DBT Note

The approach for treatment for this patient is principle-driven. Specific details:
[checkbox name="T: Emotion-oriented approaches, such as supportive psychotherapy, reminiscence therapy, and validation therapy to enhance emotional well-being,reduce behavioral symptoms and promote everyday functioning " value=" DBT to learn new skills to address behaviors and emotions that have been identified as causing problems in life. Use of person centered therapy approaches including providing unconditional positive regard, empathetic understanding, and genuineness|Cognitive Behavioral Therapy for the exploration of patterns of certain thoughts, feelings and behaviors.Use of person centered therapy approaches including providing unconditional positive regard, empathetic understanding, and genuineness|Cognitive processing Theory that will help client to learn how to modify and challenge unhelpful beliefs related to the trauma; Cognitive Theory to assist client with modifying the pessimistic evaluations and memories of trauma, with the goal of interrupting the disturbing behavioral and/or thought patterns that have been interfering in daily life."]
History of Present Illness/Interval History
[select name="variable_1" value="Symptoms of anxiety continue but less frequent and less severe as previously described|Symptoms of depression continue but less frequent and less severe as previously described|Symptoms of both anxiety and depression continue as severe as previously described"]

Client report of recent symptoms/behaviors
[select name="variable_1" value="None|X|XX"]

Patient mainly spoke about[checkbox value="interpersonal conflict with family|interpersonal conflict with significant other|occupational stress|[checkbox value="loss of independence|adjustment difficulties"][checkbox value="interpersonal conflict|self-esteem|parenting|health|housing|mood|family|work|grief&loss|legal|relationship"] 
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"].
Suicide Risk Factors
The patient was screened for the following risk factors:
[checkbox name="variable_1" value="prior attempt|current attempt|history of medically serious attempt|recent psychiatric hospital discharge|recent loss (particularly interpersonal or fall in social status)| currently diagnosed with Major Depression|currently diminished concentration or indecision (Cognitive Impairment)| current sleep problems|currently experiencing hopelessness|currently experiencing panic or significant anxiety|psychotic symptoms or underlying thought disorder or loss of rational thought (i.e., dementia)|currently diagnosed with Borderline Personality Disorder|current ETOH or drug use|history of impulsivity|intense level of agitation|actively making death arrangements (updated will, suicide note, recently purchase life insurance, giving away possessions, etc.)| lethal methods available or easily obtained|likely to be alone, currently socially isolated| family member committed suicide|history of childhood sexual abuse|unemployed| financial strain| and physical illness."]

The following risk factors for suicide/self-harm exist for this patient
[textarea name="variable_1" default="Prior attempt
 Current attempt
 History of medically serious attempt
 Recent psychiatric hospital discharge
 Recent Loss (particularly interpersonal or fall in social status)
 Currently diagnosed with Major Depression
 Currently diminished concentration or indecision [Cognitive Impairment]
 Current sleep problems
 Currently experiencing hopelessness
 Currently experiencing panic or significant anxiety
 Psychotic symptoms or underlying thought disorder or loss of rational thought (i.e. dementia)
 Currently diagnosed with Borderline Personality Disorder
 Current ETOH or drug use
 History of impulsivity
 Intense level of agitation
 Actively making death arrangements (updated will, suicide note, recently purchased life insurance, giving away possessions, etc)
 Lethal methods available or easily obtained
 Likely to be alone; currently socially isolated
 Family member committed suicide
 History of childhood sexual abuse
 Unemployed
 Financial Strain
 Physical illness

Suicide Protective Factors
[textarea name="variable_1" default="Taking steps to engage in treatment,Hopeful that current treatment direction will be effective"]
Actively making future plans
Verbalizes hope for the future
Displays self-efficacy in problem area
Shows attachment to life
Has responsibilities to kids, family, others
Embedded in protective social network/family
Attached to therapy and at least one therapist
Belief that suicide is immoral or will be punished (is religious, particularly Catholic)
Hopeful that current treatment direction will be effective
Taking steps to engage in treatment

Addressing Imminent Risk
[textarea name="variable_1" default="sample text"]
Addressing Diagnoses
[textarea name="variable_1" default="sample text"]

Clinical Global Impressions
[checkbox name="variable_1" value="this patient's condition is minimally 
improved since the initiation of treatment.|this patient's condition has not changed|Minimally worse"]

[textarea name="variable_1" default="sample text"]


Interventions Utilized
[checkbox name:"Variable4" value="Actively listened to client discuss current stressors, symptoms, and general functioning|Psychoeducation on nature of depression, characteristic symptoms, diet, sleep, self-esteem, self-image and physical exercise|Psychoeducation on nature of anxiety and panic symptoms, the role of avoidance, and the rationale for various interventions, particularly exposure therapy approaches|CBT Interventions used for the exploration of patterns of certain thoughts, feelings and behaviors|Led client in Relaxation Techniques|Led client in Mindfulness Activity|skills training"] [checkbox value="Assessed and monitored the clients suicide potential| / [checkbox value="Validated distress and difficulties as understandable given circumstances, thoughts and feelings|++|+++"]
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 - 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|manipulative|argumentative"][checkbox value="+|++|+++"]
Mood reported & affect observed: [checkbox value="euthymic|tearful|labile affect|restricted affect|blunted affect|flat affect|dysphoric|anxious|angry |apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric|neutral"][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"]
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="+|++|+++"]

Homework
[checkbox name="variable_1" value="option A|option B|option C"]

PLAN

Focus of next session: [textarea default=""]

Mental Status Examination:
General: [select name="variable_2" value="alert and oriented in all spheres|obtunded|disoriented"].
Appearance: [select name="variable_3" value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"].
Behavior - general: [select name="variable_4" value="in no acute distress|in acute psychological distress"].
Behavior - stability: [select name="variable_5" value="calm|agitated"].
Behavior - interactivity: [select name="variable_6" value="warm with comments and behavior|interactive|withdrawn"].
Behavior - eye contact: [select name="variable_7" value="eye contact good|eye contact fair|eye contact avoidant"].
Mood/Affect - stated: [select name="variable_8" value="normal|upbeat|euthymic|depressed"].
Mood/Affect - emotional range: [select name="variable_9" value="normal|broad|restricted"].
Mood/Affect - intensity: [select name="variable_10" value="normal|expansive|blunted|flat"].
Mood/Affect - congruence: [select name="variable_11" value="mood is congruent with affect|mood and affect are not congruent"].
Thought form and content: [select name="variable_12" value="normal|future oriented|logical, linear and goal-oriented|past oriented and somber|goal directed|scattered|hopeful|remorseful|enthusiastic|resigned"]
Attention: [select name="variable_13" value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"].
Perception - insight: [select name="variable_14" value="normal insight|poor insight"]
Perception - general: [select name="variable_15" value=normal|normal - denied any preoccupations, obsessions, delusions, hallucinations or perceptual disturbances"]
Cognition/Memory: [select name="variable_16" value="normal|grossly intact|below average|above average"].
Cognition/Memory - abstraction: [select name="variable_17" value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
Judgment: [select name="variable_18" value="normal|poor|good"].
Suicide/Assault: [select name="variable_19" value="no current or past ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"].
Patient is currently assessed to be at [select name="variable_20" value="low|moderate|high"] risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.

Signature 
[text name="variable_1" default="sample text"]