Running head: PSYCHIATRIC CONSUMER ASSIGNMENT 1

Psychiatric Consumer Assignment

by

Isabella Flego-Peter

for

Scott Harris

Institution: CQUniversity Australia

18 December 2012
PSYCHIATRIC CONSUMER ASSIGNMENT 2

Contents
Part Two: Clinical Report...........................................................................................................3

Case History...............................................................................................................................3

Further Interview Inquiry...........................................................................................................4

Assessment of Dylan..................................................................................................................4

Trigger and Risk Factors............................................................................................................5

Treatment...................................................................................................................................7

Management Plan.......................................................................................................................7

References..................................................................................................................................9
PSYCHIATRIC CONSUMER ASSIGNMENT 3

Part Two: Clinical Report

Depression in adolescence and adulthood is a common phenomenon, affecting

approximately 20 per cent of these populations. Notably, depression is a significant public

health issue and is often linked with substantial suffering and functional impairment.

Particularly, adolescent-onset depression tends to be a malignant and an intractable condition,

increasing the probability of relapses and chronicity in later life. Indeed, depression

significantly lowers the quality of life for young people, escalates the risk of suicide, and

often exacerbates the outcomes of other physical or mental health problems. Clinical

presentations for numerous medical and psychiatric conditions, as well as individual reactions

to psychosocial stressors, however, can imitate or confound the diagnosis of depression in

teenagers (beyondblue, 2010). Accordingly, careful clinical assessment and differential

diagnosis are necessary. Moreover, effective treatments, both psychosocial and

pharmacological in nature are necessary alongside early detection and intervention. This

report presents a case review of Dylan Cholly, a teenager presenting with depression. The

current report offers an overview of Dylans symptoms, assessment, and clinical decision-

making strategies as well as offering suggestions for managing depression in the patient.

Case History

Dylan Cholly, aged 19 years, is referred to the General Practice Office by his G.P.

Dr John Alexander. His medical history reports good health and he has had no notable

illnesses since his childhood. Dylan, however, has been overweight from the age of three and

within the past six months, his GP notes significant weight loss (30kgs). Further, the medical

report shows that in the past, Dylan was referred to a private psychologist due to nightmares

occasioned by his witnessing his best friend being bullied. Conversely, Dylan is described as
PSYCHIATRIC CONSUMER ASSIGNMENT 4

a bright student and has excellent academic performance. Dylan is dressed in oversized

clothes that are totally black and is malodorous at the initial appointment. When directly

questioned, Dylan states that he feels fine and he doesnt understand why everyone is

stressing. Further, he denies any suicidal ideas although he says sometimes I wish I would

just go to sleep and not wake up. Dylans mother mentions that he spends most of his time in

his room, on his computer and has no real friends. In addition, Dylan has blacked out his

room and his mother reports that he has difficulty sleeping. When questioned about this

Dylan states he does not need anything since he can get all he wants from the Internet and

that he has friends who live far away. When asked about the future, Dylan says he really

does not want to do anything and he says ... I just dont care ... I feel really lost. Dylans

mother is worried especially since the family has a strong history of depression.

Further Interview Inquiry

To add to this history, with regard to Dylans recent behaviour, there is need to

interview him on any major changes in his life, his general feelings about his family, and the

society in which he lives. Further, it would be necessary to revisit the bullying incident to

establish how he felt, and his ongoing thoughts regarding the incident. Additionally, it would

be relevant to establish any changes and problems at school. Accordingly, it is necessary to

establish how the incident was handled at school, the psychological interventions offered by

the private psychologist and overall family environment. Other questions may also be needed

to establish any substance abuse, any other recent negative events, the reasons as to why

Dylan sought to go back to his old school, whether or not he is in a relationship and his

thoughts about it, and his views about himself as an individual.

