case studies is important to verifying the validity of each study.

In considering case studies, researchers continuously test and reevaluate the conclusions made by past psychologists to continue offering the most up-to-date and effective care to modern clients. Prospective case studies are continually being developed based on previous findings and multiple case studies done in one area can lend credence to the findings. Learning about the famous psychology case studies can help you understand how research continues to shape what psychologists know about the human experience and mind. 

Examples of the most famous case study in psychology

Hundreds of thousands of case studies have been done in psychology, and narrowing a list of the most ground-breaking studies can be challenging. However, the following seven case studies present findings that have defied expectations, achieved positive outcomes for humanity, and launched further research into existing knowledge gaps within the niche.

Phineas Gage

The case of Phineas Gage is perhaps the  most cited study  in psychology. This famous case study showed how different areas of the brain affect personality and cognitive ability. While working as a construction foreman on a railroad, Phineas Gage was involved in an accident in which a rod was pushed through his cheek and brain. He survived, but because of the accident, both his personality and his ability to learn new skills were affected.

Although the case is frequently cited and referenced in psychology, relatively little information about Gage's life before and after the accident is known. Researchers have discovered that the last two decades of his life were spent in his original job, which may have been unlikely to have been possible if the extent of his injuries were as severe as initially believed. Still, his case was a starting point for psychology research on how memory and personality work in the brain, and it is a seminal study for that reason.

Genie the "feral child"

Although an outdated term, "feral children" referred to children raised without human interaction, often due to abuse or neglect. One  famous case study of a neglected child was done with a child known as Genie. She was raised in a single bedroom with little human interaction. She never gained the cognitive ability of an average adult, even though she was found at age 13. Later in life, she regressed and stopped speaking altogether. Her case has been studied extensively by psychologists who want to understand how enculturation affects cognitive development. It's one of many cognitive psychology examples that have had an impact on this field.

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Henry Molaison

The case study  of Henry Molaison has helped psychologists understand memory. It is one of the most famous case studies in neuroscience. Henry Molaison was in a childhood accident that left him with debilitating seizures. Doctors could stop the seizures by removing slivers of his brain's hippocampus, though they did not fully understand what they were doing at the time. As a result, scientists learned how important the hippocampus is to forming long-term memories. After the surgery, Molaison could no longer form long-term memories, and his short-term memory was brief. The case study started further research into memory and the brain.

Jill Price had one of a few documented cases of hyperthymesia, a term for an overactive memory that allowed her to remember such mundane things as what she had for dinner on an average day in August 20th years previously. Her  case study  was used as a jumping-off point to research how memory works and why some people have exceptional memories. 

However, through more research, it was discovered that her overall memory was not exceptional. Rather, she only remembered details of her own life. She was diagnosed with obsessive-compulsive disorder (OCD), with memories being part of her obsession. This case study is still relevant because it has helped modern psychologists understand how mental illness affects memory.

In the John/Joan  case study , a reputable sexologist tested his theory that nurture, not nature, determined gender. The case study has been cited extensively and laid the groundwork for other research into gender identity. However, the case study was not legitimate. In this study, Dr. John Money performed surgery on an infant whose genitals were damaged during circumcision. 

The boy was raised as a girl; however, he never identified as female and eventually underwent gender-affirming surgery as an adult. Because Dr. Money didn't follow up with the patient appropriately and did not report adverse findings, the case study is still often cited as successful.

Anna O. was the pseudonym given to a German woman who was one of the first to undergo psychoanalysis. Her case inspired many of the theories of Freud and other prominent psychologists of the time. It was determined at the time that Anna's symptoms of depression were eliminated through talk therapy. More recently, it has been suggested that Anna O. had another illness, such as epilepsy, from which she may have recovered during the therapy. This  case study is still cited as a reason psychologists believe that psychotherapy, or talk therapy, can be helpful to many patients. 

Victor the "wild boy" of Aveyron

Another study done on a child that had grown up without parents was done with a boy named "Victor" who had been found wandering in the wilderness and was thought to have been living alone for years. The boy could not speak, use the bathroom, or connect with others. However, through the study of his condition, he was able to learn bathroom habits, how to dress, writing, and primary language. Psychologists today speculate that he may have been autistic. 

Ethical concerns for doing a case study

When case studies are flawed through not having enough information or having the wrong information, they can be harmful. Valuable research hours and other resources can be wasted while theories are used for inappropriate treatment. Case studies can therefore cause as much harm as benefit, and psychologists are often careful about how and when they are used.

Those who are not psychologists and are interacting with studies can also practice caution. Psychologists and doctors often disagree on how case studies should be applied. In addition, people without education in psychology may struggle to know whether a case study is built on a faulty premise or misinformation. It can also be possible to generalize case studies to situations they do not apply. If you think a case study might apply to your case or that of a loved one, consider asking a therapist for guidance. 

Case studies are descriptions of real people. The individuals in the studies are studied intensively and often written about in medical journals and textbooks. While some clients may be comfortable being studied for science, others may not have consented due to the inability or lack of consent laws at the time. In addition, some subjects may not have been treated with dignity and respect. 

When considering case study content and findings from psychology, it can be helpful to think of the cases as stories of real individuals. When you strip away the science and look at the case as a whole person in a unique situation, you may get more out of the study than if you look at it as research that proves a theory. 

Therapeutic implications of a case study

Case examples are sometimes used in therapy to determine the best course of treatment. If a typical case study from psychology aligns with your situation, your therapist may use the treatment methods outlined in the study. Psychiatrists and other mental health professionals also use case examples to understand mental illness and its treatment.

Researchers have reviewed the role of case studies in counseling and psychotherapy. In  one study , the authors discussed how reading case studies benefits therapists, providing a conceptual guide for clinical work and an understanding of the theory behind the practice. They also stressed the importance of teaching psychotherapy trainees to do better case study research. They encouraged practitioners to publish more case studies documenting the methods they use in their practice.

How a case study is used in counseling

If you want to meet with a psychologist, counseling may benefit you. Therapists often use theories behind popular case studies and can discuss their implications with you. In addition, you may be able to participate in case studies in your area, as psychologists and psychiatrists often perform clinical trials to understand treatments on a deeper level.

Online therapy can also be beneficial if you cannot find a therapist in your area. Through a platform like BetterHelp , you can get matched with a provider meeting your needs and choose between phone, video, or live chat sessions. When experiencing symptoms of a mental health condition, it can sometimes be hard to leave home for therapy. You can use many online therapy platforms from the comfort and safe space of your own home. 

Therapy is a personal experience; not everyone will go into it seeking the same outcomes. Keeping this in mind may ensure you get the most out of online therapy, regardless of your specific goals. If you're interested in learning more about the effectiveness of online therapy, you can look into various clinical studies that have shown it can be as effective , if not more effective, than in-person options. 

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Psychology Case Study Examples: A Deep Dive into Real-life Scenarios

Peeling back the layers of the human mind is no easy task, but psychology case studies can help us do just that. Through these detailed analyses, we’re able to gain a deeper understanding of human behavior, emotions, and cognitive processes. I’ve always found it fascinating how a single person’s experience can shed light on broader psychological principles.

Over the years, psychologists have conducted numerous case studies—each with their own unique insights and implications. These investigations range from Phineas Gage’s accidental lobotomy to Genie Wiley’s tragic tale of isolation. Such examples not only enlighten us about specific disorders or occurrences but also continue to shape our overall understanding of psychology .

As we delve into some noteworthy examples , I assure you’ll appreciate how varied and intricate the field of psychology truly is. Whether you’re a budding psychologist or simply an eager learner, brace yourself for an intriguing exploration into the intricacies of the human psyche.

Understanding Psychology Case Studies

Diving headfirst into the world of psychology, it’s easy to come upon a valuable tool used by psychologists and researchers alike – case studies. I’m here to shed some light on these fascinating tools.

Psychology case studies, for those unfamiliar with them, are in-depth investigations carried out to gain a profound understanding of the subject – whether it’s an individual, group or phenomenon. They’re powerful because they provide detailed insights that other research methods might miss.

Let me share a few examples to clarify this concept further:

• One notable example is Freud’s study on Little Hans. This case study explored a 5-year-old boy’s fear of horses and related it back to Freud’s theories about psychosexual stages.
• Another classic example is Genie Wiley (a pseudonym), a feral child who was subjected to severe social isolation during her early years. Her heartbreaking story provided invaluable insights into language acquisition and critical periods in development.

You see, what sets psychology case studies apart is their focus on the ‘why’ and ‘how’. While surveys or experiments might tell us ‘what’, they often don’t dig deep enough into the inner workings behind human behavior.

It’s important though not to take these psychology case studies at face value. As enlightening as they can be, we must remember that they usually focus on one specific instance or individual. Thus, generalizing findings from single-case studies should be done cautiously.

