Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

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.

For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.

To Prepare:

· Review this week’s Learning Resources and consider the insights they provide.

· Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.

· By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.

· 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.

By Day 7 of Week 8

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

· Objective: What observations did you make during the psychiatric assessment? 

· Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

· Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

· American Psychiatric Association. (2022). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders

· Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

· Chapter 4, “Substance Use and Addictive Disorders”

· Chapter 2 only section 2.17, “Adolescent Substance Abuse”

· Chapter 27 “Ethics and Professionalism”

· Chapter 28 “Forensic and Legal Issues”

Training title 114-2

· BEGIN TRANSCRIPT:

· 00:00:00DISCLAIMER

· 00:00:00THE INFORMATION CONTAINED HEREIN IS OF A GENERAL NATURE AND CANNOT SUBSTITUTE FOR THE ADVICE OF A MEDICAL PROFESSIONAL. THE CONTENT PROVIDED MAY NOT APPLY TO YOU OR YOUR SYMPTOMS. YOU SHOULD NOT RELY ON THIS INFORMATION AS A SUBSTITUTE FOR, NOR DO THEY REPLACE, PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS OR TREATMENT. IF YOU HAVE ANY CONCERNS OR QUESTIONS ABOUT YOUR HEALTH OR THE CONTENT. YOU SHOULD ALWAYS CONSULT WITH A PHYSICIAN OR OTHER HEALTH-CARE PROFESSIONAL. DO NOT DISREGARD. AVOID OR DELAY OBTAINING MEDICAL OR HEALTH RELATED ADVICE FROM YOUR HEALTH-CARE PROFESSIONAL. THE CONTENT SHOULD NOT BE USED IN PLACE OF A CALL OR VISIT TO A MEDICAL, HEALTH OR OTHER COMPETENT PROFESSIONAL, WHO SHOULD BE CONSULTED BEFORE ADOPTING ANY OF THE SUGGESTIONS IN THE CONTENT OR DRAWING INFERENCES FROM IT.

· 00:00:00SYMPTOM MEDIA, LLC DISCLAIMS ALL RESPONSIBILITY FOR ANY LIABILITY LOSS OR RISK, PERSONAL OR OTHERWISE, WHICH IS INCURRED AS A CONSEQUENCE, DIRECTLY OR INDIRECTLY, OF THE USE AND APPLICATION OF ANY OF THE CONTENT CONTAINED HEREIN.

· 00:00:15Ally (ph) Really, come on. I’m missing first period. And now you want me to be late for my second class. Can we do this during my third period break?

· 00:00:25UNKNOWN I… I’m sorry, Ally(ph) but principal Michaels requested that you and I take some time this morning and talk. I… I know we worked together before right now, I’m going to have to put on my professional app.

· 00:00:35Ally (ph) That’s ridiculous. Why?

· 00:00:35UNKNOWN Well, maybe you can tell me why.

· 00:00:40Ally (ph) I have a class waiting for me.

· 00:00:45UNKNOWN Well, you been frequently late for your classes. In fact, let’s say uh… 22 days so far this year?

· 00:00:50Ally (ph) It has not been 22 days.

· 00:00:55UNKNOWN Yes, it has, something not right here at school or something not right at home.

· 00:01:00Ally (ph) My personal life is fine. And personal.

· 00:01:05UNKNOWN I know you haven’t changed addresses so it can’t be the traffic.

· 00:01:10Ally (ph) Jesus. The History Department had a party last night a Darrel’s(ph). Why don’t you bring him in here and question him?

· 00:01:20UNKNOWN So are you saying the Darrel’s(ph) party is the reason that you were late? That was last night? I don’t understand.

· 00:01:25Ally (ph) Okay. Alcohol was served. We had a bit much to drink. Not just me. We’re adults here. And I mean, the… the school host of social hour on campus every month.

· 00:01:40UNKNOWN So what are you saying? Are you saying that you were drunk?

· 00:01:45Ally (ph) I drank, but no.

· 00:01:45UNKNOWN Were you intoxicated enough that you passed out?

