Example Case Study Format

At some point in your study of psychology, you may be required to write a case study. These are often used in clinical cases or in situations when lab research is not possible or practical. In undergraduate courses, these are often based on a real individual, an imagined individual, or a character from a television show, film, or book.

The specific format for a case study can vary greatly. In some instances, your case study will focus solely on the individual of interest.

Other possible requirements include citing relevant research and background information on a particular topic. Always consult with your instructor for a detailed outline of your assignment.

What Is a Case Study?

A case study is an in-depth study of one person, group, or event. Much of Freud's work and theories were developed through the use of individual case studies. Some great examples of case studies in psychology include Anna O, Phineas Gage, and Genie.

In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. The hope is that learning gained from studying one case 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.

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

The case study of Genie, for example, allowed researchers to study whether language could be taught even after critical periods for language development had been missed.

In Genie's case, her horrific abuse had denied her the opportunity to learn language at critical points in her development. This is clearly not something that researchers could ethically replicate, but conducting a case study on Genie allowed researchers the chance to study otherwise impossible to reproduce phenomena.


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

  • Explanatory case studies are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have actually caused certain things to occur.
  • Exploratory case studies 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.
  • Descriptive case studies involve starting with a descriptive theory. The subjects are then observed and the information gathered is compared to the pre-existing theory.
  • Intrinsic case studies are a type of case study in which the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic cast study can contribute to the development of a psychological theory.
  • Collective case studies involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community of people.
  • Instrumental case studies occur when the individual or group allows researchers to understand more than what is initially obvious to observers.


There are also different methods that can be used to conduct a case study:

  • Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.
  • Retrospective case study methods are those that involve looking at historical information. For example, researchers might start with an outcome, such as a disease, and then work their way backward to look at information about the individuals life to determine risk factors that may have contributed to the onset of the illness.

Sources of Information Used

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

  1. 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.
  2. Interviews: One of the most important methods for gathering information in case studies. An interview can involves structured survey-type questions or more open-ended questions.
  3. Documents: Letters, newspaper articles, administrative records, etc.
  4. Archival records: Census records, survey records, name lists, etc.
  5. Physical artifacts: Tools, objects, instruments and other artifacts often observed during a direct observation of the subject.
  6. Participant observation: Involves the researcher actually serving as a participant in events and observing the actions and outcomes.

Section 1: A Case History

1. 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.

2. 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.

3. Your Diagnosis

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

Section 2: The Intervention

The second section of your paper will focus on the intervention used to help the client. Your instructor might require you to choose from a particular theoretical approach or ask you to summarize two or more possible treatment approaches.

Some of the possible treatment approaches you might choose to explore include:

1. 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.

2. 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.

3. 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.


  • Do not refer to the subject of your case study as "the client." Instead, use his or her name or a pseudonym.
  • Remember to use APA format when citing references.
  • Read examples of case studies to gain and idea about the style and format.

A Word From Verywell

Case studies can be a useful research tool but they need to be used wisely. In many cases, they are best utilized in situations where conducting an experiment would be difficult or impossible. They can be helpful for looking at unique situations and allow researchers to gather a great deal of information about a specific individual or group of people.

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 that you are required to follow.


Gagnon, YC. The Case Study as a Research Method: A Practical Handbook. Quebec: PUQ; 2010.

Yin, RK. Case Study Research: Design and Methods. Sage Publications; 2013.

This set of guidelines provides both instructions and a template for the writing of case reports for publication. You might want to skip forward and take a quick look at the template now, as we will be using it as the basis for your own case study later on. While the guidelines and template contain much detail, your finished case study should be only 500 to 1,500 words in length. Therefore, you will need to write efficiently and avoid unnecessarily flowery language.

These guidelines for the writing of case studies are designed to be consistent with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” referenced elsewhere in the JCCA instructions to authors.

After this brief introduction, the guidelines below will follow the headings of our template. Hence, it is possible to work section by section through the template to quickly produce a first draft of your study. To begin with, however, you must have a clear sense of the value of the study which you wish to describe. Therefore, before beginning to write the study itself, you should gather all of the materials relevant to the case – clinical notes, lab reports, x-rays etc. – and form a clear picture of the story that you wish to share with your profession. At the most superficial level, you may want to ask yourself “What is interesting about this case?” Keep your answer in mind as your write, because sometimes we become lost in our writing and forget the message that we want to convey.

Another important general rule for writing case studies is to stick to the facts. A case study should be a fairly modest description of what actually happened. Speculation about underlying mechanisms of the disease process or treatment should be restrained. Field practitioners and students are seldom well-prepared to discuss physiology or pathology. This is best left to experts in those fields. The thing of greatest value that you can provide to your colleagues is an honest record of clinical events.

