Case Study 2
Diagnosis: Substance Abuse Disorder
- Outline the major symptoms of this disorder.
- Substance Abuse Disorder is signified through psychological, cognitive, and behavioral indicating the individual continued use despite problems associated with substance use (American Psychiatric Association, 2013). Changes in brain circuits, persistent after detoxification which manifests through repeated relapse and substance cravings triggered by environmental cues (American Psychiatric Association, 2013). Substance abuse disorder is diagnosed based on some categorical criteria. The first group of criteria, impaired control, explains the individual may increase usage over a longer period of and be unable to cut down usage even though expressing a desire (American Psychiatric Association, 2013). Additionally, a great deal of time is spent attaining the substance which may cause the individual to incorporate activities around the substance and develop cravings for the substance (American Psychiatric Association, 2013). The second group, social impairments, identifies recurrent use is hindering daily life such as work, school and home combined with continued use despite deficits in interpersonal relationships (American Psychiatric Association, 2013). Important and enjoyable activities may be given up for the substance as well as familial withdraw for the use of the substance (American Psychiatric Association, 2013).
The third group, risky use, includes the failure to abstain from the substance despite, physical or psychological impairments caused by the substance (American Psychiatric Association, 2013). The fourth group, pharmacological criteria, is defined as a marked tolerance for the substance and the presence of withdrawal syndrome (American Psychiatric Association, 2013). At this point, the individual likely no longer continues use for the effect of the substance, rather avoid the effects of withdrawing as the body has now become dependent on the substance for the feeling of normality (American Psychiatric Association, 2013). However, according to the DSM-V, individuals who use and become dependent on a substance solely for medical treatment should not be diagnosed with substance abuse disorder (2013). Additionally, Substance Abuse disorders are diagnosed by severity according to specific coding for a specific substance (American Psychiatric Association, 2013).
- Briefly outline the client’s background (age, race, occupations, etc.).
- Bobby is a thirty-one-year-old female who claims sobriety for ten years. She lives in an apartment with her five-year-old son, Tyler and her boyfriend. April 10, 1989, Bobby was diagnosed with HIV although she does not know how she contracted the virus. She does continue to work a part-time job at this point. Bobby established that her issue began at nine years old when she desperately desired her mother who was inconsistent in her life. Her mother was an addict and very sporadic. She remembers being sexually abused by her stepbrother from the age of nine to fifteen. At the age of nine, she began doing things for attention from her father such as attempting suicide. She recalls the attention she received from her father was a “slap in the face” or “a knee in the stomach.” However, later in the interview, she claimed not to have experienced abuse from her father, rather witness domestic violence towards her mother by her father. By twelve she was smoking cigarettes and drinking alcohol. Her father moved her three times in Tucson, assuming this gave her a sense of instability, her acting out progressed. By thirteen she was smoking pot and at fourteen was drinking vodka daily. At fifteen, Bobby dropped out of school, and her life revolved around, “partying” and sex (McGraw Hill Higher Education, 2007).
At sixteen Bobby ran away from her father’s home hitchhiking to Iowa and experienced her first rape and began using cocaine, speed, and acid. She started living with her mother, in Portland, who introduced her to heroin through a cotton ball as a chew for a mouth infection. Her mother was busy with her life, so Bobby took to the streets and began prostituting, shooting up, and went through an abusive relationship. By twenty, Bobby was using 2.5grams of heroin and 1gram of cocaine a day, was prostituting in the street almost twenty-four hours a day, and entertaining bisexual relationships. She felt consumed by her substance abuse and would turn tricks with a partner to make more money (McGraw Hill Higher Education, 2007).
When Bobby was twenty-one, she was sent to prison for the second time. A diagnosis of HIV soon followed which brought her to the realization she was going to die yielding her to sobriety. Although she maintains sobriety from her adolescent lifestyle, Bobby admits to smoking pot to alleviate side effects of her medications, occasionally drink and have a methadone dependency which allows her to get out of bed each day. However, she said choosing to smoke pot was difficult because it crosses the line of addiction. Bonny maintains she is fearful of returning to addiction even though she has no desire. It is a battle each day for her, but she is adamant on helping others turn their life around or prevent addiction in potential users. She has returned to school for medical office assisting (McGraw Hill Higher Education, 2007).
- Describe any factors in the client’s background that might predispose him or her to this disorder.
