Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Substance-related or Addictive Disorder Soap Note

Subjective:

Biodata: Ally Patel, 48-year-old female.

Chief Complaint (CC): Drinking too much alcohol.

Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

HPI: Ally Patel is a 48-year-old female who presents to the school EAP counselor following concerns of suspected substance use by her supervisor. The patient reports that she has been consuming alcohol in large quantities and often passes out. She had passed out at a colleague’s party the previous night and had consequently reported late for class. This has happened several times, although the patient strongly denies this claim.

There have also been complaints from both parents and students that she has reported to class several times under the influence of alcohol. Ally Patel strongly refutes these accusations. The client notes that she mostly drinks alone, though she sometimes frequents the bar to drink with her friends or at school functions. Ally Patel adds that alcohol affects her differently, and she often has to drink up to five or six glasses of wine before she feels intoxicated.

Past Psychiatric History: Not Known

Family Psychiatric/Substance Use History: Her father was an alcoholic. For most of her childhood, her father was a heavy alcohol drinker. He later joined AA and became sober.

Psychosocial History: The patient has a Ph.D. in Biology and a Master’s Degree in high school education and is currently a teacher. She was previously in a relationship with a guy named Ryan, though they later split. She denies her alcohol consumption as the cause of the breakup and says she has been seeing someone new for the past year.

Medical History:

  • Past medical history: No previous hospital admissions.
  • Current Medications: No current medications
  • Allergies: No known drug or food allergies.

ROS:

  • GENERAL: Alert. Well-oriented to person, place, and time.
  • HEENT: normal vision, visual fields normal; mucous membranes moist, no lymphadenopathy, neck supple.
  • SKIN: No lesions or rashes
  • CARDIOVASCULAR: S1 and S2 heard. no murmurs.
  • RESPIRATORY: CTA bilaterally
  • GASTROINTESTINAL: No nausea, vomiting, no constipation, diarrhea, or abdominal pain.
  • GENITOURINARY: No hematuria or dysuria
  • NEUROLOGICAL: No fainting; no paralysis or seizures; or weakness; no tremors or memory changes.
  • MUSCULOSKELETAL: No joint stiffness or pains;
  • HEMATOLOGIC: No bleeding, bruising, or anemia;
  • LYMPHATICS: No lymphadenopathy

Objective:

During the assessment, the patient denies that she is addicted to alcohol. She firmly believes that alcohol affects her differently, and she is no different from the rest of her friends who drink.

Mental Status Examination:

On examination, the patient is well-kempt, conscious, and attentive. Her level of concentration is normal. She has normal speech and motor functions. She is well-oriented to time, place, and person. Her memory is intact, both short—term and long-term.  Her mood and affect are congruent. She has poor insight into her condition and strongly denies any alcohol addiction.

Primary Diagnosis.

My primary diagnosis is alcohol use disorder. Alcohol use disorder is a condition characterized by problems controlling one’s drinking, being overly preoccupied with alcohol, continued alcohol consumption despite significant interference with an individual’s daily activities, consuming more to achieve the same effects, or experiencing withdrawal symptoms (Kranzler et al., 2018).

DSM-5 requires two or more of the symptoms exhibited within 12 months. The patient exhibits at least three of these symptoms. She continuously consumes large amounts of alcohol each day. This has greatly affected her day-to-day activities. She has been late for class severally. The patient also has to consume more alcohol to achieve the same effect experienced previously.

Differential Diagnosis.

Major depressive disorder is one of the differential diagnoses. Major depressive disorder is a condition characterized by extended durations of feelings of sadness and loss of interest in previously pleasurable activities. Ally Patel says she no longer enjoys teaching, though previously she did. She cites the lack of discipline among students as the primary cause of her loss of interest.

According to the DSM-5 criteria, symptoms associated with major depressive disorder must be present simultaneously over a two-week period (Kennis et al., 2019). The patient only displays a loss of interest in an activity she previously enjoyed. Heavy alcohol use is a significant risk factor predisposing the patient to major depressive disorder.

Dysthymic disorder is characterized by a loss of interest in daily activities, feelings of hopelessness, reduced esteem, and overall feelings of inadequacy. These feelings persist over time and significantly affect a person’s relationships, work, and social life in general. DSM-5 requires a depressed mood most days for at least two years to make a diagnosis of dysthymic disorder (Schramm et al., 2020). The exact duration of our patient’s symptoms is not given, therefore ruling out dysthymic disorder.

Reflection.

Ally Patel is clearly suffering from alcohol use disorder. She consumes large quantities of alcohol over extended periods. The alcohol has dramatically affected her normal daily activities as a teacher. She also consumes larger alcohol volumes to achieve the effects experienced before. If I were to conduct this session again, I would like to find out if the patient has any previous psychiatric illnesses.

I would also ask about any thoughts of suicide or self-harm that the patient has experienced. Key ethical considerations to consider in this case are confidentiality and autonomy (Fiske et al., 2019). Regarding health promotion and health awareness, consideration of mental health education and literacy is critical. The patient should be made aware of her condition and any factors predisposing her to the condition.

References.

  • Fiske, A., Henningsen, P., & Buyx, A. (2019). Your robot therapist will see you now: Ethical implications of embodied artificial intelligence in psychiatry, psychology, and psychotherapy. Journal of Medical Internet Research, 21(5). https://doi.org/10.2196/13216
  • Kennis, M., Gerritsen, L., van Dalen, M., Williams, A., Cuijpers, P., & Bockting, C. (2019). Prospective biomarkers of major depressive disorder: A systematic review and meta-analysis. Molecular Psychiatry, 25(2), 321–338. https://doi.org/10.1038/s41380-019-0585-z
  • Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder. JAMA, 320(8), 815. https://doi.org/10.1001/jama.2018.11406
  • Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: History, correlates, and clinical implications. The Lancet Psychiatry, 7(9), 801–812. https://doi.org/10.1016/s2215-0366(20)30099-7

Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders Instructions

An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms.

What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.

To Prepare:

  • Review this week’s Learning Resources and consider the insights they provide.
  • Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
  • Select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

By Day 7 of Week 8

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).