To illustrate my point using numbers: let’s say we have 1 million people suffering from condition X worldwide; if only 20 unique cases have been studied so far (which would be quite typical for rare conditions), then our understanding is based on just 0.002% of the total cases! That’s why multiple sources and types of research are vital when trying to understand complex psychological phenomena fully.

In the grand scheme of things, psychology case studies are just one piece of the puzzle – albeit an essential one. They provide rich, detailed data that can form the foundation for further research and understanding. As we delve deeper into this fascinating field, it’s crucial to appreciate all the tools at our disposal – from surveys and experiments to these insightful case studies.

Importance of Case Studies in Psychology

I’ve always been fascinated by the human mind, and if you’re here, I bet you are too. Let’s dive right into why case studies play such a pivotal role in psychology.

One of the key reasons they matter so much is because they provide detailed insights into specific psychological phenomena. Unlike other research methods that might use large samples but only offer surface-level findings, case studies allow us to study complex behaviors, disorders, and even treatments at an intimate level. They often serve as a catalyst for new theories or help refine existing ones.

To illustrate this point, let’s look at one of psychology’s most famous case studies – Phineas Gage. He was a railroad construction foreman who survived a severe brain injury when an iron rod shot through his skull during an explosion in 1848. The dramatic personality changes he experienced after his accident led to significant advancements in our understanding of the brain’s role in personality and behavior.

Moreover, it’s worth noting that some rare conditions can only be studied through individual cases due to their uncommon nature. For instance, consider Genie Wiley – a girl discovered at age 13 having spent most of her life locked away from society by her parents. Her tragic story gave psychologists valuable insights into language acquisition and critical periods for learning.

Finally yet importantly, case studies also have practical applications for clinicians and therapists. Studying real-life examples can inform treatment plans and provide guidance on how theoretical concepts might apply to actual client situations.

• Detailed insights: Case studies offer comprehensive views on specific psychological phenomena.
• Catalyst for new theories: Real-life scenarios help shape our understanding of psychology .
• Study rare conditions: Unique cases can offer invaluable lessons about uncommon disorders.
• Practical applications: Clinicians benefit from studying real-world examples.

In short (but without wrapping up), it’s clear that case studies hold immense value within psychology – they illuminate what textbooks often can’t, offering a more nuanced understanding of human behavior.

Different Types of Psychology Case Studies

Diving headfirst into the world of psychology, I can’t help but be fascinated by the myriad types of case studies that revolve around this subject. Let’s take a closer look at some of them.

Firstly, we’ve got what’s known as ‘Explanatory Case Studies’. These are often used when a researcher wants to clarify complex phenomena or concepts. For example, a psychologist might use an explanatory case study to explore the reasons behind aggressive behavior in children.

Second on our list are ‘Exploratory Case Studies’, typically utilized when new and unexplored areas of research come up. They’re like pioneers; they pave the way for future studies. In psychological terms, exploratory case studies could be conducted to investigate emerging mental health conditions or under-researched therapeutic approaches.

Next up are ‘Descriptive Case Studies’. As the name suggests, these focus on depicting comprehensive and detailed profiles about a particular individual, group, or event within its natural context. A well-known example would be Sigmund Freud’s analysis of “Anna O”, which provided unique insights into hysteria.

Then there are ‘Intrinsic Case Studies’, which delve deep into one specific case because it is intrinsically interesting or unique in some way. It’s sorta like shining a spotlight onto an exceptional phenomenon. An instance would be studying savants—individuals with extraordinary abilities despite significant mental disabilities.

Lastly, we have ‘Instrumental Case Studies’. These aren’t focused on understanding a particular case per se but use it as an instrument to understand something else altogether—a bit like using one puzzle piece to make sense of the whole picture!

So there you have it! From explanatory to instrumental, each type serves its own unique purpose and adds another intriguing layer to our understanding of human behavior and cognition.

Exploring Real-Life Psychology Case Study Examples

Let’s roll up our sleeves and delve into some real-life psychology case study examples. By digging deep, we can glean valuable insights from these studies that have significantly contributed to our understanding of human behavior and mental processes.

First off, let me share the fascinating case of Phineas Gage. This gentleman was a 19th-century railroad construction foreman who survived an accident where a large iron rod was accidentally driven through his skull, damaging his frontal lobes. Astonishingly, he could walk and talk immediately after the accident but underwent dramatic personality changes, becoming impulsive and irresponsible. This case is often referenced in discussions about brain injury and personality change.

Next on my list is Genie Wiley’s heart-wrenching story. She was a victim of severe abuse and neglect resulting in her being socially isolated until she was 13 years old. Due to this horrific experience, Genie couldn’t acquire language skills typically as other children would do during their developmental stages. Her tragic story offers invaluable insight into the critical periods for language development in children.

Then there’s ‘Little Hans’, a classic Freudian case that delves into child psychology. At just five years old, Little Hans developed an irrational fear of horses -or so it seemed- which Sigmund Freud interpreted as symbolic anxiety stemming from suppressed sexual desires towards his mother—quite an interpretation! The study gave us Freud’s Oedipus Complex theory.

Lastly, I’d like to mention Patient H.M., an individual who became amnesiac following surgery to control seizures by removing parts of his hippocampus bilaterally. His inability to form new memories post-operation shed light on how different areas of our brains contribute to memory formation.

Each one of these real-life psychology case studies gives us a unique window into understanding complex human behaviors better – whether it’s dissecting the role our brain plays in shaping personality or unraveling the mysteries of fear, language acquisition, and memory.

How to Analyze a Psychology Case Study

Diving headfirst into a psychology case study, I understand it can seem like an intimidating task. But don’t worry, I’m here to guide you through the process.

First off, it’s essential to go through the case study thoroughly. Read it multiple times if needed. Each reading will likely reveal new information or perspectives you may have missed initially. Look out for any patterns or inconsistencies in the subject’s behavior and make note of them.

Next on your agenda should be understanding the theoretical frameworks that might be applicable in this scenario. Is there a cognitive-behavioral approach at play? Or does psychoanalysis provide better insights? Comparing these theories with observed behavior and symptoms can help shed light on underlying psychological issues.

Now, let’s talk data interpretation. If your case study includes raw data like surveys or diagnostic tests results, you’ll need to analyze them carefully. Here are some steps that could help:

• Identify what each piece of data represents
• Look for correlations between different pieces of data
• Compute statistics (mean, median, mode) if necessary
• Use graphs or charts for visual representation

Keep in mind; interpreting raw data requires both statistical knowledge and intuition about human behavior.

Finally, drafting conclusions is key in analyzing a psychology case study. Based on your observations, evaluations of theoretical approaches and interpretations of any given data – what do you conclude about the subject’s mental health status? Remember not to jump to conclusions hastily but instead base them solidly on evidence from your analysis.

In all this journey of analysis remember one thing: every person is unique and so are their experiences! So while theories and previous studies guide us, they never define an individual completely.

Applying Lessons from Psychology Case Studies

Let’s dive into how we can apply the lessons learned from psychology case studies. If you’ve ever studied psychology, you’ll know that case studies offer rich insights. They shed light on human behavior, mental health issues, and therapeutic techniques. But it’s not just about understanding theory. It’s also about implementing these valuable lessons in real-world situations.

One of the most famous psychological case studies is Phineas Gage’s story. This 19th-century railroad worker survived a severe brain injury which dramatically altered his personality. From this study, we gained crucial insight into how different brain areas are responsible for various aspects of our personality and behavior.

• Lesson: Recognizing that damage to specific brain areas can result in personality changes, enabling us to better understand certain mental conditions.

Sigmund Freud’s work with a patient known as ‘Anna O.’ is another landmark psychology case study. Anna displayed what was then called hysteria – symptoms included hallucinations and disturbances in speech and physical coordination – which Freud linked back to repressed memories of traumatic events.

• Lesson: The importance of exploring an individual’s history for understanding their current psychological problems – a principle at the heart of psychoanalysis.

Then there’s Genie Wiley’s case – a girl who suffered extreme neglect resulting in impaired social and linguistic development. Researchers used her tragic circumstances as an opportunity to explore theories around language acquisition and socialization.

• Lesson: Reinforcing the critical role early childhood experiences play in shaping cognitive development.

Lastly, let’s consider the Stanford Prison Experiment led by Philip Zimbardo examining how people conform to societal roles even when they lead to immoral actions.

• Lesson: Highlighting that situational forces can drastically impact human behavior beyond personal characteristics or morality.

These examples demonstrate that psychology case studies aren’t just academic exercises isolated from daily life. Instead, they provide profound lessons that help us make sense of complex human behaviors, mental health issues, and therapeutic strategies. By understanding these studies, we’re better equipped to apply their lessons in our own lives – whether it’s navigating personal relationships, working with diverse teams at work or even self-improvement.

