Professional Documents
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2014 PSYCH Case Report
2014 PSYCH Case Report
2014 PSYCH Case Report
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 1
We will now consider each section in turn with examples. For each example, and for your own report,
consider the following:
Is is clear and understandable?
Is it well-organized?
Is the information contained in it relevant to the section heading it is under?
Is the information complete for its purpose?
What works and does not work?
It is recommended that you first write out the information, note word count, and then revise to look for
efficient ways to present the information and avoid redundancies. It is ok to refer the reader to
other sections of your report that provide more detail on a particular point.
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 2
1. CASE HISTORY
1.1 Introduction
This should be a brief, clear and concise opening that identifies the key issues of the case in a nutshell
(i.e. set the scene at the very beginning of your report, giving some idea of the nature of the illness; for
example, acute psychotic episode versus chronic illness exacerbation). Also include the circumstances
of your involvement as well as demographic information on the patient (de-identify the patient and
others involved using pseudonyms, and explicitly indicate that you have done so via a
footnote).
Framework
Name
Demographic information (gender / age / marital status/
cultural and-or language background)
Occupation
Presenting symptom(s) and duration without detail found in
HOPC
Referral details, if applicable
Admission status (eg. voluntary or involuntary)
Sources of case information (and quality of information if
relevant)
Point at which you assessed the patient
TIPS
Nutshell
description of
patient
Present the central
problem facing the
patient eg. type
of episode
Example 1:
Julie, a 25-year-old single accountant, and a practising Jehovahs Witness, lives with her retired
parents. She was referred by her family doctor with an abrupt onset of psychotic symptoms. This
followed two weeks of lowered mood after the break-up of her first ever relationship, which was
with a co-worker who unexpectedly left to travel overseas.
(Bloch and Singh, 2007:90)
Example 2:
Lisa Nguyen* is a 17 year old, unmarried, unemployed female of Vietnamese origin. Lisa
migrated to Australia from Vietnam in 2006, and is currently studying year 11 at home through
distance education. She presented to the emergency department of a metropolitan hospital after
being referred by her general practitioner for depressed mood and increasing suicidal ideation.
Lisa was transferred from the emergency department to an inpatient child and adolescent unit where
she has been an involuntary patient for four weeks. Information for this report was gathered
th
through two interviews with Lisa during the 4 week of her admission along with patient notes,
observation of Lisa in groups, and discussion with treating physicians and nursing staff.
* Pseudonyms have been used to protect patient confidentiality.
Page 3
FRAMEWORK:
a. Discuss psychiatric symptoms:
Present a chronological narrative of the evolution of their symptoms for the current
episode. Start with when they began to feel unwell for the current episode describe
any triggering events or prodrome. When presenting associated relevant symptoms,
attempt to group symptoms together in your discussion so that depressive, psychotic and
anxiety related symptoms appear next to each other in your text. (ie. make connections
between the isolated symptoms that the patient may have revealed to you somewhat randomly
in their interview; this will help your writing to develop logical sequences). Comment on relevant
negative as well as positive symptoms (eg. patient admits topatient denies). Present
any relevant symptoms related to the differential diagnoses you will discuss later.
Present the patients description of their symptoms contrasted with the description by other
witnesses, if applicable.
b. Comment on the impact of the illness on the patients life:
work
social relationships
self-care
TIPS
In this section,
emphasize the
patients
description of
their symptoms
at the time.
Be descriptive,
but save analysis
for later sections
of the report
Include any
information you
want to discuss
later
Example 3:
The patient describes an eight-month history of anxiety symptoms, which began two months
after a car accident. She experiences apprehensiveness when out of her home, inability to cope
with anything out of the ordinary, initial insomnia and irritability, and she has withdrawn socially. More
recently she has had trouble concentrating on her work. Five days ago she was taken to her local GP
after experiencing a typical attack in the supermarket. She has become housebound since, ruminating
that Im terrified of suffering a heart attack and dying suddenly like my mother. She has begun
drinking up to a bottle of wine a day in an effort, she says, to calm myself down and make things
more bearable.
