Assignment: Week 8 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Week 8: Substance-Related and Addictive Disorders

Many individuals seeking treatment meet the criteria for both mental health and substance-related disorders. Regardless of whether you specialize in substance-related disorders, all advanced practice nurses should know their signs and symptoms and how to assess and diagnose them. There are assessment and screening tools available to clinicians, and a plethora of information can be obtained through the diagnostic interview. It takes time and experience to know what types of questions to ask to gain the most information, in addition to a basic knowledge of the substances and behaviors you are trying to assess. It can be complicated to sort out substance use disorders from other mental health disorders, but most clients seeking treatment have comorbidities.

This week, you apply DSM-5-TR substance use and addictive criteria as you formulate a diagnosis for a patient in a case study.
Learning Objectives

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Students will:

Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information
Formulate differential diagnoses using DSM-5-TR criteria for patients with substance-related and addictive disorders across the lifespan

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2022). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders

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

Chapter 20, Substance Use and Addictive Disorders
Chapter 31.16, Adolescent Substance Abuse

Document: Comprehensive Psychiatric Evaluation Template

Document: Comprehensive Psychiatric Evaluation Exemplar

Required Media (click to expand/reduce)

Classroom Productions. (Producer). (2016). Addictive disorders [Video]. Walden University.

Complex Care Consulting. (2018, April 4). Addiction neuroscience 101 [Video]. YouTube. https://www.youtube.com/watch?v=bwZcPwlRRcc

Video Case Selections for Assignment (click to expand/reduce)

Select one of the following videos to use for your Assignment this week. Then, access the document â€œCase History Reportsâ€ and review the additional data about the patient in the specific video number you selected.

Symptom Media. (Producer). (2017). Training title 82 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-82

Symptom Media. (Producer). (2018). Training title 114-2 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-114-2

Symptom Media. (Producer). (2018). Training title 151 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-151

Document: Case History Reports

Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

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 patientâ€™s cultural background.
To Prepare:

Review this weekâ€™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 â€œCase History Reportsâ€ 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?â€¯
Assessment: Discuss the patientâ€™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?â€¯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.).

Submission and Grading Information

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Please save your Assignment using the naming convention â€œWK8Assgn+last name+first initial.(extension)â€ as the name.
Click the Week 8 Assignment Rubric to review the Grading Criteria for the Assignment.
Click the Week 8 Assignment link. You will also be able to â€œView Rubricâ€ for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as â€œWK8Assgn+last name+first initial.(extension)â€ and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.

Grading Criteria

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Week 8 Assignment Rubric

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Submit your Week 8 Assignment draft and review the originality report.

Submit Your Assignment by Day 7 of Week 8

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Week 8 Assignment

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Subjective:

CC (chief complaint): “I feel Scared. 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”

HPI: L.T is a 33-year-old Caucasian female presenting in a Naples FL detox facility with the thought of trying a long-term rehab but she is scared of going to the rehab. She presents for a review and wants to be persuaded to go to rehab. She reports having been using alcohol and cannabis. She reports using opiates worth roughly $100 every day and half a gallon of vodka every day. She reports using cannabis 1-2 times every week with the excuse of having a medical card. She also reports being Hepatitis C positive and is planning on getting treatment. She is scared of people branding her as an addict and she expresses strongly that she does not want to be an addict. She expresses that she has lost control of her drinking and drug problems. She reports having a boyfriend who uses crack. The client reports having relationship problems with her boyfriend who she accuses of unfaithfulness and running down their business by using the money to buy drugs. She reports to abhor rehabs and associates them with stigma. She reports having been introduced to smoking crack by her boyfriend. She has a diminished appetite and prefers smoking to food. She also reports having sleep disturbances and is only able to sleep for not more than 6 hours.

Past Psychiatric History:

General Statement: L.T is a 33 year-old Caucasian female with a history of abuse of alcohol and crack for a long unreported duration. L.T’s past psychiatric history is not clear. Her duration for alcohol and drug abuse is unknown. She reports that her seropositive status for Hepatitis C prompted her to seek detoxification.
Caregivers: There is no reported past psychiatric care given to the patient.
Hospitalizations: There are no past hospitalizations reported.
Medication trials: There are no reported trials of psychotropic drugs for the treatment of L.T’s illness.
Psychotherapy or Previous Psychiatric Diagnosis: There are no reported past psychiatric admissions or treatments.

Substance Current Use and History: She reports to be using crack approximately worth $100 daily, she admits using cannabis 1-2 times per week, and she also reports taking half a gallon of Vodka daily. She reports that when she does not smoke crack, she feels horrible which prompts her to smoke and feel good from time to time.

