Assignment: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction
Impulsivity, compulsivity, and addiction are challenging disorders for patients across the life span. Impulsivity is the inclination to act upon sudden urges or desires without considering potential consequences; patients often describe impulsivity as living in the present moment without regard to the future (MentalHelp.net, n.d.). Thus, these disorders often manifest as negative behaviors, resulting in adverse outcomes for patients. For example, compulsivity represents a behavior that an individual feels driven to perform to relieve anxiety (MentalHelp.net, n.d.). The presence of these behaviors often results in addiction, which represents the process of the transition from impulsive to compulsive behavior.  Assessing and Treating Patients With Impulsivity Essay
In your role as the psychiatric nurse practitioner (PNP), you have the opportunity to help patients 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.
Reference: MentalHelp.net. (n.d.). Impaired decision-making, impulsivity, and compulsivity: Addictions’ effect on the cerebral cortex. https://www.mentalhelp.net/addiction/impulsivity-and-compulsivity-addictions-effect-on-the-cerebral-cortex/
To prepare for this Assignment:
• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring therapy for impulsivity, compulsivity, and addiction.
The Assignment: 5 pages
Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

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BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem.”
SUBJECTIVE
Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past 2 years and she is concerned about the negative effects of the cigarette smoking on her health.
She states that she attempts to abstain from drinking but she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much,” but she enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much. She currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.
Mrs. Perez is quite concerned today because she borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. When you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation and self-reported mood. She denies visual or auditory hallucinations, and no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact; however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.
Diagnosis: Gambling disorder, alcohol use disorder
Decision Point One
Select what you should do:

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
Antabuse (disulfiram) 250 mg orally daily
Campral (acamprosate) 666 mg orally three times/day
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Mrs. Perez reports to the office complaining of sedation, fatigue, and a “metallic taste” in her mouth, which “seems to be going away.” She also reports that she had just one drink about 5 days after starting the drug and thought that she would “die.” She reports that her face was red, and she felt that her heart would “pound right out of my chest.”
Mrs. Perez also reports that she continues to visit the casino but has not been spending as much money there. She has noticed that her cigarette smoking is increasing
Decision Point Two
Select what you should do next:
Continue current dose of Antabuse and begin Campral (acamprosate) 666 mg orally BID
Continue current dose of Antabuse and refer to counseling for ongoing gambling issues
Continue current dose of Antabuse and begin Wellbutrin (bupropion) XL 150 mg orally daily
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Mrs. Perez in 4 weeks and reports that she has met with the counselor, but she did not really like her. She also started going to a local meeting of Gamblers Anonymous
She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group. She also reports that she is still smoking quite a bit
Decision Point Three
Select what you should do next:
Explore the issue that Mrs. Perez is having with her counselor, encourage her to continue attending the Gamblers Anonymous meetings, and discuss smoking cessation options
Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group. Discuss smoking cessation options
Discontinue Antabuse, encourage Mrs. Perez to continue seeing her counselor and participating in the Gamblers Anonymous group. This would also be an appropriate time to discuss smoking cessation options
Guidance to Student
Sedation/fatigue is a common complaint of people who take Antabuse; the best approach would be to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

Although controversy exists in the literature regarding how long to maintain a client on disulfiram, 8 weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As will be covered in more depth in future courses, ruptures in the therapeutic alliance can result in the client stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (as opposed to the client who receives therapy). Recall that there are no FDA-approved treatments for gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the Gamblers Anonymous meetings, she should be encouraged to continue her participation with this group.
Resources
Learning Resources

Required Readings (click to expand/reduce)

Kelly, J. E., & Renner, J. A. (2016). Alcohol-Related disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.
Renner, J. A., & Ward, N. (2016). Drug addiction. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.  Assessing and Treating Patients With Impulsivity Essay

Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders: Treatment improvement protocol series, no. 32. http://www.ncbi.nlm.nih.gov/books/NBK64350/
• Chapter 1, “Substance Use Among Adolescents”
• Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”
• Chapter 7, “Youths with Distinctive Treatment Needs”

University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control. Journal of Psychosocial Nursing & Mental Health Services, 54(4), 15.

Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. https://doi.org/10.1111/j.1365-2125.2012.04457.x

Hulvershorn, L. A., Schroeder, K. M., Wink, L. K., Erickson, C. A., & McDougle, C. J. (2015). Psychopharmacologic treatment of children prenatally exposed to drugs of abuse. Human Psychopharmacology, 30(3), 164–172. https://doi.org/10.1002/hup.2467

Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10–15. https://doi.org/10.3928/00989134-20160314-04

Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74–84. https://doi.org/10.1080/15504263.2012.648439

Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., Olvera, R., Swann, A. C., & Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337–1341. https://doi.org/10.1016/j.comppsych.2014.04.018

Medication Resources (click to expand/reduce)

IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.
• naltrexone (revia/vivitrol)
• naloxone
• acamprosate
• disulfiram

Required Media (click to expand/reduce)

Case Study: A Puerto Rican Woman with Comorbid Addiction
Note: This case study will serve as the foundation for this week’s Assignment.

