Dr Tarun Yadav

FRANZCP, MD Psychiatry,MBBS
Provider No: 459169NW

Black Dog Institute Clinical Services

Depression Clinic
Hospital Road, Randwick NSW 2031
T. 02 9382 2991 F. 02 9382 8510
www. blackdoginstitute.org.au

Supported by the NSW Ministry of Health

PRIVATE AND CONFIDENTIAL

TY/BDI
12.06.2020

Dear (TBA)

Re: Dominic Le Souef D.O.B. 05.10.1975

Thank you for referring Dominic 44 years old, whom I saw for initial assessment today. As noted in
your letter of referral, the main aim of the evaluation was for an assessment for diagnostic
clarification and management.

Dominic is currently living with his wife Samantha and three children. Sam works as a teacher for
autistic children and was present throughout the interview. She at times had to continue with the
interview process on her own when Dominic had to leave when he got emotional while talking about
his perceived childhood trauma during the interview process. Dominic has worked in the past as a
music teacher and has a few different qualifications in arts and music. He has not worked since 2012
and is on Centrelink. Dominic’s reporting of his past history was affected by the nature of his
symptoms and a lot of information was gathered from a letter provided by Sam.

Dominic was born and brought up in Melbourne in an “affluent” family but also commented how his
father had financial problems. His mother possibly had alcohol use disorder and was a stay-at-home
mum who also was part of a ”cult” believing in “immortality, thoughts creating reality”. He gave a
contrasting history of having a great childhood with lots of happy memories along with history of
being sexually abused by family members which impacted his development significantly. He has
reported these allegations to authorities as an adult but the validity of same has been questioned by
his siblings and other family members which Dominic has found quite invalidating and distressing.

He denied having any significant behavioural problems in primary school but mention him being a
bully to other younger children. He dropped out of school after year 11 and worked in his family
business. He later studied music and has a few qualifications in the field of arts and music and did
some teaching but reported struggling to keep jobs due to symptoms of anxiety, dissociation and not

1
feeling safe in the world secondary to the experience of previous trauma. He met Sam around 16
years ago at Uni and has been with her since then.

Over the years, Dominic has had assessments with multiple therapists including two psychiatrist
leading to him being diagnosed with an array of diagnosis including complex PTSD, panic disorder,
major depression, and anxiety. He has had trauma therapy for extended periods with limited
benefits as he felt invalidated and not understood by most of his therapists. He has never required
any admissions to an inpatient facility but continues to struggle with ongoing internal and
interpersonal distress on a daily basis with Sam being his only support. His only medication trial has
been with Sertraline up to a maximum dose of 100 mg which he found difficult to tolerate due to the
side effects of restless legs, insomnia, and increased stress. He has been prescribed occasional
benzodiazepines for panic attack and recently been taking Seroquel 50 mg on and off for
emotionally overwhelming situations.

On specific questioning and corroboration by Sam’s account, Dominic has a history suggestive of
long-standing patterns going back to his childhood, of significant identity confusion and disordered
sense of self, where he struggles with a sense of what he wants to achieve in his life. He acts
differently with different people in different relationships and makes decisions to please others in an
attempt to avoid perceived abandonment without being sure of what he likes. He has features of
excessive emotional instability with daily emotional crisis situations involving self-harm due to him
being excessively sensitive to minor or even perceived criticism. He also reported chronic feelings of
nothingness or emptiness with emotional numbing and has had chronic suicidal ideation. In
addition, there is history of frequent anger outbursts, with emotional lability and impulsive
behaviours without thinking about the consequences. There were also some suggestions regarding
rejection sensitivity and patterns of idealisation and devaluation in his thinking.

Regarding his trauma symptoms it is difficult to confirm the extent and the validity of his reported
sexual abuse as a child. However, he certainly appears to have been traumatised by the experience
of chronic invalidation by different people in his life including his family and previous therapists.
There are clear symptoms of hyperarousal manifesting as panic attacks and anxiety along with
severe avoidance where he is literally house bound with fear of being persecuted or being
threatened all the time. He frequently disassociates and fluctuates between a dorsal vagal and
sympathetic overdrive with fewer moments of ventral vagal state. He has significant negative
cognition and feelings, as in negative beliefs about himself, inability to have positive emotions,
diminished interest in various activities or a sense of foreshortened future all of which affect his
ability to control affective dysregulation and interferes with his relationships negatively.

