Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
Use at least 5 references
Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.
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.
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a 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 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.).
Training Title 114 Name: Name: Ally Chen
Gender: female
Age: 44 years old
Background: Only child, raised by parents in Philadelphia, PA. Has PhD in biology and master’s degree in high school education (8–12). Her supervisor has asked the school EAP counselor to intervene with concerns regarding potential substance use in effort to facilitate getting her help and be able to retain her. She is divorced, has a 4-year-old son who lives with his father. Appetite healthy, sleeping 9 hours/24 hrs., wakes 2-3 times during the night. Denied drug use. had DUI when she was age 21.
00:00:15Ally (ph) Really, come on. I’m missing first period. And now you want me to be late for my second class. Can we do this during my third period break?
00:00:25UNKNOWN I… I’m sorry, Ally(ph) but principal Michaels requested that you and I take some time this morning and talk. I… I know we worked together before right now, I’m going to have to put on my professional app.
00:00:35Ally (ph) That’s ridiculous. Why?
00:00:35UNKNOWN Well, maybe you can tell me why.
00:00:40Ally (ph) I have a class waiting for me.
00:00:45UNKNOWN Well, you been frequently late for your classes. In fact, let’s say uh… 22 days so far this year?
00:00:50Ally (ph) It has not been 22 days.
00:00:55UNKNOWN Yes, it has, something not right here at school or something not right at home.
00:01:00Ally (ph) My personal life is fine. And personal.
00:01:05UNKNOWN I know you haven’t changed addresses so it can’t be the traffic.
00:01:10Ally (ph) Jesus. The History Department had a party last night a Darrel’s(ph). Why don’t you bring him in here and question him?
00:01:20UNKNOWN So are you saying the Darrel’s(ph) party is the reason that you were late? That was last night? I don’t understand.
00:01:25Ally (ph) Okay. Alcohol was served. We had a bit much to drink. Not just me. We’re adults here. And I mean, the… the school host of social hour on campus every month.
00:01:40UNKNOWN So what are you saying? Are you saying that you were drunk?
00:01:45Ally (ph) I drank, but no.
00:01:45UNKNOWN Were you intoxicated enough that you passed out?
00:01:50UNKNOWN I woke up and Darrel’s(ph) cash responding. And, and fuck him for not waking me. He came to school on time but let’s be there lying on the couch.
00:02:00UNKNOWN Have you passed out other times?
00:02:05Ally (ph) We have all passed out at times. I’m sure I’ve seen you drunk at those parties.
00:02:10UNKNOWN Are you still feeling intoxicated this morning?
00:02:15Ally (ph) No, Course not.
00:02:15UNKNOWN Have you ever been drunk? While you were here teaching?
00:02:20Ally (ph) No.
00:02:20UNKNOWN I’m asking that because we’ve had complaints.
00:02:25Ally (ph) Complaints from who?
00:02:25UNKNOWN Students, parents.
00:02:30Ally (ph) Well, bring him in. Let them tell that to my face because it’s totally not true.
00:02:35UNKNOWN They’ve complained that at different times you came into class and then you ordered the kids to read from their textbook or you ordered the kids to copy notes from the board while you were sleeping with your head on the desk.
00:02:45Ally (ph) You have to be kidding me.
00:02:50UNKNOWN Several students and several parents have complained.
00:02:55Ally (ph) Exactly who, Alexis? Do you know how many problems she’s created for the teachers at the school.
00:03:00UNKNOWN But you were drinking last night. And it sounds like you drank enough that you passed out and had to sleep on Darrel’s(ph) couch?
00:03:10Ally (ph) Yes. I mean, I did.
00:03:15UNKNOWN So, is there something going on in your personal life?
00:03:20Ally (ph) No.
00:03:20UNKNOWN How’s Ryan?
00:03:25Ally (ph) Ryan? First time I’ve known you to travel slow here. We split up before the school year started. Last summer.
00:03:35UNKNOWN What happened?
00:03:35Ally (ph) I’m really, really uncomfortable sharing anything about my relationships with you.
00:03:45UNKNOWN Okay, that’s fair. That is your personal life.
00:03:50Ally (ph) Is there any reason I just can’t walk out of this office right now?
00:03:50UNKNOWN Well, I don’t know the specifics of what the Board of Education would decide if you don’t cooperate, but I’m guessing at something pretty serious.
