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. Please note: I will attach more materials and case after bid. My email is failing me right now because of the large files I think.
Week 8: Therapy for Clients With Impulsivity, Compulsivity, and Addiction
Impulsivity and compulsivity have a wide range of clinical presentations and often overlap with many
other psychiatric disorders. Some individuals act without forethought and have difficulty saying “no” to
certain things such as using illicit drugs or spending money, whereas other individuals engage in
compulsive behaviors with undesirable consequences. In some cases, these impulsive and compulsive
behaviors also fuel issues with addiction. To effectively assess and treat clients, you must understand
how these disorders differ, as well as how their symptoms impact clients and their families.
This week, as you examine therapies for individuals with impulsivity, compulsivity, and addiction, you
explore the assessment and treatment of clients with these disorders. You also consider ethical and legal
implications of these therapies.
Photo Credit: [Apolinar B. Fonseca]/[Moment]/Getty Images
Assignment: Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction
Impulsivity, compulsivity, and addiction are challenging disorders for clients across the lifespan. These
disorders often manifest as negative behaviors, resulting in adverse outcomes for clients. In your role as
the psychiatric mental health nurse practitioner, you have the opportunity to help clients address
underlying causes of the disorders and overcome these behaviors. For this Assignment, as you examine
the client case study in this week’s Learning Resources, consider how you might assess and treat clients
presenting with impulsivity, compulsivity, and addiction.
Learning Objectives
Students will:
•
Assess client factors and history to develop personalized therapy plans for clients with
impulsivity, compulsivity, and addiction
•
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients
requiring therapy for impulsivity, compulsivity, and addiction
•
Evaluate efficacy of treatment plans
•
Analyze ethical and legal implications related to prescribing therapy for clients with impulsivity,
compulsivity, and addiction
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List,
found in the Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take
you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
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”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the
Stahl Online website and select the appropriate medication.
Review the following medications:
For insomnia
For obsessive-compulsive disorder
•
Citalopram
•
clomipramine
•
escitalopram
•
fluoxetine
•
fluvoxamine
•
paroxetine
•
sertraline
•
venlafaxine
•
vilazodone
For alcohol withdrawal
•
chlordiazepoxide
•
clonidine
•
clorazepate
•
diazepam
•
lorazepam
•
oxazepam
For bulimia nervosa and binge eating
•
fluoxetine
•
topiramate
•
zonisamide
For alcohol abstinence
•
acamprosate
•
disulfiram
For alcohol dependence
•
nalmefene
•
naltrexone
For opioid dependence
•
buprenorphine
•
naltrexone
For nicotine addiction
•
bupropion
•
varenicline
Book Excerpt: Substance Abuse and Mental Health Services Administration. (1999). Treatment of
adolescents with substance use disorders. Treatment Improvement Protocol Series, No. 32. Retrieved
from http://www.ncbi.nlm.nih.gov/books/NBK64350/
•
Chapter 1, “Substance Use Among Adolescents”
•
Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”
•
Chapter 7, “Youths with Distinctive Treatment Needs”
University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control in
adulthood, study finds. Retrieved from
https://www.sciencedaily.com/releases/2016/01/160120201324.htm
Note: Retrieved from Walden Library databases.
Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological
gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. doi:10.1111/j.13652125.2012.04457.x
Note: Retrieved from Walden Library databases.
Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical
considerations and challenges. Journal of Gerontological Nursing, 42(4), 10–15. doi:10.3928/0098913420160314-04
Note: Retrieved from Walden Library databases.
Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older
adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74–84.
doi:10.1080/15504263.2012.648439
Note: Retrieved from Walden Library databases.
Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., & … Soares, J. C.
(2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar
parents. Comprehensive Psychiatry, 55(6), 1337–1341. doi:10.1016/j.comppsych.2014.04.018
Note: Retrieved from Walden Library databases.
Required Media
Laureate Education (2016c). Case study: A Puerto Rican woman with comorbid addiction [Interactive
media file]. Baltimore, MD: Author
Note: This case study will serve as the foundation for this week’s 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.
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
o
Which decision did you select?
o
Why did you select this decision? Support your response with evidence and references
to the Learning Resources.
o
What were you hoping to achieve by making this decision? Support your response with
evidence and references to the Learning Resources.
o
Explain any difference between what you expected to achieve with Decision #1 and the
results of the decision. Why were they different?
Decision #2
o
Why did you select this decision? Support your response with evidence and references
to the Learning Resources.
o
What were you hoping to achieve by making this decision? Support your response with
evidence and references to the Learning Resources.
o
Explain any difference between what you expected to achieve with Decision #2 and the
results of the decision. Why were they different?
Decision #3
o
Why did you select this decision? Support your response with evidence and references
to the Learning Resources.
o
What were you hoping to achieve by making this decision? Support your response with
evidence and references to the Learning Resources.
o
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.
Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female
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
Decision Point One
Select what the PMHNP should do:
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
Co-morbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female
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
Decision Point Two
Refer to a counselor to address gambling issues
RESULTS OF DECISION POINT TWO
•
Client returns to clinic in four weeks
•
Client reports that the anxiety that she had been experiencing is gone
•
Client reports that she has met with the counselor, but did not really like her. She did start
going to a local meeting gamblers anonymous. She stated that last week, for the first time,
she spoke during the meeting. She reports feeling supported in this group
Decision Point Three
Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue
attending the Gamblers Anonymous meetings
Guidance to Student
Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, four
weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner
should explore the issues that Mrs. Perez is having with her counselor. As you will learn in future courses,
ruptures and the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not
continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than
had the client continued to receive therapy). Recall that there are no FDA approved treatments for
gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez
reports good perceived support from the gamblers anonymous meetings, she should be encouraged to
continue her participation with this group.
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.