Therapy for Patients with Impulsivity and Substance Abuse Disorders
Impulsivity, Compulsivity and Addiction.
Impulsivity can be defined as inappropriate, premature and harmful behaviour or tendencies that lead to negative outcomes. Compulsivity, on the other hand, is the constant repetitio of these harmful and habitual tendencies that result in undesired consequences. These two often result in addiction (Blum et al., 2020). Excessive alcohol use and gambling are some of the commonly witnessed impulsive traits. This essay focuses on a 53-year-old Puerto Rican female who is presenting with a condition that she terms as an “embarrassing problem.” This paper aims at summarizing the patient’s condition and highlighting the major decisions made towards her treatment and management.
The lady says that she has been struggling with alcohol since her late twenties and has been on and off the Alcoholics Anonymous campaign for the past 25 years. The condition has been made worse following the opening of a casino near her residence. The patient points out that gambling exhilarates her and she often has a few drinks to cool her nerves each time she gambles. Her cigarette use has also greatly increased over the past two years which greatly concerns her. She is also concerned because she has borrowed money from her retirement account to pay off her gambling debts, something which her husband is unaware of.
The diagnosis made is gambling disorder and alcohol use disorder. Patient specific factors affecting decision making include patient’s age, gender, duration of presenting complaints and socioeconomic status.
The first decision was the use of Vivitrol (naltrexone) injection, three hundred and eighty milligrams intramuscularly in the gluteal region every four weeks. Naltrexone is a medication that is commonly used in the management of alcohol and opioid use. The medication, according to Stewart et al. (2019), functions by reducing the cravings and feelings of euphoria that are commonly experienced following the use of alcohol or other substances. Naltrexone manages alcohol use disorder by reducing the amount of alcohol consumed or generally stopping alcohol use altogether. The patient reports that she has not consumed any alcohol since her first injection. The urge of gambling has also greatly reduced though she spends more each time she gambles. She is still smoking and experiences anxiety which are of concern. Naltrexone has, however, aided in treating the patient’s alcohol use.
The other available options were Antabuse (disulfiram) 250 milligrams orally daily and 666 milligrams of Campral (acamprosate) orally thrice a day. I opted for naltrexone. All drugs are effective in managing and treating alcohol use disorder. Naltrexone injection stays within the patient’s system for approximately one month and reduces frequency of administration consequently reducing chances of forgetting to administer the drug. Naltrexone also presented with better results and less severe side effects. With disulfiram use, patient reported of sedation, fatigue and a metallic taste (Grant et al., 2017). The patient had also tried to consume alcohol during the concurrent period of disulfiram use which ahs resulted in severe side effects. The drug did help slightly with the gambling addiction but increased her cigarette smoking. Acamprosate on the other hand brought about a suicidal ideation with the patient experiencing severe anxiety.
The major goal of decision number one was to reduce or completely stop alcohol use. That is why I opted for naltrexone as it showed better results and had less severe side effects. It is critical to ensure that I am not judgemental towards the patient. Maintenance of confidentiality is critical in establishing and maintain trust between me and the patient (Karaca et al., 2019). Educating the patient on all possible available options and their side effects is critical in enabling the patient to make an informed decision. Communication should be clear, goal oriented and empathetic. This is critical in facilitating better understanding and enhancing compliance.
The second decision to make in the treatment and management of this patient is referral to a counsellor to address her gambling issues. Counselling greatly helps in addressing gambling issues. As Brown et al. (2020 Therapy for Patients with Impulsivity and Substance Abuse Disorders) notes, cognitive behavioural therapy has particularly aided in understanding patients’ behaviours and feelings consequently addressing the root cause of their gambling addiction. The counsellor provides information and advice and enlightens on the negative effects of gambling. After addressing the alcohol use disorder, it is important to focus on the gambling and anxiety witnessed following use of naltrexone.