00:04:00Ally (ph) This is unbelievable.
00:04:05UNKNOWN Wait, wait. Wait a minute. The administration asked me to speak with you. The school wants to work with you if you’ll cooperate. And as someone who really likes you. I am warning to understand. I’m hoping to help you. So just, okay, thank you. Good. Now, what’s going on?
00:04:30Ally (ph) I don’t know.
00:04:30UNKNOWN Okay. How much did you drink last night?
00:04:35Ally (ph) Too much.
00:04:35UNKNOWN How often do you drink too much?
00:04:40Ally (ph) I don’t know.
00:04:45UNKNOWN How much would you estimate that you drink in a typical week?
00:04:50Ally (ph) Every night.
00:04:50UNKNOWN Do you drink with friends, family, by yourself?
00:04:55Ally (ph) Alone. Once in a while I’ll go to a bar with my friends or drink at school functions. Where I might add they do supply alcohol liberally.
00:05:05UNKNOWN Yes.
00:05:10Ally (ph) They’re removing our social hours to downtown.
00:05:10UNKNOWN Do you go out and drink other than with friends?
00:05:15Ally (ph) Occasionally.
00:05:15UNKNOWN Do you drink alone at home?
00:05:20Ally (ph) Few glasses of wine while a grade takes the edge off the day.
00:05:25UNKNOWN Takes the edge off.
00:05:30Ally (ph) Yes. The kids here are getting worse by the year. The teachers talk about it. We all know what’s going on. They become they just become more… more vicious, more mean. I’m talking about kids who have no hint of remorse, no empathy, no thoughtfulness for others. When was the last time you try teaching them?
00:05:45UNKNOWN I have to admit it has been a while.
00:05:50Ally (ph) Just last week, I caught Alexis filming me on her phone. I was bent over picking up trash a student through on the floor. It was not flattering. And you know what she did?
00:06:00UNKNOWN No.
00:06:05Ally (ph) Send it out to the whole grade adding a really obscene title.
00:06:05UNKNOWN Was she punished?
00:06:10Ally (ph) Do the kids here ever get punished? All she caught was a bucking set down with their neuter principal. And then her mom comes threaten Sue again and naturally our fearless leader backs down. Michaels humiliated me. Did the administration tell you that?
00:06:25UNKNOWN No.
00:06:30Ally (ph) Humiliated me. I work for a place that has no backbone, no spine. Who runs this place here? The students or the teachers.
00:06:40UNKNOWN Sounds horrible.
00:06:45Ally (ph) And it goes on day after day. Rich kids who have no respect while you struggle to teach. I’m trying to pay bills here. Pay uh… pay the gas, driving shitty car, pay off student loans.
00:06:55UNKNOWN That does sound like a lot of stress.
00:07:00Ally (ph) Sounds like.
00:07:00UNKNOWN Do you like teaching?
00:07:05Ally (ph) Once upon a time when it had meaning.
00:07:05UNKNOWN What about now?
00:07:10Ally (ph) We aren’t supported.
00:07:15UNKNOWN Do you think all of this stress is contributing to your drinking?
00:07:15Ally (ph) Of course it is.
00:07:20UNKNOWN Do you drink during the day?
00:07:20Ally (ph) No, no, absolutely not.
00:07:25UNKNOWN When you do drink, how much do you drink?
00:07:25Ally (ph) Enough.
00:07:30UNKNOWN Enough to pass out?
00:07:30Ally (ph) If I’m lucky.
00:07:35UNKNOWN How much do you have to drink to get that feeling of being intoxicated?
00:07:40Ally (ph) Five or six glasses of wine, a couple of mixed drinks.
00:07:45UNKNOWN Do you think that’s more than it takes most people to get intoxicated?
00:07:50Ally (ph) I don’t know, but… but I can.
00:07:50UNKNOWN So, so do you think alcohol affects your body differently than it affects your friends?
00:07:55Ally (ph) Yes, alcohol affects. Yes.
00:08:00UNKNOWN Do you drink more than your friends and the other teachers?
00:08:05Ally (ph) I… I drink, but… but you’re not understanding it, it affects me differently.
00:08:15UNKNOWN Has it prevented you from doing things or interfered with relationships?
00:08:25Ally (ph) Are you specifically talking about Ryan here?
00:08:25UNKNOWN Yeah.
00:08:30Ally (ph) Okay, Ryan did not leave me because I drink.
