Dr Oday Rafoka

Springwood Family Practice

16 Ferguson Rd

Springwood

NSW 2777

05.11.2024

Re: Alice Bauerhuit (DOB: 01/06/2005) NBM10953 Mental health assessment and review

Dear Dr Rafoka,

Thank you for referring Alice Bauerhuit to see me in July, 2024 for chronic severe anxiety and depression, under a GP MHCP, followed by a Wentworth Healthcare PTS plan. I am her allocated provider and write to provide you with a mental health assessment and update at the end of this referral. Alice would like to request another referral.

Alice attended the first consultation on the 3rd of July, 2024. She was initially cautious to engage, however soon gained trust and has been able to open up about her past and present stressors.

Initial Presentation

At the time of her initial consultation, Alice opened up about her current life challenges. She reported multiple bereavements in past 10 years, including the unexpected death of her father 9 months prior while on a 3/12 work trip in the USA. His cause of death was unknown. She was very close with her father. Alice stated that she hasn't processed the loss and is aware that she has suppressed the grief, rather than allow emotions to externalise. This has been a pattern of dealing with emotional experiences throughout her life, and one she considers is across all family members.

Alice identified stressors/triggers for her emotional distress as the series of bereavements, as well as unhealthy relationships in her early teens. Her response pattern to heightened emotions is to avoid and shut down, instead of expressing, which results in pent up feelings which can then come out at unexpected times. Alice spoke of exhaustion and her emotional dysregulation when her “cup is too full.” She reported panic attacks, with increased heart rate, shaking, nausea and sobbing.

Due to her level of anxiety in the initial session, we agreed to explore things slowly over time (trauma informed care principles).

Alice works as a nurse in aged care, mostly on night shift.

Mental health history

Alice reported a history of mental health challenges since the age of 14, with a past history of deliberate self-harm (DSH) and 4 suicide attempts. Her mother knew about one attempt and arranged counselling for her. Apart from that, she has not engaged with psychological support.

Medical history (from GP referral)

Menstrual irregularity

Coeliac disease susceptible genotype

PCOS

Endometrial polyp

Developmental history

Alice spoke about her childhood of feeling like she didn’t fit in with her family, which she reacted to be withdrawing and isolating herself.

In high school, Alice reported a similar pattern of putting up a “big wall to protect myself” from being hurt, and remembers not letting people get close to her. Through sessions in therapy, she has come to realise that led to negative core beliefs that she wasn’t good enough.

Family history

History of alcohol dependence in her father and other family members.

AOD

Smokes cannabis to “calm myself”

Recreational alcohol use.

Cannabis use started in year 11 and 12

Smokes tobacco

Medication (from GP referral)

Microlut 30mcg tablet – 1 tablet daily

Propranolol 40mg tablet – ½ tabled bd for migraine prevention and tachycardia.

Supports

Alice’s main support is her boyfriend/partner, Brayden.

Alice lives at home with mother and sister, Holly. She is estranged from her brother. Alice would like to move out of home in the near future.

Update

Over the past four months, Alice has engaged well in therapy. A range of psychotherapeutic interventions have been utilised to support her recovery, with good effect. She has developed insight about the underlying causes contributing to her anxiety and family relationships and strategies for managing emotional regulation. She has resorted to DSH on a few occasions when emotionally overwhelmed, however has learned to talk about her feelings with her family and with Brayden, which has created better understanding and less distress.

During this time, she has had other major triggers, including the anniversary of her father’s death and the death of her mother’s best friend, who has been like a second mother to Alice. In addition, Brayden has had his own emotional challenges which have impacted Alice. She also had a shoulder work injury, which required her to go onto day shifts for two months, however she has now returned to her preferred night shifts.

Some sessions have been in conjunction with Brayden, which Alice has found helpful, with the outcome that both have a better understanding of each others’ triggers and responses.

At the time of Alice’s review on the 30th of October, 2024, Alice reported “I am coping much better than before; I have more courage to talk about feelings and to have difficult conversations with loved ones.” She reported that therapy had felt validating and given her more confidence to speak with others.

30.10.2024 K10 score: 38/50. This score reflects recent psychosocial stressors re the death of a close family member and a significant stress experienced by her partner.

MSE

Dressed in casual clothes; reasonable attention to hygiene and grooming.

Comfortable and relaxed in session; good eye contact and easy rapport.

Normal tone, volume and rate of speech T/F logical and sequential

Content as stated above

Mood: stress appropriate to life stressors

Affect: congruent with mood

Oriented to time place and person

Formulation:

19 year old employed woman, living at home with her mother and sister, presenting with anxiety and low mood following the death of her father a year ago, and with a history of mood dysregulation, DSH and suicidality as a teenager.

Impression:

It is outside my scope of practice to diagnose, however, consider:

Anxiety; adjustment disorder;

Plan

Alice would like to continue seeing me, particularly whilst navigating the recent challenges. Should you agree, could you please contact the WHL mental health access line: 1800 223 365 to organise an additional referral?

Yours sincerely,

Michelle Hookham