Vignette Case Analysis 1
This
assignment focuses on vignette analysis and direct application of
course concepts to the persons and situations presented in the vignette
for each question. All discussions must take into account
the legal and ethical considerations, as well as issues of culture and
human diversity that may pertain to the situation presented below.
Culture and Legal/Ethical issues can be found in the course text, but
you are encouraged to use outside sources in culture and ethics to
enhance your work.
Please keep your responses
focused on what is presented in the vignette. Do not add information but
use your creativity to support what you see in the vignette as
written.
All assignments MUST be typed,
double-spaced, in APA style and must be written at graduate level
English. The content, conciseness and clarity of your answers will be
considered in the evaluation of your work.
You must integrate the material presented in the text and DSM-5. You are encouraged to use outside research to enhance the text material, but not to replace the text. Please cite all work according to APA format.
Your response to each case should be approx. 3-4 pages per case.
Your entire assignment should be 6-8 pages total.
Case of Larry
Larry is a 51-year-old African American man who has bounced around
between homelessness/unemployment and a few part-time jobs while living
in a shelter or occasionally on his own via renting a room. Living on
the streets, Larry has been exposed to violence, both as an observer and
recipient. Larry has a long-term 30+ year history of relatively
consistent heroin use. He reports two prior instances of abstinence when
admitted into inpatient treatment, but both times he ceased treatment
and returned to substances within three weeks-time due to feeling “awful
and crazy” when not taking heroin.
Heroin Use History
Larry began using heroin in his early 20’s after being stabbed in a
gang related incident. He quickly became addicted to heroin and
continued using ever since. Larry reports using heroin multiple times
per day, but varying in actual number. He states experiences which show
he likely has developed tolerance to the substance, but still takes it
because it offers some effect, though not as intense as he used to
experience in his earlier years.
Larry has had
two recent failed treatment episodes. His first-ever attempt at
treatment was two years ago when he was living temporarily with a
friend. Larry attended a 28-day inpatient program at a local medical
center. Approximately three weeks into treatment, Larry began sensing he
was seeing “shadowy figures” out of his peripheral vision. He also
recalled feeling very on-edge and paranoid. Larry was discharged from
treatment because he had overheard his clinician was holding a staff
meeting and Larry was convinced they were discussing him. He barged into
the meeting and accused the staff of unethical behavior. He had to be
escorted to the ER by medical center security. Larry was discharged from
the program after receiving a “clean bill of health” from the ER
doctors who deemed him simply “not ready for treatment.” Larry recalls
them saying that about him.
Larry next tried
treatment four weeks ago when he was admitted into a residential
therapeutic community (TC) where he was diagnosed as HIV/AIDS positive
along with Hepatitis C. He was given a referral to a physician, which he
declined. After four weeks of being heroin-free, Larry began
demonstrating odd behavior that included hearing voices and overwhelming
experiences of paranoia. Larry describes feeling as if certain
important TC staff were watching him and waiting to trap him. However,
Larry could not elaborate on what the trap would be and why they would
feel a need to snare him in a trap.
Larry’s Presentation
In your initial session with Larry, he is convinced that your session is being recorded.
Please respond to the following questions:
1. This
may be a case of substance-induced psychotic disorder or this may be a
case of an undiagnosed co-occurring psychotic disorder which had been
unknowingly self-medicated and controlled via heroin use. How would you
work with Larry to ascertain the appropriate diagnosis?
2. How would you use the clinical interview discussed in Chapter 2 of the text to solidify your diagnosis.
3. How would you clinically work with the psychotic symptom(s) if substance-induced? If co-occurring psychotic disorder?
4. What
would be the appropriate level of care for Larry? Consider health
issues (HIV/AIDS and Hepatitis C), risk assessment, trauma and violence
potential.
Case of Sharon
Sharon
is an 82-year-old Chinese American widow living alone for the past six
years since the death of her husband. Her husband was killed by a drunk
driver in an auto accident. Sharon was in the car, but survived without
injury. Sharon lives within 10 minutes of her children and
grandchildren. For the past few years, Sharon has been secretly
drinking, with her alcohol consumption increasing in amount and
frequency over the past 18 months. Sharon now consumes a bottle of wine
per day, drinking primarily in the late afternoon and evening. Sharon
was referred to counseling due to an increased presentation of anxiety.
Her children and friends noticed that Sharon was more anxious, noting
her being “jittery,” “hypervigilant,” and more “worried” than usual. The
counselor referred her to a psychiatrist who prescribed an anti-anxiety
medication. Unfortunately, ageism and stereotypes led both these
professionals to ignore the potential of any alcohol or substance use.
Anxiety Presentation History
Sharon
noted how she would be “on-edge” all the time. Sharon recalled one
recent incident where she was playing cards with some friends. She
reports that the room just started spinning and that she almost passed
out. “I didn’t tell anyone, but I really, really wanted a drink. The
wine just helps me calm down.”
Sharon went to a
psychiatrist, who prescribed Xanax (0.25 mg, 2–3 times per day). After a
few weeks of taking the Xanax as prescribed, Sharon became frustrated
with the medication “doing nothing” for her anxiety. During these few
weeks, Sharon continued to drink alcohol, but cut back somewhat as she
did not like taking medication with alcohol.
Alcohol Use History
Sharon
was never “much of a drinker” but started to drink 1–2 glasses of wine
in the years following the death of her husband. Slowly, Sharon
increased to 3–5 glasses of wine, noting how it helped her fall asleep.
Sharon denied drinking to cope with anxiety or any other affect, mood,
or cognition. Within the past 18 months, Sharon noticed that she was
drinking most of the bottle of wine. Her reasoning for drinking the
entire bottle was simply “the wine doesn’t stay well once uncorked, even
for a day.”
Sharon’s Presentation
In
addition to the anxiety, Sharon also presents with the following recent
symptoms: mood swings, memory loss, sleep difficulties, and
difficulties with decision-making. Her family is oblivious to her
drinking, and is very concerned because of these symptoms, coupled with
her anxiety and the apparent ineffectiveness of the Xanax on treating
the anxiety.
Please respond to the following questions:
1. How does Sharon’s cross-tolerance issues impact the prescribed benzodiazepine?
2. In
consideration of the older adult treatment issues and grief and
trauma-related issues discussed in the text, what would be some key
concepts in the assessment and treatment planning for Sharon’s alcohol
use, mood swings, memory loss, sleep difficulties, and difficulties with
decision-making?
3. Building off of the content in question #2, what level of care do you recommend and why?
4. How would you use motivational interviewing and cognitive-behavioral therapy in your treatment of Sharon?
Activity Outcomes
Evaluate theories and models of intervention with co-occurring disorders.
Formulate diagnoses of co-occurring psychiatric and substance-related disorders
