MH – Brief Therapy Note

Psychiatry & Psychology
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PRESENTING CONCERNS

[comment memo="Passive dependent concerns"]

[checkbox value="Pt lacks self-confidence due to over-idealizing others and self-devaluation|Pt has difficulty making everyday decisions without an excessive amount of advice and reassurance from others|Pt needs others to assume responsibility for most major areas of life|Pt has difficulty expressing disagreement with others because of fear of loss of support or approval.|Pt has difficulty initiating projects or doing things alone|Pt goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant|Pt feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care oneself|Pt urgently seeks another relationship as a source of care and support when a close relationship ends|Pt is unrealistically preoccupied with fears of being left alone"].

[comment memo="Active dependent concerns"]

[checkbox value="Pt is uncomfortable in situations in which she is not the center of attention|Pt's interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour|Pt displays rapidly shifting and shallow expression of emotions|Pt constantly uses physical appearance to gain attention|Pt has a style of speech that is excessively impressionistic and lacking in detail|Pt shows self-dramatization, theatricality, and exaggerated expression of emotion|Pt is is easily influenced by others or circumstances|Pt considers relationships to be more intimate than they actually are"].

[comment memo="Ambivalent dependent concerns"]

[checkbox value="Pt is extremely extroverted in all settings|Pt is overly energetic and struggles to switch off|Pt is intensely emotional and struggles to implement reason and logic|Pt is hyper-confident, ambitious and impulsive in settings where this is unwarranted|Pt is frequently perceived to be somewhat rude, irritable, and irresponsible|Pt is behaviourally disorganized, has a decreased need for sleep, is extremely distractible, has chronic flight of ideas, and exercises poor judgment|Pt is driven by a need for excitement and stimulation|Pt is unable to delay gratification, and evidences a penchant for momentary excitements and fleeting adventures|Pt is notably thrill-seeking, easily infatuated, and overly, but transiently, attached to one thing or person following another|Pt often lacks social
dependability, exhibiting a disdain for the effects of her behaviors|Pt has a capricious disregard for agreements hastily assumed, and leaves a trail of
broken promises and contracts, squandered funds, distraught acquaintances, and so on|Pt finds it hard to settle down, concentrate, and expend effort"]

[comment memo="Passive compulsive concerns"]

[checkbox value="Pt is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost|Pt shows perfectionism that interferes with task completion|Pt is excessively devoted to work and productivity to the exclusion of leisure activities and friendships|Pt is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values|Pt is unable to discard worn-out or worthless objects even when they have no sentimental value|Pt is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things|Pt adopts a miserly spending style toward both self and others|Pt shows rigidity and stubbornness|Pt makes gestures of excessive self-sacrifice to regulate distressing thoughts or feelings"].

[comment memo="Active compulsive concerns"]

[checkbox value="Pt passively resists fulfilling routine social and occupational tasks|Pt complains of being misunderstood and unappreciated by others|Pt is sullen and argumentative|Pt unreasonably criticizes and scorns authority|Pt expresses envy and resentment toward those apparently more fortunate|Pt voices exaggerated and persistent complaints of personal misfortune|Pt alternates between hostile defiance and contrition|Pt is discontented with society because others are not pulling their weight"]

[comment memo="Ambivalent compulsive concerns"]

[checkbox value="Pt makes frantic efforts to avoid real or imagined abandonment|Pt has a pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation|Pt has a markedly and persistently unstable self-image or sense of self|Pt has impulsivity in areas that are potentially self-damaging|Pt has recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior|Pt has affective instability due to a marked reactivity of mood such as intense episodic dysphoria, irritability|Pt has chronic feelings of emptiness|Pt has inappropriate, intense anger or difficulty controlling anger that can include recurrent physical fights|Pt has transient, stress-related paranoid ideation|Pt has dissociative symptoms"]

[comment memo="Passive independent concerns"]

[checkbox value="Pt has a grandiose sense of self-importance|Pt has excessive mirror needs|Pt exaggerates achievements and talents, and expects to be recognized as superior without commensurate achievements|Pt is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love|Pt believes that she is special and unique and can only be understood by, or should associate with, other special or high-status people or institutions|Pt requires excessive admiration|Pt has a sense of entitlement|Pt has unreasonable expectations of especially favorable treatment or automatic compliance with her expectations|Pt takes advantage of others to achieve her own ends|Pt lacks empathy and is unwilling to recognize or identify with the feelings and needs of others|Pt is often envious of others or believes that others are envious of him or her|Pt shows arrogant, haughty behaviors or attitudes|Pt lacks insight into the effects of their behaviour on others|Pt assumes centralized importance in the lives of others"].

