Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Many individuals seeking treatment meet the criteria for both mental health and substance-related disorders. Regardless of whether you specialize in substance-related disorders, all advanced practice nurses should know their signs and symptoms and how to assess and diagnose them. There are assessment and screening tools available to clinicians, and a plethora of information can be obtained through the diagnostic interview. It takes time and experience to know what types of questions to ask to gain the most information, in addition to a basic knowledge of the substances and behaviors you are trying to assess. It can be complicated to sort out substance use disorders from other mental health disorders, but most clients seeking treatment have comorbidities.

· Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information

· Formulate differential diagnoses using DSM-5 criteria for patients with substance-related and addictive disorders across the lifespan

An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

· Consider what history would be necessary to collect from this patient.

· Consider what interview questions you would need to ask this patient.

· Identify at least three possible differential diagnoses for the patient.

CASE STUDY

Name: Lisa Pittman Gender: female Age: 29 years old T- 99.8 P- 101 R 20 178/94 Ht 5’6 Wt 140lbs Background: Lisa is in a West Palm Beach, FL detox facility thinking about long term rehab. She has been smoking crack cocaine, approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”), and 2–3 alcohol drinks once weekly. She has past drug possession and theft convictions; currently on 2 yr probation with randomized drug screens. She tries to find the pattern for the calls in order not to test dirty urine. Her admission labs abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive for cocaine, THC. Negative for alcohol or other drugs. BAL 0; other labs within normal ranges. She reports sexual abuse as child ages 5–7, perpetrator being her father who went to prison for the abuse and drug charges. She is estranged from him. Mother lives in Alabama, hx of anxiety, benzodiazepine use. Older brother has not contact with family in last 10 years, hx of opioid use. Sleeps 4-5 hrs, appetite decreased, prefers to get high instead of eating. Allergies: amoxicillin She is considering treatment for her Hep C+ but needs to get clean first.

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00:00:00TRANSCRIPT OF VIDEO FILE:

00:00:00______________________________________________________________________________

00:00:00BEGIN TRANSCRIPT:

00:00:00[sil.]

00:00:20LISA Well I had to be here in this hospital if that answers your question.

00:00:25OFF CAMERA Yes, thank you. Can I get you a drink of water or something else to drink? Anything?

00:00:35LISA A drink isn’t going to convince me, right? You’re going to have to convince me.

00:00:40OFF CAMERA What is you want me to persuade you to do?

00:00:45LISA Going to rehab.

00:00:50OFF CAMERA What worries you about going to rehab?

00:00:55[sil.]

00:01:00LISA Everything.

00:01:00OFF CAMERA Okay. I tell you what let’s go back a little bit and tell me about how you’re feeling today.

00:01:10LISA Scared.

00:01:15OFF CAMERA Can you tell me more about that feeling of being scared?

00:01:20LISA Well, I don’t want to be. I don’t want to be what people say I am because if I say it and I’m not going to say it because I ain’t going to change. I can’t.

00:01:35OFF CAMERA What do people say you are?

00:01:40LISA And I’m not.

00:01:45OFF CAMERA What don’t you want to be?

00:01:45LISA An addict.

00:01:50OFF CAMERA Do you use drugs and alcohol?

00:01:50LISA Yeah sometimes I have a drink. You know with friends [inaudible] but it doesn’t matter. I’m in control.

00:02:00OFF CAMERA Do you feel in control now?

00:02:05LISA Maybe I could just get that drink [inaudible].

00:02:10OFF CAMERA Sure. Sure. Here you go.

00:02:15LISA Thank you.

00:02:20[sil.]

00:02:30LISA You know what I just think I should leave.

00:02:30OFF CAMERA You keep saying you should leave. You said that earlier but do you really want to leave?

00:02:40LISA No.

00:02:45OFF CAMERA Okay. Tell me why you are here.

00:02:45LISA Because I’m scared.

00:02:50OFF CAMERA You said that earlier. You think if you could — then I could figure out together why you’re scared and maybe we can come up to a plan. Up with a plan and if we do that, then maybe your fears will disappear.

00:03:05LISA No not these fears [inaudible] because it’s over.

00:03:10OFF CAMERA What’s over?

00:03:10LISA Everything. The business.

00:03:15OFF CAMERA What do you mean?

00:03:20LISA Jeremy.

00:03:25OFF CAMERA Who is Jeremy?

00:03:25LISA He’s my boyfriend. I saw him naked with Alisa [assumed spelling] with the same fucking name as me. We now have the same fucking boyfriend. In my office, he was screwing that fucking cunk.

00:03:45OFF CAMERA So you’re the one who caught Jeremy cheating?

00:03:55LISA Yeah. Cheating? Yeah that’s a clever word shrinks use.

00:04:05OFF CAMERA So you and Jeremy share an office?

00:04:05LISA Yeah we do commercials for local businesses, you know, build websites, that kind of stuff. We started a business together. He moved in with me.

00:04:15OFF CAMERA How long ago was that?

00:04:20LISA Nine months.

00:04:20OFF CAMERA Do you have any children?

00:04:20LISA Not with that fucking asshole.

00:04:25[sil.]