Challenges and Critiques of Psychological Case Studies

Delving into the world of psychological case studies, it’s not all rosy. Sure, they offer an in-depth understanding of individual behavior and mental processes. Yet, they’re not without their share of challenges and criticisms.

One common critique is the lack of generalizability. Each case study is unique to its subject. We can’t always apply what we learn from one person to everyone else. I’ve come across instances where results varied dramatically between similar subjects, highlighting the inherent unpredictability in human behavior.

Another challenge lies within ethical boundaries. Often, sensitive information surfaces during these studies that could potentially harm the subject if disclosed improperly. To put it plainly, maintaining confidentiality while delivering a comprehensive account isn’t always easy.

Distortion due to subjective interpretations also poses substantial difficulties for psychologists conducting case studies. The researcher’s own bias may color their observations and conclusions – leading to skewed outcomes or misleading findings.

Moreover, there’s an ongoing debate about the scientific validity of case studies because they rely heavily on qualitative data rather than quantitative analysis. Some argue this makes them less reliable or objective when compared with other research methods such as experiments or surveys.

To summarize:

• Lack of generalizability
• Ethical dilemmas concerning privacy
• Potential distortion through subjective interpretation
• Questions about scientific validity

While these critiques present significant challenges, they do not diminish the value that psychological case studies bring to our understanding of human behavior and mental health struggles.

Conclusion: The Impact of Case Studies in Understanding Human Behavior

Case studies play a pivotal role in shedding light on human behavior. Throughout this article, I’ve discussed numerous examples that illustrate just how powerful these studies can be. Yet it’s the impact they have on our understanding of human psychology where their true value lies.

Take for instance the iconic study of Phineas Gage. It was through his tragic accident and subsequent personality change that we began to grasp the profound influence our frontal lobes have on our behavior. Without such a case study, we might still be in the dark about this crucial aspect of our neurology.

Let’s also consider Genie, the feral child who showed us the critical importance of social interaction during early development. Her heartbreaking story underscores just how vital appropriate nurturing is for healthy mental and emotional growth.

Here are some key takeaways from these case studies:

• Our brain structure significantly influences our behavior.
• Social interaction during formative years is vital for normal psychological development.
• Studying individual cases can reveal universal truths about human nature.

What stands out though, is not merely what these case studies teach us individually but collectively. They remind us that each person constitutes a unique combination of various factors—biological, psychological, and environmental—that shape their behavior.

One cannot overstate the significance of case studies in psychology—they are more than mere stories or isolated incidents; they’re windows into the complexities and nuances of human nature itself.

In wrapping up, I’d say that while statistics give us patterns and trends to understand groups, it’s these detailed narratives offered by case studies that help us comprehend individuals’ unique experiences within those groups—making them an invaluable part of psychological research.

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What Is a Case Study in Psychology?

Categories Research Methods

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A case study is a research method used in psychology to investigate a particular individual, group, or situation in depth . It involves a detailed analysis of the subject, gathering information from various sources such as interviews, observations, and documents.

In a case study, researchers aim to understand the complexities and nuances of the subject under investigation. They explore the individual’s thoughts, feelings, behaviors, and experiences to gain insights into specific psychological phenomena. 

This type of research can provide great detail regarding a particular case, allowing researchers to examine rare or unique situations that may not be easily replicated in a laboratory setting. They offer a holistic view of the subject, considering various factors influencing their behavior or mental processes. 

By examining individual cases, researchers can generate hypotheses, develop theories, and contribute to the existing body of knowledge in psychology. Case studies are often utilized in clinical psychology, where they can provide valuable insights into the diagnosis, treatment, and outcomes of specific psychological disorders. 

Case studies offer a comprehensive and in-depth understanding of complex psychological phenomena, providing researchers with valuable information to inform theory, practice, and future research.

Table of Contents

Examples of Case Studies in Psychology

Case studies in psychology provide real-life examples that illustrate psychological concepts and theories. They offer a detailed analysis of specific individuals, groups, or situations, allowing researchers to understand psychological phenomena better. Here are a few examples of case studies in psychology: 

Phineas Gage

This famous case study explores the effects of a traumatic brain injury on personality and behavior. A railroad construction worker, Phineas Gage survived a severe brain injury that dramatically changed his personality.

This case study helped researchers understand the role of the frontal lobe in personality and social behavior. 

Little Albert

Conducted by behaviorist John B. Watson, the Little Albert case study aimed to demonstrate classical conditioning. In this study, a young boy named Albert was conditioned to fear a white rat by pairing it with a loud noise.

This case study provided insights into the process of fear conditioning and the impact of early experiences on behavior. 

Genie’s case study focused on a girl who experienced extreme social isolation and deprivation during her childhood. This study shed light on the critical period for language development and the effects of severe neglect on cognitive and social functioning. 

These case studies highlight the value of in-depth analysis and provide researchers with valuable insights into various psychological phenomena. By examining specific cases, psychologists can uncover unique aspects of human behavior and contribute to the field’s knowledge and understanding.

Types of Case Studies in Psychology

Psychology case studies come in various forms, each serving a specific purpose in research and analysis. Understanding the different types of case studies can help researchers choose the most appropriate approach. 

Descriptive Case Studies

These studies aim to describe a particular individual, group, or situation. Researchers use descriptive case studies to explore and document specific characteristics, behaviors, or experiences.

For example, a descriptive case study may examine the life and experiences of a person with a rare psychological disorder. 

Exploratory Case Studies

Exploratory case studies are conducted when there is limited existing knowledge or understanding of a particular phenomenon. Researchers use these studies to gather preliminary information and generate hypotheses for further investigation.

Exploratory case studies often involve in-depth interviews, observations, and analysis of existing data. 

Explanatory Case Studies

These studies aim to explain the causal relationship between variables or events. Researchers use these studies to understand why certain outcomes occur and to identify the underlying mechanisms or processes.

Explanatory case studies often involve comparing multiple cases to identify common patterns or factors. 

Instrumental Case Studies

Instrumental case studies focus on using a particular case to gain insights into a broader issue or theory. Researchers select cases that are representative or critical in understanding the phenomenon of interest.

Instrumental case studies help researchers develop or refine theories and contribute to the general knowledge in the field. 

By utilizing different types of case studies, psychologists can explore various aspects of human behavior and gain a deeper understanding of psychological phenomena. Each type of case study offers unique advantages and contributes to the overall body of knowledge in psychology.

How to Collect Data for a Case Study

There are a variety of ways that researchers gather the data they need for a case study. Some sources include:

• Directly observing the subject
• Collecting information from archival records
• Conducting interviews
• Examining artifacts related to the subject
• Examining documents that provide information about the subject

The way that this information is collected depends on the nature of the study itself

Prospective Research

In a prospective study, researchers observe the individual or group in question. These observations typically occur over a period of time and may be used to track the progress or progression of a phenomenon or treatment.

Retrospective Research

A retrospective case study involves looking back on a phenomenon. Researchers typically look at the outcome and then gather data to help them understand how the individual or group reached that point.

Benefits of a Case Study

Case studies offer several benefits in the field of psychology. They provide researchers with a unique opportunity to delve deep into specific individuals, groups, or situations, allowing for a comprehensive understanding of complex phenomena.

Case studies offer valuable insights that can inform theory development and practical applications by examining real-life examples. 

Complex Data

One of the key benefits of case studies is their ability to provide complex and detailed data. Researchers can gather in-depth information through various methods such as interviews, observations, and analysis of existing records.

This depth of data allows for a thorough exploration of the factors influencing behavior and the underlying mechanisms at play. 

Unique Data

Additionally, case studies allow researchers to study rare or unique cases that may not be easily replicated in experimental settings. This enables the examination of phenomena that are difficult to study through other psychology research methods . 

By focusing on specific cases, researchers can uncover patterns, identify causal relationships, and generate hypotheses for further investigation.

General Knowledge

Case studies can also contribute to the general knowledge of psychology by providing real-world examples that can be used to support or challenge existing theories. They offer a bridge between theory and practice, allowing researchers to apply theoretical concepts to real-life situations and vice versa. 

Case studies offer a range of benefits in psychology, including providing rich and detailed data, studying unique cases, and contributing to theory development. These benefits make case studies valuable in understanding human behavior and psychological phenomena.

Limitations of a Case Study

While case studies offer numerous benefits in the field of psychology, they also have certain limitations that researchers need to consider. Understanding these limitations is crucial for interpreting the findings and generalizing the results. 

Lack of Generalizability

One limitation of case studies is the issue of generalizability. Since case studies focus on specific individuals, groups, and situations, applying the findings to a larger population can be challenging. The unique characteristics and circumstances of the case may not be representative of the broader population, making it difficult to draw universal conclusions. 