00:08:30UNKNOWN Okay.
00:08:35Ally (ph) I’m seeing someone new. We weren’t even together for a year.
00:08:35UNKNOWN Is drinking wine, beer, other alcoholic drinks in the evenings. Is that something new for you? Or was that something typical than your past?
00:08:50Ally (ph) No. Look, my father was an alcoholic growing up. When I was really little he drank. He got into AA and got sober. Mom was very supportive of him, but extremely strict with us in drinking.
00:09:10UNKNOWN How did you feel about her being so strict with alcohol?
00:09:15Ally (ph) As a teenager it sucked. I went out with my friends I got drunk. And then freshman year was a huge vendor. Eventually I just I mellowed out.
00:09:25UNKNOWN And after college?
00:09:25Ally (ph) In grad school I drank here and there but not much.
00:09:30UNKNOWN Do you think your alcohol intake is less that when you were in college or is it gone the other way? Has it increased recently?
00:09:40[sil.]
00:09:50Ally (ph) More.
00:09:55END TRANSCRIPT
Important
Informal blogs, internet posts and websites that are not part of a scholarly review process. This includes popular hospital websites (such as MayoClinic.org), Patient facing websites with information designed for the patient, not the provider (such as WebMD, Healthline and MedicineNet, among many others), and UptoDate.com. Information should not be utilized from UptoDate.com since all information is a synthesis of the most up to date literature available. If you wish to use information from UpToDate, use the original sources, not the UpToDate website.
Another student’s work. Regardless of where it is obtained, the use of another student’s written work is never appropriate. This includes use of another student’s work as a “reference”, or exemplar assignment. Templates and examples are often provided in the classroom. If they are not and you would like one, please request this from your instructor.
Criteria
Ratings
Pts
This criterion is linked
to a Learning OutcomeCreate documentation
in the Comprehensive Psychiatric Evaluation Template about the patient you
selected. In the Subjective section, provide: • Chief complaint• History of
present illness (HPI)• Past psychiatric history• Medication trials and
current medications• Psychotherapy or previous psychiatric diagnosis•
Pertinent substance use, family psychiatric/substance use, social, and
medical history• Allergies• ROS
20 to >17.0 pts
Excellent
The response throughly and accurately describes the patient’s
subjective complaint, history of present illness, past psychiatric history,
medication trials and current medications, psychotherapy or previous
psychiatric diagnosis, pertinent histories, allergies, and review of all systems
that would inform a differential diagnosis.
17 to >15.0 pts
Good
The response accurately describes the patient’s subjective complaint,
history of present illness, past psychiatric history, medication trials and
current medications, psychotherapy or previous psychiatric diagnosis,
pertinent histories, allergies, and review of all systems that would inform
a differential diagnosis.
15 to >13.0 pts
Fair
The response describes the patient’s subjective complaint, history of
present illness, past psychiatric history, medication trials and current
medications, psychotherapy or previous psychiatric diagnosis, pertinent
histories, allergies, and review of all systems that would inform a
differential diagnosis, but is somewhat vague or contains minor innacuracies.
13 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the
patient’s subjective complaint, history of present illness, past
psychiatric history, medication trials and current medications,
psychotherapy or previous psychiatric diagnosis, pertinent histories,
allergies, and review of all systems that would inform a differential
diagnosis. Or, subjective documentation is missing.
20 pts
This criterion is linked
to a Learning OutcomeIn the Objective
section, provide:• Physical exam documentation of systems pertinent to the
chief complaint, HPI, and history• Diagnostic results, including any labs,
imaging, or other assessments needed to develop the differential diagnoses.
20 to >17.0 pts
Excellent
The response thoroughly and accurately documents the patient’s
physical exam for pertinent systems. Diagnostic tests and their results are
thoroughly and accurately documented.
17 to >15.0 pts
Good
The response accurately documents the patient’s physical exam for
pertinent systems. Diagnostic tests and their results are accurately
documented.
15 to >13.0 pts
Fair
Documentation of the patient’s physical exam is somewhat vague or
contains minor innacuracies. Diagnostic tests and their results are
documented but contain minor innacuracies.
13 to >0 pts
Poor
The response provides incomplete or inaccurate documentation of the
patient’s physical exam. Systems may have been unnecessarily reviewed, or,
objective documentation is missing.
