Evaluating a Psychiatric Patient

The following example essay on “Evaluating a Psychiatric Patient” discuss the case of Ji-woo, a 19-year-old female who presents with what appears to be an opioid addiction. Her current state was prompted by a traumatic accident in which she sustained massive injuries and suffered the loss of one of her friends.

She was prescribed opiate medications for pain management but after weeks of treatment her doctor refused to continue prescribing the medication. Since then, Ji-woo has found illegal means to continue getting the medicine.

When she does not take the medicine, she complains of intrusive memories, sleep disturbances, feelings of a loss of self or identity, and suicide ideation.

The goal of this case study is to select and analyze assessment tools to begin the diagnostic process for identifying if the client has a substance use disorder and any mental health issues. Assessments will be selected to evaluate Ji-woo for SUD as well as other mental health issues. They will be evaluated for their appropriateness for use with diverse clients, and information will be included to formulate a differential diagnosis.

Lastly, a provisional diagnosis will be formulated using the DSM-5 criteria.

Assessment Tools

For this case, appropriate assessment tools are the Drug Abuse Screening Test (DAST-2), Addiction Severity Index-Multimedia Version (ASI-MV), the Beck Scale for Suicide Ideation (BSS), and the UCLA PTSD Reaction Index for DSM-5 (PTSD-RI).

The DAST-2 is a 2-item measure developed to quickly identify drug use disorders (Tiet, Leyva, Moos, & Smith, 2017).

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It was adapted from the longer version the 28-item DAST which has been validated numerous times and is one of the most commonly used drug screen instruments (Tiet, Leyva, Moos, & Smith, 2017). The DAST-2 was selected because it is recommended that a practical screening tool only consist of 4 items, making the original version the DAST-28, as well as the other adapted shorter versions the DAST-20 and DAST-10 inappropriate due to their length (Tiet, Leyva, Moos, & Smith, 2017).

The next instrument, the ASI-MV is an adapted version of the ASI a 200-item semi-structured interview (Butler, Black, McCaffrey, Ainscough, & Doucette, 2017). Because of its comprehensive questioning, the ASI is considered an ideal instrument for the screening of substance abuse and for the development of treatment plans (Butler, Black, McCaffrey, Ainscough, & Doucette, 2017). It addresses several factors related to substance use such as health status, drug history, legal status, job status and support, alcohol use, psychological status, and family and social status (Butler, Black, McCaffrey, Ainscough, & Doucette, 2017).

The ASI-MV was deemed more appropriate than the ASI for the following reasons:

• the ASI takes approximately one hour to complete and 10-20 minutes to score whereas the ASI-MV takes approximately 40 minutes to complete and is immediately scored and more accurate,
• the ASI is expensive whereas the ASI-MV is cost efficient,
• the ASI has a high rate of interviewer variability whereas the ASI-MV is self-administered (Butler, Black, McCaffrey, Ainscough, & Doucette, 2017).

Since the client admits to having suicide ideation (SI) , it is necessary to further evaluate her current state. This will be done using the Beck Scale for Suicide Ideation (BSS). The BSS is a commonly used scale to evaluate clients for SI (de Beurs, Fokkema, de Groot, de Keijser, & Kerkhof, 2015). It is composed of 19 items that measure the users frequency of suicidal behaviors, intentions, and attitudes (de Beurs et al., 2015). The first five items are designed to screen for SI (de Beurs et al., 2015). If users have no evidence of SI or intention to harm themselves, they can then skip the next 14 additional items (de Beurs et al., 2015). This makes this scale a quick and effective SI screening tool.

Although the MMPI, MMPI-2, and the MMPI-2-RF are the most commonly used instruments to evaluate suicide risk and ideation (Gottfried, Bodell, Carbonell, & Joiner, 2014), they were deemed inappropriate because of the length of each assessment. For example, the MMPI-2-RFconsists of 338 true/false questions made up of six sets of scales (Gottfried et al., 2014). It includes questions about recent SI as well as behaviors, but it also evaluates personality and psychopathology (Gottfried et al., 2014). Since the client is already taking multiple assessments, it was deemed inappropriate for use at this time.

The final instrument, the PTSD-RI for DSM-5 was selected because it is one the most utilized assessments for evaluating posttraumatic stress reactions and evaluating PTSD in children and young adults who have been exposed to trauma (Kaplow, Rolon-Arroyo, Layne, Rooney, Oosterhoff, Hill, Steinberg, Lotterman, Gallagher, & Pynoos, 2019). The items are both age appropriate and correlate with the DSM-5 diagnostic criteria for PTSD (Kaplow et al., 2019). For these reasons, the PTSD-RI was deemed an appropriate assessment for Ji-woo.

