Transtorno de personalidade

PRESENTING CONCERNS

[comment memo="Dependent Personality"]
[checkbox name="Dependencyconcerns" value="Pt presents as being overly cooperative, subordinating and acquiescent to the needs of others. In particular, the Pt"][conditional field="Dependencyconcerns" condition="(Dependencyconcerns).is('Pt presents as being overly cooperative, subordinating and acquiescent to the needs of others. In particular, the Pt')"] [checkbox value="lacks self-confidence due to excessive self-devaluation|has difficulty making everyday decisions without an excessive amount of advice and reassurance from others|passively encourages others to assume responsibility for most major areas of their life|has difficulty expressing disagreement with others because of fear of loss of support or approval|has difficulty initiating projects|struggles to do things alone|goes to excessive lengths to obtain nurturance and support from others|willing to endure excessive discomfort to please others|feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care oneself|urgently seeks another relationship as a source of care and support when a close relationship ends|is preoccupied with fears of being left alone"].

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

The Pt feels oppressed by their inate strivings towards independence. Pt feels unstable and anxious without the support and approval of an idealized other. 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 the responsiveness and-or proximity of an idealised other. When idealized others fail in this regard, Pt feels devitalised, anxious and fragmented. Pt is pre-occupied by self-doubt, worried about abandonment, and insecure over autonomous behaviours such that they compensate by attaching to others, and passively encouraging them to take the lead through submission, agreeableness and cooperativeness.

TREATMENT GOALS[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"]

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions:[checkbox value="Emotional needs are gratified externally|A lack of social approval alienates me|Independence equates with isolation|Isolation is intolerable|I cannot dissappoint others|My idealistic strivings are wrong|Group identity is a preferable substitute for individual identity|I will never be as good as others"][/conditional]
[comment memo="Hypomanic Personality"]
[checkbox name="Hypo" value="Pt presents as unremittingly full of life and socially buoyant, with an intolerance of passivity and negative emotions. In particular, the Pt"][conditional field="Hypo" condition="(Hypo).is('Pt presents as unremittingly full of life and socially buoyant, with an intolerance of passivity and negative emotions. In particular, the Pt')"] [checkbox value="is extremely extroverted in all settings|is overly energetic and struggles to switch off|is easily swayed by momenary flights of fancy, and struggles with foresight|appears hyper-confident, ambitious and impulsive in settings where this is unwarranted|is frequently perceived to be rude, irritable, and irresponsible|is behaviourally disorganized, and has a decreased need for sleep|can be extremely distractible with chronic flight of ideas|exercises poor judgment in decisions of high impact|is driven by an unremitting need for excitement and stimulation|is poorly able to delay gratification, evidences a penchant for momentary excitements and fleeting adventures|is notably thrill-seeking, easily infatuated, and overly, but transiently, attached to one thing or person following another|often lacking social dependability, exhibiting a disdain for the effects of impulsive behaviours|has a capricious disregard for agreements hastily assumed, and leaves a trail of broken promises and contracts, squandered funds, distraught acquaintances, and so on|finds it hard to settle down, concentrate, and expend effort on a focussed task"]

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Fighting against an inner emptiness and feelings of self-loathing, Pt compensates by maintaining a disposition of excessive cheer and goodwill - driven by the hope that all emotional needs can be gratified externally. Pt covers their emptiness and fights against their dependent longings with excessive positivity and locomotion. Pt wrestles with their dependent needs through either acts of counter-dependency or more commonly the excessive cheer derived from dependency-denial. In other words, the Pt is driven to create self-esteem without apparent need of any responsiveness from an idealised other. It is as if Pt has realised the world is full of delights to be savoured like an enormous candy store and one must grab what they can. On a good day this is more drive and energy, more self-confidence, increased social and physical activity, happy mood, faster thinking, and on darker days this is more irritablilty and impatience, distractible attention, foolish business ventures, imprudent driving, increased consumption of coffee, cigarettes, alcohol, and substances. A person of appetites you could say. Another conceptualisation is the Pt is constantly defending against deep feelings they cannot bare to face in a body they fail to recogise as having limits.

TREATMENT GOALS

[checkbox value="refer Pt to GP to consider mood stabilizing medications|support Pt to confront inner 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"]

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value="Emotional needs are gratified externally|Appearance is everything|I am only valued for my positivity|my actions have no consequences|I have no substatial agency|Autonomy equates with isolation"][/conditional]
[comment memo="Histrionic Personality"]
[checkbox name="Hist" value="Pt presents as being overly exhibitionistic and attention seeking. In particular, the Pt"][conditional field="Hist" condition="(Hist).is('Pt presents as being overly exhibitionistic and attention seeking. In particular, the Pt')"] [checkbox value="is uncomfortable in situations in which they are not the center of attention|is preoccupied with matters relating to their identity|interacts with others in a way characterized by sexual seduction or provocative behaviour|displays rapidly shifting and shallow expression of emotions|over relies on physical appearance to gain attention|has a style of speech that is excessively impressionistic and lacking in detail|shows self-dramatization and theatricality to demonstrate emotion|is easily influenced by others or circumstances|considers relationships to be more intimate than they actually are"]