20 pts
This criterion is linked
to a Learning OutcomeIn the Assessment
section, provide:• Results of the mental status examination, presented in
paragraph form.• At least three differentials with supporting evidence. List
them from top priority to least 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.
25 to >22.0 pts
Excellent
The response thoroughly and accurately documents the results of the
mental status exam…. Response lists at least three distinctly different
and detailed possible disorders in order of priority for a differential
diagnosis of the patient in the assigned case study, and it provides a
thorough, accurate, and detailed justification for each of the disorders
selected.
22 to >19.0 pts
Good
The response accurately documents the results of the mental status
exam…. Response lists at least three distinctly different and detailed
possible disorders in order of priority for a differential diagnosis of the
patient in the assigned case study, and it provides an accurate
justification for each of the disorders selected.
19 to >17.0 pts
Fair
The response documents the results of the mental status exam with
some vagueness or innacuracy…. Response lists at least three different
possible disorders for a differential diagnosis of the patient and provides
a justification for each, but may contain some vaguess or innacuracy.
17 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the
results of the mental status exam and explanation of the differential
diagnoses. Or, assessment documentation is missing.
25 pts
This criterion is linked
to a Learning OutcomeReflect on this case.
Discuss what you learned and what you might do differently. Also include in
your reflection a discussion related to legal/ethical considerations
(demonstrate critical thinking beyond confidentiality and consent for
treatment!), social determinates of health, 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.).
10 to >8.0 pts
Excellent
Reflections are thorough, thoughtful, and demonstrate critical
thinking.
8 to >7.0 pts
Good
Reflections demonstrate critical thinking.
7 to >6.0 pts
Fair
Reflections are somewhat general or do not demonstrate critical
thinking.
6 to >0 pts
Poor
Reflections are incomplete, inaccurate, or missing.
10 pts
This criterion is linked
to a Learning OutcomeProvide at least three
evidence-based, peer-reviewed journal articles or evidenced-based guidelines
that relate to this case to support your diagnostics and differential
diagnoses. Be sure they are current (no more than 5 years old).
15 to >13.0 pts
Excellent
The response provides at least three current, evidence-based
resources from the literature to support the assessment and diagnosis of
the patient in the assigned case study. The resources reflect the latest
clinical guidelines and provide strong justification for decision making.
13 to >11.0 pts
Good
The response provides at least three current, evidence-based
resources from the literature that appropriately support the assessment and
diagnosis of the patient in the assigned case study.
11 to >10.0 pts
Fair
Three evidence-based resources are provided to support assessment and
diagnosis of the patient in the assigned case study, but they may only
provide vague or weak justification.
10 to >0 pts
Poor
Two or fewer resources are provided to support assessment and
diagnosis decisions. The resources may not be current or evidence based.
15 pts
This criterion is linked
to a Learning OutcomeWritten Expression and
Formatting—Paragraph development and organization:Paragraphs make clear
points that support well-developed ideas, flow logically, and demonstrate
continuity of ideas. Sentences are carefully focused—neither long and
rambling nor short and lacking substance. A clear and comprehensive purpose statement
and introduction are provided that delineate all required criteria.
5 to >4.0 pts
Excellent
A clear and comprehensive purpose statement, introduction, and
conclusion are provided that delineate all required criteria. …Paragraphs
and sentences follow writing standards for flow, continuity, and clarity.
4 to >3.5 pts
Good
Purpose, introduction, and conclusion of the assignment are stated,
yet they are brief and not descriptive. …Paragraphs and sentences follow
writing standards for flow, continuity, and clarity 80% of the time.
3.5 to >3.0 pts
Fair
Purpose, introduction, and conclusion of the assignment is vague or
off topic. … Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 60%-79% of the time.
3 to >0 pts
Poor
No purpose statement, introduction, or conclusion were provided. …
Paragraphs and sentences follow writing standards for flow, continuity, and
clarity less than 60% of the time.
5 pts
This criterion is linked
to a Learning OutcomeWritten Expression and
Formatting—English writing standards: Correct grammar, mechanics, and
punctuation
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors
4 to >3.0 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation errors
3 to >2.0 pts
Fair
Contains several (three or four) grammar, spelling, and punctuation
errors
2 to >0 pts
Poor
Contains many (≥ five) grammar, spelling, and punctuation errors that
interfere with the reader’s understanding
5 pts
Total Points: 100