Applicability of Assessments to Diverse Populations

Clinicians have an ethical responsibility to take account of their clients personal and cultural backgrounds and to facilitate their well-being by selecting appropriate assessments (American Counseling Association, 2014, E.). With this in mind, clinicians must recognize the impact that culture has on how problems are both interpreted and experienced and consider these factors when reaching a mental health diagnosis (ACA, 2014, E.5.b.). Before making a diagnosis, clinicians should assess both the positive and negative effects (ACA, 2014, E.5.d.). If they believe it will cause harm to the client or others, they may refrain from diagnosing and reporting any mental health issues (ACA, 2014, E.5.d.).

The first instrument, the DAST-2 was shown to perform well with diverse clients varying in age, gender, education, race or ethnicity, and marital status (Tiet, Leyva, Moos, & Smith, 2017). It also showed moderate to high levels of validity and excellent test-retest reliability of kappa = 0.78 ((Tiet et al., 2017). In addition, it was shown to be 95%-97% sensitive and 89%-91% specific for the identification of drug use disorders (Tiete y al., 2017). Information on its performance with Korean clients was unable to be located; however, this author believes it is appropriate to include and consider the results from the Korean version of the slightly longer version the DAST-10.

The Korean version of the DAST-10 was found to be a sound instrument due to its high level of internal consistency reliability and convergent validity (Kim, 2014). In addition, cutoff scores were the same as the English version (Kim, 2014). Taking this into consideration, clinicians can use this information to provide the rationale for selecting the DAST-2. It should be noted that a lack of research on substance abuse in Korea has prompted the need for the development of standardized instruments (Kim, 2014).

The second instrument, the ASI-MV has been proven to be reliable and valid for use with varying populations, ethnic groups, and age ranges (Butler, Black, McCaffrey, Ainscough, & Doucette, 2017). It was estimated that in 2015 more than 600,000 individuals in the United States successfully completed the ASI-MV (Butler, Black, McCaffrey, Ainscough, & Doucette, 2017). For these reasons, it was deemed an appropriate assessment for Ji-woo.

The third instrument, the Beck Scale for Suicide Ideation (BSS), was deemed an appropriate tool because of its ease of use and quick administration and scoring. It should be noted there is no agreement on which assessment is most effective for measuring SI in specific populations (Batterham, Ftanou, Pirkis, Brewer, Mackinnon, Beautrais, Fairweather-Schmidt, & Christensen, 2015). For this reason, the BSS was deemed appropriate for use in this case.

The final instrument, the PTSD-RI was shown to have excellent internal consistency and high test-retest reliability when used with diverse populations ranging from child to young adult (Kaplow et al., 2019). For Ji-woo it may be beneficial to consider using the Korean version the Abbreviated University of California, Los Angeles, PTSD Reaction Index (Abb-UCLA-PTSD RI). It is a 22-item scale developed to assess Korean children and adolescents for PTSD (Kim, Han, Yoo, Lee, Kim, & Chung, 2018). The instrument revealed that in Korean adolescents, feelings of sadness, unwanted thought or images of the trauma, fear, anger, depression, avoidance, and not wanting to talk about it are markers for PTSD (Kaplow et al., 2019). All things considered, the Abb-UCLA PTSD RI-Korean version is a sound screening instrument.

Differential Diagnosis

Determining a differential diagnosis is an essential part of the counseling process (Kimball, n.d.). When making a differential diagnosis, clinicians gather all relevant information to establish a timeline of event (Kimball, n.d.). In short, a differential diagnosis allows the clinician to determine if the behavior can be attributed to substance abuse or other mental health issues (Kimball, n.d.).

With adjustment disorders, the trauma can be any type and level of severity and does not have to meet the PTSD criteria (APA, 2013). The diagnosis of adjustment disorder can be given when the response to the trauma does not meet PTSD or other mental health disorder criteria (APA, 2013). If the symptoms meet criteria for other mental health disorders that diagnosis should be given (APA, 2013). In this case, acute stress disorder can be ruled out because the symptoms exceed the duration period listed in the criteria. Major depression disorder can also be ruled out because client has symptoms which meet several of the criteria for PTSD.

Opioid use disorders may present symptoms that are characteristic of other mental health disorders such as depressive disorder (APA, 2013). Despite this, opioids impact psychological function, causing less disturbances than most drugs (APA, 2013).

Systemic Approach

A family systems approach is often used when treating children and adolescents with substance use disorder or other addictive disorders. In a family systems approach, all members of the family are involved in the counseling process (NIDA, 2014). This means in addition to addressing the initial concerns of the adolescent, issues within the family such as communication, conflict, mental health history, behavioral issues, and other areas will be discussed (NIDA. 2014).

It is important to include families in the treatment process because they are directly impacted by the addiction and are often responsible for helping the addicted member receive care (Kelly, Fallah-Sohy, Cristello, & Bergman, 2017). Opioid addiction negatively impacts family relationships, causes financial hardships because of the addiction or health problems resulting from it, and creates issues of co-dependency within the family system (Effects of opiate addiction n.d.).

It should be noted that the family may be hesitant to discuss past or current issues because of shame, embarrassment, or other feelings. This can be problematic especially when the initial client has been impacted by those situations. Refusal to be open about family issues may directly impact the counseling process.

