DARP Progress Note

• Client/ID: Liam O'Connor / MRN: 482-910-34
• Therapy Provider: Dr Sarah Jenkins, Clinical Psychologist
• Session Date: 14/05/2024
• Start and Finish Time: 10:00 – 10:50 AEST

Data

The client presented on time for his scheduled individual therapy session to address ongoing symptoms of generalised anxiety and work-related stress. The clinician observed that the client was neatly groomed, dressed casually, and maintained appropriate eye contact, though he exhibited mild psychomotor agitation by frequently tapping his foot. His affect was anxious and constricted, while his speech was normal in rate, rhythm, and volume, and his thought process remained linear and goal-directed. Subjectively, the client reported experiencing heightened anxiety over the past week due to an upcoming performance review, stating, "I feel like I am going to fail and lose my job." He also reported middle insomnia, waking up twice nightly, and noted ongoing adherence to sertraline (Zoloft®) 50 mg PO daily prescribed by his GP. Objectively, a routine administration of the GAD-7 screener yielded a score of 12, indicating moderate anxiety, which is a slight reduction from his baseline score of 15 four weeks ago. The clinician delivered Cognitive Behavioural Therapy (CBT) interventions, specifically focusing on cognitive restructuring to challenge catastrophic thinking patterns regarding his employment, and guided the client through a 5-minute progressive muscle relaxation (PMR) exercise in-session to address his somatic tension.

Assessment

The client continues to meet DSM-5 criteria for Generalised Anxiety Disorder (F41.1), with no diagnostic changes indicated at this stage. Upon formal risk assessment by the clinician, the client explicitly denied any current or historical suicidal ideation, intent, or plan, and denied any self-harm behaviours or homicidal ideation, indicating a low acute risk profile. The client is demonstrating steady progress toward his primary treatment goal of reducing daily anxiety symptoms and improving emotional regulation, as evidenced by the 3-point decrease in his GAD-7 score and his consistent engagement in therapy. However, occupational triggers and sleep maintenance insomnia remain key areas requiring clinical attention, as cognitive distortions surrounding workplace perfectionism continue to perpetuate his physiological hyperarousal.

Response

The client responded receptively to the cognitive restructuring intervention, actively participating in the Socratic questioning process and successfully identifying "catastrophising" and "all-or-nothing thinking" in his self-talk regarding his upcoming work review. By the end of the cognitive exercise, the client reported a subjective reduction in his immediate anxiety, noting that generating alternative, balanced thoughts helped him feel more grounded. Following the guided PMR exercise, the clinician observed a visible reduction in the client's foot tapping and shoulder tension, and the client stated that he felt physically calmer and capable of replicating the technique independently at home.

Plan

The current treatment plan remains appropriate and requires no major revisions, continuing with weekly CBT sessions focused on cognitive restructuring and somatic regulation to achieve the objective of reducing the client's GAD-7 score to the mild range. For homework, the client agreed to complete a daily CBT thought record whenever he notices spike in workplace anxiety, and to practice the PMR exercise for 10 minutes each night prior to sleep to address his middle insomnia. The clinician asked the client to reflect on the evidence supporting his competence at work over the past year ahead of his performance review. The client was also advised to follow up with his local GP regarding his persistent sleep disturbances and ongoing pharmacotherapy review. The next session is scheduled for 21/05/2024 at 10:00 AEST at the Sydney CBD clinic.