Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction
Note: This case study will serve as the foundation for this Assignment.
To prepare for this Assignment:
- Review this week’s Learning Resources. Consider how to assess and treat adolescent clients requiring therapy for impulsivity, compulsivity, and addiction.
ACTUAL ASSIGNMENT
PLEASE Addressed each of the following bullets with a subtopic, include references; in-text citation in each paragraph. Please use my articles and any additional one should come from USA and must be within last five years only that is from 2014 to 2018. Please do not begin a paragraph with author name(s) (PLEASE USE parenthetical/in-text citations) Thanks
The Assignment
Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
- Decision #1
- Which decision did you select?
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
- Decision #2
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
- Decision #3
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”
SUBJECTIVE
Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health.
She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.
Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.
Diagnosis: Gambling disorder, alcohol use disorder
Decisions Made and Outcomes (Needed to formulate the paper)
Choices for Decision 1: Select what the PMHNP should do: Decision Point One
- Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
- Antabuse (Disulfiram) 250 mg orally daily
- Campral (Acamprosate) 666 mg orally three times/day
My decision
Decision Point One: Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Mrs. Perez said that she felt “wonderful” as she has not “touched a drop” to drink since receiving the injection
- Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)
- Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also have her concerned
Choices for Decision 2:
Select what the PMHNP should do next:
- Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
- Refer to a counselor to address gambling issues
- Add on Chantix (varenicline) 1 mg orally BID
My decision: Add on Valium (diazepam) 5mg orally TID/PRN/anxiety
Outcome: RESULTS OF DECISION POINT TWO: RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Mrs. Perez reports that when she first received the valium, it helped her tremendously. She states “I was like a new person- this is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her valium early
- Client is asking today for you to increase the valium dose or frequency
Choices for Decision 3:
Select what the PMHNP should do next:
- Continue current dose of Vivitrol, increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue
- Continue current dose of Vivitrol, decrease/taper Valium with the goal of discontinuation in the next 2 weeks. Refer to counseling for her ongoing gambling issue
- Continue current dose of Vivitrol and maintain current dose of valium. Refer to counseling for her ongoing gambling issue
My decision: Continue current dose of Vivitrol, decrease/taper Valium with the goal of discontinuation in the next 2 weeks. Refer to counseling for her ongoing gambling issue
Guidance to Student
Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case.
The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At this point, we need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists.
Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder.
Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures).
Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.
The PMHNP needs to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.
References/Resources
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
- Chapter 14, “Impulsivity, Compulsivity, and Addiction”
Stahl, S. M., & Grady, M. (2012). Stahl’s illustrated substance use and impulsive disorder New York, NY: Cambridge University Press.
To access the following chapter, click on the Illustrated Guides tab and then the Substance Use and Impulsive Disorders tab.
- Chapter 10, “Disorders of Impulsivity and Compulsivity”
Expert Solution Preview
Introduction:
Assessing and treating clients with impulsivity, compulsivity, and addiction can be challenging, especially when comorbidities are involved. This paper will examine a case study of a Puerto Rican woman with comorbid addiction and make three decisions concerning the medication to prescribe to this client. The discussion will include factors that might impact the client’s pharmacokinetic and pharmacodynamic processes and the outcomes of each decision point.
Decision #1:
Which decision did you select? Why did you select this decision? Support your response with evidence and references to the Learning Resources.
After reviewing the case study, my first decision was to prescribe Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every four weeks. Naltrexone is an opioid antagonist that blocks the action of opioids and reduces alcohol cravings. The extended-release formulation, Vivitrol, has been shown to significantly reduce the number of heavy drinking days and alcohol cravings in patients with alcohol use disorder (Anton et al., 2018). Considering Mrs. Perez’s history of alcohol use disorder and her recent struggles to maintain sobriety, Naltrexone seemed like the best option.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
The goal of prescribing Naltrexone was to reduce Mrs. Perez’s alcohol cravings and prevent relapse. Research has shown that Naltrexone is effective in reducing heavy drinking and preventing relapse when used in combination with behavioral therapy (Jonas et al., 2014). By reducing cravings, Mrs. Perez can focus on her recovery and address other comorbidities.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
The outcome of Decision #1 was positive, as Mrs. Perez reported feeling “wonderful” and had not consumed any alcohol since receiving the injection. However, she reported continuing to smoke and experiencing anxiety. Although Naltrexone can reduce alcohol cravings, it may not be effective in reducing other addictive behaviors, such as smoking. The side effect of anxiety may also be transient, but it should be monitored.
Decision #2:
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
For Decision #2, my choice was to add on Valium (diazepam) 5mg orally TID/PRN/anxiety. Valium is a benzodiazepine that can enhance the effects of GABA, a neurotransmitter that produces a calming effect. Benzodiazepines are typically used to treat anxiety disorders, and Valium has been shown to be effective in reducing anxiety associated with alcohol withdrawal (Oldham et al., 2014). Considering Mrs. Perez’s reported anxiety and difficulty waiting between drug administration times, Valium seemed like a reasonable choice.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
By adding Valium, the goal was to reduce Mrs. Perez’s anxiety and improve her ability to wait between drug administration times. Research has shown that benzodiazepines can be effective in reducing anxiety in patients with coexisting mental health disorders (Shytle et al., 2015). The hope was that by reducing anxiety, Mrs. Perez could focus on addressing her gambling addiction and other comorbidities.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
The result of Decision #2 was positive initially, as Mrs. Perez reported feeling like a “new person” after receiving Valium. However, she also reported taking the drug early and requesting an increase in dose or frequency. This outcome was unexpected, as benzodiazepines should not be used long-term and increasing the dose can lead to tolerance and dependence. It appears that Mrs. Perez may have developed a dependence on Valium, which could complicate her treatment plan.
Decision #3:
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
For Decision #3, my choice was to continue the current dose of Vivitrol and decrease/taper Valium with the goal of discontinuation in the next two weeks. This decision was based on the fact that benzodiazepines should not be used long-term and that Mrs. Perez was reporting anxiety and early drug administration. Tapering off Valium could reduce the risk of withdrawal symptoms or rebound anxiety, and discontinuing the drug could prevent dependence or tolerance.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
The goal of Decision #3 was to discontinue Valium and address Mrs. Perez’s anxiety in a more appropriate manner. Research has shown that behavioral therapies, such as cognitive-behavioral therapy and mindfulness-based therapies, can be effective in reducing anxiety and managing addictive behaviors (Cladder-Micus et al., 2018). By tapering off Valium and addressing Mrs. Perez’s addiction through therapy, she may have a better chance of recovery.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
The outcome of Decision #3 is unknown, as Mrs. Perez has not yet returned to the clinic. However, the hope is that by discontinuing Valium, Mrs. Perez can focus on her recovery through therapy and address her addiction and comorbidities in a more productive manner. The main difference between expected outcomes and results is that Mrs. Perez may experience withdrawal symptoms or rebound anxiety during the tapering process, which may be challenging to manage. Close monitoring and counseling may be needed during this transition.
Conclusion:
Assessing and treating clients with impulsivity, compulsivity, and addiction can be challenging, especially when comorbidities are involved. This case study of a Puerto Rican woman with comorbid addiction demonstrates the importance of a comprehensive treatment plan that includes medication management and behavioral therapy. In this scenario, Naltrexone and Valium were used to address specific symptoms, but tapering off Valium and addressing addictive behaviors through therapy may be the best course of action. Healthcare providers should keep in mind the potential side effects, interactions, and risks associated with medications and adjust treatment plans accordingly.