[comment memo="Active independent concerns"]

[checkbox value="Pt fails to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are ground for arrest|Pt is frequently deceitful, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure|Pt impulsively fails to plan ahead|Pt is frequently irritability and aggressiveness|Pt has a reckless disregard for safety of self or others|Pt is consistently irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honour financial obligations|Pt demonstrates a lack of remorse, as indicated by being indifferent to or rationalizing having
hurt, mistreated, or stolen from others"].

[comment memo="Ambivalent independent concerns"]

[checkbox value="Pt suspects, without sufficient basis, that others are exploiting, harming, or deceiving her|Pt is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates|Pt is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her|Pt reads hidden demeaning or threatening meanings into benign remarks or events|Pt persistently bears grudges and is unforgiving of insults, injuries, or slights|Pt perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack|Pt has recurrent suspicions, without justification, regarding the fidelity of her sexual partner"]

[comment memo="Passive detached concerns"]

[checkbox value="Pt neither desires nor enjoys close relationships, including being part of a family|Pt almost always chooses solitary activities|Pt has little, if any, interest in having sexual experiences with another person|Pt takes pleasure in few, if any, activities|Pt lacks close friends or confidants other than first-degree relatives|Pt appears indifferent to the praise or criticism of others|Pt shows emotional coldness, detachment, or flattened affectivity"]

[comment memo="Active detached concerns"]

[checkbox value="Pt avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection|Pt is unwilling to get involved with people unless certain of being liked|Pt shows restraint within intimate relationships because of the fear of being shamed or ridiculed|Pt is preoccupied with being criticized or rejected in social situations|Pt is inhibited in new interpersonal situations because of feelings of inadequacy|Pt views self as socially inept, personally unappealing, or inferior to others|Pt is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing"]

[comment memo="Ambivalent detached concerns"]

[checkbox value="Pt has a persistent pattern of intense discomfort with and decreased capacity for close relationships|Pt has cognitive or perceptual distortions and eccentricities of behaviour|Pt has unusual ideas of reference|Pt lives in accordance with odd beliefs or magical thinking|Pt reports unusual perceptional experiences|Pt has an odd style of thought and speech|Pt has suspicions or paranoid thoughts|Pt demonstrates incongruous or limited affect|Pt has an odd, eccentric, set of behaviours|Pt demonstrates odd and unusual manner of dressing|Pt has a lack of close friends or confidants|Pt has excessive social anxiety that does not lessen with familiarity"]

[textarea default=""]

SUBJECTIVE REPORT

[textarea cols=80 rows=20 default=""].

