Substance-Use and Anxiety Presentations
This assignment focuses on vignette analysis and direct application of course concepts to the persons and situations presented in the vignette for each question.
Please keep your responses focused on what is presented in the vignette. Do not add information but use your creativity to support what you see in the vignette as written.
There are two cases: Larry and Sharon. Each case should be approx. 3.5 pages with 6 references each
The entire assignment should be 7 pages total plus a title and reference pages
Case of Larry
Larry is a 51-year-old African American man who has bounced around between homelessness/unemployment and a few part-time jobs while living in a shelter or occasionally on his own via renting a room. Living on the streets, Larry has been exposed to violence, both as an observer and recipient. Larry has a long-term 30+ year history of relatively consistent heroin use. He reports two prior instances of abstinence when admitted into inpatient treatment, but both times he ceased treatment and returned to substances within three weeks’ time due to feeling “awful and crazy” when not taking heroin.
Heroin Use History
Larry began using heroin in his early 20's after being stabbed in a gang related incident in which he also suffered a head injury. He quickly became addicted to heroin and continued using ever since. Larry reports using heroin multiple times per day, but varying in actual number. He disclosed experiences which indicate he has likely developed tolerance to the substance including that he still uses because it offers some effect, though not as intense as he used to experience in his earlier years.
Larry has had two recent failed treatment episodes. His first-ever attempt at treatment was two years ago when he was living temporarily with a friend. Larry attended a 28-day inpatient program at a local medical center. Approximately three weeks into treatment, Larry began sensing he was seeing “shadowy figures” out of his peripheral vision. He also recalled feeling very confused, disoriented, on-edge and paranoid. Larry was discharged from treatment because he had overheard his clinician was holding a staff meeting and Larry was convinced they were discussing him. He barged into the meeting and accused the staff of unethical behavior. He had to be escorted to the ER by medical center security. Larry was discharged from the program after receiving a “clean bill of health” from the ER doctors. Larry recalls them saying that he was deemed simply “not ready for treatment.”
Larry next tried treatment four weeks ago when he was admitted into a residential therapeutic community (TC) where he was diagnosed as HIV/AIDS positive along with Hepatitis C. He was given a referral to a physician, which he declined. After four weeks of being heroin-free, Larry began demonstrating odd behavior that included hearing voices, confused regarding his surroundings, and overwhelming experiences of paranoia. Larry describes feeling as if certain important TC staff were watching him and waiting to trap him; however, Larry could not elaborate on what the “trap” might be or why they would feel a need to snare him in a trap.
Larry’s Presentation
In your initial session with Larry, he is convinced that your session is being recorded.
Please respond to the following questions:
1. This may be a case of substance-use disorder, an undiagnosed co-occurring psychotic disorder, or an undiagnosed cognitive disability. How would you work with Larry to ascertain the appropriate diagnosis?
2. How would you use the clinical interview questions outlined below to solidify your diagnosis.
a. referral source
b. primary presenting problem(s)
c. History of substance use disorder and any past treatments
d. Current substance use (frequency, amount, administration)
e. History of psychiatric disorder or symptoms and any past treatment(s)
f. Current psychiatric symptoms
g. History of /current suicidal ideation, intent, plan, or acts
h. History of /current homicidal (harm to others) ideation, intent, plan, or acts
i. Living arrangements
j. Marital/relationship status
k. Any children (if applicable)
l. Family of origin history
m. School and work history
n. Mental status
o. Insight and judgement
3. How would you clinically work with the psychotic symptom(s) if substance-induced? If co-occurring psychotic disorder? If psychotic disorder due to another medical condition?
4. Using ASAM Criteria (2013) Levels of Care what would be the appropriate level of care for Larry? Consider medical issues (HIV/AIDS, Hepatitis C, brain injury), risk assessment, trauma, and violence potential.
ASAM Criteria (2013) Levels of Care: https://americanaddictioncenters(dot)org/rehab-guide/asam-criteria-levels-of-care
5. Given that Larry is a 51-year-old African American man, provide a brief discussion of legal and ethical considerations.
Case of Sharon
Sharon, is an 82-year-old Chinese American widow living alone for the past six years since the death of her husband. Her husband was killed by a drunk driver in an auto accident. Sharon was in the car. Although she survived, she lost her vision in one eye and suffers from chronic back pain. Sharon lives within 10 minutes of her children and grandchildren. For the past few years, Sharon has been secretly drinking, with her alcohol consumption increasing in amount and frequency over the past 18 months. Sharon now consumes a bottle of wine per day, drinking primarily in the late afternoon and evening. She claims her back pain is unbearable. Sharon was referred to counseling due to an increased presentation of anxiety. Her children and friends noticed that Sharon was more anxious, appeared “jittery,” “hypervigilant,” and more “worried” than usual. The counselor referred her to a psychiatrist who prescribed anti-anxiety medication; and to a pain management doctor who prescribed narcotic pain medication. Unfortunately, ageism and stereotypes led both these professionals to ignore the potential of any alcohol or substance use.