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Pt feels unstable and anxious without the attention of idealized others. As such, Pt is willing to subordinate autonomous needs in order to secure responsiveness from idealized others. The Pts dependency serves a protective function - by seeking out idealized others by actively soliciting their attention, Pt feels vitalised, calmed and secure by their responsiveness and-or proximity. When idealized others fail in this regard, Pt feels devitalised, anxious and fragmented. Moreover. Pts exploratory needs, and needs for autonomy remain unrewarded. This pattern has resulted in the Pt struggling with feelings of emptiness, abandonment, and insecurity. Pt then doubles down and increases attempts to actively solicit the attention and approval of others by cultivating an acceptable identity, theatrics and hyper-socializing. This reinforces the assumption that the Pts feelings of vitality are dependent on their 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.

TREATMENT GOALS

[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"]

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value="emotional needs are gratified externally|lack of social approval alienates me|Isolation is intolerable|fickle and flighty behaviours dissappoint others|autonomy alienates me|appearance is everything|the approval of others is core to my being|I will never be as good as others"][/conditional]
[comment memo="Compulsive Personality"]
[checkbox name="Compu" value="Pt presents as excessively conscientious and self-sacrificing. In particular, the Pt"][conditional field="Compu" condition="(Compu).is('Pt presents as excessively conscientious and self-sacrificing. In particular, the Pt')"] [checkbox value="is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost|shows perfectionism that interferes with task completion|is excessively devoted to work and productivity to the exclusion of leisure activities and friendships|is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values|is unable to discard worn-out or worthless objects even when they have no sentimental value|is reluctant to delegate tasks or to work with others unless they submit to exactly to the correct way of doing things|adopts a miserly spending style toward both self and others|shows a passive rigidity and stubbornness to the wishes of others|makes gestures of excessive self-sacrifice to regulate distressing thoughts and feelings|tries to magically undo imagined catastrophies by self-sacrifice"].

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

The Pt has an ambivalent relationship to their own idealism. On the one hand, idealism motivates the Pt towards excessive striving and hard work, yet, on the other hand, idealism reminds the Pt how unworthy they are. In other words, the Pt wants to gratify their idealism through hard work and self-sacrifice, yet having unrealistically high standards means they constantly fail to reach the penultimate perfection they dream of.The Pt feels oppressed by unrelentingly high standards. Failure in this regard signals to the Pt that they must work harder, faster, longer, better, etc. It is as if the Pt behaves under the assumption that a malevolent God is looking down upon them and disapproving of their shortcomings. It is as if the Pt is saying love me for how well behaved I am. This leads to a variety of compulsive concerns of varying self-sacrificial themes. The Pt is in effect punishing themselves to mitigate an unremitting guilt for their imagined shortcomings. Whether its over-meticulousness in manner or dress, preoccupation with dirt or cleanliness, diet, body weight, moral standards, too much joy, decision-making, superstitions etc. the Pt remains unyielding in the face of adopting a more relaxed and reasonable position.Aside from managing an umremitting guilt, the Pt has a propensity towards managing excessive doubt. Because their internal standards are unrealistically high, the Pt is never sure whether their choices are adequate. Given the externality of the Pts idealistic standards, the Pt is unable to accept their own inner subjective position that who they are and what they do is inately acceptable. This is occassionally reported to be an inner emptiness, or a sense of coming apart which leads to a subtle dysphoria and feeling of being out of control. This feeling leads the Pt to double down and compensate by rigid obedience, subjugation of needs and excessive self-sacrifice.

TREATMENT GOALS

[checkbox value="Reduce preoccupation with rules, details, and minutiae|Recognise and 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|learn an inner arbitration and standard is acceptable|explore projections of malevolence"]

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value="I must avoid mistakes at all costs|There is one right path-answer-behaviour in each situation|Mistakes are intolerable||I must always be careful and thorough|I must pay attention to details|I must notice mistakes immediately so they can be corrected|To make a mistake is to deserve criticism|Absolute control makes me fee safe|Any departure from what is right is automatically wrong|I can prevent disasters or mistakes by worrying about them|If the perfect course of action is unclear, it is better to do nothing|Catastrohizing protects me|I am only worth what I can achieve|Downtime must be filled with activity|I am constantly being judged and scutinized by someone or something"][/conditional]
[comment memo="Ambivalent Personality"]
[checkbox name="Ambi" value="Pt presents with chronic feelings of emptiness, a capricious interpersonal style, rapidly fluctuating and antithetical perceptions about others, self and the world in general. In particular, the Pt"][conditional field="Ambi" condition="(Ambi).is('Pt presents with chronic feelings of emptiness, a capricious interpersonal style, rapidly fluctuating and antithetical perceptions about others, self and the world in general. In particular, the Pt')"] [checkbox value="has a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation|has a markedly and persistently unstable self-image or sense of self|has impulsivity in areas that are potentially self-damaging|has recurrent suicidal behavior, gestures, or threats, or self-mutilating behaviour|has affective instability due to a marked reactivity of mood such as intense episodic dysphoria, irritability|has chronic and unbearable feelings of emptiness|has inappropriate, intense anger or difficulty controlling anger that can include recurrent interpersonal conflicts|has transient, stress-related paranoid ideation|Pt has dissociative symptoms|Pt oscillates betweed sadistically hostile outbursts and guilty self-remorse"].

