Dr Dalley

Glossodia Medical Centre

3/162 Golden Valley Drive

Glossodia

NSW 2756

01.10.2024

Re: Noah Godsell (DOB: 22.03.2000) Comprehensive mental health assessment

Dear Dr Dalley,

Thank you for referring Noah Godsell for a Wentworth Healthcare PTS mental plan for psychological support for mood dysregulation and suicidal ideation in August 2024. I write to provide you with a mental health assessment and update. I had previously seen Noah in June, 2022, at which time he had a few counselling sessions.

Noah attended the first session of this plan on the 28th of August, 2024. He has been attending weekly to fortnightly and is motivated to continue attending at this time, and requires another referral.

Current Presentation

At the time of his initial consultation, Noah reported having had a psychotic episode in June 2024, which he considered to be a drug induced psychosis. At that time, he reported feeling anxious and paranoid. He had thoughts that “people were out to get me; that I was being monitored (eg. Phone being tracked)”, and he felt aggravated by loud city noises and police cars. Three weeks prior to his first episode of psychosis (FEP), Noah had been diagnosed with ADHD by Dr Alexandra Krupinska and commenced dexamphetamine. He also had a history of recreational substance use, including regular cannabis use for the past five years. Following the FEP, Noah has since stopped all substance use.

Following his FEP, Noah returned to Sydney from Melbourne to stay with his family for support, where he recommenced coming to see me in person. He reported emotional dysregulation, from episodes of high anxiety and panic attacks, alternating with elevated mood and with low mood with suicidal ideation. He described his mood as “erratic; I’m crying every day.” His family were actively monitoring his wellbeing and had increased their support to ensure his safety.

During his assessment, Noah was observed to have pressured speech and flight of ideas; He stated, "I feel sped up; I can't control the inner monologue.” He spoke of existential questions that were preoccupying his thoughts and preventing sleep, including environmental catastrophe, climate activism and dystopia. He spoke of the intense driver to “save the world, but there is not enough time, so I have to be hyper-activist”. Some thoughts had a grandiose quality, such as "I can do something everyone else can't; I think I'm being prepared to be a public figure; I’ve got to save the world.” He was unable to sleep due to the activities of his mind, stating “I can't sleep as my brain sees it as the time to solve the world's problems.” He spoke of feeling disconnected; of existing ‘outside his body’, with difficulty grounding himself. Noah reported feeling restless and had been walking for miles every day.

Additional stressors in his life included having recently started working for a corporate finance company in Melbourne (he is qualified in acting/performance/dance/singing) and was struggling to align his personal beliefs with the work culture. He was also having relationship difficulties with his partner, Dwayne.

Identity and queer identity has been an ongoing source of existential questioning for Noah, including statements such as: "I don't feel secure in my identity; my identity is fractured; who should I be?” He has guilt around his sexual identity, stating, "It feels biblical; like I've sinned and need to repent and don't know how." He has a deep sense of shame “related to my queerness”, and through our sessions together, he has gained insight that perhaps his difficulty reconciling/integrating these aspects are causing a split within himself.

From Noah’s current presentation, his history, and from previous consultations in 2022, Noah has presented with symptoms that may be consistent with elevated mood or even hypomania. However, since the FEP, Noah has had a sudden episode of low mood with suicidal ideation which is new to him. He reported anhedonia, stating “I’ve forgotten what brings me joy; I feel empty.” He reported feeling worthless "all the time", and stated "I don't love myself; I have nothing to give the world." He also reported alternating states between feeling “sped up and slowed down/paralysed” and the “drive to save the world”, alternating with “paralysis to act in case I make things worse”. Suicidal ideation presented as intrusive thoughts around not wanting to be here, however he denied a current plan or intent.

Noah reported involuntary motions of his right shoulder (tic) upwards when anxiety is high.

06.09.24 K10 score: 34/50

Developmental history

Born six-weeks premature, though dates of pregnancy uncertain.

Long labour and --> venteuse extraction; 3lb birthweight; healthy; short period in humidicrib

Milestones normal

Nature: happy go luck; bubbly; lots of friends in preschool

Recurrent sinus infections; Grommets between 4- 9 years

Developmental assessment in Year 2 (as queried dyslexia) showed no learning disorders detected and found to have extremely high IQ

Enjoyed lots of after school activities – dance in particular

St Paul’s High School; completed year 12

Year 11, was offered scholarship to a university in Sydney, as high achieving and Dux of Year 11 and had recognised gift in performing arts

Challenges in late high school associated with emerging homosexuality and being in the Catholic education system and had just started a relationship

Years 11 and 12 were difficult, as MGF died and they were close, and Noah’s sister, Molly had serious mental health challenges and was in and out of adolescent mental health units.

