Dr Tara Hajimir

Kurrajong Medical Centre

66 Old Bells Line of Road,

Kurrajong

NSW 2758

01.04.2024

Re: Shane Fox (DOB: 05.11.1972) SOS4569 NBM9733

CONFIDENTIAL

Dear Dr Hajimir,

Thank you for re-referring Shane Fox for psychological therapeutic support for generalised anxiety in September, 2023. I am his allocated provider through the Wentworth Healthcare PTS program and I write to give you feedback at the end of this plan.

Shane attended the first consultation of this plan on the 27th of September, 2023. He attended fortnightly to monthly consultations, with a total of eleven sessions. His review was on the 18th of March, 2024, evidencing that he has progressed very well, hence the referral has been closed (see below for update).

Shane had seen me previously, referred by Dr Theo at My Health, North Richmond. Past referrals:

FLO125-I, between 30.06.21 – 07.07.21

SOS4152, between 06.07.21 – 06.09.21

SOS4569, between 24.01.22 – 14.03.22

Current Presentation and update

At the time of his initial consultation under this plan, Shane reported an increase in anxiety, stating that it was “out of control.” He had increased irritability, easily triggered to outbursts of anger, for example if another driver on the road cut him off. He reported that he felt agitated and was “arguing with anyone over nothing.” He had been self-medicating with THC over the past few years, however was trying to reduce intake and had also quit smoking.

Shane informed me that he had recently been diagnosed with ADHD, but needed to see a psychiatrist for confirmation, and also Addison’s Disease, by Dr Hussein. He had not commenced on ADHD medication at that time.

Contributing factors: Although Shane had managed to consolidate and pay off his debts, he continued to feel the burden of financial and accommodation stressors, since he was renting a property off his mother in law, who planned to sell the property. He had commenced part-time work at an automobile retail outlet, which he was enjoying.

Shane reported continued low appetite and weight loss.

Brief background from previous referrals

At the time of his first consultation in June 2021, Shane presented with a history of anxiety following marital breakdown in background of infidelity related to bisexuality.

Shane reported having difficulty relaxing and feeling hypervigilant around his every-day life actions and the perception of his wife around these. He stated “I have a constant fear of doing the wrong thing and making a mistake.” The underlying fear is that his wife will end the marriage. Shane has overcompensated by being “OCD” in the domestic load to prove to Imogen that he has made changes and is committed to their relationship.

Shane disclosed adverse childhood events from age 8 to 14 yrs. He continues to struggle with his sexual preferences, which he considers to be directly related to the abuse.

Shane reported feelings of guilt and low self-worth, stating “I’m nothing; dirt; scum.” He described his mood as “depressed” and reported “suicidal ideation I can’t shake”. He denied a current plan and his focus on improving his relationship is a protective factor. Shane has a history of previous suicide attempt by car exhaust in 2020, but turned off the engine and sought help Nepean Hospital for assessment.

14.03.22: K10:45/50

Update

The initial focus of treatment was on nutrition and diet, to stabilise metabolism and blood sugar levels and decrease stimulants of excess caffeinated drinks. Therapeutic support then progressed to a CBT-style of program to break the cycle of anxiety, and for developing strategies to coping with anxiety. Once Shane’s emotional wellbeing was more stable, we began to address underlying causes associated with childhood trauma. Shane had been avoiding deeper work related to this in previous referrals, but now felt ready to address these injuries. Shane engaged really well with all of these psychodynamic processes and gained a lot of insight about his past and associated unhelpful behaviour patterns.

Over the next few months, Shane gained more confidence and capacity to return to full-time work. He has also managed to abstain from cannabis intake and his mood became more stable. The restlessness and poor concentration is much better, to the point where Shane now feels able to focus on work every day and not be distracted by other thoughts and feelings. This has been a significant shift and has enabled Shane to make some major lifestyle changes.

At the time of his review on the 18th of March, 2024, Shane and his partner had just purchased a property near Newcastle and were planning to move in the next two months. He felt very excited about the move. He reported that his mood was more stable and he was less reactive. He requested to close the referral as he considered that he had nothing further to work through at this time.

18.03.24: K10 score: 20/50 – significant improvement.

Formulation

52 year old employed male, about to move to Newcastle region, living with his wife and adult son, presenting with generalised anxiety in background of complex biopsychosocial stressors, including childhood trauma and addiction. Currently doing well.

Impression

Complex trauma

Hyperactivity

Anxiety

Substance use disorder (currently abstinent)

Plan

Referral has been closed.

Shane is aware that once he moves out of area, he will no longer be able to access referrals under Wentworth Healthcare’s PTS program. He is aware that he can either book an appointment with me directly on a fee-for-service basis, or connect with psychological support once he has settled into his new home.

Regards,

Michelle Hookham