OBSERVATIONS

Pt is a [checkbox value="male|female"] [checkbox value="young adult|mid-aged adult|older adult|young teen|older teen|child"]. [checkbox value="Reasonably|Not well|Meticiulously"] kempt [checkbox value="+|++|+++"], [checkbox value="average weight|overweight|underweight"][checkbox value="+|++|+++"].
Posture [checkbox value="relaxed|rigid|stooped|confident|aggressive|tense|slumped"][checkbox value="+|++|+++"]
Movement [checkbox value="unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous"][checkbox value="+|++|+++"]
Attention: [checkbox value="no concerns - attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"][checkbox value="+|++|+++"]
Engagement: [checkbox value="no concerns - warm, chatty, and engaged well|avoided eye contact|fixed staring|glaring at author|tense facial expression|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|guarded|paranoid|defensive and resistant|cold, aloof and inaccessible|manipulative|argumentative"][checkbox value="+|++|+++"]
Mood reported: [text default=""]
Affect observed: [checkbox value="mainly euthymic|tearful|labile|restricted|blunted |flat|dysphoric|anxious|angry |apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric"][checkbox value="+|++|+++"]
Speech: [checkbox value="spontaneous|normal RTV|abnormal RTV|clear and articulate|selectively mute|mute|loud|laconic|verbose|quiet|pressured|rambling|babbling|incongruent with mood and current circumstances"][checkbox value="+|++|+++"]
Thinking: [checkbox value="logical|linear|rigid and concrete|personalizing|persecutory|indecisive|unrealistic|difficulties of reference|magical ideas of influence|distorted|pseudologica fantastica|memory difficulties|provided unnecessary detail (circumstantial)|wandered between many topics (tangential)|jumped from one idea to another (loose associations)|racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentence (thought blocking)|tended to loop or repeat themes (obsessive)|stuck on over-valued ideas (preoccupations)"][checkbox value="+|++|+++"]
Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial"][checkbox value="+|++|+++"]
Stressors disclosed without prompting: [checkbox value="nil|self-esteem|parenting|spouse|money|school|physical health|energy|sleep|body weight\shape|eating|food|housing|employment|mood|family|work|grief and loss|illness|transitions|legal|peers|relationship"][checkbox value="+|++|+++"]
Suicide risk: [select value="denied active suicidal ideation when asked|vague suicidal ideation|intense suicidal ideation|has a suicide plan without strong intent|has strong intent to suicide without a plan|has strong intent and a plan to complete suicide"].

ASSESSMENT

Since our last contact, the Pt's presenting concern has [checkbox value="remained unchanged|improved|worsened"]. Over the last week the Pt rated their depression as [checkbox value="normal - no concerns|mild|severe|extremely severe"], their anxiety as [checkbox value="normal - no concerns|mild|severe|extremely severe"], and their overall stress as [checkbox value="normal - no concerns|mild|severe|extremely severe"].
[comment memo="Dependent Traits"]
[checkbox name="DPT" value="Deferential personality traits underlie the Pts clinical concern, due to having a diffuse sense of identity. Pt projects Idealizing transference too readily. This leads the Pt to idealize external sources of approval, belonging, and affection."][conditional field="DPT" condition="(DPT).is('Deferential personality traits underlie the Pts clinical concern, due to having a diffuse sense of identity. Pt projects Idealizing transference too readily. This leads the Pt to idealize external sources of approval, belonging, and affection.')"]. This has resulted in the Pt feeling [checkbox value="self-doubt, worried about abandonment, and insecure over autonomous behaviours. Pt compensates by passively attaching to others, and encouraging them to take the lead through submission, agreeableness and cooperativeness|depressed, irritable, and self-loathing. Pt compensates by maintaining a disposition of cheer and goodwill|empty, abandoned, and insecure. Pt compensates by actively soliciting the attention and approval of others by cultivating an acceptable identity, occasional theatrics and socializing"].[/conditional]
[comment memo="Compulsive traits"]
[checkbox name="IAPT" value="Independent-ambivalent personality traits underlie the Pts clinical concern. Pt struggles to Idealize and is chronically ambivalent about Idealised objects leading the Pt striving for independence, yet reluctant to relinquish emotional dependency on key attachment figures."][conditional field="IAPT" condition="(IAPT).is('Independent-ambivalent personality traits underlie the Pts clinical concern, leading the Pt striving for independence, yet reluctant to relinquish emotional dependency on key attachment figures.')"]. This has resulted in the Pt feeling [checkbox value="ambivalence around autonomy and an out-of-control dysphoria. Pt compensates by rigid obedience, subjugation of needs and self-sacrifice|ambivalence around simultaneously needing attention and affection and autonomous independence. Pt compensates through capricious hot and cold mood swings|ambivalence around dependency needs. Pt compensates through complaining, righteousness, idealism, passive aggression, irritability, and fault-finding"].[/conditional]
[comment memo="Narcissistic Traits"]
[checkbox name="IPT" value="Independent personality traits underlie the Pts clinical concern, Pt has excessive mirror needs and is dependent-phobic leading to Pt to expect recognition and admiration from others, as well as fighting for self-determination at any cost, however, Pt is struggling to elicit these needs from others and feeling constrained by the strictures of their social milieu."][conditional field="IPT" condition="(IPT).is('Independent personality traits underlie the Pts clinical concern, leading to Pt to expect recognition and admiration from others, as well as fighting for self-determination at any cost, however, Pt is struggling to elicit these needs from others and feeling constrained by the strictures of their social milieu.')"]. This has resulted in the Pt feeling [checkbox value="empty, flat, bored, and resentful of others. Pt compensates by recognition seeking, grandiose fantasies, devaluing others, denying faults, and excessive self-focus|paranoid about others and society more broadly. Pt compensates by paranoid projections justifying a strike first attitude|others are unreliable and unworthy of power. Pt compensates by domineering behaviours, retributive behaviours, and denying the rights others."].[/conditional]
[comment memo="Schizoid Traits"]
[checkbox name="DAPT" value="Detached-ambivalent personality traits underlie the Pts clinical concern. Pt is ambivalent about their mirroring needs which leads the Pt longing for deep intimate connections with others, yet avoiding others due to fears of engulfment or emotional pain."][conditional field="DAPT" condition="(DAPT).is('Detached-ambivalent personality traits underlie the Pts clinical concern, leading the Pt longing for deep intimate connections with others, yet avoiding others due to fears of engulfment or emotional pain.')"]. This has resulted in the Pt feeling [checkbox value="ambivalent around wanting to be undisturbed and inconspicuous, on the one hand yet longing for intimacy on the other|ambivalent around wanting to create intrigue and social interest, yet keeping a safe distance from others|ambivalent around longing for intimacy but having self-conscious sensitivity to social rejection."].[/conditional]

