NURS 6630 Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

Background

Mrs. Maria Perez, a 53-year-old Puerto Rican woman, has presented with an issue that she finds “embarrassing.”

Subjective

Mrs. Perez has struggled with alcohol since her father’s death in her late teens. She has been in and out of Alcoholics Anonymous for the past 25 years. Recently, she has been finding it difficult to maintain her sobriety due to the opening of the “Rising Sun” casino near her home. During a visit to the casino’s grand opening, Mrs. Perez became hooked on gambling, which provides her with a sense of high.

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She often drinks while gambling, which leads to reckless gambling and further drinking. She has also noticed an increase in cigarette smoking over the past two years, which worries her about its negative effects on her health. Mrs. Perez has attempted to stop drinking but finds it challenging to resist the high she experiences from gambling. She has gained seven pounds from drinking and weighs 122 lbs.

Mental Status Exam

During the clinical interview, Mrs. Perez demonstrated an alert and oriented state of mind. Her speech was clear, coherent, and goal-directed, and her eye contact was somewhat avoidant. She had no noteworthy mannerisms, gestures, or tics. Although her self-reported mood was “sad,” her affect was appropriate to the conversation and her mood. She reported no visual or auditory hallucinations, delusional or paranoid thought processes, and her insight and judgment were intact. However, her impulse control was impaired, and she denied any suicidal or homicidal ideation.

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Diagnosis

Mrs. Perez has been diagnosed with gambling disorder and alcohol use disorder.

Introduction

Compulsivity and impulsivity can manifest in various ways and often coincide with other psychiatric disorders. Individuals who act without thinking may struggle to refuse certain things, such as spending money or using illegal drugs. Some people may engage in compulsive behavior that leads to adverse consequences.

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In many cases, compulsivity and impulsivity contribute to addiction-related problems. To assess and treat clients effectively, a Psychiatric Mental Health Nurse Practitioner (PMHNP) must have a clear understanding of the differences between these disorders, their symptoms, and their impact on both clients and their families (Bandelow, Michaelis, & Wedekind, 2017).

Decision #1

I have selected to begin the Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks for the patient described in the case. My decision to choose Naltrexone was based on its effectiveness in reducing alcohol consumption, craving, and relapse rates in patients with alcohol use disorder.

Studies have demonstrated the efficacy of Naltrexone in reducing alcohol use in patients with alcohol use disorder, including those with comorbid psychiatric conditions. Additionally, Naltrexone has been shown to improve overall treatment outcomes and increase the likelihood of abstinence. In the context of the patient’s case, Naltrexone could help her maintain her sobriety by blocking the pleasurable effects of alcohol and reducing her craving for alcohol (Ray et al., 2019).

nurs 6630  assessing and treating patients with impulsivity, compulsivity, and addiction
NURS 6630 Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

I did not select Campral (Acamprosate) or Antabuse (Disulfiram) for the patient because they have different mechanisms of action and may not be as effective as Naltrexone in this particular case. Campral works by reducing cravings and withdrawal symptoms in patients who have already stopped drinking.

While it is generally well-tolerated, it has not been shown to be effective in reducing heavy drinking or promoting abstinence in patients with alcohol use disorder (Akbar et al., 2018). Antabuse, on the other hand, works by causing a psychologically unpleasant reaction if the patient drinks alcohol, which can serve as a deterrent. However, it has limited efficacy and is associated with low patient adherence due to its side effects (De Souza, 2019).

By choosing Naltrexone, I hoped to achieve a reduction in the patient’s alcohol consumption, craving, and risk of relapse. I also hoped to improve her overall treatment outcomes and increase her likelihood of abstinence. Studies such as Ray et al. (2019) have shown Naltrexone to be effective in reducing alcohol use in patients with alcohol use disorder, and I hoped to have similar results replicated in this case.

Ethical considerations play a significant role in the treatment plan and communication with patients. It is important to obtain informed consent from the patient before initiating any treatment, ensuring that they understand the risks and benefits associated with the treatment. In the case of Naltrexone, it is important to inform the patient of the potential side effects, including nausea, headache, and fatigue, and monitor them for any adverse reactions.