Finally, remember that a case study is primarily a chronicle of a patient’s progress, not a story about chiropractic. Editorial or promotional remarks do not belong in a case study, no matter how great our enthusiasm. It is best to simply tell the story and let the outcome speak for itself. With these points in mind, let’s begin the process of writing the case study:

  • Title page:
    1. Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet. They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. Thus, our title should contain the phrase “case study,” “case report” or “case series” as is appropriate to the contents. The two most common formats of titles are nominal and compound. A nominal title is a single phrase, for example “A case study of hypertension which responded to spinal manipulation.” A compound title consists of two phrases in succession, for example “Response of hypertension to spinal manipulation: a case study.” Keep in mind that titles of articles in leading journals average between 8 and 9 words in length.

    2. Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing – at the very least they must be able to explain and even defend the article. Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. Contact information – either home or institutional – should be provided for each author along with the authors’ academic qualifications. If there is more than one author, one author must be identified as the corresponding author – the person whom people should contact if they have questions or comments about the study.

    3. Key words: Provide key words under which the article will be listed. These are the words which would be used when searching for the article using a search engine such as Medline. When practical, we should choose key words from a standard list of keywords, such as MeSH (Medical subject headings). A copy of MeSH is available in most libraries. If we can’t access a copy and we want to make sure that our keywords are included in the MeSH library, we can visit this address: http://www.ncbi.nlm.nih.gov:80/entrez/meshbrowser.cgi

  • Abstract: Abstracts generally follow one of two styles, narrative or structured.

    A narrative abstract consists of a short version of the whole paper. There are no headings within the narrative abstract. The author simply tries to summarize the paper into a story which flows logically.

    A structured abstract uses subheadings. Structured abstracts are becoming more popular for basic scientific and clinical studies, since they standardize the abstract and ensure that certain information is included. This is very useful for readers who search for articles on the internet. Often the abstract is displayed by a search engine, and on the basis of the abstract the reader will decide whether or not to download the full article (which may require payment of a fee). With a structured abstract, the reader is more likely to be given the information which they need to decide whether to go on to the full article, and so this style is encouraged. The JCCA recommends the use of structured abstracts for case studies.

    Since they are summaries, both narrative and structured abstracts are easier to write once we have finished the rest of the article. We include a template for a structured abstract and encourage authors to make use of it. Our sub-headings will be:
    1. Introduction: This consists of one or two sentences to describe the context of the case and summarize the entire article.

    2. Case presentation: Several sentences describe the history and results of any examinations performed. The working diagnosis and management of the case are described.

    3. Management and Outcome: Simply describe the course of the patient’s complaint. Where possible, make reference to any outcome measures which you used to objectively demonstrate how the patient’s condition evolved through the course of management.

    4. Discussion: Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned.

  • Introduction: At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe. The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly. If there is something especially challenging about the diagnosis or management of the condition that we are describing, now is our chance to bring that out. Each time we refer to a previous study, we cite the reference (usually at the end of the sentence). Our introduction doesn’t need to be more than a few paragraphs long, and our objective is to have the reader understand clearly, but in a general sense, why it is useful for them to be reading about this case.

  • Case presentation: This is the part of the paper in which we introduce the raw data. First, we describe the complaint that brought the patient to us. It is often useful to use the patient’s own words. Next, we introduce the important information that we obtained from our history-taking. We don’t need to include every detail – just the information that helped us to settle on our diagnosis. Also, we should try to present patient information in a narrative form – full sentences which efficiently summarize the results of our questioning. In our own practice, the history usually leads to a differential diagnosis – a short list of the most likely diseases or disorders underlying the patient’s symptoms. We may or may not choose to include this list at the end of this section of the case presentation.

    The next step is to describe the results of our clinical examination. Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.

    If we are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, we should describe the actual results, since not all readers will have the same understanding of what constitutes a “positive” or “negative” result.

    X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is submitted.

    At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.

  • Management and Outcome: In this section, we should clearly describe the plan for care, as well as the care which was actually provided, and the outcome.

    It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used. It does not help the reader to simply say that the patient received “chiropractic care.” Exactly what treatment did we use? If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized.

    We may want to include the patient’s own reports of improvement or worsening. However, whenever possible we should try to use a well-validated method of measuring their improvement. For case studies, it may be possible to use data from visual analogue scales (VAS) for pain, or a journal of medication usage.

    It is useful to include in this section an indication of how and why treatment finished. Did we decide to terminate care, and if so, why? Did the patient withdraw from care or did we refer them to another practitioner?

  • Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed. This is usually impossible. Nor should we feel obligated to list or generate all of the possible hypotheses that might explain the course of the patient’s condition. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case.

  • Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.

  • References: References should be listed as described elsewhere in the instructions to authors. Only use references that you have read and understood, and actually used to support the case study. Do not use more than approximately 15 references without some clear justification. Try to avoid using textbooks as references, since it is assumed that most readers would already have this information. Also, do not refer to personal communication, since readers have no way of checking this information.

    A popular search engine for English-language references is Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

  • Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend.

  • Tables, figures and photographs should be included at the end of the manuscript.

  • Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher. Also, if we use any photographs which might identify a patient, we will need their written permission.

  • In addition, patient consent to publish the case report is also required.

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