Question Description
I need an explanation for this Psychology question to help me study.
Personality disorders can arise through trauma, and they often carry added stigma. In this Discussion, you analyze a case study focused on a personality disorder while also reflecting on how power, privilege, and stigma affect such diagnoses.
To prepare: Review the case provided by your instructor for this week’s Discussion and consider your differential diagnostic process for them. Be sure to consider any past diagnoses and what influence those might have on their current diagnosis and needs. Finally, return to the Week 1 resources on stigma and reflect on stigma related to personality disorders.
Post a response in which you address the following:
Provide the full DSM-5 diagnosis. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
Support your decision by identifying the symptoms which meet specific criteria for each diagnosis.
Identify any close differentials and why they were eliminated. Concisely support your decisions with the case materials and readings.
Explain how diagnosing a client with a personality disorder may affect their treatment.
Analyze how power and privilege may influence who is labeled with a personality disorder and which types of personality disorders.
Identify how trauma affects the case, either precipitating the diagnosis and/or resulting from related symptoms or treatment of diagnosis.
Post a 300- to 500-word response in which you address the following:
•
Provide the full DSM-5 diagnosis for Betty. Remember, a full diagnosis should
include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z
codes (other conditions that may need clinical attention). Keep in mind a diagnosis
covers the most recent 12 months.
F10.20 Alcohol Use Disorder, moderate
F10.280 Substance/medication-induced anxiety disorder
Z55.9 Academic or Educational Problem
Z72.9 Problem Related to Lifestyle
•
Explain the diagnosis by matching the symptoms identified in the case to the specific
criteria for the diagnosis.
F10.20 Alcohol Use Disorder, moderate
1. A problematic pattern of alcohol use leading to clinically significant impairment or
distress, as manifested by at least two of the following, occurring within a 12-month
period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended:
Betty reports that over the last two months, she has begun drinking at work as well as at college
parties.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use:
Betty states that she often tries to limit herself to three cocktails per weekend evening but often is
“not bothered” to maintain those limits.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or
home
Betty’s grades have begun to suffer, and she recently had to drop a class due to nonattendance.
7. Important social, occupational, or recreational activities are given up or reduced because of
alcohol use
Betty states that she has “no time” for a boyfriend, clubs, sports, or regular exercise.
11. Withdrawal, as manifested by either of the following
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid
withdrawal symptoms
Betty reports drinking in the morning to reduce hand tremors and feelings of nausea and
“fogginess.”
F10.280 Substance/medication-induced anxiety disorder
1. Panic attacks or anxiety is predominant in the clinical picture.
Betty is reporting “chronic anxiety” that makes it difficult to sleep without the use of alcohol, has
had to drop a class due to nonattendance, has experienced a drop in her usual grades, and has
started withdrawing from social connections.
1. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or
withdrawal or after exposure to a medication
Betty started drinking during the second semester of her sophomore year, and now, in her junior
year, has begun reporting chronic anxiety symptoms, including difficulty sleeping, irritability,
and difficulty concentrating.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.
Betty misuses alcohol, which is known to produce the symptoms in Criterion A.
C. The disturbance is not better explained by an anxiety disorder that is not
substance/medication-induced.
Betty is not reporting any anxiety symptoms prior to this year and has not given any evidence to
suggest that an anxiety disorder existed before the alcohol misuse.
D. The disturbance does not occur exclusively during the course of a delirium.
Betty reports symptoms of anxiety even during times of sobriety.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
Betty’s functioning in school and social situations has begun to decline, causing her GPA to
suffer, classes to be dropped, and her to “not have time” for a boyfriend, sports, clubs, or
exercise.
Z55.9 Academic or Educational Problem
Betty is reporting that her academic performance has declined and that she has had to drop
classes, which makes academics an important clinical focus. There may be a need to focus
clinical interventions on increasing Betty’s time management skills, building motivation and
determination, and improving sleep hygiene and addressing her insomnia.
Z72.9 Problem Related to Lifestyle
Betty currently works at a bar/restaurant, hangs out with college/“bar” friends, drinks at and after
work, as well as at parties – she has been known to be “out all night partying and drinking.”
Betty’s current lifestyle would not support sobriety, and clinical intervention may be needed to
adjust priorities, limit temptation, and pursue recovery.
