Case Analysis of Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Substance Abuse Nicole Gapp University of Minnesota School of Nursing Case Analysis of Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Substance Abuse Major Depressive Disorder (MDD) is a mood disorder with symptoms that greatly affect the life of the individual. MDD could in fact be called a public health crisis, as it is projected that it will soon overtake heart diseases as the major worldwide health concern (Boyd, 2008).
Diagnostic criteria for MDD are depressed mood or loss of interest or pleasure in nearly all activities, present for at least 2 weeks. Findings and behaviors associated with MDD are disruption of sleep, suicidal ideation, feelings of worthlessness and hopelessness, and fatigue and loss of energy. MDD is also associated with a high impairment in occupational, social, and physical functioning, causing as much disability and distress as chronic medical disorders (United States Department of Health and Human Services, 1999).
MDD has been shown to be associated with increased medical illnesses. MDD can make everyday living a challenge, as research shows that depressive symptoms are associated with impaired everyday problem-solving ability directly and indirectly mediated through learning and memory, and reasoning (Yen, Rebok, Gallo, Jones, & Tennstedt, 2011). It is important for MDD to be identified and treated early on, as MDD that is not treated appropriately results in recurrent depressive episodes, with each successive episode increasing in severity.
As MDD is highly associated with suicidal ideation and suicide, it is imperative that MDD be treated to ensure patient safety. Risk factors for MDD are a prior episode of depression, lack of social support, lack of coping abilities, medical comorbidity, substance use, and presence of life and environmental stressors. In addition, major depression may follow adverse or traumatic life events, especially those that involve the loss of an important human relationship or role in life. Social isolation, deprivation, and financial deprivation are also risk factors (APA, 2002).
Genetics play a role in the development of MDD, and deficiency or dysregulation of neurotransmitters are also thought to play a part in its etiology. Psychological theories of MDD hypothesize that an early lack of love and warmth may be involved with the development of depressive symptoms, while developmental and family theorists have proposed that parental loss, emotionally inadequate parenting styles, or maladaptive patterns in family interaction may contribute to the etiology of MDD.
Women are twice as likely as men to be diagnosed with MDD, though it is believed that the incidence in men is under-diagnosed. Prevalence rates are unrelated to race (Boyd, 2008). Nursing responses to MDD should involve interventions to treat symptoms within the biologic domain, such as changes in appetite, weight, sleep, or energy, as well as symptoms within the psychological domain, such as changes in mood and affect, thought content, suicidal behavior, and cognition and memory. Many types of interventions are used to treat the varied effects and symptoms of MDD.
Pharmacologic interventions, such as selective serotonin reuptake inhibitors, tricylic antidepressants, monoamine oxidase inhibitors, and other classes of antidepressants may be used to decrease or manage depressive symptoms. Medication should be continued for at least six months to a year after complete remission of depressive symptoms. Lifestyle patterns, such as good sleep hygiene, activity and exercise, and adequate intake of well-balanced meals should also be encouraged, as these patterns help the client move toward a healthy daily routine that supports remission or recovery.
Psychotherapy, such as cognitive therapy, behavior therapy, and interpersonal therapy, has been shown to be effective in individuals with MDD, and a combination of psychotherapy and pharmacotherapy is recommended for patients with severe or recurrent MDD as a strategy to prevent relapse (Boyd, 2008). In addition, electroconvulsive therapy has been shown to be an effective treatment for MDD, especially severe MDD that has not responded to medications. Major depression frequently occurs in conjunction with ther psychiatric disorders, such as anxiety or substance use disorders, which can also affect antidepressant responsiveness. In such cases, the co-occurring mental health problem should be treated in addition to major depression (President and Fellows of Harvard College, 2011). The patient described in this case analysis has comorbid diagnoses of generalized anxiety disorder and substance abuse. Generalized Anxiety Disorder is a psychiatric disorder characterized by excessive worry and anxiety with an insidious onset.
The anxiety of GAD persists for at least six months, with excessive anxiety and worry occurring for more days than not, and for some individuals, persisting daily. Risk factors for GAD are thought to be unresolved conflicts, cognitive misinterpretations, and multiple stressful life events (Boyd, 2008)). Few studies have examined the genetic basis of GAD, but it is thought to be moderately heritable. In clinical settings, the incidence of GAD is equally distributed in women and men. However, in wider studies GAD is twice as common in women.
In no studies has the prevalence of GAD been related to race (Boyd, 2008). Patients with GAD often have associated depressive symptoms, and MDD is a common comorbid disorder. For this reason, there has been debate surrounding whether GAD is a separate disorder than MDD, or if GAD symptoms are part of the course of MDD. However, research shows that many patients with GAD do not present with a distinct MDD symptom profile. This does not support the hypothesis that co-morbidity between MDD and GAD is artificially inflated because of the similar symptom criteria required by the current diagnostic system.
Instead, MDE and GAD may be thought of as two distinct diagnostic entities that frequently co-occur because of a shared underlying trait (Sunderland, Mewton, Slade & Baillie, 2010). Current diagnostic criteria state that GAD exists when the excessive worry does not occur exclusively during a mood disorder, psychotic disorder, or pervasive developmental disorder. For example, a patient who experiences persistent excessive anxiety but has minimal or no depressive symptoms would be diagnosed with GAD (Boyd, 2008). However, research has shown that the presence of a comorbid anxiety disorder may make MDD harder to resolve or manage.
