ASSESSING AND DIAGNOSING PATIENTS WITH SUBSTANCE-RELATED AND ADDICTIVE DISORDERS

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Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive
your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms
impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses?
Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to
lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking
process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for
the specific patient case.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also
include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking
beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into

consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic,
cultural background, etc.).
Training Title 114
Name: Ally Chen
Gender: female
Age: 44 years old
Background: Only child, raised by parents in Philadelphia, PA. Has PhD in biology and master’s
degree in high school education (8–12). Her supervisor has asked the school EAP counselor to
intervene with concerns regarding potential substance use in effort to facilitate getting her help
and be able to retain her. She is divorced, has a 4-year-old son who lives with his father. Appetite
healthy, sleeping 9 hours/24 hrs., wakes 2-3 times during the night. Denied drug use. had DUI
when she was age 21.
Symptom Media. (Producer). (2018). Training title 114-2 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-114-2
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case
Selections choices in the Learning Resources. View your assigned video case and review the additional data for
the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.

 

Sample Solution

The Impact of Different Restraints on Trauma: A Delicate Balance

Restraints are a complex issue in clinical practice, particularly when considering their potential impact on trauma. While sometimes necessary to ensure safety for patients and staff, the use of restraints can be re-traumatizing for individuals with a history of trauma.

Here’s a breakdown of the impact of different restraints:

Physical Restraints:

  • Negative Impacts: Physical restraints can be a frightening and humiliating experience, triggering memories of past abuse or violence. The feeling of being overpowered and controlled can exacerbate feelings of helplessness and powerlessness. Additionally, physical restraints can cause physical injuries, further adding to the trauma.
  • Positive Impacts: In some emergency situations, physical restraints may be necessary to prevent harm to the patient or others. They can be a last resort to de-escalate a situation and ensure safety.

Pharmacological Restraints:

  • Negative Impacts: Medications used for restraint can have various side effects, including drowsiness, confusion, and disorientation. These effects can be disorienting and frightening, potentially contributing to a sense of being out of control. Additionally, some medications can interact with other drugs or underlying health conditions, creating further complications.
  • Positive Impacts: Medications can be a helpful tool for calming agitated patients and preventing self-harm or violence. In some cases, they can be used to create a window of opportunity for de-escalation and communication.

Minimizing Trauma:

  • Alternatives to Restraint: Whenever possible, healthcare professionals should explore de-escalation techniques, verbal communication, and environmental modifications before resorting to restraints.
  • Trauma-Informed Care: Understanding the potential for re-traumatization is crucial. Approaching patients with empathy and respect, even during agitated states, can help minimize the negative impact of restraints.
  • Minimizing Use: Restraint use should be a last resort and for the shortest duration necessary.
  • Debriefing: After a restraint episode, it’s important to debrief with the patient (when possible) to understand their experience and address any emotional distress.

Conclusion:

While restraints can be a necessary safety measure, their use requires careful consideration, particularly for individuals with a trauma history. Implementing trauma-informed practices, minimizing use, and exploring alternatives can help reduce the potential for re-traumatization and promote patient safety and well-being.

 

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