It is also important to involve the patient in the decision-making process and respect their autonomy by considering their preferences and values. Additionally, confidentiality and privacy must be maintained throughout the treatment process, and the patient’s dignity and respect must be upheld (Adams & Volkow, 2020).

Decision #2

I selected to refer the client to a counselor to address her gambling issues. This decision was based on the client’s primary concern being gambling disorder and the potential benefits of concurrent counseling with her current medication regimen. Research has shown that counseling and therapy are effective in treating gambling disorder, including cognitive-behavioral therapy (CBT) and motivational interviewing (MI) (Hodgins et al., 2019).

Counseling can help the client identify and address the underlying reasons for their gambling behavior, develop coping skills, and improve their self-efficacy and motivation to change. Furthermore, counseling can provide ongoing support for maintaining sobriety and reducing the risk of relapse.

I did not select the other two options provided. Adding on Chantix (varenicline) may be effective in reducing nicotine dependence, but it does not address the client’s primary concern of gambling disorder. Additionally, the client’s smoking may be a secondary issue that can be addressed through counseling or other means.

Adding on Valium (diazepam) also presents a risk for the client due to her history of alcohol and drug abuse. Valium is a benzodiazepine meaning it has potential for being abused. Mixing alcohol with Valium is also associated with side effects such as slowed breathing which can be life threatening (Powers, 2022).

By referring the client to a counselor to address gambling issues, I hope to achieve additional support for the client’s primary concern of gambling disorder. The counselor can work with the client to identify triggers and develop coping strategies to prevent relapse. Additionally, the counselor can help the client address any underlying psychological or emotional issues that may be contributing to their gambling behavior (Knaebe et al., 2019).

Ethical considerations play a significant role in the treatment plan and communication with patients. It is essential to obtain informed consent from the patient and respect their autonomy in making decisions about their treatment. The patient must understand the benefits and risks associated with counseling and be able to provide informed consent. Confidentiality must also be maintained, and the patient’s privacy and dignity must be upheld. Additionally, the counselor must be appropriately trained and qualified to address the client’s specific needs and concerns (Adams & Volkow, 2020).

Referring the client to a counselor to address gambling issues was the appropriate decision based on the patient’s primary concern and the potential benefits of concurrent counseling with her current medication regimen. Counseling can help the client identify underlying issues and develop coping strategies to prevent relapse. Ethical considerations must be considered throughout the treatment plan to ensure the patient’s autonomy and privacy are upheld (Knaebe et al., 2019).

 Decision #3

I selected to explore the issue that Mrs. Perez is having with her counselor and encourage her to continue attending the Gamblers Anonymous meetings for decision #3. This decision was based on the client’s report that she did not really like her counselor and the potential benefits of addressing this issue and continuing with Gamblers Anonymous. Research has shown that a positive therapeutic alliance between the patient and therapist is critical for successful treatment outcomes (Knaebe et al., 2019).

Patients who have a positive relationship with their therapist are more likely to engage in therapy, feel supported, and make progress towards their treatment goals. Therefore, addressing the issue that Mrs. Perez is having with her counselor is crucial for maintaining her engagement in counseling and improving her treatment outcomes.

I did not select the other two options provided in the exercise. Encouraging Mrs. Perez to continue seeing her current counselor may not be effective if she does not have a positive therapeutic alliance with her therapist. Discontinuing Vivitrol is not recommended as it has been shown to be effective in reducing alcohol consumption and preventing relapse in patients with alcohol use disorder (Ray et al., 2019).

By exploring the issue that Mrs. Perez is having with her counselor and encouraging her to continue attending the Gamblers Anonymous meetings, I hope to improve her engagement in counseling and increase her chances of successful treatment outcomes. By addressing the issue with her counselor, we can work to improve the therapeutic alliance and ensure that Mrs. Perez is receiving effective treatment. Additionally, continuing with Gamblers Anonymous provides her with additional support and resources for maintaining sobriety and preventing relapse.

Ethical considerations must be considered throughout the treatment plan and communication with patients. It is essential to respect the patient’s autonomy and preferences in their treatment. Mrs. Perez must be informed of the potential benefits and risks associated with continuing with her current counselor and encouraged to express any concerns or issues she may have.

