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[ANSWERED 2022] Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Assessing and Diagnosing Patients With SubstanceRelated and Addictive Disorders

For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.

To Prepare:

  • Review this week’s Learning Resources and consider the insights they provide.
  • Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
  • By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

By Day 7 of Week 8

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

TRANSCRIPT OF VIDEO FILE: 

00:00:00______________________________________________________________________________

00:00:00BEGIN TRANSCRIPT:

00:00:00[sil.]

00:00:20LISA Well I had to be here in this hospital if that answers your question.

00:00:25OFF CAMERA Yes, thank you. Can I get you a drink of water or something else to drink? Anything?

00:00:35LISA A drink isn’t going to convince me, right? You’re going to have to convince me.

00:00:40OFF CAMERA What is you want me to persuade you to do?

00:00:45LISA Going to rehab.

00:00:50OFF CAMERA What worries you about going to rehab?

00:00:55 [sil.]

00:01:00 LISA Everything.

00:01:00 OFF CAMERA Okay. I tell you what let’s go back a little bit and tell me about how you’re feeling today.

00:01:10 LISA Scared.

00:01:15 OFF CAMERA Can you tell me more about that feeling of being scared?

00:01:20 LISA Well, I don’t want to be. I don’t want to be what people say I am because if I say it and I’m not going to say it because I ain’t going to change. I can’t.

00:01:35 OFF CAMERA What do people say you are?

00:01:40 LISA And I’m not.

00:01:45 OFF CAMERA What don’t you want to be?

00:01:45 LISA An addict.

00:01:50 OFF CAMERA Do you use drugs and alcohol?

00:01:50 LISA Yeah sometimes I have a drink. You know with friends [inaudible] but it doesn’t matter. I’m in control.

00:02:00 OFF CAMERA Do you feel in control now?

00:02:05LISA Maybe I could just get that drink [inaudible].

00:02:10OFF CAMERA Sure. Sure. Here you go.

00:02:15LISA Thank you.

00:02:20[sil.]

00:02:30LISA You know what I just think I should leave.

00:02:30OFF CAMERA You keep saying you should leave. You said that earlier but do you really want to leave?

00:02:40LISA No.

00:02:45OFF CAMERA Okay. Tell me why you are here.

00:02:45LISA Because I’m scared.

00:02:50OFF CAMERA You said that earlier. You think if you could — then I could figure out together why you’re scared and maybe we can come up to a plan. Up with a plan and if we do that, then maybe your fears will disappear.

00:03:05LISA No not these fears [inaudible] because it’s over.

00:03:10OFF CAMERA What’s over?

00:03:10LISA Everything. The business.

00:03:15OFF CAMERA What do you mean?

00:03:20LISA Jeremy.

00:03:25OFF CAMERA Who is Jeremy?

00:03:25LISA He’s my boyfriend. I saw him naked with Alisa [assumed spelling] with the same fucking name as me. We now have the same fucking boyfriend. In my office, he was screwing that fucking cunk.

00:03:45OFF CAMERA So you’re the one who caught Jeremy cheating?

00:03:55LISA Yeah. Cheating? Yeah that’s a clever word shrinks use.

00:04:05OFF CAMERA So you and Jeremy share an office?

00:04:05LISA Yeah we do commercials for local businesses, you know, build websites, that kind of stuff. We started a business together. He moved in with me.

00:04:15OFF CAMERA How long ago was that?

00:04:20LISA Nine months.

00:04:20OFF CAMERA Do you have any children?

00:04:20LISA Not with that fucking asshole.

00:04:25[sil.]

00:04:30LISA I have a daughter, Sarah. Gosh, she’s beautiful. She stays with some friends. She’s not related to Jeremy, thank God.

00:04:45OFF CAMERA And where are you staying?

00:04:45LISA I’m renting a place far away from here. You know I ran down to the bank to empty both our bank accounts.

00:04:55OFF CAMERA Business accounts?

00:04:55LISA Yeah. And do you know that asshole has been draining them for 4 months? I swear.

00:05:05OFF CAMERA Taking money out of your account without your knowledge.

00:05:05LISA Yeah. For his buys.

00:05:10OFF CAMERA Buys?

00:05:10LISA Yeah, to payoff his debts with my money.

00:05:20OFF CAMERA Or crack cocaine?

00:05:25LISA Yeah for crack.

00:05:25OFF CAMERA How long have you know he’s been smoking crack?

00:05:30LISA Ever since I saw him with that — every since I saw with her naked. The both of them naked.

00:05:40OFF CAMERA What was that like seeing Jeremy and Alisa naked and smoking crack?

00:05:40LISA Well have you ever seen someone you love naked smoking crack?