Impulsivity and Compulsivity in Comorbid Alcohol Use Disorder (AUD) and Gambling Disorder
Amongst psychiatric conditions, there are those that are characterized by actions that one feels compelled to do even if those actions or behaviors cause them harm, suffering, or other negative consequences. This state is referred to as impulsivity; a state in which a mentally ill person does not see reason in displaying actions that would harm them where a reasonable person would not venture. But as though performing actions that are detrimental to them was not enough, persons with mental illness who engage in impulsivity also have the tendency of repeating the same time and time again. This is referred to as compulsivity (Chamberlain et al., 2018; Sadock et al., 2015; APA, 2013). Mental disorders that display impulsivity and compulsivity include substance use disorders and gambling disorder. In this case study of 53 year-old Puerto Rican woman, she is displaying the classic symptoms of impulsivity and compulsivity with regard to her alcohol addiction and gambling habit. As an alcoholic, she is feeling compelled to repeatedly take etoh so that she can get the same feeling that she is used to. It does not matter at what cost this impulsivity is realized. Definitely, alcohol has to be bought and this means that the addiction will eat into her finances and eventually affect the family. The same case is true for gambling. As a gambler, the Puerto Rican woman only thinks about the prospect of making a winning. It does not matter to her that this is just a probability and may not happen in quite a long time. She is borrowing money after exhausting the family savings and this is putting her and her family deeper and deeper into debt. But she continues to gamble and to take etoh despite all this. It is unreasonable, and that is why these are mental disorders. The Puerto Rican female has been diagnosed with gambling disorder and alcohol use disorder (AUD) that are comorbid or exist together in the same person. She states that she has been an alcoholic since her teens after the loss of a significant family member. As for gambling; the fact that a casino had recently been opened near her home has made it very difficult for her to resist the temptation to go and gamble. For about 25 years, she has been a member of Alcoholics Anonymous (AA) but keeps on relapsing back to alcohol from time to time. The patient is alert and oriented in time, space, place, person and event. Her speech is also clear, coherent, spontaneous, and goal-directed. This paper is about three decisions on her pharmacotherapeutic and psychotherapeutic interventions to treat the comorbid AUD and gambling disorder.

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Decision Point Number One
In this initial decision point, the clinician is expected to make a choice amongst three options for beginning the Puerto Rican patient on pharmacotherapy. The options are naltrexone (Vivitrol) 380 mg intramuscularly every month, disulfiram (Antabuse) 250 mg by mouth every day, or acamprosate (Campral) 666 mg by mouth three times a day (Stahl, 2017). According to Stahl (2017), all these three pharmacotherapeutic agents have been FDA-approved to be used in treating alcoholism. However, from a pharmacokinetic and pharmacodynamic perspective, they do not have the same safety and therapeutic profile as would be expected. As a matter of fact, Winslow et al. (2016) confirm in a study that among the three there are some that are more efficacious than others. This is according to available evidence from scholarly sources that inform evidence-based practice or EBP.
The choice I made in this first decision pint was to commence the lady on disulfiram (Antabuse) 250 mg orally every day. The reason for this choice is that disulfiram has been approved by the US Food and Drug Administration or FDA for the treatment of alcohol dependence. The other reason is that it is mentioned in scholarly literature as being among those medications that are effective in treating individuals with alcohol use disorder (Winslow et al., 2016). The other two options were equally good and also FDA-approved; but were not chosen because disulfiram has a good record of alleviating dependence on alcohol from anecdotal, circumstantial, and scholarly evidence. It was expected that the patient would start avoiding alcohol immediately and would begin to be disabused of the habit of drinking. In selecting the treatment for the Puerto Rican lady, her opinions were respected and they had input into the decision about the course of their treatment. This is respect for the bioethical principle of autonomy (Haswell, 2019). This careful choice of the suitable medication was also aimed at preventing the patient from being harmed by debilitating side effects and hence respecting the principle of nonmaleficence.  Assessing and Treating Patients With Impulsivity Essay

