Comprehensive Initial Psychological Assessment

Clinical Interview

Presenting Problem(s)

• Referred by GP under Mental Health Treatment Plan (MHTP) on 12/05/2026 for persistent low mood, anhedonia, and severe workplace anxiety.
• Reports daily panic attacks prior to morning shifts, accompanied by palpitations, SOB, and GI distress.
• Experiencing escalating interpersonal conflict with management and fear of imminent termination.

Current Functioning

• Persistently dysphoric and anxious; reports feeling "overwhelmed and numb."
• Initial and middle insomnia; averaging 4–5 hrs/night with frequent waking at 03:00 and inability to return to sleep due to rumination.
• Employed FT as a logistics coordinator; currently on 2 weeks stress leave following a panic attack at work.
• Lives with de facto partner (supportive, though strained by patient's recent withdrawal); estranged from father, infrequent contact with mother.
• Socially withdrawn over past 3 months; declining invitations from close friends, relies solely on partner for support.
• Sedentary; ceased regular gym attendance 4 months ago due to lethargy.
• Decreased appetite; skipping breakfast and lunch, relies on convenience foods in the evening; 4 kg weight loss over 2 months.
• Profound diurnal fatigue; energy lowest in the morning (2/10), slight improvement by late evening (4/10).
• Previously enjoyed amateur photography and bushwalking; no engagement in hobbies for > 8 weeks.

History

• Onset of subclinical anxiety 12 months ago following company restructuring; acute deterioration over past 3 months with emergence of depressive symptoms and panic attacks after workload doubled.
• Saw a university counsellor briefly in 2018 for exam stress (4 sessions CBT, good response).
• Diagnosed with GAD by GP in 2021; managed in primary care without specialist psychiatric input. No inpatient admissions.
• Hx of mild asthma and IBS. Family medical Hx: Father has T2DM and HTN.
• Escitalopram (Lexapro®) 10 mg PO mane (commenced by GP 3 weeks ago); salbutamol (Ventolin®) 100 mcg INH PRN.
• Alcohol: 2–3 standard drinks (wine) nightly to aid sleep (increased from weekend social drinking 3 months ago). Caffeine: 4x espresso/day. Denies tobacco, vaping, or illicit substance use.
• Mother has Hx of MDD; maternal aunt diagnosed with Bipolar II Disorder; father has suspected undiagnosed AUD.
• Met all developmental milestones WNL; describes childhood environment as "high-pressure and critical."
• Second-generation Australian (Italian heritage); non-practising Catholic; notes strong familial cultural expectation of stoicism and work ethic contributing to guilt regarding stress leave.
• Nil forensic history or current legal issues.

Risk Assessment

• Reports passive suicidal ideation ("wishing I wouldn't wake up") 2–3x/week over the past month; explicitly denies active suicidal intent, plan, or history of attempts.
• Denies homicidal ideation.
• History of superficial cutting to forearms at age 16; no DSH in the past 12 years.
• Denies history of violence or aggression towards others or property.
• Increasing reliance on alcohol as a sleep aid noted; denies gambling, compulsive shopping, or other behavioural addictions.
• Denies current risk-taking behaviours or impulsivity.

Mental State Exam

• 28yo female, appears stated age, casually dressed, grooming adequate, slight dark circles under eyes.
• Cooperative and engaged; mild psychomotor agitation (fidgeting with rings, shifting in seat); intermittent eye contact.
• Normal rate and volume; mildly monotone prosody.
• "Exhausted and on edge."
• Restricted range, anxious and dysphoric, congruent with stated mood; tearful when discussing workplace expectations.
• Denies auditory, visual, or tactile hallucinations; reports mild depersonalisation during peak panic attacks.
• Logical, linear, and goal-directed; content preoccupied with occupational failure and financial security.
• Intact; no flight of ideas, loosening of associations, or tangentiality.
• Oriented to time, place, and person.
• Immediate, recent, and remote memory grossly intact during clinical interview.
• Mildly impaired; requested repetition of two multi-part questions during history taking.
• Sustained attention adequate for the 50-minute consultation, though easily distracted by external hallway noise.
• Intact; recognises need for medical leave and psychological intervention.
• Good; attributes physical symptoms and sleep disturbance to underlying anxiety and occupational burnout.

Formal Psychometric Assessments

DASS-21 administered 14/05/2026: Depression = 24 (Severe), Anxiety = 20 (Extremely Severe), Stress = 28 (Severe). K10 Score = 36 (Very High psychological distress).

Clinical Formulation

• Genetic vulnerability to mood/anxiety disorders (maternal MDD); perfectionistic temperament; hyper-critical upbringing fostering maladaptive core beliefs regarding self-worth and productivity.
• Workplace restructuring 12 months ago, compounded by acute workload increase and management conflict 3 months ago.
• Avoidance of workplace, social withdrawal, maladaptive coping via evening alcohol use, excessive caffeine intake, and sleep deprivation maintaining HPA-axis dysregulation.
• Supportive de facto partner, high insight, stable housing, absence of active suicidality, and prior positive engagement with CBT.

Treatment Plan

1. Major Depressive Disorder, single episode, moderate, with anxious distress (DSM-5-TR: F32.1)

• Behavioural activation (re-establishing daily routine, morning walk, regular meal times); sleep hygiene education and gradual reduction of evening alcohol intake; cognitive restructuring targeting perfectionism and catastrophic thinking.
• Repeat DASS-21 and K10 at session 6 and session 10; weekly self-monitoring via mood and activity log.

2. Panic Disorder (DSM-5-TR: F41.0)

• Psychoeducation on the fight-or-flight response; caffeine reduction; interoceptive and graded in-vivo exposure to workplace triggers; diaphragmatic breathing and progressive muscle relaxation (PMR) training.
• Panic Attack Severity and Frequency log reviewed weekly; Panic Disorder Severity Scale (PDSS) administered monthly.