One particular study comparing individuals with MDD and individuals with MDD and a comorbid anxiety disorder showed that after adjusting for the severity of depression, those in the anxious depression group had significantly younger onset age, had been suffering from depression for a longer period, were more likely to experience a recurrence, and obtained lower scores on a scale assessing quality of life. The anxious depression group was also characterized by a significantly higher proportion of individuals reporting significant suicidal ideation and previous suicide attempts (Seo, Jung, Kim, T. , Kim, J. Lee, Kim, J. & Jun, 2011). Patients with GAD are often highly somatic, with many complaints of physical symptoms. One study concluded that painful physical symptoms in patients with GAD are twice as prevalent as in the control group, which consisted of individuals with neither GAD nor MDD. The presence of comorbid MDD was associated with a significantly higher prevalence of painful physical symptoms. Painful physical symptoms were significantly associated with functioning and health status impairment both in GAD alone and in GAD and comorbid MDD compared with controls (Romera, Fernandez, Perez, Montejo, Caballero, F. Caballero, L. , Arbesu & Gilaberte, 2010). In addition, those with GAD also often experience poor sleep habits, irritability, and poor concentration. Patients with GAD often feel frustrated, demoralized, and hopeless. They often feel restless and on edge and experience clinically significant distress or impairment of functioning resulting from anxiety, worry, or physical symptoms. GAD has a significant negative impact on work functioning, although smaller than the effect of MDD (Plaisier, Beekman, de Graaf, Smit, van Dyck & Penninx, 2010).
Interventions addressing symptoms of the biologic domain include eliminating caffeine, diet pills, amphetamines, ginseng, and ma huang, which have all been shown to be anxiety-producing substances (Boyd, 2008). In addition, good sleep hygiene should be promoted, as a common symptom of GAD is sleep disturbances. The nurse should teach the patient breathing control and progressive muscle relaxation as calming techniques, help the patient identify other positive coping strategies, and educate the patient on time management.
Pharmacological interventions, such as the use of benzodiazepines, certain antidepressants, and other non-benzodiazepine anxiolytics may be effective in reducing anxiety. Roughly 75% of those with GAD have at least one additional current or lifetime psychiatric diagnosis, with MDD being one of the more common comorbidities. Alcoholism is also a significant problem associated with GAD. Patients may use alcohol, anxiolytics or barbiturates to relieve anxiety, and this may lead to abuse and dependency. Such is the case of the patient described in the case analysis, who also has a substance-related disorder.
The DSM-IV-TR defines substance abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress. This impairment may be manifested by recurrent use, resulting in failure to fulfill major role obligations at work or home, recurrent use in situations that are physically hazardous, recurrent substance related legal problems, or continued use despite feeling persistent or recurrent effects of the substance. To constitute substance abuse, three or more of these manifestations must be present within a 12-month period.
In general, men consume more alcohol and abuse drugs more than women, though women are more likely to abuse prescription medication. Substance abuse and dependency are not correlated so much with gender as with an early age of initiation of substance use (Boyd, 2008). Comorbid mental disorders occur often with substance dependence and abuse. For some, comorbid mental disorders are byproducts of long-term substance abuse. Other people have mental conditions that predispose them to substance abuse, with substance abuse becoming a comorbid problem as they use drugs and/or alcohol to self-medicate existing mental illnesses.
There is a well-documented association between depression and alcohol abuse and dependence which cannot be explained solely by the random overlapping of these two conditions. A systematic review of 35 studies estimated the prevalence of current alcohol problems in depressed patients to be 16%, as compared to 7% in the general population. The three most commonly described causal hypotheses for this comorbidity are as follows: 1) an independent depressive episode (e. g. he self-medication theory), 2) alcohol induced depressive symptoms and 3) the existence of shared biological and environmental factors that predispose persons to both (Cohn, Epstein, McCrady, Jensen, HunterReel, Green & Drapkin, 2011). In addition, men with at least four heavy drinking occasions were found to be 2. 6 times as likely to be classified as being depressed as men who drank heavily less than four times in the previous 28 days (Levola, Holopainen & Aalto, 2011). Specific substances that have been abused by the patient who is the subject of this analysis are alcohol, cocaine, heroin, and the prescription drugs oxycodone and Valium.
At the time of admission, the patient was no longer regularly using drugs or alcohol, but his history of substance abuse, including overdose, is extensive. Thus, although the patient is already withdrawn from drugs and alcohol, his long-term substance use has significant physical and mental consequences. The depression of the central nervous system by alcohol causes relaxed inhibitions, heightened emotions, mood swings, and cognitive impairments such as reduced concentration and attention, and impaired judgment and memory. In particular, this patient engages in periodic binge drinking, drinking up to 15 drinks in one evening.
This alcohol use would result in several days of intoxication, which were interspersed with periods of sobriety. The amount of alcohol consumed in an episode of binge drinking can cause severely impaired motor function and coordination difficulties, emotional lability, stupor, disorientation, and in extreme cases, even coma, respiratory failure, or death. Long-term abuse of alcohol can adversely affect all body systems, and research has shown a connection between alcohol dependence and increased risk for diabetes mellitus, gastrointestinal problems, hypertension, liver disease, and stroke (Smith & Book, 2010).
Cocaine users typically report that cocaine enhances their feelings of well-being and reduces their anxiety. However, long-term cocaine use leads to increased anxiety. Severe anxiety, restlessness, and agitation are all symptoms or cocaine withdrawal. Withdrawal causes intense depression, craving, and drug seeking behavior that may last for weeks (Boyd, 2008). Valium, a benzodiazepine, is a prescription drug that this patient abused. Patients who abuse benzodiazepines often feel hyperactive or anxious after using them.
