Assessment Report PSYC2595 PDF

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ANU Psychology Clinic

Canberra ACT 0200 Australia T: +61 2 6125 8498 F: +61 2 6125 9656 www.anu.edu.au/psychology/

A Centre for Clinical Practice and Research in Psychology Building No. 39, Research School of Psychology

INITIAL ASSESSMENT REPORT

Name: Gabriella Smith

Client ID: 1821

DOB: 04/03/XXXX

Age: 20

Address: 17 College Street Acton 2601 ACT Referred by: Dr Ima Doctor Reason for referral: Depressed mood, following break up from boyfriend. Loss of energy and motivation, increased alcohol use, low self-worth. Date of Assessment: 23rd February 2018 Date of Report: 04/05/2018 Psychologist: Jessica Collins

Introduction and Background Ms Gabriella Smith is a 20 year old female who was referred to the ANU Psychology Clinic by her GP for treatment for depression. Ms Smith is a 1st year Medical Science student at the ANU, currently taking a break from study due to low mood. Ms Smith has recently been employed part-time at a restaurant in Civic but self-describes as being slow and not very good at this. She has a history of disrupted schooling due to being displaced by her fathers military postings however has lived in Canberra for the past 3 years, where she currently resides, with both her parents and younger sister. Her brother, whom she is closest to, remains in Brisbane. Relationship with parents is “okay” but feels like she is a disappointment. Described her mother as a “worrier’, and both parents as perfectionistic Otherwise, no previous history of psychiatric illness in the family. Ms Smith had a depressive episode several years ago following her family’s move to Canberra, and briefly saw a counsellor in

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relation to this in high school. Ms Smith’s current episode appears to have been triggered by the long-term relationship breakdown she experienced with her ex-boyfriend in early 2017.

Presenting Issue/s Ms Smith was referred to the ANU Psychology Clinic by her current GP, Dr Ima Doctor on the 4th of March 2018, due to her depressed mood, following her recent break up with her long-term boyfriend. Presenting issues include loss of energy and motivation, increased alcohol use and low self-worth. When she presented to the clinic, Ms Smith described having a loss of energy and motivation coupled with low self-worth, and reported that she was increasingly avoiding social situations.

Psychosocial History

Ms Smith was born in the UK and moved to Australia at the age of 9 due to her father being posted here with the Royal Air Force. He subsequently transferred to the Royal Australian Air Force and settled the family in Australia, however he’s military employment meant the family spent the next 11 years moving around Australia. Ms Smith thus spent her childhood and adolescence across the UK, Perth, Brisbane and Canberra. Ms Smith found moving “fun” and “interesting” whilst younger, but later increasingly found relocating disruptive and distressing.

Her father remains in the RAAF, while her mother teaches at Dickson College. Relationship with parents is “okay” but feels like she is disappointment. Both parents were very ambitious and pushed her to study medicine.

Her sister is currently in year 10 at Canberra Girls Grammar, while her brother is currently studying law at UQ and resides in Brisbane. Ms Smith reported a good relationship with her brother, however misses his support now that she doesn’t seem him often due to living interstate. She is not as close with her sister, who she perceives as her parents favourite.

In regards to relationships, Ms Smith reported several short term boyfriends in high school, however only one long-term relationship. This relationship began in year 11, however ended Page 2 of 10

this year “out of the blue” because he couldn’t “handle my moods”. Reported feeling devastated – now difficult for her to trust, avoiding close relationships.

Ms Smith attended primary schools in the UK, Perth and Brisbane. She describes having been confident in primary school and after moving to Brisbane, however that regular moving became more disruptive and distressing, especially in high school, subsequently affecting her confidence and overall mood. The move from Brisbane to Canberra at the end of year 10 was hardest for her as she had spent 5 years in Brisbane and became depressed and highly distressed at the thought of leaving her friends and changing school again. She reports having lost her confidence after the move to Canberra as she felt as though she didn’t fit in at her new school because the other girls were “cliquey”. She also noted jealousy of her sister who had been younger when they moved and had fitted in more easily due to being more outgoing.

Despite this, Ms Smith completed year 11 and 12 at Canberra Girls Grammar before commencing Medical Science at the ANU. Ms Smith completed her first year of studies in Medical Science at the ANU however is currently having a break from university due to low mood. She reports feeling like a disappointment as both her parents were very ambitious and pushed her to study medicine. She feels as though she would be letting them down if she left uni.

In regards to work, Ms Smith just started part-time job at a restaurant in Civic but described herself as not being very good, being slow and that she made mistakes on her first shift.

Ms Smith suffered from asthma as a child and still experiences breathlessness when she exerts herself, requiring her to use a Ventolin puffer at times. She also experiences hay fever and has cited that this has worsened since moving to Canberra. Lastly, Ms Smith had her tonsils removed at age 12 and reports recurring sinus problems which have been impacting on her sleep. There is no previous history of psychiatric illness in the family. However, describes her mother as a “worrier” and both parents as perfectionistic. In regards to previous treatment for presenting problems, Ms Smith briefly saw a counsellor in high school in relation to a previous depressive episode. She was prescribed Zoloft 10 Page 3 of 10

mg as treatment for this. Ms Smiths Current medications are a Ventolin puffer and Zoloft 10mg.