- Evidence suggests that genetic factors influence the risk of substance abuse disorders with inheritability at fifty percent or more ((Dick, Ph. D. & Agrawal, Ph. D., 2008). Additionally, twin studies suggest dependence is determined by a combination of genetic and environmental factors (Dick, Ph. D. & Agrawal, Ph. D., 2008). Both facts imply Bobby has a genetic predisposition for the development of substance abuse disorder. According to an article found on the NIDA website, females who were sexually abused as children were three times more likely to develop a substance dependence as adults (Zickler, 2002), supports the effect of the sexual abuse and intercourse experienced by Bobby via her step brother from age nine to fifteen. Additionally, Bobby exposed that she believed she felt worthless, unloved, and unwanted. To attempt to receive what she desired and needed, she began to reach out in the world and gain acceptance from anyone who would oblige it. She found comfort in using drugs and drinking and felt as if she knew everything which directed her toward leaving to her mother. Her mother then exposed her to other drugs building upon the dependence she had already influenced herself which is consistent with the environmental factors discussed in twin studies earlier (McGraw Hill Higher Education, 2007).
- Describe any symptoms that you have observed that support the diagnosis. You can include direct quotes or behaviors that you may have observed.
- Bobby exhibited impaired control through her behaviors such as prostitution and the evolution of her experimentation with drugs into dependence. Social impairments were evident in her abusive relationship, separating herself from her father, and dropping out of school after planning her future as an astronaut for the Air Force. Shooting up, prostitution, and bisexual relations identify with risky behavior as explained by the DSM-V as she exposed herself to sexually transmitted diseases and contracted HIV. She met the fourth criteria due to the high dosages she needed at the time she chose sobriety. Additionally, Bobby currently has an addiction to methadone, claiming she takes it to get out of bed in the morning. She also exposed that she currently smokes marijuana, although she uses it for medicinal purposes, it was understood she obtained it illegally and became defensive when explaining herself. She also admitted to drinking socially from time to time which implies that she is still triggered in the environment. She fears to relapse in her addiction, but the implication is that she has not completely broken the addiction, rather substitutes through prescription and medicinal purposes.
- Describe any symptoms or behaviors that are inconsistent with the diagnosis.
- The DSM states that an individual should not be diagnosed with a substance abuse disorder if the dependency evolved directly from medical treatment (American Psychiatry Association, 2013). Due to the methadone being prescribed for the pain she endures from neuropathy caused by HIV drugs, currently, she would not fall under the substance dependence criteria. However, she did not distinguish if the methadone was originally prescribed as a detoxification tool or for medical treatment.
- Provide any information that you have about the development of this disorder.
- Bobby claims she was desperate for love and attention which prompted her negative behavior. In her mind, at the time, any attention was good attention, and she sought it at all extremes. She was genetically predisposed through her mother who also fought heroin addiction. She moved three times in a short period which implies an unstable lifestyle in childhood which is stressful and holds potential to ignite negative behavior. Additionally, she endured sexual abuse heightening her risk for developing a substance dependence in adulthood (McGraw Hill Higher Education, 2007).
- Did you observe any evidence of general medical conditions that might contribute to the development of this disorder?
- Bobby’s current usage is due to the pain and sickness she endures while battling HIV. However, it appears that childhood depression caused by family dysfunction and abuse led her to develop the disorder. She was desperately looking for a place in the world to fit in and be loved.
- Did you observe any evidence of psychosocial and environmental problems that might contribute to this disorder?
- Bobby claimed as a child she just wanted to be loved. However, looking back she believed she was unhappy due to an absent mother and feelings of abandonment brought on by her father who fostered more attention toward his stepdaughter. She chose the crowd of people who accepted her with her flaws and had ways to make her feel better through the use of alcohol and illicit drugs. At sixteen she was raped and at that point, it seems her dependence heightened as she claimed using heroin dulled the emotional pain she experienced (McGraw Hill Higher Education, 2007).
- As per your observations, what is the client’s overall level of safety regarding the potential harm to self or others (suicidality or homicidality)?
- Bobby attempted suicide twice seeking attention and love from her father. She was scared by the death sentence she received being diagnosed with HIV and decided to change her lifestyle. She claims she does no want to die because she wants to watch her son grow and be a mother to him, so he does not experience what she did (McGraw Hill Higher Education, 2007). However, it is imperative to use caution. Bobby has a terminal disease that makes life difficult and painful for her. As she recalls memories of her past, she becomes very emotional especially memories about her health status. If she falls ill again, she holds potential for harming herself because she may fear her son watching her die from AIDs.