•
Describe the assessment(s) you would use to validate her diagnosis, clarify missing
information, or track her progress.
To validate Betty’s AUD diagnosis and check progress, I would utilize either the AUDIS
(American, 2019) or the Brief DSM-5 AUD Assessment (Hagman, 2017). The AUDIS is a short,
10-item self-report assessment that attempts to determine the frequency and severity of alcohol
misuse (American, 2019). The Brief DSM-5 AUD Assessment is still being studied but attempts
to create a standardized brief assessment tool that utilizes the DSM-5 AUD criteria as other
screening tools predate the DSM-5 and is more cost-effective than a clinical interview (Hagman,
2017).
Brady, Haynes, Hartwell, & Killeen (2013) point out that determining an independent anxiety
disorder from a substance/medication-induced anxiety order is not easy nor an exact science. The
authors suggest an observation of anxiety symptoms over time and continuing re-evaluations as
sober time increases, and if anxiety begins to resolve, then it is substance/medication-induced,
but if not, consider another diagnosis (Brady, Haynes, Hartwell, & Killeen, 2013). However,
there has been no determined timeframe for how long this process may take, but it is noted that it
changes depending on the substance, and is left up to clinical judgment (Brady, Haynes,
Hartwell, & Killeen, 2013). Given that Betty has no sober time yet, and I could not locate a
specific tool to assess for substance/medication-induced anxiety disorders, I would use the GAD7 to track symptoms over time and see if any improvements are made as she maintains sobriety
(Anxiety, 2019). If not, I would re-evaluate and consider a diagnosis of generalized anxiety
disorder.
•
Summarize how you would explain the diagnosis to Betty.
I would explain to Betty that even though she does not drink every day, and that several of her
friends may be drinking just as much, if not more, than her that her unique situation does fit the
criteria for an alcohol-use disorder. I would also explain that paradoxically, alcohol may cause
anxiety, especially during intoxication or withdrawal, and that I suspect it may have a part to
play in her experiences of chronic anxiety. However, I’d be upfront that it may be possible that
her anxiety is an independent and co-occurring diagnosis and that we will keep an on-going
evaluation of her symptoms and adjust accordingly.
•
Explain how you would engage her in treatment, identifying potential cultural
considerations related to substance use.
Betty is a second-generation Thai immigrant as her parents had moved to the United States as
children. Fun & Park (2008) cite some factors that contribute to Thai immigrants’ increase in
drinking are immigration stress, Thai drinking norms and traditions, the influence of
Confucianism, acculturation, availability of Thai alcohol, and health treatment disparities. So, I
would have a conversation with Betty to determine what cultural factors are applicable and
relevant to her experience and then work with her to determine a treatment plan. It is difficult to
determine how best to engage her in treatment, given the limited information we have. I do not
know how important her Thai heritage is to her, if she is rebelling against it, what religion she is
a part of it, or what hobbies she may have or would want back. The case study does not tell us if
she even wants to stop drinking or sees it as a problem, so it is possible that she wants no part of
chemical dependence treatment at this time. If she does not, I would attempt to use motivational
interviewing to try and increase her motivation and decrease her ambivalence towards treatment.
•
Describe your initial recommendations for her treatment and explain why you
would recommend MAT or ABT.
My initial recommendation is to refer Betty to a medically supervised detoxication unit as she is
already reporting side effects such as tremors, fogginess, and nausea and there she can get a
psychiatric evaluation for potential medication as well. At this time, I would not recommend
MAT unless a physician or psychiatrist were recommending it or Betty was requesting it as she
has not yet attempted treatment of any kind. So, I would prefer to start without medication and
utilize motivational interviewing and cognitive behavioral therapy techniques to help her identify
why she is drinking, how her behaviors contribute to her thoughts and emotions and address her
ambivalence about treatment. It may be that changing her people, places, and things, increasing
her coping skills, and addressing her issues with motivation, insomnia, and focus may be enough
to curb her alcohol use.
•
Identify specific resources to which you would refer her. Explain why you would
recommend these resources based on her diagnosis and other identity
characteristics (e.g., age, sex, gender, sexual orientation, class, ethnicity, religion,
etc.).