Researcher bias is another possible limitation. The researcher’s subjective interpretation and personal beliefs can influence the data collection, analysis, and interpretation process. This bias can affect the objectivity and reliability of the findings, raising questions about the study’s validity. 

Case studies are often time-consuming and resource-intensive. They require extensive data collection, analysis, and interpretation, which can be lengthy. This can limit the number of cases that can be studied and may result in a smaller sample size, reducing the study’s statistical power. 

Case studies are retrospective in nature, relying on past events and experiences. This reliance on memory and self-reporting can introduce recall bias and inaccuracies in the data. Participants may forget or misinterpret certain details, leading to incomplete or unreliable information.

Despite these limitations, case studies remain a valuable research tool in psychology. By acknowledging and addressing these limitations, researchers can enhance the validity and reliability of their findings, contributing to a more comprehensive understanding of human behavior and psychological phenomena. 

While case studies have limitations, they remain valuable when researchers acknowledge and address these concerns, leading to more reliable and valid findings in psychology.

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Crowe, S., Cresswell, K., Robertson, A., Huby, G., Avery, A., & Sheikh, A. (2011). The case study approach. BMC Medical Research Methodology , 11(1), 100. https://doi.org/10.1186/1471-2288-11-100

Paparini, S., Green, J., Papoutsi, C., Murdoch, J., Petticrew, M., Greenhalgh, T., Hanckel, B., & Shaw, S. (2020). Case study research for better evaluations of complex interventions: Rationale and challenges. BMC Medicine , 18(1), 301. https://doi.org/10.1186/s12916-020-01777-6

Willemsen, J. (2023). What is preventing psychotherapy case studies from having a greater impact on evidence-based practice, and how to address the challenges? Frontiers in Psychiatry , 13, 1101090. https://doi.org/10.3389/fpsyt.2022.1101090

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

The Week in Review: April 1-5

Blue Light, Depression, and Bipolar Disorder

An Update on Bipolar I Disorder

Four Myths About Lamotrigine

Recap: Mood Disorders 2024

Evidence-Based Novel Therapies for Bipolar Depression: Top 5 Takeaways

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Module 3: Clinical Assessment, Diagnosis, and Treatment

3rd edition as of July 2023

Module Overview

Module 3 covers the issues of clinical assessment, diagnosis, and treatment. We will define assessment and then describe key issues such as reliability, validity, standardization, and specific methods that are used. In terms of clinical diagnosis, we will discuss the two main classification systems used around the world – the DSM-5-TR and ICD-11. Finally, we discuss the reasons why people may seek treatment and what to expect when doing so.

Module Outline

3.1. Clinical Assessment of Abnormal Behavior

3.2. diagnosing and classifying abnormal behavior, 3.3. treatment of mental disorders – an overview.

Module Learning Outcomes

• Describe clinical assessment and methods used in it.
• Clarify how mental health professionals diagnose mental disorders in a standardized way.
• Discuss reasons to seek treatment and the importance of psychotherapy.

Section Learning Objectives

• Define clinical assessment.
• Clarify why clinical assessment is an ongoing process.
• Define and exemplify reliability.
• Define and exemplify validity.
• Define standardization.
• List and describe seven methods of assessment.

3.1.1. What is Clinical Assessment?

For a mental health professional to be able to effectively help treat a client and know that the treatment selected worked (or is working), they first must engage in the clinical assessment of the client, or collecting information and drawing conclusions through the use of observation, psychological tests, neurological tests, and interviews to determine the person’s problem and the presenting symptoms. This collection of information involves learning about the client’s skills, abilities, personality characteristics, cognitive and emotional functioning, the social context in terms of environmental stressors that are faced, and cultural factors particular to them such as their language or ethnicity. Clinical assessment is not just conducted at the beginning of the process of seeking help but throughout the process. Why is that?

Consider this. First, we need to determine if a treatment is even needed. By having a clear accounting of the person’s symptoms and how they affect daily functioning, we can decide to what extent the individual is adversely affected. Assuming a treatment is needed, our second reason to engage in clinical assessment will be to determine what treatment will work best. As you will see later in this module, there are numerous approaches to treatment.  These include Behavior Therapy, Cognitive and Cognitive-Behavioral Therapy (CBT), Humanistic-Experiential Therapies, Psychodynamic Therapies, Couples and Family Therapy, and biological treatments (psychopharmacology). Of course, for any mental disorder, some of the aforementioned therapies will have greater efficacy than others. Even if several can work well, it does not mean a particular therapy will work well for that specific client. Assessment can help figure this out. Finally, we need to know if the treatment we employed worked. This will involve measuring before any treatment is used and then measuring the behavior while the treatment is in place. We will even want to measure after the treatment ends to make sure symptoms of the disorder do not return. Knowing what the person’s baselines are for different aspects of psychological functioning will help us to see when improvement occurs.

In recap, obtaining the baselines happens in the beginning, implementing the treatment plan that is agreed upon happens more so in the middle, and then making sure the treatment produces the desired outcome occurs at the end. It should be clear from this discussion that clinical assessment is an ongoing process.

3.1.2. Key Concepts in Assessment

The assessment process involves three critical concepts – reliability, validity, and standardization. These three are important to science in general. First, we want the assessment to be reliable or consistent. Outside of clinical assessment, when our car has an issue and we take it to the mechanic, we want to make sure that what one mechanic says is wrong with our car is the same as what another says, or even two others. If not, the measurement tools they use to assess cars are flawed. The same is true of a patient who is suffering from a mental disorder. If one mental health professional says the person suffers from major depressive disorder and another says the issue is borderline personality disorder, then there is an issue with the assessment tool being used. Ensuring that two different raters are consistent in their assessment of patients is called interrater reliability . Another type of reliability occurs when a person takes a test one day, and then the same test on another day. We would expect the person’s answers to be consistent, which is called test-retest reliability . For example, let’s say the person takes the MMPI on Tuesday and then the same test on Friday. Unless something miraculous or tragic happened over the two days in between tests, the scores on the MMPI should be nearly identical to one another. What does identical mean? The score at test and the score at retest are correlated with one another. If the test is reliable, the correlation should be very high (remember, a correlation goes from -1.00 to +1.00, and positive means as one score goes up, so does the other, so the correlation for the two tests should be high on the positive side).

In addition to reliability, we want to make sure the test measures what it says it measures. This is called validity . Let’s say a new test is developed to measure symptoms of depression. It is compared against an existing and proven test, such as the Beck Depression Inventory (BDI).  If the new test measures depression, then the scores on it should be highly comparable to the ones obtained by the BDI. This is called concurrent or descriptive validity . We might even ask if an assessment tool looks valid. If we answer yes, then it has face validity, though it should be noted that this is not based on any statistical or evidence-based method of assessing validity. An example would be a personality test that asks about how people behave in certain situations. Therefore, it seems to measure personality, or we have an overall feeling that it measures what we expect it to measure.

Predictive validity is when a tool accurately predicts what will happen in the future. Let’s say we want to tell if a high school student will do well in college. We might create a national exam to test needed skills and call it something like the Scholastic Aptitude Test (SAT). We would have high school students take it by their senior year and then wait until they are in college for a few years and see how they are doing. If they did well on the SAT, we would expect that at that point, they should be doing well in college. If so, then the SAT accurately predicts college success. The same would be true of a test such as the Graduate Record Exam (GRE) and its ability to predict graduate school performance.

Finally, we want to make sure that the experience one patient has when taking a test or being assessed is the same as another patient taking the test the same day or on a different day, and with either the same tester or another tester. This is accomplished with the use of clearly laid out rules, norms, and/or procedures, and is called standardization . Equally important is that mental health professionals interpret the results of the testing in the same way, or otherwise, it will be unclear what the meaning of a specific score is.

3.1.3. Methods of Assessment

So how do we assess patients in our care? We will discuss observation, psychological tests, neurological tests, the clinical interview, and a few others in this section.

            3.1.3.1. Observation. In Section 1.5.2.1 we talked about two types of observation – naturalistic , or observing the person or animal in their environment, and laboratory , or observing the organism in a more controlled or artificial setting where the experimenter can use sophisticated equipment and videotape the session to examine it later. One-way mirrors can also be used. A limitation of this method is that the process of recording a behavior causes the behavior to change, called reactivity. Have you ever noticed someone staring at you while you sat and ate your lunch? If you have, what did you do? Did you change your behavior? Did you become self-conscious? Likely yes, and this is an example of reactivity. Another issue is that the behavior made in one situation may not be made in other situations, such as your significant other only acting out at the football game and not at home. This form of validity is called cross-sectional validity. We also need our raters to observe and record behavior in the same way or to have high inter-rater reliability.