Over the years he has had multiple depressive episodes along with some anxiety symptoms as well
most of which can be understood in context of chronic state of stress due to above-mentioned
symptoms. He does have periods of relative improved functioning where he has been able to
complete construction projects at home in limited time but does not appear to have other classical
features of a hypomanic/manic episodes.

Currently he reports some mood symptoms such as emotional lability with fluctuating energy levels
and some anhedonia. He denied any problems with sleep and appetite.

2
He has migraine but denied any other chronic medical issues such as diabetes, hypertension,
seizures, or head injuries. There is family history of depression in his father and mother had
problems with alcohol use and later on developed Alzheimer’s dementia.

Dominic currently does not appear to have any substance use problems but has history of binge
alcohol use in the past.

MSE:

Dominic presented as a Caucasian male who was casually dressed. He appeared quite anxious
throughout the review and got overwhelmed while talking about his childhood trauma and
perceived invalidation of the same. He spoke in a monotonous voice with normal rate and little
prosody. His mood was described as up and down and affect appeared to be emotional and anxious,
with slightly reduced reactivity. There were no abnormalities of thought form but in thought
content he expressed concerns regarding his symptoms with some negative cognitions associated
with complex trauma such as shame, low self-worth and difficulty to trust others. There were
cognitive patterns suggestive of all or none thinking with chronic ideas of self-harm. However, he
denied any imminent intent or plan to act on those thoughts and finds his partner as protective. He
denied any perceptual abnormalities and his insight and judgement currently appears to be affected
by his mental state.

Clinical formulation

Dominic appears to have some genetic predisposition to depression and substance use given the
family history. He may have been born with biological sensitivity, which in combination with
emotionally invalidating parenting style and traumatic experiences, may have led to development of
insecure attachment style with the establishment of maladaptive beliefs. This may have led to the
development of range of negative attitudes, attributions and expectation including views about
himself as being flawed incapable and unlovable. Dominic’s affect regulation skills appear to be
quite poorly developed with significant mood lability and self-directed destructive and impulsive
behaviours. He has not develop effective problem-solving, social and affect regulation skills and
when confronted with stressful life events such as criticism or separation, he becomes vulnerable to
rapid mood swings and begins to use range of dysfunctional coping strategies such as suicidal
gestures impulsive behaviour to ameliorate his negative feelings and to re-establish a sense of
connection or attachment with others. In addition, his chronic symptoms of trauma continue to
interfere with his ability to learn other coping strategies thus maintaining chronic dysregulated
patterns contributing to stress in his life.

He currently appears to meet the criteria for depressive illness with complex PTSD on the
background of cluster B personality vulnerabilities, borderline personality structure. A possibility of
bipolar spectrum Type II illness is unlikely based on current history. However, further longitudinal
assessment can be done to confirm this.

3
Recommendation

I have discussed the above formulation and the limitations of categorical diagnoses in psychiatry and
how his symptoms are perhaps best viewed as being on a continuum of cluster B personality
structure vulnerabilities and trauma which they seem to agree with.

I am not sure what investigations have been carried out recently. However, I think that it is
important that it is ensured that all organic causes have been excluded. If they have not already
been completed, I would suggest that Dominic have blood tests including Thyroid function tests, a
haemoglobin, LFT, KFT, vitamin B12, folate, CRP, A1C and lipid levels and Auto Immune markers. It
would also be important to make sure that Dominic has had appropriate neuro imaging since his
symptoms began. If Dominic was to be commenced on medication he should have an ECG prior to
this occurring.

Regarding his biological management, Dominic can be considered for a trial of dual acting agent such
as desvenlafaxine with slow titration of his dose starting at 50 mg. In addition, I have discussed a
range of medication to assist with his mood instability. Medications have a limited role in
management of borderline personality disorder. However, the best evidence is for mood stabilisers
to treat some aspects of affective instability and treatment of comorbid anxiety and depressive
symptoms.

