Substance-Use and Anxiety Presentations

This assignment focuses on vignette analysis and direct application of course concepts to the persons and situations presented in the vignette for each question.
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.
There are two cases: Larry and Sharon. Each case should be approx. 3.5 pages with 6 references each
The entire assignment should be 7 pages total plus a title and reference pages
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 in which he also suffered a head injury. 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 disclosed experiences which indicate he has likely developed tolerance to the substance including that he still uses 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 confused, disoriented, 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. Larry recalls them saying that he was deemed simply “not ready for treatment.”
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, confused regarding his surroundings, 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” might be or 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-use disorder, an undiagnosed co-occurring psychotic disorder, or an undiagnosed cognitive disability. How would you work with Larry to ascertain the appropriate diagnosis?
2. How would you use the clinical interview questions outlined below to solidify your diagnosis.
a. referral source
b. primary presenting problem(s)
c. History of substance use disorder and any past treatments
d. Current substance use (frequency, amount, administration)
e. History of psychiatric disorder or symptoms and any past treatment(s)
f. Current psychiatric symptoms
g. History of /current suicidal ideation, intent, plan, or acts
h. History of /current homicidal (harm to others) ideation, intent, plan, or acts
i. Living arrangements
j. Marital/relationship status
k. Any children (if applicable)
l. Family of origin history
m. School and work history
n. Mental status
o. Insight and judgement
3. How would you clinically work with the psychotic symptom(s) if substance-induced? If co-occurring psychotic disorder? If psychotic disorder due to another medical condition?
4. Using ASAM Criteria (2013) Levels of Care what would be the appropriate level of care for Larry? Consider medical issues (HIV/AIDS, Hepatitis C, brain injury), risk assessment, trauma, and violence potential.
ASAM Criteria (2013) Levels of Care: https://americanaddictioncenters(dot)org/rehab-guide/asam-criteria-levels-of-care
5. Given that Larry is a 51-year-old African American man, provide a brief discussion of legal and ethical considerations.
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. Although she survived, she lost her vision in one eye and suffers from chronic back pain. 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. She claims her back pain is unbearable. Sharon was referred to counseling due to an increased presentation of anxiety. Her children and friends noticed that Sharon was more anxious, appeared “jittery,” “hypervigilant,” and more “worried” than usual. The counselor referred her to a psychiatrist who prescribed anti-anxiety medication; and to a pain management doctor who prescribed narcotic pain medication. Unfortunately, ageism and stereotypes led both these professionals to ignore the potential of any alcohol or substance use.
Anxiety Presentation History
Sharon reported feeling “on-edge” all the time. She recalled one recent incident where she was playing cards with some friends and “the room just started spinning.” She stated 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’s psychiatrist 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. Sharon continues to drink alcohol and take both her anxiety and pain medications.
Alcohol Use History
Sharon was never “much of a drinker,” but in the years following the death of her husband she started to drink 1–2 glasses of wine per day. Slowly, Sharon increased to 3–5 glasses of wine per day, noting how it helped her fall asleep. Sharon denied drinking to cope with anxiety or pain. 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. She also reports increased blurriness in her good eye. Her family is oblivious to her drinking, but is very concerned about these other symptoms, coupled with her anxiety and the apparent ineffectiveness of the Xanax to treat the anxiety. They are also concerned about Sharon’s safety when driving.
Please respond to the following questions:
1. How does Sharon’s cross-tolerance issues impact the prescribed benzodiazepine and pain medications?
2. In consideration of her medical issues, older adult treatment issues, and grief and trauma-related issues, what would be some key concepts in the assessment and treatment planning for Sharon’s alcohol use, mood swings, memory loss, sleep difficulties, disabilities and difficulties with decision-making?
3. Building off of the content in question #2, what level of care do you recommend and why (Use Quadrant of Care Model)?
4. How would you use motivational interviewing and cognitive-behavioral therapy in your treatment of Sharon? What other modalities might you recommend for Sharon? Use Dialectical behavioral Therapy (DBT) and Family Systems Therapy
5. Given that Sharon is a 82-year-old Chinese American widow, provide a brief discussion of legal and ethical considerations.