            3.1.3.2. The clinical interview. A clinical interview is a face-to-face encounter between a mental health professional and a patient in which the former observes the latter and gathers data about the person’s behavior, attitudes, current situation, personality, and life history. The interview may be unstructured in which open-ended questions are asked, structured in which a specific set of questions according to an interview schedule are asked, or semi-structured , in which there is a pre-set list of questions, but clinicians can follow up on specific issues that catch their attention. A mental status examination is used to organize the information collected during the interview and systematically evaluates the patient through a series of questions assessing appearance and behavior. The latter includes grooming and body posture, thought processes and content to include disorganized speech or thought and false beliefs, mood and affect such that whether the person feels hopeless or elated, intellectual functioning to include speech and memory, and awareness of surroundings to include where the person is and what the day and time are. The exam covers areas not normally part of the interview and allows the mental health professional to determine which areas need to be examined further. The limitation of the interview is that it lacks reliability, especially in the case of the unstructured interview.

            3.1.3.3. Psychological tests and inventories. Psychological tests assess the client’s personality, social skills, cognitive abilities, emotions, behavioral responses, or interests. They can be administered either individually or to groups in paper or oral fashion. Projective tests consist of simple ambiguous stimuli that can elicit an unlimited number of responses. They include the Rorschach or inkblot test and the Thematic Apperception Test which asks the individual to write a complete story about each of 20 cards shown to them and give details about what led up to the scene depicted, what the characters are thinking, what they are doing, and what the outcome will be. From the response, the clinician gains perspective on the patient’s worries, needs, emotions, conflicts, and the individual always connects with one of the people on the card.  Another projective test is the sentence completion test and asks individuals to finish an incomplete sentence. Examples include ‘My mother…’ or ‘I hope…’

Personality inventories ask clients to state whether each item in a long list of statements applies to them, and could ask about feelings, behaviors, or beliefs. Examples include the MMPI or Minnesota Multiphasic Personality Inventory and the NEO-PI-R, which is a concise measure of the five major domains of personality – Neuroticism, Extroversion, Openness, Agreeableness, and Conscientiousness. Six facets define each of the five domains, and the measure assesses emotional, interpersonal, experimental, attitudinal, and motivational styles (Costa & McCrae, 1992). These inventories have the advantage of being easy to administer by either a professional or the individual taking it, are standardized, objectively scored, and can be completed electronically or by hand. That said, personality cannot be directly assessed, and so you do not ever completely know the individual.

            3.1.3.4. Neurological tests. Neurological tests are used to diagnose cognitive impairments caused by brain damage due to tumors, infections, or head injuries; or changes in brain activity. Positron Emission Tomography or PET is used to study the brain’s chemistry. It begins by injecting the patient with a radionuclide that collects in the brain and then having them lie on a scanning table while a ring-shaped machine is positioned over their head. Images are produced that yield information about the functioning of the brain. Magnetic Resonance Imaging or MRI provides 3D images of the brain or other body structures using magnetic fields and computers. It can detect brain and spinal cord tumors or nervous system disorders such as multiple sclerosis. Finally, computed tomography or the CT scan involves taking X-rays of the brain at different angles and is used to diagnose brain damage caused by head injuries or brain tumors.

            3.1.3.5. Physical examination. Many mental health professionals recommend the patient see their family physician for a physical examination, which is much like a check-up. Why is that? Some organic conditions, such as hyperthyroidism or hormonal irregularities, manifest behavioral symptoms that are like mental disorders. Ruling out such conditions can save costly therapy or surgery.

            3.1.3.6. Behavioral assessment. Within the realm of behavior modification and applied behavior analysis, we talk about what is called behavioral assessment , which is the measurement of a target behavior. The target behavior is whatever behavior we want to change, and it can be in excess and needing to be reduced, or in a deficit state and needing to be increased. During the behavioral assessment we learn about the ABCs of behavior in which Antecedents are the environmental events or stimuli that trigger a behavior; Behaviors are what the person does, says, thinks/feels; and Consequences are the outcome of a behavior that either encourages it to be made again in the future or discourages its future occurrence. Though we might try to change another person’s behavior using behavior modification, we can also change our own behavior, which is called self-modification. The person does their own measuring and recording of the ABCs, which is called self-monitoring. In the context of psychopathology, behavior modification can be useful in treating phobias, reducing habit disorders, and ridding the person of maladaptive cognitions.

            3.1.3.7. Intelligence tests. Intelligence testing determines the patient’s level of cognitive functioning and consists of a series of tasks asking the patient to use both verbal and nonverbal skills. An example is the Stanford-Binet Intelligence test , which assesses fluid reasoning, knowledge, quantitative reasoning, visual-spatial processing, and working memory. Intelligence tests have been criticized for not predicting future behaviors such as achievement and reflecting social or cultural factors/biases and not actual intelligence. Also, can we really assess intelligence through one dimension, or are there multiple dimensions?

Key Takeaways

You should have learned the following in this section:

• Clinical assessment is the collecting of information and drawing conclusions through the use of observation, psychological tests, neurological tests, and interviews.
• Reliability refers to consistency in measurement and can take the form of interrater and test-retest reliability.
• Validity is when we ensure the test measures what it says it measures and takes the forms of concurrent or descriptive, face, and predictive validity.
• Standardization is all the clearly laid out rules, norms, and/or procedures to ensure the experience each participant has is the same.
• Patients are assessed through observation, psychological tests, neurological tests, and the clinical interview, all with their own strengths and limitations.

Section 3.1 Review Questions

• What does it mean that clinical assessment is an ongoing process?
• Define and exemplify reliability, validity, and standardization.
• For each assessment method, define it and then state its strengths and limitations.
• Explain what it means to make a clinical diagnosis.
• Define syndrome.
• Clarify and exemplify what a classification system does.
• Identify the two most used classification systems.
• Outline the history of the DSM.
• Identify and explain the elements of a diagnosis.
• Outline the major disorder categories of the DSM-5-TR.
• Describe the ICD-11.
• Clarify why the DSM-5-TR and ICD-11 need to be harmonized.

3.2.1. Clinical Diagnosis and Classification Systems

Before starting any type of treatment, the client/patient must be clearly diagnosed with a mental disorder. Clinical diagnosis is the process of using assessment data to determine if the pattern of symptoms the person presents with is consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the DSM-5-TR or ICD-11 (both will be described shortly). Any diagnosis should have clinical utility , meaning it aids the mental health professional in determining prognosis, the treatment plan, and possible outcomes of treatment (APA, 2022). Receiving a diagnosis does not necessarily mean the person requires treatment. This decision is made based upon how severe the symptoms are, level of distress caused by the symptoms, symptom salience such as expressing suicidal ideation, risks and benefits of treatment, disability, and other factors (APA, 2022). Likewise, a patient may not meet the full criteria for a diagnosis but demonstrate a clear need for treatment or care, nonetheless. As stated in the DSM, “The fact that some individuals do not show all symptoms indicative of a diagnosis should not be used to justify limiting their access to appropriate care” (APA, 2022).

Symptoms that cluster together regularly are called a syndrome . If they also follow the same, predictable course, we say that they are characteristic of a specific disorder .  Classification systems provide mental health professionals with an agreed-upon list of disorders falling into distinct categories for which there are clear descriptions and criteria for making a diagnosis. Distinct is the keyword here. People suffering from delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior, and/or negative symptoms are different from people presenting with a primary clinical deficit in cognitive functioning that is not developmental but acquired (i.e., they have shown a decline in cognitive functioning over time). The former suffers from a schizophrenia spectrum disorder while the latter suffers from a neurocognitive disorder (NCD). The latter can be further distinguished from neurodevelopmental disorders which manifest early in development and involve developmental deficits that cause impairments in social, personal, academic, or occupational functioning (APA, 2022). These three disorder groups or categories can be clearly distinguished from one another. Classification systems also permit the gathering of statistics to determine incidence and prevalence rates and conform to the requirements of insurance companies for the payment of claims.

The most widely used classification system in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is a “medical classification of disorders and as such serves as a historically determined cognitive schema imposed on clinical and scientific information to increase its comprehensibility and utility. The classification of disorders (the way in which disorders are grouped) provides a high-level organization for the manual” (APA, 2022, pg. 11). The DSM is currently in its 5th edition Text-Revision (DSM-5-TR) and is produced by the American Psychiatric Association (APA, 2022). Alternatively, the World Health Organization (WHO) publishes the International Statistical Classification of Diseases and Related Health Problems (ICD) currently in its 11th edition. We will begin by discussing the DSM and then move to the ICD.

 3.2.2. The DSM Classification System

            3.2.2.1. A brief history of the DSM . The DSM-5 was published in 2013 and took the place of the DSM IV-TR (TR means Text Revision; published in 2000). In March 2022, a Text-Revision was published for the DSM-5, making it the DSM-5-TR.