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Pt tends to idealise and then rapidly devalue the world, self and others. Having no internalised standards for idealistic longings, the Pt relies on unreliable idealised others for feeback in that regard. This leads to a tendency towards rapid cycling of idealization and devaluation. Which, to the observer, appears as capricious hot and cold mood swings and ambivalence around autonomy - wanting it whilst rejecting it.This intense ambivalence along with unbearable feelings of emptiness, represent intense fragmentation states - denoting experiences portending a sense of dissolution, as if one were coming apart. Such a state is so aversive the Pt will do almost anything to escape the perceptions brought about by fragmentation. Such fragmentation phenomena may produce frantic activity to elicit attention, substance abuse, delinquent actions, and-or a variety of acting out behaviours, all of which may represent desperate attempts to subdue perturbations of immobilizing anxiety or depression. These concerning behaviours likely represent the Pts attempts to manage marked destabilization of selfcohesion. Even when Pt is able to establish a brief Idealization of a reponsive other, the slightest let down represents a grave wound to the Pts need to rely on that idealized other, resulting in frequent relationship conflicts followed by an intense dysphoria and guilty self-loathing.From the Pts perspective, the Idealised other represents an ambiguous figure of reward and punishment. Having a poor sense of internalised standards for self-worth and idealistic striving, the Pt relies on unreliaable external others for validation, yet refuses to accept their validation. It is as if the Pt is saying I need you close, but go away. This leads to a variety of self-worth concerns of varying severity that cause immense interpersonal conflict. From the Pts side the subjective experience is one of coming apart which is experienced as out-of-control dysphoria -- Pt then compensates by excessive self-sacrifice or sadistic rages directed outwardly at dissappointing others.

TREATMENT GOALS

1. Terminate suicidal and-or self-mutilating behavior.
2. Stabilize interpersonal relationships.
3. Increase respect for self.
4. Increase behavioural skills, such as problem-solving and communication skills.
5. Increase emotional modulation and decrease emotional reactivity.
6. Increase realistic judgment while decreasing crisis-generating behavior.

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value=The world is dangerous and malevolent|I am powerless and vulnerable.|I am inherently unacceptable.|other people are malevolent|others cannot be trusted|Others will abandon you|others will punish you|my emotional pain will never stop|I will always be alone|There will be nobody who cares for me|I long for consolation and nurturance but also fear it"][/conditional]
[comment memo="Negativistic Personality"]
[checkbox name="Nega" value="Pt presents as discontented with self, world and others. In particular, the Pt"][conditional field="Nega" condition="(Nega).is('Pt presents as discontented with self, world and others. In particular, the Pt')"] [checkbox value="passively resists fulfilling routine social and occupational tasks|complains of being misunderstood and unappreciated by others|is prone to becoming sullen and argumentative|unreasonably criticizes and scorns authority|expresses envy and resentment toward those apparently more fortunate|voices exaggerated and persistent complaints of personal misfortune|alternates between hostile defiance and contrition|is discontented with society because others are not pulling their weight|is irritable and upset about the world and others falling short of expectations"].

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Pt struggles to Idealize self, world, and others and is therefore chronically ambivalent about their idealized longings. This has resulted in the Pt being caught in a state of discontent about how the world ought to be, and how it actually is. In other words the Pt longs to satisfy their idealistic strivings, and at the same time being sceptical such ideals are even possible.The Pts reluctance to idealise or mirror, overlays intense fragmentation states - denoting experiences portending a sense of dissolution, as if one were coming apart. The Pt is unwilling to acknowledge they hold the world to unreasonaly high standards that are internally generated yet presumed to be external. Confoundingly, the Pt idealizes others but then resists any recognition of the other, prefering to fault-find. They feel contained and coherent as they fight against or rage against idealised others such that they appear to be dissappointed Idealists. As sadistic impulses flood the Ego, Pt defends against these impulses through projective identification. It is as if the Pt feels autonomy only through the contrarian position - finding and fighting ideals.The desire to be in favor with those in power remains in direct contradiction to their belief that to remain autonomous they must circumvent or ignore rules or expectations. As a means of managing this ambivalence, independence is maintained through passive behavior that does not directly confront or challenge the Idealised authority. Pt retains control and autonomy by avoiding conflict and potential disapproval.

