Psychology Discharge Summary

Discharge Summary

Client Name: Chloe Maree Henderson

Date of Birth: 14/05/1992

Date of Discharge: 24/10/2023

Referral Information

• Referral Source: Dr. Aravind Patel, Bayside Family Medical Practice, 112 Brighton Rd, Sandringham VIC 3191 (Ph: 03 9555 0142)
• Reason for Referral: Management of escalating generalised anxiety, panic attacks, and occupational burnout under a Better Access Mental Health Treatment Plan (MHTP).

Presenting Issues

• Persistent, uncontrollable worry regarding work performance and health, accompanied by somatic symptoms (muscle tension, restlessness, initial insomnia) and episodic panic attacks triggered by high-pressure meetings.

Diagnosis

• Generalised Anxiety Disorder (DSM-5-TR: F41.1)

Treatment Summary

• Duration of Therapy: 06/06/2023 to 24/10/2023
• Number of Sessions: 10
• Type of Therapy: Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT)
• Therapeutic Goals:
  • Reduce frequency and severity of panic attacks using somatic grounding and interoceptive exposure.
  • Identify and cognitive-restructure maladaptive perfectionistic beliefs related to workplace performance.
  • Establish sustainable work-life boundaries and improve sleep hygiene.
• Individual 50-minute outpatient psychotherapy sessions delivered fortnightly via face-to-face consultations.
• escitalopram (Lexapro®) 10 mg PO mane (prescribed and managed by referring GP).

Progress and Response to Treatment

• Client demonstrated a strong positive response to intervention. DASS-21 scores decreased from Severe ranges at intake (Depression: 14, Anxiety: 22, Stress: 28) to Normal/Mild ranges at discharge (Depression: 4, Anxiety: 6, Stress: 10).
• Progress Toward Goals:
  • Panic attacks have ceased over the past 6 weeks; client effectively utilises box breathing and cognitive defusion at early onset of physiological arousal.
  • Client successfully challenged "all-or-nothing" cognitive distortions, demonstrating increased tolerance for minor workplace uncertainties.
  • Sleep onset latency reduced to < 20 minutes following implementation of a strict wind-down routine and cessation of after-hours work emails.

Clinical Observations

• Client's Engagement: Attended all 10 scheduled sessions punctually; highly collaborative and consistently completed between-session behavioural experiments and thought diaries.
• Client's Strengths:
  • High psychological insight and strong capacity for self-reflection.
  • Supportive domestic partnership and stable social network.
  • High motivation for behavioural change.
• Client's Challenges:
  • Deeply ingrained schema of unrelenting standards.
  • High-demand corporate work environment with frequent external stressors.

Risk Assessment

• Low risk. No current or historical suicidal ideation, intent, or self-harm behaviours. No risk to others identified.

Outcome of Therapy

• Current Status: Symptom remission achieved. Affect is bright and reactive; mood is euthymic. Functioning well across occupational and social domains.
• Remaining Issues: Mild anticipatory anxiety prior to quarterly executive presentations, which the client is currently managing independently.
• Client's Perspective: Reports feeling "back in control" of her physiological responses and confident in her ability to maintain boundaries at work without guilt.
• Therapist's Assessment: Treatment goals have been successfully met. Client has internalised CBT/ACT principles and possesses a robust relapse prevention toolkit, warranting discharge from active psychological care.

Reason for Discharge

• Discharge Reason: Successful completion of planned 10-session MHTP course and achievement of treatment goals.
• Client's Understanding and Agreement: Discharge was mutually agreed upon during Session 9, with Session 10 utilised for relapse prevention planning. Client is agreeable to step-down care.

Discharge Plan

• Return to care of GP (Dr. Patel) for ongoing medication review. Client may re-engage for booster sessions in the future if significant life stressors arise.

Recommendations

• Consolidate therapeutic gains through ongoing independent application of CBT and ACT skills.
• Follow-Up Care:
  • Follow up with GP in 4 weeks to review ongoing need for escitalopram maintenance therapy.
  • Consider a booster psychology session in 3–6 months if workplace demands escalate.
• Self-Care Strategies:
  • Maintain daily 15-minute mindfulness practice using the Smiling Mind app.
  • Adhere to strict digital detox after 20:00 on weeknights.
  • Continue regular aerobic exercise (running 3x weekly).
• Crisis Plan: In the event of acute distress or relapse, utilise the documented Relapse Prevention Plan, contact GP for re-referral, or reach out to Lifeline (13 11 14) / Beyond Blue (1300 22 4636) for immediate 24-hour support.
• Support Systems: Partner (Liam) and sister, both of whom are aware of the client's early warning signs for burnout.

Additional Notes

• A copy of this discharge summary has been forwarded to Dr. Aravind Patel to fulfil MHTP reporting requirements.

Final Note

• Therapist's Closing Remarks: Chloe has worked exceptionally hard throughout our sessions. Her dedication to between-session tasks was instrumental in her rapid recovery. I wish her all the best.

Clinician's Name: Dr. Sarah Jenkins, Clinical Psychologist (AHPRA: PSY0001849201)

Clinician's Signature: S. Jenkins

Date: 25/10/2023

Attachments (If Any)

• Pre- and Post-Treatment DASS-21 Psychometric Summary
• Personalised Relapse Prevention Blueprint