Confidentiality must also be maintained, and any communication with her counselor must be conducted with her informed consent. The goal is to provide Mrs. Perez with the best possible care while respecting her autonomy and privacy (Adams & Volkow, 2020).

Conclusion

In summary, my recommendations for the treatment of Mrs. Perez’s alcohol and gambling disorders involved a combination of pharmacological and psychosocial interventions. Treating addiction, compulsivity, and impulsivity disorders presents significant challenges to healthcare providers. These disorders are often associated with negative behaviors that can have adverse consequences for patients. It is crucial for Psychiatric Mental Health Nurse Practitioners (PMHNPs) to actively listen to clients with these disorders, evaluate their circumstances, and create a comprehensive treatment plan.

The decision to administer Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks. Was based on the effectiveness of Naltrexone in reducing alcohol cravings and preventing relapse in patients with alcohol use disorder (Ray et al., 2021). The client responded well to this medication, with reduced alcohol consumption and improved sobriety. In Mrs. Perez’s case, there are inadequate FDA-approved medications for gambling addiction.

However, counseling has been shown to be an effective treatment option for this disorder. For the gambling disorder, I referred her to a counselor to address her gambling issues and encouraged her to participate in Gamblers Anonymous meetings. This decision was based on research that supports the effectiveness of counseling and support groups combined with pharmacological intervention in treating comorbid alcohol abuse and gambling disorder (Kraus, Etuk, & Potenza, 2020).

The client reported feeling supported and engaged in the Gamblers Anonymous group, and her anxiety and gambling behaviors improved. For the third decision point, I recommended exploring the issue that Mrs. Perez was having with her counselor and encouraging her to continue attending Gamblers Anonymous meetings. This decision was based on the importance of a positive therapeutic alliance in successful treatment outcomes (Knaebe et al., 2019) and the potential benefits of addressing any concerns with the counselor and continuing with the support provided by Gamblers Anonymous.

Overall, the combination of pharmacological and psychosocial interventions was effective in treating Mrs. Perez’s alcohol and gambling disorders. Ethical considerations were also taken into account throughout the treatment plan to ensure the patient’s autonomy and privacy were respected. It is important to note that every patient is unique, and treatment plans must be tailored to their specific needs and concerns. Clinicians must consider the patient’s individual history, comorbidities, preferences, and potential risks and benefits of treatment options. Therefore, ongoing assessment and modification of the treatment plan are necessary for successful outcomes.

References

Adams, V. J. M., & Volkow, N. D. (2020). Ethical imperatives to overcome stigma against          people with substance use disorders. AMA Journal of Ethics22(8), 702-708. Doi:         10.1001/amajethics.2020.702.

Akbar, M., Egli, M., Cho, Y. E., Song, B. J., & Noronha, A. (2018). Medications for alcohol use disorders: An overview. Pharmacology & therapeutics, 185, 64-85.     https://doi.org/10.1016/j.pharmthera.2017.11.007

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues

De Souza, A. (2019). Disulfiram in the Management of Alcohol Dependence.             https://link.springer.com/chapter/10.1007/978-981-32-9876-7_3

            in clinical neuroscience, 19(2), 93. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow

Knaebe, B., Rodda, S. N., Hodgins, D. C., & Lubman, D. I. (2019). Behaviour change strategies endorsed by gamblers subtyped by psychological distress, risky alcohol use, and            impulsivity. Journal of Gambling Studies35(1), 275-292. https://doi.org/10.1007/s10899-      018-9803-x

Kraus, S. W., Etuk, R., & Potenza, M. N. (2020). Current pharmacotherapy for gambling disorder: a systematic review. Expert Opinion on Pharmacotherapy21(3), 287-296.             https://doi.org/10.1080/14656566.2019.1702969

Powers, H. (2022). The use of valium in alcohol withdrawal.           https://scholarworks.utep.edu/cohort_10/5/

Ray, L. A., Green, R., Roche, D. J., Magill, M., & Bujarski, S. (2019). Naltrexone effects on        subjective responses to alcohol in the human laboratory: A systematic review and meta‐        analysis. Addiction Biology, 24(6), 1138-1152. https://doi.org/10.1111/adb.12747

Psychopharmacological Approach to Treat Psychopathology

Impulsivity disorders are characterized by the inability to resist the sudden, powerful desire to do something and difficulties controlling emotions or behaviors. On the other hand, addiction is a complex mental condition characterized by compulsive substance use regardless of detrimental consequences. The purpose of this paper is to describe a patient with an addiction disorder and the treatment interventions.