(Bloch and Singh, 2007:90)
Example 4:
Lisa experienced a prolonged prodrome of symptoms and events leading up to her current
presentation. During Year 10 (last year), Lisa experienced a progressively increasing social and
academic difficulty along with increasing depressive symptoms. She reports suffering bullying from
both her peers and teachers. She was called stupid and retarded and feels a marked sense of
injustice and maltreatment by her teachers. Lisa had very few friends, and admits to having
difficulty with social interaction. As the year progressed, Lisa became increasingly frustrated in class,
was prone to yelling at teachers and began opting out of group participation in all her classes. There
was a decline in her homework quality and amount handed in over time. She believed nothing could
help her, withdrew significantly from her few friends, and found it increasingly difficult to attend school.
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 4
Lisa was seen by three psychologists at school during Year 10. She shouted at the
psychologists during most of her first assessment, however, stated that she was not angry but
extremely anxious. Intellectual disability was suspected by her teachers, and testing was performed
using the Wechsler Intelligence Scale for Children Fourth Edition (WISC-IV). Results were
inconclusive; though Lisa scored below average in most sections, this may have been due to poor
English skills rather than cognitive deficits. However, Lisa did very well in perceptual reasoning. In
October of last year, Lisa punched a student who bullied her, and suffered her first panic attack. She
describes this as being an unexpected feeling of intense anxiety and distress associated with chest pain
and breathlessness. Lisa claims that this display of aggression was very uncharacteristic of her. She
deeply regretted it and attributes it to her extremely low mood at the time. At the conclusion of Year 10,
Lisa failed every subject except mathematics. She was recommended to repeat Year 10, but instead
opted to do Year 11 via distance education.
During distance education this year, Lisa has become increasing socially isolated, and has
struggled to teach herself core material, especially Physics and English. She states that her only hope
of passing these subjects is to get private tutors, which her family cannot afford. Lisas mother also
cannot afford taking time off to support Lisa due to financial difficulties. Lisa felt overwhelmed, and said
she was confused by her thoughts at times. Lisas depressive symptoms have also increased; her
general practitioner suggested antidepressant medication, which she declined as she did not think it
could help.
In terms of depressive symptoms, since the start of Year 10 Lisa has experienced
decreasing mood, and a moderate degree of anhedonia. She has also had initial middle
and terminal insomnia, with early morning wakening in the last two months, and regular
nightmares about study and her sister. Lisa has had chronic fatigue and exhaustion, a
paucity of concentration and short term memory, and frequent episodes of her mind going
blank, especially over the last 6 months. She has gained 10kg over the last 2 years, which
she attributes to studying more and exercising less. This year, she has had increasing
feelings of guilt and hopelessness with suicidal ideation over the last month. She states
suicide is her only option, and has plans to jump in front of a car. She has not written a
suicide note, and has only informed her general practitioner of these plans. The only self
harm reported is that she has started to bang her head into her wrists recently. Lisa denies
any diurnal variation of mood, psychomotor retardation or anorexia.
Lisa also displays symptoms of anxiety; she has had three panic attacks, though
she denies any persistent worry of having another attack or change in behaviour between
the attacks. She has also had 12 months of irritability, and more recent muscle tension,
though she denies restlessness. Lisa has also had substantial somatic symptoms. She
has reported generalised pains (at times specifically in her chest and abdomen), and limb
clumsiness at all times; no physical cause was found for these complaints. Lisa denies ever
experiencing psychotic symptoms such as visual and auditory hallucinations and delusions.
She also denies ever experiencing manic symptoms such as elevated mood, uninhibited
behaviour, thoughts racing, impulsiveness and elevated energy levels.
QUESTIONS
1. How is clinical
reasoning made
evident?
2. What makes this
section easily
readable?
Lisa was referred to the emergency department by her general practitioner in mid-March of this
year. She was then transferred from the emergency department to an inpatient child and adolescent
unit where she has been an involuntary patient for 4 weeks. Two weeks ago, Lisa was started on 75mg
of Venlafaxine daily which has just been increased to 150mg daily. After starting the medication she
experienced dizziness which subsided rapidly. Her depressive symptoms have improved dramatically
though she still experiences some insomnia and occasional irritability, low mood, and feelings of guilt.
In addition, she no longer has any suicidal ideation. She does not want to be discharged, not even into
a day program or community service. She fears that she will get much worse if she leaves, and feels
worse when she goes home from the unit on leave. Initially, she would not attend group activities in the
unit, but now often enjoys them. However, she still gets very irritable and tearful when changes or long
term solutions are discussed, such as a transition program. She feels helpless when asked to make
decisions regarding her future.