Assessment of Dylan

According to the Diagnostic And Statistical Manual Of Mental Disorders IV, an

adolescent must present with five out of the nine identified characteristic symptoms most of
PSYCHIATRIC CONSUMER ASSIGNMENT 5

the time, for a minimum of two weeks for a diagnosis of major depressive disorder. Amongst

these, at least one of these symptoms should be either depressed or irritable mood or a

pervasive loss of pleasure or interest in activities that were once liked (Shiregps, 2005). In the

case of Dylan, physical examination shows a dull, uninterested teenager, who displays lack of

enthusiasm and motivation towards life in general. Other symptoms include anhedonia;

thoughts of death or suicide; decrease in appetite (resulting in weight loss); disrupted sleep

rhythms; and avoidance of family interactions and activities. Indeed, his general appearance

shows impairment in carrying out activities of daily living such as personal hygiene that may

be attributed to his general lack of enthusiasm to life.

Essentially, Dylan portrays three major challenges. First, Dylan portrays severe social

isolation and maladaptive social behaviour, evidenced by his keeping to his room and

inability to make real life friends. Particularly, Dylan has been unable to participate in

organised sport and is unable to have any social interactions, outside his school life. Even

though this behaviour has been characteristic of Dylan, it has greatly amplified over the past

six months and has been accompanied by sever weight loss. Second, Dylan exhibits chronic

low self-esteem, ineffective or inadequate coping skills alongside feelings of helplessness.

This is particularly evidenced by his relying on the Internet as a social support group and his

lack of motivation towards establishing friendships. Moreover, his mode of dressing reflects a

desperate need to become invisible in the social sense. Last, Dylan exhibits feelings of

hopelessness and expresses suicidal thoughts and feelings.

Trigger and Risk Factors

The vulnerability-stress model provides a sound basis for understanding depression and

its trigger factors. In reference to this model, adolescent depression arises from susceptibility

for depression, which is then activated or convoluted by environmental stress (Cook,

Peterson, & Sheldon, 2009). The precise nature of the disposition to depression may consist
PSYCHIATRIC CONSUMER ASSIGNMENT 6

of biologic and cognitive factors. This interaction between the stresses of life and cognitive

and biologic susceptibilities is often attributed to depression in an adolescent (Pelkonen,

Marttunen, Kaprio, Huurre & Aro, 2008). Accordingly, some of the identified risk factors for

depression include family history, loneliness and lack of social support, recent stressful life

experiences, and underlying medical conditions (Sheffield, Spence, Rapee, et. al 2006).

In the case of Dylan, depression associated symptoms may be associated with the

incident where he witnessed his friend being bullied. The incident aggravated his genetic

predisposition to depression as evidenced by the strong family history of depression. Notably,

the abnormal, behaviour started presenting about six months ago, when he asked to transfer

back to his old school. Indeed, this may have been occasioned by his inability to cope at the

new school; however, upon returning to his new school, Dylan found himself, revisiting the

bullying incident which augmented the stress levels. Moreover, Dylans upbringing also

contributes to this behaviour in that from an early age his mother did not encourage him to

participate in organised sport for fear that he would get hurt. As a result, his social skills were

severely underdeveloped. In addition, his father is always absent in the family.

From the case and interview, the identifiable risk factors in Dylans case may include

his evident lack of social skills, possible negative self-image arising from his being

overweight (evident in oversize clothing and completely black attire), dysfunctional home

environment and his obvious lack of control in negative situations. Additionally, other

suspected risk factors may be alcohol or substance abuse or other medical issues related to

being overweight. Subsequent, to the identification of these risks it is important to analyse

both the home and school environment in which Dylan lives to ascertain possible

interventions. Indeed, some of the management interventions in this case may be eradication

of the trigger factors and provision of a safe and secure environment by engaging

collaborative monitoring from the significant members of Dylans life. In the case of
PSYCHIATRIC CONSUMER ASSIGNMENT 7

underlying medical conditions the relevant medical interventions should be applied.