Ms Smith tends to avoid situations where she has to put herself forward or be the centre of attention. As a result, she tends to drink when socializing and occasionally take ecstasy in party settings in order to feel comfortable. Ms Smith reports that its rare for her not to drink on a Friday or Saturday night, and that she also drinks occasionally during the week. She expressed concern about her drinking, which is increasing, and states that this had started to affect her studies. She also reports increasing alcohol consumption since taking a break from uni.

In regards to social support, she has some friends at uni, however has become increasingly isolated since her recent break up with her boyfriend and since taking a break from her studies.

Problem Analysis

Onset and Course On presentation, Ms Smith described feeling depressed following a recent break up with her boyfriend. She advised that she first experienced a depressive episode in high school following a move to Canberra where she changed schools for the 5th time. She described this period as disruptive and distressing, due to the loss of established friendships. Moreover, she noted that she lost her confidence during this time as she felt as though she didn’t fit in at her new school due to the other girls being “cliquey”. She also described a tendency to feel “butterflies” when nervous, and that she usually tends to avoid situations where she has to put herself forward or be the centre of attention. She also worries that she blushes easily and that people notice and think negatively of her. She reports drinking alcohol in order to make herself comfortable in social situations, however that this had begun to affect her studies prior to her taking a break from her studies altogether.

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Specific Symptoms: Physical, Behavioural and Cognitive: Ms Smiths depression thus appears to be having a significant impairment on her functioning. She advises that she is increasingly lethargic and now finds it hard to wake up in the mornings, whilst also finding it difficult to go to sleep due to rumination. Moreover, she reports that she can’t be bothered eating but when she does eat, that she tends to eat junk food. This loss of energy and low motivation have culminated in her increasingly withdrawing socially, which serves to maintain her depression by reinforcing her thoughts of low-self worth e.g. “I’m a disappointment” and “I’m no good at anything”. Moreover, her reliance upon alcohol and ecstasy in social situations also serves as a maintaining factor because as a consequence of this substance use, her studies have been affected reinforcing her core belief that she’s “a failure”. While she recognises the need to maintain a stable routine, when her depression is most severe, she tends to withdraw socially, further serving to maintain her depression. Ms Smith questions “what’s the point” and has even had regular suicidal thoughts, although admits that she would not act on these.

Psychometric Assessment Ms Smith was administered the Depression Anxiety Stress Scales [ CITATION Lov95 \l 3081 ] in the first session on the 17th of March 2018. The results show that Ms Smith’s depression is extremely severe which is consistent with the impression gained in interview that the client is experiencing a depressive episode.

The Depression, Anxiety and Stress Scale (DASS) is a 42 item questionnaire which includes three self-report scales designed to measure the negative emotional states of depression, anxiety and stress. Ms Smith had a very high score on the depression scale, indicating that she is suffering from severe depression, while she scored slightly above normal on the anxiety scale, and within the normal range on the stress scale.

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Depression and Anxiety Stress Scale (DASS)

Scale Depression Anxiety Stress

Raw Score 40 9 12

Severity Extremely Severe Mild Anxiety Normal

The Beck Depression Inventory (BDI)

Ms Smith was also administered the The Beck Depression Inventory Second Edition (BDIII)in the first session on the 17th of March 2018. The results show that Ms Smith’s depression is severe which is consistent with the impression gained in interview that the client is experiencing a depressive episode and consistent with the aforementioned psychometric data.

The Beck Depression Inventory Second Edition (Beck, 1961) is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression as listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV; 1994).

BDI has been used for 35 years to identify and assess depressive symptoms, and has been reported to be highly reliable regardless of the population. It has a high coefficient alpha, (.80) its construct validity has been established, and it is able to differentiate depressed from non-depressed patients.[ CITATION Dia00 \l 3081 ][ CITATION Dia00 \l 3081 ][ CITATION Dia13 \l 3081 ][ CITATION Jef14 \l 3081 ]

BDI Total Score 36

Severity Severe

Mental State Examination

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Ms Smith is a 20 year old female of medium height and build, who appeared of stated age. She was dressed comfortably in jeans and a sweater and had long, brown hair that was slightly unkept, though not to the extent that would indicate a lack of self-care. Ms Smith wore minimal makeup.

Ms Smith spoke at a slow rate, low tone and volume often pausing throughout sentences. Despite this, she was cooperative during the assessment answering all questions, responding without appearing to become defensive. While Ms Smiths speech content was relevant, she avoided eye contact both in response to questions and when speaking. She presented as somewhat anxious, often looking away when being questioned and when responding to questions, looking to the side or downwards. In regards to body language, she was hunched over throughout the session. Psychomotor agitation was also observed; Ms Smith fidgeted with the cuffs of her sweater throughout the session. Ms Smith described ongoing, negative thoughts around self-worth and the idea that she was a “failure”. She was also observed to become subdued when talking about the expectations of her parents when prompted to discuss her university studies. This was further observed when asked to discuss how her first shift at the restaurant went, stating that she felt like an “inconvenience”.