Year 12, Noah stopped dancing; lost motivation with school work and begun first relationship.

Following Year 12, Noah went moved to Perth to complete a Ba Music Theatre at WAPA.

Covid lockdowns began during Noah’s last year of uni in Perth, so he had long periods without family contact.

Moved to Melbourne in 2022. Has had difficulty finding employment and keeping employment since that time.

Mental health history

(Self-diagnosed) drug induced psychosis in June, 2024 and presentation consistent with FEP.

Noah has had some adverse relationship experiences which may have been traumatic for him and need further psychological therapeutic intervention.

Noah’s previous presentation to see me in June, 2022, he had been asked to leave a share house in Melbourne, and had to move in with his partner, which he did not feel ready to do. He had increased anxiety and had left a job to prioritise his mental health. He reported the experience that “everything was going a million miles an hour” and he felt unable to slow down; and he described his mood as “a roller coaster of highs and lows.” He wasn’t sleeping and had reverse sleep cycle.

Physical health history

Slight scoliosis of spine

Family history

Father: Dx ADHD

Sister: Dx ADHD; CPTSD

MGF: heart failure; prostate cancer

Supports

Has been living with his partner of 18 months, Dwayne, in Melbourne, however is currently staying with his parents in Gross Wold, Western Sydney, whilst recovering from his psychotic episode.

Medication

Aripiprazole 10mg OD

Mirtazapine 7.5mg OD

Sertraline 100mg OD

AOD

Daily cannabis use from age 19.

Heavy alcohol use 19 – 20

Currently denies substance use.

MSE

Caucasian male, identifies as queer and non-binary, wearing shorts and t-shirt; clean and good attention to hygiene and grooming

Engaged well; good eye contact and easy rapport

Mood: “I feel erratic.” - Labile; laughing alternating with low mood and crying.

Affect: congruent with mood

Restless in the chair, changing position often

Behaviour: reported walking for hours each day

Pressured speech; normal tone and volume

Thought form: Initially tangential; some grandiosity of thoughts eg. "I can do something everyone else can't; I think I'm being prepared to be a public figure." At time of review, Thought form is logical and sequential, showing significant improvement

Insight: Noah is introspective and developing insight around underlying causes of emotional dysregulation

Judgement: good. Noah is seeking help and supports to get through current mental health challenge

Formulation

24 year old Caucasian unemployed male, who identifies as queer and in a de facto relationship, presenting with mood dysregulation following a first episode of psychosis in June 2024, currently low mood with suicidal ideation, following previous presentation of elevated mood.

Update

Noah has been seeing yourself, his GP, regularly and myself weekly for the past month. Since commencing medication, his mood has dropped and he has had a period of low mood with suicidal ideation and anhedonia. My impression is that there has been an improvement in his affective disorder following medication, from being in an elevated or manic state to low mood, which is gradually improving. Despite the low mood, I see improvement because Noah’s thought form is now more logical and sequential, the pressured speech and tangientiality/flight of ideas has reduced, he is sleeping through the night and has less intrusive existential thoughts.

Impression

There is evidence of previous 2 – 4 year history of symptomatology consistent with a presentation of mania or hypomania, with pressured speech, flight of ideas and grandiosity. Following medical treatment for a first episode of psychosis in June, 2024, Noah now is presenting with low mood, with suicidal ideation and anhedonia.

His childhood developmental assessment did not detect any learning or behavioural disorders, but it did reveal a very high IQ. Throughout his schooling, Noah was a high achieving, driven student and thrived on extra-curricular activities, especially dance. I question if dancing helped his physical and emotional regulation through expression and physical activity, and whether this would be helpful for his recovery.

Consider:

It is outside my scope of practice to formally diagnose mental health conditions. However, some thoughts for you to consider include:

Situational crisis (life stressors)

Recovering from first episode of psychosis

Substance use disorder

Bipolar affective disorder

Trauma disorder

Plan

Weekly consultations whilst acute, followed by fortnightly sessions whilst needed.

Noah would like to continue seeing me, however his PTS plan has ended. I have requested extra sessions with Wentworth Healthcare, however could you please call the intake line, Dr Dalley and request another referral? Noah meets the criteria for an SOS plan.

Yours sincerely,

Michelle Hookham