Family Psychiatric/Substance Use History: L.T’s family has a rich history of alcohol use, drug abuse, and mental illness. She reports that her father went to prison for abuse and drug charges. She reports having a contumacious, belligerent, and disaffected connection to her father. Her mother has a history of agoraphobia and benzodiazepine abuse. She reports that her brother has not been in contact with the family for 10 years. He also has a history of opioid use.

Psychosocial History: L.T reports that both her parents are alive. Her father was imprisoned and is now estranged from her. Her mother lives in Maine. She mentions having an elder brother who she has not been in contact with for about 10 years. She lives with her boyfriend with whom they have relationship problems and disagreements from time to time. She has a daughter who stays with her friends. She is currently unemployed as she and her boyfriend ran down their business. Her level of education is not mentioned. She has been arrested previously for possession of drugs. She reports having been a victim of sexual abuse and violence when she was 6-9 years old. The perpetrator of the sexual abuse was her father.

Medical History:

She is currently Hepatitis C positive but has not started medication.

Current Medications: L.T is currently not under any medication.
Allergies: She reports being allergic to azithromycin.

Reproductive Hx: L.T reports having one child. Her menstrual history is not mentioned. Her sexual practices are also not mentioned.

ROS:

GENERAL: She reports having lost an unsubstantiated weight, has no fever, no general body malaise, and no chills reported.
HEENT: She reports no headache, no eye pain, no haziness in vision, no diplopia, no exophthalmos, no tearing, no sensitivity to light, and no growths on the ear, she reports normal hearing, there is no reported nasal congestion, no pain or soreness of the throat.
SKIN: No skin rashes, striae, or abnormal growths on the skin.
CARDIOVASCULAR: She reports having palpitations from time to time, she reports on and off chest pain, no shoulder pains, and no edema of the limbs.
RESPIRATORY: No chest pain, no difficulty in breathing, or cough.
GASTROINTESTINAL: There is no reported abdominal pain, no bilious or bloody vomitus, no pale stool or diarrhea, and no melena, she reports loss of appetite.
GENITOURINARY: There is no reported increased urinary urgency, frequency, or incontinence. No reported genital warts or swellings and ulcers in the genital area.
NEUROLOGICAL: No dizziness, no change in gait, no headaches, No sphincter incontinence. No tremors, and no weakness of the limbs.
MUSCULOSKELETAL: no back pain, no joint pains, and there is no restriction in the range of motion of the joints.
HEMATOLOGIC: no pallor, no jaundice, no petechial hemorrhages.
LYMPHATICS: there is no lymphadenopathy.
ENDOCRINOLOGIC: she reports palpitations, no darkening of skin pigmentation, no polyuria or increased feeling of thirst, and no heat or cold intolerance.

Objective:

Physical exam: vital signs: Temperature- 100 F, Pulse rate- 82, Respiratory rate 20, Blood Pressure 180/110mmHg Height 5’6 Weight 146lbs.

Diagnostic results: Liver Function Tests- ALT 168 (high), AST 200 (high), ALK 250 (high), bilirubin 2.5, albumin 3.0 (marginally low). UDS is positive for opiates, THC, alcohol, and other drugs. BAL 308. Complete Blood Count, Thyroid function tests, and Renal function tests are all normal.

Assessment:

Mental Status Examination: L.T is a 33 years old female Caucasian of medium build and looks slightly older than her age. She is seated and has assumed a slouched posture. She is averagely untidy. She is glib in manner. She looks bored, disinterested, and internally preoccupied. She is also tense and fidgety. She avoids eye contact. Her speech rate, rhythm, and volume are normal. She has spontaneous speech. Her mood is subjectively blunted. Her affect is congruent with her mood. Her stream of thought is coherent. She has a depressed cognition marred with the guilt of how people will view her. She is anxious. She experiences a few instances of thought blocking attributed to heightened emotions. She has no perception disturbances. She is oriented to the domains of person, place, and time. She has intact memory and judgment. She has a restricted insight as she is slightly aware she is mentally ill and needs help but keeps denying the help at the same time.

Primary Diagnosis: DSM-5 304.00 (F11.20) Severe Opioid use disorder co-occurring with Moderate Alcohol Use disorder and 305.20 (F12.10) Mild Cannabis use disorder. This patient meets the DSM-V diagnostic criteria for alcohol and substance use disorder. Severe opioid use disorder is evidenced by taking substantial amounts of the opioid over some period, constant desire to reduce or stop, craving to use, continued use despite social, economic, and glaring health challenges, withdrawal symptoms occurring when the opiate is not used (American Psychiatric Association, 2013). All these features are present in the patient. she uses $100 daily on crack. she is currently unemployed, and positive for Hepatitis C but still uses crack. This has led her to abandon her parental responsibilities as her daughter lives with her friends. She experiences withdrawal symptoms as she feels horrible when she abstains from the crack. L.T meets the DSM-V criteria for mild cannabis use disorder.