TREATMENT GOALS

1. Perform obligations responsibly and reliably.
2. Reduce the frequency of contrary behaviors and increase cooperativeness.
3. Express feelings of anger and resentment directly, and take responsibility for those expressions.
4. Resolve or reduce the intensity of ambivalence regarding whether to be independent of others or connected to them.
5. Stabilize erratically changing actions and emotions.
6. Increase perceptions of joy, happiness, and contentedness.
7. Reduce frequency of complaining about misfortunes or authority figures.
8. Interact with others in a sensitive, empathic manner that elicits kindness rather than exasperation and anger.
9. Develop a for win-win mindsetACTIONUsing a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value="No one should control me|To conform means I have no control|Compliance means defeat|Compliance is synonymous with a loss of control and freedom|Control means freedom|I cannot accept influence from others|It is my role to teach others valuable lessons|I have no autonomy needs|Compromise means I am being taken advantage of|No one should ever tell me what to do|Disagreement does not mean hostility towards me"][/conditional]
[comment memo="Narcisisstic Personality"]
[checkbox name="Narc" value="Pt presents with unmet needs for acknowledgement and recognition. In particular, the Pt"][conditional field="Narc" condition="(Narc).is('Pt presents with unmet needs for acknowledgement and recognition. In particular, the Pt')"] [checkbox value="has a grandiose sense of self-importance|makes excessive demands for recogntion|is unable or unwilling to Idealise others|exaggerates achievements and talents, and expects to be recognized as superior without commensurate achievements|is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love|believes that they are special and unique and can only be understood by, or should associate with, other special or high-status people or institutions|requires excessive admiration|has an unrealistic sense of entitlement|has unreasonable expectations of especially favorable treatment or automatic compliance with expectations|takes advantage of others to achieve her own ends|lacks empathy and is unwilling to recognize or identify with the feelings and needs of others|is often envious of others or believes that others are envious of them|shows arrogant, haughty behaviors or attitudes|lacks insight into the effects of their behaviour on others|assumes centralized importance in the lives of others|minimises nor is able to accept any shortcomings|is deluded about how well their life if going|is hostile towards the reality of their underachievement"].

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Pt vacillates between an irrational overestimation of self as well as irrational feelings of inferiority, and therefore over-relies on others to regulate self esteem and provide a sense of value. It is speculated that Pt is not able to overtly idealize responsive others, rather, expects and prefers others to mirror and acknowledge them.In this way, Pts ambitions are highly contingent on having others acknowlege their acheivements, which fuels incredible energy for acheivement, so long as the flow of acknowledgement and recognition remains unbroken. Second to this, Pt aspires to incredibly grandiose ideals, which remain unmet due to poor reality-testing and difficulty submitting to the work required to achieve these ideals.When acknowledgement needs remain unmet the Pt experiences an enormous loss of self-esteem and experiences feelings of inadequacy leading to a frantic demand for acknowledgement. When unrecogised for some form of specialness, the Pt struggles to enjoy physical or mental activities and experiences emptiness and despair. Furthermore, this leads to an inability to sustain a pursuit of desired goals, reinforcing a deep sense of meaninglessness and-or purposelessness.Without adequate acknowledgement, the Pt is poolry able to self-sooth, resulting in a difuse state of anxiety, insomina and psychomotor slowing. Self regulation suffers leading to problems associated with impulsivity, and eventually an apathetic state of dysphoria where they are unable to be excited by anything.When Pt remains unacknowledged, rather than modifying behaviours to meet those needs, Pt doubles down and tries harder to have those needs met, even if it means ignoring the constraints of reality. When adequately acknowledged, the Pt is better able to cope and feels energised.

TREATMENT GOALS

1. Increase tendency to act rather than merely fantasize about achievements.
2. Improve empathy, increasing the ability and desire to understand others feelings.
3. Decrease arrogant attitudes and behaviors.
4. Moderate tendency to see self as perfect and invulnerable.
5. Decrease or eliminate interpersonal exploitation.
6. Increase capacity to set realistic, achievable goals.
7. Reduce feelings of entitlement and expectations of special treatment.
8. Reduce or eliminate tendency to denigrate or put down others.
9. Acquire greater discipline and self-control over emotions, especially anger and rage.
10. Reduce feelings of envy and suspiciousness toward others

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value="the need to present as special and superior|that being unimportant is unacceptable|irrelevence is a signal that one is defeated|validation requires external symbols|feelings of inferiority must be defeated at all costs|I deserve more than others|As others fail I win|inferiority is unacceptable|I deserve special treatment|I need people to admire me|I cannot look bad|If I look bad I am bad|my power absolves me from responsibility|domination over doubt|reality doesnt apply to me|image is everything|others make me look bad|my needs are the most important needs|whatever I want I will have|If Im not happpy no one else should be|Im of central importance in every setting"][/conditional]
[comment memo="Paranoid Personality"]
[checkbox name="Para" value="Pt presents with hostile vigilance and interpersonal guardedness. In particular, the Pt"][conditional field="Para" condition="(Para).is('Pt presents with hostile vigilance and interpersonal guardedness. In particular, the Pt')"] [checkbox value="suspects, without sufficient basis, that others are exploiting, harming, and being deceitful|is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates|is reluctant to confide in others because of unwarranted fear that the information will be used maliciously|reads hidden demeaning or threatening meanings into benign remarks or events|persistently bears grudges and is unforgiving of insults, injuries, or slights|perceives character attacks or reputation attacks that are not apparent to others and is quick to react angrily or to counterattack|has recurrent suspicions, without justification, regarding the fidelity of their partner"].

