South Tyneside Primary Care Mental Health Services

19/06/2013
Shona Wardell, DoB: 18/10/1992
To Whom it may concern,
Please find enclosed a referral for the above named individual. Following
three assessment based sessions it is felt that the nature of her difficulties
ensure that she is more appropriate for a longer term intervention within
secondary care. Potentially appropriate for longer term
psychotherapy/CAT. Appears to demonstrate potential personality based
problems including a fragmented sense of self, high levels of dissociation,
rapid movements between self states, push-pull relational patterns, and
issues around self-harm previous overdose attempts. Clustered as cluster
8. Currently prescribed fluoxetine 40mg. Please see below for a more
detailed assessment;
Reports that she lives with her mother and 11-month old brother. Reports
that she has been in a relationship with her boyfriend for approximately
one year. Reports that she currently works part time at a local racecourse
and nightclub.
Reports that she has long term difficulties around her mental health.
Describes difficulties around low mood and low self esteem. Poor sleep,
and concentration.
Reports that since her early teenage years she feels that she has
difficulties around the use of food. Reports that in particular she feels that
she tends to restrict her intake when she feels sad. States that she feels
that at times this can result in her not eating properly for 2-3 weeks.
During these episodes she will tend to mainly drink water.
States that she feels that these episodes can happen regularly. Discussed
the potential health ramifications of this. States that she feels that her
periods are highly irregular and that she is aware that she tends to feel
cold a lot of the time, that she can feel dizzy, and that she tends to
experience aches in her bones at times. Reports that she is not currently
sure what her BMI is. Discussed the importance of her arranging an
appointment to discuss this with her GP. Reports that she does not binge
or purge in relation to food but that her usage revolves more around the
restriction of her intake.
States that she feels she has long term difficulties in relation to her body
image. Reports that she feels she experiences repetitive negative
thoughts around comparing her body to others. Reports that she feels that
she finds it difficult to look at herself in the mirror.
Reports that she has long term difficulties around forming and maintaining

relationships. Perceives that this relates to attempting to push a partner

away when in a relationship. States that this is particularly the case when
she feels the relationship is going well.
States that she has difficulty managing her anger with her partner.
Reports that she feels this particularly tends to happen in arguments
when she feels the relationship may be ending. She states that she feels
this can lead to her blanking out and becoming increasingly angry.
Reports that she feels that she finds this difficult to stop when she has
started and that she wont back down when in an argument. Feels that
she has a self destruct button in relation to her experience of
relationships. Perceives that this relates to having difficulty trusting and
having high turn over of friends. States that this stems from her cutting
them off if she feels they they are not treating her well by cancelling
arrangements or not being available for her. Some of these relational
patterns appear to have manifested in her difficulty in forming therapeutic
relationships within the PCMHS which has previously led to the therapy
breaking down and complaints around staff.
Reports that she feels that much of her childhood was unstable and
traumatic. States that her mother and father split up before she was born
and that she subsequently spent most of her time at her mothers. States
that she would see her father and paternal grandmother on the weekend.
Reports that her childhood was characterized by high levels of neglect by
her mother. States that there where long periods of time when she was
not fed or her needs met. States that this resulted in her having to
attempt to grow up quickly and become responsible for feeding, clothing
herself and cleaning the house. States that she feels much of the neglect
relates to her use of food now. States that as a child she would tend to eat
more at the weekend when she was at her grandmothers and perceives
that this pattern can continue now.
States that her mother had significant difficulties around the use of
alcohol and drugs and that she felt much of the time she was out of it.
Reports that there would be frequent all night parties at her house when
many strangers where present and highly intoxicated. States that for
much of her childhood she was not able to sleep due to the noise levels in
the house.
Perceives that due to the amount of strangers regularly in the house that
much of her childhood was characterized by fear of what may happen to
her. States that she feels she survived this by hiding in her room. Reports
that she feels that she hated this and regularly wanted to call the police.
Reports that there were no social services input and that she has always
felt angry that her father did not remove her from the situation. States
that she feels that her only place of safety during her childhood was her
grandmothers.

