MH – Personality Based SOAPNOTE II

PRESENTING CONCERNS

[comment memo="Dependent concerns"][checkbox value="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|Pt feels uncomfortable or helpless when alone|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="Histrionic concerns"][checkbox value="Pt is uncomfortable in situations in which she is not the center of attention|Pts interaction with others is often characterized by inappropriate seductive or provocative behaviours|Pt does not tend to feel deeply about people or issues|Pt over-relies on physical appearance to gain attention|Pt preferences impressions and avoids small detail|Pt dramatizes and externalises internal feeling states|Pt exaggerates expressed emotions|Pt is easily influenced by others or circumstances|Pt considers relationships to be more intimate than they actually are"].

[comment memo="Hypomanic dependent concerns"][checkbox value="Pt is extremely extroverted in all settings|Pt is overly energetic and struggles to switch off|Pts strong emotions override reason and logic|Pt is hyper-confident, ambitious without the requisite skills|Pt is frequently perceived to be 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 an excessive need for excitement and stimulation|Pt is poorly able 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 their 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="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="Negativistic 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 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="Narcissistic 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="Antisocial 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="Paranoid 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="Schizoid 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="Avoidant 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="Schizotypal 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=""].OBSERVATIONSPt 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"].ASSESSMENTSince 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="Pt feels unstable and anxious without support of idealized others. As such, Pt is willing to subordinate autonomous needs in order to secure responsiveness from idealized others. In this way, the Pts dependency serves a protective function - by seeking out omnipotent idealized others and attaching to, or attracting them, Pt feels vitalised, calmed and secure by their responsiveness and-or proximity. When idealized others fails in this regard, Pt feels devitalised, anxious and fragmented. Moreover. Pts exploratory needs, and needs for challenge remain unrewarded."][conditional field="DPT" condition="(DPT).is('Pt feels unstable and anxious without support of idealized others. As such, Pt is willing to subordinate autonomous needs in order to secure responsiveness from idealized others. In this way, the Pts dependency serves a protective function - by seeking out omnipotent idealized others and attaching to, or attracting them, Pt feels vitalised, calmed and secure by their responsiveness and-or proximity. When idealized others fails in this regard, Pt feels devitalised, anxious and fragmented. Moreover. Pts exploratory needs, and needs for challenge remain unrewarded.')"]. 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. In other words, Pt covers their emptiness and dependent longings with excessive cheer|empty, abandoned, and insecure. Pt compensates by actively soliciting the attention and approval of others by cultivating an acceptable identity, occasional theatrics and socializing. Pts exhibitionistic needs for play and display needs remain chronically unmet. Failure to secure responsiveness from idealised others devitalises the Pt. As such, Pt openly idealizes others to secure some responsiveness. Pt's feelings of vitality are therefore dependent on the Pts ability to secure responsiveness from idealised others. When Pt struggles to recruit the responsiveness of idealised others, the Pt tends to become increasingly flighty and desperate in that regard"].[/conditional][comment memo="Compulsive traits"]
[checkbox name="IAPT" value="Compulsive 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('Compulsive 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.')"]. 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="Autonomous 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('Autonomous 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.')"]. 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 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 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.')"]. 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]TREATMENT PLAN[checkbox name="DTP" value="Gently reduce tendency towards idealization by passively assuming a mirroring role, and explore support Pt to fulfill unmet efficacy needs by:"][conditional field="DTP" condition="(DTP).is('Gently reduce tendency towards idealization by passively assuming a mirroring role, and explore support Pt to fulfill unmet efficacy needs by:')"] [checkbox value="improving self-confidence|decreasing submissive and obsequious behavior|increasing comfort with being alone and engaging in independent activities|increasing the range and adequacy of coping behaviors, social skills, and competencies|increasing decisiveness and independence in decision making|increasing assertiveness|increasing awareness of own desires and needs|decreasing fear of being alone|reducing frequency and intensity of clinging behaviours"][/conditional][checkbox name="HTP" value="Gently reduce tendency towards idealization by actively assuming a mirroring role, and explore support Pt to fulfill unmet efficacy needs by:"][conditional field="HTP" condition="(HTP).is('Explore idealizing transference and Pts overt attempts to fulfill unmet efficacy needs by:')"] [checkbox value="Reducing focus on gaining attention from others while strengthening self-awareness and self-image|decreasing actions designed to gain attention from others|forming genuine social relationships|decreasing seductive behavior and excessive use of physical appearance to secure attention|stabilizing erratic moods and dramatic displays of emotion|reorienting flighty cognitive style, increasing attention to relevant detail|Improving self-esteem|Decreasing suggestibility"] [/conditional][checkbox name="ExTP" value="Gently reduce tendency towards idealization by assuming a mirroring role, and explore support Pt to fulfill unmet efficacy needs by:"][conditional field="ExTP" condition="(ExTP).is('Gently reduce tendency towards idealization by assuming a mirroring role, and explore support Pt to fulfill unmet efficacy needs by:')"] [checkbox value="Referring to GP to consider mood stabilizing medications|Supporting 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|Supporting Pt to self-monitor cognitive attitudes and emotional moods.|Support Pt to accept and continue with medications|Flagging the social disruptions of Pt's life associated with hypomanic energy"][/conditional][checkbox name="CoTP" value="Explore Pts covert resistance to mirroring, and support fulfilling unmet adversarial needs by:"][conditional field="CoTP" condition="(CoTP).is('Explore Pts covert resistance to mirroring, and support fulfilling unmet adversarial needs by:')"] [checkbox value="reduce preoccupation with rules, details, and minutiae|reduce perfectionism|decrease guilt and self-criticism|increase flexibility in problem solving and in interpersonal relationships|enhance ability to relax|increase emotional expressiveness and richness of inner emotional experience|brighten solemn or melancholy mood|let go of hoarded items and money"][/conditional][checkbox name="NPTP" value="Explore Pts overt resistance to mirroring, and support fulfilling unmet adversarial needs by:"][conditional field="NPTP" condition="(NPTP).is('Explore Pts overt resistance to mirroring, and support fulfilling unmet adversarial needs by:')"] [checkbox value="reduce preoccupation with rules, details, and minutiae|reduce perfectionism|decrease guilt and self-criticism|increase flexibility in problem solving and in interpersonal relationships|enhance ability to relax|increase emotional expressiveness and richness of inner emotional experience|brighten solemn or melancholy mood|let go of hoarded items and money"][/conditional]ACTIONUsing a modified CBT framework, I supported Pt to challenge unhelpful cognitions:
[comment memo="Dependent Traits"]
[checkbox value="Emotional needs are gratified externally|Lack of social approval alienates me|Isolation is intolerable|I cannot dissappoint others|Exhibistionistic needs are wrong|Appearance is everything|I need an identity|I am only loved for my positivity|I will never be as good as others"][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"]