Assessing and Treating Clients With Impulsivity Essay

Week 8 assignment Assignment: Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Impulsivity, compulsivity, and addiction are challenging disorders for clients across the lifespan. These disorders often manifest as negative behaviors, resulting in adverse outcomes for clients. In your role as the psychiatric mental health nurse practitioner, you have the opportunity to help clients address underlying causes of the disorders and overcome these behaviors. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with impulsivity, compulsivity, and addiction. Assessing and Treating Clients With Impulsivity Essay. Learning Objectives Students will: Assess client factors and history to develop personalized therapy plans for clients with impulsivity, compulsivity, and addiction Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for impulsivity, compulsivity, and addiction Evaluate efficacy of treatment plans Analyze ethical and legal implications related to prescribing therapy for clients with impulsivity, compulsivity, and addiction Learning Resources Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Required Readings Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.).

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New York, NY: Cambridge University Press. To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter. Chapter 14, “Impulsivity, Compulsivity, and Addiction” Stahl, S. M., & Grady, M. (2012). Stahl’s illustrated substance use and impulsive disorder New York, NY: Cambridge University Press. To access the following chapter, click on the Illustrated Guides tab and then the Substance Use and Impulsive Disorders tab. Chapter 10, “Disorders of Impulsivity and Compulsivity” Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press. To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication. Review the following medications: For insomnia For obsessive-compulsive disorder Citalopram clomipramine escitalopram fluoxetine fluvoxamine paroxetine sertraline venlafaxine vilazodone For alcohol withdrawal chlordiazepoxide clonidine clorazepate diazepam lorazepam oxazepam For bulimia nervosa and binge eating fluoxetine topiramate zonisamide For alcohol abstinence acamprosate disulfiram For alcohol dependence nalmefene naltrexone For opioid dependence buprenorphine. Assessing and Treating Clients With Impulsivity Essay

Severe mood disorders along with delusions are diagnosed as a form of borderline personality disorder (BPD). The symptoms are extremely hard to detect as people often display emotional stressors that creates mental insecurities, on how they relate to others and on how they behave. These conditions if not treated can lead to illnesses that will develop into serious health and mental conditions. Many BPD clients experience images within their minds where they feel worthless and flawed that their self-image and sense of self often rapidly changes. One symptom others will notice is angry dispositions as being impulsivity with frequent mood swings, which hinder relationships by pushing others away. However, BPD with proper treatment clients can live happier and peaceful lives. This hypothetical case study and treatment plan is pertaining to the client’s mood swings and anxiety experiences. It will define and described from the DSM-IV-TR psychologist diagnosis book the types of circumstances defining their psychological conditions.Assessing and Treating Clients With Impulsivity Essay

Introduction

This paper presents a hypothetical case of a male adult that is suffering from mood swings, obsessive anger as Borderline Personality Disorder (BPD) that proposes a treatment plan for this mental disorder. Borderline personality disorder is a mental ailment that involves prolonged disturbance of an individual’s personality function, and is usually found in persons over eighteen years of age, although it can also occur in adolescence. Borderline personality disorder is characterized by deep and varying moods, and involves unusual levels of instability in mood; black and white thinking, or splitting; the disorder often manifests itself in idealization and devaluation episodes, as well as chaotic and unstable interpersonal relationships, self-image, identity, and behavior; as well as a disturbance in the individual’s sense of self (American Psychiatric Association, 2000).