Formulation On presentation, Ms Smith reported experiencing a low mood for some time ultimately culminating in a loss of energy and motivation, increased alcohol use and low self-worth. These symptoms appear to have been precipitated by a recent breakup with her long-term boyfriend. Ms Smiths experiences of moving constantly throughout her childhood and adolescence appear to have predisposed her to the later development of depression by impairing her ability to form and maintain relationships, leading to social isolation and a loss of confidence. According to a US study comparing children of military parents with geographic moves vs those without geographic moves, geographic moves were shown to increase the likelihood of mental health encounters[ CITATION Jef14 \l 3081 ]. Moreover, in regards to adolescents, this increase was found to extend to psychiatric hospitalizations and emergency visits. Additionally, Ms Smith experienced several early events involving the perception of negative Page 7 of 10

evaluation from others, including being teased in primary school for her accent, which are likely sources of her anxious tendencies and low-self worth i.e. the idea that she is “a failure”. According to a US study, being the victim of bullying in childhood increases the likelihood of psychiatric disorders not just in childhood, but at a later onset, during adolescence[ CITATION Adu \l 3081 ]. Thus, these experiences, coupled with beliefs around needing to be successful, have caused her to develop rules and assumptions such as “If I don’t do well in this, I am a failure”. These cognitions are triggered when Ms Smith doesn’t meet the high expectations of her parents, and subsequently, herself, with fears that she will be negatively evaluated, which accordingly is associated with a belief of failure.

It is likely that Ms Smith is experiencing a Major Depressive Episode precipitated by a strong loss of sense of self and self-worth as a result of her recent break up with her boyfriend. This breakdown in her sense of self may have stemmed from her sense of identity initially being formed around trying to please her parents, which has later proved to not be fulfilling. It is unlikely that she has any genetic vulnerability to experiencing depressive symptoms based on her family history. Ms Smiths recent relationship breakdown, in combination with social withdrawal, increased substance use, poor sleep and diet are all serving to exacerbate and maintain her sense of poor achievement, low motivation and sadness. She also reports recurrent suicidal thoughts, which further contribute to her feelings of depression and a sense of hopelessness. Her experience of ostracization after her move to Canberra in year 10 may have contributed to her mild social anxiety, specifically to her discomfort in social situations to the extent where she relies upon substances such as alcohol and ecstasy to be social. This is likely to be contributing to her avoidance of social situations but is also contributing to her difficulty in interacting and building relationships with peers and colleagues. She is likely to respond well to both cognitive and behavioural interventions given prognostic factors such as her motivation to improve, familial support network and engagement in therapy and her prescribed medication to improve her functioning.

Diagnosis Based on the results of psychometric testing, and the impression gained in interview, Ms Smiths’ symptoms appear to be consistent with a diagnosis of Major Depressive Disorder, recurrent episode, severe, with anxious distress (296.32; F33.1). She reported having a Page 8 of 10

depressed mood for most of the day, has diminished pleasure in activities, feelings of worthlessness, recurrent suicidal ideation without a specific plan and insomnia or hypersomnia nearly every day (Criteria A). These symptoms are causing significant impairment (Criteria B) to the extent that she has withdrawn from studies this year as a result and are not due to the effects of a substance or medical condition (Criteria C). Further, there appears to be no occurrence of a manic episode (Criteria E).

Goals and Recommendations Ms Smith reported seeking therapy in order to reduce her symptoms of depression and social anxiety along with increasing her self-confidence. It is recommended that Cognitive Behavioural Therapy be employed in the treatment of her depression in order to assist her to challenge maladaptive cognitions around her sense of self-worth, and provide her with assistance to build motivation and confidence for daily activities. Behavioural activation techniques will be used to reintroduce pleasurable activities to her schedule, and to address and reduce suicidal ideation by highlighting reasons for living. In addition, it is recommended that she be engaged with psychoeducation around Depression and sleep hygiene.

Bibliography

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Beck, A. W. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Diagnostic and statistical manual of mental disorders (5th Ed.). (2013). Washington, DC: American Psychiatric Association. Diagnostic and statistical manual of mental disorders(4th Ed). (2000). Washington, DC: American Psychiatric Association. Jeffrey Millegan, M. M. (2014, January 7rh). The Effect of Geographic Moves on Mental Healthcare Utilization in Children. Journal of Adolescent Health, 55, 276-280. Lovibond, S. &. (1995). Manual for the Depression Anxiety Stress Scales. (2nd. Ed.). Sydney: Psychology Foundation. William E. Copeland, P., Dieter Wolke, P., Adrian Angold, M., & al, e. (2013, April). Adult Psychiatric Outcomes of Bullying and Being Bullied by Peers in Childhood and Adolescence. JAMA Psychiatry, 70(4), 419.

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