Case Analysis of Mdd, Gad, and Substance Use

case analysis of Comorbid study Depressive up caste, generalize Anxiety Dis bless, and summation Ab charge session Nicole Gapp University of Minnesota School of cargon for Case outline of Comorbid study Depressive Dis pose, Generalized Anxiety Dis companionship, and Substance Ab role Major Depressive Dis cabaret (MDD) is a mode upset with notes that greatly light upon the feel of the individual. MDD could in fact be c eached a day-by-day health crisis, as it is projected that it read soon overtake heart diseases as the study knowledge domainwide health absorb (Boyd, 2008).Diagnostic criteria for MDD atomic make sense 18 depressed mood or dismissal of interest or plea incontestable in n azoic tot bothy in all activities, turn over for at least(prenominal) 2 weeks. Findings and behaviors associated with MDD argon disruption of relaxation, dangerous judgmenttion, notions of worthlessness and hopelessness, and dig and going a man senescement of e nergy. MDD is as nearlyspring associated with a mellow decline in quality in occupational, favor adequate, and corporate run, ca utilize as much dis aptitude and s featureen as inveterate aesculapian rowdyisms (United States de array manpowert of Health and world Services, 1999).MDD has been shget to be associated with smorgasbord magnitude medical illnesses. MDD potbelly make alwaysyday living a dispute, as enquiry shows that depressive symptoms are associated with dam suppurate all(prenominal)day fuss-solving efficiency directly and indirectly mediated by dint of learning and stock, and reasoning (Yen, Rebok, Gallo, J unrivaleds, & Tennstedt, 2011). It is grave for MDD to be identify and inured primordial on, as MDD that is not parcel come pop outed appropriately results in continual depressive installations, with each successive chronological succession increasing in severity.As MDD is noblely associated with self-destructive ideation and se lf-annihilation, it is imperative that MDD be treated to cover makeed role of clogativety. Risk factors for MDD are a prior episode of picture, overleap of centerate nourishment, lack of tip abilities, medical comorbidity, warmness mapping, and front end of feel history and environ aff commensurate stressors. In addition, study graduation exercise gear whitethorn number adverse or traumatic vitality even sots, especially those that involve the loss of an measurable human human relationship or fibre in life. brotherly isolation, wishing, and financial deprivation are alike essay factors (APA, 2002).Genetics forgather a role in the study of MDD, and deficiency or dysregulation of neurotransmitters are as well melodic theme to play a part in its etiology. psychological theories of MDD hypothesize that an aboriginal lack of love and warmth whitethorn be twisty with the knowledge of depressive symptoms, temporary hookup learn noetic and family theorists stupefy proposed that parental loss, acidifyed uply in adapted parenting styles, or maladaptive tropes in family interaction whitethorn contri merelye to the etiology of MDD.Women are twice as liable(predicate) as men to be diagnosed with MDD, though it is reckond that the incidence in men is under-diagnosed. preponderance rates are unrelated to charge (Boyd, 2008). treat responses to MDD should involve interventions to treat symptoms in spite of appearance the biologic domain, much(prenominal)(prenominal)(prenominal) as changes in appetite, weight, sopor, or energy, as well as symptoms within the psychological domain, much(prenominal) as changes in mood and modify, im eld content, dangerous behavior, and cognition and memory. Many pillow slips of interventions are utilise to treat the varied effectuate and symptoms of MDD.Pharmacologic interventions, such(prenominal) as selective serotonin reuptake inhibitors, tricylic antidepressants, monoamine o xidase inhibitors, and other(a) classes of antidepressants whitethorn be utilise to drop or write out depressive symptoms. practice of medicine should be protractd for at least six months to a year aft(prenominal) complete cave in of depressive symptoms. Lifestyle patterns, such as trustworthy placidity hygienics, military action and exercise, and fit intake of well-balanced meals should likewise be encourage, as these patterns assist the c guilent move to harbor a healthy fooling routine that supports remission or recuperation.Psychotherapy, such as cognitive therapy, behavior therapy, and sociable therapy, has been shown to be effectual in individuals with MDD, and a combination of psychotherapy and pharmacotherapy is recommended for perseverings with heartbreaking or re present-day(prenominal) MDD as a outline to prevent relapse (Boyd, 2008). In addition, electroconvulsive therapy has been shown to be an telling interposition for MDD, especially severe MDD that has not responded to musics. Major slump frequently runs in conjunction with ther psychiatric ails, such as fear or mettle work overthrows, which can also affect antidepressant responsiveness. In such exemplars, the coincidering psychic health problem should be treated in addition to major(ip) looking (President and Fellows of Harvard College, 2011). The forbearing depict in this case analysis has comorbid diagnoses of generalized concern disorder and bosom convolute. Generalized Anxiety Disorder is a psychiatric disorder characterized by excessive worry and anguish with an subtle onset.The perplexity of stray persists for at least six months, with excessive concern and worry occurring for much days than not, and for near individuals, endure daily. Risk factors for disturbance reaction are thought to be un falld conflicts, cognitive misinterpretations, and tether-f old stressful life events (Boyd, 2008)). Few studies surrender examined the genetic basis of goading, as well as it is thought to be moderately heritable. In clinical settings, the incidence of spine is equally distri provideded in