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 5
Example 5:
KD first began using heroin in 1990, he claims initially as a social habit which quickly became his
preferred means of escaping stress. By 1998, he was using it up to three times a week while still able
to function and hold a full-time job. He denies a history of depressive, anxious or psychotic symptoms
prior to the death of his son in 1998 (social aspects of this event are described in Developmental
History).
Following the death of his son in September 1998, he experienced severe guilt and blamed himsefl
for not taking adequate care of him while under the influence of heroin. He also experienced
insomnia, anhedonia, and depressed mood, with an inability to cope with day-to-day tasks. This
culminated in a suicide attempt by overdose when he was barred from attending his sons funeral by
his then wife. He had an epileptic fit following the overdose and was admitted to hospital, but left four
days later AMA. He does not recall medical or psychological treatment at the time.
In the years that followed, he experienced daily nightmares in which the accident would replay in his
mind, and had panic attacks whenever he was reminded by cues such as screeching tyres, etc, and
avoided visiting the place of the accident.
In 2000, when his wife officially divorced him, he became despondent and again attempted suicide by
heroin overdose and was admitted and diagnosed with PTSD and Antisocial Personality Disorder
(see Developmental History for a description of other personality traits) as well as Reactive Disorder.
This prompted an ultimatum from his two remaining children to clean up his act. This initiated the
successful completion of a 12-month residential rehabiltation program, and he has since been able to
abstain from heroin use.
Example 6:
Prior to the current admission, Lisa has had no previous psychiatric admissions, diagnoses or
treatment. She has not attempted suicide previously though she reports having suicidal ideation
during her childhood around the age of 10. Lisa had depressive symptoms during that period; similar
to but less severe than her current episode. She is unsure if there were any stressors or precipitating
factors for this episode and does not know how long it lasted. During the interval between episodes
Lisa has been able to function quite well. She was able to keep up with school work and participated
in extracurricular activities, though she made few friends.
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 6
Forensic History
Example 8:
John lost his license due to driving under the influence of alcohol for 6 months in 2006, and has had
several drunk and disorderly charges brought against him.
Emphasize medical conditions in the patients history that may bear some
relationship to the psychiatric presentation (and avoid expanding your discussion of
medical details that are irrelevant to the psychiatric presentation), for example:
o thyrotoxicosis anxiety
o hypothyroidism depression
TIP
Include a list of all medications (including dosage and schedule) taken by the patient prior
to admission, as well as any allergies. This can be in table form if you wish. You may wish to
list current psychiatric medications with the past psychiatric history and medications for other
chronic conditions in past medical history, or use one table for all. Any compliance issues or
problems with medications should be discussed. Also include any over-the-counter
medications used regularly or alternative therapies.
relationship between
medical conditions and
psychiatric symptoms, and
b. can appreciate the
complexity of medical
problems that might be
exacerbated by psychiatric
conditions.
Example 9:
Two years ago Tom was diagnosed by his GP with leg ulcers due to peripheral vascular disease,
exacerbated by the fact that he was sleeping upright in an armchair. This habit began after his wife
left him, as he could not bear to sleep in the bedroom because of the memories. He also found that
the only thing that could get his mind off ruminating about the separation was to watch old movies on
the ABC at night during this time he would doze off and manage to get some sleep. The problem of
his leg unlcers and infective cellulitis has deteriorated over the two years and he now has decreased
sensation bilaterally in his lower legs as well as large weeping wounds on sloughy skin. He has been
admitted to hospital six times this year for exacerbations of this chronic condition.
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 7
TIP
Framework:
You must include a genogram (drawing of family tree). You may wish to indicate affected
individuals with different colours or cross-hatching. You need to include a key with your genogram,
particularly defining any non-standard symbols. Always indicate Ego on your genogram.
49 Depression/
Panic Attacks
Father 38
Depression?
Mother
38
Mick
(17)
Jenny
(13)
Micks parents divorced when he was 10 years old. His mother has been in a relationship since
2005. Though not formally diagnosed, Mick says that he thinks his father has depression. Micks
maternal uncle suffers from depression and has panic attacks. Mick reports that Jenny does not have
any depressive symptoms, and that his grandparents do not have any mental health issues.
