Initial Psychological Assessment Note

Presenting Problems

• Severe sleep disruption with recurrent vivid nightmares related to a motor vehicle accident (MVA).
• Irritability, angry outbursts, and disproportionate emotional reactions to minor daily stressors.
• Feeling chronically overwhelmed with marked difficulty regulating emotional responses.
• Intrusive daytime flashbacks triggered by traffic noise and driving.

History of Presenting Problems

• Symptoms commenced following a high-speed MVA on 12/11/2025.
• Hyperarousal and avoidance behaviours have progressively worsened over the past 8 weeks.
• Currently prescribed escitalopram (Lexapro®) 10 mg PO mane by GP, commenced 4 weeks ago with mild reduction in baseline anxiety.
• Symptom exacerbation noted in the evenings and prior to commuting.

Current Functioning

• Sleep: Initial insomnia taking > 2 hours to fall asleep; frequent nocturnal awakenings due to nightmares, averaging 4 hours of fragmented sleep per night.

• Employment/Education: Employed full-time as a logistics coordinator; currently working reduced hours from home due to driving phobia and impaired concentration.

• Family: Resides with supportive wife and two children (aged 6 and 9); reports marital strain and guilt due to recent irritability and emotional withdrawal.

• Social: Relocated from Melbourne to Sydney in August 2025; limited local social network and progressive withdrawal from recreational running club since the accident.

Psychiatric History

• Psychiatric History: Prescribed escitalopram (Lexapro®) 10 mg PO mane and melatonin (Circadin®) 2 mg PO nocte; attended 4 sessions of EAP counselling in 2021 for work-related stress; nil previous psychiatric admissions.

Developmental, Social and Family History

Family

• Raised in a strict household where emotional expression was discouraged; father had a history of untreated depression and alcohol misuse; developmental milestones met within normal limits.

Substance Use

• Consumes 2–3 standard alcoholic drinks (beer) per night to assist with sleep onset, increased from social weekend drinking pre-MVA; denies illicit substance or tobacco use.

Self-Harm

• Denies any current or historical self-harm behaviours or suicidal ideation.

Relevant Cultural/Religious/Spiritual Issues

• Relevant Cultural/Religious/Spiritual Issues: Identifies as Roman Catholic; previously attended local parish weekly, which provided community support, but has ceased attendance since November 2025 due to low mood and crowd avoidance.

5P Formulation

• Presenting Problem: Post-traumatic stress symptoms (re-experiencing, hyperarousal, avoidance, sleep disturbance, and emotional dysregulation) following an MVA.

• Predisposing Factors: Paternal history of depression; childhood environment discouraging emotional vulnerability.

• Precipitating Factors: Involvement in a severe MVA on 12/11/2025; recent interstate relocation reducing immediate social buffers.

• Perpetuating Factors: Behavioural avoidance of driving and social settings; maladaptive use of alcohol as a sleep aid; suppression of emotional distress.

• Protecting Factors: Supportive spouse; stable employment with flexible working arrangements; strong motivation for recovery to engage with his children.

Case Formulation

The client presents with symptoms consistent with Post-Traumatic Stress Disorder (PTSD) precipitated by a severe MVA in November 2025, occurring shortly after a major interstate relocation. Vulnerability to these difficulties is underpinned by a family history of mood disorder and early developmental experiences that reinforced emotional suppression. The presentation is currently maintained by behavioural avoidance of trauma reminders (driving) and social withdrawal, alongside the use of evening alcohol to manage hyperarousal, which paradoxically degrades sleep architecture and lowers his threshold for irritability. Despite these challenges, the client possesses strong protective factors, including a supportive marital relationship, workplace accommodations, and high intrinsic motivation to engage in psychological therapy.

Intervention

• Provided psychoeducation regarding the neurobiology of trauma, the fight-or-flight response, and the maintenance cycle of avoidance.
• Introduced progressive muscle relaxation (PMR) and grounded breathing (box breathing) to manage acute physiological hyperarousal.
• Discussed sleep hygiene principles, specifically the negative impact of evening alcohol consumption on REM sleep and nightmare frequency.

Goals

• Reduce nightmare frequency and improve total sleep duration to 6–7 hours per night.
• Decrease frequency of angry outbursts by implementing early emotion regulation strategies.
• Gradually resume independent driving on local roads via graded exposure.

Next Steps

• Practise box breathing and PMR twice daily (morning and pre-sleep).
• Review provided psychoeducational handout on PTSD and sleep hygiene.
• Reduce alcohol intake on weeknights to evaluate impact on sleep quality.

Next Appointment

• Scheduled for 24/03/2026 at 10:00 (Australia/Sydney) at the clinic.