The history of the DSM goes back to 1952 when the American Psychiatric Association published the first edition of the DSM which was “…the first official manual of mental disorders to contain a glossary of descriptions of the diagnostic categories” (APA, 2022, p. 5). The DSM evolved through four major editions after World War II into a diagnostic classification system to be used by psychiatrists and physicians, but also other mental health professionals. The Herculean task of revising the DSM began in 1999 when the APA embarked upon an evaluation of the strengths and weaknesses of the DSM in coordination with the World Health Organization (WHO) Division of Mental Health, the World Psychiatric Association, and the National Institute of Mental Health (NIMH). This collaboration resulted in the publication of a monograph in 2002 called A Research Agenda for DSM-V . From 2003 to 2008, the APA, WHO, NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) convened 13 international DSM-5 research planning conferences “to review the world literature in specific diagnostic areas to prepare for revisions in developing both DSM-5 and the International Classification of Disease, 11th Revision (ICD-11)” (APA, 2022, pg. 6).

After the naming of a DSM-5 Task Force Chair and Vice-Chair in 2006, task force members were selected and approved by 2007, and workgroup members were approved in 2008. An intensive 6-year process of “conducting literature reviews and secondary analyses, publishing research reports in scientific journals, developing draft diagnostic criteria, posting preliminary drafts on the DSM-5 website for public comment, presenting preliminary findings at professional meetings, performing field trials, and revisiting criteria and text” was undertaken (APA, 2022, pg. 7). The process involved physicians, psychologists, social workers, epidemiologists, neuroscientists, nurses, counselors, and statisticians, all who aided in the development and testing of DSM-5 while individuals with mental disorders, families of those with a mental disorder, consumer groups, lawyers, and advocacy groups provided feedback on the mental disorders contained in the book. Additionally, disorders with low clinical utility and weak validity were considered for deletion while “Conditions for Future Study” were placed in Section 3 and “contingent on the amount of empirical evidence generated on the proposed diagnosis, diagnostic reliability or validity, presence of clear clinical need, and potential benefit in advancing research” (APA, 2022, pg. 7).

            3.2.2.2. The DSM-5 text revision process. In the spring 2019, APA started work on the Text-Revision for the DSM-5. This involved more than 200 experts who were asked to conduct literature reviews of the past 10 years and to review the text to identify any material that was out-of-date. Experts were divided into 20 disorder review groups, each with its own section editor. Four cross-cutting review groups to include Culture, Sex and Gender, Suicide, and Forensic, reviewed each chapter and focused on material involving their specific expertise. The text was also reviewed by an Ethnoracial Equity and Inclusion work group whose task was to “ensure appropriate attention to risk factors such as racism and discrimination and the use of nonstigmatizing language” (APA, 2022, pg. 11).

As such, the DSM-5-TR “is committed to the use of language that challenges the view that races are discrete and natural entities” (APA, 2022, pg. 18). Some of changes include:

• Use of racialized instead of racial to indicate the socially constructed nature of race
• Ethnoracial is used to denote U.S. Census categories such as Hispanic, African American, or White
• Latinx is used in place of Latino or Latina to promote gender-inclusive terminology
• The term Caucasian is omitted since it is “based on obsolete and erroneous views about the geographic origin of a prototypical pan-European ethnicity” (pg. 18)
• To avoid perpetuating social hierarchies, the terms minority and non-White are avoided since they describe social groups in relation to a racialized “majority”
• The terms cultural contexts and cultural backgrounds are preferred to culture which is only used to refer to a “heterogeneity of cultural views and practices within societies” (pg. 18)
• The inclusion of data on specific ethnoracial groups only when “existing research documented reliable estimates based on representative samples.” This led to limited inclusion of data on Native Americans since data from nonrepresentative samples may be misleading.
• The use of gender differences or “women and men” or “boys and girls” since much of the information on the expressions of mental disorders in women and men is based on self-identified gender.
• Inclusion of a new section for each diagnosis providing information about suicidal thoughts or behavior associated with that diagnosis.

            3.2.2.3. Elements of a diagnosis. The DSM-5-TR states that the following make up the key elements of a diagnosis (APA, 2022):

• Diagnostic Criteria and Descriptors – Diagnostic criteria are the guidelines for making a diagnosis and should be informed by clinical judgment. When the full criteria are met, mental health professionals can add severity and course specifiers to indicate the patient’s current presentation. If the full criteria are not met, designators such as “other specified” or “unspecified” can be used. If applicable, an indication of severity (mild, moderate, severe, or extreme), descriptive features, and course (type of remission – partial or full – or recurrent) can be provided with the diagnosis. The final diagnosis is based on the clinical interview, text descriptions, criteria, and clinical judgment.
• Subtypes and Specifiers – Subtypes denote “mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis” (APA, 2022, pg. 22). For example, non-rapid eye movement (NREM) sleep arousal disorders can have either a sleepwalking or sleep terror type. Enuresis is nocturnal-only, diurnal-only, or both. Specifiers are not mutually exclusive or jointly exhaustive and so more than one specifier can be given. For instance, binge eating disorder has remission and severity specifiers. Somatic symptom disorder has a specifier for severity, if with predominant pain, and/or if persistent. Again, the fundamental distinction between subtypes and specifiers is that there can be only one subtype but multiple specifiers. As the DSM-5-TR says, “Specifiers and subtypes provide an opportunity to define a more homogeneous subgrouping of individuals with the disorder who share certain features… and to convey information that is relevant to the management of the individual’s disorder” (pg. 22).
• Principle Diagnosis – A principal diagnosis is used when more than one diagnosis is given for an individual. It is the reason for the admission in an inpatient setting or the basis for a visit resulting in ambulatory care medical services in outpatient settings. The principal diagnosis is generally the focus of attention or treatment.
• Provisional Diagnosis – If not enough information is available for a mental health professional to make a definitive diagnosis, but there is a strong presumption that the full criteria will be met with additional information or time, then the provisional specifier can be used.            

            3.2.2.4. DSM-5 disorder categories. The DSM-5 includes the following categories of disorders:

Table 3.1. DSM-5 Classification System of Mental Disorders

3.2.3. The ICD-11

In 1893, the International Statistical Institute adopted the International List of Causes of Death which was the first international classification edition. The World Health Organization was entrusted with the development of the ICD in 1948 and published the 6th version (ICD-6). The ICD-11 went into effect January 1, 2022, though it was adopted in May 2019. The WHO states:

ICD serves a broad range of uses globally and provides critical knowledge on the extent, causes and consequences of human disease and death worldwide via data that is reported and coded with the ICD. Clinical terms coded with ICD are the main basis for health recording and statistics on disease in primary, secondary and tertiary care, as well as on cause of death certificates. These data and statistics support payment systems, service planning, administration of quality and safety, and health services research. Diagnostic guidance linked to categories of ICD also standardizes data collection and enables large scale research.

As a classification system, it “allows the systematic recording, analysis, interpretation and comparison of mortality and morbidity data collected in different countries or regions and at different times.” As well, it “ensures semantic interoperability and reusability of recorded data for the different use cases beyond mere health statistics, including decision support, resource allocation, reimbursement, guidelines and more.”

Source: http://www.who.int/classifications/icd/en/

The ICD lists many types of diseases and disorders to include Chapter 06: Mental, Behavioral, or Neurodevelopmental Disorders. The list of mental disorders is broken down as follows:

• Neurodevelopmental disorders
• Schizophrenia or other primary psychotic disorders
• Mood disorders
• Anxiety or fear-related disorders
• Obsessive-compulsive or related disorders
• Disorders specifically associated with stress
• Dissociative disorders
• Feeding or eating disorders
• Elimination disorders
• Disorders of bodily distress or bodily experience
• Disorders due to substance use or addictive behaviours
• Impulse control disorders
• Disruptive behaviour or dissocial disorders
• Personality disorders and related traits
• Paraphilic disorders
• Factitious disorders
• Neurocognitive disorders
• Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium

It should be noted that Sleep-Wake Disorders are listed in Chapter 07.

To access Chapter 06 of the ICD-11, please visit the following:

https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f334423054

3.2.4. Harmonization of DSM-5-TR and ICD-11

According to the DSM-5-TR, there is an effort to harmonize the two classification systems: 1) for a more accurate collection of national health statistics and design of clinical trials aimed at developing new treatments, 2) to increase the ability to replicate scientific findings across national boundaries, and 3) to rectify the issue of DSM-IV and ICD-10 diagnoses not agreeing (APA, 2022, pg. 13). Complete harmonization of the DSM-5 diagnostic criteria with the ICD-11 disorder definitions has not occurred due to differences in timing. The DSM-5 developmental effort was several years ahead of the ICD-11 revision process. Despite this, some improvement in harmonization did occur as many ICD-11 working group members had participated in the development of the DSM-5 diagnostic criteria and all ICD-11 work groups were given instructions to review the DSM-5 criteria sets and make them as similar as possible (unless there was a legitimate reason not to). This has led to the ICD and DSM being closer than at any time since DSM-II and ICD-8 (APA, 2022).