Provisional DSM Diagnosis

• Principal DSM-5 Diagnosis: 309.81 Posttraumatic Stress Disorder
• Additional DSM-5 diagnoses: 292.9 Opioid Use Disorder

Relevant Medical Diagnoses: Not currently known. Additional information should be collected to rule out any possible medical conditions as well as other mental health disorders.

Note: V62.4 Acculturation Difficulty-The family immigrated to the United States from Korea approximately 17 years ago. Although the family has many relatives that live in the United States the matriarchs-grandparents still live in Korea. The impact this has on the family system will need to be explored as well as any acculturation difficulties Ji-woo and her immediate family may have experienced. To measure the clients symptom severity, the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult and WHODAS 2.0 will be administered.

The diagnosis of PTSD was formulated using the DSM-5 diagnostic criteria. According to the DSM-5, PTSD is the exposure to a traumatic event in which the person is threatened with death, injury, or sexual assault (American Psychiatric Association, 2013). The individual must meet the criteria listed under each category for a diagnosis. The client has the following conditions which meet the diagnostic criteria:

• direct exposure,
• intrusive memories
• efforts to avoid memories,
• persistent feelings of guilt, diminished interest, and inability to experience positive feelings-not feeling like herself,
• self-destructive behavior and sleep disturbance,
• duration of disturbance is more than one month,
• decreased functioning,
• not attributed to another medical condition (APA, 2013).

It should also be noted that the client has suicide ideation, but it is not known if there have been any attempts. Existence of PTSD increases the rate of suicidal ideation and suicide planning and attempts (APA, 2013).

The diagnosis of opioid addiction was formulated using the DSM-5 diagnostic criteria. According to the DSM-5, opioid use disorder is a problematic use of opioids with 2 conditions within a 12-month time frame (APA, 2013). The client has the following conditions listed under the diagnostic criteria:

1. opioids are taken longer than initially prescribed and in larger quantities,
2. client engages in drug seeking behaviors,
3. strong urge to use,
4. activities are given up because of use (APA, 2013).

According to the DSM-5, the clients current severity level is 304.00 (F11.20) Moderate (APA, 2013).

To formulate a more definitive diagnosis about the opioid addiction more information is needed such as names of medication taken, amount, and frequency. This information will be crucial for the development of a treatment plan and in determining what type of detoxification the client will need. The previously selected assessments will provide the clinician with a comprehensive view of the client’s mental state and severity of the addiction severity.

The client appears to have a supportive family system which will beneficial in the therapeutic process. Treating the family will allow the clinician to evaluate the impact the opioid and PTSD has on others and explore other issues within the family that may be impacting the client. Along with benefits of formulating a holistic view of the client and family system there are also challenges.

The clinician must be aware that traditionally, Asian cultural norms are quite different than those of the Western world, especially in communication (Kim & Park, 2015). The family make speak in a more indirect manner and be hesitant to say anything that could offend the listener (Kim & Park, 2015). In addition, they may shut down when asked to clarify themselves, show little to no emotion, and be hesitant to discuss their problems (Kim & Park, 2015).

Assessment Summary

Assessments are a crucial part of the counseling process. They are used to measure behavior, identify problems, and help clinicians develop a more comprehensive view of their client (Whiston, 2017). For these reasons, clinicians must constantly be aware of the most current and effective assessments, be able to select the most appropriate one for their clients needs, and be trained on how to administer it and interpret the results. Selecting the right assessment instrument in counseling is instrumental in determining client outcomes.

So much so, that when clients and counselors can agree on the problem and counseling needs, then clients are more likely to continue therapy (Whiston, 2017). It must be noted that assessments should be used continually throughout the counseling process to ensure the clinician remains aware of the clients needs (Whiston, 2017).

The following assessments were selected based on the presenting symptoms of the client (1) Drug Abuse Screening Test (DAST-2), (2) Addiction Severity Index-Multimedia Version (ASI-MV), (3) the Beck Scale for Suicide Ideation (BSS), and (4) the UCLA PTSD Reaction Index for DSM-5 (PTSD-RI). The items from each assessment will be scored and determined based on the assessment criteria. It is possible that the client may downplay their answers which would directly impact the assessment results and treatment plan (Morgen, 2017). If this occurs, it may require that the clinician administer additional assessments and develop a new treatment plan.

References

1. Effects of opiate addiction on the family (n.d.). Retrieved form American Counseling Association (2014). 2014 ACA code of ethics. Retrieved from
2. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
3. Batterham, P. J., Ftanou, M., Pirkis, J., Brewer, J. L., Mackinnon, A. J., Beautrais, A., Fairweather-Schmidt, A. K., & Christensen, H. (2015). A systematic review and evaluation of measures for suicidal ideation and behaviors in population-based research. Psychological Assessment, 27(2), 501-512. doi:10.1037/pas0000053