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

When the Pts needs for recognition and acknowledgement are met with approval, rather than feel gratified, the Pt reacts with ambivalence - wanting the narcissistic supply on the one hand, yet resenting the need for for others to provide such a supply. This results in a profound distrust of responsive others.Without acknowledgement nor recognition, the Pt experiences self-depreciation, low moods and enui, however, rather than eliciting these needs from others, the Pt defends against feelings by projecting blame externally. In this way the Pt has become sensitive to perceived slights and criticisms. Moreover, rageful reactions are often apparent that represent the anger resulting from rebuffed expectations of acknowledgement from others. In other words, rather than vitalising the Pt, approval and acknowledgement have the paradoxical effect of fragmenting self-cohesion - others are just saying nice things but dont mean it.Without self-cohesion, the Pt risks further decompensation with behaviours that resemble Axis I and Axis II disorders characterized by perversions of painful affect states, addictions, delinquency, or propensity for intense outbursts of helpless anger. These behavioral dysfunctions typically achieve only momentary soothing.The other challenge for having their needs for recognition met is the Pt is difficult to like, and their company is nearly impossible to tolerate, let alone enjoy. Pt has difficulty comprehending the loneliness they may feel because their serious, hostile guardedness causes others to retreat from even the most casual involvement. This is perpetuated by misinterpreting others intentions and by suspecting other people of undermining their autonomy. Feelings of envy underlie the touchiness the Pt brings to most situations and their tendency to externalize blame for their own failures or short-comings. The Pt self-protectively finds reasons why problems are characteristically provoked by others and never by themselves.The Pt envies others and resents them for it, but simulatanouesly assumes this envy is reciproacted, leading to an excessive need to defend and fortify. The Pt has replaced an enthusiastic welcoming of acknowledgement and approval from others with the expectation that others will fail to respond to their needs. Consequently, the Pts wariness is rarely assuaged by interactions with other people, who respond to the Pts paranoid suspiciousness with cautiousness and shy away from providing the very sentiments the Pt craves most. Thus, selfprotective aloofness reinforces the Pts perceptions that the intersubjective field so created is hostile or cold.The Pt presents with a heightened sensitivity to aggression. The Pt fears being influenced by others such that their ability to preserve a sense of self with firm boundaries may be compromised, which fosters their keeping emotional distance from people. Underlying this is a concern around the fear of dissolution of the self, representing loss of identity, contributed to the Pts latent grandiosity. Put differently, the Pt presents with profound attachment anxiety, referring to sensitivity to loss of autonomy and control. This accounts for the Pts difficulty being dependent on others and their sensitivity to betrayal or to being manipulated. It is as if grandiose defences have replaced a diminished or undermined existence with a sense of self and of external reality that is more acceptable.

TREATMENT GOALS

1. Reduce suspiciousness of others and increase trust.
2. Let go of distorted suspicious beliefs and replace them with more reasonable, reality-based beliefs.
3. Increase appropriate involvement with other people and decrease selfprotective withdrawals.
4. Increase flexibility in thinking and problem solving.
5. Express anger in a healthy manner.
6. Reduce or eliminate provocations of rejection from others.
7. Increase comfort with feelings of vulnerability and attachment.

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value="Pts ruminations around persecution and mistreatment at the hands of others|People are malevolent and deceptive|people will attack if they get the chance|you can only be ok if you are on guard|people should be universally benevolent and trustworthy|attachment makes you vulnerable|I may not notice when others are trying to take advantage of me|power equates with exploitation|mistreatment deserves retaliation|sensitivity is weakness|I have no needs for admiration|fault must be attributed to someone"][/conditional]
[comment memo="Antisocial Personality"]
[checkbox name="Anti" value="Pt presents with an intrepid and markedly nonconfmorming personality style. In particular, the Pt"][conditional field="Anti" condition="(Anti).is('Pt presents with an intrepid and markedly nonconfmorming personality style. In particular, the Pt')"] [checkbox value="fails to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are possibly grounds for arrest|is frequently deceitful, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure|impulsively fails to plan ahead|is frequently irritability and aggressive when needs arent met|has a reckless disregard for safety of self or others|is consistently irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations|demonstrates a lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from others"].