00:05:45OFF CAMERA No.

00:05:50LISA Yeah no I didn’t think so.

00:05:50OFF CAMERA So what has that been like for you knowing Jeremy’s smoking crack?

00:05:55LISA Well, I’ve never seen him do drugs before. You know he drinks a lot, smokes weed, but crack cocaine. I mean God have mercy.

00:06:15OFF CAMERA What are you thinking about?

00:06:20LISA Everyone’s going to know.

00:06:25OFF CAMERA Know what?

00:06:30LISA That I was getting high to stay in this hospital and get cleaned up.

00:06:35OFF CAMERA You mean rather than go to rehab.

00:06:40LISA Rehab, man they’re fucking dirty places and I’m sick and tired of dirty places.

00:06:45OFF CAMERA No, no, no this rehab place is very clean. I’ve seen it. There are a lot of nice people there. People who feel like they get much better help than here in the hospital. In fact, I can call someone for you and let you talk with them.

00:06:55LISA No, no, no, no, no, no, no, no, don’t do that.

00:07:00OFF CAMERA You’re really fearful of going to rehab.

00:07:05LISA Well if everyone finds out that I’ve been to rehab, I won’t get a job. I won’t be hired anyway.

00:07:10OFF CAMERA Plus if people are fearful of the stigma and fearful of what people will think of them.

00:07:20LISA Yeah, but he says that I’m not addicted. It’s just — you know something wrong with my personality.

00:07:25OFF CAMERA Who says there’s something wrong with your personality?

00:07:30LISA Jeremy.

00:07:30OFF CAMERA When did he tell you that?

00:07:35LISA Lots of times.

00:07:35OFF CAMERA I thought you said you and Jeremy split up after you caught him cheating.

00:07:40LISA I —

00:07:45OFF CAMERA It’s okay. Take your time.

00:07:50LISA Well yeah he moved back in.

00:07:50OFF CAMERA Into your new home?

00:07:55LISA Yeah. What changed that you two decided to get back together?

00:08:00OFF CAMERA Well he said he was sorry and he begged me. He’s done it before so I took him back.

00:08:10LISA And how has that been being back with Jeremy?

00:08:15OFF CAMERA Well I love Jeremy. I do and don’t want to go out and find another boyfriend. I mean we lost 80,000 dollars on that business. And he promised me that he would make it all back.

00:08:30LISA So is that why you took him back? Has Jeremy continued smoking crack?

00:08:45OFF CAMERA Yeah a little but he’s not addicted. He says that it calms him down. Me too.

00:09:05LISA You too?

00:09:05OFF CAMERA So do you smoke crack with Jeremy?

00:09:15LISA Yeah we — he made me try it.

00:09:25[sil.]

00:09:30[ Crying ]

00:09:40LISA And then he tried just once. We did it together. [Inaudible] I could.

00:09:55[ Crying ]

00:10:00LISA Hit me like a bullet. And it felt so good. I felt so good. And real fast.

00:10:20[sil.]

00:10:25LISA Have you ever felt like you were dancing with butterflies?

00:10:30OFF CAMERA Dancing with butterflies? No I have not.

00:10:40[sil.]

00:10:45LISA But he says it’s not addictive, Jeremy.

00:10:50OFF CAMERA What do you think?

00:10:55LISA Well I know I can’t get enough.

00:11:00[ Crying ]

00:11:10LISA And I know I don’t want to go back to feeling horrible again because when I don’t smoke it I get worse. And when I have it, I feel good. And then it’s gone. And then I know that I’m going to be needing another hit.

00:11:45OFF CAMERA That sounds a lot like addiction.

00:11:55LISA Yeah but I know I don’t want it to be.

00:12:00OFF CAMERA It sounds like you are very scared of getting help and yet at the same very time, it sounds like you know you need that help.

00:12:15LISA I know I don’t need help. I don’t need anything. Jeremy promised me that everything is going to be okay. And when you love someone like I do, you got to believe him. Right?

00:12:45[sil.]

00:12:45END TRANSCRIPT

Expert Answer and Explanation

Substance Abuse Disorder

Subjective:

CC: “I am scared and worried about going to a rehab facility.”

HPI: Lisa Pittman is a 29-years-old female of white origin. She came to West Palm Beach, FL, detox facility to get a piece of advice on whether to join a rehab institution. Lisa is scared of joining a rehab facility because of how society will treat her. She says that if she goes to rehab, she will not get a job. She is also scared that people will see her as an addict when she joins a rehab facility. She says that Jeremy, her boyfriend influenced her to take crack cocaine. She spends a lot of money on cocaine. She says that she has to use cocaine regularly to feel good. She reports that if she does not use cocaine, she will feel worse and horrible. She continues to use cocaine even if she knows that she needs help. Her cocaine use has affected her daily activities. She does not eat properly and has poor sleeping habits.