Studies indicate that people with Borderline personality disorder tend to experience frequent, strong and long-lasting states of aversive tension, often triggered by perceived rejection, being alone or perceived failure. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation. Patients may also experience temperamental sensitivity to emotive stimuli (American Psychiatric Association, 2000).Assessing and Treating Clients With Impulsivity Essay

Narrative Case Description

The client is a divorced male who is currently unemployed with a history of mood instability. The John Doe client has a career history of working in the field of liquidations with a successful managerial career of supervising others. However, displays high turnover in staffing due to his outrageous behavior. He received a new district manager who re-evaluated his high turnover of people reporting to him. Management after long thought and consideration decided that his services were not in the best interest of the company objectives. He was dismissed with a six month pay to support his needs until he was able to find work. However, this client also suppressed but suffers with episodes of severe idealization and devaluation, which has led to unstable and chaotic interpersonal relationships where he seems to be disturbed about his sense of self. He is fearful of being alone, shows impulsive and risky behaviors. The client has high levels of drastic and rapid shifts from one emotion to another.

Therefore, this patient clinician is finding it challenging with the use of the word ‘borderline’ in describing this illness. Although there have been numerous articles written about the diagnosis of borderline personality disorder, and there is still little known about the nature of the illness, based on empirical research, there have been some studies carried out which suggest that people with borderline personality disorder frequently experience strong, sustained periods of aversive tension, which are usually set off when the patient perceives that he or she is being rejected, or due to perceived failure. Individuals with borderline personality disorder may fluctuate between anger and anxiety or between depression and anxiety and temperamental sensitivity to emotive stimuli (Koenigsberg et al., 2002).Assessing and Treating Clients With Impulsivity Essay

As the assigned therapist it is possible that this client would eventually self-harm himself where suicidal behavior is a major diagnostic criterion in DSM-IV-TR, and after diagnosis, managing an illness of this nature and recovery can be a very challenging experience. Diagnosis of borderline personality is based on a clinical assessment of the case by qualified mental health professionals and assessing such a case will incorporate the self-reported experiences of the patient, and the observations of the mental health professional. Although the client has episodes of hostility, impulsive behaviors which has hindered relationships, the client is seeking treatment with this therapist on his own free will.

Treatment Plan

In reviewing the DSM-IV-TR for a diagnosis on patient the proposed treatment plan for this client will be based on psychotherapy, with medications playing a lesser role in the treatment. The individual case presentation here will form the foundation of the treatment plan. Although a number of techniques including interpersonal, psychodynamic and cognitive behavioral therapy have been studied for the treatment of borderline personality disorder, evidence suggests that medications like mood stabilizers, omega-3, fatty acids, anti-depressants and anti-psychotics will however, be utilized for treating depression and other co-morbid symptoms of this mental illness.

This proposed treatment plan consists of medication to contain the more stubborn affective symptoms, combined with some form of long-term psychotherapeutic intervention. Psychological treatment will be based on theories of personality, learning and interpersonal communication.Assessing and Treating Clients With Impulsivity Essay

One possible course of therapy is Dialectical Behavioral Therapy (DBT). Dialectical Behavioral Therapy is a modern variant of cognitive therapy that was developed for treatment of mental ailments like Borderline personality disorder. This treatment plan appears to be as helpful in treatment as any other standard cognitive behavioral therapy.

The therapy part of the treatment will also include schema therapy, which is an integrative psychotherapy. Schema therapy is based on a cognitive schema model that is aimed at identification and adjustment of dysfunctional modes and schemas through cognitive, experiential and behavioral pathways the schema therapy has been specifically developed for patients with personality disorders (Linehan & Marsh, 1993). Although the effectiveness of this treatment has been demonstrated in controlled random trials, it has not been extensively evaluated in regular mental healthcare settings.

Identifying Information

The most widely used criteria for the diagnosis of borderline personality disorder, as well as for classifying mental disorders involves the International Classification of Diseases produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) which is produced by the American Psychiatric Association (APA). Both list categories of disorder and provide standardized criteria for diagnosis. They have deliberately united their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be used in non-western cultures (Koehler, 2005). The identifying information of the patient, his name is John Doe, who is 56 years of age, Caucasian male, has a college degree in mathematics. The initial start date for this treatment plan will start immediately March 28, 2011up to four months. Then based on successful treatment responses other treatment plans will be determined at that time. The name of the assigned clinician providing treatment is Cynthia A Johnson.Assessing and Treating Clients With Impulsivity Essay