I have suggested a trial of Lamotrigine as a mood stabiliser according to below mentioned titration
schedule.

LAMOTRIGINE TITRATION
TIME MORNING DOSE EVENING DOSE COMMENTS
Week 1 & 2 NIL 25 mg If you experience
unwanted side effects:
Week 3 & 4 25 mg 25 mg MILD: Remain on your
current dose until they
Week 5 & 6 50 mg 50 mg resolve.
MODERATE: Return to
Week 7 & 8 100 mg 100 mg your previous dosing
schedule and contact GP
Week 9 & 10 100 mg 100 mg INTOLERABLE or RASH:
Cease medication and
Week 11 & 12 100 mg 100 mg contact GP.

Week 13 & 14 100 mg 100 mg

Week 15 & 16 100 mg 100 mg

4
He should be educated regarding the common side effects and written information should be
provided. In future, he may be considered for a trial of medications like lithium if the mood
symptoms, including bipolar hypomanic episodes becomes prominent.

He can also be considered for SNRI group of medication once he is on good enough dose of mood
stabiliser Like Lamotrigine/lithium to assist with his anxiety and comorbid depressive symptoms.

Fish Oil:

I would recommend that Dominic take fish oil in a dose of 4 capsules (1000 mg daily). The omega-3
in fish oil tends to enhance the effects of mood stabilising and antidepressant medication. There is
some evidence for L methyl Folate supplementation as well.

Psychological therapy:

I would re-iterate the role of psychological therapy as a mainstay of treatment for Dominic in the
long-term, highlighting the role of dialectical behaviour therapy (DBT) in cluster B personality
vulnerabilities. I believe he has previously seen multiple therapist and still has some foundational
skills from a previous psychological therapy experience, which he can build on. The other option is
for Mentalisation based therapy which has good evidence based for treating borderline personality
disorder. Understanding the concepts of political theory may also assist him in having improved
awareness of his emotional states and ability to regulate them.

He will also benefit from reviewing resources and information at a project air website with following
link

https://www.projectairstrategy.org/index.html

https://www.dbtregulator.com.au/

he can also try and find the “gold card clinic” to assist with the same.

Sleep Hygiene:

I have discussed the importance of healthy sleep hygiene techniques with Dominic, including
consistent sleep and wake times, minimising sleeping in the day-time.

Mood charting:

Please provide Dominic with mood charts available via the Black Dog institute Website. I have
suggested that he self-monitor mood daily over the next six months, to help assess response to
treatment and help to identify triggers for mood and anxiety symptoms.

5
Alternatively, Dominic could record mood daily via

MyCompass: https://www.mycompass.org.au/ which offers an online service that can be modified

to record mood each day.

Online interventions:

Evidence based on-line clinical interventions for mood, anxiety (all) and PTSD (Mindspot and
ecentreclinic):

https://www.mycompass.org.au/

https://www.mindspot.org.au/

https://www.ecentreclinic.org/

https://thiswayup.org.au/clinic/

These are effective as stand-alone treatments or as adjuncts to face-to-face therapy.

Exercise:

I have highlighted the role of exercise in mood and anxiety disorders, pointing out the benefits upon
mood, anxiety, and physical fitness.

Emergency safety planning:

Please also discuss emergency safety planning with Dominic, including contacting yourself, his
psychologist, or the 24-hour mental health helpline ( 1800 011 511), if there is any deterioration in
mental state or should any safety concerns arise.

His partner, Sam should also be involved in the discussion regarding his diagnosis and
psychoeducation should be provided to her including information regarding emergency crisis plan.

I have made future appointments in three months’ time, but I believe that it is most appropriate for
him to be continuing to be followed up by yourself and psychologist for psychological therapy in DBT
or mentalisation based therapy framework. I am happy for my report to be communicated to his
future psychologist.

Thank you again for referring Dominic for assessment. I would be happy to discuss this letter if you
would like any additional information. In the event of requiring after-hours care, please refer
Dominic to their local mental health service, either directly to their local hospital, or via the
statewide mental health referral line: 1800 011 511.

Yours sincerely

6
Dr Tarun Yadav
Consultant Psychiatrist