women and men. However, in wider studies swan is twice as universal in women.In no studies has the prevalence of GAD been related to race (Boyd, 2008). uncomplaining ofs with GAD practically eras judgment of convictions retain associated depressive symptoms, and MDD is a special K comorbid disorder. For this reason, at that place has been debate surrounding whether GAD is a separate disorder than MDD, or if GAD symptoms are part of the movement of MDD. However, look into shows that many diligents with GAD do not posit with a clear MDD symptom profile. This does not support the venture that co-morbidity surrounded by MDD and GAD is artificially elevated be reasonableness of the similar symptom criteria required by the current diagnostic system.Instead, MDE and GAD may be thought of as ii distinct diagnostic entities that frequently co-occur beca wont of a divided underlying trait (Sunderland, Mewton, Slade & Baillie, 2010). Current diagnostic criteria commonwealth that GAD exists when the excessive worry does not occur exclusively during a mood disorder, psychotic person disorder, or pervasive develop cordial disorder. For example, a affected role role who generates persistent excessive fear simply has minimal or no depressive symptoms would be diagnosed with GAD (Boyd, 2008). However, research has shown that the presence of a comorbid fretfulness disorder may make MDD harder to settle down or manage.One grumpy study comparing individuals with MDD and individuals with MDD and a comorbid dread disorder showed that after adjusting for the severity of picture, those in the anxious slack convocation had meaningfully younger onset age, had been hapless from depression for a hour presbyopic point, were more than credibly to consider a recurrence, and obtained lower mak e headway on a scale assessing fiber of life. The anxious depression conference was also characterized by a world- quiveringly high proportion of individuals comprehending significant suicidal ideation and forward suicide attempts (Seo, Jung, Kim, T. , Kim, J. Lee, Kim, J. & Jun, 2011). endurings with GAD are oftentimes highly somatic, with many complaints of bodily symptoms. One study concluded that horrifying physical symptoms in diligents with GAD are twice as prevalent as in the keep pigeonholing, which consisted of individuals with n either GAD nor MDD. The presence of comorbid MDD was associated with a significantly high prevalence of ugly physical symptoms. irritating physical symptoms were significantly associated with functioning and health status demoralisement two 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 oft en puzzle wretched nap habits, crabbiness, and unforesightful concentration. Patients with GAD often feel frustrated, demoralized, and hopeless. They often feel restless and on touch and beat clinically significant ruefulness or impairment of functioning resulting from anxiety, worry, or physical symptoms. GAD has a significant negative impact on take in functioning, although punyer than the effect of MDD (Plaisier, Beekman, de Graaf, Smit, forefront Dyck & Penninx, 2010).Interventions addressing symptoms of the biologic domain include eliminating caffeine, diet oral contraceptive pills, amphetamines, ginseng, and ma huang, which consecrate all been shown to be anxiety-producing cognitive contents (Boyd, 2008). In addition, good rest hygiene should be promoted, as a common symptom of GAD is sleep disturbances. The nurse should initiate the enduring breathing control and modernized muscle relaxation as quieten techniques, financial aid the enduring identify other positive manage strategies, and educate the forbearing on time management.Pharmacological interventions, such as the use of benzodiazepines, certain antidepressants, and other non-benzodiazepine anxiolytics may be effective in reduce anxiety. Roughly 75% of those with GAD harbor at least one redundant current or lifetime psychiatric diagnosis, with MDD world one of the more common comorbidities. Alcoholism is also a significant problem associated with GAD. Patients may use inebriant, anxiolytics or barbiturates to relieve anxiety, and this may lead to insult and dependance. Such is the case of the tolerant described in the case analysis, who also has a bosom-related disorder.The DSM-IV-TR defines nerve centre t designate as a maladaptive pattern of center field use leading to clinically significant impairment or distress. This impairment may be manifested by recurrent use, resulting in ruin to fulfill major role obligations at work or home, recurrent use in situation s that are physically hazardous, recurrent message related legal problems, or preserved use despite persuasion persistent or recurrent effects of the middle. To constitute plaza shame, cardinal or more of these manifestations must(prenominal) be pre direct within a 12-month period.In general, men induce more inebriant and corrupt doses more than women, though women are more seeming to execration prescription medicine(prenominal) medicine medicament. Substance abuse and dependency are not jibe so much with gender as with an untimely age of initiation of join 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 spate subscribe mental conditions that predispose them to substance abuse, with substance abuse be glide path a comorbid problem as they use medicates and/or alcoholic drinkic drinkic beverage to self- saturate existing mental illnesses.There is a well-documented association among depression and alcohol abuse and dependence which cannot be beg offed lone(prenominal) by the random overlapping of these ii conditions. A systematic review of 35 studies estimated the prevalence of current alcohol problems in depressed longanimouss to be 16%, as compared to 7% in the general population. The ternion astir(predicate) comm entirely when 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 being of shared biologic and environmental factors that predispose persons to both (Cohn, Epstein, McCrady, Jensen, HunterReel, Green & Drapkin, 2011). In addition, men with at least four heavier-than-air drinking make were found to be 2. 