Anxiety Presentation History
Sharon reported feeling “on-edge” all the time. She recalled one recent incident where she was playing cards with some friends and “the room just started spinning.” She stated that she almost passed out. “I didn’t tell anyone, but I really, really wanted a drink. The wine just helps me calm down.”
Sharon’s psychiatrist prescribed Xanax (0.25 mg, 2–3 times per day). After a few weeks of taking the Xanax as prescribed, Sharon became frustrated with the medication “doing nothing” for her anxiety. Sharon continues to drink alcohol and take both her anxiety and pain medications.
Alcohol Use History
Sharon was never “much of a drinker,” but in the years following the death of her husband she started to drink 1–2 glasses of wine per day. Slowly, Sharon increased to 3–5 glasses of wine per day, noting how it helped her fall asleep. Sharon denied drinking to cope with anxiety or pain. Within the past 18 months, Sharon noticed that she was drinking most of the bottle of wine. Her reasoning for drinking the entire bottle was simply “the wine doesn’t stay well once uncorked, even for a day.”
Sharon’s Presentation
In addition to the anxiety, Sharon also presents with the following recent symptoms: mood swings, memory loss, sleep difficulties, and difficulties with decision-making. She also reports increased blurriness in her good eye. Her family is oblivious to her drinking, but is very concerned about these other symptoms, coupled with her anxiety and the apparent ineffectiveness of the Xanax to treat the anxiety. They are also concerned about Sharon’s safety when driving.
Please respond to the following questions:
1. How does Sharon’s cross-tolerance issues impact the prescribed benzodiazepine and pain medications?
2. In consideration of her medical issues, older adult treatment issues, and grief and trauma-related issues, what would be some key concepts in the assessment and treatment planning for Sharon’s alcohol use, mood swings, memory loss, sleep difficulties, disabilities and difficulties with decision-making?
3. Building off of the content in question #2, what level of care do you recommend and why (Use Quadrant of Care Model)?
4. How would you use motivational interviewing and cognitive-behavioral therapy in your treatment of Sharon? What other modalities might you recommend for Sharon? Use Dialectical behavioral Therapy (DBT) and Family Systems Therapy
5. Given that Sharon is a 82-year-old Chinese American widow, provide a brief discussion of legal and ethical considerations.
Dual Diagnosis
Your Name
Subject and Section
Professor’s Name
May 29, 2023
* Larry’s Case
1 In order to ascertain the appropriate diagnosis for Larry, conducting a comprehensive assessment that thoroughly evaluates his substance use history, psychiatric symptoms, and cognitive functioning would be essential. The following steps can be taken:
1 Build rapport and establish a therapeutic alliance: First, develop a trusting relationship with Larry to create a safe and non-judgmental space where he feels comfortable sharing his experiences.
2 Conduct a structured clinical interview: Utilize the clinical interview questions outlined below to gather information about his referral source, primary presenting problems, history of a substance use disorder, past treatments, current substance use patterns, history of psychiatric disorders and treatments, current psychiatric symptoms, history of suicidal or homicidal ideation, living arrangements, relationship status, family history, school, and work history, and any relevant medical conditions.
3 Assess for cognitive functioning: After building rapport and conducting a structured clinical interview, the next step is to evaluate Larry's cognitive abilities and screen for any potential cognitive disabilities that may influence his symptoms or impair his decision-making abilities. This is important considering Larry’s presentation of psychological distress and hallucinations.
4 Consider collateral information: The final step is gathering information from collateral sources, such as treatment records or reports from previous healthcare providers, to understand Larry's history and current challenges better.
2 In relation to Larry’s case, here are some of the clinical interview questions outlined below that can help solidify the diagnosis:
5 Referral source: Inquire about who referred Larry for treatment or who brought him to the session. Understanding the referral source can help identify the initial concerns and motivations for seeking help. For example, suppose a healthcare professional or a support service agency referred Larry. In that case, it may indicate a recognition of the need for intervention and a collaborative approach to his care.
It must be noted that the main reason for ascertaining the referral source is that it provides contextual information and can shed light on the perceived severity of the presenting issues. Research suggests that collaboration among multiple stakeholders, such as healthcare providers and social service agencies, improves treatment outcomes and enhances engagement in individuals with substance use disorders (Lin et al., 2021).
6 Primary presenting problem(s): Additionally, it would be best to explore the main issues Larry is currently facing, such as heroin addiction, psychiatric symptoms (e.g., paranoia, confusion, hearing voices), and difficulties with engagement in treatment.
Identifying the primary presenting problems helps prioritize treatment goals and interventions. It allows clinicians to focus on the most immediate and impactful areas of concern, such as addressing substance use and stabilizing Larry's mental health symptoms. Studies highlight the importance of integrated treatment approaches that target both substance use disorders and co-occurring psychiatric conditions for improved outcomes (Murthy et al., 2019).