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 8
The patient, the eldest in a family of three daughters, still lives at home. Her mother, a 45-year-old
primary-school teacher and her father, a 50-year-old electrician, are described as strict and intrusive, a
pattern she ascribes to their strong Catholic beliefs. Their marriage is described as over years ago;
they never talk or touch and the atmosphere at home as tense. The patient is close to her younger
sister in whom she confides. One sister has responded to a similarly distant relationship with both
parents by getting married after a whirlwind romance, the other by moving to another city.
Her mother was hospitalised with post-natal depression twenty years ago. There is no other family
history of psychiatric illness.
(Bloch and Singh, 2007:92)
Example 12:
Lisa was delivered at 40 weeks gestation; the pregnancy was uneventful. She
reached all milestones normally and was walking at 13 months. Lisa states
that she had social difficulties even during early childhood, for example she
could not understand jokes until she was 8 years old and always found the
classroom more comfortable than the playground. Lisa had very few friends
during childhood, was bullied and remembers it as an unhappy time. However,
her mother reports no early concerns about her interpersonal skills. Lisas
mother described her as an easygoing, obedient and honest child who enjoyed
childcare and particularly liked drawing. Lisa also reports that she has always
found change difficult even when she moved schools within Vietnam as a child.
QUESTION
What
information is
inappropriate
for this section?
Where would it
be better
placed?
Page 9
she usually leaves Lisa and Wendy alone for the weekends to visit him. This upsets Lisa a lot; her
main complaint with being at home is her sister. Lisa believes that if her sister was not living with her,
life would be improved greatly. The few friends she has made she describes as nerds and very
friendly. She does not confide in them when she feels upset and only engages in enjoyable activities
with them; it appears that she does not have any close interpersonal relationships. Lisa still struggles
with assimilating into the local culture.
Lisa values achieving a successful career above all other pursuits and therefore academic
failure is not an option for her. She says If I cant get a degree, how can I face the world; I would
rather be dead. Prior to her migration to Australia, she passed all years of schooling undertaken. Lisa
has never been employed.
Lisas menarche was at the age of 11. Her menstruation is very regular, occurring once a
month for 5 days with normal flow. She reports a significant decrease in her mood prior to each period
which she finds quite distressing. Since being in hospital, her menstruation has been delayed by a
week. Lisa has never had sex or been a relationship.
Lisa plays the piano, which she is very passionate about and has continued to play throughout
her illness. She practiced Tae Kwon Do for years, but withdrew recently due to academic stress and
financial difficulties. Lisa also enjoys drawing though she has not been drawing often in the last year.
Lisas family is Christian though she does not consider herself religious as she does not share any of
their religious beliefs. However, she goes to church with them.
Premorbid Personality and Coping Skills
Example 13:
Lisa describes herself as introverted, diligent, determined, organised, and inflexible. She has trouble
making friends; Lisa thinks that her main problem is she doesnt understand people. She has
particular difficulty in understanding peoples body language, tone and social cues. She tends to take
things literally and have concrete thinking. Lisa values diligence and hard work above all else.
Lisas main coping skills are focused on distraction with activities. When feeling down or anxious she
studies or switches to a different activity, often specifically playing piano. She has also tried deep
breathing exercises for anxiety but these did not alleviate her symptoms.
general appearance
rapport
behaviour
speech
mood
affect
o quality
o range
o appropriateness/ congruence
thought
o stream
o form
o content
perception
cognition (including MMSE)
judgement
insight
TIPS
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 10
Example 14:
Lisas mental state has improved significantly since her admission. Of note, her insight and mood have
improved, she is no longer a guarded historian and has no suicidal ideation or depersonalisation.
Detailed findings are as follows:
Current Mental State Examination (4 weeks after admission)
Appearance
Lisa is a tall young girl who looks her age. She is casually and neatly dressed in a
T-shirt, track pants and sneakers. She slouches in her chair.
Behaviour
She is a good historian, answering in complete sentences and going into detail on
all topics. Lisa is cooperative and maintains good eye contact. She displays no
evidence of psychomotor retardation or agitation.
Speech
Lisa speech is accented, with normal volume and rate. She speaks spontaneously
in a monotonous tone. Her English fluency is proficient enough to understand and
answer all questions asked though she often asks for clarification. No aphasia or
dysarthria is evident.
Mood
Lisa describes her mood as fine, not sad. She rates it as a 5 out of 10; 10 being
the most elevated.