I preferred referring to a counsellor over the use of five milligrams of Valium orally or the use of one milligram of varenicline orally. Counselling has been greatly shown to address the issue of gambling and is quite pivotal in dealing with mild anxiety. The use of Valium greatly predisposes to addiction with the patient reporting taking her dose early and requesting an increase in her dosage (Cheng et al., 2018). The use of varenicline was discontinued by the patient due to the occurrence of abnormal dreams and agitation. Patient also reported nausea and vomiting after initial use. The best course of action is therefore referring to a counsellor after initial administration of naltrexone.
The second decision was aimed at addressing the patient’s gambling addiction. After the initial treatment of her alcohol addiction with naltrexone, patient reported less frequenting of the casino but increased expenditure each time she went there. The drug use also resulted in mild anxiety. Referring to a counsellor is critical in addressing both these issues. After referral, the patient also joined gamblers anonymous and has reported positive outcomes. Confidentiality should be maintained and I should only disclose information that will be helpful towards patient care and management. Educating the patient on the need to refer is critical to ensure compliance.
The next course of action is to explore the issues that my patient has with her counsellor and encourage her to continue attending the Gamblers Anonymous meetings. This is the best action to take. Gamblers Anonymous is a group of men and women who share experiences, give each other hope and strength with the purpose of overcoming gambling addiction and other complications related to gambling (McGrath et al., 2018). Counselling has been proving useful in addressing her concerns. The Gamblers Anonymous meetings have also been key and fruitful as the patient has recently opened up during a recent meeting.
Discontinuation of naltrexone after about eight weeks is considered too soon. As the psychiatric mental health nurse, I should explore the issues arising between my client and her counsellor. This drift can result in the client discontinuing her therapy sessions. According to Jennissen et al. (2020 Therapy for Patients with Impulsivity and Substance Abuse Disorders), such a move can greatly impact the overall results increasing the likelihood of the reoccurrence of gambling later. Counselling is the most effective method of dealing with gambling addiction as there is no recommended drug treatments. Good support from her gamblers anonymous group is also critical in helping the patient deal with her gambling addiction. Discussing possible smoking cessation options with my client is also important to ensure improved overall health.
This decision was aimed at addressing the issue of gambling. There are no FDA recommended drugs for use in gambling addiction. Counselling is therefore the best possible option. Psychotherapy or cognitive behavioural therapy are particularly useful for gambling addiction. They provide an avenue to address deep rooted concerns that may be causing the gambling problem by creating a platform to address those concerns. (Schwarzkopf et al., 2021). It also provides an avenue to address the patient’s smoking to achieve overall good health. The decisions made have fully addressed the initial concerns of alcohol use disorder and gambling addiction. The decisions made will fully address all the patient’s concerns.
Ensuring that the care provided is of the highest quality and confers the best outcomes is critical as the psychiatric mental health nurse. Respect for my client’s decisions is another key ethical consideration. Respect entails recognizing that an individual is autonomous, unique and free to make decisions (Happell et al., 2017). I should respect my client’s decision, beliefs and choices. This is after offering her all available options to enable her make well informed decisions. Effective communication is key in building trust and rapport that enable my patient to open up and inform me of any complications between her and her counsellor to facilitate reconciliation.
In conclusion, as the psychiatric mental health nurse, I opted to start my patient off with naltrexone injection. This was followed by referring her to a counsellor to address her gambling issues and later encouraging her to continue seeing her counsellor as well as continuing with her Gamblers Anonymous group. The patient was diagnosed with gambling disorder and alcohol use disorder. These options proved to be the most useful in addressing these concerns while also displaying minimum side effects.
The naltrexone injection was the most effective in addressing the alcohol use disorder. Naltrexone greatly reduces the feelings of euphoria associated with alcohol consumption consequently reducing craving and reducing or completely eliminating alcohol use. To address the gambling disorder, counselling is the most effective course of action. Currently, there are no FDA approved medications to deal with this issue (Carneiro et al., 2020). The counselling sessions will also provide an avenue to address the patient’s smoking concerns to generally improve the client’s overall health. Groups such as gamblers anonymous create a platform to share and address concerns in an environment free from discrimination. As the nursing practitioner, I should address any issues arising between my client and the counsellor to ensure effectiveness of therapy. These decisions greatly aid in addressing the patient’s concerns.
