Assignment: Psychopharmacological Approaches to Treat Psychopathology: The Case of a 48 Year-Old Caucasian Female with Alcohol Use Disorder (AUD)

Assignment: Psychopharmacological Approaches to Treat Psychopathology: The Case of a 48 Year-Old Caucasian Female with Alcohol Use Disorder (AUD)

Assignment: Psychopharmacological Approaches to Treat Psychopathology: The Case of a 48 Year-Old Caucasian Female with Alcohol Use Disorder (AUD)

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.

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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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.).

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

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’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

Name: NRNP_6635_Week8_Assignment_Rubric to Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
EXCELLENT
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
18 (18%) – 20 (20%)
The response thoroughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.
23 (23%) – 25 (25%)
The response thoroughly and accurately documents the results of the mental status exam.
Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

Reflect on this case. Discuss what you learned and what you might do differently. 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.).
9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
14 (14%) – 15 (15%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.

Written Expression and Formatting—Paragraph development and organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors

PLEASE INCLUDE A INTRODUCTORY AND CLOSING PARAGRAPH

Training Title 114
Name: Ally Patel
Gender: female
Age: 48 years old
Background: Only child, raised by parents in San Francisco, CA. Has PhD in biology and
master’s degree in high school education (8–12). Her supervisor has asked the school EAP
counselor to intervene with concerns regarding potential substance use in effort to facilitate
getting her help and be able to retain her.
Symptom Media. (Producer). (2018). Training title 114-2 [Video]. https://video-alexanderstreet-
com.ezp.waldenulibrary.org/watch/training-title-114-2