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Pt experiences inordinate envy, both conscious and unconscious, and devalues others as a defense against this envy. Pt has a centralised attitude towards their needs and sees others as tools to gratify their needs. This is reflected in greediness, appropriation of others ideas or property, and entitlement. The basic ego state of the Pt is characterized by a chronic sense of emptiness, evidence of an incapacity to learn, a sense of aloneness, stimulus hunger, and a diffuse sense of meaninglessness of life.Without having their needs for acknowledgement, recongnition and approval met, the Pt considers that others are either unreliable or unworthy in that regard. Pt compensates by domineering behaviours, retributive behaviours, and-or denying the rights others. Pt demonstrates an intolerable loss sensitivity and therefore acts assertively to preemptively prevent real and imaged losses, which are proxies for the lack of acknowledgement and approval. In others words it is as if the ego ideals of childhood have not sufficiently been replaced with the ego ideals of society.The Pt, seems unable to internalise conflicts, and has a tendency to externalise them. It is as if the Pt is part of a grand play where their life is full of dramatic action. Something is always happening, as if they are literally driven by a compulsion to deviate from the law, provoke a retaliatory response, and then play out the conquences of trangressing the law.Antisocial acts likely reflect a breakthrough of repressed aspects of the grandiose self. Behaviour in this context signifies the mobilization of normally repressed archaic grandiose-exhibitionistic needs or strivings. As a result, delinquent or antisocial acting out emerges in place of a secure sense of pride about ones accomplishments or abilities. The grandiosity of antisocial acting out likely signals a history of inadequate mirroring responsiveness in a selfobject environment that did not sufficiently affirm the Pts legitimate needs for admiration.As a result, Pt denies longing for an idealised other, fearing that the awareness of affectionate, admiring feelings would indicate weakness or vulnerability. Moreover, the Pts yearnings for acknowledgement andapproval are also defended out of fear of traumatic disillusionment should approving others let them down. Consequently, the heightened grandiosity represented defensive self-protection from the disappointment and ensuing depression associated with the risk of devitalization.From childhood factors identified by Pt, it appears normal development of grandiose—exhibitionistic self, dominated as it is by archaic omnipotence, was poorly attended to by caregivers such that the modulation of the Pts boundless power and greatness has been arrested. With mirroring needs unmet, Pts development of healthy greatness was perceived to be unwelcome and unappreciated. As a result, rather than being tempered, the Pts unbounded narcissistic or grandiose
exhibitionistic displays persist in an archaic form, apparently unresponsive to caregiver or environmental constraints.I should consider their developmental process further compromised by the underlying neurobiological anomalies that give rise to defective learning, impaired empathic capacity, and socialization deficits.

TREATMENT GOALS

1. restimulate concealed longings to admire a powerful other.
2. accept rather than challenge Pts overt grandiose sense of omnipotence.
3. Demonstrate increased sensitivity to the needs of others.
4. Improve impulse control and reduce reckless, shortsighted behavior.
5. Decrease excessive anger and irritability while learning to handle everyday anger appropriately.
6. Learn to view affection and cooperation positively.
7. Exhibit interpersonally responsible conduct.
8. Accept that ordinary rules of law and conduct apply to everyone.

ACTION

Using a modified CBT framework, I supported Pt to challenge cognitions that reinforce:[checkbox value="Justification - wanting something or wanting to avoid something justifies my actions.|Thinking is believing - My thoughts and feelings are completely accurate, simply because they occur to me.|Personal infallibility - I always make good choices.|Feelings make facts - I know I am right, because I feel right in what I do.|The impotence of others - The views of others are irrelevant to my decisions, unless they directly control my immediate consequences.|Low impact consequences - Undesirable consequences will not occur or will not matter to me.|Pts ruminations around persecution and mistreatment at the hands of others|People are malevolent and deceptive|people will attack if they get the chance|you can only be ok if you are on guard|people should be universally benevolent and trustworthy|attachment makes you vulnerable|I may not notice when others are trying to take advantage of me|power equates with exploitation|mistreatment deserves retaliation|sensitivity is weakness|I have no needs for admiration|fault must be attributed to someone"][/conditional]
[comment memo="Schizoid Personality"]
[checkbox name="Schi" value="Pt presents as retiring, undemonstrative, and interpersonally aloof. In particular, the Pt"][conditional field="Schi" condition="(Schi).is('Pt presents as retiring, undemonstrative, and interpersonally aloof. In particular, the Pt')"] [checkbox value="neither desires nor enjoys close relationships, including being part of a family|almost always chooses solitary activities|has little, if any, interest in having sexual experiences with another person|takes pleasure in few, if any, activities, most especially group or social activities|lacks close friends or confidants other than first-degree relatives|appears indifferent to the praise or criticism of others|shows emotional coldness, detachment, or flattened affectivity"]