Reports that she feels she is unable to recall much of her early years and
feels that she has big gaps in her memory.
Reports that at times she would be left at strangers houses when her
mother was parting. Disclosed that this led to her being exposed to
extreme levels of sexual abuse at the age of 10 for several months by a
female who was older than her. States that she feels she has only
remembered this in the last 3-4 months. Reports that she feels she does
not experience flashbacks to this.
States that she feels that she experienced a high level of shame at the
extent of the neglect that she suffered at home and that this resulted in
her isolating herself at school and then missing parts of her schooling.
Reports that she was bullied at school.
Reports that she feels that she didnt matter to her mother and that their
relationship was characterized by her starting to feel that she wasnt
important and didnt exist. States that she feels that as she started to
enter her teenage years that she started to grow an increasing anger
about the situation that she started to stand up to her mother. Reports
that she feels that some of this anger started to turn against herself in
relation to self harm.
States that she has previously made 1 suicide attempt through the taking
of overdoses. States that these happened in 2010. Reports that this
overdose involved her taking approximately 60 paracetemol alongside 60
ibuprofens. States that she had short period of hospital treatment after
this but that she did not engage with any therapy. Reports that she feels
that this was at the time an attempt to kill herself.
Reports that she feels that she started to attempt suicide and self harm as
she felt that my mother would be better off without me. States that she
feels that the overdose at 18 was planned and was a deliberate attempt to
die. States that she on being released from hospital she returned home
her mother then left her to go out drinking. Her mother then proceeded to
kick her out of her house after several complaints about the noise.
Reports that the overdose was also connected to attempting to gain some
form of attention from her mother as she felt as a child this would only
happen if she was hurt/upset. Recalls pretending to be so and perceives
this to continue in relationships in the here and now.
Reports that during the time of the overdose she has felt that she has
started to see suicide as a potential way out in relation to the problems
she has. Reports that she feels that the attention that she received after
and the upset she caused to family and friends has resulted in her starting
to think that this is not a viable option for her. Reports that she is now
pleased that she has survived the previous attempt. Reports that she feels
she is able to provide guarantees around her personal safety. States that

she feels that she cites her partner, family, and friends as strong
protective factors. Reports that over recent months the frequency of
thoughts of life not worth living have reduced. Reports that she currently
experiences these approximately once every couple of weeks. States that
feels that they last for several hours and are experienced in their
intensity as 5-6 out of 10. Reports that these are not currently
accompanied by any thoughts around harming herself.
Reports that she has a long history of self harm in relation to cutting.
States that this first started in approximately 2008 and perceived that
over time this evolved into a habit that she would pursue whenever she
was upset. States that this would happen regularly. Reports that this
would involve her cutting her lower arms and thighs with razor blades.
States that prior to the last week the last time she self harmed was on
Boxing Day 2012 when she cut herself in the crease of her elbow following
an argument with her boyfriend. Shona subsequently showed the site
where she had cut and it appeared to be a deep wound. It appeared that
several old scars were also on her lower arm.
Reports that over the last two years she has had difficulties around the
use of drugs. States that this involved the using of approximately 6 Es per
weekend. Reports that this also involved what she felt was a heavy use of
Mkat. States that she has not used any drugs for approximately 3 months.
Reports that she has no difficulties around the use of alcohol.
Many of these patterns appeared to be played out in the time between
assessments 2 and 3 when she reported that a week ago she split up with
her long-term partner. States that during an argument she attempted to
push him away emotionally and that this resulted in her ending the
relationship. States that she feels that she didnt mean to do this but that
her partner took the threat seriously and that she feels the relationship is
now over. States that they have had no contact in the time since.
States that she feels that she does this by being nasty verbally. Reports
that she finds it difficult to recall what she has said during this episode
and that she finds it difficult to calm down after one. Reports that this
typically results in her feeling alone and depressed States that this is
followed by her then feeling what she beats myself up about this.
Reports that this involves her self-punishing.
States that during the past week she has done this by reducing her intake
of food and self-harming.
Reports that in relation to food that when she punishes herself that she
will tend to eat one small meal a day and that this can also result in her
not eating. States that on Sunday 16th she had nothing to eat at all and
that during the week she has had a small meal per day.

Disclosed that following the break down of the relationship she has selfharmed during the course of the week. States that this happened on
Thursday 13th and that this involved her cutting the tops of her thighs with
a broken piece of glass. Reports that she did this approximately 10-11
times during the course of that day. Reports that she does not feel that
these were deep in their nature and contrasted this to the last time she
self harmed in late 2012. Reports that following cutting herself she
cleaned the wounds and dressed them.
States that she feels that this was not connected to any intent to end her
life. Reports that she feels that during the course of the last week she has
had thoughts of life not worth living 2-3 times. States that these have
lasted between 1-2 hours and that she rates them in intensity as 5 out of
10. Reports that the thoughts of life not worth living have not been
accompanied by any thoughts of potentially taking her life. States that the
historical thoughts of taking overdoses have not returned during this
period.
Reports that she feels she still feels hope for the future and that she feels
she is able to provide guarantees around her personal safety. States that
she cites her younger brother and mother as protective factors.
States that the thoughts of harming herself through cutting have not
returned since last Thursday. Reports that she thinks that this follows the
pattern for her around self-harm. States that she perceives that this links
to moving between feeling nothing and everything. Discussed the
distressing nature of this for her and reports that she feels that cutting
can help the intensity of this to reduce for her.
Shona subsequently scored highly in relation to dissociation on the DES2
and in relation to movement between different self-states on the PSQ
please find copies of both questionnaires enclosed. States that she feels
she often feels childlike. Provided the example of initially refusing to
have contact with her younger brother and of giving him hacky looks for
the first few months of his life due to the jealousy she felt. States that she
did not attempt to harm him during this period and that she has now
started to bond with him.
Shona states she is aware of the possibility of contacting the Crisis Team,
presenting at casualty of contacting her GP should this be appropriate
prior to being assesses in secondary care.