Treatment

Research shows that a supportive and collaborative relationship amongst the health

professional and both the young patient and the parents, is effective in providing a stable,

accommodating and supportive setting in which treatment can occur. Accordingly, this is the

recommended approach in Dylans case, since it helps the establishing a therapeutic

relationship. The therapeutic relationship is essential in this case since as already established,

Dylan is unaware of his problems, in conflict with his parents, and is resistant to change.

Some of the enhancing factors for this approach to work include stressing the confidential

nature of the discussions, adopting a listening position, being non-judgmental and

consistency (Robinson, Power, & Allan, 2010).

The other approach relevant for Dylans case is Cognitive Behavioural Therapy that is

based on the theory that an individuals thoughts about an event and their reaction, is

influential in how they feel about the event. Indeed, in depression CBT has been found to be

effective in changing the way an individual feels (Shirk, Gudmundsen, Kaplinski, &

McMakin,2008). This approach is necessary in Dylans case since it will enable him to open

up about the issues that are affecting him. Particularly, this approach is necessary as an

intervention towards the likely suicidal tendencies that Dylan is presenting. In addition, to the

psychosocial treatments, Dylan should also undergo pharmacological treatments in order to

suppress the depression symptoms. These include antidepressants which are essential to

prevent further episodes and avert the suicidal ideations.

Management Plan

The main objective for the management plan for Dylan is intended to identify and

alleviate the trigger factors and manage their outcomes. Accordingly, the first phase of the

management plan, should involve fact finding through the psychosocial treatment
PSYCHIATRIC CONSUMER ASSIGNMENT 8

approaches. At this stage, all efforts should be directed at establishing a collaborative

relationship with Dylan to get him to open up about his problems as well as define the range

of the disorder. At this initial stage, it is also important to establish the necessary relationship

with Dylan and his support group, which is effective in upholding the treatment plans

suggested for Dylan (Patel & Jakopac, 2011). This phase should take one to six weeks. The

second phase of the management plan should be the administering of pharmacological

treatment, mainly anti-depressants, to further alleviate Dylans symptoms and enhance the

outcomes of the psychosocial treatments. The third phase of the management plan involves

sustenance and modification of the psychosocial treatments to prevent further relapses or

future events of depression.

PSYCHIATRIC CONSUMER ASSIGNMENT 9

References

beyondblue. (2010). Clinical practice guidelines: Depression in adolescents and young

adults. Melbourne, Vic: Author.

Cook, M., Peterson, J., & Sheldon, C. (2009). Adolescent depression. Psychiatry (Edgmont),

6(9), 1731.

Fortinash, K., & Worret , P. (2006). Psychiatric nursing care plans (5th ed.). New York, NY:

Mosby.

Patel, S., & Jakopac, K. (2011). Manual of psychiatric nursing skills. Sudbury, MA : Jones &

Bartlett Publishers.

Pelkonen, M., Marttunen, M., Kaprio, J., Huurre T., & Aro H. (2008). Adolescent risk factors

for episodic and persistent depression in adulthood. A 16-year prospective follow-up

study of adolescents. J Affect Disord, 106(12), 12331.

Robinson, E., Power, L., & Allan, D. (2010). What works with adolescents? Family

connections and involvement in interventions for adolescent problem behaviours.

Australian Family Relationships Clearinghouse. Australian Family Relationships

Clearinghouse No.16.

Sheffield, J., Spence, S., Rapee, R., Kowalenko N, Wignall A, Davis A, & McLoone J.

(2006). Evaluation of universal, indicated, and combined cognitive-behavioral

approaches to the prevention of depression among adolescents. J Consult Clin

Psychol, 74(1), 6679.

Sutherland Division of General Practice(Shiregps). (2005). Assessment and diagnosis of

depression. Sutherland, NSW : Author.