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Detached personality traits underlie the Pts clinical concern. Pt is ambivalent about their needs for acknowledgement and approval, and finds interpersonal connection aversive. It is likely the Pt longs for deep intimate connections with others, yet avoids the experiences due to fears of engulfment or risk of emotional pain.Although the Pt is devitalised by a lack of approval and acknowledgement, social distancing due to engulfment concerns precludes this. In other words, Pt has a profound wariness of attachment figures and responsive others, which perpeturates unmet needs for admiration and approval. Pt further demonstrates profound reluctance to acknowledge and approve of others, which appears as a struggle to generate enthusiasm for the lives of others, which further serves to isolate. Without acknowledgement and approval Pt has become profoundly devitalised as their own ambitions have been submerged.Pt lacks the vitality that often comes from having burning desires or feeling passionate about interests. Pt often experiences chronic boredom, and they feels as if they are drifting through life without purpose or direction. A sense of buoyancy is replaced by a feeling of depletion and psychological invisibility.Pt has a tendency towards chronic withdrawal from unresponsive other, acquiring as a result an aloof, precocious self-sufficiency that has become a predominant reaction to empathic unresponsiveness. Detachment and affective constriction have become a self-protective defense operation.An internal capacity to regulate intense affect states seemingly has not developed because an internal structure has not been not formed. For the Pt, however, a lack of responsive others risks leading in a more ominous direction - believing that anything they might do would lead nowhere - there is a psychological disappearingy of sort, into a type of existence where feeling unimportant or unrecognized is normalised.Pt is unable, and perhaps fearful, of evoking a psychologically alive social environment and, as a result, experiences life as profoundly disengaged from others. Expecting little from the world, the Pt has retreated entirely into themself to gratify needs. The isolation serves to protect the Pt from threats to self-cohesion offered by a world that has come to feel unrewarding in its neglect of and unresponsiveness to normal mirroring needs.

TREATMENT GOALS

1. Enhance experience of pleasure in activities and-or relationships.
2. Increase activity level.
3. Reduce social withdrawal.
4. Increase interest in and performance of sexual activity.
5. Increase emotionality, including the experience and expression of feelings.
6. Improve interpersonal skills, such as conversational behavior and empathy skills, thereby decreasing social isolation.
7. Bring clarity to vague cognitions.
8. Decrease apathy by increasing level of energy and enthusiasm.
9. Increase ability to have warm, intimate, personal relationships.

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value="social interactions are difficult or damaging|isolation is healing|intimacy is abnormal|solitude is emotionally safe|people are cruel|I am different|I am a loner|I am an oddity|I am a misfit|Im half a person|I have an ugly personality|Im not normal|I am worthless|I am boring and dull|I am nothing|People are unfulfilling|others dont like me|the world is hostile|if I try and befriend others they will notice I am different and ridicule me|if I speak to others they will notice how dull I am and will reject and taunt me|if people dont fit in, they will not be welcome and cannot have friends|people should only talk if there is something to say|if I try and talk to others, there will be nothing to say and no point in this communication|people should only talk if there is something to say|if people see I am anxious, they will consider me weak|if I aggravate people, then they will hurt me."][/conditional]
[comment memo="Schizotypal Personality"]
[checkbox name="Schizotypa" value="Pt presents as socially idiosyncratic with pronounced eccentricities of character. In particular, the Pt"][conditional field="Schizotypa" condition="(Schizotypa).is('Pt presents as socially idiosyncratic with pronounced eccentricities of character. In particular, the Pt')"] [checkbox value="has a persistent pattern of intense discomfort with and decreased capacity for close relationships|has cognitive or perceptual distortions and eccentricities of behaviour|has unusual ideas of reference|lives in accordance with odd beliefs or magical thinking|reports unusual perceptional experiences|has an odd style of thought and speech|has suspicions or paranoid thoughts|demonstrates incongruous or limited affect|has an odd, eccentric, set of behaviours|demonstrates odd and unusual manner of dressing|has a lack of close friends or confidants|has excessive social anxiety that does not lessen with familiarity|Pt presents with autistic defenses, but is not ASD"]

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Pt presents with schizotypal personality concerns leading to ambivalence around wanting to create intrigue and social interest, yet keeping a safe distance from others. This overideational form of the personality type is characterized by an enormous wealth of fantasy, obsessive ideation, obsessions and a preoccupation with themselves and the body.Existing in an affectively barren mileu, with nowhere to turn to relieve a devitalized affectively barren existence, Pt compensates with schizotypal defenses. In other words, Pt wants, yet is ambivalent about needs for acknowledgement and recognition, combined with a need for interpersonal distance.Detachment from others and alienation from self are principal features of this Pts life overall. Notable are - deficient social behaviours - a lack of social competence similar to ASD, and social intelligence derivable from and contributing to deficits in interpersonal interest and feelings of social unworthiness. Moreover, being unable to orient thoughts logically - as the Pt lacks touch with others and is unable to order ideas in terms relevant to reciprocal social communications. Depersonalization anxiety - feeling oneself to be insubstantial, foreign and disembodied, detached and uninvolved observers of the passing scene, looking from the outside in. Pt presents with impoverished affect - a blandness of mood, listlessness and lack of spontaneity, a lack of ambition and interest in life activities.There is an underlying fear of attacking, humiliating control - such that the wish is that others will leave the Pt alone. The Pts baseline position is one of hostile withdrawal and selfneglect. The Pt believes in a capacity for magical influence that can be implemented directly through telepathy or indirectly via control through ritual. The Pt imposes these apparent powers from a distance. Although the Pt is aware of aggressive feelings, usually restrains them.The Pt elects to live separately, rejecting the rest of the world. As the withdrawal has been relatively complete over a long period of time, the Pt seems to have lost touch with social norms, and developed their own rules for personal hygiene, dressing, and social stereotypes.