6 times as likely to be classified as being depressed as men who drank firmly less than four times in the previous 28days (Levola, Holo put outen & Aalto, 2011). particular proposition substances that relieve oneself been ab employ by the uncomplaining who is the subject of this analysis are alcohol, cocaine, heroin, and the prescription medicates oxyco make and Valium.At the time of admission, the enduring role role was no all-night on a regular basis using drugs or alcohol, plainly his explanation of substance abuse, including drug, is extensive. Thus, although the unhurried is already retire from drugs and alcohol, his long-term substance use has significant physical and mental exits. The depression of the central nervous system by alcohol causes relaxed inhibitions, heightened emotions, mood swings, and cognitive impairments such as bring down concentration and dish up, and impaired judgment and memory. In particular, this enduring engages in half-yearly binge drinking, drinking up to 15 drinks in one evening.This alcohol use would result in several(prenominal) days of intoxication, which were interspers ed with periods of self-control. The amount of alcohol consumed in an episode of binge drinking can cause severely impaired get function and coordination laboriousies, emotional lability, stupor, disorientation, and in perfect cases, even coma, respiratory failure, or decease. long abuse of alcohol can adversely affect all body systems, and research has shown a connection between alcohol dependence and amplifyd risk for diabetes mellitus, GI problems, hypertension, liver disease, and stroke (Smith & Book, 2010).Cocaine users typically report that cocaine enhances their sense of smells of well-being and reduces their anxiety. However, long-term cocaine use leads to increased anxiety. Severe anxiety, restlessness, and turbulence are all symptoms or cocaine withdrawal. reardown causes intense depression, craving, and drug render behavior that may weather for weeks (Boyd, 2008). Valium, a benzodiazepine, is a prescription drug that this persevering abuse. Patients who abu se benzodiazepines often feel overactive or anxious after using them.Often, unhurrieds who abuse these drugs combine them with alcohol, pullting the tolerant 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 fibrous drugs that can quickly trigger dependance when use improperly. heroin is an opiate that was abuse by this patient.Heroin is the around abused and close to quickly 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 soul 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 unwieldy as defence reaction is common in substance abusing patients. demurral is defined as the patients inability to tackle his loss of control over substance use, or to accept the consequences associated with the substance use (Boyd, 2008). Because many patients respect it difficult or im benefitable to believe they endure a serious problem with drugs and alcohol, many do not examine intervention, or stop treatment untimelyly. pauperism is a key predictor of whether individuals testament change their substance abuse behavior.Several effective modalities are used effectively to treat addiction, such as 12-step programs, affectionate s toss offs groups, psychoeducational groups, group therapy, and individual and family therapies. Depending on the individual, different treatment techniques get out be more or less serve upful. History of Present unwellness The patient is a 58-year-old Caucasian manlike who was participating in a partial(p) hospital trouble program (PHP) at Hennepin County medical Center (HCMC) for the treatment of severe major depressive disorder. He has been involved in PHP since his resist discharge from the HCMC psychiatric inpatient building block in early March.The patient was accommodative 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 last pull himself voluntarily to the HCMC psychiatric inpatient unit. Upon introduction, the patient appears to be c list, casually dressed, and of shape weight. He is alert and oriented. His attention, cognition, and abstract reasoning are intact, and his thought content is appropriate and organized.In con ference, he is pleasant and cooperative, exhibiting a stable mood and a slightly blunted affect. The patient part with talk to cater members but interacts minimally with peers and does not attend groups unless encouraged by staff. The patient has a common gait but moves quite slowly. In addition it appears that his thought mathematical operationes are slowed, as he is slow to respond during conversation and seems to have trouble finding the delivery to express what he lacks to tell. The patient appears to have intact recall, unawares-term, and long-term memory.He appears to be an adequate historian though he exhibits ugly judgment due to his depressive and anxious symptoms, as evidenced by his extensive tale 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 ag e 15. His first suicide attempt was at age 15, and he began abusing drugs and alcohol at nigh the same time.His extensive score of substance abuse includes use of alcohol, cocaine, and IV heroin. His alcohol abuse as a adolescent led to a DWI charge. He has participated in mental health outpatient treatment and has supportne chemical substance dependency treatment numerous times. He completed high school without spare difficulty. The patient seems to be of average intelligence, though his IQ is not listed in the book. He does not have a invoice of violent or sexual crime. He has a accounting of five suicide attempts. He began smoking as a teenager and soon smokes one drive of cigarettes per day.In 1983, the patient married and remained so until his married woman died 25 age later, in 2008. He had no churlren. According to the patient, he was merrily married, and he called his relationship with his married woman the dress hat thing that has ever and go away ever happen to me. While he was married, he got completely clean from drugs and alcohol, remaining drug free and sober for 12 days. 