DSM Diagnosis: Include behaviors & symptoms consistent with diagnosis. 303.90 Alcohol Use Disorder, Sever; F.10.24 Alcohol Induced Depressive Disorder; Bipolar; Pancreatitis, severe; primary and social Background information: John Smith is a Caucasian male in his mid-forties residing Truman, AR. Pt reported he has an ongoing struggle with substance abuse addiction since the age of seventeen. Pt was admitted voluntarily to SBBH for suicidal ideation. Also, pt reports he has receive several therapeutic treatments. Recently, the patient reports he quit his job a couple of weeks ago; therefore, he has no source of income. Pt reports he has been arrested about fourteen years ago for possession of drugs. Currently, pt reports he does not have any legal matters. The pt barrier to treatment is substance abuse. John’s strengths include: verbal and use of health care system. His weaknesses consist of abuse of substances and unemployed. Pt’s systems are frustration, stress, hard to fall asleep, sleep disturbances, and irritable. John’s hobbies and interest are fishing and cooking. …show more content…
Pt has taken alcohol in larger amounts or over a longer period than was intended, interferes with his daily function, such as occupational, and recurrent alcohol use in situations in which it is physically hazardous. Pt meets criteria for F.10.24 Alcohol Induced Depressive Disorder. Pt has symptoms that persist for a substantial amount of time after the cessation of acute withdrawal or severe intoxication and a history of recurrent non-substance/medication-related episodes. John Smith presents in a flat affect during the interview. Pt maintained good eye
Co-occurring disorders are common with most client cases that are presenting with a substance use disorder. Rosa is presenting with a history of several suicide attempts, alcohol use disorder, Post traumatic Stress Disorder (PTSD), and Borderline Personality Disorder (BPD). The client’s most severe symptoms are anger, fear, and shame. It is these symptoms that are complicating her life, causing distress, and self harming behaviors. Additionally, her treatment history is limited since she does not finish her therapy sessions.
PO started Intensive Outpatient Treatment on 05-24-2016. PO attended all scheduled groups and actively participated in the group activity. The individual treatment goal is to maintain abstinence. PO response to treatment overall is positive and is making progress towards to his treatment goal, as evidenced by attending sober support group regularly, and used learning skills to manage urges and cravings. No positive UA was reported.
He also seemed confident and showed an understanding of the seriousness of his medical problem. While the social worker can empathize with the client and has noticed some similarities in their backgrounds and life experiences, the client showed poor judgment in drinking and using alcohol to lower his stress. The counselor does not believe that counter-transference issues developed during the assessment. Patrick is a sixty-eight-year-old single, male.
Pt has history of drug abuse and numerous admission to substance abuse program for heroine and crack/cocaine abuse. She was able to maintain abstinence for certain period of times only during incarceration. Pt has recently arrested after fighting with a woman, whom pt perceived as threatening. Pt was arrested since pt's attack led to the other woman's injury. Pt is currently on probation for 4 1/2 years for second degree assault and theft.
During those two years K was sober. Clinical Impressions Including Mental Status Assessment
D: Client was on time for intake appointment. Together, discussed the assessment recommendation and barriers to successful treatment outcomes. Client reviewed and signed of all treatment admission paperwork, including treatment agreement, ROIs, THS treatment policies, THS alcohol drug Services patient rights, THS patient responsibilities, THS health and safety information, THS counselor disclosure information, patient grievance procedures, THS HIV/AIDS information, THS notice of privacy practices, referral to Quit smoking, and marijuana policy. Treatment plan was developed, which was focused on Dim 4, 5, and 6; focusing on developing readiness to change, identifying relapse potential, and building a strong family and social support system.
Pt. reported positive activities that he involves himself to stay busy and keep recovery on track are working, remodeling his house, exercising, going to the beach early in the morning and meditating there. Pt. identified his wife and two sons as his main supportive people. Pt. indicated that he loves his wife and trusts her. At the end of the session Counselor explained that no matter how strong someone is, counting on his willpower to remain clean and wanting to be abstinent is not enough by itself. Counselor told him to be open to the idea to come back to the program or to call the program for any help to do
Substance/medication-induced depressive disorder appears to be related to Mrs. Smith mood disturbance; it has been used for many years as a coping mechanism. Based on the medications that Mrs. Smith has taken prior, this diagnosis best fits her symptoms and treatments. The secondary differential diagnosis is acute stress disorder acute stress disorder is caused by a traumatic event that has occurred in an individual’s life. Mrs. Smith has endured traumatic events in her life and these events occurred when she was a child. Child-abuse, self-mutilating and then eventually substance abuse is what brought me to this
PHP Behavior Program Specialist Kristi Hatcher submitted 7/15 - 8/15 progress notes, obc data, bm data, sleep data & mood charts; since James’s last visit his bowel movements are regular, per the progress notes his sleep varies between 5.5 – 13 hours per day, psychiatrics symptoms have however he is still smoking ,only targeted behaviors exhibited was verbal aggression; He currently works on the PHP Lawn crew in the morning & attends Day Hab in the afternoon.
For the last six years, I have been working in the substance abuse industry in both inpatient and outpatient settings. It would be fair to say that most people that are in need of substance abuse treatment have a co-occurring disorder such as depression, bipolar disorder, schizophrenia, and anxiety. These people are diagnosed by a psychiatrist or medical doctor and are typically given medication to help the patient. However, the problem can be that if a person sees a psychiatrist and is not honest about their substance abuse history the mental diagnosis can be deceiving.
The demographic, academic and economical factors frame this model to present relevant concerns the United States Department of Health & Human Services has regarding excessive drinking. This model represent (but not limited to) the HHS focus of study among excessive drinking in adolescents between the ages of 12-20 who have reported drinking in the past month. Race Ethnicity - The fastest growing ethnic groups regarding excessive alcohol consumption in U.S is Whites and Asian American, respectfully. African Americans and Latinos have the lowest rate of monthly and heavy drinking. Among gender in adolescence men are more likely to drink than women and consume more alcohol overall.
Society has left an invisible impact on how we perceive the college lifestyle as a whole. This ranges from the belief that all students are sleep deprived from staying up too late to finish their homework. Also the sociological acceptance that college is the place to party and drink every single weekend. Theirs a sociological point of view and how society has played a key part in underage drinking being accepted in college towns. Not just limited to the effects of alcohol on a student’s wellbeing; also, the short term and long term conditions that can arise from binge drinking.
The patient is a 53 year old male who presented to the ED via EMS intoxicated and reporting suicidal thoughts. The patient denies homicidal ideations and symptoms of psychosis. The patient endorses depressive symptoms including: tearfulness, isolation, and insomnia. During the time of the assessment the patient is awake, alert, cooperative, and clam. the patient reports that he had been drinking to 2 pints of alcohol earlier during the day.
Smith informed staff the reason of herself referral for service is due to her rape incident when she hooked up with a guy she met at the bar where she was going to buy crack. Another reason Client is seeking for service is due to her daughter safety and protecting her daughter from the child’s father. Client report that she began drinking several times a week around the age of 13. She stated she started drinking heavily, when she felt depressed and that is an everyday situation. Jessica drinking became progressively worse over the years and she did not notice it was a problem until after she began using crack.
ALCOHOLISM How many times have you heard about the consequences of alcoholism? Have you taken them into account? Alcoholism is one of the major problems in society. People don’t take it so seriously but it actually is a disease. The effects of this disease are really serious.