Affect
Thought
Perception
Cognition
Lisas thought stream is normal and she has no formal thought disorder. She is
preoccupied with worry over the future especially discharge. Lisa also ruminates
over past negative experiences such as bullying. She has no suicidal ideation,
thought insertion/withdrawal, ideas of reference or any other delusions.
Lisa denies experiencing any hallucinations or illusions, and reports no other
perceptual abnormalities.
A Mini Mental State Examination (MMSE) was conducted. Lisa scored 29 out of 30;
she missed 1 point on recall. This is within the normal range. She reports poor
short term memory and concentration (though she was very proficient at subtracting
serial 7s, continuing for longer than required).
Frontal/executive function is normal. This was tested by asking Lisa to compare
objects (similarities and differences) and to draw a clock-face.
Insight
Judgment
Rapport
Lisa has moderate insight. She knows that she has depression and needs
treatment and understands the importance of compliance with medication but does
not fully understand the symptoms of depression and how it affects her.
Lisas judgement is good. This is evident through general conversation and her
sound reasoning through scenarios.
Lisa has good rapport, she was friendly and engaged. She even made jokes at
times though they appeared awkward; her intonation often made it unclear whether
she was joking without clarification.
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 11
General
appearance
Vital signs
Cardio
Vascular
Lungs
Abdomen
Neurological
all normal
heart rate 68 bpm
blood pressure 110/70 mmHg
respiratory rate 14 bpm
o
temperature 36.5 C.
Lisa was extensively investigated. Bloods tests such as full blood examination (FBE), urea and
electrolytes (U&E), renal function, liver function test (LFT), thyroid function test (TFT), urine toxicology,
and blood sugar levels (BSL), were conducted. All values were within normal limits. Imaging studies
such as MRI head and CT abdomen were unremarkable.
(Note: If you have already included investigation results in your History of Presenting Complaint when
describing treatment to date, no need to re-itemize here but refer the reader back to where you
discussed it.)
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 12
TIPS
1. The summary must draw on all areas in the
earlier parts of the report. Do not
For each differential diagnosis, present evidence from the earlier parts of the report
that serve to support/ discount the likelihood of the differential diagnosis. You
may wish to organize your information in prose (paragraphs) or as dot points. Draw links to
DSM diagnostic criteria.
A patient may have more than one co-morbidity or diagnosis on Axis I (eg. Alcohol Abuse and
Major Depression). Present the primary diagnosis and co-morbidity for the current presentation
first, then list differential diagnoses for the primary diagnosis.
Example16: Summary
KD is a 42 year-old married, recently unemployed man with a past history of IVDU and PTSD. He
presents with suicidal ideation as a result of recurrent intrusive flashbacks and nightmares,
representing an exacerbation of PTSD from when he witnessed his sons death. This has occurred in
the setting of a number of physical and psychosocial stressors such as suffering a stroke, the loss of
his home and business, and an inability to resuscitate a dying man. He has a history of an abusive and
emotionally deprived background. He also has an Antisocial Personality Disorder with limited
maladaptive coping mechanisms, and minimal social supports apart from his immediate family.
Page 13
Axis II
Obsessive Compulsive Personality traits:
o Although Lisa does not fully meet the criteria of obsessive-compulsive personality
disorder she does exhibit some emerging traits
She can become quite preoccupied with rules, order, organisation and
schedules
Lisa can be excessively devoted to work to the exclusion of all other
activities; when doing home school on most days she studies from 9am
10pm , with no breaks, eating while she studies
She can be quite rigid and stubborn (describes herself as inflexible)
o However, these traits may also be due to a pervasive development disorder
(specifically Aspergers Syndrome)
Possible Mental Retardation
o This is most likely mild due to her level of functioning
o Lisa was tested for intellectual disability by a school psychologist after concerns
from teachers due to her poor school performance
o Although she performed below average in many areas testing, results are
inconclusive as they may be due to her English skills
Axis III
None
Axis IV
Problems with primary support group: mother often absent and doesnt get along with sister
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 14
Axis V
55 on Childrens Global Assessment Scale [CGAS] - used instead of Global Assessment
of Functioning [GAF] for people under the age of 18
o Lisa has variable functioning with sporadic difficulties in several but not all social
areas (does have some friends and some normal parent interaction)
o These would be apparent to those who encounter her in a dysfunctional time or
setting but not in other settings
5. Risk Assessment
Your risk assessment must include the day of assessment, as the risk assessment changes over time.