TRAINING TITLE 114ALLY (ph) My personal life is fine. And personal.
00:01:05UNKNOWN I know you haven’t changed addresses so it can’t be the traffic.
00:01:10ALLY (ph) Jesus. The History Department had a party last night a Darrel’s(ph). Why don’t you bring him in here and question him?
00:01:20UNKNOWN So are you saying the Darrel’s(ph) party is the reason that you were late? That was last night? I don’t understand.
00:01:25ALLY (ph) Okay. Alcohol was served. We had a bit much to drink. Not just me. We’re adults here. And I mean, the… the school host of social hour on campus every month.
00:01:40UNKNOWN So what are you saying? Are you saying that you were drunk?
00:01:45ALLY (ph) I drank, but no.
00:01:45UNKNOWN Were you intoxicated enough that you passed out?
00:01:50UNKNOWN I woke up and Darrel’s(ph) cash responding. And, and fuck him for not waking me. He came to school on time but let’s be there lying on the couch.
00:02:00UNKNOWN Have you passed out other times?
00:02:05ALLY (ph) We have all passed out at times. I’m sure I’ve seen you drunk at those parties.
00:02:10UNKNOWN Are you still feeling intoxicated this morning?
00:02:15ALLY (ph) No, Course not.
00:02:15UNKNOWN Have you ever been drunk? While you were here teaching?
00:02:20ALLY (ph) No.
00:02:20UNKNOWN I’m asking that because we’ve had complaints.
00:02:25ALLY (ph) Complaints from who?
00:02:25UNKNOWN Students, parents.
00:02:30ALLY (ph) Well, bring him in. Let them tell that to my face because it’s totally not true.
00:02:35UNKNOWN They’ve complained that at different times you came into class and then you ordered the kids to read from their textbook or you ordered the kids to copy notes from the board while you were sleeping with your head on the desk.
00:02:45ALLY (ph) You have to be kidding me.
00:02:50UNKNOWN Several students and several parents have complained.
00:02:55ALLY (ph) Exactly who, Alexis? Do you know how many problems she’s created for the teachers at the school.
00:03:00UNKNOWN But you were drinking last night. And it sounds like you drank enough that you passed out and had to sleep on Darrel’s(ph) couch?
00:03:10ALLY (ph) Yes. I mean, I did.
00:03:15UNKNOWN So, is there something going on in your personal life?
00:03:20ALLY (ph) No.
00:03:20UNKNOWN How’s Ryan?
00:03:25ALLY (ph) Ryan? First time I’ve known you to travel slow here. We split up before the school year started. Last summer.
00:03:35UNKNOWN What happened?
00:03:35ALLY (ph) I’m really, really uncomfortable sharing anything about my relationships with you.
00:03:45UNKNOWN Okay, that’s fair. That is your personal life.
00:03:50ALLY (ph) Is there any reason I just can’t walk out of this office right now?
00:03:50UNKNOWN Well, I don’t know the specifics of what the Board of Education would decide if you don’t cooperate, but I’m guessing at something pretty serious.
00:04:00ALLY (ph) This is unbelievable.
00:04:05UNKNOWN Wait, wait. Wait a minute. The administration asked me to speak with you. The school wants to work with you if you’ll cooperate. And as someone who really likes you. I am warning to understand. I’m hoping to help you. So just, okay, thank you. Good. Now, what’s going on?
00:04:30ALLY (ph) I don’t know.
00:04:30UNKNOWN Okay. How much did you drink last night?
00:04:35ALLY (ph) Too much.
00:04:35UNKNOWN How often do you drink too much?
00:04:40ALLY (ph) I don’t know.
00:04:45UNKNOWN How much would you estimate that you drink in a typical week?
00:04:50ALLY (ph) Every night.
00:04:50UNKNOWN Do you drink with friends, family, by yourself?
00:04:55ALLY (ph) Alone. Once in a while I’ll go to a bar with my friends or drink at school functions. Where I might add they do supply alcohol liberally.
00:05:05UNKNOWN Yes.
00:05:10ALLY (ph) They’re removing our social hours to downtown.
00:05:10UNKNOWN Do you go out and drink other than with friends?
00:05:15ALLY (ph) Occasionally.
00:05:15UNKNOWN Do you drink alone at home?
00:05:20ALLY (ph) Few glasses of wine while a grade takes the edge off the day.
00:05:25UNKNOWN Takes the edge off.
00:05:30ALLY (ph) Yes. The kids here are getting worse by the year. The teachers talk about it. We all know what’s going on. They become they just become more… more vicious, more mean. I’m talking about kids who have no hint of remorse, no empathy, no thoughtfulness for others. When was the last time you try teaching them?
00:05:45UNKNOWN I have to admit it has been a while.
00:05:50ALLY (ph) Just last week, I caught Alexis filming me on her phone. I was bent over picking up trash a student through on the floor. It was not flattering. And you know what she did?
00:06:00UNKNOWN No.
00:06:05ALLY (ph) Send it out to the whole grade adding a really obscene title.
00:06:05UNKNOWN Was she punished?
00:06:10ALLY (ph) Do the kids here ever get punished? All she caught was a bucking set down with their neuter principal. And then her mom comes threaten Sue again and naturally our fearless leader backs down. Michaels humiliated me. Did the administration tell you that?
00:06:25UNKNOWN No.
00:06:30ALLY (ph) Humiliated me. I work for a place that has no backbone, no spine. Who runs this place here? The students or the teachers.
00:06:40UNKNOWN Sounds horrible.
00:06:45ALLY (ph) And it goes on day after day. Rich kids who have no respect while you struggle to teach. I’m trying to pay bills here. Pay uh… pay the gas, driving shitty car, pay off student loans.
00:06:55UNKNOWN That does sound like a lot of stress.
00:07:00ALLY (ph) Sounds like.
00:07:00UNKNOWN Do you like teaching?
00:07:05ALLY (ph) Once upon a time when it had meaning.
00:07:05UNKNOWN What about now?
00:07:10ALLY (ph) We aren’t supported.
00:07:15UNKNOWN Do you think all of this stress is contributing to your drinking?
00:07:15ALLY (ph) Of course it is.
00:07:20UNKNOWN Do you drink during the day?
00:07:20ALLY (ph) No, no, absolutely not.
00:07:25UNKNOWN When you do drink, how much do you drink?
00:07:25ALLY (ph) Enough.
00:07:30UNKNOWN Enough to pass out?
00:07:30ALLY (ph) If I’m lucky.
00:07:35UNKNOWN How much do you have to drink to get that feeling of being intoxicated?
00:07:40ALLY (ph) Five or six glasses of wine, a couple of mixed drinks.
00:07:45UNKNOWN Do you think that’s more than it takes most people to get intoxicated?
00:07:50ALLY (ph) I don’t know, but… but I can.
00:07:50UNKNOWN So, so do you think alcohol affects your body differently than it affects your friends?
00:07:55ALLY (ph) Yes, alcohol affects. Yes.
00:08:00UNKNOWN Do you drink more than your friends and the other teachers?
00:08:05ALLY (ph) I… I drink, but… but you’re not understanding it, it affects me differently.
00:08:15UNKNOWN Has it prevented you from doing things or interfered with relationships?
00:08:25ALLY (ph) Are you specifically talking about Ryan here?
00:08:25UNKNOWN Yeah.
00:08:30ALLY (ph) Okay, Ryan did not leave me because I drink.
00:08:30UNKNOWN Okay.
00:08:35ALLY (ph) I’m seeing someone new. We weren’t even together for a year.
00:08:35UNKNOWN Is drinking wine, beer, other alcoholic drinks in the evenings. Is that something new for you? Or was that something typical than your past?
00:08:50ALLY (ph) No. Look, my father was an alcoholic growing up. When I was really little he drank. He got into AA and got sober. Mom was very supportive of him, but extremely strict with us in drinking.
00:09:10UNKNOWN How did you feel about her being so strict with alcohol?
00:09:15ALLY (ph) As a teenager it sucked. I went out with my friends I got drunk. And then freshman year was a huge vendor. Eventually I just I mellowed out.
00:09:25UNKNOWN And after college?
00:09:25ALLY (ph) In grad school I drank here and there but not much.
00:09:30UNKNOWN Do you think your alcohol intake is less that when you were in college or is it gone the other way? Has it increased recently?
00:09:40[sil.]
00:09:50ALLY (ph) More.
00:09:55END TRANSCRIPT