Often, patients who abuse these drugs combine them with alcohol, putting the patient at risk of coma or death. Symptoms during benzodiazepine withdrawal include anxiety rebound, such as tension, agitation, tremulousness and insomnia, as well as symptoms of autonomic rebound, sensory excitement, motor excitation, and cognitive excitation, such as nightmares and hallucinations (Boyd, 2008). Opiates are powerful drugs that can quickly trigger addiction when used improperly. Heroin is an opiate that was abused by this patient.
Heroin is the most abused and most rapidly acting of all opiates. It can be injected intravenously, and such was the method of delivery for this patient. Heroin produces profound degrees of tolerance and physical dependence. Withdrawal from opiates should be tapered, and if abruptly withdrawn from someone dependent on them, severe physical symptoms may occur, along with nervousness, restlessness and irritability (Boyd, 2008). In addition to heroin use, the patient attempted to commit suicide by overdosing on oxycodone, a prescription opiate.
Overcoming substance abuse and preventing relapse can be especially difficult as denial is common in substance abusing patients. Denial is defined as the patient’s inability to accept his loss of control over substance use, or to accept the consequences associated with the substance use (Boyd, 2008). Because many patients find it difficult or impossible to believe they have a serious problem with drugs and alcohol, many do not seek treatment, or stop treatment prematurely. Motivation is a key predictor of whether individuals will change their substance abuse behavior.
Several effective modalities are used effectively to treat addiction, such as 12-step programs, social skills groups, psychoeducational groups, group therapy, and individual and family therapies. Depending on the individual, different treatment techniques will be more or less helpful. History of Present Illness The patient is a 58-year-old Caucasian male who was participating in a partial hospitalization program (PHP) at Hennepin County Medical Center (HCMC) for the treatment of severe major depressive disorder. He has been involved in PHP since his last discharge from the HCMC psychiatric inpatient unit in early March.
The patient was cooperative with treatment and medication compliant. He was put on a 72-hour hold after becoming angry and hostile during the PHP group and threatening to hang himself that evening when he got home from PHP. He eventually committed himself voluntarily to the HCMC psychiatric inpatient unit. Upon introduction, the patient appears to be clean, casually dressed, and of normal weight. He is alert and oriented. His attention, cognition, and abstract reasoning are intact, and his thought content is appropriate and organized.
In conversation, he is pleasant and cooperative, exhibiting a stable mood and a slightly blunted affect. The patient will talk to staff members but interacts minimally with peers and does not attend groups unless encouraged by staff. The patient has a normal gait but moves quite slowly. In addition it appears that his thought processes are slowed, as he is slow to respond during conversation and seems to have difficulty finding the words to express what he wants to say. The patient appears to have intact recall, short-term, and long-term memory.
He appears to be an adequate historian though he exhibits poor judgment due to his depressive and anxious symptoms, as evidenced by his extensive history of drug and alcohol abuse and dependency. The patient has psychiatric diagnoses of severe and recurrent major depressive disorder, generalized anxiety disorder, and polysubstance abuse. The patient has been suffering from MDD with chronic suicidal ideation since age 15. His first suicide attempt was at age 15, and he began abusing drugs and alcohol at approximately the same time.
His extensive history of substance abuse includes use of alcohol, cocaine, and IV heroin. His alcohol abuse as a teenager led to a DWI charge. He has participated in mental health outpatient treatment and has undergone chemical dependency treatment numerous times. He completed high school without apparent difficulty. The patient seems to be of average intelligence, though his IQ is not listed in the record. He does not have a history of violent or sexual crime. He has a history of five suicide attempts. He began smoking as a teenager and currently smokes one pack of cigarettes per day.
In 1983, the patient married and remained so until his wife died 25 years later, in 2008. He had no children. According to the patient, he was happily married, and he called his relationship with his wife “the best thing that has ever and will ever happen to me. ” While he was married, he got completely clean from drugs and alcohol, remaining drug free and sober for 12 years. Though he struggled with episodes of depression and suicidal ideation, he was able to manage his symptoms with medication and mental health outpatient treatment. Most of my problems faded into the background,” said the patient. During this time, he and his wife bought a condo, and the patient was employed as a janitor and handyman, working at the Minneapolis-Saint Paul airport. He remained at this job for over a decade and was promoted to the position of supervisor. He had, as he said “everything I ever wanted. ” In 2007, his wife became very ill and eventually died in 2008 after complications from a surgery intended to prolong her life. The patient reports that as his wife got sicker, he became increasingly depressed.
Unlike in the previous 12 years, medication and outpatient treatment did not seem to manage his symptoms. In addition, he started experiencing extreme and persistent anxiety, feeling “like I was always one second away from a panic attack. ” He was diagnosed with generalized anxiety disorder and was prescribed benzodiazepines to manage this condition. As his wife got sicker, he slowly began to self medicate with alcohol and admitted to “popping an extra pill” occasionally to decrease his anxiety.
When his wife died, the patient became so depressed and anxious that he was unable to concentrate at work. He had to give up his job as a supervisor, and said, “I couldn’t even manage myself, how was I supposed to handle anyone else. ” As his depression and anxiety got worse, he turned increasingly to alcohol and drugs. He reported binge drinking, consuming up to 20 drinks in one evening. He would remain intoxicated for several days, and would switch to using drugs as the alcohol cleared his system. He reported being either drunk, high, or both almost every day.