7 History of substance use disorder and any past treatments: Gather information about the duration and patterns of Larry's heroin use, including any prior attempts at treatment, periods of abstinence, or relapses. Obtain details about the effectiveness and duration of his previous treatment episodes.
Understanding Larry's substance use history and treatment experiences provides insight into the chronicity and severity of his addiction. It helps in tailoring treatment approaches and anticipating potential challenges during recovery. Research indicates that a longer substance use duration is associated with a higher likelihood of relapse, underscoring the need for comprehensive and sustained interventions (Witkiewitz et al., 2022).
8 Current substance use (frequency, amount, administration): Collect detailed information about Larry's current heroin use, including the frequency, quantity, and route of administration (e.g., intravenous, smoking). Assess whether there have been recent changes in his substance use patterns.
Obtaining specific details about current substance use assists in determining the severity of addiction, monitoring progress, and identifying potential risk factors. Research suggests that the intensity and frequency of substance use are correlated with the likelihood of experiencing physical and mental health complications (Chavez et al., 2021).
9 History of psychiatric disorder or symptoms and any past treatment(s): Inquire about Larry's history of psychiatric symptoms, such as paranoia, confusion, and hearing voices. Identify any previous diagnoses or treatments for mental health issues, including medication trials or therapy. For example, Larry noted that he saw "shadowy figures in his peripheral visions," which should be considered greatly. Overall, assessing Larry's psychiatric history provides an essential context for understanding the relationship between his substance use and mental health symptoms. Comorbidity between substance use and psychiatric disorders is common, and integrated treatment approaches have improved outcomes for individuals with co-occurring conditions (Edlund, 2020).
10 Current psychiatric symptoms: As mentioned earlier, Larry’s presentation of hallucinations should be linked with his past and present psychological status. Accordingly, the next step is to explore the specific nature and intensity of Larry's current psychiatric symptoms, including hallucinations, delusions, disorientation, and paranoia. Assess their impact on his daily functioning.
Evaluating Larry's current psychiatric symptoms helps determine the severity of his mental health condition and its interplay with his substance use disorder. Identifying symptoms like hallucinations, delusions, and paranoia may indicate the presence of a co-occurring psychotic disorder, which requires tailored treatment approaches (Krause et al., 2019).
History of/current suicidal ideation, intent, plan, or acts: Larry's suicidal thoughts or behaviors, including any current ideation, intent, or plans, should also be assessed. Determine the severity and frequency of any past suicidal acts.
Evaluating Larry's suicidal history and current ideation is crucial for assessing his safety and implementing appropriate interventions. Research indicates that individuals with substance use disorders and co-occurring psychiatric conditions are at higher risk for suicidal behavior, highlighting the need for vigilant assessment and integrated treatment strategies (Borges et al., 2017).
History of/current homicidal (harm to others) ideation, intent, plan, or acts: Inquire about any history or current presence of homicidal thoughts, intentions, plans, or acts. Evaluate the risk of harm to others and the need for safety measures.
Assessing homicidal ideation is essential for ensuring the safety of Larry and others involved in his care. The research underscores the importance of conducting thorough risk assessments to guide intervention strategies and promote a safe treatment environment (Boduszek et al., 2021).
Living arrangements: Obtain information about Larry's current situation, including stability, safety, and social support, since there was no mention of any family member or relative.
Marital/relationship status: Assess Larry's marital status and the quality of his current relationships to gain insight into his social support system, which can be used to improve holistic treatment.
Any children (if applicable): Inquire about Larry's parental status, if applicable, and the impact of his substance use and mental health on his children or family.
Family of origin history: Explore Larry's family background, including any history of substance use, mental health issues, or trauma within his family, since the patient did not provide these details.
School and work history: Obtain information about Larry's educational and employment history to understand potential influences or stressors related to his substance use and mental health.
Mental status: Conduct a comprehensive mental status examination to assess Larry's cognitive, emotional, and behavioral functioning.
Insight and judgment: Finally, evaluate Larry's insight into his problems and ability to make sound decisions regarding his well-being and treatment.
3 Clinical approach for working with psychotic symptoms:
Substance-induced psychotic symptoms: If the psychotic symptoms are substance-induced, the first step would be prioritizing abstinence from substances. A thorough assessment of Larry's substance use patterns and triggers should be conducted (i.e., poverty and homelessness), and a tailored treatment plan should be developed. Engaging Larry in substance abuse treatment and maintaining abstinence can help alleviate the psychotic symptoms. Additionally, integrating supportive therapies, such as cognitive-behavioral therapy (CBT), can help address distorted thinking and improve coping strategies.
Co-occurring psychotic disorder: If Larry is diagnosed with a co-occurring psychotic disorder, a comprehensive treatment plan should be developed that addresses both the substance use disorder and the psychotic symptoms. This may involve medication management, individual therapy (such as CBT or other evidence-based therapies for psychosis), and psychosocial interventions to enhance social support and functional recovery.
Psychotic disorder due to another medical condition: If the psychotic symptoms are attributed to another medical condition, such as a brain injury or a medical illness, a thorough medical evaluation s...