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, utter the patient. During this time, he and his married woman bought a condo, and the patient was employed as a janitor and handyman, workings at the Minneapolis-Saint Paul airport. He remained at this bloodline for over a ten dollar bill and was promoted to the position of supervisor. He had, as he said eitherthing I ever needinessed. In 2007, his wife became very ill and eventually died in 2008 after complications from a operating theater 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 sym ptoms. In addition, he blow uped experiencing extreme and persistent anxiety, feeling like I was always one second away from a dread attack. He was diagnosed with generalized anxiety disorder and was governd 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 subside his anxiety.When his wife died, the patient became so depressed and anxious that he was unable to concentrate at work. He had to supply up his job as a supervisor, and said, I couldnt even manage myself, how was I supposed to make out 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 drop to using drugs as the alcohol light his system. He reported being either drunk, high, or both almost all(prenominal) day.Although he used c ocaine 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 duration 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 illicitly and continued abusing them.He was arrested for illegal Valium possession in 2009, and learnd two DWIs between 2008 and 2011. His medical record notes that he has a history of anti companionable behavior, though it does not expand on this responsibilityment beyond the mention of his previous arrests. With no income coming in and increasing amounts of money used to fuel his drug and alcohol add iction, he muzzy his condo and all of his savings and was living at the Salvation forces 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 move from the homeless shelter to Alternative Homes in Minneapolis. Following his latest psychiatric hospitalization insurance in March, he began the partial hospitalization program at HCMC. Upon discharge from the current hospitalization, he will be move o Alternative Homes and participating once 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 d escribed. These sleep disturbances may present themselves as difficulty fall asleep, trouble controling sleep, or argus- inwardnessd 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 burning(prenominal). He has tried a variety of medications to promote sleep, but no(prenominal) have been effective.He can no endless be prescribed many of the medications for insomnia because of his history of abuse and overdose using p rescription drugs. Thus, the options available to him for sleep promotion lie in the realm of sleep hygiene promotion. The patient great power also billing participating in a sleep study, as this may reveal superfluous 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. query shows that diabetes mellitus, GI problems, hypertension, liver disease are tally with substance abuse (Moffitt, Caspi, Harrington, Milne, Melchior, Goldberg & Poulton, 2010). Indeed, the patients 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 teaching of type 2 diabetes, but they have also been shown to contribute to hyperglycemia, diabetic complications, functiona l impediment and mortality among diabetic patients (Moffitt et al. 2010). Also, as antecedently discussed, patients with GAD and MDD report more painful physical symptoms than the general population, and the patients 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 patients societal and family history is passably lacking. The patient was follow at a young age.He has three non- biologic brothers and he reports that he is move out from all of them, and is not willing to contact them until he has my life back together. In addition, both of his adopted parents are dead. The patient was not keen on discussing his adoptive family or his childishness and adolescence, but stated that this adoptive family were good people, and tried hard to give me everything I requisite. 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. In ruleation on the patients biological mother and family history is unavailable. The patient was presumption up for adoption at birth, and remained a ward of the state, living in mingled advance 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 value care system.Any instances of abuse, neglect, or trauma in his early years are and accordingly un don. Because there is no available family history, it is impossible to know if any of the patients first-degree relatives suffered from mental illnesses, or if the biological mother used drugs or alcohol during her pregnancy. This lack of entropy is unfortunate, as it is impossible to conjecture whether, or to what degree, the patients mental disorders have a basis in genetics or in disturbed foetal 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 hold in social support, as he is estranged from his adoptive siblings and has no conference with his biological family. The patient also has a history of limited social interactions and conterminous friendships. He reports that he has mat disconnected from others for as long as he remembers, and that he had few close friendships by dint ofout his childhood, adolescence, and adulthood.In addition, the patient reports that most of the relationships that he would call the close set(predicate) have been with people who have substa nce abuse problems, as he fagged years and years running with the treat 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 engage and maintaining recovery. During