There is recurrent use that prevents one from carrying out social duties at home, at the workplace, use despite having recurring social challenges, and use despite knowing that it is physically hazardous (American Psychiatric Association, 2013). L.T meets these three criteria as earlier described. She also meets the diagnostic criteria for 303.90 (F10.20) Moderate Alcohol Use Disorder. She takes a daily half a gallon of vodka, she has a desire to cut down and detoxify, her recurrent use could have led to them running down the business, and there exist relationship problems between her and her boyfriend that could be attributed to alcohol and the other drugs. Alcohol tends to amplify and aggravate liver disease (Xu et al., 2021). In this situation, despite alcohol use causing a greater danger to health, L.T continues to use it. Apart from the diagnostic features, supporting features for this co-occurrence are the urodynamic studies that are positive for opiates, THC, alcohol, and other drugs. Other supporting features are the positive test for Hepatitis C and the deranged liver function tests that is evident for hepatic inflammation.

Differential Diagnoses: 301.7 (F60.2) antisocial personality disorder, 300.02 (F41.1) Generalized Anxiety Disorder, and 300.4 (F34.1) Persistent Depressive Disorder.

Antisocial personality disorder qualifies as a differential diagnosis based on the presenting features which include being unlawful, irresponsibility at work, and in managing social and family obligations (Marzilli et al., 2021). According to DeLisi et al., (2019) adverse childhood experiences are precipitants to an antisocial personality disorder. L.T faced sexual abuse as a child perpetrated by her father. However, it is unclear if L.T had a conduct disorder before age 15. Generalized anxiety disorder is a probable diagnosis as L.T is generally tensed, has sleep difficulty as she can only manage 5-6 hours of sleep, and she is in significant social and occupational distress. However, there lacks a temporal association between any phobias and the anxiety state and the presence of an underlying use of drugs edges out this differential. Dysthymia qualifies as a differential diagnosis due to poor appetite and sleeps disturbance (Schramm et al., 2020). However, there is not a clear demonstration of a depressed mood and these symptoms may be attributed to an underlying substance use disorder.

Reflections: An in-depth examination and history taking are key to the proper diagnosis of a patient (Flugelman, 2021). It is altogether a skill that must be meticulously done. This patient presents with alcohol use disorder and a myriad of substance use disorders. These may not be the only illnesses present in this patient. These could be mere maladjustment symptoms to a greater problem (Lo et al., 2020). The root of the problem seems to emanate from an abuse-ridden childhood that could have borne a conduct disorder and a subsequent antisocial personality disorder. There is a big role for genetics and environment in the development of mental illness as described in this case. If I were to revisit the history taking, in this case, I would unearth childhood experiences, relationships, education, and how, and when the alcohol and substance abuse started. Alcohol and substance abuse is a complex interplay that involves social, religious, and individual beliefs. Opinions tend to be divergent when discussing drug abuse. This tends to cause unease, animosity, and stigma in different cultures.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th edition). Reference Reviews, 28(3). https://doi.org/10.1108/rr-10-2013-0256

DeLisi, M., Drury, A. J., & Elbert, M. J. (2019). The etiology of antisocial personality disorder: The differential roles of adverse childhood experiences and childhood psychopathology. Comprehensive Psychiatry, 92, 1–6. https://doi.org/10.1016/j.comppsych.2019.04.001

Flugelman, M. Y. (2021). History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education, 38(6), Doc109. https://doi.org/10.3205/zma001505

Lo, T. W., Yeung, J. W. K., & Tam, C. H. L. (2020). Substance Abuse and Public Health: A Multilevel Perspective and Multiple Responses. International Journal of Environmental Research and Public Health, 17(7), 2610. https://doi.org/10.3390/ijerph17072610

Marzilli, E., Cerniglia, L., & Cimino, S. (2021). Antisocial Personality Problems in Emerging Adulthood: The Role of Family Functioning, Impulsivity, and Empathy. Brain Sciences, 11(6), 687. https://doi.org/10.3390/brainsci11060687

Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. The Lancet Psychiatry, 7(9), 801–812. https://doi.org/10.1016/S2215-0366(20)30099-7

Xu, H.-Q., Wang, C.-G., Zhou, Q., & Gao, Y.-H. (2021). Effects of alcohol consumption on viral hepatitis B and C. World Journal of Clinical Cases, 9(33), 10052–10063. https://doi.org/10.12998/wjcc.v9.i33.10052