One specific resource I would refer Betty to is WATER Recovery as it both an in-person and
web-based recovery support network that features psychoeducation, trained facilitators, and has
no abstinence requirements if she is not ready to stop drinking (WATER, 2019). There are also
message boards that can offer more specialized support, such as separate boards for college
students, women, and co-occurring anxiety disorders, or she could start a thread about being a
second-generation immigrant as well (WATER, 2019). Similarly, In the Rooms is the 12-step
alternative which features online as well as in-person meetings and also has specialized groups
such as a women-only group and meditation groups which may be something Betty is interested
in (In, 2019). Refuge Recovery is a Buddhism-based recovery model that has readings and
meetings rooted in Buddhist principals that may be more appealing for Betty. During my time
interning in a residential substance abuse facility, I found that the younger generations were
more resistant, critical, and disapproving of the 12-step model, so I had to locate alternative
resources for them, which may benefit Betty as well. Depending on the college, there may be
support groups on campus for alcohol misuse or anxiety or a club for Thai-American students
that she may find support in. I would absolutely utilize whatever resources I could find at the
school, given that financial, transpiration, and time restraints are significant considerations for
her. It is why I was also attempting to find resources she could access from home for little to no
fees.
References
American Society of Addiction Medicine. (2019). Screening & Assessment tools. Retrieved from
Anxiety and Depression Association of America. (2019). GAD-7 Anxiety. Retrieved from
Brady, K.T., Haynes, L.F., Hartwell, K.J. & Killeen, T.K. (2013). Substance use disorders and
anxiety: A treatment challenge for social workers. Social Work Public Health. 28(0). 407-423.
DOI: 10.1080/19371918.2013.774675
Hagman, B. T. (2017). Development and psychometric analysis of the Brief DSM-5 Alcohol Use
Disorder Diagnostic Assessment: Towards effective diagnosis in college students. Psychology of
Addictive Behaviors, 31(7), 797–806. doi:10.1037/adb0000320
In the Rooms. About. Retrieved from
Refuge Recovery. (2019). About. Retrieved from
WATER Recovery. (2019). About. Retrieved from
Yun, S.H., & Park, W. (2008). Clinical characteristics of alcohol drinking and acculturation
issues faced by Thai immigrants in the United States. Journal of Social Work Practice in the
Addictions. 8(1). DOI: 10.1080/15332560802108597
CASE OF MR. WILSON
Intake Date: May 2019
DEMOGRAPHIC DATA:
This is a voluntary intake for a 33-years-old Caucasian, Protestant male. Mr.
Wilson has had several psychiatric hospitalizations in the past. He has been
married for 8 years and has been separated from his wife for the past ten months.
He initially moved in with his parents but recently moved to his own place for the
past five months. His wife lives two blocks from him. Mr. Wilson has had
difficulty in jobs and has not been at any job longer than two years.
CHIEF COMPLAINT:
“I miss my wife and do not want to live if I have to live without her”.
HISTORY OF ILLNESS:
Mr. Wilson reports first seeking psychiatric treatment when he was seventeen
years old. He was prescribed anti-depressants but does not remember what kind.
The anti-depressants worked well for his depressed mood, so he remained on antidepressants for three years until he believed he did not need them anymore since
things started changing for him. He was feeling much better, happier, freer, able to
get out there and conquer the world. At 21, he began drinking. His chemical use
increased in his early twenties when he began using cocaine and amphetamines.
His use of alcohol and pills continued throughout his late twenties. At twentynine-years-old, he attempted suicide after his wife left for the first time. He was
hospitalized in a psychiatric unit for thirty days where he was also treated for drug
and alcohol addiction. At this time, he became involved with AA and NA few a
short period of time. After the reconciliation with his wife, their financial
difficulties, which existed from the start of the marriage, continued. At that time,
Mr. Wilson was put on Depakote with continued successful results three years.
Mr. Wilson reports being in a car accident six months ago where he hurt his back
and was prescribed Oxycontin. He began using the medication more often than
prescribed. Shortly after the accident, he began using other medication once in a
while that he would obtain from friends, such as Klonopin. He decided to return to
self-help meetings to end this behavior, but it did not last long because he felt
uncomfortable.
1
In December 2018, Mr. Wilson returned to his psychiatrist because he was
becoming depressed again, feeling sad, fearful, and suicidal. He was given Luvox.