Include your assessment of the patients risks of harm to self and/or others, risk of neglect of self and/or
others (including non-compliance), risk of absconding, risk of exploitation, risk of homelessness and
other safety risks. Although you may use a standardized form on your placement for risk assessment,
do not include the form with your report, although you may use it as a guide for sub-section headings.
Quantify each risk and provide evidence from earlier sections of the report as appropriate.
Example 18: Risk Assessment on day 2 of admission
Suicide: Lisa had suicidal ideation for a month before admission and had made plans.
Currently she denies suicidal ideation, her mood has improved and she no longer has
feelings of hopelessness so she is at low risk of suicide. She has made no previous
suicide attempts.
Self-Harm: At the present time, Lisa denies any thoughts of harming herself though
previously she has by banging her head into her wrists so she is at low risk.
Harm to others: Lisa does get quite irritable and annoyed at staff and occasionally raises
her voice though she has never harmed staff; her risk is low to moderate.
Risk of exploitation: Lisa has a moderate risk of exploitation as she seems quite trusting
of friendly people and as she has a lot of trouble understanding people she is unlikely to
be able to know their intentions and may be easily led.
Absconding: Lisa has no apparent risk of absconding because she likes being an
inpatient and feels safe and happiest when she is in the unit; she does not like going
home on leave and is always eager to return.
Financial: Lisa is at no apparent financial risk as she spends very little and as a teenager
is not given the means to spend large amounts.
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 15
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors
Attempt to define the psychological, biological and social forces that have contributed towards
the development of the above-mentioned factors in your discussion. You need to be able to draw on
relevant pieces of information from earlier parts of your report in your discussion and analysis.
You can also integrate evidence and concepts from the wider literature, although a literature review
is not the primary task of this report. This is where you need to demonstrate your understanding
of the patient and their problems by making links between the information you have presented.
Regardless of whether you include it or not in your final report (if you have word space), it is useful to
draw up a table as in example 19 for yourself to help you identify and classify all your information before
you write your final version. Remember that psychological evidence relates to the patients
thinking or view of themselves and the outside world, while social evidence relates to relationships,
interactions, and observed behaviour.
Example 19 (table):
Biological
Psychological
Social
Predisposing
Precipitating
Perpetuating
Protective
- Peak onset of
anorexia nervosa
is in
adolescence
- Menarche
- Desires to
remain little and
associates dirty
menstruation and
secondary sexual
characteristics
with weight gain
- Age of onset
associated with
better likelihood
of remission than
if Eve had
developed
anorexia nervosa
later in life
- Sleep
disturbance
- Pervasive fear of
failure,
particularly not
achieving a high
enough VCE
score for
admission to law
course
- Began dieting as
a New Years
resolution to gain
control over her
life and be like
the popular girls
- Losing weight
gives Eve a sense
of control, security
and
accomplishment
- Desire for
control over life
- Desire for
independence
from her family
- Controlling
mother
- Famiy
dysfunction
- Media promotes
a slender
physique
- An overweight
body is
- Parents had an
acrimonious divorce
when Eve was 5 yrs
old
- Absent and
idealised father
- Ambivalent
relationship with
controlling and
- Close
relationship with
paternal
grandmother and
school teachers
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 16
unaffectionate
mother
- Poor coping styles
exhibited by her role
models (mothers
nervous breakdowns,
substance abuse by
father, ascetic
maternal
grandmother)
- Poor social
integration and no
close relationships
with peers (feels like
an outsider and a
charity case in their
company)
considered as an
expression of
weak willpower
and laziness by
many subcultures
of Australian
society, including
Eves peer group
Example 20 (prose):
...
Predisposing Factors
In this case, KDs witnessing of his childs death was a significant enough event to signal his
unconscious to utilise defences and coping mechanism to deal with the stress. KDs personal history
and antisocial personality traits have resulted in him having a very limited range of maladaptive
coping techniques, which were inadequate to deal with the stress of the situation. His main method of
problem solving and dealing with conflict is through physical aggression and anger This was probably
adapted from his harsh adolescence living on the streets and amongst gangs, time spent in jail, and
also through modelling from his fathers own violence towards KD.