TREATMENT GOALS

1. Bring clarity to vague cognitions.
2. Reduce odd, magical thinking and feelings of depersonalization.
3. Enhance experience of pleasure in activities and-or relationships.
4. Improve interpersonal skills, such as conversational behavior and empathy skills, thereby decreasing social isolation.
5. Increase emotionality, including the experience and expression of feelings.
6. Reduce fears and ruminations regarding rejection and humiliation or suspiciousness of others motives.
7. careful husbanding of the scarce pleasure capacity.
8. shift the burden of adaptive tasks to others despite ambivalent overdependency.
9. the adequacy with which nonemotional thoughts can replace limited pleasurable feelings.

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce: [checkbox value="I am different|I am worthless|I am uninteresting|I am abnormal|other people are cruel|other people are dangerous|other people cant be trusted|the world is unfriendly|if I try and befriend others, then they will reject me or hurt me|if I am very different, then other people will notice me|if I have unusual experiences, then I can be important|if I can be interesting, then I will not be alone|if people see how odd I am, then they will be interested|if I let people see I am upset, then they will hurt me”][/conditional]
[comment memo="Avoidant Personality"]
[checkbox name="Avoi" value="Pt presents as socially avoidant with preoccupations around social ridicule, social shame and public exposure. In particular, the Pt"][conditional field="Avoi" condition="(Avoi).is('Pt presents as socially avoidant with preoccupations around social ridicule, social shame and public exposure. In particular, the Pt')"] [checkbox value="avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection|is unwilling to get involved with people unless certain of being liked|shows restraint within intimate relationships because of the fear of being shamed or ridiculed|is preoccupied with being criticized or rejected in social situations|is inhibited in new interpersonal situations because of feelings of inadequacy|views self as socially inept, personally unappealing, or inferior to others|is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing"]

SUBJECTIVE REPORT

[textarea cols=80 rows=15 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

Pt is unable or unwilling to turn to responsive others in expectation of being admired and acknowledged, anticipating derision or chronic empathic failures because they cannot count on the assurance of reponsive others. Thus, social avoidance may represent not so much anxious withdrawal as it does a self-protective turning inward to the safety of isolation as a place to assuage the injuries to self-esteem that lead to a devitalized self.Without resorting to schizoid defenses, the Pts response to deficient acknowledge, approval and recongition, is not found by isolating themselves from responsive others, rather, they instead maintain the expectation that acknowledgement and approval might be possible, but they cautiously insulate themselves from the painful rejection of empathic failure by keeping an affective distance in the same manner as one might expect with a preoccupied attachment style. Put differently, although hesitant to approach responsive others out of fear that occasional indications of acknowledgement and aproval may be untrustworthy, the Pt remains vigilantly engaged with attachment figures and responsive others. Although distanced, Pt seems more comfortable watchfully waiting for signs, not so much that the coast is clear but rather that responsive others will be empathically responsive to their recognition needs.As a result, Pt tends to vacillate between positions of attachment longings and the self-protective distance of an unrecognised and approvable self. Pts hypersensitivity to social rejection is better comprehended as a hypersensitivity to approval and acknowledgement failures.

TREATMENT GOALS

1. Reduce social withdrawal and loneliness due to social anxiety.
2. Improve conversational behaviors and other interpersonal skills, thereby decreasing social isolation.
3. Improve self-esteem and reduce self-criticism.
4. Increase active focus on pleasurable, values-oriented stimuli and decrease focus on painful stimuli.
5. Increase willingness to take risks in interpersonal contexts.
6. Reduce fears and ruminations regarding rejection and humiliation.
7. Improve intimacy in relationships.

ACTION

Using a modified CBT framework, I supported Pt to challenge unhelpful cognitions that reinforce:[checkbox value="Im unlovable and unworthy|If I hide my true self I may appear more acceptable to others|If I show my true self I will be rejected|If I keep a lid on my emotions Ill be ok|If I feel bad I wont be able to tolerate it|I dont have anything to say|Im defective|Im unlikable|Im different|I dont fit in|other dont like me|others reject me|If Im treated bad I must be bad||Im pathetic|deceiving others about my true self protects me|If anyone judges me negatively it must be true|being evaluated by others is risky|if others really knew me, they wouldnt like me"][/conditional]
PRESENTING CONCERNS

Dependent Personality

Hypomanic Personality

Histrionic Personality

Compulsive Personality

Ambivalent Personality

Negativistic Personality

Narcisisstic Personality

Paranoid Personality

Antisocial Personality

Schizoid Personality

Schizotypal Personality

Avoidant Personality

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.93, 388 form elements, 2 boilerplate words, 12 text boxes, 12 text areas, 328 checkboxes, 12 drop downs, 12 comments, 12 conditionals, 2474 total clicks
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