Decision Point Number Two
After four weeks of therapy, the patient returns for evaluation. She reports that she took just one drink after beginning therapy and the effect was not pleasant at all (this is the intended purpose of disulfiram anyway). She suffered palpitations and thought that she was going to die. But she also reported some side effects that luckily she said were now going away. These were fatigue, sedation, and a metallic taste in the mouth. She accepted that she still visits the casino, which meant that the gambling problem also needed to be looked into now. She said she was smoking more; and this could be compensatory for the alcohol that was now not being taken.
The second decision point comprised of (i) continuing with the current dose of disulfiram but adding acamprosate 666 mg orally twice daily; (ii) continuing with the current dose of disulfiram and but referring the patient for counselling about the continuing gambling disorder; and (iii) continuing the current dose of disulfiram but also adding bupropion (wellbutrin) XL 150 mg orally every day. The choice I made was number (ii) – continuing with the disulfiram (Antabuse) dose as it is but referring the patient to a counselor so that they can receive therapy for the gambling issue. The therapist would deliver psychoeducation and cognitive restructuring through cognitive behavioral therapy or CBT (Corey, 2017; Hilliard, 2020). The other two available options in decision point number two were not taken simply because they included the addition of further medications which would just complicate the treatment. To begin with, the patient despite having tolerance issues reported that the side effects of disulfiram were reducing. They were also responding to the drug because they were not taking alcohol anymore after the incident with the one drink. Another reason is that polypharmacy would just predispose the patient to even more side effects that would make adherence and compliance to treatment difficult. What was hoped with this choice was that the client would start reducing her visits to the casino and eventually stop them altogether after attending several sessions of CBT. The ethical considerations here were clear. It is nonmaleficence that ruled this second decision making. The other two options were rejected because they included adding more drugs that would have caused the patient suffering through even more side effects.
Decision Point Number Three
When the patient came in for review again, she had already been on treatment with disulfiram (Antabuse) for a total of eight weeks. She was no tolerating the medication well and was having a good therapeutic response. She stated that she indeed went and met the counselor as had been planned. Unfortunately she said that she did not form a bond with the counselor. In other words, she did not feel that she liked her. But she added that she had started attending meetings of Gamblers Anonymous since she last left the clinic. She had even started talking at their meetings and she says that she felt appreciated and loved there. From a clinical perspective, it was clear that the patient had started benefitting from this Gamblers Anonymous (GA) group by way of group curative factors such as altruism and catharsis (Ezhumalai et al., 2018). The third and last decision point in this case had three options too. These were (i) to explore the problem that the patient was having with the counselor but encourage them to continue attending the GA meetings and then discuss how to stop smoking; (ii) to continue visiting the counselor and attending the GA meetings even as discussions are held about stopping smoking; and (iii) stopping disulfiram and encouraging the patient to continue attending sessions with the counselor, to continue with GA, and to review smoking cessation options available.

I chose to go with the first option of exploring what could be wrong between the patient and the counselor, to let the patient continue with GA, and to start discussing with her how she would stop smoking. The reason for taking this decision was that it was the most desirable decision from an evidence-based clinical point of view. Te other two options did not appear attractive as they disregarded finding the reason for the patient disliking the counselor. What was planned to be achieved was the establishment of a therapeutic relationship between the counselor and the patient. This would enable therapy to have its intended effect and stop the patient from gambling. Beneficence was evident in this decision because the clinician shows concern for the patient by wanting to find out the real issue behind the patient not liking the counselor.
Conclusion
This is a case study that tests the clinical critical skills of the psychiatric-mental health nurse practitioner or PMHNP as the clinician for psychiatric patients at the primary care level. The three decisions taken at each of the three stages in this case are evidence-based and are the best for producing desired patient outcomes. Disulfiram (Antabuse) is an evidence-based option for managing alcohol use disorder; while psychoeducation (counselling) as well as cognitive behavioral therapy or CBT are both best practice for managing gambling disorder. Combined, these interventions were set to treat the 53 year-old Puerto Rican woman of her comorbid gambling disorder and alcohol use disorder.

References
American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.
Chamberlain, S.R., Stochl, J., Redden, S.A., & Grant, J.E. (2018). Latent traits of impulsivity and compulsivity: Toward dimensional psychiatry. Psychological Medicine, 48(5), 810-821. http://dx.doi.org/10.1017/S0033291717002185
Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Cengage Learning.
Ezhumalai, S., Muralidhar, D., Dhanasekarapandian, R., & Nikketha, B.S. (2018). Group interventions. Indian Journal of Psychiatry, 60(Suppl. 4), S514-521. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_42_18
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
Hilliard, J. (September 17, 2020). Gambling addiction. Addiction Center. https://www.addictioncenter.com/drugs/gambling-addiction/
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.
Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.
Winslow, B.T., Onysko, M., & Hebert, M. (2016). Medications for alcohol use disorder. American Family Physician, 93(6), 457-465. https://www.aafp.org/afp/2016/0315/p457.html     .  Assessing and Treating Patients With Impulsivity Essay