Assessing and Treating Patients with Impulsivity Compulsivity and Addiction

Assessing and Treating Patients with Impulsivity Compulsivity and Addiction

Mrs. Maria Perez, a 53-year-old Puerto Rican woman, presents to the clinic complaining of a gambling and alcohol use problem. She notes that she has struggled with alcohol use from her late teenage following her father’s death. She has also been on and off with Alcoholics Anonymous for 25 years. She notes that in the last two years, her alcohol problem intensified after the “Rising Sun” casino was opened near her home. The casino triggered a compulsion for gambling, and due to the intensity and anxiety of the gambling, she drinks one or two bottles to calm her down. This only ends with her often spiraling into excessive drinking and risky gambling behavior. She also notes that she has smoked excessively in the last two years. Mrs. Perez notes that her weight has increased from 115 lbs. to 122 lbs. due to her drinking. Mrs. Perez expresses her concern as she has secretly borrowed an estimated $50,000 from her retirement account to finance her debts from gambling.

During the mental state evaluation of Mrs. Perez, she exhibited alertness, was well-oriented, was well-dressed, and spoke clearly coherently, and was goal-directed. However, she has avoidant eye contact. She also has a sad mood with a matching effect. She denies visual or auditory hallucinations, delusional and paranoid thought processes, as well as suicidal or homicidal thoughts. Her insight and judgment are grossly intact, with her impulse control impaired. Mrs. Perez is diagnosed with gambling disorder and alcohol use disorder. This diagnosis is based on a review of her health history, including alcohol use, gambling, and related factors. Her treatment plan ability will include pharmacotherapeutic and nonpharmacological options. This essay presents three decisions made by the PMHNP regarding pharmacotherapy and other issues arising during the treatment period throughout three visits and the reasons for each decision made.

Decision #1

The first decision was to prescribe Antabuse (disulfiram) 250 mg for Mrs. Perez to be taken orally every morning. This decision is based on the diagnosis of the patient with alcohol use disorder and morbid gambling disorder. Antabuse (disulfiram) is one of the first-line FDA-approved medications for the management of alcohol dependence (Qian & Cantrell, 2022). Mrs. Perez is also adding weight due to her drinking. Animal-based tests of disulfiram on obese mice have shown that the drug can normalize body weight (Bernier et al., 2020). Neurological studies have also shown a relationship between the underlying functions leading to gambling and alcohol use problems (Quaglieri et al., 2020). Therefore, using disulfiram is expected to help Mrs. Perez manage her alcohol use, gambling, and her weight.

The other two medication options, Vivitrol (naltrexone) injection and Campral (acamprosate) were not selected. However, they can both be used to manage alcohol dependence, but due to the risk of side effects and addiction with long-term use, for instance, long-acting Vivitrol (naltrexone) injection has been found to only reduce craving but not AUD aversion with a risk of overstimulating opioid receptors in the brain (Mason & Heyser, 2021). Campral (acamprosate) is also effective in balancing the brain’s neurotransmitters but will only reduce alcohol cravings for a short time.

Antabuse (disulfiram) was prescribed for Mrs. Perez to reduce cravings for alcohol by associating alcohol use with subsequent discomfort. The mechanism of action of disulfiram includes interfering with the body’s metabolic process of oxidating acetaldehyde into less harmful acetic acid (Qian & Cantrell, 2022). Therefore, acetaldehyde builds up, causing undesirable hangovers that will push Mrs. Perez to reduce her alcohol consumption.

Ethical considerations during the first decision point will include appreciating Mrs. Perez’s autonomy in making well-informed decisions and privacy during communication as a person with a mental health condition. The selection of disulfiram as the drug of choice will ensure that it is beneficial to the patient in managing the alcohol use disorder with minimum risk for side effects.

Decision #2

During the second visit, the decision was to require Mrs. Maria Perez to continue with the current dose of Antabuse and refer her for counseling for the ongoing gambling issues. Sedation, fatigue, and a metallic taste are common and acceptable side effects of using disulfiram (Qian & Cantrell, 2022). Therefore, no need for alarm. On the other hand, counseling for the ongoing gambling issues was necessary as gambling led to Mrs. Perez drinking impulsively. Counseling as a psychotherapeutic approach can help understand the psychological mechanisms of gambling addiction and address the underlying factors and triggers (Mollaeva et al., 2019). Therefore, counseling will improve her gambling and alcohol use disorders.