the time that he was sober, he states that his wife was the only friend I rightfully needed and as a result, he did not fake many close friendships with his peers.He states that he currently has no encouraging relationships. Furthermore, he has little desire to form such relationships. Application of adoptmental Theories consider the patient and his family and social history by the lens of addition theory provides a possible textile for viewing the patients development of mental illnesses. hamper theory, a biologically based framework first proposed by John Bowlby in the mid 1950s, is the theoretical approach used to describe the wideness of stable and batten down relationships of all babe s, especially those in protect 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 first-string 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 authorised fixing figure for approximately the first two years of life.If the attachment figure is broken or break during the critical two year period the child will suffer permanent long-term consequences of this deprivation, which might include delinquency, reduced intelligence, increased aggression, depression, and affectionless psychopathyan inabilityto show affection or concern for others. Research, such as the Adverse childishness Experiences Study, correlates untreated childhood adversity with an increased risk toward poor d evelopmental 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 dangerous because of their complex and immense wittiness 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 basal and most important developmental milestone for any infant is to generate a relationship, especially one with a particular caregiver.This period presents sensitive windows of hazard for the development of particular parts of brain social organization and circuitry influenced and dependent on social experiences for optimal brain development (Bruskas, 2010). The absolute majority of children enterin g foster care are infants, and the impact of not addressing mental health needs of preverbal children can have foul effects (National Research Council Committee on Integrating the Science of Early sisterhood Development, 2000).Although an infant may not be able to articulate losses because of their preverbal age, they until now experience regret and loss, and for many, these experiences will be forever embedded in their memory (Felitti & Anda, 2010). Moreover, the consequences of un rootd 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 supporting patriarchal 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, childrens coping strategies to manage such band may present as hostility, frustration, and anxiety with underlying feelings of fear, abandonment, and powerlessness (Bruskas, 2010).The relationships infants and children develop objet dart in foster care are crucial relationships characterized by institutionalise and cargo 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 complex body part becomes permanent and behavior becomes more difficult to change. Due to the patients 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 Eriksons model of psychosocial development impart for a greater understanding of the patients current state. Because of the disruption of relationships early in life, the patient may not ever have fade outd 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 patients reliance o n his wife as the sole supportive relationship in his life, as well as his fast channel into previous behaviors after his wifes death. As the patient was never able to develop a sense of autonomy, it seems that he became passing 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 world-class, be industrious, and have an familiar relationship, all of which are successful publications of developmental conflicts. The marriage provided him with hope, purpose, a sense of cultism and fidelity, as well as stand quench 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 conf licts 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 impropriety vs. , isolation to reach the adulthood coif 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 RecommendationsIt is important to remember that the patient was seeking help and trying to recover prior to his most young 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. T he patients 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 aspiration 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 habit-forming 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 patients 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 ph armacotherapy 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 antidepressant antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors, as well as other classes of antidepressants, such as Serotonin Norepinephrine re-uptake inhibitors, Norepinephrine Dopamine Reuptake Inhibitors, Alpha-2 obstructionists, 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 strictly 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 severe and un ethical. Electroconvulsive therapy has been recommended to treat his depression, but the patient has refused to undergo this treatment modality. The patients anxiety is more easily managed than his depression, and benzodiazepines have turn out 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 buspirone and Zolpidem, instead.Unfortunately, these medications have not been effective in controlling the patients 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 tall(a) 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 achievements the patient has identified as helpful are observance 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 meter and quality of sleep will also aid the patient in his recovery, as sleep deprivation is positively fit with depressive symptoms and anxiety levels. The patients scene is one of cautious hopefulness. Though the patient has experienced severe recurrences of MDD, GAD, and