Introduction to the Case

The case scenario depicts Mrs. Perez, a 5-year-old Puerto Rican woman with alcohol drinking problems since her late teenage years. Perez has been part of Alcoholics Anonymous from time to time for the last 25 years. The patient also reports that she has been finding it more difficult to remain sober in the past two years since a casino was opened in her neighborhood.

Perez mentions that she gets high when gambling since she takes some drinks when playing high-stake gambling games. However, this leads to increased alcohol consumption and irresponsible gambling. In addition, the client states she has increasingly been smoking in the past two years and is worried about the adverse health impacts.

Mrs. Perez reports that she has tried refraining from alcohol consumption, but gambling makes her high, making her take a few drinks to even up. She has also realized that when she consumes alcohol, she smokes minimally, but she enjoys smoking when gambling. The patient has experienced weight gain from excessive drinking, and her current weight is122 lbs, having gained 7 lbs.

The patient is worried since she borrowed more than $50,000 from her retirement account to pay gambling debts. Noteworthy MSE findings include avoiding eye contact, sad mood, and impaired impulse control. Mrs. Perez is diagnosed with Gambling disorder and alcohol use disorder. The patient factors that may affect decision-making with regard to treatment include age, overall health status, comorbid mental health illnesses, the patient’s previous experience with medication, the patient’s beliefs and opinions on useful therapies, history of treatment compliance, and the patient’s motivation for abstinence.

Decision #1

Vivitrol (naltrexone) injection, 380 mg IM in the gluteal region four-weekly.

Reason for this Decision

Naltrexone was the ideal treatment because it is an FDA-indicated drug for treating alcohol use disorder (AUD). Joshi et al. (2021) explain that naltrexone alleviates alcohol cravings, decreases alcohol consumption, and the monthly injectable formulation helps in compliance. Kranzler and Soyka (2018) explain that naltrexone decreases mesolimbic opioidergic activity, thus controlling the dopamine-mediated rewarding effects of alcohol, resulting in decreased alcohol consumption.

Why Other Decisions Were Not Selected

Disulfiram was not ideal because the physical reaction of alcohol and disulfiram causes dizziness, tachycardia, nausea, flushing, chest pain, and BP changes, which can harm patients, making it less recommended (Joshi et al., 2021).

Acamprosate was not selected because it is approved by the FDA to promote abstinence in patients who are abstinent when starting treatment (Kranzler & Soyka, 2018). Mrs. Perez was not abstinent and thus not a suitable candidate for acamprosate therapy.

What I Was Hoping To Achieve By Making This Decision

The PMHNP hoped that naltrexone would reduce the patient’s alcohol cravings and excessive consumption (Witkiewitz et al., 2019). Kranzler and Soyka (2018) found that naltrexone effectively reduces the risk of relapse into alcohol and relapse to binge drinking.

Ethical Considerations Impact on Treatment Plan and Communication

Nonmaleficence impacted the treatment plan since the PMHNP had to select the intervention with the best outcomes and the least side effects. Consequently, naltrexone was chosen for its strong safety profile, and disulfiram was rejected. Respect for autonomy impacted communication  with Mrs. Perez. For example, the clinician had to obtain patient consent to initiate treatment.

Decision #2

Refer the patient to a counselor to address gambling issues.

Reason for this Decision

The patient was referred to a counselor because she had persistent gambling issues that got her into financial problems. Menchon et al. (2018) explain that psychological therapies are the most effective approach for gambling disorders and are connected with marked improvements in the short and the long term. Counseling focuses on the patient, enabling them to search and solve uncertainties, and improving their willingness to change behavior (Ribeiro et al., 2021).