The other two options of continuing with the current Antabuse and adding Campral: Campral or adding Wellbutrin (bupropion) were not selected as Campral is basically an anti-craving drug and will add to unnecessary costs of care (Holzbach et al., 2019). Wellbutrin, although an effective antidepressant with effects on smoking cessation (Huecker et al., 2022), the treatment for Mrs. Perez specifically targets gambling and alcohol disorder, which Wellbutrin does not treat directly.

Continuing with the current Antabuse dosage aims to help suppress Mrs. Perez’s alcohol consumption cravings. On the other hand, referring her to counseling for gambling issues aims to help her access specialized support to address the underlying psychological factors contributing to her gambling problem. Counseling is among the major effective psychological management approaches to gambling, especially with comorbid psychiatric conditions (Echeburúa & Amor, 2021).

During the second visit, communication with Mrs. Perez will consider the ethical principles of autonomy and beneficence. In this case, the PMHNP must consider the best care approaches for Mrs. Perez and provide clear details of the available options, including what they entail, and then let her choose. The decision to see the counselor will solely be Mrs. Perez’s.

Decision #3

For the fourth visit, the decision was to seek to understand Mrs. Perez’s issue with her counselor, encourage her to continue attending the Gamblers Anonymous meetings, and discuss the available options for smoking cessation. The relationship with the counselor is essential to helping Mrs. Perez overcome her gambling issues. On the other hand, attending Gamblers Anonymous meetings will provide her with a peer support network which has been noted to help with recovery attempts for alcohol or drug addictions (Kelly et al., 2019).

The other two options, encouraging Mrs. Perez to continue with her counselor and attending Gamblers Anonymous meetings and discontinuing Antabuse and continuing attending her counseling and Gamblers’ Anonymous meetings, are both effective in managing her gambling and impulsive drinking problems. However, in both cases, continuing with the counselor without a good client-therapist relationship will have negative mental outcomes for both the therapist and Mrs. Perez. Additionally, Mrs. Perez has gained Antabuse tolerance which has helped her abstain from alcohol. Discontinuing Antabuse now can undo these gains.

Mending the relationship between Mrs. Perez and her counselor, continuing with her attendance at the Gamblers’ Anonymous, and taking Antabuse aims to improve her aversion to alcohol while improving her coping skills. The relationship with her counselor will improve the therapeutic effect of counseling, including effects on smoking cessation.

During Mrs. Perez’s fourth visit, communication will be guided by respect for her autonomy and the need to provide the most beneficial care. The PMHNP must ensure Mrs. Perez understands the available options as well as consider her preferences. The ethical principle of beneficence will guide the PMHNP to ensure the care decisions made collaboratively with the patient align with her needs and expected care outcomes.

Maintaining open, honest, and respectful communication, considering her values and preferences, and addressing her concerns contribute to an ethical treatment plan that supports her journey to recovery.

(Please note that the provided response is hypothetical and does not constitute medical advice. Actual medical decisions should be made based on a comprehensive evaluation of the patient’s individual circumstances and in consultation with a qualified healthcare professional.)

Conclusion

Mrs. Maria Perez, a 53-year-old Puerto Rican woman, was diagnosed with comorbid gambling disorder and alcohol use disorder. All treatment decisions made during her routine visits consider individual mental health and behavioral needs per Mrs. Perez’s health and treatment history. For instance, Antabuse (disulfiram), started at 250 mg orally every morning, was selected despite the other available options for managing alcohol dependence as Antabuse has been found to be effective in the aversion of alcohol use and with a more acceptable risk profile as compared to other medications (Qian & Cantrell, 2022). As alcohol disorder and gambling disorder have linked psychological and neurological mechanisms (Quaglieri et al., 2020), managing Mrs. Perez’s alcohol use disorder with disulfiram is expected to significantly reduce her need to gamble. The decision to address the relationship issues between Mrs. Perez and her counselor is to ensure that the two work together to help her with the gambling problem, as research evidence shows that developing collaborative relationships with patients during the first sessions of psychotherapy determines the progress and outcomes of the sessions (Spencer et al., 2019). A good relationship between Mrs. Perez and her counselor will also help address her gambling and smoking problems and any other issues she may have. Additionally, encouraging Miss Perez to continue attending Gamblers Anonymous is expected to provide her with a community that can support her in her journey to overcoming alcohol dependence. In conclusion, Mrs. Perez’s comorbid gambling and alcohol use problems require a comprehensive treatment plan that includes pharmacotherapeutic and psychotherapeutic approaches to effectively improve alcohol aversion and address underlying psychological triggers of gambling and impulsive drinking.