A most significant aspect of KDs life is the childhood trauma he suffered as a result of both his
mothers abandonment, and also his fathers physical and emotional abuse. According to Freud, it is
possible that the trauma of his sons death symbolically reactivated the previously quiescent,
unresolved psychological conflict of his childhood abuse. As a result it is postulated that the ego
relives, and thereby tries to master and reduce the anxiety associated with the earlier trauma (Sadock
& Sadock 2003: 1472-3).
Example 21
Leo has several factors which predispose him to schizophrenic psychosis. The primary biological factor,
given he has no reported family history, is being male. Males have a slightly higher prevalence of the
disease and slightly poorer prognosis.(3) Factors, likely psychosocial in nature, which also predispose
him to this condition are early loss of a parent(5), urban upbringing(3), and being born in winter(6).
The time period 15-20 years ago appears a number of times in his history. This may have been the
onset of his disease or more likely a crisis period where his disease worsened significantly. During this
period, Leos first son committed suicide, Leos house burned down and he was severely injured in the
blaze, Leo retired from the workforce, and Leos marriage broke down. Leos retirement is most likely
a result of this crisis rather than a precipitating factor, and similarly it is most reasonable to assume
the suicide of his son was a precipitating factor rather than a consequence of his disease. The fire was
allegedly due to electrical fault and thus could have been a traumatic precipitating factor, or it also
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 17
may have been set by him, though this makes it no less traumatic and it clearly still affects him in one
way or another. Finally the breakdown of his marriage is likely a consequence of his disease rather
than a precipitating factor, but were it to be true his wife did leave him for another man (or even
simply left as a result of the sons suicide) this could have been a precipitant to a crisis in his condition.
7. MANAGEMENT
On the basis of your formulation, you will need to outline an appropriate management plan, including:
a. further investigations and why they are indicated
b. immediate plans (during hospital stay)
c. short-term goals (post-discharge plans and interventions)
d. long-term goals (on-going plan)
e. consider appropriate medications, psychological therapies, other non-
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relationship needs to worked on especially in regards to jealousy and bullying issues. It is also
worthwhile to assess Wendy for depression as she has many of the same risk factors as Lisa and in
addition has a depressed sibling who she lives with, adding to her predisposition. Lisas counselling
must focus on explaining the need for discharge and the temporary nature of inpatient stay along with
the support she will receive after being discharged and that she will not be on her own as this
thought greatly distresses her when discharge has previously been brought up. Lisas history needs
to be examined to determine her early warning signs of relapse including irritability, insomnia and
anxiety. Lisa and her family need to be educated on detecting these signs and seeking help.
Mindfulness based Cognitive Behaviour Therapy would be of benefit for her to work on both
her obsessive-compulsive traits and to challenge any negative thoughts associated with her
depression. Acceptance and commitment therapy may also be of use to help Lisa manage her
feelings by increasing her psychological flexibility. Lisa has trouble initiating leisure activities and
tends to only study if left alone unless she has appointed scheduled activities to attend. Therefore a
schedule could be made to help her plan periods of leisure.
A day program, for a few weeks at the inpatient unit, can be considered to ease Lisas
transition. To aid her studies and encourage socialising Lisa could join a study group at a local
library. In addition, Lisa may be able to get financial assistance for private tutors or free tutoring
through one of the various community support groups catered towards adolescents. Lisa should be
encouraged to resume group social activities such as Tai Kwon Do and possibly additional activities in
her areas of interest such as a drawing class. Lisa may benefit from joining a local Vietnamese
cultural group as she could meet and learn from teenagers of her own culture who have adjusted well
to Australian culture. Community groups and online resources for teens who have suffered
depression may also be of use for Lisa.
Lisa is unsure whether her insomnia begun before or after her depression. If it does not
resolve with her depressive symptoms any sleep hygiene issues should be explored and advice
should be given. This issue along with her ongoing risk assessment and medication monitoring can
be managed by Lisas general practitioner. Lisas case manager should also be liaised with
especially in regards to referral to available community services.
DOs
DONTs
References:
Bloch, S., and B.S. Singh (2007). Foundations of Clinical Psychiatry (3rd Ed.). Melbourne: Melbourne
University Press. Especially, Chapter 16, available online via Voyager Catalogue:
http://images.lib.monash.edu.au/med1022/04118932.pdf
Psychiatry Year 4 MBBS 2012 Metro Student Guide, Monash University
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
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past
NOW
future
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
Page 20