· 00:01:50UNKNOWN I woke up and Darrel’s(ph) cash responding. And, and fuck him for not waking me. He came to school on time but let’s be there lying on the couch.

· 00:02:00UNKNOWN Have you passed out other times?

· 00:02:05Ally (ph) We have all passed out at times. I’m sure I’ve seen you drunk at those parties.

· 00:02:10UNKNOWN Are you still feeling intoxicated this morning?

· 00:02:15Ally (ph) No, Course not.

· 00:02:15UNKNOWN Have you ever been drunk? While you were here teaching?

· 00:02:20Ally (ph) No.

· 00:02:20UNKNOWN I’m asking that because we’ve had complaints.

· 00:02:25Ally (ph) Complaints from who?

· 00:02:25UNKNOWN Students, parents.

· 00:02:30Ally (ph) Well, bring him in. Let them tell that to my face because it’s totally not true.

· 00:02:35UNKNOWN They’ve complained that at different times you came into class and then you ordered the kids to read from their textbook or you ordered the kids to copy notes from the board while you were sleeping with your head on the desk.

· 00:02:45Ally (ph) You have to be kidding me.

· 00:02:50UNKNOWN Several students and several parents have complained.

· 00:02:55Ally (ph) Exactly who, Alexis? Do you know how many problems she’s created for the teachers at the school.

· 00:03:00UNKNOWN But you were drinking last night. And it sounds like you drank enough that you passed out and had to sleep on Darrel’s(ph) couch?

· 00:03:10Ally (ph) Yes. I mean, I did.

· 00:03:15UNKNOWN So, is there something going on in your personal life?

· 00:03:20Ally (ph) No.

· 00:03:20UNKNOWN How’s Ryan?

· 00:03:25Ally (ph) Ryan? First time I’ve known you to travel slow here. We split up before the school year started. Last summer.

· 00:03:35UNKNOWN What happened?

· 00:03:35Ally (ph) I’m really, really uncomfortable sharing anything about my relationships with you.

· 00:03:45UNKNOWN Okay, that’s fair. That is your personal life.

· 00:03:50Ally (ph) Is there any reason I just can’t walk out of this office right now?

· 00:03:50UNKNOWN Well, I don’t know the specifics of what the Board of Education would decide if you don’t cooperate, but I’m guessing at something pretty serious.

· 00:04:00Ally (ph) This is unbelievable.

· 00:04:05UNKNOWN Wait, wait. Wait a minute. The administration asked me to speak with you. The school wants to work with you if you’ll cooperate. And as someone who really likes you. I am warning to understand. I’m hoping to help you. So just, okay, thank you. Good. Now, what’s going on?

· 00:04:30Ally (ph) I don’t know.

· 00:04:30UNKNOWN Okay. How much did you drink last night?

· 00:04:35Ally (ph) Too much.

· 00:04:35UNKNOWN How often do you drink too much?

· 00:04:40Ally (ph) I don’t know.

· 00:04:45UNKNOWN How much would you estimate that you drink in a typical week?

· 00:04:50Ally (ph) Every night.

· 00:04:50UNKNOWN Do you drink with friends, family, by yourself?

· 00:04:55Ally (ph) Alone. Once in a while I’ll go to a bar with my friends or drink at school functions. Where I might add they do supply alcohol liberally.

· 00:05:05UNKNOWN Yes.

· 00:05:10Ally (ph) They’re removing our social hours to downtown.

· 00:05:10UNKNOWN Do you go out and drink other than with friends?

· 00:05:15Ally (ph) Occasionally.

· 00:05:15UNKNOWN Do you drink alone at home?

· 00:05:20Ally (ph) Few glasses of wine while a grade takes the edge off the day.

· 00:05:25UNKNOWN Takes the edge off.

· 00:05:30Ally (ph) Yes. The kids here are getting worse by the year. The teachers talk about it. We all know what’s going on. They become they just become more… more vicious, more mean. I’m talking about kids who have no hint of remorse, no empathy, no thoughtfulness for others. When was the last time you try teaching them?