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Psychopharmacological Approaches to Treat Psychopathology: The Case of a 48 Year-Old Caucasian Female with Alcohol Use Disorder (AUD)

Alcohol use disorder (AUD) is an addictive disorder that is concerned with the excessive consumption of etoh. It is found in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5 under Substance-Related and Addictive Disorders (APA, 2013; Sadock et al., 2015). This is the case of a 48 year-old Caucasian female teacher who presents with alcohol use that is now interfering with her work and social life.

Subjective:

CC (chief complaint): The patient presents with daily alcohol use and dependence. She is taking alcohol and binge drinking whenever the opportunity arises. The drinking interferes with her occupational duties as well as her interpersonal relationships.

HPI: The patient is a 48 year-old Caucasian female who presents with alcohol addiction. She does not deny a previous history of drinking and accepts that she does so frequently mostly alone but at times with friends. The onset of this habit was when she was in college as she states that they would from time to time get drunk. The habit is constant and recurring and she engages in it even though she knows that it affects her work performance and could get her fired. It is aggravated by solitude and slightly relieved by being in unfamiliar environments. She rates the severity of her alcohol craving symptoms at 6/10.

Past Psychiatric History: She has a long history of alcohol use but no history of treatment for the same.

• General Statement: She is dependent on alcohol to cope with her daily routine and work. She says that some students are disrespectful and so it is foreseeable that the drinking is to mask her disappointments.
• Caregivers (if applicable): She does not yet need caregivers as she can carry pout her own tasks including activities of daily living.
• Hospitalizations: She never been hospitalized for any psychiatric condition or received any therapy for the same.
• Medication trials: There is no history of her being put on any medication previously for her AUD or any other psychiatric illness.
• Psychotherapy or Previous Psychiatric Diagnosis: She has not had a past diagnosis of a mental condition, nor had any therapy for the same.

Substance Current Use and History: The patient admits to starting to take alcohol when she was in college. Allegedly her mother was very strict when it came to matters alcohol. She has therefore been drinking both clandestinely and openly since her college days.

Family Psychiatric/Substance Use History: The patient volunteers information that her own father was an alcoholic with alcohol use disorder. He was however treated and recovered sobriety after joining Alcoholics Anonymous. She does not give any indication that her mother had been a drinker too.

Psychosocial History: The patient was born and brought up in San Francisco, California. She was an only child and was raised by both her parents. She is an educated lady and has a master’s degree in high school education and a PhD in Biology. Currently, she works as a high school teacher. She does not profess any other hobby apart from drinking with friends.

Medical History: She does not give any history of hospitalizations.

• Current Medications: She is presently not taking any medication.
• Allergies: She has no known allergies.

• Reproductive Hx: She is a heterosexual female but does not have children.

ROS:

• GENERAL: She denies weight loss of weight, fatigue, malaise, chills, or fever.
• HEENT: Negative for double vision, photophobia, myopia, tinnitus or otorrhea. Also negative for rhinorrhea, epistaxis, or sneezing as well as sore throat or dysphagia.
• SKIN: She denies pruritus, eczema, or rashes.
• CARDIOVASCULAR: Negative for chest tightness, chest discomfort, edema, or difficulty in breathing.
• RESPIRATORY: Denies shortness of breath, wheezing, coughing, or the production of phlegm.
• GASTROINTESTINAL: Negative for nausea, vomiting, diarrhea, abdominal pains, or a change in bowel movements.
• GENITOURINARY: Denies painful micturition, frequency of micturition, dribbling or urinary incontinence. She is also negative for polyuria and oliguria.
• NEUROLOGICAL: Denies weakness, numbness, pins and needles, dizziness, syncope, or loss of sensation in the peripheries. She also denies the loss of bowel and/ or bladder control.
• MUSCULOSKELETAL: She is negative for muscular pain, joint stiffness, or joint pain.
• HEMATOLOGIC: She denies having blood or blood clotting disorders in her family.
• LYMPHATICS: She is negative for lymphadenopathy and denies ever having undergone splenectomy.
• ENDOCRINOLOGIC: She denies a past history of hormonal therapy. She is also negative for polydipsia and/ or polyphagia. Also denies excessive sweating and heat/ cold intolerance.

