Dr Ruby Thavakulasingam

46A Derby St

Kingswood

NSW 2747

11.07.2024

Re: Delores Craig (DOB: 05.11.1963) Mental health assessment (MH Ax)

Dear Dr Thavakulasingam,

I am a Credentialed Mental Health Nurse (CMHN) in private practice. I write to provide you with a mental health assessment for Delores Craig, to assist her engagement with you. It is my understanding that Delores was referred to you by her GP, Dr Webb, for diagnostic and care-planning purposes. In addition, Delores is currently in the process of applying for the Disability Support Pension (DSP), which her GP has suggested. She requires a formal psychiatric assessment by a psychiatrist to complete her application. I have enclosed my report prepared for Delores’s DSP application process, for your information. Some of the information overlaps with this MH Ax.

Background

Delores Craig was initially referred to me by her GP in November, 2019 for psychological support for complex post-traumatic stress disorder (CPTSD), generalised anxiety disorder and depression, associated with multiple biopsychosocial stressors. I have provided her with psychological support over the past four years and can affirm that Delores continues to experience challenges with her mental health. Mental/emotional ill health combined with physical health problems, have an ongoing impact on her ability to function, significantly diminishing her capacity to socialise, engage with the community and maintain employment in a financially sustainable way.

Initial Presentation

At the time of initial appointment in November, 2019, Delores presented with a 3-year history of not coping with complex psychosocial stressors over the previous three years, after separating from her partner. At that time, she reported high anxiety and panic about meeting financial obligations and fear of homelessness. She reported suicidal ideation and past thoughts about ways to suicide where she cannot be found, to minimise distress to others. Protective factors included her 3 children and of wanting to live her life in a better way. Delores reported chronic tiredness and disrupted sleep. She had tried antidepressant medication, but stated that she was very sensitive to medication and found the medication too debilitating.

At the time of her initial engagement with myself, Delores had been significantly impacted by a period of homelessness in 2018/2019. She had lived in a tent and the insecurity about her safety triggered a worsening of PTSD symptoms, including high anxiety levels and hypervigilance. She felt insecure about the future and reported anxious thoughts about whether she would become homeless again. She had applied for public housing and had just signed a lease for short-term accommodation.

Mental health history and current presentation

2016: Diagnosed with anxiety and depression.

2017: Diagnosed with anxiety and PTSD. Delores stated that the PTSD stemmed back to the disappearance of her partner in 1989 (who has never been found and whom Del continues to have nightmares about his disappearance).

Delores reports a ten-year history of not coping with everyday life, due to impacts of psychosocial stressors, associated with traumatic life events. She reports high anxiety and panic about everyday functioning, including situations that require engaging with the community, seeking employment, managing activities of daily living and meeting financial obligations. Preoccupation with anxious thoughts can become overwhelming to the point where Delores becomes anxious about leaving the house and questions the value of staying alive.

In her words: “anxious thoughts become overwhelming to the point where I just freeze and then can’t go outside.” Delores frequently has dissociative episodes and withdraws from people and becomes socially isolated, which contributes further to low mood. She states that when anxious thoughts “all come crashing in, I have dark thoughts about not wanting to be here.” She reports suicidal ideation and thinks about ways to end her life when emotions become overwhelming. She frequently reports states of terror, with high levels of fear, out of proportion to the trigger, associated with the PTSD. At these times, she becomes agitated, has shaking throughout her body, followed by periods of fatigue that lasts for days. Nightmares and flashbacks impact sleep, further affecting functional capacity.

Delores states that anxiety and panic attacks have affected every job she has had. For example, she described “irrational thoughts and anxiety about germs” causing difficulty touching things in communal areas. She cited examples of where she was overwhelmed in the work place to the point of having panic attacks and being completely unable to move and having to be assisted by staff; and another occasion of involuntary screaming at work when overwhelm led to a major panic attack.

Her K10 score for psychological distress is consistently 37/50, which indicates “severe psychological distress”.

Recent contributing factors include the 2020 – 2022 Hawkesbury bushfires and flooding events were other major triggers for anxiety, with further activation of PTSD, because of the association with other traumatic life events involving the death of loved ones in a house fire. Delores has experienced a recent trigger of past trauma associated with the registered missing person, and previous partner.

Developmental history

Born in Crown Street Hospital.

Delores was born into a complex family system. Her mother had a previous marriage to Gordon and they had three children. This marriage separated and she married Gordon’s brother and had another four children, including Delores.

