Considering a differential diagnosis, what is your initial assessment and diagnostic impressions of Adam and why? Consider the depressive disorders and posttraumatic stress disorder concurrent with substance related disorders in your response. Please present other ideas that you have for Adam.
Various psychiatric conditions can bring about the uncontrolled consumption of alcohol, which in turn can lead to alcoholism. They can also cause a person to resort to alcoholism. In the case of mental health, the presence of alcoholism brings with it various complications, which may hinder the reaching of a precise diagnosis of the psychiatric condition. This seems to be the case with Adam. In cases like his, where there is a psychiatric disorder present as well as alcoholism, suicide becomes a possibility, and the person will need the services from the mental health institutions. Where a person is dependent on alcohol, one of the risks that emerge is that of suicide. Adam has depended heavily on alcohol because of his family situation, which has had several deaths. Alcoholism is seen as an illness, and in the case of Adam, a response to various challenges. In its contribution to suicide, only depression comes before alcoholism as a triggering factor. In Adam’s case there are two possibilities. His addiction to alcohol may have been caused by depression from his extreme circumstances. It could also be that depression is caused by the alcohol addiction. Alcoholism and depression have symptoms that are similar, and it is not easy to make the separation. Adam seems to be depressed, but it might not be obvious to him that the problem with alcohol actually adds to the depression. Alcohol consumption may not result in suicide or depression. However, there are many negative results of alcohol addiction, some of which are the loss of employment, family disputes, aggressive behavior and even illegal actions. In addition to this, the person suffers from being ostracized by society, the loss of friendships and associations and the inability to interact with others. For a person like Adam, this situation may cause his self-worth to diminish and this may lead him to associate with the people who are like him. Thus, Adam’s depression may be the result of his alcoholism and this depression can lead to suicidal thoughts (Olson, 2012; DSM-5 American Psychiatric Association, 2013).
A person who has been subject to harsh circumstances early in life, as Adam has, may be more susceptible to problems of mental health and this may be expressed in the form of dependence on alcohol. Trauma thus comes before the alcoholism. A direct association between trauma and alcoholism may not easily be established, though Adam seems to display this association as he has suffered a lot of trauma in his early life and is now battling alcoholism. Where there exist symptoms of trauma from early life, there may also be the use of alcohol to deal with or cope with these problems. One common co-occurrence is that of Post-Traumatic Stress Disorder along with the dependence on alcohol. Where the patient experiences withdrawal symptoms from alcohol, they may intensify the PTSD, resulting in a greater likelihood of relapsing. Adam may be suffering from PTSD from the trauma he experienced as a child and this may have led to the dependence on alcohol. The victimization that he suffered as a child seems to have resulted in low self-worth. The use of alcohol thus may have been as a coping mechanism picked up to deal with the harmful thoughts he had of himself. The negative circumstances that he found himself in may have caused Adam to stay away from healthy social interactions and bonds because he felt like he was different from other people. This may have pushed him to groups that used alcohol freely. The alcohol dependence disorder in this case may have thus resulted from the childhood trauma.
For Adam, consider the Six Dimensions Checklist in Appendix E in “The Addiction Treatment Planner” and the Mental Health Screening Form III and Simple Screening Instrument for Substance Abuse in Appendix H of “Substance Abuse Treatment for Persons with Co-Occurring Disorders”
Treatment that is based on evidence is essential in today’s society because of the need for quality in the treatment of mental health issues as well as accountability for the same. There must be treatments that are pharmacological as well as those that target behavior when treating a case such as Adam’s, where there is both PTSD as well as dependence on alcohol. Cognitive behavior therapies are the ones that are most highly recommended when treating alcohol dependence and PTSD. These therapies can be focused on managing stress and anxiety, focused on cognition and based on exposure. In the exposure based therapies, a patient with PTSD will be given the opportunity in a secure environment, to challenge situations that cause stress and anxiety. This can be in vivo exposure or imaginal exposure. In vivo requires confronting the location of trauma while imaginal is the recollection of the ordeal. Where these exposures are protracted and repeated, the stress from the trauma is removed. Where therapy is cognition focused, the patient will be allowed to explore the meaning that they drew from the traumatic experience. In this, there will also be the processing of the cognition, which will try to alter the harmful thoughts concerning worth, relationships, security and trust. The management of stress will inculcate in the patient the ability to cope with the PTSD symptoms. Some of the techniques encouraged here include: breathing techniques, relaxation techniques, skills for problem solving, skills to stop negative thoughts, managing anger and self-instruction.