- In your opinion, what are the appropriate short-term goals of this intervention?
- Bobby needs to focus on healing from living with HIV. She fears the future or the thought of the future because she feels doomed to death. If Bobby can view the future in a positive manner, she will have more success at battling her health and raising her son. The development of a goal plan will give her a reason to keep fighting. The plan should include medical, personal, educational, and her son’s milestones. Once Bobby is able to accept her past and view the future, she can begin a full recovery.
Bobby should continue working with inmates. Telling her story to others is part of the healing process and will allow her to see clearly what was void to her before. It serves, in a sense, as a group therapy. Walking into the prison is a reminder of the potential behind relapse and telling her story can reach someone else fulfilling her desire to help others.
- In your opinion, what are the appropriate long-term goals of this intervention?
- Bobby admits to continued use of Marijuana, alcohol, and an addiction to methadone. Although she explains, the above are used for medicinal purpose, she appears emotional to her past. When speaking of the past, one should be able to do so with confidence that emanates the pleasure and peacefulness of the change. I don’t think Becky is there yet, hence her continued usage, and possibly replacement addiction. Bobby should ween off the methadone and replace with a healthier pain management strategy. Additionally, Bobby needs to come to terms and accept the mistakes that she made in order to have a positive future. A healthy psyche leads to biological health.
It is also important that Bobby continue her education goal. She desires to be needed, wanted, and make a difference in someone else’s life. Continuing her education will give her a sense of accomplishment and boost her self-esteem and allow her to set the positive example she wants for her son. Additionally, helping in the HIV/AIDs field as she desires will help her better accept her life in its current state, despite the hardship.
- Which therapeutic strategy seems the most appropriate in this case? Why?
- A behavioral therapeutic approach would allow Bobby incentives to maintain sobriety. That incentive is a longer, healthier life for her son. Currently, Bobby suffers from HIV which has led her to a drastic life change. However, Bobby still has addictive tendencies as seen with her current usage. Although she has eliminated the lifestyle and the addiction that led her to HIV, she dabbles with other drugs and alcohol and has developed a new addiction to a prescription. Behavioral therapy aims to modify attitude and behavior (“NIH”, 2012), such as the thought of using is okay because it alleviates medical symptoms. Additionally, Bobby will learn coping skills for times of stress or environments that trigger cravings (“NIH”, 2012), such as drinking in social settings.
- Which therapeutic modality seems the most appropriate in this case? Why?
- The harm reduction model discussed in the treatment section of the interactive seems to be the most appealing for Bobby. In the Harm-Reduction Model, the individual is taught that relapse is not a personal weakness, rather caused by the situation (McGraw Hill Higher Education, 2007). When an individual is led to believe their fall is from a personal deficit, it may cause them to believe they are not able to conquer their demon which triggers the addictive behaviors to reignite. In the Harm-Reduction model, the experience of relapse is examined to identified what caused the slip and coping skills for the scenario are developed to avoid repeat relapse in the future (McGraw Hill Higher Education, 2007). However, there is a drawback, relapse rate is higher (McGraw Hill Higher Education, 2007). However, as found in conditioning, repetitive negative reinforcement deters the behavior and eventually the individual is strong enough to beat the addiction. Using this model can help Bobby recover from her methadone addiction and permanently release her from marijuana and alcohol use.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Dick, Ph. D., D. M., & Agrawal, Ph. D., A. (2008). The genetics of alcohol and other drug dependence. Alcohol Research and Health, 3(2), 111- 118. Retrieved from http://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf
Johnson, A. B., Gentile, J. P., & Correll, T. L. (2010). Accurately diagnosing and treating borderline personality disorder: a psychotherapeutic case. Psychiatry (Edgmont), 7(4), 21–30.
McGraw Hill Higher Education. (2007). Faces of abnormal psychology interactive [Multimedia]. Retrieved from McGraw Hill Higher Education, Maladaptive Behavior & Psychopathology | FP6005 A01 website.
NAMI. (2016). Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder
NIH. (2012). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapiesNIH. Retrieved from http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
Nolen-Hoeksema, Susan. (12/2013). Abnormal psychology, 6th edition. [VitalSource Bookshelf Online]. Retrieved fromhttps://digitalbookshelf.argosy.edu/#/books/1259316335/
Zickler, P. (2002, April). Childhood sex abuse increases risk for drug dependence in adult women. NIDA, 17(1),. Retrieved from http://archives.drugabuse.gov/NIDA_Notes/NNVol17N1/Childhood.html