Objective:

Physical exam: Patient LP is appropriately dressed although her hair seems a bit disheveled. She is alert and oriented to person, place, time, and event. Her speech is coherent though at times hesitant and is also goal-directed. Her vital signs are T 99.8; P 101; BP 178/94; BMI 22.6 kg/m² (normal BMI).

Diagnostic results: Albumin 2.1 mg/dL (low); bilirubin 2.0 mg/dL (high); AST>ALT; WBC 7.6 x 10⁹; Hb 12.0 g/dL. MRI of the abdomen shows evidence of liver cirrhosis.

Assessment:

Mental Status Examination (MSE)

The patient is a 48 year-old Caucasian female who is alert and oriented in place, space, person, time, and event. Her speech is clear, coherent and goal oriented. She is well groomed and dressed for the weather and the time of the day. She is quite cooperative during the entire interview and maintained good eye contact with the interviewer. There were no gestures, mannerisms, or tics noted with the patient. The self-reported mood is “good” but the observed affect is dysphoric. This meant that the mood and the affect were not congruent. She denied experiencing any hallucinations or delusions. She also denied having suicidal thoughts or homicidal ideation. Her insight was good as was her judgment. The diagnosis that was made in the end was 303.90 (F10.20) Moderate Alcohol Use Disorder or AUD (APA, 2013; Sadock et al., 2015).

Differential Diagnoses

1. Alcohol Use Disorder (AUD) – 90 (F10.20)

This is the most likely primary diagnosis for this patient given her history and the fact that she drinks alcohol almost every day without fail. She meets most of the DSM-5 diagnostic criteria for AUD and thus qualifies for this diagnosis. For instance, she has clinically significant impairment and distress shown by several factors within the past 12 months. These factors include increasingly consuming alcohol in larger amounts than initially intended, inability to resist taking alcohol even when she tries, repeated drinking of alcohol resulting in failure to perform at work, a strong urge to consume alcohol, spending a lot of productive time looking for and consuming alcohol, as well as development of tolerance and withdrawal symptoms (APA, 2013; Sadock et al., 2015). She has demonstrated all these and is therefore fit for the diagnosis of AUD.

2. Non-pathological Alcohol Use

It is possible that this patient is just an occasional binge drinker but just takes alcohol in moderate amounts every day. This would mean that she has not necessarily developed alcohol dependence and addiction but is just a regular drinker (APA, 2013). In this case the condition is not pathological and she may not require therapy for it.

3. Conduct Disorder in Childhood

The presence of a pre-existing conduct disorder from childhood has been known to predispose to wanton alcohol use. It is therefore prudent to rule this out before any diagnosis of AUD can be made (APA, 2013).  

Reflection

What I have learnt in this case was that it is important to take a proper history when dealing with a potential diagnosis of addiction for any substance. This is because there is so much similarity in presentation that one may easily miss a correct diagnosis with disastrous therapeutic consequences. I believe I did the best by following the evidence-based protocols for history taking and physical examination (Carlat, 2017). Because of this, I would still follow the same protocol if I were to interview and assess the same patient again. The ethical considerations that were observed include autonomy (in informed consent), nonmaleficence, and beneficence (Haswell, 2019). Health education and promotion were given along the lines of accepting therapy in the form of group cognitive behavioral therapy or CBT (Wheeler, 2020). She was also encouraged to join the 12-step approach Alcoholics Anonymous or AA self-help group (The University of Arizona, n.d.). This would help her recover and stay sober.

Conclusion

Addiction to alcohol is like any other addiction to any substance. There is dependence and when attempts are made at not taking the substance withdrawal symptoms emerge. In essence the person cannot function without taking the substance. Unfortunately, their judgment is impaired in the case of alcohol and so they get impaired in occupational, social, and self-care domains. This case of a 48 year-old female teacher is a case in point.

 References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Carlat, D.J. (2017). The psychiatric interview, 4^th ed. Wolters Kluwer.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

The University of Arizona (n.d.). Self-help groups and 12-step oriented approaches. https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=226

Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice, 3^rd ed. Springer Publishing Company, LLC.