Although he used cocaine and heroine, which were the drugs he used as a teenager, he also became dependent on prescription benzodiazepines to manage his increasingly severe anxiety. The increase in anxiety may be explained by his cocaine use, which, though it reduces anxiety while high, causes increased anxiety with long term use. Additionally, though proper use of benzodiazepines decreases anxiety, benzodiazepine abuse or dependency results in increased anxiety levels. When his request for more prescription benzodiazepines was denied due to drug seeking behavior, he gained possession of Valium illegally and continued abusing them.
He was arrested for illegal Valium possession in 2009, and received two DWIs between 2008 and 2011. His medical record notes that he has a history of antisocial behavior, though it does not expand on this statement beyond the mention of his previous arrests. With no income coming in and increasing amounts of money used to fuel his drug and alcohol addiction, he lost his condo and all of his savings and was living at the Salvation Army homeless shelter by June 2008. His depression grew in severity as the major life losses piled up and his substance dependency problem worsened.
In 2008, he lost consciousness due to heroin intoxication. In August of that year, the patient overdosed on oxycodone, intending to kill himself. He was brought to HCMC, and for the past several years has experienced being in and out of the psychiatric inpatient. In 2010, he moved from the homeless shelter to Alternative Homes in Minneapolis. Following his latest psychiatric hospitalization in March, he began the partial hospitalization program at HCMC. Upon discharge from the current hospitalization, he will be returning o Alternative Homes and participating again in the PHP program. A common finding associated with a diagnosis of either MDD, GAD, or substance abuse is the presence of sleep disturbances. Such is the case with the patient described. These sleep disturbances may present themselves as difficulty falling asleep, trouble maintaining sleep, or waking up too early (National Insititute of Health, 2005). This patient currently experiences insomnia, getting only 3-4 hours of sleep per night. Reportedly, this insomnia has been a chronic issue.
The insomnia the patient experience sets him up for a negative cycle. Because of his depression and anxiety, it is difficult for the patient to sleep. This lack of sleep, in turn, exacerbates his anxiety and depressive symptoms. As his symptoms progress in severity, he turns to substances to self medicate. The use of substances results in a worsening of his insomnia. Thus, finding a way for the patient to get adequate sleep is important. He has tried a variety of medications to promote sleep, but none have been effective.
He can no longer be prescribed many of the medications for insomnia because of his history of abuse and overdose using prescription drugs. Thus, the options available to him for sleep promotion lie in the realm of sleep hygiene promotion. The patient might also consider participating in a sleep study, as this may reveal additional factors that prevent him from getting the sleep he needs. In addition to his mental illnesses, the patient also has significant medical problems. He has been diagnosed with hypertension, hepatitis C, diabetes mellitus, osteoarthritis of the left shoulder, and acid reflux.
Research shows that diabetes mellitus, gastrointestinal problems, hypertension, liver disease are correlated with substance abuse (Moffitt, Caspi, Harrington, Milne, Melchior, Goldberg & Poulton, 2010). Indeed, the patient’s hepatitis C is a direct consequence from his use of street drugs. Interestingly, multiple studies have revealed that not only are depressive symptoms a risk factor for the development of type 2 diabetes, but they have also been shown to contribute to hyperglycemia, diabetic complications, functional disability and mortality among diabetic patients (Moffitt et al. 2010). Also, as previously discussed, patients with GAD and MDD report more painful physical symptoms than the general population, and the patient’s osteoarthritis pain could well be exacerbated by the presence of these psychiatric conditions. Thus, it is possible that with improved management of his psychiatric conditions, his medical problems may improve as well. Family and Social History The patient’s social and family history is somewhat lacking. The patient was adopted at a young age.
He has three non-biological brothers and he reports that he is estranged from all of them, and is not willing to contact them until he has “my life back together. ” In addition, both of his adoptive parents are dead. The patient was not keen on discussing his adoptive family or his childhood and adolescence, but stated that this adoptive family “were good people, and tried hard to give me everything I needed. ” He denies any history of physical, emotional, or sexual abuse. According to the social history, there is no history of mental illness in his adoptive family.
This does not mean that environmental or social factors play no role in the etiology of his mental illness, but that these factors may be less obvious. Information on the patient’s biological mother and family history is unavailable. The patient was given up for adoption at birth, and remained a ward of the state, living in various foster homes, until he was adopted at age 3. As the patient was given up for adoption and adopted at such a young age, he has he has no recollection of his biological family or his time in the foster care system.
Any instances of abuse, neglect, or trauma in his early years are thus unknown. Because there is no available family history, it is impossible to know if any of the patient’s first-degree relatives suffered from mental illnesses, or if the biological mother used drugs or alcohol during her pregnancy. This lack of information is unfortunate, as it is impossible to conjecture whether, or to what degree, the patient’s mental disorders have a basis in genetics or in disturbed fetal development.
Because MDD, GAD, and substance abuse have all been shown to have a moderate to high degree, of heritability, it is very plausible that mood, anxiety, or substance related disorders were present in his biological family. The patient seems to have very limited social support, as he is estranged from his adoptive siblings and has no communication with his biological family. The patient also has a history of limited social interactions and close friendships. He reports that he has felt disconnected from others for as long as he remembers, and that he had few close friendships throughout his childhood, adolescence, and adulthood.