Why Other Decisions Were Not Selected

Adding diazepam to treat anxiety was not ideal because the patient’s anxiety is a likely side effect of naltrexone therapy and thus does not justify medication (Joshi et al., 2021). Chantix was also not added to promote smoking cessation because the smoking problem was linked to gambling, and thus it is important first to solve the gambling issue. Menchon et al. (2018) explain that cognitive behavioral therapy (CBT) facilitates an individual’s understanding of cognitive distortions connected to gambling behavior.

What I Was Hoping To Achieve By Making This Decision

The PMHNP hoped that psychological therapy would help the patient identify cognitive distortions connected with her gambling behavior. Counseling weakens the irrational beliefs, perseveration patterns, and magical thinking associated with the gambling disorder (Menchon et al., 2018). Ribeiro et al. (2021) explain that counseling primarily focuses on the patient’s behavior, cognition, and motivation, thus solving the psychological determinants of gambling.

Ethical Considerations Impact on Treatment Plan and Communication

Beneficence influenced the patient’s treatment. For example, the PMHNP had to refer the patient for counseling to address the gambling issue and promote better health outcomes. Confidentiality impacted communication as the practitioner is  obligated to ensure confidentiality. In this case, the PMHNP had to ensure the patient’s health information was kept confidential and only shared after obtaining the patient’s consent.

Decision #3

Identify the patient’s problem with her counselor, and encourage her to continue attending GA meetings.

Reason for this Decision

The PMHNP selected this decision because the client reported not liking her counselor, which could affect her adherence to counseling sessions and treatment outcomes. Bolsinger et al. (2020) explain that creating a good therapeutic relationship (TR) in counseling is crucial to improving clinical outcomes, quality of patient care, and patient satisfaction. Kleiven et al. (2020) explain that it is essential for the patient to open up to and connect with personal issues internally, despite this being highly uncomfortable.

Why Other Decisions Were Not Selected

It was not ideal to encourage the patient to continue counseling without addressing the concerns with the counselor because it would have further worsened the therapeutic relationship between Mrs. Perez and the counselor. Kleiven et al. (2020) explain that the TR in psychotherapy is crucial since it facilitates the clients’ ability to approach, acknowledge, and reflect upon challenging issues with sincerity and authenticity. Discontinuing naltrexone was not also ideal because it exhibited efficacy in alleviating alcohol consumption and cravings (Joshi et al., 2021).

What I Was Hoping To Achieve By Making This Decision

The PMHNP hoped that exploring Mrs. Perez’s issues with her counselor would enable her to open up and have an effective relationship with the counselor (Kleiven et al., 2020). Bolsinger et al. (2020) found that a positive TR is connected with better therapy outcomes with regard to clinical improvement, rehospitalization, and patient satisfaction.

Ethical Considerations Impact on Treatment Plan and Communication

Beneficence affected the treatment plan as the clinician is mandated to select interventions associated with the best outcomes. For instance, the PMHNP had to help the patient identify her issues with the counselor to create a positive TR, promoting better outcomes. Besides, the respect for autonomy affected communication with the client because the PMHNP is required to engage the client in developing the treatment plan. For example, the PMHNP had to engage the patient to identify the issues with the counselor and address them.

Conclusion

Mrs. Perez was diagnosed with alcohol use disorder and gambling disorder based on her history of excessive alcohol consumption and gambling, which got her in financial trouble. The patient was prescribed Naltrexone injection, 380 mg four weekly, since it reduces alcohol consumption and alcohol cravings (Joshi et al., 2021). Besides, naltrexone is well-tolerated and is not associated with dependence. Disulfiram was not selected because of its disulfiram-alcohol interaction, which causes BP changes, nausea, chest pain, flushing, dizziness, and tachycardia. Acamprosate was not also ideal because it is indicated for patients who have already achieved abstinence (Kranzler & Soyka, 2018).

The patient’s gambling disorder persisted, and the PMHNP referred her for counseling. A psychotherapy approach was the most ideal since it is considered the most treatment for gambling disorders and associated with marked improvements in the short and the long term (Menchon et al., 2018). However, she reported having issues

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