 PSYCHIATRIC CONSUMER ASSIGNMENT
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Shirk, S., Gudmundsen, G., Kaplinski, H., & McMakin, D. L(2008). Alliance and outcome in

cognitive-behavioral therapy for adolescent depression. J Clin Child Adol Psychol,

37(3), 63139.

Smith, M., Saisan, J., & Segal, J. (2012, Nov). Understanding depression. Retrieved

December 15, 2012, from Help guide:

http://www.helpguide.org/mental/depression_signs_types_diagnosis_treatment.htm
 PSYCHIATRIC CONSUMER ASSIGNMENT
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Mental Health Care Plan

By

Isabella Flego-Peter

CQUniversity Australia

for

Scott Harris

Date: December 18, 2012

 PSYCHIATRIC CONSUMER ASSIGNMENT
12

Mental Health Care Plan

Step 1 Assessment and Demographics
Patient Dylan Cholly Outcome Tool Result
Name:
DOB: Not Given Gender: Male Date:

GP Name: Dr. John Alexander Current Plan:

Challenges in Assessment
noted
Number 1: No eye contact throughout the interview
Number 2: Social isolation
Number 3: Feelings of hopelessness
Number 4: Suicidal ideation
Number 5: Negative self-image
Number 6: Self-neglect

Medications
Not Stated

Mental Health History/Treatment

Dylan has never received specialist mental health care; however, at age fourteen, Dylan was
referred to a private psychologist due to nightmares that presented after witnessing his best friend
being bullied. The psychologists report notes that Dylan attended three appointments and then
ceased contact because the nightmares stopped after changing school.

Language spoken: Not stated

Family History of Mental Illness

Dylans family has a strong history of depression.

Dylans maternal grandmother suffered depression episodes throughout her life.
Dylans eldest cousin suicide after his wife left him, 12 months ago.
Personal History (e.g., childhood, education, relationship history, coping with previous
stressors)Social History
Dylan has been overweight since the age of three.
Dylan has never participated in any organised sports
Dylan has little social interaction which became worse after he persuaded his parents to allow
him to return to his old school six months after changing schools
In the past six months Dylan spends most of his time in his room and long periods on his
computer
Dylans parents are working professionals, and his father is away from home for extended periods
of time because of his job.
 PSYCHIATRIC CONSUMER ASSIGNMENT
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Dylan has never been employed before

Allergies
Not Stated

Alcohol or Substance Use/Abuse)

Not stated

Relevant Physical and Mental Examination

Unknown

Physical Investigations (ordered or suggested)

Suggested screening for alcohol and substance abuse

Mental Status Examination

Appearance/ Behaviour Mood
19- year- old Caucasian male Dylan states he feels fine and does not
Wears completely black clothes that appear understand why everyone is worried
large for frame
Malodorous
Long matted hair
Slumped Posture
No eye contact
Thinking Affect
Coherent Dull
Delusions Restricted
Flattened

Perception: Sleep
Dylan denies perceptual disturbance Does not sleep well according to mother
Passivity
Cognition Appetite
Diminished abstract thinking Not known though medical records show
Thought blocking evident significant weight loss of approximately 30
Passivity kg in the past six months
Negative body image
Attention/Concentration Motivation/Energy/Interest/Pleasure
Reduced concentration Dylan has limited social contact due to
Uninterested, shows no emotion or reaction long hours on the internet
when mother recounts his history Dylan appears to have no motivation or
No eye contact energy towards life

Memory (Short and Long Term) Judgment

Good and has both long and short term Unimpaired
 PSYCHIATRIC CONSUMER ASSIGNMENT
14

memory
Insight Anxiety Symptoms
Diminished Evident
Does not understand why people are worried
about him
Orientation Speech
Orientated to time, place and person Polite and soft spoken
Intense short and to the point

Risk Assessment
Suicidal Ideation Denies active Suicidal Intent With the presence of
suicidal ideation or suicidal ideation, it is
intent however, likely that Dylan may
states wishing that develop suicidal
he would go to sleep intentions if this is not
and never wake up. addressed.
Further, Dylan says
he feel lost about
future life and feels
he does not want to
do anything
Risk to Others Unknown

