Dr Alice Choi

Pitt Town Surgery

53 Bathurst St

Pitt Town

NSW 2756

30.04.2024

Re: Angelica Bortolussi (DOB: 25/01/2007) NBM10835 mental health assessment and review

Dear Dr Choi,

Thank you for referring Angelica Bortolussi for ‘anxiety, depression and substance use disorder’ on the 29th of February, 2024. I am her allocated provider through the Wentworth Healthcare PTS program and write to provide you with feedback at the end of this plan.

Angelica attended the first consultation of this plan on the 15th of March, 2024. She missed a couple of scheduled appointments, however engaged well in therapy when she did attend. Her review was on the 29th of April, 2024 – see update below.

Initial Presentation

Angelica was referred to mental health services in November, 2023 following suicidal ideation with threat to hang herself.

At the time of her initial consultation, she reported increased panic attacks. She had a job at a food outlet, however frequently experienced heightened anxiety prior to a shift, rising to panic.

Angelica reported emotional dysregulation, with episodes of anger where she is unable to calm down. She stated that she says things she doesn’t want to say and “I can’t control it.” Uses DSH to “take the edge off”, by cutting legs with a knife. The last time was in February, 2024. She reported suicidal ideation, with thoughts of “not wanting to be here”, however had protective factors of her pets and would use cannabis to distract herself when thoughts increased.

Angelica has low self-worth “I don’t love myself; I’m a bad person”. She reported episodes of online bullying by previous close friends, which was hurtful, and is triggered by fear of abandonment. She feels good when people worry about her, but realises she needs very strong signals from people to feel that they care.

She feels better with her animals. Her hobbies include drawing anime, video games and playing the guitar.

Mental health history

Anjelica reported a history of anxiety from age 12 and self-harming from age 13.

Nov 2023: threatened to hang herself following an altercation with her mother. Taken to Blacktown Hospital and discharged to a PTS plan with another therapist, with whom she chose not to continue.

Feb 2024: scheduled by police and taken to Hornsby Hospital. Angelica was unable to calm herself down and was self-harming by banging her fist on the wall, in context with argument with mother. Referred to Plains Access on discharge.

Angelica stated that she has threatened suicide since the age of 10, and had her first attempt in November 2023.

Family history

Twin brother has seen a psychologist and is on medication.

Mother: major depression and anxiety; “very sick during primary school – sleeping a lot and vomiting”; cancer in 2023 (from Angelica)

Physical health

No reported physical health conditions.

Medication

No medication at this time.

Developmental history

Angelica has a twin brother. Her father and mother co-parented until age 11, but were not together.

Angelica reported that she felt neglected as a young child, due to her mother’s mental illness.

Enjoyed primary school, however had frequent leave due to sickness – colds and stomach aches

Was at Windsor High

School refusal from year 7, with increasing absence, worse after Covid lockdowns.

Home schooled since age 14, however is not participating in the program.

Angelica reported a history of complex family systems challenges. She stated that at age 14, her mother came off anti-depressants and had aggressive outbursts. Angelica reported episodes of feeling “terrified”, to the point where once she jumped off her balcony and slept in the laundry for a year.

She reported constant arguments with her mother from age 15. Emotions seemed to escalate when Angelica was 11, which she attributed to when her mother asked her father to leave. She reported times where her mother “tries to kick me out, which is bad for my mental health”, and episodes where she has attempted to run away.

Angelica reported episodes of witnessing domestic violence by her mother’s precious partner. She also reported being a victim of domestic violence by the same person.

I would have liked to verify this information with Angelica’s mother and to get corroborative history, however the opportunity did not arise.

AOD

Uses cannabis since age 15; worse since age 16 “it stops me thinking”

Supports

Is close with her father, however Angelica does not want to live with him at this time.

Has four close friends from primary school.

Update

Following the initial consultation, Angelica had a period of improvement. She reported a decrease in suicidal ideation and generally felt more at ease. We were able to complete a CBT-style exercise on breaking the cycle of anxiety, which she engaged well in and gained some strategies to help manage anxiety at home. Unfortunately, she then missed a couple of appointments, so did not have continuity of care.

At the time of her review on the 29th of April, 2024, Angelica reported a recent attempted polypharmacy overdose of 26 pills, triggered by a panic attack after her mother put pressure on her about planning for her future. Her mother called an ambulance and she was taken to Hornsby Hospital and had an overnight admission. Angelica had not thought to call me when the thoughts escalated, however called a close friend, who called her mother.

Exploring the most recent overdose, Angelica gained insight that her behaviours stem from her insecurities about her future. She reported having difficulty trusting that people like her, unless they show extraordinary efforts in caring for her. She stated "I need heaps of validation to believe people like me. It causes me to hurt myself so they worry about me." This is a significant realisation, for future psychological intervention.

Angelica considers that she may have borderline personality disorder and would like an assessment for a formal diagnosis. She considers that this will help her get the right treatment. We discussed pathways for referral to a psychiatrist, and I recommended Dokotela, which requires a GP referral, and enables her three free appointments with a psychiatrist online.

Angelica is also experiencing sleep disruptions from intense nightmares.

Her father has just rented a property in Bligh Park. Given the conflict with her mother, we discussed whether she would prefer to live with her father, however at this time, she does not want to consider this, even though she feels close with her father.

Angelica enjoys drawing anime and is currently working on a comic. We discussed the possibility that she could study art at TAFE, however at this time, she is not interested as she considers she has everything she needs to know to produce her work.

At the time of her review, we discussed options for therapy going forward, including getting a new referral to see me; or going to Headspace for young people. I informed Angelica, that if we were going to continue together, it would be important for me to speak with her mother about her developmental history. Angelica was uncertain about that as she considered her mother would present a different perspective to what she has described. Angelica stated that she didn't think she would continue with me at this time. I noticed that she had six sessions with a previous therapist. Going forward, it will be important for Angelica to find a therapist she feels comfortable to work with for a longer period of time. It feels as though we were just starting to have the rapport and trust to get to the underlying causes of distress.

MSE

Caucasian female, dressed in black jeans and t-shirt, with long curly hair, half blonde; half black, tied back. High attention to hygiene and grooming today. Initially withdrawn, with eyes downcast and difficult to engage, however soon warmed and opened up about underlying causes of anxiety and suicidal ideation.

Reported recent suicide attempt, however denied current thoughts, plan or intent. Described mood as "slightly stressed, but otherwise calm."

Affect, flat initially, but reactive once began to engage.

Orientated

Insight is developing; judgement - she described as quick to anger and impulsive, not thinking about her actions

Formulation

16 year old Caucasian female, with twin brother, living at home with her mother and brother, presenting with anxiety, depression, substance use and suicidal ideation with recent overdose, in background of complex psychosocial stressors and past history of domestic violence and queried childhood neglect.

Impression

Suspected adverse childhood events, including witness to DV and queried neglect. Possibly meets diagnostic criteria for BPD, however, I see the range of behaviours as a response to adverse childhood events.

Low self-worth.

Plan

Close referral. Should Angelica need support at another time, I would be happy to see her.

Regards,

Michelle Hookham