Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
Lisa Pittman, 29-year-old female
CC (chief complaint): Feeling scared and worried about joining a rehab.
HPI: Lisa Pittman is a 29-year-old female who presents in a detox facility with thoughts of long-term rehabilitation. The patient provides information that she feels worried about joining a rehab. She reports that she feels scared today. She reports that she sought help because she is scared. When asked about it, she reports that she is scared of everything. She gives further clarification that she does not want people to call her an addict or find out that she is an addict. She reveals that she uses cocaine and has been using it ever since she got back with her boyfriend. It is her boyfriend who introduced her to using cocaine, and she says that she liked the feeling. She compared the feeling to the feeling one gets when dancing with butterflies. Lisa describes the reason she doesn’t want to go to rehab is that she fears the stigma. She is fearful of people finding out she has been to rehab. She is fearful that she might never be hired if people knew she had been to rehab. Another reason she gives is that rehabs are dirty.
Past Psychiatric History: Not Known
Substance Current Use and History: She has been smoking crack cocaine daily. She has a medical card for cannabis and takes it 1-2 times weekly. She also takes 2-3 drinks of alcohol once weekly.
Family Psychiatric/Substance Use History: Her mother has a history of anxiety and is on benzodiazepines. Her brother has a history of opioid use.
Psychosocial History: She has previously been convicted for drug possession and theft. She is currently on a 2-year probation. She occasionally has randomized drug tests. She has a history of sexual abuse from when she was a child aged 5-7. The perpetrator was her father, who is in prison for the offence. She is estranged from her father. She has an elder brother with who she has not had contact with for the last 10 years. She also has a boyfriend.
Medical History:
Past medical history: The patient has Hepatitis C, for which she is considering treatment.
Current Medications: No current medications
Allergies: NKDA
Reproductive Hx: The patient has one child, a girl.
ROS:
GENERAL: Alert. Well-oriented to person, place, and time.
HEENT: Normal vision and visual fields; mucous membranes are moist, there is no lymphadenopathy, and the neck is supple.
SKIN: no lesions or rashes
CARDIOVASCULAR: S1 and S2 heard. No murmurs.
RESPIRATORY: CTA bilaterally
GASTROINTESTINAL: No nausea, vomiting, constipation, diarrhea, or abdominal pain.
GENITOURINARY: No hematuria or dysuria
NEUROLOGICAL: No fainting, no paralysis, seizures, or weakness; no tremors or memory changes.
MUSCULOSKELETAL: No joint stiffness or pains.
HEMATOLOGIC: No bleeding, bruising, or anemia.
LYMPHATICS: No lymphadenopathy
Objective:
Physical exam: The patient weighs 140 lbs. and her height is 5’6”. Her pulse rate is 101 beats per minute. Her blood pressure is 178/94 mmHg, while her temperature is 99.8.
Diagnostic results: ALT 168, AST 200, ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive for cocaine, THC. Negative for alcohol. All other labs are within normal limits.
Assessment:
During the assessment, the patient is in denial that she is an addict. She seems to be unaware that cocaine is addictive and that she is addicted to it. She believes it because her boyfriend, Jeremy, says that it is not addictive. She also says that she does not need help with her addiction.
Mental Status Examination:
On examination, the patient is well-kempt, conscious, and attentive. Her level of concentration is normal. She has normal speech and motor functions. She is well oriented to time, place and person. Her memory is intact, both short—term and long-term. Her mood and affect are congruent. She has poor insight into her condition. Her judgement is affected.
Primary diagnosis: My primary diagnosis is cocaine use disorder. This is a substance use disorder (SUD). SUDs involve both physical and psychological dependence on the substance of use. Dependence is characterized by an inability to control the use of that substance. Prolonged stress plays a role in the development of drug-seeking behaviour. Stimulants such as cocaine act by preventing the reabsorption of serotonin, dopamine and norepinephrine from the synaptic cleft (Brandt et al., 2021). This results in high concentrations of these neurotransmitters in the synaptic cleft. The effect of this high concentration is euphoria. To establish a diagnosis of substance use, the DSM 5 recommends that at least two out of 11 criteria must be met. Two of the criteria met by the patient are:
Withdrawal symptoms experienced by the patient after discontinuing use. Continuation of substance use relieves the withdrawal symptoms.
The patient has strong cravings for the substance.
Differential Diagnoses: Cocaine use disorder differential diagnoses are anxiety disorders and mood disorders (Schmick et al., 2018).