Key Family/Support Mother is concerned about Dylans health and accompanied him for this
Contact visit

Other Mental Health Professionals Involved in Patient Care

Name/Profession: Referred by his G.P. Dr. John Alexander Contact Number :

Step 2 - Mental Health Care Plan

Challenges Goal (e.g., reduce Action/Task (ege.g., psychological or

Number 1:
Not maintaining eye contact
symptoms, improve pharmacological treatment, referral,
functioning) engagement of family and other supports)
Assist Dylan to Establish a collaborative and trusting
develop and maintain relationship whereby Dylan is able to
eye contact maintain eye contact with health professional
(Patel & Jakopac, 2011)
 PSYCHIATRIC CONSUMER ASSIGNMENT
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Number 2:
Social isolation Identify Psychological counselling , CBT;
Dylans Engagement of family and friends;
positive pharmacological treatment (antidepressants)
beliefs and
characteristics
Assist Dylan
to identify
self-limiting
behaviours
and mental
health
promotion
behaviors
(Jakopac &
Patel, 2009)
Number 3:
Hopelessness feelings Assist Dylan Interpersonal therapy, Psychotherapy, CBT,
in Spend time with the patient and listen.
determining Provide positive support for the patient's self-
socially esteem (Schultz & Videbeck, 2009)
adaptive
behaviors.
Assist Dylan
in identifying
life interests
and people
who have
meaning to
him. Provide
positive
support for
the patient's
self-esteem
(Fortinash &
Holoday-
Worret, 2008)

Number 4:
Suicidal Ideation Encourage
recognition and Family engagement for close patient
verbaliszation of supervision, CBT, psychological counseling,
nege.g., ative feelings Spend time with the patient and listen.
within appropriate Provide positive support for the patient's self-
limits (Lloyd, 2012). esteem

Number 5:
Nege.g.,ative self-image Help Dylan Analytic psychotherapy, CBT, Family
identify the engagement , psychodynamic therapy
 PSYCHIATRIC CONSUMER ASSIGNMENT
16

reason for his

negative body
image
Assist Dylan
to eliminate
the source of
the negative
thoughts
about himself
Assist Dylan
to develop
positive self-
outlook
Number 6:
Self-negeglect Assist Dylan Psychodynamic therapy
to pay more
attention to
himself and
self-hygiene
Emergency Care/Relapse During working hours
Prevention Rush the patient to the nearest medical facility

Afterhours:
Contact his G.P

Further services suggested

Necessary interventions in the case of
substance abuse or biological causes
of depression

Patient Education given: Yes Key family contact/support details/phone:

Copy of MH Plan given to Yes

patient:
Patient Consent Given Yes

Review Date:
(Add a Recall in MD for 1-6 15th January, 2013
months after the Plan date)

Record of Patient Consent

 PSYCHIATRIC CONSUMER ASSIGNMENT
17

Patient Signature: Date: 15th December, 2012

Dr. Signature: Date: 15th December, 2012

References
Fortinash, K., & Holoday-Worret, P. (2008). Psychiatric mental health nursing ( 4th ed.).

New York, NY: Mosby Elsevier.

Jakopac , K., & Patel, S. (2009). Psychiatric mental health case studies and care plans.

Massachusetts: Jones and Bartlett Publishers.

Lloyd, M. (2012). Practical care planning for personalised mental health care. New York,

NY: McGraw-Hill International.

Patel, S., & Jakopac, K. (2011). Manual of psychiatric nursing skills. Sudbury, MA : Jones &

Bartlett Publishers.

Schultz, J., & Videbeck, S. (2009). Lippincott's manual of psychiatric nursing care plans.

Philadelphia, PA: Lippincott Williams & Wilkins.