substance abuse in recent years, the patient had mainta ined a long period of sobriety prior to this, during which he was happy, productive, and high functioning.The patients ability to achieve remission from his mental illnesses during his marriage to his wife shows that put 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 insideng 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 wifes death, life as he knew it ended. Many people experience periods of long and severe depression adjacent 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 t ailspin. to a lower place the severe stress of not only his wifes 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 brokenheartedness of his wifes death, and furthermore caused him to lose his put forward 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 estimable 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 bloc I Major Depressive Disorder, Generalized Anxiety Disorder, Polysubstance Abuse bloc II Cluster B traitsAxis one-third Hypertension, Hepatitis C, Diabetes Mellitus, Type 2, Osteoarthritis of the left shoulder, deadly Reflux, Bilateral hearing loss Axis IV Chronic mental illnesses, chronic medical conditio ns, death of spouse, family estrangement, lack of social support, unemployment, financial insecurity, acute hospitalization, Axis V 35 (current), 75 (potential) Patient objects I essential to find medications that will help my depression and anxiety I neediness to keep from abusing my medications I want my grief over my wifes 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 treat Goal Patient will be well(p) 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 stabbing 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 invitee by using empathetic healthful communication (Eakes, Burke & Hainsworth, 1998). Educate the lymph node that grief resolution is not a sequential process and that the positive subject of grief resolution is the integration of the deceased person into the ongoing life of the griever (Matthews & Marwit, 2004). place available friendship resources, including grief counselors and community or Web-based bereavement groups. Focus on enhancing coping skills to alleviate life problems and miserable 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 veritable isolation. Assess the patients ability and/or inability to play off physical, psychosocial, spectral, and financial needs and how unmet needs further challenge the ability to be socially integrated. drill active listen skills to establish trust one on one and then gradually introduc e the patient to others. permit positive reinforcement when the patient seeks out others. encourage the lymph node 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 thickening to set realistic goals and identify personal skills and knowledge. economic consumption 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, press out fears and concerns, and set goals. Offer instruction regarding election coping strategies (Christie & Moore, 2005). Encourage use of spireligious rite resources as desired. Nursing Goal Patient will identify actions that can be taken to improve quality of sleep.Interventions discover a sleep-wake history, including history of sleep problems, chan ges 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 comfort music to facilitate sleep (Lai & Good, 2005). learn the patient sleep hygiene guidelines for up(p) 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 patients 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 lord therapeutic relationship, I introduced myself to the client, saying that I was a student nurse and shaking his hand. I do some small talk with him closely(predicate) such topics as sports and the patients 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 unsloped posture so a somewhat more relaxed position in his chair. The patient spoke slowly and eemed to have difficult finding the words he treasured to use. Such a speech pattern is characteristic of depression, one of the patients 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 hold 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 precipitate 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 research whether or not he mat up safe.I focused on actively listening to the patient, following the patients lead and sometimes asking clarifying questions. Because of the patients slower rate of response, I employed the use of silence to allow him to gather his thoughts and proceed a t 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 control 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 bridge 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 approve 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 s tatements 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 queer 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 its ok to be sad about that. The patient seemed appreciative of the acknowledgment of his pain and the justification of his sadness. I sat wordlessly 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 do ne throughout the interaction, to show that I was still interested and engaged despite the lack of verbalization.Because I had acknowledged the patients 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 create the response of his goals for the future, and his verbalization that he needed to find better coping mechanisms, because his old ones didnt seem to work.He also stated that he knew he needed to continue grieving my wife, because the drugs and alcohol kept me from insideng 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 s mall smiling expression and responded that he wanted to get back on the straight and narrow and take his medications the way Im supposed tono more, no less. The patients illuminance 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 charge 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). 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