References for Therapy for Patients with Impulsivity and Substance Abuse Disorders.
Blum, A. W., Lust, K., Christenson, G., & Grant, J. E. (2020). Links between sexuality, impulsivity, compulsivity, and addiction in a large sample of university students. CNS Spectrums, 25(1), 9–15. https://doi.org/10.1017/S1092852918001591
Brown, K. L., & Russell, A. (2020). Exploration of Intervention Strategies to Reduce Public Stigma Associated with Gambling Disorder. Journal Of Gambling Studies, 36(2), 713–733. https://doi.org/10.1007/s10899-019-09888-3
Carneiro, E., Tavares, H., Sanches, M., Pinsky, I., Caetano, R., Zaleski, M., & Laranjeira, R. (2020). Gender Differences in Gambling Exposure and At-risk Gambling Behavior. Journal Of Gambling Studies, 36(2), 445–457. https://doi.org/10.1007/s10899-019-09884-7
Cheng, T., Wallace, D. M., Ponteri, B., & Tuli, M. (2018). Valium without dependence? Individual GABAA receptor subtype contribution toward benzodiazepine addiction, tolerance, and therapeutic effects. Neuropsychiatric Disease And Treatment, 14, 1351–1361. https://doi.org/10.2147/NDT.S164307
Grant, J. E., Potenza, M. N., Kraus, S. W., & Petrakis, I. L. (2017). Naltrexone and Disulfiram Treatment Response in Veterans With Alcohol Dependence and Co-Occurring Problem-Gambling Features. The Journal Of Clinical Psychiatry, 78(9), e1299–e1306. https://doi.org/10.4088/JCP.16m11220
Hagen, J., Hjelmeland, H., & Knizek, B. L. (2017). Relational Principles in the Care of Suicidal Inpatients: Experiences of Therapists and Mental Health Nurses. Issues In Mental Health Nursing, 38(2), 99–106. https://doi.org/10.1080/01612840.2016.1246631
Happell, B., Bennetts, W., Tohotoa, J., Wynaden, D., & Platania-Phung, C. (2019). Promoting recovery-oriented mental health nursing practice through consumer participation in mental health nursing education. Journal Of Mental Health (Abingdon, England), 28(6), 633–639. https://doi.org/10.1080/09638237.2017.1294734
Jennissen, S., Nikendei, C., Ehrenthal, J. C., Schauenburg, H., & Dinger, U. (2020). Influence of patient and therapist agreement and disagreement about their alliance on symptom severity over the course of treatment: A response surface analysis. Journal Of Counseling Psychology, 67(3), 326–336. https://doi.org/10.1037/cou0000398
Karaca, A., Yildirim, N., Cangur, S., Acikgoz, F., & Akkus, D. (2019). Relationship between mental health of nursing students and coping, self-esteem and social support. Nurse Education Today, 76, 44–50. https://doi.org/10.1016/j.nedt.2019.01.029
McGrath, D. S., Kim, H. S., Hodgins, D. C., Novitsky, C., & Tavares, H. (2018). Who Are the Anonymous? Involvement and Predictors of Gamblers Anonymous Attendance Among Disordered Gamblers Presenting for Treatment. Journal Of Gambling Studies, 34(4), 1423–1434. https://doi.org/10.1007/s10899-018-9774-y
Schwarzkopf, L., Loy, J. K., Braun-Michl, B., Grüne, B., Sleczka, P., & Kraus, L. (2021). Gambling disorder in the context of outpatient counselling and treatment: Background and design of a prospective German cohort study. International Journal Of Methods In Psychiatric Research, 30(2), e1867. https://doi.org/10.1002/mpr.1867
Stewart, S. H., Walitzer, K. S., Blanco, J., Swiatek, D., Paine Hughes, L., Quiñones-Lombraña, A., & Shyhalla, K. (2019). Medication-enhanced behavior therapy for alcohol use disorder: Naltrexone, Alcoholics Anonymous Facilitation, and OPRM1 genetic variation. Journal Of Substance Abuse Treatment, 104, 7–14. https://doi.org/10.1016/j.jsat.2019.05.004