Relevant Information/Referral

The negative emotional states specific to Borderline Personality Disorder may be grouped into four categories: destructive or self-destructive feelings; extreme feelings in general; feelings of fragmentation or lack of identity; and feelings of victimization. Individuals with Borderline Personality Disorder can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness (Brand, 2001). Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone. Self-image can also change rapidly from extremely positive to extremely negative, impulsive behaviors are common, including alcohol or drug abuse, unsafe sex, gambling and recklessness in general (Zanarini, et al., 1998). Research indicates that individuals with Borderline Personality Disorder are usually very novelty or intimacy seeking, but can be hyper-alert to any signs of rejection. Thus, they tend to be quite insecure, ambivalent, and display fearfully preoccupied patterns in their relationships with other people. They tend to view the world generally as dangerous and malevolent, and tend to view themselves as powerless, vulnerable, unacceptable and unsure in self-identity (American Psychiatric Association, 2001). The client John Doe is self-referred.Assessing and Treating Clients With Impulsivity Essay

Presenting Problem

The client is seeking treatment, as a result of the symptoms of mental illness he faces. The client has been suffering from irrational mood swings and obsessive anger, which has led to instability in his personal relationship with other individuals, and has affected his self-image. The clients sought treatment as he was in a state of desperation, and had tried some other treatment plans, but had not received any treatment so far that greatly improved his own self-image.

DSM-IV-TR Multiaxial Diagnosis

There is some evidence that BPD diagnosed in adolescence is predictive of the disease continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for patients (Austrian, 2000).

DSM-IV-TR Diagnosis

Axis I: 296.90 Mood Disorder NOS (Not otherwise specified)

Axis II: 301.83 BPD

Axis III: None

Axis IV: Client living alone and divorce-Social Problem

Axis V: GAF=30 (Current)

Long term Goals

The client John Doe’s long term treatment plan involves psychotherapy as well as medication. Drug prescription consists of atypical antipsychotics and in mood stabilizers. The Psychological aspect of the treatment combines cognitive behavioral therapy with group therapy.

This treatment plan will be beneficial to the client in several ways including the alleviation of mental illness symptoms, improvement of interpersonal relationships, and improvement of the client’s self image.

1. Alleviation of mental illness symptoms

The treatment plan will help in reducing symptoms thereby resulting in improvement in the client’s behavior and feelings.Assessing and Treating Clients With Impulsivity Essay

2. Improvement of interpersonal relationships

This treatment plan will enable continued improvement in the client’s interpersonal functioning, even after the period of treatment.

3. Improvement of the client’s self image.

This plan is designed to help the client find help with emotional and relationship problems, thereby improving self image

Methods or Interventions

Typically, patients receiving treatment for mental illnesses are given anti-depressant medication and patients also receive counseling and psychotherapy in many cases, but the effectiveness of anti-depressant medicines in mild or moderate cases is questionable. By drawing the client’s attention to the important issues involved during treatment, the treatment plan will help the client to understand himself and the situation better and thus be able to change the way that the client responds to situations. This will also enable the meeting of long-term goals for this treatment plan.

Estimated Length of Treatment

The estimated length of treatment is 36 weeks. Appointments shall be scheduled once every week for the duration of the treatment.

Outcome Measures

The measures that will be used in assessing the progress of the patient include semi-structured interviews and self-report measures on the disorder, the quality of life, psychopathology, therapeutic alliance and costs during interval periods of 6 months, 12 months, 18 months and 36 months. The criteria for measuring recovery include the achievement and maintenance of good BPDSI-IV scores until the final assessment, as well as reliable change that reflects individual clinically significantly improvement (Aviram, Brodsky, & Stanley, 2006).Assessing and Treating Clients With Impulsivity Essay

Critique

There are certain ethical issues concerning such a case. The efficacy of mood stabilizers, fatty acids, anti-depressants and anti-psychotics that will be utilized for treating depression and other co-morbid symptoms of this mental illness is unproven. Although omega 3 fatty acids, may have beneficial effects on depressive symptoms in addition to normal pharmacological treatment, research about this has been scarce and of variable quality.