PLAN

[comment memo="Dependent Traits"]
[checkbox value="Support an increase in autonomous social encounters to reduce clinging behaviours|Target cognitions of inadequacy and supporting competency as well as fears of failure|Assess the validity of the Pts own beliefs around asserting oneself|Promote independent thinking and validate the Pt's ideas about the world|Establish an independent identity|Suport communication skills training|Support Pt to learn to express negative feelings|Support the Pt to express their needs and assert their boundaries with others|Given the Pt's belief that an external source of Idealization is required for stability, the goal is to increase their active involvement is pusuing need satisfaction without excessive support from others."]

[comment memo="Histrionic Traits"]
[checkbox value="Correct the Pts tendency to fulfill their needs by focusing on others to the exclusion of self.|Relaxation training and problem solving to reduce interpersonal distress.|Challenge the Pts assumptions about their fundamental lack of capacity to care for themselves|Promote assertiveness and boundary setting.|Help the Pt to tolerate alone time and occasional solitude|Provide warm sympathy toward the observing ego (the part of the patient that can rationally understand the ways certain behaviors can lead to problems), with whom the therapist can gang up against the 'enemy' - that part of the patient that feels compelled to keep acting out damaging histrionic patterns|Establish clear ideas about what the Pts therapeutic objectives are (how their lives will be different) to help ensure that the goals are meaningful|Reinforce assertive and competent responses from the Pt so as not to encourage the dependent patterns|Support development of a rich interior life.|Support the Pt to link thoughts, feelings and behaviours.|Support Pt to develop their observing ego, particularly automatic thoughts. Support the Pt identify authentic wants to facilitate genuine communication to others.|Identify Pts desires to support discovering a sense of identity|Draw attention to the tendency to paying to much time focusing on others in an attempt to get their attention and approval|Support Pt to notice how they modify their behaviour to impact on others|Support Pt to make a list of things they know about themselves to begin building a self-concept|Support Pt to notice their fears around rejection and the possibility of a relationship ending|Support Pt to notice how their behaviours are designed to make it difficult for others to leave them|Explore cognitions around rejection and imagining what life was like before a particular relationship, and how the patient could manage to survive in the future if a particular relationship were to end."]

[comment memo="Hypomanic Traits"]
[checkbox value="Refer to GP to consider mood stabilizing medications|Support Pt to confront weaknesses and deficiencies, enabling Pt to recognize the wisdom of gaining increased self-control and learning to adopt attitudes that foster congenial social living|Support Pt to self-monitor cognitive attitudes and emotional moods.|Support Pt to accept and continue with medications|Flag the social disruptions of Pt's life associated with hypomanic energy"]