• Clinical diagnosis is the process of using assessment data to determine if the pattern of symptoms the person presents with is consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the DSM-5-TR or ICD-11.
• Classification systems provide mental health professionals with an agreed-upon list of disorders falling into distinct categories for which there are clear descriptions and criteria for making a diagnosis.
• Elements of a diagnosis in the DSM include the diagnostic criteria and descriptors, subtypes and specifiers, the principle diagnosis, and a provisional diagnosis.

Section 3.2 Review Questions

• What is clinical diagnosis?
• What is a classification system and what are the two main ones used today?
• Outline the diagnostic categories used in the DSM-5-TR.
• Clarify reasons why an individual may need to seek treatment.
• Critique myths about psychotherapy.

3.3.1. Seeking Treatment

            3.3.1.1. Who seeks treatment? Would you describe the people who seek treatment as being on the brink, crazy, or desperate? Or can the ordinary Joe in need of advice seek out mental health counseling? The answer is that anyone can. David Sack, M.D. (2013) writes in the article 5 Signs Its Time to Seek Therapy , published in Psychology Today, that “most people can benefit from therapy at least some point in their lives,” and though the signs you need to seek help are obvious at times, we often try “to sustain [our] busy life until it sets in that life has become unmanageable.” So, when should we seek help? First, if we feel sad, angry, or not like ourselves. We might be withdrawing from friends and families or sleeping more or less than we usually do. Second, if we are abusing drugs, alcohol, food, or sex to deal with life’s problems. In this case, our coping skills may need some work. Third, in instances when we have lost a loved one or something else important to us, whether due to death or divorce, the grief may be too much to process. Fourth, a traumatic event may have occurred, such as abuse, a crime, an accident, chronic illness, or rape. Finally, if you have stopped doing the things you enjoy the most. Sack (2013) says, “If you decide that therapy is worth a try, it doesn’t mean you’re in for a lifetime of head shrinking.” A 2001 study in the Journal of Counseling Psychology found that most people feel better within seven to 10 visits. In another study, published in 2006 in the Journal of Consulting and Clinical Psychology, 88% of therapy-goers reported improvements after just one session.”

For more on this article, please visit:

https://www.psychologytoday.com/blog/where-science-meets-the-steps/201303/5-signs-its-time-seek-therapy

            3.3.1.2. When friends, family, and self-healing are not enough. If you are experiencing any of the aforementioned issues, you should seek help. Instead of facing the potential stigma of talking to a mental health professional, many people think that talking through their problems with friends or family is just as good. Though you will ultimately need these people to see you through your recovery, they do not have the training and years of experience that a psychologist or similar professional has. “Psychologists can recognize behavior or thought patterns objectively, more so than those closest to you who may have stopped noticing — or maybe never noticed. A psychologist might offer remarks or observations similar to those in your existing relationships, but their help may be more effective due to their timing, focus, or your trust in their neutral stance” ( http://www.apa.org/helpcenter/psychotherapy-myths.aspx ). You also should not wait to recover on your own. It is not a failure to admit you need help, and there could be a biological issue that makes it almost impossible to heal yourself.

            3.3.1.3. What exactly is psychotherapy? According to the APA, in psychotherapy “psychologists apply scientifically validated procedures to help people develop healthier, more effective habits.” Several different approaches can be utilized to include behavior, cognitive and cognitive-behavior, humanistic-experiential, psychodynamic, couples and family, and biological treatments.

            3.3.1.4. The client-therapist relationship. What is the ideal client-therapist relationship? APA says, “Psychotherapy is a collaborative treatment based on the relationship between an individual and a psychologist. Grounded in dialogue, it provides a supportive environment that allows you to talk openly with someone who’s objective, neutral and nonjudgmental. You and your psychologist will work together to identify and change the thought and behavior patterns that are keeping you from feeling your best.” It’s not just about solving the problem you saw the therapist for, but also about learning new skills to help you cope better in the future when faced with the same or similar environmental stressors.

So how do you find a psychotherapist? Several strategies may prove fruitful. You could ask family and friends, your primary care physician (PCP), look online, consult an area community mental health center, your local university’s psychology department, state psychological association, or use APA’s Psychologist Locator Service ( https://locator.apa.org/?_ga=2.160567293.1305482682.1516057794-1001575750.1501611950 ). Once you find a list of psychologists or other practitioners, choose the right one for you by determining if you plan on attending alone or with family, what you wish to get out of your time with a psychotherapist, how much your insurance company pays for and if you have to pay out of pocket how much you can afford, when you can attend sessions, and how far you are willing to travel to see the mental health professional. Once you have done this, make your first appointment.

But what should you bring? APA suggests, “to make the most of your time, make a list of the points you want to cover in your first session and what you want to work on in psychotherapy. Be prepared to share information about what’s bringing you to the psychologist. Even a vague idea of what you want to accomplish can help you and your psychologist proceed efficiently and effectively.” Additionally, they suggest taking report cards, a list of medications, information on the reasons for a referral, a notebook, a calendar to schedule future visits if needed, and a form of payment. What you take depends on the reason for the visit.

In terms of what you should expect, you and your therapist will work to develop a full history which could take several visits. From this, a treatment plan will be developed. “This collaborative goal-setting is important, because both of you need to be invested in achieving your goals. Your psychologist may write down the goals and read them back to you, so you’re both clear about what you’ll be working on. Some psychologists even create a treatment contract that lays out the purpose of treatment, its expected duration and goals, with both the individual’s and psychologist’s responsibilities outlined.”

After the initial visit, the mental health professional may conduct tests to further understand your condition but will continue talking through the issue. He/she may even suggest involving others, especially in cases of relationship issues. Resilience is a skill that will be taught so that you can better handle future situations.

            3.3.1.5. Does it work? APA writes, “Reviews of these studies show that about 75 percent of people who enter psychotherapy show some benefit. Other reviews have found that the average person who engages in psychotherapy is better off by the end of treatment than 80 percent of those who don’t receive treatment at all.” Treatment works due to finding evidence-based treatment that is specific for the person’s problem; the expertise of the therapist; and the characteristics, values, culture, preferences, and personality of the client.

            3.3.1.6. How do you know you are finished? “How long psychotherapy takes depends on several factors: the type of problem or disorder, the patient’s characteristics and history, the patient’s goals, what’s going on in the patient’s life outside psychotherapy and how fast the patient is able to make progress.” It is important to note that psychotherapy is not a lifelong commitment, and it is a joint decision of client and therapist as to when it ends. Once over, expect to have a periodic check-up with your therapist. This might be weeks or even months after your last session. If you need to see him/her sooner, schedule an appointment. APA calls this a “mental health tune up” or a “booster session.”

For more on psychotherapy, please see the very interesting APA article on this matter:

http://www.apa.org/helpcenter/understanding-psychotherapy.aspx

• Anyone can seek treatment and we all can benefit from it at some point in our lives.
• Psychotherapy is when psychologists apply scientifically validated procedures to help a person feel better and develop healthy habits.

Section 3.3 Review Questions

• When should you seek help?
• Why should you seek professional help over the advice dispensed by family and friends?
• How do you find a therapist and what should you bring to your appointment?
• Does psychotherapy work?

Module Recap

That’s it. With the conclusion of Module 3, you now have the necessary foundation to understand each of the groups of disorders we discuss beginning in Module 4 and through Module 14.

In Module 3 we reviewed clinical assessment, diagnosis, and treatment. In terms of assessment, we covered key concepts such as reliability, validity, and standardization; and discussed methods of assessment such as observation, the clinical interview, psychological tests, personality inventories, neurological tests, the physical examination, behavioral assessment, and intelligence tests. In terms of diagnosis, we discussed the classification systems of the DSM-5-TR and ICD-11. For treatment, we discussed the reasons why someone may seek treatment, self-treatment, psychotherapy, the client-centered relationship, and how well psychotherapy works.

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Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

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Case study: A patient with severe delusions who self-mutilates

Lesiba t. lebelo.

2 Department of Psychiatry, School of Medicine, University of Pretoria, Pretoria, South Africa

Gerhard P. Grobler

1 Department of Psychiatry, Mamelodi Hospital, Pretoria, South Africa

Associated Data

Data sharing is not applicable to this article as no new data were created or analysed in this study.this study.

Background and introduction

Although some overlapping features exist between self-injury and intention to die, there is growing recognition that non-suicidal self-injury (NSSI), including major self-mutilation (MSM), and suicidal behaviour are distinct entities as evidenced by their significance in terms of aetiology, psychiatric impairment, psychological function, method of self-harm and course or outcome between the two phenomena. 1

We present a case of self-harm in a mental healthcare user diagnosed with schizophrenia to highlight the distinction made above.

