Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Patient Information:

Initials: AB       Age: 28        Sex: Female     Race: White

Cc (Chief complaint): ‘I feel scared people are going to know I was in a rehab’. Yes, I smoke crack, 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. ‘Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

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HPI: AB is a 28 years old white female who presents to the unit with complaints of feeling horrible due to use of cocaine. AB reported to the hospital to seek help due to her cocaine addiction. She is too anxious and restless, and her concentration is low. She is also angry and depressed, and she cries while being interviewed. AB accepts that she is addicted and understands that she will need to remain in rehab for a while. However, she is afraid that people will know about it, and even employers will not consider her for employment. She has a boyfriend who abuses cocaine, smocks tobacco, and drinks a lot of alcohol. Her boyfriend introduced her to cocaine abuse. AB is angry about a cheating boyfriend whom she found having sex with his workmate. AB and her boyfriend are workmates too. Her main concern is getting help with cocaine addiction but does not want to be admitted to a rehab center. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Past psychiatric history: AB was first diagnosed with bipolar I disorder at 22 years, a year after completing school. She was started on valium 20mg intravenous dose and chlorpromazine 200mg STAT doses and Haldol 10mg BD and Tegretol 200mg BD as maintenance doses. Six months before hospital admission, she had complete a three-month rehabilitation to manage substance abuse. However, she experienced adverse side effects of antipsychotics that forced the caregiver to tapper down Tegretol doses to 100mg BD. The condition has relapsed twice since; however, both have been managed out of the hospital. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Current Medication: AB was discharged three months later on Haldol 5mg BD and Tegretol 100mg OD. She was also attending psychiatric clinics where the primary caregiver was updating the same drug’s list on her medical records. The caregiver tapered down the dosage tapered down due to noticeable improvement in AB’s mental health. She, however, stopped taking the medication a year ago.

Allergies: No known food and drug and allergies (NKFDA).

Therapies: AB was booked for psychotherapy sessions once every week as the frequency reduced gradually with improving conditions. Some of these sessions included group therapy that significantly improved her condition. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Family Hx: ABs Dad died of liver cirrhosis at 45 years. Five years ago, her mother was diagnosed with bipolar depressive disorder. She was started on Haldol 5mg BD and Tegretol 100mg OD and other behavioural therapies, which responded positively. Two of her paternal uncles are alcohol addicts.Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders. Lisa’s paternal grandfather had diabetes and hypertension, and he used to smoke tobacco and occasional alcohol drinker. He succumbed to a heart attack. Lisa’s elder brother was involved in a road accident while drunk driving with a group of friends. Her maternal grandfather was a known psychiatric patient with relapsing bipolar depressive disorder. He was admitted more than five times at a psychiatric unit. He committed suicide by jumping down the cliff. Her maternal uncles also abuse alcohol. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Substance Use History: AB started consuming alcohol at 20 years in college after she met college friends in her second last year who introduced her to alcohol, tobacco and cocaine. AB was consistent with alcohol and not the rest before she met her current boyfriend. Three months ago, her boyfriend introduced her to cocaine, which has become addicted to. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Social Hx: AB is the last born in a family of three with two elder brothers. Her Dad died when she 13 years old. Her mother is still alive but resides in another city far from her. She has a boyfriend who she stays with. AB graduated at 24 years with a degree in information technology. Currently, she is actively engaged in creating commercials for local businesses together with her boyfriend. She likes to sing and was a choir member at a local church around their home. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Medical History: AB is a known peptic ulcer disease patient since her teenage.

Current medications: Alugel syrup 10mls OD. Also takes Protonix 20mg PRN, OTC.

Allergies: no known food and drug allergy.

Reproductive Hx: she is not pregnant, has a regular menstrual cycle of 28 days, no concerns. Has a normal sexual pattern. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

ROS

GENERAL: patient stable, no fever, chills, weakness and or fatigue.