Anxiety disorder. Anxiety is linked to fear. Fear is an automatic physiological state of alarm. Anxiety can be caused by medications, substance abuse trauma and childhood experiences. Another risk factor is a family history of anxiety (Chand & Marwaha, 2021). The patient abuses cocaine. The patient also has a past history of trauma as she was sexually abused by her father when she was a child. The patient’s mother has a history of anxiety and is on benzodiazepines. One of the characteristic symptoms seen in pathological anxiety is the fear of negative evaluation by others. This is one of the symptoms observed in this patient, as she reports that she does not want to go to rehabilitation as she is afraid of the stigma associated with rehab. Another symptom is the avoidance of threatening situations. This is another symptom seen in the patient. The patient cites that another reason she does not want to go to rehab is that she believes that those places are dirty, and she doesn’t want to go to another dirty place. The DSM 5 (APA, 2013) divides anxiety disorders into nine different disorders. One of those disorders is Substance/Medication- Induced Anxiety Disorder.
Mood disorder. Mood disorders are marked disruptions in emotions. The DSM 5 broadly classified mood disorders as depressive and bipolar disorder (APA, 2013). Bipolar disorder is a mood disorder characterized by a combination of depressive or hypomanic episodes, and manic episodes. Bipolar disorders can be classified as bipolar 1, bipolar 2, substance/medication-induced bipolar and related disorder, etc. Certain drugs and medications can lead to symptoms that simulate those of a mood disorder. Cocaine is one of the drugs. Stressful life changes and childhood abuse can also predispose one to mood disorders. The patient reports that she caught her partner cheating with another woman. This can be a stressful event. She also reports that she found out that her partner had withdrawn money from their joint account. Also, she says that a total of $80,000 was lost in a business she had started with her partner. Lastly, the patient has a history of childhood abuse.
Reflections
Stimulant use disorders such as cocaine use have no approved pharmacological treatments. Options available for therapy include non-pharmacological methods such as contingency management. This method involves operant conditioning, whereby certain types of behaviours are influenced via behavioural rewards. A reward is given in exchange for the desired behaviour.
Individuals who abuse substances for long periods develop a dependence on these substances. These individuals usually can’t help themselves as attempts to stop using these substances yield severe symptoms that make the individuals to start using the substance again. Substance use is determined by predicting factors. Some of the predicting factors are how the individual copes with stress, the severity of cravings, availability of the substances, motivation for abstinence, etc. One of the complications of substance use is Hepatitis C. It is possible that the patient’s Hepatitis C is related to her substance use.
If I were to conduct this session all over again, I would also like to know if the patient has ever been diagnosed with a psychiatric illness. I would also want to know if she has ever tried to harm herself. For her substance use history the patient has a family history of substance use. Her older brother has a history of opioid use. This is important because a family can influence one’s risk of substance abuse.
When considering legal/ethical considerations for a psychiatric patient, the patient’s consent, autonomy and confidentiality must be taken into account. For health promotion, health awareness, predisposing factors, and improving mental health literacy should be considered. The patient should be made aware of her condition and educated on the various aspects of her environment that might predispose her to substance abuse (Ramchand et al., 2017).
References
American Psychiatric Association (APA). (2013). Substance-related and addictive disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author. doi:10.1176/app.books.9780890425596.dsm16
Brandt, L., Chao, T., Comer, S. D., & Levin, F. R. (2021). Pharmacotherapeutic strategies for treating cocaine use disorder—what do we have to offer? Addiction, 116(4), 694-710.
Chand, S.P. & Marwaha, R. (2021). Anxiety. In: StatPearls [Internet]. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470361/
Ramchand, R., Ahluwalia, S. C., Xenakis, L., Apaydin, E., Raaen, L., & Grimm, G. (2017). A systematic review of peer-supported interventions for health promotion and disease prevention. Preventive Medicine, 101, 156-170. https://doi.org/10.1016/j.ypmed.2017.06.008.
Schmick, A., Jenewein, J., & Böttger, S. (2018). Diagnosis, differential diagnosis and therapy of substance use disorders in a general hospital (general section). Neuropsychiatrie: Klinik, Diagnostik, Therapie und Rehabilitation: Organ der Gesellschaft Osterreichischer Nervenarzte und Psychiater, 32(2), 57-68.
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Question 
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.
Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
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 a 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 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rule 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.).