Clinical Psychologist – Diagnostic Formulation Template

Diagnostic Formulation Template Date of Formulation: 1 November 2024 Referral and Presenting Concerns: Patient referred by District Mental Health Services due to escalating self-harming behaviours, social withdrawal, and academic decline over the past six months. Key presenting psychological symptoms include persistent low mood, anhedonia, excessive guilt, and recurrent suicidal ideation without current plan or intent. Behavioural symptoms include cutting, isolation, and refusal to attend school. Diagnostic Summary: Provisional Diagnosis: Major Depressive Disorder, single episode, severe with melancholic features (ICD-10: F32.2). Justification based on meeting DSM-5 criteria for a major depressive episode lasting over two weeks, with marked distress and significant functional impairment. Symptoms include depressed mood, diminished interest/pleasure, significant weight loss (unintentional), insomnia, psychomotor agitation, fatigue, feelings of worthlessness/guilt, diminished concentration, and recurrent thoughts of death. The context of a recent family bereavement and ongoing financial strain in a low-income South African community is considered relevant. Formulation (4P Model): Predisposing Factors: Patient has a family history of depression (maternal grandmother). Early life adversity included a period of parental separation during formative years (ages 5-7). Reported an anxious attachment style, often seeking excessive reassurance. No overt neurodevelopmental issues noted. Patient exhibits a self-critical personality structure. Precipitating Factors: Recent triggering events include the sudden death of a beloved aunt three months prior, leading to profound grief. Additionally, her mother lost her job six weeks ago, creating significant financial instability and household stress, exacerbating existing family tensions. Patient also experienced academic failure in her most recent school term, leading to feelings of inadequacy. Perpetuating Factors: Ongoing perpetuating factors include social isolation, as the patient has withdrawn from peer groups and school activities. Entrenched family conflict, particularly between the patient and her mother, centres around perceived lack of support and communication breakdown. Cognitive avoidance, specifically ruminating on negative thoughts and avoiding social interaction, maintains symptoms. Limited access to recreational activities due to financial constraints also contributes. Protective Factors: Strengths include a supportive extended family network (paternal grandmother is actively involved), regular school attendance prior to the recent decline (demonstrating previous engagement), and a strong religious community involvement through her church youth group. Patient expresses some insight into her difficulties and a stated motivation to feel better, despite current hopelessness. Functional Impact: Significant impact on daily functioning. Patient is unable to attend school regularly (absent for 70% of the last term), has ceased performing household responsibilities, and struggles with self-care (poor hygiene, irregular eating patterns). Relationships with peers have deteriorated, and she spends most of her time in her room, disengaged from family. Risk Profile: Assessed risk includes moderate suicidal ideation (passive thoughts of not wanting to wake up, but no specific plan or intent to act). History of self-harm (superficial cutting to inner forearms, 3 instances in the last 2 months). No history of violence towards others. Vulnerable to exploitation due to low self-esteem and social isolation. Housing is stable, but financial instability is a significant stressor for the family. No involvement of SAPS, child protection services, or psychiatric hospitalisation to date. Therapeutic Implications and Recommendations: Recommend a comprehensive intervention package. Individual Cognitive Behavioural Therapy (CBT) to address cognitive distortions, behavioural activation, and coping skills for self-harm. Psychoeducation for the patient and family on depression and self-harm. Referral to a local NGO for family mediation and support regarding financial stress. Explore state psychiatric follow-up for potential medication review in conjunction with therapy. School-based support structures to be engaged for re-integration plan and academic support. Potential Occupational Therapy (OT) input to address daily functioning and engagement in meaningful activities.