In addition, the patient reports that most of the relationships that he would call the closest have been with people who have substance abuse problems, as he spent “years and years running with the wrong crowd. ” The basis of most of these relationships was a shared interest in drug and alcohol use, and he does not think that these friends would be of any support to him in pursuing and maintaining recovery. During the time that he was sober, he states that his wife was “the only friend I really needed” and as a result, he did not form many close friendships with his peers.
He states that he currently has no supportive relationships. Furthermore, he has little desire to form such relationships. Application of Developmental Theories Viewing the patient and his family and social history through the lens of attachment theory provides a possible framework for viewing the patient’s development of mental illnesses. Attachment theory, a biologically based framework first proposed by John Bowlby in the mid 1950s, is the theoretical approach used to describe the importance of stable and secure relationships of all infants, especially those in foster care (Bruskas, 2010).
This theoretical approach reasons that infants and children have a need to belong and to experience secure relationships with a small number of consistent “preferred” primary caregivers in order to successfully develop into normal healthy adults who can actively and emotionally participate in social life (Boyd, 2008). In particular, a child should receive the continuous care of this single most important attachment figure for approximately the first two years of life.
If the attachment figure is broken or disrupted during the critical two year period the child will suffer irreversible long-term consequences of this deprivation, which might include delinquency, reduced intelligence, increased aggression, depression, and affectionless psychopathy–an inabilityto show affection or concern for others. Research, such as the Adverse Childhood Experiences Study, correlates untreated childhood adversity with an increased risk toward poor developmental health and other major diseases seen later in life such as cardiac disease, depression, and even premature death (Felitti & Anda, 2010).
Studies reveal that infants in foster care are among the most vulnerable because of their complex and immense brain development, and the importance of attaining developmental milestones. The onset of brain development begins soon after conception and will continue to mature well into adulthood, but the most abundant and dramatic time of growth is during the first few years of life, specifically within the first three years. The primary and most important developmental milestone for any infant is to establish a relationship, especially one with a primary caregiver.
This period presents sensitive “windows of opportunity” for the development of particular parts of brain structure and circuitry influenced and dependent on social experiences for optimal brain development (Bruskas, 2010). The majority of children entering foster care are infants, and the impact of not addressing mental health needs of preverbal children can have deleterious effects (National Research Council Committee on Integrating the Science of Early Childhood Development, 2000).
Although an infant may not be able to articulate losses because of their preverbal age, they nonetheless experience grief and loss, and for many, these experiences will be forever embedded in their memory (Felitti & Anda, 2010). Moreover, the consequences of unresolved losses have a much more devastating affect in infancy than adulthood because of the potentially permanent psychological impact on the developing brain of an infant or child (Bruskas, 2010).
Infants and children in foster care who are not afforded supportive primary caregivers to help them develop an internal ability to regulate their own will continue to use whatever coping methods they can. Under stress-provoking adversities such as abuse, neglect, and relationship disruptions, children’s coping strategies to manage such circumstances may present as hostility, frustration, and anxiety with underlying feelings of fear, abandonment, and powerlessness (Bruskas, 2010).
The relationships infants and children develop while in foster care are crucial; relationships characterized by trust and commitment help an infant or child become more resilient toward the challenges and obstacles that all humans face in life; conversely, a lack of such relationships in life can result in long-term dysfunction socially and physically. Attachments and “templates” of the world are significantly developed by the time a child reaches a year old (Bruskas, 2010).
Efforts to address behavioral problems later in life may prove to be more difficult and costly as brain structure becomes permanent and behavior becomes more difficult to change. Due to the patient’s experience of foster care as an infant and toddler, it is likely that he was unable to form a secure attachment with a primary caregiver. Although this disruption in attachment is not the sole contributor to his problems with depression, anxiety, and substance abuse, it is very possible that the chaotic structure of his early years play a large role in the development of these conditions.
Applying the concepts of Erikson’s model of psychosocial development allow for a greater understanding of the patient’s current state. Because of the disruption of relationships early in life, the patient may not ever have resolved the developmental conflict of basic trust vs. mistrust, which is often resolved in infancy. This may be one reason behind his feeling of disconnectedness from others. According to Erikson, this inability to resolve this developmental conflict results in a decreased sense of drive and hope. It is also likely that the patient was able to resolve the developmental conflict of autonomy vs. hame and doubt, which is often resolved in toddlerhood (Boyd, 2008). This may explain the patient’s reliance on his wife as the sole supportive relationship in his life, as well as his fast descent into previous behaviors after his wife’s death. As the patient was never able to develop a sense of autonomy, it seems that he became extremely emotionally dependent on his wife. Because of this relationship, he was able to progress at his job and maintain his recovery. However, with the death of his wife, he was brought back to the conflict of autonomy vs. shame and doubt.
Really, it was through the presence of his wife that he was able to take initiative, be industrious, and have an intimate relationship, all of which are successful outcomes of developmental conflicts. The marriage provided him with hope, purpose, a sense of devotion and fidelity, as well as affiliation and love. In short, it seems that his wife was his mental and emotional anchor. The recurrence of symptoms of his mental disorders after the loss of the anchor of his life threw him back into the early developmental conflicts that he was unable to resolve due to his unstable childhood.
