Substance-Related and Psychiatric Disorders

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Subjective: The patients history of substance use and chief complaint being her reluctance to seek treatment all point towards a substance use disorder as the primary diagnosis. It is clear that her symptoms have been present for an extended period of time and have been severe, as evidenced by her abnormal lab results. The patients symptoms are impacting her functioning in life: she reports being scared and feeling that everything is over.

CC (chief complaint): The patients chief complaint is her fear of being labeled an addict and the resulting reluctance to go to rehab.

HPI: The patient is fearful but believes she has control over her drug and alcohol use, so she is unsure of her hospitalizations purpose.

Past Psychiatric History:

General Statement: n/a
Caregivers (if applicable): n/a
Hospitalizations: n/a
Medication trials: n/a
Psychotherapy or Previous Psychiatric Diagnosis: n/a

Substance Current Use and History: The patient acknowledges daily use of opioids, occasional use of cannabis, and daily consumption of 1/2 gallon of vodka. She was previously arrested for possessing drug paraphernalia.

Family Psychiatric/Substance Use History: Father of the patient was sentenced to prison for drug and sexual offenses. She has a mother who resides in Maine and who has abused benzodiazepines in the past. Her older brother has a history of opioid use and has not been in touch with the family in ten years.

Psychosocial History: The patient claims that her father sexually abused her while she was a child between the ages of 6 and 9; they are no longer in contact.

Medical History: The patient has Hepatitis C+.

Current Medications: n/a
Allergies: azithromycin
Reproductive Hx: n/a

ROS:

GENERAL: The patient has decreased appetite and prefers to get high instead of eating.
HEENT: n/a
SKIN: n/a
CARDIOVASCULAR: The patients blood pressure is 180/110.
RESPIRATORY: n/a
GASTROINTESTINAL: n/a
GENITOURINARY: n/a
NEUROLOGICAL: n/a
MUSCULOSKELETAL: n/a
HEMATOLOGIC: n/a
LYMPHATICS: n/a
ENDOCRINOLOGIC: n/a

Objective: The patients name, gender, and age were recorded during the psychiatric assessment as L. T., a 33-year-old female. Also recorded were the patients vital signs: blood pressure of 180/110, height of 56, weight of 146 lbs.

Physical exam: n/a

Diagnostic results: ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, and GGT are all abnormal according to her admission test results. Alcohol, THC, and opiates all test positive on UDS. Other labs are within normal norms, and the BAL is.308.

Assessment:

Mental Status Examination: The patient is receptive to the conversation and appears agreeable if nervous. A trace of reluctance can be seen in the patients affect, which is consistent with her reported mood. Although the thoughts of the patient seem reasonable and well-organized, she is nevertheless reserved and occasionally evasive. There have been no reports of hallucinations or delusions, and the patients perception seems to be normal.
Differential Diagnoses: Substance use disorder can be said to be the primary diagnosis. A pattern of use that causes clinically significant impairment or suffering is one of the DSM-5-TR diagnostic criteria for drug use disorder (McNeely & Adam, 2020). This is demonstrated by the patients history of using drugs as well as possessing drug paraphernalia. Moreover, her aberrant lab findings are consistent with drug use.

The second possible diagnosis is post-traumatic stress disorder (PTSD). The patients father has a history of sexually abusing her as a child. Sexual violence is one of the potential inciting events for PTSD (First et al., 2021). However, the patient does not meet the criteria of experiencing recurring upsetting recollections as a result being subjected to stimuli that resemble a feature of the traumatic event.

Finally, the third diagnosis for the patient is major depressive disorder. The patients appetite has reduced, she sleeps five to six hours per day, and would rather get high than eat. This falls within the DSM-5-TR diagnostic criteria for major depressive disorder: depressed mood or loss of interest or pleasure in nearly all activities, decreased appetite, and insomnia (Pitanupong et al., 2022). However, the patient did not exhibit suicidal ideation, ruling out this diagnosis.

In this case, the primary diagnosis would be substance use disorder. The patient has a history of abusing drugs and alcohol. A diagnosis of substance use disorder is further supported by the patients reluctance to seek treatment out of concern about being branded an addict. Heavy substance use and abnormal lab results are relevant positives. No known history of receiving psychiatric treatment or being hospitalized is an important negative.

Reflections: I would learn more about the patients prior psychiatric history, including any treatment or inpatient stays. I would also go into more detail about the patients motivations for using drugs. Within legal and ethical reasons, it is important to consider the patients autonomy and respect her right to make decisions about her own treatment. Furthermore, it is important to consider the patients background and cultural context, and to provide culturally sensitive care.

In terms of health promotion, it is important to find as much information as possible to have a better understanding of the patients situation. To provide the most appropriate treatment, I would highlight the hazards connected to the patients substance use, including how it may affect her Hepatitis C+ and overall physical health. I would also share links for addiction therapy as well as information on harm reduction techniques.

References

First, M. B., Gaebel, W., Maj, M., Stein, D. J., Kogan, C. S., Saunders, J. B., Poznyak, V. B., Gureje, O., LewisFernández, R., Maercker, A., Brewin, C. R., Cloitre, M., Claudino, A., Pike, K. M., Baird, G., Skuse, D., Krueger, R. B., Briken, P., Burke, J. D.,& Reed, G. (2021). An organization and categorylevel comparison of diagnostic requirements for mental disorders in ICD11 and DSM5. World Psychiatry, 20(1), 3451. Web.

McNeely, J., & Adam, A. (2020). Substance use screening and risk assessment in adults. National Library of Medicine. Web.

Pitanupong, J., Sathaporn, K., & Tepsuan, L. (2022). Residual symptoms and their associated factors among Thai patients with depression: a multihospital-based survey. Annals of General Psychiatry, 21(1). Web.

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