00:04:30LISA I have a daughter, Sarah. Gosh, she’s beautiful. She stays with some friends. She’s not related to Jeremy, thank God.

00:04:45OFF CAMERA And where are you staying?

00:04:45LISA I’m renting a place far away from here. You know I ran down to the bank to empty both our bank accounts.

00:04:55OFF CAMERA Business accounts?

00:04:55LISA Yeah. And do you know that asshole has been draining them for 4 months? I swear.

00:05:05OFF CAMERA Taking money out of your account without your knowledge.

00:05:05LISA Yeah. For his buys.

00:05:10OFF CAMERA Buys?

00:05:10LISA Yeah, to payoff his debts with my money.

00:05:20OFF CAMERA Or crack cocaine?

00:05:25LISA Yeah for crack.

00:05:25OFF CAMERA How long have you know he’s been smoking crack?

00:05:30LISA Ever since I saw him with that — every since I saw with her naked. The both of them naked.

00:05:40OFF CAMERA What was that like seeing Jeremy and Alisa naked and smoking crack?

00:05:40LISA Well have you ever seen someone you love naked smoking crack?

00:05:45OFF CAMERA No.

00:05:50LISA Yeah no I didn’t think so.

00:05:50OFF CAMERA So what has that been like for you knowing Jeremy’s smoking crack?

00:05:55LISA Well, I’ve never seen him do drugs before. You know he drinks a lot, smokes weed, but crack cocaine. I mean God have mercy.

00:06:15OFF CAMERA What are you thinking about?

00:06:20LISA Everyone’s going to know.

00:06:25OFF CAMERA Know what?

00:06:30LISA That I was getting high to stay in this hospital and get cleaned up.

00:06:35OFF CAMERA You mean rather than go to rehab.

00:06:40LISA Rehab, man they’re fucking dirty places and I’m sick and tired of dirty places.

00:06:45OFF CAMERA No, no, no this rehab place is very clean. I’ve seen it. There are a lot of nice people there. People who feel like they get much better help than here in the hospital. In fact, I can call someone for you and let you talk with them.

00:06:55LISA No, no, no, no, no, no, no, no, don’t do that.

00:07:00OFF CAMERA You’re really fearful of going to rehab.

00:07:05LISA Well if everyone finds out that I’ve been to rehab, I won’t get a job. I won’t be hired anyway.

00:07:10OFF CAMERA Plus if people are fearful of the stigma and fearful of what people will think of them.

00:07:20LISA Yeah, but he says that I’m not addicted. It’s just — you know something wrong with my personality.

00:07:25OFF CAMERA Who says there’s something wrong with your personality?

00:07:30LISA Jeremy.

00:07:30OFF CAMERA When did he tell you that?

00:07:35LISA Lots of times.

00:07:35OFF CAMERA I thought you said you and Jeremy split up after you caught him cheating.

00:07:40LISA I —

00:07:45OFF CAMERA It’s okay. Take your time.

00:07:50LISA Well yeah he moved back in.

00:07:50OFF CAMERA Into your new home?

00:07:55LISA Yeah. What changed that you two decided to get back together?

00:08:00OFF CAMERA Well he said he was sorry and he begged me. He’s done it before so I took him back.

00:08:10LISA And how has that been being back with Jeremy?

00:08:15OFF CAMERA Well I love Jeremy. I do and don’t want to go out and find another boyfriend. I mean we lost 80,000 dollars on that business. And he promised me that he would make it all back.

00:08:30LISA So is that why you took him back? Has Jeremy continued smoking crack?

00:08:45OFF CAMERA Yeah a little but he’s not addicted. He says that it calms him down. Me too.

00:09:05LISA You too?

00:09:05OFF CAMERA So do you smoke crack with Jeremy?

00:09:15LISA Yeah we — he made me try it.

00:09:25[sil.]

00:09:30[ Crying ]

00:09:40LISA And then he tried just once. We did it together. [Inaudible] I could.

00:09:55[ Crying ]

00:10:00LISA Hit me like a bullet. And it felt so good. I felt so good. And real fast.

00:10:20[sil.]

00:10:25LISA Have you ever felt like you were dancing with butterflies?

00:10:30OFF CAMERA Dancing with butterflies? No I have not.

00:10:40[sil.]

00:10:45LISA But he says it’s not addictive, Jeremy.

00:10:50OFF CAMERA What do you think?

00:10:55LISA Well I know I can’t get enough.

00:11:00[ Crying ]

00:11:10LISA And I know I don’t want to go back to feeling horrible again because when I don’t smoke it I get worse. And when I have it, I feel good. And then it’s gone. And then I know that I’m going to be needing another hit.

00:11:45OFF CAMERA That sounds a lot like addiction.

00:11:55LISA Yeah but I know I don’t want it to be.

00:12:00OFF CAMERA It sounds like you are very scared of getting help and yet at the same very time, it sounds like you know you need that help.

00:12:15LISA I know I don’t need help. I don’t need anything. Jeremy promised me that everything is going to be okay. And when you love someone like I do, you got to believe him. Right?

00:12:45[sil.]

00:12:45END TRANSCRIPT

Comprehensive Psychiatric Evaluation Template

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

· Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.