According to Erikson, in order for the patient to move forward from his regressed state he must tackle and resolve the conflicts of trust vs. mistrust, autonomy vs. shame and doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role diffusion, and intimacy vs. , isolation to reach the adulthood stage of generativity vs. stagnation. Ultimately, with the resolution of all these conflict, the patient will reach a mature state in which he is able to attain ego integrity instead of falling into despair. Patient Prognosis and Treatment Recommendations
It is important to remember that the patient was seeking help and trying to recover prior to his most recent hospitalization. He was enrolled in and regularly attending the partial hospitalization program. In addition, he was no longer abusing drugs or alcohol. PHP staff report that he had been medication compliant, cooperative, and was motivated to change. The patient’s recent hospitalization was precipitated by a change in drug dose and type. He reported that it was only after the medication change that the suicidal ideation intensified.
Thus, an important goal for this patient is to find the drug types and dosages that will successfully manage his depression and anxiety. However, because the patient has such an extensive history of addiction, primary care providers are hesitant to prescribe large dosages of often highly addictive medications. This hesitation is especially understandable given the patients past abuse of prescription drugs, including an overdose with the intent to commit suicide. However, the types and dosages of the drugs he is currently receiving are not enough to manage his symptoms.
The severity of the patient’s depression and anxiety necessitates the use of powerful antidepressants and anxiolytics, but his past substance abuse and dependency make the prescription of these drugs a last resort. Appropriate pharmacotherapy is also complicated by the fact that this patient has tried various classes and types of drugs to manage his symptoms, but no drug therapy has been effective enough to prevent the periodic recurrences of major episodes of depression and anxiety.
To manage his depression, the patient has tried typical and atypical antipsychotics, anticonvulsants, tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors, as well as other classes of antidepressants, such as Serotonin Norepinephrine Reuptake inhibitors, Norepinephrine Dopamine Reuptake Inhibitors, Alpha-2 Antagonists, and Serotonin-2 Antagonist/Reuptake Inhibitors. Although the apparent failure of all these drugs to manage his depression might cause one to suspect that he is exhibiting purely drug seeking behaviors, the depressive symptoms he xperiences impair and affect him so severely that a denial of the reality of these symptoms would be unsafe and unethical. Electroconvulsive therapy has been recommended to treat his depression, but the patient has refused to undergo this treatment modality. The patient’s anxiety is more easily managed than his depression, and benzodiazepines have proven effective. However, his past abuse of benzodiazepines make his primary care providers reluctant to give them to him, and they have prescribed non-benzodiazepines, such as Buspar and Zolpidem, instead.
Unfortunately, these medications have not been effective in controlling the patient’s anxiety. As a result, the patient has been asking repeatedly for benzodiazepines, while promising that he will use them responsibly. Ultimately, for the patient to achieve effective maintenance of his comorbid mental disorders, he must be able to take medications as prescribed. Due to his history of substance abuse and his still unstable depression and anxiety, it is unlikely that the patient will be able to take his medications as prescribed.
It is recommended that a staff member have control of his drugs while he is attending the PHP, and that once discharged, a home health nurse be sent to administer his medication. This would reduce the potential for abuse. In addition, the use of coping mechanisms besides substance abuse may help the patient adhere to the prescribed drug regimen, as well as decrease his depression and anxiety. Coping skills the patient has identified as helpful are watching television and spending some quiet time alone.
However, interaction with others should also be encouraged, as too much time spent alone will only reinforce depressive symptoms of isolation. An increase in the quantity and quality of sleep will also aid the patient in his recovery, as sleep deprivation is positively correlated with depressive symptoms and anxiety levels. The patient’s prognosis is one of cautious hopefulness. Though the patient has experienced severe recurrences of MDD, GAD, and substance abuse in recent years, the patient had maintained a long period of sobriety prior to this, during which he was happy, productive, and high functioning.
The patient’s ability to achieve remission from his mental illnesses during his marriage to his wife shows that investing in a supportive relationship is an important and powerful coping skill for this patient. Thus, if the patient is able to form and maintain new supportive relationships, his chance of recovery will improve substantially. It is also important to remember that he was doing very well until his wife died. According to the Holmes and Rahe Index, the death of a spouse is the number one most stressful event that occurs in the life of an individual (Perry & Potter, 2009).
It is not an exaggeration to say that with his wife’s death, life as he knew it ended. Many people experience periods of long and severe depression following the death of a loved one. For this patient, his descent into depression, combined with the resurgence of his anxiety sent his life into a complete tailspin. Under the severe stress of not only his wife’s death but also his inability to keep working, he returned to his former coping mechanisms of drug and alcohol abuse.