[comment memo="Compulsive Traits"]
[checkbox value="Sensitize patient to the anxiety-provoking stimuli that promotes problematic compulsive behaviour|Establish a hierarchy of stimuli within a relevant context, followed by relaxation training|Consider flooding Pt with aversive stimuli|Consider modeling behaviours|Consider stimulus and response prevention|Consider satiation Therapy|Consider thought-stopping training|Set prioritized problem specifics and systematic problem-solving approach designed to overcome indecisiveness and procrastinating behaviors|Consider formal relaxation procedures to modulate underlying tensions and anxieties|Consider social skills training, combined with an effort to reduce commitment to constant work|Enable Pt to openly recognize the character of early learning critical parent experiences and to develop a measure of empathy, if not compassion, for that younger self| Expose needs for perfection and absolute control as unrealizable aims|Support Pt to see values and relationships are best seen as variegated and multidimensional rather than black-and-white phenomena|Work with the Pt around congitive splits - there are right and wrong behaviors, decisions, and emotions - to make a mistake is to have failed - failure is intolerable - I must be perfectly in control of my environment as well as of myself - loss of control is intolerable and dangerous - I am powerful enough to initiate or prevent the occurrence of catastrophes by magical rituals or obsessional ruminations - Without my rules and rituals, I’ll collapse into an inert pile|Identify NATS - The automatic thoughts that interfere with the attainment of goals|Help Pt refute illogical catastrophic cognitions|Examine the belief that worry will prevent a distaster|Explore the fearing a loss of control and the upsurge of untoward thoughts and emotions|Promote risk taking and emotionally based decision making"]



ACTION

Using a modified CBT framework, I supported Pt to
[comment memo="Dependent Traits"]
[checkbox value="challenge dichotomous cognitions that one is completely dependent and in need of help or totally independent and therefore alone|challenge dichotomous cognitions that one is only accepted for having positive mood states and that negative moods are unacceptable|challenge dysfunctional cognitions that all validation is external, and monolithic identities are fragile."]

[comment memo="Compulsive Traits"]
[checkbox value="challenge dysfunctional cognitions that mistakes are intolerable and perfection is desirable and realistic|challenge all dichotomous cognitions as unhelpful and unrealistic|challenge win-lose cognitions and reveal covert perfectionism"]
[comment memo="Narcissistic Traits"]
[checkbox value="challenge cognitions that lead to overvaluing oneself, and underestimating the value of others|challenge cognitions around overestimating the threat posed by the situation, underestimating the capacity to solve the problem, and promoting a more realistic appraisal of ones own coping ability|challenge self-serving perceptual bias or schemas used to justifying devaluing the rights of others."]
[comment memo="Schizoid Traits"]
[checkbox value="challenge cognitions that support isolation from others, normalizing intimacy needs, and linking thoughts to feelings|challenge Pts tendency towards emotional reasoning as well as challenging ideas of reference, paranoid ideation, or pseudo hallucinations.|challenging cognitions around distorted social expectancies and magical thinking around what others must be thinking about them."].

PLAN

[textarea default="Will continue to support Pt address distorted cognitions, linking behaviours to feelings, self monitoring, and reflecting on the content of the session as it applies to their day-to-day functioning "]

NEXT APT

[textarea default="seeing the Pt on"]
PRESENTING CONCERNS

Passive dependent concerns

.

Active dependent concerns

.

Ambivalent dependent concerns



Passive compulsive concerns

.

Active compulsive concerns



Ambivalent compulsive concerns



Passive independent concerns

.

Active independent concerns

.

Ambivalent independent concerns



Passive detached concerns



Active detached concerns



Ambivalent detached concerns





SUBJECTIVE REPORT

.

OBSERVATIONS

Pt is a . kempt , .
Posture
Movement
Attention:
Engagement:
Mood reported:
Affect observed:
Speech:
Thinking:
Orientation:
Stressors disclosed without prompting:
Suicide risk: .

ASSESSMENT

Since our last contact, the Pt's presenting concern has . Over the last week the Pt rated their depression as , their anxiety as , and their overall stress as .
Dependent Traits

Compulsive traits

Narcissistic Traits

Schizoid Traits


PLAN

Dependent Traits


Histrionic Traits


Hypomanic Traits


Compulsive Traits




ACTION

Using a modified CBT framework, I supported Pt to
Dependent Traits


Compulsive Traits

Narcissistic Traits

Schizoid Traits
.

PLAN



NEXT APT

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