Case study on dual diagnosis and complex needs

The following assignment is formulated on partial information extracted from a case analysis; the client is a 26-year-old female who has extensive history of illicit substance use since her early teenage years. I will be describing how I would proceed with specific interventions to gain further information and to assist the clients’ safe engagement with a tier 4 treatment provider. The client was referred to us from a General Practitioner which would fall into the Tier 1 category as outlined by the National Treatment Agency for substance misuse .

With the clients arrival at our facility she would engage with a screening or gatekeeping process to attain her suitability and our available resources to manage and contain her presenting problems. Clearly, with her previous history of self-harm, and her stated fear of not being able to resist her impulsive urges to stick needles in her eyes, a comprehensive risk assessment will be taken. The objective of this risk assessment would also be a collaborative management plan; the responsibility to implement its agreed contents would be the clients and that of our agencies staff members. If adhered to this would prevent any manifestation of self-harming or aggressive behaviour. On arrival at our facility, a portion of the induction is for the client to have full medical assessment with our General Practitioner. The object would be to review the prescribing of any current medication the client may have or to prescribe additional medical interventions. As this client could have coexisting mental health issues these appointments would be on going throughout her treatment duration. A sample of breath and urine are tested to provide information of any possible lingering substances in her system, records of the results are recorded and stored according to Data Protection Act .

As the client is in her second day at our facility, her assigned drug and alcohol worker would now take a comprehensive assessment . This assessment would be of a semi-structured format to attain further information about the client in specific areas. Additional information gained would contribute to informing the initial treatment care plan. The semi-structured process would also allow the client to speak with an amount of freedom introducing her own emphasis and priorities. During this stage of the assessment process additional tools can be used which could include the Leeds dependency questionnaire (see appendix 1).

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With the client’s consent, I would gain further information from other agencies that she has used, in this case it would be the psychiatric hospital where she recently finished an opiate detox. In addition, I would contact the clients General Practitioner and possibly her parents. Before any information is shared it is likely that the agency providing the information would require written consent from the client .

In reaching a potential diagnosis for the young woman in the case analysis, some further investigation would be required to make a fully informed conclusion. Making a judgement in the real workplace setting with limited information would of course be malpractice. For the purpose of the assignment with partial information known, I will attempt to arrive at several diagnoses and give a rationale why I have reached my decisions.

The client presents a history of illicit drug use since her early teenage years; she has used Cannabis, alcohol, amphetamines, Methylenedioxymethamphetamine. More recently, she has used crack Cocaine and heroin, offering that she has experienced several unsuccessful attempts at cessation the latter substances. The client presents because of her illicit drug use she has been out of work three times, for more than several months. Before entering our facility, she successfully completed an unknown opiate detoxification regime in the local psychiatric hospital. At this point, I have to ask myself a question, Opioid abuse or Opioid dependence? As there are not specific criteria for Opioids, clinicians are encouraged to use that of substance abuse and dependence which are believed to apply to all psychoactive agents . Considering her opiate use is more recent; according to the American Psychiatric Association she is already displaying two of the necessary criteria for substance abuse as outlined below, (see appendix 2 for full criteria)

Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use. Substance-related absences, suspensions, or expulsions from school; neglect of children or household).

Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g. Arguments with spouse about consequences of intoxication, physical fights).

This diagnosis would fall into the category of psychoactive substance use disorder (axis 1).

Supporting information would strongly indicate that this particular client has some form of coexisting mental health issue which onset during adolescence at a similar age of her initial substance use. Taking into account that her substance use and behavioural & emotional problems appear to be entirely independent entities yet occur concurrently, with no real influence on one another takes me a step closer to a diagnosis. Considering the clients presenting behaviours of,

Poor attachments

interpersonal relationship struggles

impulsive behaviour

substance use

aggressive reactions

recurrent suicidal behavioural gestures

Efforts to avoid real or imagined abandonment.

The client presents the necessary five required criteria for Borderline Personality Disorder, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (see appendix 3). All of her criteria are classified as dramatic, emotional or erratic which falls into Cluster B of Common Mental Disorders (Axis II). Another factor that could inform my decision would be that 75% of diagnosed cases are in females .

Appendix 1

Leeds Dependency Questionnaire

(Raistrick, Bradshaw, Tober, Weiner, Allison, & Healy; 1994)

Here are questions about the importance of alcohol and/or other drugs in your

life. Think about your drinking/other drug use in the last two weeks and answer each question by ticking the closest answer to how you see yourself.

Never

Sometimes

Often

Nearly always

1. Do you find yourself thinking about when you will next be able to have another drink (drug)?

0

1

2

3

2. Is drinking (drug use) more important to you than anything else you might do during the day?

0

1

2

3

3. Do you feel your need for drink (the drug) is too strong to control?

0

1

2

3

4. Do you plan your days around getting alcohol (the drug) and drinking (using the drug)?

0

1

2

3

5. Do you drink (use the drug) in a particular way in order to increase the effect it gives you?

0

1

2

3

6. Do you drink (use the drug) morning, afternoon and evening?

0

1

2

3

7. Do you feel you have to carry on drinking (drug use) once you have started?

0

1

2

3

8. Is getting the effect you want more important than the particular drink (drug) you use?

0

1

2

3

9. Do you want to drink (use the drug) more when the effect starts to wear off?

0

1

2

3

10. Do you find it difficult to cope with life without alcohol (drugs)?

0

1

2

3

To find out your score, simply add up the numbers from each of your answers.

Interpretation

Total LDQ score

0 No dependence

1-10 Low to moderate dependence

11-20 Moderate to high dependence

21-30 High dependence

This score is to be used as a guide to your level of dependence over the two weeks or so. It does not indicate whether your consumption is at risky levels or the extent of other alcohol or drug use related problems.

Appendix 2

Criteria for Substance Abuse

A maladaptive pattern of substance use leading to clinically significant impairment

or distress, as manifested by one (or more) of the following, occurring within a 12-

month period:

(1) Recurrent substance use resulting in a failure to fulfil major role obligations at

work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences. suspensions, or expulsions

from school; neglect of children or household)

(2) Recurrent substance use in situations in which it is physically hazardous (e.g

driving an automobile or operating a machine when impaired by substance use)

(3) Recurrent substance-related legal problems (e.g., arrests for substance related

disorderly conduct)

(4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g

arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Taken from DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. (4th Rev ed.)(1990). Diagnostic criteria for Substance abuse.