These habits detracted him from working through the grief of his wife’s death, and furthermore caused him to lose his house and his savings, thus increasing his depression and anxiety, thus perpetuating the substance abuse. Now that the patient has withdrawn from drugs and alcohol and is in a safe environment, he can continue his grief work. As a result, his depression may begin to subside, and he may be able to get closer to his previous level of functioning. DSM-IV-TR Axis I: Major Depressive Disorder, Generalized Anxiety Disorder, Polysubstance Abuse Axis II: Cluster B traits
Axis III: Hypertension, Hepatitis C, Diabetes Mellitus, Type 2, Osteoarthritis of the left shoulder, Acid Reflux, Bilateral hearing loss Axis IV: Chronic mental illnesses, chronic medical conditions, death of spouse, family estrangement, lack of social support, unemployment, financial insecurity, acute hospitalization, Axis V: 35 (current), 75 (potential) Patient Goals: • I want to find medications that will help my depression and anxiety • I want to keep from abusing my medications • I want my grief over my wife’s death to get better • I want to take one day at a time • I want to feel less alone • I want to get better sleep
Nursing Goal: Patient will be safe during hospital stay. Interventions: • Assess for suicidal ideation every shift. • Perform rounds every 15 minutes to ensure patient safety. • Ensure that the patient has no access to potentially harmful objects and/or substances. • Observe, record, and report any changes in mood or behavior that may signify increasing suicide risk and document results of regular surveillance checks. Nursing Goal: Patient will seek help in dealing with grief-associated problems. Interventions: • Develop a trusting relationship with the client by using empathetic therapeutic communication (Eakes, Burke & Hainsworth, 1998). Educate the client that grief resolution is not a sequential process and that the positive outcome of grief resolution is the integration of the deceased into the ongoing life of the griever (Matthews & Marwit, 2004). • Identify available community resources, including grief counselors and community or Web-based bereavement groups. • Focus on enhancing coping skills to alleviate life problems and distressing symptoms such as anxiety and depression. Nursing Goal: Patient will practice social and communication skills needed to interact with others. Interventions: • Discuss causes of perceived or actual isolation. Assess the patient’s ability and/or inability to meet physical, psychosocial, spiritual, and financial needs and how unmet needs further challenge the ability to be socially integrated. • Use active listening skills to establish trust one on one and then gradually introduce the patient to others. • Provide positive reinforcement when the patient seeks out others. • Encourage the client to be involved in meaningful social relationships and support personal attributes (Gulick, 2001). Nursing Goal: Patient will use effective coping strategies instead of abusing drugs and alcohol.
Interventions: • Assist the client to set realistic goals and identify personal skills and knowledge. • Use verbal and nonverbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client to express emotions such as sadness, guilt, and anger, verbalize fears and concerns, and set goals. • Offer instruction regarding alternative coping strategies (Christie & Moore, 2005). • Encourage use of spiritual resources as desired. Nursing Goal: Patient will identify actions that can be taken to improve quality of sleep.
Interventions: • Obtain a sleep-wake history, including history of sleep problems, changes in sleep with present illness, and use of medications and stimulants. • Encourage the patient to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts. • Encourage the patient to use soothing music to facilitate sleep (Lai & Good, 2005). • Teach the patient sleep hygiene guidelines for improving sleep habits (ie. go to bed only when sleepy, avoid afternoon and evening naps, use the bed only for sleeping, get up at the same time every morning). Use relaxation techniques to decrease anxiety before going to sleep. • Refer to a sleep center if interventions are ineffective. Analysis of Interaction Before interacting with the patient, I read the patient’s medical record and notes. I paid particular attention to ways the patient said he learned best, which for my patient was one on one conversation. Prior to approaching the client, I asked myself if I had any beliefs, biases, or limitations that would affect my interaction with the patient or prevent the formation of a therapeutic relationship.
In order to set the tone of a professional therapeutic relationship, I introduced myself to the client, saying that I was a student nurse and shaking his hand. I made some small talk with him about such topics as sports and the patient’s hobbies in order to show interest in the patient and develop rapport. During this conversation, the patient grew more visibly at ease. His face became less taut, his answers became longer and less forced, and he moved from an erect posture so a somewhat more relaxed position in his chair. The patient spoke slowly and eemed to have difficult finding the words he wanted to use. Such a speech pattern is characteristic of depression, one of the patient’s psychiatric diagnoses. This first conversation was punctuated with the start of morning group. After morning group, I gave the patient some space, as I did not want him to feel overwhelmed or threatened by my questions. About a half hour later, I asked the patient if we could continue the conversation we were having that morning, and he agreed without hesitation. In this second interaction, I began with a few open-ended questions about how group had been.
I then started asking the patient some more questions about his readmission into the hospital and precipitating events. I asked open-ended question, and often responded to his answers by asking further open-ended questions. For example, after asking the patient if he was having suicidal thoughts, he responded that he did not want to hurt himself right now. I replied with the open-ended question, “So are you feeling safe? ” using reflection to redirect the idea back to the patient and allow him to explore whether or not he felt safe.
I focused on actively listening to the patient, following the patient’s lead and sometimes asking clarifying questions. Because of the patient’s slower rate of response, I employed the use of silence to allow him to gather his thoughts and proceed at his own pace. As the patient told me more about recent events in his life, including the death of his wife, the loss of his job and his descent into substance abuse, he began to look away more and more. This decrease in eye contact might be the result of the patient feeling ashamed, embarrassed, or guilty about his feelings and behaviors.
In order to maintain connection with the patient and assure him of my nonjudgmental view of his situation, I used empathy and restatement, saying, “It sounds as though you have had a very difficult past couple of years. ” Upon saying this, the patient looked up, maintained eye contact, and agreed. He then began to expand on his current feeling of hopelessness, saying, “I wonder if life is worth living, and sometimes I just want to go to sleep and not wake up. ” As he explored and expanded on his feelings I alternated between using silence and validating what he said.
The silence allowed him to express intense feelings without interruption, while statements of restatement and interpretation, such as “ It sounds like you have been feeling pretty hopeless,” demonstrated empathy and a nonjudgmental attitude toward what the client was feeling. At one point, the patient put his head in his hands, saying “I had so much going for me, and after my wife died, everything went to pot. ” I felt that in this moment, what the client needed was neither a cheery reassurance that things would get better, nor dispensation of advice, but rather a person to understand and acknowledge his current misery.