Delores reported “I didn’t have a childhood. It wasn’t nice.”

Grew up in Marsfield until age 13.

Nocturnal enuresis until age 12 as too scared to go to the toilet (because of D/V in the home – see below)

Age 14, found out that the children had two different fathers.

Delores reported that her father was a war veteran and had severe mental health impacts from being in the armed forces, including frequent bouts of “insanity” and rage. The family grew up in an environment of domestic violence and fear. Delores stated that she learned to run away and hide and developed her own capacity to dissociate through her imagination. She reported incidents of violence towards herself and of witnessing horrific violence towards her mother and sister.

Del’s mother left her father when she was age 13, and they moved to Castle Hill with no financial security and lived in poverty.

Marsfield Public primary school.

Cheltenham Girls High School.

Left school age 15, then worked in a chicken shop.

Completed university entry exams age 31.

Studied biology at Katoomba, 1993, age 31.

Had three children to three different fathers, the second partner of whom became an official missing person, and the third who changed sexual orientation later in their relationship.

Family history

Father: war veteran; PTSD; alcohol abuse; “very violent”; violence directed at family members, worse when intoxicated. Emergency services called to the house on occasions, and he would be restrained and removed from the home.

All siblings have mental health challenges as a result of childhood trauma, including domestic violence and sexual assault.

MGM – died when Del’s mother was 5yrs and her mother grew up with her grandparents.

Del’s mother had a history of multiple CVAs and Myocardial infarctions; she was born with dextrocardia (heart upside down), which was surgically corrected in her teenage years.

Paternal grandparents both had Hashimotos.

Sister has had anaphylactic episodes.

Current physical health problems

Chronic back pain, with recent exacerbation, with CT scans showed bulging discs in the lumbar region.

Ongoing episodes of vertigo with weakness in legs; shaking in arms and legs, unsteady gait; and hand tremor. There is concern about a neurological disorder and Del has been referred to a neurologist for further exploration. Recent brain scans showed alcohol acquired brain injury.

Delores has a 10-year history of chronic fatigue syndrome, which impacts her ability to think clearly. She reports associated visual disturbance; low energy and the need to sleep excessive hours. She has had a range of clinical examinations, referrals to specialists and investigations, which have not found a reason for her level of exhaustion.

Haemochromatosis

2018: Brain aneurysm

2020: Diagnosed with bilateral hearing impairment

2020: Diagnosed with lower back pain and osteoarthritis

AOD

Currently trying to quit smoking. Del has tried medication in the past, but had adverse side effects; currently using nicotine gum. Denies other substance use, aside from the very occasional cannabis use.

Functioning and Supports

Delores is currently residing in a private rental property in Kurrajong, which causes increased financial stressors due to affordability of paying rent. She is on the emergency housing list for social housing, however two properties that she has been shown to date have been unsatisfactory, as Del considers that they were squalid and would not support her mental health.

Del continues to live on Centrelink benefits – job seeker, which is not adequate to cover cost of living. Constant pressure to look for work that she feels incapable of doing is a major cause of heightened anxiety.

Delores has 3 children: Paloma: 31 (next of kin), Son, Tyrone: 36, Stein (Beau): 40

She has a few friends, who are supportive.

Del is estranged from all of her siblings, as she finds it too triggering when they are all together, due to past family history of trauma and their respective mental health issues.

MSE

Appearance: Caucasian woman with curly henna-coloured hair, wearing smart casual clothing; clean and well groomed.

Behaviour: Good eye contact and easy rapport. Unable to sit still due to back pain. Gets up and down and walks around the room at frequent intervals during consultations. Can become agitated and distressed when speaking about traumatic events.

Thought form: Logical, sequential. Can be tangential.

Affect: congruent with mood. Reactive, animated; anxious expression at times.

Mood: “I’m so angry and deeply sad.”

Speech: at times pressured.

Content: as stated above.

Perception: reports history of auditory and visual hallucinations, which present as more of a psychic experience rather than psychotic phenomena.

Insight/judgement: has awareness about her mental/emotional symptoms and is seeking help to understand her inner experiences better.

Formulation:

60-year-old woman presenting with anxiety, depression and PTSD in background of complex biopsychosocial stressors.

Impression:

Complex PTSD, anxiety, depression.

Plan

Fortnightly appointments or as needed.

Psychotherapeutic exploration of issues.

Care coordination as required.

Trauma informed care.

Care coordination/case management.

Formal psychiatric assessment.

DSP application.

Yours sincerely,

Michelle Hookham