HEENT: Eyes – proper vision with no identifiable double vision, blurred vision, or red sclerae; Ears – no build-up or hearing loss, Nose & Throat – no sneezing, nasal congestion, and running nose.Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

SKIN: Fresh scars all over the face, no rashes or itching. Skin is moist, cool and has a normal turgor.

CARDIOVASCULAR: normal heart sounds heard, normal capillary refill. No chest pain voiced. No palpitations or edema noted. No murmurs noted.

RESPIRATORY: normal lung sounds, normal breathing pattern, lungs expand and contract symmetrically bilaterally. No cough.

GASTROINTESTINAL: bowel sounds present in all the quadrants, no inflammation, stool normal, not bloody. No pain, nausea, vomiting or diarrhea. Experienced acid reflux frequently, no tenderness noted.

GENITOURINARY: Bright yellow color of urine with no episode of burning or pain on urination. No urinary incontinence. No history of blood in the urine.

NEUROLOGICAL: No headache or dizziness.

MUSCULOSKELETAL: No swelling and pain. No history of back pain and in upper extremity joints.

PSYCHIATRIC: restlessness, irritability and tense mood.

ALLERGIES: the patient has no history of eczema, asthma, and or rhinitis. No known food and drug allergies.

Physical exam: only one part related to the CC is psychiatry and requires mental state assessment

Diagnostic results: FBC (full blood count), urinalysis, lipid profile, renal profile, EEG, MRI/ PET  Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Mental State Assessment: AB is 28 years old who looks older and frustrated. Her clothes are in order, her hair is unkempt, and the nails are too long and untidy. She appears wasted, and she reports her eating habits have changed. Her behavior is wanting; she is restless and wants to quit the interview every time. She is outraged and too anxious at the same time. Her speech is incoherent, normal in volume and ton. Affect is distressed and is congruent with the mood. She is delusional, paranoid and extra anxious, especially when rehabilitation is discussed. She has loose association and experiences though block at times. She skips from one question to another before providing a complete answer.Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders. She has both visual and audio hallucinations and says he can hear people talking to him or ordering him to say or do something. She denies suicidal and homicidal ideation. Her attention is very poor, and she starts crying in the middle of the interview. She is oriented to place but not time and person. Her memory is poor; she cannot recall remote and recent events but recalls the immediate one. Her judgement is good, can internalize scenarios and provide an appropriate answer.  Her insight is poor, as she is aware she has a problem but does not want to get help. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Differential diagnosis

1. I) Substance Abuse Disorder- this a condition that erupts from abuse of hard drugs that interfere with the normal brain functions. Some of the most commonly misused drugs include; alcohol, amphetamine, caffeine, cannabis, cocaine, hallucinogens, inhalants, opioids, PCP and sedative-hypnotics. According to LeTendre et al., (2017), the substance abuse may induce several mental health disorders that include; dementia, delirium, persisting amnestic disorder, psychotic disorders, anxiety disorders, mood disorders, sleep disorders and sexual dysfunction. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.According to Hasin et al., (2021), the DSM V criteria for people who abuse stimulants like cocaine commonly present with symptoms that include, extravagance, deficient sleep, urge to use drugs every time, skipping duties to abuse drugs, restlessness, stealing to get finance to purchase drugs, drastic nutritional change and decreased cognitive functions. AB is addicted to cocaine and alcohol, thus highly at risk of developing substance abuse disorder. Cocaine is a highly addictive drug and most patients quickly develop dependence and finally a mental illness.Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

1. II) Schizophrenia- This is a form of mental illness in which patients present with three categories of symptoms; positive, negative and cognitive. The DSM V manual describes the positive symptoms as hallucinations, disorganized speech and extremely bizarre behaviour. Some of the negative symptoms of schizophrenia include; the poverty of speech, anhedonia, flat affect, loss of motivation, attentional deficits and social withdrawal (de Pablo et al., 2020). Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.Cognitive symptoms include interference with cognitive functions such as impaired thought process and perceptions. According to McCutcheon et al. (2020), schizophrenia accounts for 1% of the population. Additionally, more than 70% of patients treated for schizophrenia experience relapse due to medication non-adherence. AB is at high risk of developing this condition due to substance abuse and genetic predisposition from her mother. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