· 00:05:45UNKNOWN I have to admit it has been a while.

· 00:05:50Ally (ph) Just last week, I caught Alexis filming me on her phone. I was bent over picking up trash a student through on the floor. It was not flattering. And you know what she did?

· 00:06:00UNKNOWN No.

· 00:06:05Ally (ph) Send it out to the whole grade adding a really obscene title.

· 00:06:05UNKNOWN Was she punished?

· 00:06:10Ally (ph) Do the kids here ever get punished? All she caught was a bucking set down with their neuter principal. And then her mom comes threaten Sue again and naturally our fearless leader backs down. Michaels humiliated me. Did the administration tell you that?

· 00:06:25UNKNOWN No.

· 00:06:30Ally (ph) Humiliated me. I work for a place that has no backbone, no spine. Who runs this place here? The students or the teachers.

· 00:06:40UNKNOWN Sounds horrible.

· 00:06:45Ally (ph) And it goes on day after day. Rich kids who have no respect while you struggle to teach. I’m trying to pay bills here. Pay uh… pay the gas, driving shitty car, pay off student loans.

· 00:06:55UNKNOWN That does sound like a lot of stress.

· 00:07:00Ally (ph) Sounds like.

· 00:07:00UNKNOWN Do you like teaching?

· 00:07:05Ally (ph) Once upon a time when it had meaning.

· 00:07:05UNKNOWN What about now?

· 00:07:10Ally (ph) We aren’t supported.

· 00:07:15UNKNOWN Do you think all of this stress is contributing to your drinking?

· 00:07:15Ally (ph) Of course it is.

· 00:07:20UNKNOWN Do you drink during the day?

· 00:07:20Ally (ph) No, no, absolutely not.

· 00:07:25UNKNOWN When you do drink, how much do you drink?

· 00:07:25Ally (ph) Enough.

· 00:07:30UNKNOWN Enough to pass out?

· 00:07:30Ally (ph) If I’m lucky.

· 00:07:35UNKNOWN How much do you have to drink to get that feeling of being intoxicated?

· 00:07:40Ally (ph) Five or six glasses of wine, a couple of mixed drinks.

· 00:07:45UNKNOWN Do you think that’s more than it takes most people to get intoxicated?

· 00:07:50Ally (ph) I don’t know, but… but I can.

· 00:07:50UNKNOWN So, so do you think alcohol affects your body differently than it affects your friends?

· 00:07:55Ally (ph) Yes, alcohol affects. Yes.

· 00:08:00UNKNOWN Do you drink more than your friends and the other teachers?

· 00:08:05Ally (ph) I… I drink, but… but you’re not understanding it, it affects me differently.

· 00:08:15UNKNOWN Has it prevented you from doing things or interfered with relationships?

· 00:08:25Ally (ph) Are you specifically talking about Ryan here?

· 00:08:25UNKNOWN Yeah.

· 00:08:30Ally (ph) Okay, Ryan did not leave me because I drink.

· 00:08:30UNKNOWN Okay.

· 00:08:35Ally (ph) I’m seeing someone new. We weren’t even together for a year.

· 00:08:35UNKNOWN Is drinking wine, beer, other alcoholic drinks in the evenings. Is that something new for you? Or was that something typical than your past?

· 00:08:50Ally (ph) No. Look, my father was an alcoholic growing up. When I was really little he drank. He got into AA and got sober. Mom was very supportive of him, but extremely strict with us in drinking.

· 00:09:10UNKNOWN How did you feel about her being so strict with alcohol?

· 00:09:15Ally (ph) As a teenager it sucked. I went out with my friends I got drunk. And then freshman year was a huge vendor. Eventually I just I mellowed out.

· 00:09:25UNKNOWN And after college?

· 00:09:25Ally (ph) In grad school I drank here and there but not much.

· 00:09:30UNKNOWN Do you think your alcohol intake is less that when you were in college or is it gone the other way? Has it increased recently?

· 00:09:40[sil.]

· 00:09:50Ally (ph) More.

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