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Tentative theory and diagnostic impression

Select one vignette from the DSM case study book to analyze. In considering the bio-psycho-social perspective and research on addiction in the noted resource, formulate a tentative theory and diagnostic impression as follows: • Formulate a tentative theory to the etiology (causes) of the chosen client’s problems. • Consider any cultural issues that must be considered in your assessment and treatment for the client. • Address any legal and ethical issues that could arise in the client’s treatment. • Create an outline of a treatment plan for the selected case study. Remember to use the terminology presented in the DSM when discussing any mental health disorder. Support your paper with at least two resources (in addition to the specified resources for this assignment). These must include scholarly resources such as peer-reviewed articles. Length: 5-7 pages, not including title and reference pages Case 16.3 Addiction Petros Levounis, M.D., M.A. Oliver Vincent never saw himself as an addict. He had always been “on top of things.” At age 35, he was independently wealthy as the owner of several clothing franchises, lived with an ex-partner in a more-than-comfortable apartment in New York City, worked out every day, enjoyed the company of a group of loving friends, and, although single, had not given up on the idea of someday (preferably soon) finding the perfect man to share his life with. Mr. Vincent came out to his Irish Catholic family when he was 19. His parents had already guessed that Mr. Vincent was gay long before he told them, and they took the non-news fairly well. Their main concern had been that their son might be discriminated against because of his sexuality, get hurt, and live a lonely life. Nothing could be farther from the way things turned out: Mr. Vincent was “out and proud” and living it up. When Mr. Vincent found himself with a substance use problem, he addressed it the same way he had dealt with pretty much everything else: head on. For the first time in his life, he decided to see a psychiatrist. Mr. Vincent described a pattern that revolved around weekend “party and play” activities. On Friday and Saturday evenings—and occasionally during the week—he would go out to dinner with friends and then to a club or a private party. He tended to drink two or three cocktails and four to five glasses of wine during the evening. Without the alcohol, he found he could easily say “no” to substances, but “after a good buzz, if someone has coke—and there is always someone around who has coke—I use. And then my heart starts to race, and then I do everything I can to hook up. I used to go online, but these days, it’s all on Grindr.” Party and play are code words for drugs and sex, respectively. The term is sometimes abbreviated PNP. Grindr is a smartphone application that uses GPS to identify and connect similarly inclined individuals in a person’s geographical vicinity. Overall, Mr. Vincent drank alcohol and used cocaine three to four times a week and “occasionally used tina and bath salts.” He could hardly attend Monday morning meetings, much less prepare for them, and had been trying to cut down on his cocaine use for the prior 6 months without success. Tina is slang for crystal methamphetamine. Bath salts is slang for a powder that contains a variety of synthetic stimulants. Since Mr. Vincent had started using cocaine regularly, he had lost weight and had trouble sleeping. He worried that his effort at the gym was going to waste. His business continued to succeed, but his own effectiveness had decreased. Most importantly, he did not practice safer sex when high on stimulants, and he worried about HIV seroconversion. Diagnosis • Cocaine use disorder, moderate Discussion Mr. Vincent has a cocaine use disorder. If the use of crystal methamphetamine or bath salts is deemed to be significant, a more accurate diagnosis would be stimulant use disorder. According to DSM-5, a stimulant or cocaine use disorder involves a pattern of significant impairment and distress accompanied by at least two of 11 criteria. Mr. Vincent has demonstrated a persistent desire to cut down without success, has had recurrent unprotected sex while high, recognizes the attendant risks, and appears to go through withdrawal every Monday. Mr. Vincent’s illness meets at least four DSM-5 criteria and would be described as moderate in severity. Mr. Vincent’s situation supports the rationale for the shift in DSM-5 from two separate diagnoses (substance abuse and dependence) to a unified substance use disorder. In the DSM-IV system, abuse was meant to signify a less severe disorder than dependence, but a case like Mr. Vincent’s could be diagnostically challenging. If it were not for using cocaine in physically hazardous situations (unprotected sex with risk of HIV transmission), Mr. Vincent’s disorder would fully meet criteria for DSM-IV cocaine dependence but not for abuse—a confusing formulation. DSM-5 unifies these two diagnoses and then describes three levels of severity: mild, moderate, and severe. Mr. Vincent may qualify for several other DSM-5 diagnoses. If evaluated on a Saturday night, he would likely qualify for the diagnosis of cocaine intoxication, as evidenced by tachycardia and poor judgment. If evaluated on Monday morning, he would likely meet criteria for cocaine withdrawal, characterized by dysphoria and fatigue. Mr. Vincent’s alcohol use is also problematic. It appears to lead directly to the cocaine use and—depending on additional history that should be elicited—may or may not rise to the level of an alcohol use disorder. Further investigation might reveal additional symptomatology, but Mr. Vincent does not appear to be suffering from major depressive, anxiety, personality, or trauma-related disorders. His substance use seems to have been fueled primarily by social determinants, specifically a “party and play” subculture of the gay male community, which has accepted, legitimized, and eventually normalized the use of stimulants. Many substance-using patients have other co-occurring psychiatric disorders, and it is often tempting to assume that substance use must have been caused by (and/or resulted in) some type of major mood disturbance or other psychiatric problem. Nevertheless, a significant number of addicted patients have no comorbidities. Many people—possibly including Mr. Vincent’s parents—assume that lesbian, gay, bisexual, and transgender people live miserable and lonely lives, and that a variety of psychiatric diagnoses are almost inevitable. A different stereotype might suggest that stimulant use and unsafe sex is a normative part of a gay subculture and should simply be accepted as a reasonable part of the “party and play” world. Both of these stereotypes can deskill the clinician, reduce his or her effectiveness, and lead to overestimating or underestimating psychopathology. Furthermore, although dangerous and distressing behavior might sometimes seem like an inherent part of a subculture (e.g., that of young urban gay men), it is useful to recall that most people within that broad category do not routinely use substances or engage in recurrent, risky sexual behavior. By coming for a psychiatric consultation, Mr. Vincent himself has indicated that these aspects of his otherwise terrific life are out of control and in need of professional help. Suggested Readings 1. Levounis P, Arnaout B (eds): Handbook of Motivation and Change: A Practical Guide for Clinicians. Washington, DC, American Psychiatric Publishing, 2010 2. Levounis P, Herron AJ (eds): The Addiction Casebook. Washington, DC, American Psychiatric Publishing, 2014 3. Levounis P, Ruggiero JS: Outpatient management of crystal methamphetamine dependence among gay and bisexual men: how can it be done? Primary Psychiatry 13(2):75–80, 2006 4. Levounis P, Drescher J, Barber M (eds): The LGBT Casebook. Washington, DC, American Psychiatric Publishing, 2012
Select one vignette from the DSM case study book to analyze. In considering the bio-psycho-social perspective and research on addiction in the noted resource, formulate a tentative theory and diagnostic impression as follows: • Formulate a tentative theory to the etiology (causes) of the chosen client’s problems.
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