The treatment adopted here when considering the co-occurrence of PTSD together with dependence on alcohol should be the normal clinical treatment for PTSD. There may be a need to take into account the reactions that the alcohol and the treatment may have as they could be toxic. There may also be potential reactions between the treatment and other substances co-occurring with the alcohol, and these too need to be considered. Thus, the treatment that will have the lowest liability, given these considerations, should be selected. Benzodiazepines, which are highly effective for anxiety, may not be recommended because of their liability potential. They may, however, be adjunctive treatments when there is a latent onset of antidepressants. In this case, they may be used but in limited amounts and under serious monitoring of the patient (Brady & Back, 2012).
Six Dimensions Checklist in Appendix E in “The Addiction Treatment Planner”
1. Acute Intoxication and/or Withdrawal Potential-Adam’s case suggests the danger of withdrawal given the length of time that he has spent depending on alcohol.
2. Biomedical Conditions and Complications- Adam has not been using medications and his physical health seems to be okay.
3. Emotional, Behavioral or Cognitive and Complications-Adam does not seem to be impulsive. However, he clearly is depressed, has PTSD and is dependent on alcohol.
4. Readiness to Change- this needs to be assessed in Adam’s case to establish whether he can commit to recovery, and if this is not the case, then strategies to enhance his inclination this way should be adopted.
5. Relapse, Continued Use or Continued Problem Potential- Adam seems to have a serious likelihood of reverting back to alcohol dependence if he were released.
6. Recovery Environment-His family want him to recover (Jongsma & Perkinson, 2013).
The consumption of substances differs with individuals as far as the pattern is concerned. Adam demonstrates frequency of use, dependence and a long history of use (Sacks, Ries, Ziedonis & Center for Substance Abuse Treatment, 2005).
Preoccupation and Loss of Control
This relates to the large amount of time that a person spends on the substance that he/she is abusing or on issues relating to it. Adam has loss of control in the use of the substance and his behavior when he has used or is using the substance. He cannot consciously control the amount of alcohol that he consumes and the frequency of his consumption. He has no inhibitions and his behavior is many times harmful as are the thoughts of suicide that he is entertaining (Sacks, Ries, Ziedonis & Center for Substance Abuse Treatment, 2005).
Consequences of substance abuse can present themselves in various forms, including psychological effects like Adam’s case of being depressed and considering suicide. They can also be social effects, such as withdrawal from society and they can be physical (Sacks, Ries, Ziedonis & Center for Substance Abuse Treatment, 2005).
There should be a connection made between the alcohol dependence and issues arising from it, for example, the depression and suicidal thoughts. This will help Adam realize that he has a problem. There were adverse circumstances that led Adam to rely on alcohol to cope. Understanding this connection can lead to a willingness to change (Sacks, Ries, Ziedonis & Center for Substance Abuse Treatment, 2005).
Tolerance and Withdrawal
Tolerance and withdrawal can come about as a result of the long-term use of alcohol and other substances and this is the case with Adam. There may be depression and anxiety as symptoms of Adam withdrawing from the dependence on alcohol (Sacks, Ries, Ziedonis & Center for Substance Abuse Treatment, 2005).
For the treatment of Adam to be effective, there will have to be coordination between the service providers. To improve the treatment that he is receiving, the community bonds should be enhanced. Where there is competition among agencies, the care given is compromised. The treatment of Adam should be comprehensive, so that his problems are viewed in totality considering his history, his current status, and both the alcohol dependence and the PTSD. His childhood traumatic experience should be addressed as a matter of priority (Sacks, Ries, Ziedonis & Center for Substance Abuse Treatment, 2005).
Brady, K. T., & Back, S. E. (2012). Childhood trauma, posttraumatic stress disorder, and alcohol dependence. Alcohol research: current reviews, 34(4), 408.
DSM-5 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Publishing.
Jongsma, A. E., & Perkinson, R. R. (2013). The addiction treatment planner. Hoboken, N.J: Wiley.
Olson R. (2012). Alcohol Dependence and Suicide. Retrieved 26 January 2016 from http://www.suicideinfo.ca/LinkClick.aspx?fileticket=IenSG2V_ZxM%3D&tabid=579
Sacks, S., Ries, R. K., Ziedonis, D. M., & Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders.
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