Planned care assessment summary

20 May 2015
Miss Shona-Leigh Wardell

18/10/1992

DATE AND TIME

12/05/2015
Referral source reason
Referred by her GP in April of this year requesting assessments regarding
possible assessment and diagnosis of bipolar and query starting
lamotrigine. She had explained to her GP she was previously known to
services and explained Bipolar Affective Disorder was being looked at as a
possible diagnosis. She explained she was due to start Lamotrigine but
failed to attend several appointments and was subsequently discharged
from the Community Mental Health Treatment Team and has asked us to
re-assess this.
Mental state at interview
Shona was a 22-year-old lady. She was dressed casually but had evidence
of good self hygiene. She had pale blue hair and facial piercing. She had
sat calmly throughout the assessment until the end where she became
upset and angry at being told we would not be prescribing medication
today. At this point she stood up and stormed out of the room and stated
I am never coming back here again. Throughout the review I was able to
form reasonable rapport. She was able to answer all questions during
assessment. She feels her moods are up and down. Objectively her
mood was Euthymic and reactive. There was no evidence of formal
thought disorder. There was no evidence of flight of ideas. Her thoughts
where surrounding her worries of how people perceived her, and fears of
abandonment. Her thoughts where also towards her diagnosis. She feels
she has Bipolar Affective Disorder and states that during her previous
involvement with services she was due to start mood stabilizers. She
states fleeting suicidal ideation, but denies plans or intent. She disclosed
recent self harm (11/05/2015) following a bad day at work, prior to this
previous self harm was 7 months ago. She denies thoughts to harm
others. There was no evidence of perceptual abnormalities. Although not
formally assessed, her cognition was grossly intact. She has partial insight
to her mood instability, feeling that this is due to a diagnosis of Bipolar
Affective Disorder. She thinks she should be on medication, and lacks
insight in to the appropriateness of psychological therapies indicated at
this point in time (DPT).
Assessment summary
Shona is a 22-year-old lady, in full time work, who describes being
depressed and having difficulty managing her mood over the past few
years, she feels she meets the criteria for Bipolar Affective Disorder, due
to her up and down mood. Shona states she gets episodic fluctuations in

her mood and activity level, of which these problems have fairly been
longstanding, originating at an early age, against the context of trauma in
formative years leading to loss of self, self esteem and a pervasive sense
of abandonment.
Biological predisposing factors include family history of depression in
mother and father, along with previous heavy substance misuse by her
mother. Psychologically she highlights a turbulent childhood, in that her
mother used alcohol and drugs when she was young, subsequently she
felt unloved. Her mother and father split before she was born and she
states there was periods of time she was neglected as there were many
alcohol and drug fuelled parties in her mothers house in which she was
unable to sleep and felt scared of strangers being there. She has history of
sexual abuse from a female friends daughter of her mothers when she
was 10, which lasted several months.
She has had difficulty forming and maintaining relationships, feels
paranoid that others are being nasty to her. She describes an overriding
concern that others are ready to abandon her for something she has done,
and worries constantly about this. She finds that because of this she is
often angry towards friends and partners when she feels the relationship
may be ending, having great difficulty trusting people. She had recently
broken off her long term relationship, with her boyfriend 3 months ago,
due to issues highlighted above, which has caused ongoing stress for the
last few months, as she reflected that she had made a mistake. However,
1 week ago she has restarted this relationship with her boyfriend, who she
perceives as a good source of support and protective factor.
She has previously used self-harm (cuts to her legs and arms) as a form of
release from her inner tension and frustration with other people and
herself. Her most recent was 11/05/2015, where she felt overwhelmed
with worries that her boss might let her go (although there is no evidence
of this). There is history or non-lethal overdoses since age of 19, however
no further suicidal acts since 2012. She now feels her younger brother is a
major protective factor, and although she has fleeting suicide ideation,
she has no plans or intent. She reflects that her previous suicidality was
highly influenced by her concurrent use of illicit substances, which she has
not used for a few months now. Another protective factor is her reduced
alcohol consumption. She notes that around 1 month ago her alcohol use
increased, drinking up to a bottle of wine a night for a 2-week period. She
reflected that this has lowered her mood so she has taken positive steps
to stop drinking to this level. She now drinks around 2 pints of beer at the
weekend socially after work.
Other ongoing stressors highlighted were moving in with her boyfriend
and his friends in August 2014. She has found the atmosphere in the
house very lonely and states for the first few months of moving in, her
self-harm started again. She has however stated that for the last 7
months46t2qww39 she has been able to refrain from self-harm (until last

night 11/05/15). Since moving in to the house she has run up a debt of
around 1450, for council tax and water bills.
Diagnosis
Following assessment today Shona, describes symptoms that have been
well documented in her past which she has agreed to previously. She
demonstrated her relationships can be fragile and un enduring; there is a
great deal of impulsivity, low frustration threshold leading to reduced
distress tolerance, and explosive behaviour. She explained she feels bad
and rejected, with constant worries that people will leave her, spending
large amount of time worrying about this and hence trying to please
people.
There have been times in the past, where Shona may have met criteria for
depressive episode and evidence to show she has improved with anti
depressants, however since around 2009, has remained off
antidepressants and had no reoccurrence of major depressive episodes.
She reused them in 2013. She has previously presented with long history
of self-harm, and she highlights two previously impulsive overdoses, which
she feels were fuelled by her concurrent substance use (please note notes
suggest 3 previous overdoses). Although she presents with subjective
perception of elevated mood, no clear evidence to support this from
todays assessment. On assessment today, no clinical evidence for
affective disorder seen. With her previously well documented history of
behaviour and evidence gained from todays assessment, Shona meets
the criteria for Emotionally Unstable Personality Disorder.
Initial care plan
1. Shona has been offered DBT as recommended via NICE guidelines.
However Shona declined this as she does not want to participate in
group work.
2. CMHT will refer to Primary Care Psychology.
3. Attempted to provide Shona with Crisis Team numbers however
Shona explained that she disliked the Crisis Team, she was informed
that the Crisis Team in this area, is different from her last area, and
so her experiences may be different this time. She still declined. She
left the room prior to crisis numbers or helpline numbers being
provided. We will write to Shona, providing Crisis team numbers and
Mollineus center number.
4. Discharge from CMHT.