Soon after, the psychiatrist did not think this was working very well and added
Ritalin to augment his medication regiment. During the next three months, Mr.
Wilson’s mania increased. He was having angry outbursts regularly. His wife
asked him to leave the home. He took an overdose of Klonopin. Mr. Wilson was
hospitalized for 3 days until his mood was stabilized and then returned home. He
reports feeling anger towards his wife believing she forced him to be hospitalized
and started using amphetamines again.
Mr. Wilson continued on anti-depressants and Depakote. His psychiatrist was
unaware that he continued using amphetamines and other medications. Mrs.
Wilson was getting continuously concerned about their financial state because Mr.
Wilson would constantly buy presents for her that she did not need or want, nor
that they could afford. They would have arguments about this all the time. Mr.
Wilson continued his use throughout the summer and by the end of March was
asked to leave his home again because he used pills as a suicidal gesture. He
began drinking again to cope with the separation. This use continued up to his
current presentation for intake.
PSYCHOSOCIAL HISTORY:
Mr. Wilson is the only child from his parents union. Mr. Wilson reports his
growing up to be tumultuous. His mother separated from his father on several
occasions and sometimes would throw Mr. Wilson out of the house with the father.
His mother made all the decisions and his father played a more passive role. Both
parents would often have physical fights and Mr. Wilson would try to break up the
fighting from as early as he can remember.
Mr. Wilson had very few friends growing up. He learned to be nasty from his
home life and would bully and intimidate his peers. He always knew he was better
than them anyway. Sometimes he would actually initiate physical fights with his
peers.
Mr. Wilson was considered an underachiever in the early years of school. He went
on to college and graduated with a bachelor’s in science with a major in computer
science.
Mr. Wilson denies any legal history.
2
Mr. Wilson worked for many years in the family business right after college.
Although the customers liked him, he was asked to leave because of money always
missing from the day’s sales. After his addiction recovery, he entered the
computer business and was a salesperson for a major company. Mr. Wilson stayed
at his first job six months but did not like the company and left. He then became a
director in another company. He was asked to leave because printers were missing
from his area. He had several jobs for a while but would not stay long at the job.
He became a district coordinator at his next job. He stayed there three years. He
had several meetings with his supervisors because of many indications of unethical
behavior. He hated this since it reminded him of childhood when he had to do
whatever he needed to obtain favors from his peers and be able to manipulate them
for things they had. For example, he would charge vacations for his friends and
himself off as a business expense. Although the administration could not prove
any illegal activity there was always speculation.
MEDICAL HISTORY:
Mr. Wilson states he currently takes Synthroid (which he convinced his primary
care physician to give him) for a thyroid problem and this helps him keep his
weight down.
FAMILY ISSUES AND DYNAMICS:
Mr. Wilson was first married at age twenty. He reports not loving his first wife but
liked the stability of her family and asked her to marry him. They spent two years
together. He physically abused her from the beginning of their marriage. Mr.
Wilson had several affairs that ended the marriage. They had no children.
Mr. Wilson married again at twenty five. He reports not loving his second wife but
thought he should be married. He pursued the second wife right from the
beginning of their relationship to marry him.
The first four years of their marriage Mr. Wilson reported physically abusing his
wife. He stopped the physical abuse when he became sober. Over the past several
years, he believed his wife was becoming more distant from him, which angered
him. Their fighting increased, although he would not become physical with her
now.
Mr. Wilson has few friends.
3
MENTAL STATUS EXAM:
Mr. Wilson presents as a neatly dressed male who appears younger than his stated
age. His hair is a bit disheveled, although he continuously takes a brush out to fix
it. He discusses his weight and body image stating he wants to be thinner and
return to weightlifting to build up his muscles again because at one point in his life
he looked like an “Adonis”. His nails are neatly groomed. Facial expressions are
appropriate to thought content. Motor activity is appropriate. Thoughts are logical
and organized. There is no evidence of hallucinations. Mr. Wilson admits to a
history of suicidal ideation. Mr. Wilson has some manic like symptoms, i.e.
getting up, going to the men’s room, talking fast during the interview. Mr. Wilson
is oriented to time, place, and person. His intelligence appears normal.
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