III) Bipolar I Disorders- this is a mood disorder commonly known as a manic-depressive disorder. Patients with this condition experience at least one episode of mania in their lives. Manic episodes are characterized by an abnormally elevated and or irritable mood that makes the patient restless and over-anxious. According to Machado-Vieira et al. (2017), the DSM V manual describes that these patients also experience periods of depression characterized by a socially withdrawn behavior, a depressed mood and less activity. The manic-depressive disorder’s symptoms described in the manual include restlessness, uninterruptible loud speech, excess energy with hyperactivity, lack of sleep, delusions of grandeur, extravagant behaviour, etc. bizarre behaviour (Ashok et al. 2017). Therefore, AB could have the condition due to the susceptibly to hereditary disease affecting mother, substance abuse and recent encounters with her cheating and extravagant habit.Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

 Primary Diagnosis:  Substance Abuse Disorder

This is a condition that is caused by the abuse of drugs and is common among young populations. A comprehensive mental state assessment, full blood count, and history taking can improve the disorder’s diagnosis. Patients who present with a history of drug addiction and other psychotic symptoms such as a change in behavior, mood and impaired cognition likely have developed substance abuse disorder (LeTendre et al., 2017),. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.Drugs of addiction alter various neurotransmitter balance and interfere with the brain functions such as cognition, mood and behavior. Care providers should perform a detailed mental state assessment to all patients presenting psychotic symptoms to rule out the diagnosis. They are usually done by interviewing the patient to identify their thoughts, perceptions, previous history, available risk factors, and general presentation. According to LeTendre et al. (2017), a comprehensive mental state examination should provide the care provider with a detailed report on the patient psychotic condition. This report will then guide the identification of the primary diagnosis. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Risk factors

Mental illness is associated with several factors that may synergistically promote its development. The most common risk factors to mental illness include; genetic predispositions, birth complications and substance abuse. According to Gruebner et al., (2017), substance abuse disorder is associated with a family history of drug addiction, presence or risk of mental health disorder, peer pressure, early use of drugs, and lack of family bond, consumption of a highly addictive drug, challenges of daily living, socio-economic status, and stress from social and personal life. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Latin American race was more at risk of developing mental illness. Gruebner et al., (2017) describe that a combination of age over 44 years, Latin America ethnicity, low economic status, and life challenges that increase insecurity increase the chances of developing mental illness. Significantly poor choice of recreational activities and peer influence predisposed more young men to addictive substance abuse. AB is white; therefore, the ethnic risk is minimal; however; however, the choice of leisure activity and age predisposes him more to substance abuse. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Reflection of the case

A systemic review of the case identifies how the risk factors combine and promote mental illness development. AB’s Dad was alcohol, his mother and maternal grandfather have a history of bipolar depressive disorder, and both paternal and maternal uncles are alcoholics. AB’s friends from college enjoyed weekend parties. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.Her current boyfriend is addicted to cocaine, alcohol and tobacco. Notably, there is no sufficient parental guidance, early exposure to addictive drugs and the family history of mental illness. From this review, the most appropriate interventions for improving each patient’s health outcomes need to assess the patient’s environment because they influence immensely.Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Ethical considerations to be considered in this case is patient safety. Patients who are truant and irritable can pick a fight quickly hence inviting more harm. Beta &Rajshekhar (2019) such patients endanger their lives and others, thus ensuring that they are free from causing harm or being harmed. Additionally, these patients diagnosed with mental illnesses do not undergo the legal trial in court because they are deemed unfit to make rational decisions. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.

Beta &Rajshekhar. (2019, another significant ethical consideration involved the admission of forensic patients into a psychiatric unit. These patients are often brought to the unit when they are already ill and make it difficult to obtain adequate history. This compromises diagnosis and treatment because performing a mental health assessment alone is insufficient to diagnose and start the patient on therapy. The management of these patients thus depends on the clinical observation at the unit. Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders.