Treatment Plan

Running head: GUIDED IMAGERY AND PROGRESSIVE MUSCLE RELAXATION

1

Case History

Patrice Scope

SWK/5013

Capella University

Instructor: Natasha Houston

10/22/2

Mental Status Examination

Diagnosis with substance-induced depressive disorder necessitates that the depressive episodes be associated with ingestion of a substance and to begin within a month after use of the substance. The disorder is said to be with onset during intoxication when the symptoms are developed during intoxication and the criteria are met (Farré et al., 2020). Substance-induced depressive disorder is distinguished from primary depressive disorder or substance use disorder by considering the onset, course, and other factors associated with the substance use.

Mental Health History

Olly is a 30-year-old African American married woman with three children. The client has been referred to the clinic for by her professor who is concerned because of her social impairment, and alcohol consumption leading to a decline in her performance. Olly has been struggling with getting out of bed and does not enjoy studying or being at home with her family. The client sleeps more than ten hours a day and isolates herself from her family. Olly drinks all the time and claims that she feels worthless and fatigued despite resting. The patient has been previously diagnosed with alcohol use disorder when she was 16 and 24 years and depressive disorder when she was 24.

Olly’s father took her to family counseling as a teenager after her first DUI when she was 16 years old. Olly claims that the treatment was time wasting since she was not an alcoholic and drinking was not her problem. Olly began drinking shortly after her mother left them when she was 14 years old. She claimed that drinking with her boyfriend made her feel better. The second instance was after the birth of her first child. She began drinking because of her guilt for not being with her baby because of work. Olly lost her job because of drinking and she could felt overwhelmed when she had her second child. The client attempted to take her life by consuming Wellbutrin with alcohol. She was admitted to hospital and began attending AA meetings which improved her condition.

Family History

Olly claims that she grew up with loving and hard working parents. The patient states that her mother left them when she was 14 years old and that was when she began drinking. Olly lived with his father who took her for treatment after her first DUI. The patient claims that her father died two years ago because of drinking himself to death. The client also has a sister who moved out of state years ago. They only communicate over the phone occasionally because they are not close. Olly receive support from her AA members and the church as she claims they help her to get up in the morning.

Mental Status Examination

Olly is presenting the symptoms of agitation and nervousness. The patient is late for her appointment and she appears disheveled. Olly is wearing baggy clothes and has unkempt hair. The client is oriented to time, place, and person. The patient appears to be competent. The client is cooperative and answers the interview questions accurately. The patient’s tone and pitch is appropriate as she cries because she feels frustrated that she has to sacrifice her studies to support her family. The patient’s thoughts flow logically, demonstrated in her responses to open-ended questions.

The client does not have auditory or visual delusions and she does not exhibit distorted thinking. Olly claims that she feels worthless and fatigued almost every time throughout the entire day. The client reports that she can only get through the rest of her day when she is drinking. The patient has insight into her difficulties because she understands her problems at home are contributing to her drinking and depression. The client appears sad because of her marital problems which have affected her performance in school. The patient does not currently exhibit suicidality and is not on any medication. The patient is consuming alcohol.

Diagnosis

The patient is suffering from Alcohol-induced depressive disorder. The depressive disorder is associated with intoxication causing impairment in occupational, academic, and social areas of functioning consistent with Criterion E of the DSM-5 (Jiang et al., 2020). The client drinks and is depressed to the extent that she is unable to care for her children or perform well in school. The client’s peers in school do not want to work with her because she is only concerned with drinking. Criterion D requires that the symptoms incur inclusively during the course of delirium (Wang et al., 2020). Olly drinks throughout the entire day as she claims it enables her to cope.

Conclusion

Substance-induced depressive disorder can either occur during intoxication or during withdrawal depending on when the depressive episodes present. The patient is suffering from alcohol-induced depressive disorder since the symptoms exhibited are consistent with the diagnostic criteria for the condition. Moreover, the patient had been previously diagnosed with depression and substance use because of excessive alcohol consumption. The client cannot cope through the day unless she ingests alcohol.

Reference

Farré, A., Tirado, J., Spataro, N., Alías-Ferri, M., Torrens, M., & Fonseca, F. (2020). Alcohol induced depression: Clinical, biological and genetic features. Journal of Clinical Medicine, 9(8), 2668. http://hdl.handle.net/10230/48650

Jiang, Y., Liu, Y., Gao, M., Xue, M., Wang, Z., & Liang, H. (2020). Nicotinamide riboside alleviates alcohol-induced depression-like behaviours in C57BL/6J mice by altering the intestinal microbiota associated with microglial activation and BDNF expression. Food & function, 11(1), 378-391. https://pubs.rsc.org/en/content/articlehtml/2019/fo/c9fo01780a

Wang, P., Guo, P., Wang, Y., Teng, X., Zhang, H., Sun, L., … & Liang, H. (2022). Propolis Ameliorates Alcohol-Induced Depressive Symptoms in C57BL/6J Mice by Regulating Intestinal Mucosal Barrier Function and Inflammatory Reaction. Nutrients, 14(6), 1213. https://doi.org/10.3390/nu14061213