Treatment Plan

8

Clinical Intervention II

Psychosocial Case Study

Rudy Hernandez

University Ana G Mendez

34831_SWGR_607-O_2212_921_ASF: CLINICAL INTERVENTION II

Prof. Gonzalez

April 25, 2022

Clinical Intervention II

Psychosocial Case Study

Presenting Problem

Marci is a college student who has been having problems with alcohol, cigarette and marijuana. She started her habit at a young age due to peer pressure and family intervention influences. Drug and substance use have made her anxious, and she is developing depression. She says that she is worried about her habit because it has affected her life in so many ways. She is not on good terms with her parents due to excess alcohol consumption and smoking marijuana. Increased alcohol consumption has made her encounter accidents while driving, and this has happened to her more than twice. Through these accidents, she has been physically harmed. She is facing problems with the authorities due to being involved in accidents. She is facing the problem of addiction, such that she is unable to stay without using these substances. Her family has played a big part in her habitual drug and substance use (Buckner et al., 2021).

Background Information/History

The history of Marci is based on family inherited characteristics. Both Joan and John's maternal and paternal sides (Marci's mother and father, respectively) had issues with alcoholism. John's grandfather was a drunkard. John started taking alcohol when he tasted from his father's stash. He drank too much when Marci was young, but now he has seized, although he faces problems with family and work. Joan (Marci's mother) started using marijuana when she was young, and she has been fighting anxiety and depression for some years. She was also addicted to tobacco and smoking cigarettes. Joan's father was an alcohol addict, and he used to abuse his family when drunk. Joan says that he died due to a road accident thought to be a result of drunkardness. Joan's brother is a drunkard as well, and it is believed he follows in his father's footsteps. Marci's brother, Jacob, once drank beer when he was 16 years old but did not like it. Her younger sister hates alcohol and cigarettes, which she says is due to their bad smell (Dugosh & Cacciola., 2018).

Medical History

Marci has never gone through treatment in her drug and substance life. She was once given some pills to relieve her anxiety and depression but did not take them. However, increased worry and fear have made her think of taking them. During the counselling session, she was somehow upset and said though she was caught using marijuana, she feels like starting to use it again because she feels no severe problems in her body. She says that generally, she has not experienced any problems with alcohol, cigarette or marijuana. Though she denies having any problems, she is addicted to drug abuse, and she was just resisting undergoing treatment because she wanted to continue drinking and smoking (Buckner et al., 2021).

Education

Marci was a great performer during her early ages, and she scored A's and B's. Currently, she is in junior college, but instead of focusing on education, she is obsessed with drug and substance use. When she started consuming alcohol, marijuana and cigarettes, her commitment to education varnished, her parents once realized that she had started taking marijuana, and they noticed that her academic performance was going down. They thought of calling the dean head of academics to inform him about Marci's habit, but Marci threatened to quit school. Due to this, her relationship with her parents was soured, and they were not happy with her. During the interview, she responded with an anxious tone when she was questioned about poor performance in school. She was dreaming of becoming an attorney, but drug and substance use overtook the zeal she had for her life (Dugosh & Cacciola., 2018).

Employment History

Marci is currently unemployed. She used to work as a waitress in the past, and sometimes she would work as a bar attendant in search of extra cash. She has been fired severally from different workplaces due to unprofessionalism. She was accused of absenteeism and destruction of property. Being fired everywhere does not seem to be normal. She could be failing to report for a job, and property destruction would result from anxiety and depression. She could not work effectively and efficiently because she was drunk almost every day, and therefore, hangovers could not make her go to work. The work that she did for a long time was that of a waitress, where she served for six months. The employees could not tolerate her for long because she could only make organizations suffer. Though she was determined to become someone important in her life, drugs and substance could not allow her to get time to work (Dugosh & Cacciola., 2018).

Substance Abuse History

Marci started smoking cigarettes when she was 16 years old. A year ago, she stopped smoking for six months, but she has admitted that she can do without it. She learned to smoke marijuana from a high school boyfriend who used to use marijuana daily and combine it with alcohol during the weekend. She first drank wine when they had gone for church missions in Latin America. When she was 18 years old, she started drinking alcohol seriously, and she could do with four different beverages. She would then go Friday night clubbing with friends, and then on Saturday afternoon, she would drink about two glasses of wine after lunch. Later on Saturday nights, she could go to parties with friends, and she took several bottles of alcohol. She used to drink too much to miss some lessons in school due to oversleeping. However, she has seized using marijuana since her arrest, and she is now taking a few bottles of alcohol and wine a week (Buckner et al., 2021).

Mental Status Examination

From the interview, Marci did not show any mental impairment. However, she denied having any compulsions or obsession. She also denied having any problems, but she admitted that she would feel paranoid. Her mental intelligence seemed to be above average. Although she seemed to be ok, she happened to complain to her friends about anxiety and feeling depressed, which had increased over the past few months after failing to use marijuana. Nothing she seemed to be doing abnormally, and she passed the alcohol serial test. She also denied having any learning disability or any ideas to commit suicide. She also denied any kind of hallucinations and did not show any psychotic problems. However, research shows that most drug and substance users deny having any kind of problems, and therefore more diagnostic analysis needs to be done to determine their real problems (Buckner et al., 2021).

Diagnostic Impression

Diagnosis of substance use disorder ICD-10-CM

The primary diagnosis is substance use disorder 304.10 (F13.20). This is because Marci has been obsessed with many problems that result from substance use. She continues to use the substances despite having several problems. Behaviours developed from substance use clearly show that she requires a diagnosis so as to identify possible treatment. She has currently increased her consumption of alcohol and smoking marijuana. Although she has stayed without smoking marijuana for six months after she was caught, she says that she is still craving it and if she gets the means to smoke without being seen, she will do it. All her daily activities are revolved around substance use. She has failed to fulfil her obligations at school and places of work. Despite all these challenges, she never stopped engaging in substance use. she has been unable to withdraw from substance use and has developed compulsive drug-seeking behaviour. All these problems made me choose substance use as the primary diagnosis that should be done on Marci because it’s a main problem affecting her.

Depressive (ICD-9-CM and ICD-10-CM) and anxiety (ICD-9-CM and ICD-10-CM) Substance-induced disorder

Substance-induced depressive disorder (ICD-9-CM and ICD-10-CM) is one of the secondary diagnoses Marci needs. This is because Marci has been complaining of depression which has lasted for a long and it increased when she stopped using marijuana for some time. The problem arose after she started using drugs and other substances, which affected her greatly. She also experiences a history of depression from her parents, specifically Joan, her mother, who underwent depression when she was taking marijuana. The process of withdrawal from taking marijuana has prolonged Marci's impact of depression. The other secondary diagnosis is substance-induced anxiety disorder (ICD-9-CM and ICD-10-CM), ICD-9-CM started as a result of the use of marijuana, and it has extensively increased. Marci says that she has been worrying so much about her life currently, and she has informed her friends about the anxiety she is experiencing. After marijuana withdrawal, her anxiety rate increased, and she felt affected. Her anxiety and depression were mainly caused by alcohol and marijuana use and became more effective as she continued using those substances.

Alcohol and cannabis diagnosis ICD-10-CM

The tertiary diagnosis is alcohol and cannabis use disorder. Marci was experiencing an alcohol use disorder 303.90 (F10.20) and cannabis use disorder 304.30 (F12.20) that resulted in various problems in her life. She started failing in school and even failed to attend some classes. She also had problems with her employees, and she could not be maintained in a workplace for long. She also had a bad relationship with her parents after realizing she was too much into alcohol and cannabis. She was very much addicted such that she could even drive when drunk. She was involved in several accidents where the relevant authority realized that she had some alcoholic percentages in her blood. She faced physical bruises and cuts when she was involved in accidents. From her historical background, it was evident that her family had problems with alcohol and marijuana use. Regular usage resulted in her being depressed and feeling anxious over many things in her life. She was dreaming of becoming an attorney, but substance use made her give away her dreams.

Diagnostic Impression for The Client

Diagnosis of this patient requires several evaluations that may help in treatment. The client needs several laboratory tests that can help determine the level of addiction and the amount of substance in her blood. She should also provide her family background on substance use, how she started using substances and whether she has undergone any medication or visited any other psychiatrist (LeTendre & Reed., 2017). Several alcoholic and cannabis tests need to be done to identify this client's problems that have made her so much into substance abuse. Assessments also need to be thoroughly done, for example, using the ADHUD and CAGE tests and other oral tests (van der Burg et al., 2019). Apart from these tests, the client needs a mental diagnosis using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Repetitive assessments and tests need to be done because the client denies being obsessed with some problems like psychotic disorder and hallucinations. Apart from family relationships, the client needs to be done an assessment to determine how she relates with members of society. The client should also analyze how substance use has affected her education, work, and life in general (Duresso., 2021).

References

Buckner, J. D., Morris, P. E., Abarno, C. N., Glover, N. I., & Lewis, E. M. (2021). Biopsychosocial model social anxiety and substance use revised. Current psychiatry reports, 23(6), 1-9.

Dugosh, K. L., & Cacciola, J. S. (2018). Clinical assessment of substance use disorders. UpToDate. Retrieved February.

Duresso, S. (2021). Psychopharmacological Perspectives and Diagnosis of Substance Use Disorder. In Addictions-Diagnosis and Treatment. IntechOpen.

LeTendre, M. L., & Reed, M. B. (2017). The effect of adverse childhood experience on clinical diagnosis of a substance use disorder: Results of a nationally representative study. Substance use & misuse, 52(6), 689-697.

van der Burg, D., Crunelle, C. L., Matthys, F., & van den Brink, W. (2019). Diagnosis and treatment of patients with comorbid substance use disorder and adult attention-deficit and hyperactivity disorder: a review of recent publications. Current Opinion in Psychiatry, 32(4), 300-306.