Past Psychiatric History:

  • General Statement: No history of treatment for psychiatric conditions.
  • Caregivers (if applicable): No Caregivers
  • Hospitalizations: No hospitalization.
  • Medication trials: No prior history of medical trials.
  • Psychotherapy or Previous Psychiatric Diagnosis: The patient has never undergone psychiatric treatment and has no mental problems.

Substance Current Use and History: She says that she takes crack cocaine. He spends $100 daily to buy cocaine. She uses cannabis. She takes it about 1-2 times weekly. She drinks 2-3 bottles of alcohol once weekly.

Family Psychiatric/Substance Use History:  Her brother has a history of opioid abuse. Her father was jailed for drug possession. Her mother has a history of benzodiazepine abuse and anxiety.

Psychosocial History: She was born in Alabama, where her parents raised her. Her mother raised her after her father was jailed when she was 5-7 years old. She has a single sibling, a brother who has not visited them for ten years. She currently lives with her boyfriend in Florida. She has a daughter who lives with her friends. She studied digital marketing in college. She likes to party with friends and get high. She was convicted for possessing drugs and is currently on probation. She is a digital marketer and creates commercial websites for businesses. Her father sexually assaulted her when she was 5-7 years old. She recently witnessed her boyfriend having sexual intercourse with another woman.

Medical History: Lisa has hepatitis C.

  • Current Medications: No medications
  • Allergies: She has amoxicillin allergies.
  • Reproductive Hx: She is sexually active. The menstrual cycle is regular. She uses an intrauterine device as her contraceptive method. There are no reproductive concerns.

ROS:

  • GENERAL: Positive for low appetite. No weakness, chills, fever, or fatigue.
  • HEENT: No abnormalities.
  • SKIN: No itching.
  • CARDIOVASCULAR: No chest pain, edema, leg cramps, dyspnea, or ankle swelling.
  • RESPIRATORY: No pain with breathing, cough, or shortness of breath.
  • GASTROINTESTINAL: No abdominal pain, constipation, vomiting, nausea, or diarrhea.
  • GENITOURINARY: No genital lesions, dysuria, odor, retention, hematuria, or inconsistency.
  • NEUROLOGICAL: No sensory-motor loss, dizziness, headaches, or focal weakness.
  • MUSCULOSKELETAL: No musculoskeletal abnormalities.
  • HEMATOLOGIC: No anemia
  • LYMPHATICS: No gland swelling or HIV.
  • ENDOCRINOLOGIC: No polydipsia.

Objective:

Physical exam:

 Vital Signs: BP 178/94, Wt. 140lbs, P 101, Ht. 5’6″, T 99.8

  • HEENT: Head: No scars or swelling. Eyes: No glasses, PERRL, sight intact, conjunctivae clear, sclera white. Ears: TMS appears normal. Hearing intact and canal clear. Nose: No mucosal edema. Mucosa pink and moist, nares are patent and discharge clear. Throat: No inflammation.
  • Skin: No rash.
  • Cardiovascular: Regular heartbeats and rates. No ankle edema. No murmurs. No gallops. Pulse normal.
  • Respiratory: Chest clear. Breathing rate normal. No problems with breathing. Lungs clear.
  • Neurological: Cranial nerves intact.
  • Musculoskeletal: Normal gait.

Diagnostic results:

  • Laboratory test results include albumin 3.0, GGT 59, ALT 168, bilirubin 2.5, and ALK 250. The patient tests positive for cocaine in her urine. Other lab results are normal.
  • CRAFFT Screener: This tool can help a psychiatrist can be used to identify the presence of substance abuse or make an addiction diagnosis (Bivin & Riaz, 2017(. The patient scores high.
  • Drug and Alcohol Problem Quick Screen (DAP Quick Screen): This tool can help nurses assess the patient with substance abuse’s relations with people around them (Bivin & Riaz, 2017). The patient scores high.

Assessment:

Mental Status Examination: Lisa is well-developed as looks her stated age. She does not appear ill. She is not well-groomed. She engaged in the interview. Her speech is clear but slow. She is alert and oriented. Her mood is liable, and her affect is consistent with the mood. She looks frustrated. She holds her bag when speaking. Thought content is grossly intact. Her concertation is good. She denies suicidal thoughts, hallucinations, delusions, or paranoid thoughts. Judgment is impaired, but insight intact.