References

Bernier, M., Mitchell, S. J., Wahl, D., Fernandez-Hernando, C., Cuervo, A. M., De, R., & Correspondence, C. (2020). Clinical and Translational Report Disulfiram Treatment Normalizes Body Weight in Obese Mice. Cell Metabolism, 32, 203-214.e4. https://doi.org/10.1016/j.cmet.2020.04.019

Echeburúa, E., & Amor, P. J. (2021). Psychological Management of Gambling Disorder With or Without Other Psychiatric Comorbidities. Textbook of Addiction Treatment, 929–942. https://doi.org/10.1007/978-3-030-36391-8_65

Holzbach, R., Stammen, G., Kirchhof, U., & Scherbaum, N. (2019). The Prescription of Anticraving Medication and its Economic Consequences. European Addiction Research, 25(5). https://doi.org/10.1159/000500521

Huecker, M. R., Smiley, A., & Saadabadi, A. (2022). Bupropion. XPharm: The Comprehensive Pharmacology Reference, 1–4. https://doi.org/10.1016/B978-008055232-3.64054-1

Kelly, J. F., Greene, M. C., Bergman, B. G., White, W. L., & Hoeppner, B. B. (2019). How Many Recovery Attempts Does it Take to Successfully Resolve an Alcohol or Drug Problem? Estimates and Correlates From a National Study of Recovering U.S. Adults. Alcoholism: Clinical and Experimental Research, 43(7), 1533–1544. https://doi.org/10.1111/ACER.14067

Mason, B. J., & Heyser, C. J. (2021). Alcohol Use Disorder: The Role of Medication in Recovery. Alcohol Research : Current Reviews, 41(1). https://doi.org/10.35946/ARCR.V41.1.07

Mollaeva, N. R., Khatsieva, M. S., Damadaeva, A. S., Aptaeva, Kh. Kh., & Masaeva, Z. V. (2019). Psychotherapy for Rehabilitation of Patients Suffering from Gambling Addiction. 188–190. https://doi.org/10.2991/ICHW-19.2019.44

Qian, L., & Cantrell, F. L. (2022). Disulfiram. Encyclopedia of Toxicology: Third Edition, 208–209. https://doi.org/10.1016/B978-0-12-386454-3.00725-9

Quaglieri, A., Mari, E., Boccia, M., Piccardi, L., Guariglia, C., & Giannini, A. M. (2020). Brain Network Underlying Executive Functions in Gambling and Alcohol Use Disorders: An Activation Likelihood Estimation Meta-Analysis of fMRI Studies. Brain Sciences 2020, Vol. 10, Page 353, 10(6), 353. https://doi.org/10.3390/BRAINSCI10060353

Spencer, J., Goode, J., Penix, E. A., Trusty, W., & Swift, J. K. (2019). Developing a collaborative relationship with clients during the initial sessions of psychotherapy. Psychotherapy, 56(1), 7–10. https://doi.org/10.1037/

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

I would like to see more information on the patient’s disease state in the introduction. Don’t forget to include a purpose statement in future assignments. The purpose statement should explain the purpose of the essay and how the PMHNP is making three different decisions regarding pharmacotherapy every 4 weeks for three visits.

In each decision point, I would like to see more discussion regarding the reason you picked a medication instead of how the medication works. Please include patient-specific factors within each decision point. There are points mentioned in the patient’s case that you should include to support your decision.