I replied that sometimes life gets you down, and sometimes when it rains it pours, and it’s ok to be sad about that. The patient seemed appreciative of the acknowledgment of his pain and the justification of his sadness. I sat silently with him for 2-3 minutes, as I felt it was important for him to feel, sit with, and process these emotions for a short period of time. During these periods of silence, I continued to lean forward slightly, as I had done throughout the interaction, to show that I was still interested and engaged despite the lack of verbalization.
Because I had acknowledged the patient’s hardships and thereby connected with him, I felt that I was in a good position to explore with him goals he had for the future, and ideas that could help him reach these goals. I made sure to approach this topic not by giving advice or suggestions, but by asking him open-ended questions about what things made him feel less sad or anxious and what things he wanted to work on during his stay. These open ended questions elicited the response of his goals for the future, and his verbalization that he needed to find better coping mechanisms, because his old ones didn’t seem to work.
He also stated that he knew he needed to “continue grieving my wife, because the drugs and alcohol kept me from doing that. ” I thought that this realization of substance abuse as inhibitory to his grief process was very insightful, and told him so. He made a small smiling expression and responded that he wanted to “get back on the straight and narrow” and take his medications “the way I’m supposed to—no more, no less. ” The patient’s elucidation of his goals and his insight into helpful and hindering coping devices was a very positive outcome of this therapeutic conversation.
The patient seemed less burdened after the opportunity to talk about his recent losses in life, and more hopeful after verbalizing his goals and ways to meet them. References Ackley, B. J. & Ladwig, G. B. (2008). Nursing Diagnosis Handbook (7th ed. ). St. Louis, Missouri: MOSBY Elsevier. American Psychological Association. (2002). Boyd, M. A. (2008). Psychiatric nursing: contemporary practice (4th ed. ). New York: Lippincott Williams & Wilkins. Bruskas, D. (2010). Developmental health of infants and children subsequent to foster care.
Journal of Child and Adolescent Psychiatric Nursing, 23(4), 231-241. doi:http://dx. doi. org/10. 1111/j. 1744-6171. 2010. 00249. x Christie, W. & Moore, C. (2005). The impact of humor on patients with cancer. Clinical Journal of Oncology Nursing, 9(2), 211-218. Cohn, A. M. , Epstein, E. E. , McCrady, B. S. , Jensen, N. , HunterReel, D. , Green, K. E. , & Drapkin, M. L. (2011). Pretreatment clinical and risk correlates of substance use disorder patients with primary depression. Journal of Studies on Alcohol and Drugs, 72(1), 151-157. Eakes, G. G. , Burke, M. L. & Hainsworth, M. A. 1998). Middle-range theory of chronic sorrow. Image Journal Nursing Scholar, 30, 179. Felitti, V. J. & Anda, R. F. (2010). The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare. Cambridge University Press. Gulick, E. (2001). Emotional distress and activities of daily living functioning in persons with multiple sclerosis. Nursing Resolutions, 50(3), 147-154. Lai, H. L. & Good, M. (2005). Music improves sleep quality in older adults. Journal of Advanced Nursing, 49(3), 234-244.
Lawrence, A. E. , Liverant, G. I. , Rosellini, A. J. , & Brown, T. A. (2009). Generalized anxiety disorder within the course of major depressive disorder: Examining the utility of theDSM-IV hierarchy rule. Depression and Anxiety, 26(10), 909-916. Levola, J. , Holopainen, A. , & Aalto, M. (2011). Depression and heavy drinking occasions: A cross-sectional general population study. Addictive Behaviors, 36(4), 375-380. doi:http://dx. doi. org/10. 1016/j. addbeh. 2010. 12. 015 Matthews, L. & Marwit, S. (2004). Complicated grief and the trend toward cognitive-behavioral therapy.
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A. (2009). Fundamentals of Nursing (7th ed. ). St. Louis, Missouri: MOSBY Elsevier. Plaisier, I. , Beekman, A. T. F. , de Graaf, R. , Smit, J. H. , van Dyck, R. , & Penninx, B. W. J. H. (2010). Work functioning in persons with depressive and anxiety disorders: The role of specific psychopathological characteristics. Journal of Affective Disorders, 125(1-3), 198-206. doi:http://dx. doi. org/10. 1016/j. jad. 2010. 01. 072 President and Fellows of Harvard College. (2011). Harvard Mental Health Letter. Harvard Health Publications. Retrieved from http://www. health. harvard. du Romera, I. , FernandezPerez, S. , Montejo, A. L. , Caballero, F. , Caballero, L. , Arbesu, J. A. , . . . Gilaberte, I. (2010). Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: Prevalence of painful somatic symptoms, functioning and health status. Journal of Affective Disorders, 127(1-3), 160-168. doi:http://dx. doi. org/10. 1016/j. jad. 2010. 05. 009 Seo, H. , Jung, Y. , Kim, T. , Kim, J. , Lee, M. , Kim, J. , . . . Jun, T. (2011). Distinctive clinical characteristics and suicidal tendencies of patients with anxious depression.
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Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 40(7), 1113-1123. doi:http://dx. doi. org/10. 1017/S0033291709991590 United States Department of Health and Human Services. (1999). Yen, Y. , Rebok, G. W. , Gallo, J. J. , Jones, R. N. , & Tennstedt, S. L. (2011). Depressive symptoms impair everyday problem-solving ability through cognitive abilities in late life. The American Journal of Geriatric Psychiatry, 19(2), 142-150. doi:http://dx. doi. org/10. 1097/JGP. 0b013e3181e89894 Case
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