Differential Diagnoses: 

  1. Cocaine Use Disorder (CUD)
  2. Substance Use Disorder (SUD)
  3. Alcohol Use Disorder (AUD)

Primary Diagnosis 

The primary disorder is cocaine use disorder. Zaparte et al. (2019) note that CUD causes irritability, anxiety, memory problems, and lack of concertation. Gómez Pérez et al. (2020) also note that patients with CUD have sleep problems and often crave the drug. Other symptoms of CUD include the feeling to use the drug daily, using the substance even if one knows it is not healthy, possessing the drug, spending a lot of money on the drug, inability to function without the drug, and taking the substance in excess to achieve the same effect (APA, 2013). A person with CUD often feels the need to stop taking cocaine but cannot (Sadock et al., 2015). CUD has been included as the primary diagnosis because the patient meets all the DMS-5 criteria for diagnosing the disorder. She spends a lot on cocaine, was arrested for possessing the drug, feels the urge to use the drug daily, needs a lot of cocaine to feel good, and is afraid of withdrawing from cocaine addiction because she fears feeling worse without the drug. She also prefers to get high rather than eat and has sleep problems. CRAFFT Screener and DAP Quick Screen results confirm the diagnosis.

The second diagnosis for this case is SUD. McCabe et al. (2019) note that substance abuse causes tolerance, using the substance continuously when it is problematic, and the desire to withdraw and craving. The DSM-5 highlights that the symptoms of substance abuse include physical dependence, risky use, impaired control, and social issues as a result of using substances (APA, 2013). SUD has been included because the patient uses cocaine, alcohol, and cannabis. However, it is a secondary disorder because she is only addicted to cocaine. AUD has been included because the patient drinks alcohol weekly. Mattick et al. (2018) note that AUD causes alcohol dependence. This disease is a secondary disorder because the patient does not depend on alcohol. She depends more on cocaine.

Reflections: 

I support the diagnosis because it is supported by evidence-based literature and the patient’s subjective and objective data. If I was assigned this case again, I would have conducted an anxiety screening. The patient reports fear, and thus I would like to know whether she has anxiety. I would also ask the patient about her work and whether she can work without using cocaine. I would ask the patient if she cannot stay without drinking alcohol. Her answer would help me further support my diagnosis. Nurses should assess patients with the knowledge about ethical considerations they need to follow. This patient came to the clinic to seek advice on whether to join a rehab center. She has the autonomy to make decisions on whether to go to rehab or not. The nurse, in this case, should give advice and not force the patient. The nurse should also not market the rehab center; they should provide educative material and let the patient decide. It is also unethical to judge the patient during the assessment. The nurse should be objective to give partial and evidence-based advice. Another vital ethical consideration is the therapeutic relationship. The nurse should maintain a professional relationship with the patient to improve the quality of care provided. If the nurse becomes close to the patient, their judgment will be compromised, leading to poor quality care.

References

American Psychiatric Association. (2013). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm16

Bivin, J. B., & Riaz, K. M. (2017). Assessment of substance abuse among teenagers: Review of instruments commonly used in healthcare and research. Asian Journal of Nursing Education and Research, 7(2), 248-254.

Gómez Pérez, L. J., Cardullo, S., Cellini, N., Sarlo, M., Monteanni, T., Bonci, A., … & Madeo, G. (2020). Sleep quality improves during treatment with repetitive transcranial magnetic stimulation (rTMS) in patients with cocaine use disorder: A retrospective observational study. BMC psychiatry, 20(1), 1-12. https://doi.org/10.1186/s12888-020-02568-2

Mattick, R. P., Clare, P. J., Aiken, A., Wadolowski, M., Hutchinson, D., Najman, J., … & Degenhardt, L. (2018). Association of parental supply of alcohol with adolescent drinking, alcohol-related harms, and alcohol use disorder symptoms: a prospective cohort study. The Lancet Public Health, 3(2), e64-e71. https://doi.org/10.1016/S2468-2667(17)30240-2

McCabe, S. E., Veliz, P. T., Boyd, C. J., Schepis, T. S., McCabe, V. V., & Schulenberg, J. E. (2019). A prospective study of nonmedical use of prescription opioids during adolescence and subsequent substance use disorder symptoms in early midlife. Drug and Alcohol Dependence, 194, 377–385. https://doi.org/10.1016/j.drugalcdep.2018.10.027

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Zaparte, A., Schuch, J. B., Viola, T. W., Baptista, T. A., Beidacki, A. S., do Prado, C. H., … & Grassi-Oliveira, R. (2019). Cocaine use disorder is associated with changes in Th1/Th2/Th17 cytokines and lymphocytes subsets. Frontiers in Immunology, 10, 2435. https://doi.org/10.3389/fimmu.2019.02435

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