Case presentation

Mr X is a 38-year-old, unemployed, single male with no children and with an elementary level of education. This was his index presentation with a 4-year history characterised by ongoing persecutory delusions, as well as auditory hallucinations. He was brought to the Emergency Department by ambulance because he was found to be bleeding profusely from his scrotum in the toilet of a petrol filling station. He alleged that he had cut open his scrotum to remove his testicles before his ‘tormentors’ could do so. He stated clearly that he did not want to die because he valued his life. This was therefore not an attempt at suicide.

He was initially admitted to the urology ward and then referred to psychiatry. The multi-disciplinary team diagnosed him with and treated him for schizophrenia. He responded well to haloperidol 2.5 mg orally in the morning and 5 mg orally at night. A long-acting injectable antipsychotic, flupenthixol decanoate 20 mg intramuscular was also prescribed. No adverse effects were reported. Lorazepam was titrated downwards from 1 mg orally twice daily to 1 mg orally at night, and then stopped before he was discharged. Lansoprazole 30 mg daily orally, tramadol 50 mg three times daily orally and paracetamol 1 g orally were also prescribed as needed.

Upon discharge, on day 44 of the admission, the patient was symptom free with no psychotic or anxiety features.

The patient did not manifest any depressive symptoms throughout his hospitalisation, nor on his 4-week follow-up visit subsequent to discharge. He also demonstrated full and complete understanding that the voices, the self-conviction and his belief that people were coming to harm him were all part of his illness called schizophrenia. He also demonstrated full understanding that the belief of being harmed and people conspiring against him were also part of his schizophrenic illness that had been untreated for at least the past 4 years. With no negative emotion, he demonstrated intellectual understanding with unconditional acceptance of his illness. We emphasised to him that he must be consistent with medical check-ups at his local clinic as some other medical conditions can cause his illness to resurface. It was further emphasised to him that for as long as he took his treatment regularly and as prescribed the schizophrenia would be managed and controlled well. He agreed to stay away from all psychoactive substances. This user was amenable to following up with a clinical psychologist, an occupational therapist and a social worker.

He was followed up 1 month later and then referred to his local clinic for continuation of the prescribed treatment, appointments for continuation of psycho-education, counselling and relevant psycho-therapies. This patient responded well and remitted only on antipsychotic agents.

Literature review and discussion

In a study of measurable variables, paranoia and auditory hallucinations, psychotic-like experience (PLE) and stressful life events all contributed to the patient causing self-harm. Compared to those without PLEs, the prevalence of NSSI was higher than those with PLEs. 1

Psychotic-like experiences are highly prevalent in the general population, with figures of 20% or above being reported in some studies. 1 Major self-mutilation (or NSSI) is a rare but potentially catastrophic complication of severe mental illness. Most people who inflict NSSI have a psychotic disorder, usually a schizophrenia spectrum psychosis. It is not known when in the course of psychotic illness, NSSI is most likely to occur. 2 In general, schizophrenia is associated with worse social functional outcomes compared with other psychotic disorders, but the few studies that directly tested this assumption by comparing the longitudinal courses of social functioning in affective and non-affective psychoses have yielded conflicting findings. 3

Cases of genital self-mutilation reported in the literature have been in patients with psychosis, including schizophrenia. 4 Our own literature review found only a few case reports, published in 1974 (a female patient with schizophrenia and erotomania), 1986 (autocastration with biblical delusions) and in 1995. Greilsheimer writes that: ‘Men who intentionally mutilate or remove their own genitals are likely to be psychotic…’. 5

The reason for presenting the case is that there was no similar case recorded in our country, using Google Scholar search engine database of at least the past 5 years, nor elsewhere when we searched using the following keywords: ‘Self-castration, non-suicidal self-injury and psychosis, self-castration due to psychosis’.

In the South African context, the promulgation of the Traditional Health Practitioners Act no. 35 of 2004 has become an important precipitant for the local review of the place of culture and religion/spirituality in secular areas such as health, mental health and spirituality. 6 Our patient did not display delusions with religious or spiritual content. This particular patient was not practising any religion although he claims to believe in God. He emphasised that he was convinced by his delusions and hallucinations that some people known to him were conspiring to cut his scrotum and extract his testicles for some ritualistic practices. Their psychosis can eventually weaken their faith as they may think that they have been successfully bewitched and cursed even if they have been mentally stabilised.

Patients living with schizophrenia and who suffer persistently high levels of psychotic symptoms as well as poorer (psychosocial) functioning and lower self-esteem have higher severity of suicide behaviour. 7 Even in first episode psychosis, one in 10 people engages in self-harm. 8

It is important to take note of this case as it is the first of its kind and adds to existing knowledge in mental health that untreated and long-standing psychosis can result in the patient harming himself irreversibly such that they lose the capacity to reproduce.

Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon. The mobility of the scrotum may be one reason, severe injury is rare. Given the importance of preserving fertility, traumatic injuries of the testicles deserve careful attention. Testicular injuries can be divided into three broad categories based on the mechanism of injury: (1) blunt trauma, (2) penetrating trauma and (3) degloving trauma. Such injuries are typically seen in males aged 15–40 years.

Our patient was psychotic with auditory hallucinations, persecutory delusions and bizarre delusions which did not include religious delusions when he harmed himself. He was convinced that his ‘tormentors’ were listening to his thoughts and he consequently planned to cut open his scrotum to remove his testicles before they could do that to him. The main reason our patient injured himself was not to die but to relieve himself of the constant and increasing threats of being robbed of his testicles. It is important in the South African context to treat a psychiatric patient by using the multi-disciplinary team approach which is also holistic in nature and covers all aspects of mental healthcare service provision, including spirituality, as most citizens (92%) of South Africa expressed religious affiliation. 9

Not all patients who harm themselves, even severely, are suicidal. Some just want to rid themselves of tormenting psychosis as in this case.

Acknowledgements

The authors wishes to acknowledge their colleagues who supported this project and their patients from whom they learnt much.

Competing interests

The authors have declared that no competing interest exists.

Authors’ contributions

Both authors contributed equally to this work.

Ethical consideration

This article followed all ethical standards for research without direct contact with human or animal subjects.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability statement

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

How to cite this article: Lebelo LT, Grobler GP. Case study: A patient with severe delusions who self-mutilates. S Afr J Psychiat. 2020;26(0), a1403. https://doi.org/10.4102/sajpsychiatry.v26i0.1403

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DIFFERENTIAL DIAGNOSES

Differential Diagnosis I: MAJOR DEPRESSIVE DISORDER (MDD)

Rationale: Ashley presents with several signs and symptoms of major depressive disorder (MDD), including depressed mood, loss of energy, difficulty concentrating, insomnia, weight loss and recurrent thoughts of death (Center for Substance Abuse Treatment, 2008). A diagnosis of major depressive disorder can be made if the symptoms are severe enough to interfere with a person’s ability to sleep, study, eat and enjoy life (NIMH, 2015). Ashley’s testimony that she has had difficulty with school, sleep and volleyball practice therefore supports this diagnosis.

Differential Diagnosis II: GRIEF

Rationale: Ashley presents with symptoms of grief, including sadness and withdrawal from usual activities. Despite some overlap between grief and MDD, a couple key aspects can differentiate these two diagnoses: 1) In grief, feelings of sadness usually come in waves; in depression, negative mood is almost always sustained, 2) In grief, the patient maintains self-esteem; in depression, patient often has feelings of worthlessness or self-loathing (APA, 2013). Ashley’s history of prolonged feelings of worthlessness combined with her history of self-harm support a diagnosis of MDD rather than grief. Additionally, Ashley did not identify any specific trigger for her feelings of sadness (e.g. loss of a loved one), thus making a diagnosis of grief unlikely.

Differential Diagnosis III: BIPOLAR DISORDER

Rationale: Ashley presents with symptoms commonly associated with the depressed phase of bipolar disorder, such as a depressed mood and suicidal ideation. Patients experiencing a depressive episode of bipolar disorder have a very similar clinical presentation to a patient with MDD (also called unipolar depression) (Hirschfield, 2014). A key aspect of bipolar disorder that differentiates it from MDD is that patients with bipolar disorder also experience manic episodes. The fact that patients rarely present to the health care provider during a manic episode of BPD can complicate the differential diagnosis (Tesar, 2010). In order to diagnose a patient like Ashley with bipolar disorder, she would have to describe a past history of manic episodes. Since Ashley did not describe a history of manic episodes, the clinician would likely not make a diagnosis of bipolar disorder at this encounter.

Of note, antidepressants show little to no efficacy for depressive episodes associated with bipolar disorder (Hirschfield, 2014). Consequently, correct identification of bipolar disorder among patients exhibiting signs of depression is critical for effective treatment and improved outcomes (Hirschfield, 2014).

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