Although the effectiveness of the schema therapy has been demonstrated in controlled random trials, it has not been extensively evaluated in regular mental healthcare settings. Another issue is the fact that clinical interventions with verified efficacy are not necessarily implemented in normal practice, and whenever these interventions are implemented, treatment results are not always equally as good as the results of the clinical trial. Patients being treated for borderline personality disorder need extra support from their therapist in between their scheduled sessions especially during a crisis. Studies have recently been carried out which suggest that support from the therapist in the form of patients accessibility to the therapists phone outside of office hours was a major issue (Nelson et.al., 2009). Thus, accessibility outside regular office hours has been perceived to be a critical obstacle to successful implementation of treatment.Assessing and Treating Clients With Impulsivity Essay

The following assignment is formulated on partial information extracted from a case analysis; the client is a 26-year-old female who has extensive history of illicit substance use since her early teenage years. I will be describing how I would proceed with specific interventions to gain further information and to assist the clients’ safe engagement with a tier 4 treatment provider. The client was referred to us from a General Practitioner which would fall into the Tier 1 category as outlined by the National Treatment Agency for substance misuse .

With the clients arrival at our facility she would engage with a screening or gatekeeping process to attain her suitability and our available resources to manage and contain her presenting problems. Clearly, with her previous history of self-harm, and her stated fear of not being able to resist her impulsive urges to stick needles in her eyes, a comprehensive risk assessment will be taken. The objective of this risk assessment would also be a collaborative management plan; the responsibility to implement its agreed contents would be the clients and that of our agencies staff members. If adhered to this would prevent any manifestation of self-harming or aggressive behaviour. On arrival at our facility, a portion of the induction is for the client to have full medical assessment with our General Practitioner. The object would be to review the prescribing of any current medication the client may have or to prescribe additional medical interventions. As this client could have coexisting mental health issues these appointments would be on going throughout her treatment duration. A sample of breath and urine are tested to provide information of any possible lingering substances in her system, records of the results are recorded and stored according to Data Protection Act .Assessing and Treating Clients With Impulsivity Essay

As the client is in her second day at our facility, her assigned drug and alcohol worker would now take a comprehensive assessment . This assessment would be of a semi-structured format to attain further information about the client in specific areas. Additional information gained would contribute to informing the initial treatment care plan. The semi-structured process would also allow the client to speak with an amount of freedom introducing her own emphasis and priorities. During this stage of the assessment process additional tools can be used which could include the Leeds dependency questionnaire (see appendix 1).

With the client’s consent, I would gain further information from other agencies that she has used, in this case it would be the psychiatric hospital where she recently finished an opiate detox. In addition, I would contact the clients General Practitioner and possibly her parents. Before any information is shared it is likely that the agency providing the information would require written consent from the client .Assessing and Treating Clients With Impulsivity Essay

In reaching a potential diagnosis for the young woman in the case analysis, some further investigation would be required to make a fully informed conclusion. Making a judgement in the real workplace setting with limited information would of course be malpractice. For the purpose of the assignment with partial information known, I will attempt to arrive at several diagnoses and give a rationale why I have reached my decisions.

The client presents a history of illicit drug use since her early teenage years; she has used Cannabis, alcohol, amphetamines, Methylenedioxymethamphetamine. More recently, she has used crack Cocaine and heroin, offering that she has experienced several unsuccessful attempts at cessation the latter substances. The client presents because of her illicit drug use she has been out of work three times, for more than several months. Before entering our facility, she successfully completed an unknown opiate detoxification regime in the local psychiatric hospital. At this point, I have to ask myself a question, Opioid abuse or Opioid dependence? As there are not specific criteria for Opioids, clinicians are encouraged to use that of substance abuse and dependence which are believed to apply to all psychoactive agents . Considering her opiate use is more recent; according to the American Psychiatric Association she is already displaying two of the necessary criteria for substance abuse as outlined below, (see appendix 2 for full criteria)

Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use. Substance-related absences, suspensions, or expulsions from school; neglect of children or household).

Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g. Arguments with spouse about consequences of intoxication, physical fights).

This diagnosis would fall into the category of psychoactive substance use disorder (axis 1).Assessing and Treating Clients With Impulsivity Essay

Supporting information would strongly indicate that this particular client has some form of coexisting mental health issue which onset during adolescence at a similar age of her initial substance use. Taking into account that her substance use and behavioural & emotional problems appear to be entirely independent entities yet occur concurrently, with no real influence on one another takes me a step closer to a diagnosis. Considering the clients presenting behaviours of,

Poor attachments

interpersonal relationship struggles

impulsive behaviour

substance use

aggressive reactions

recurrent suicidal behavioural gestures

Efforts to avoid real or imagined abandonment.

The client presents the necessary five required criteria for Borderline Personality Disorder, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (see appendix 3). All of her criteria are classified as dramatic, emotional or erratic which falls into Cluster B of Common Mental Disorders (Axis II). Another factor that could inform my decision would be that 75% of diagnosed cases are in females .

Appendix 1

Leeds Dependency Questionnaire

(Raistrick, Bradshaw, Tober, Weiner, Allison, & Healy; 1994)

Here are questions about the importance of alcohol and/or other drugs in your

life. Think about your drinking/other drug use in the last two weeks and answer each question by ticking the closest answer to how you see yourself.

Never

Sometimes

Often

Nearly always

1. Do you find yourself thinking about when you will next be able to have another drink (drug)?Assessing and Treating Clients With Impulsivity Essay

0

1

2

3

2. Is drinking (drug use) more important to you than anything else you might do during the day?

0

1

2

3

3. Do you feel your need for drink (the drug) is too strong to control?

0

1

2

3

4. Do you plan your days around getting alcohol (the drug) and drinking (using the drug)?

0

1

2

3

5. Do you drink (use the drug) in a particular way in order to increase the effect it gives you?

0

1

2

3

6. Do you drink (use the drug) morning, afternoon and evening?

0

1

2

3

7. Do you feel you have to carry on drinking (drug use) once you have started?

0

1

2

3

8. Is getting the effect you want more important than the particular drink (drug) you use?Assessing and Treating Clients With Impulsivity Essay

0

1

2

3

9. Do you want to drink (use the drug) more when the effect starts to wear off?

0

1

2

3

10. Do you find it difficult to cope with life without alcohol (drugs)?

0

1

2

3

To find out your score, simply add up the numbers from each of your answers.

Interpretation

Total LDQ score

0 No dependence

1-10 Low to moderate dependence

11-20 Moderate to high dependence

21-30 High dependence

This score is to be used as a guide to your level of dependence over the two weeks or so. It does not indicate whether your consumption is at risky levels or the extent of other alcohol or drug use related problems.

Appendix 2

Criteria for Substance Abuse

A maladaptive pattern of substance use leading to clinically significant impairment

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or distress, as manifested by one (or more) of the following, occurring within a 12-

month period:Assessing and Treating Clients With Impulsivity Essay

(1) Recurrent substance use resulting in a failure to fulfil major role obligations at

work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences. suspensions, or expulsions

from school; neglect of children or household)

(2) Recurrent substance use in situations in which it is physically hazardous (e.g

driving an automobile or operating a machine when impaired by substance use)

(3) Recurrent substance-related legal problems (e.g., arrests for substance related

disorderly conduct)

(4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g

arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Taken from DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. (4th Rev ed.)(1990). Diagnostic criteria for Substance abuse. Assessing and Treating Clients With Impulsivity Essay