Psychology

Substance abuse is a common mental illness that many people do not seek treatment for.  Even with rehabilitation centers servicing clients as inpatients or outpatients, self-help books, television reality shows, and anonymous group meetings there are still some people who do not believe that they have a chemical dependency problem.  The reality of the chemical dependency does not usually set in until a marriage ends, children become ex-communicated, termination from employment, physical illness, or a near death experience occurs.  Chemical dependency is even used as a form of self-medicating for an undiagnosed mental illness or disorder.

Background
Present
Lara is a new patient who requested therapy. She stated that her girlfriend refused to continue the relationship unless she sought treatment for her anger issues.  Laras voluntary entry into therapy was actually an involuntary entry. Lara is currently involved with a same-sex partner, and has stated that she has had several same-sex relationships. These relationships were said to have ended because the partner withdrew from the relationship due to its intensity.  Lara is employed in the high stress industry of entertainment.  Lara admits to drinking vodka and states that she often feels anxious and desperate.  She further states that she only drinks at parties on the weekends.  She added that she uses cocaine.  The cocaine use was done at first only at parties, but indicated that she now uses at home despite her efforts to cut down by only using on the weekends and at parties. Lara stated that she has now started shooting up, been experiencing low crashes, and has been missing work.  Lara says the cocaine makes her feel alive, alert, and focused.  She recently acted out in a violent episode at a party and physically beat the car that her girlfriend was seated in.  She punched the vehicle until she put dents in the hood, and admits to having sat in her car at the residence of her girlfriend due to suspected infidelity.  Lara also believes that her girlfriend is slandering her. Lara believes that she might be depressed.

Past
Laras childhood was eventful to say the least.  Her father died from a heart attack when she was just twelve.  Her father was an attorney and was unable to spend much time at home.  He was financially in ruins but this information was not known until after his death.  Her father was also a heavy drinker.  Her mother was a homemaker and was very focused on outward appearances. Lara states that her parents argued often over her fathers drinking.  She remembers feeling detached from her mother but very close to her father.   Lara recalls her mother being ill frequently, and suspects that her mother may have had a prescription pill addiction. She also speculates that her mother was depressed. Shortly after her fathers death, Lara and her mother relocated to a new home due to the financial problems left behind from her father.  It was a step-down both socially and economically.  Lara changed schools and behaved like nothing had ever happened.

Analysis
Diagnoses
The American Psychiatric Association (AMA) uses a V Axes model for explaining and diagnosing a patient.  This model addresses clinical disorders, personality disorders, general medical conditions, psychosocial illnesses, and a scale for scoring a patients safety to themselves.  After meeting with Lara, the following are speculated diagnoses devoid of any assessment testing.  Axis I indicates the presence of Post Traumatic Stress Disorder (PTSD).  This disorder is common in people who have been exposed to a violent assault, natural or human disaster, accident, or combat type of situation (National Institute of Health, 2010).  PTSD is an anxiety disorder that festers and emerges after being exposed to an ordeal where the patient feared for their life or the life of someone close to them (American Psychiatric Association, 2000).  This is believed true in Laras circumstance given the early death of her father, followed by changing schools and moving into a new neighborhood.  Lara stated feeling anxious and has recently had trouble making it to work which is indicative of hyper-vigilance (National Institute of Health, 2010).  She also lacks a good support network.  Her fear response is negatively reinforced by her violent behavior and chemical dependency.
   
The Axis II diagnosis is Borderline Personality Disorder (BPD).  Mary Zanarini defines BPD as being a serious mental illness characterized by a frequent instability of moods (Zanarini, 2008).  Common symptoms include intense bouts and changes in mood, substance abuse, impulsive aggression, and a fear of being alone.  The bouts and changes in mood may last for only an hour or a day, but they are usually short-lived.  This behavior interrupts family and work and creates problems with self-identity.  Lara does have issues with self-identity insofar as her admitting to being in a same-sex relationship.  There are questions with regard to sexual orientation.  Alcohol and drug use have been indicated during some of the violent outbursts that Lara has had.  While Lara claims to be suspicious of her girlfriends fidelity in the relationship, it is questionable as to whether or not Lara simply cannot cope with being alone.  This would offer an answer to her stalking-like behavior. This is not to discredit Laras initial assertion that she questions her partners fidelity as trust issues are common in patients with BPD.  Relationships for someone with BPD are often chaotic, intense, and unstable whereby the patient often makes frantic attempts to avoid being alone (Zanarini, 2008).

There is no diagnosis for Axis III as there is not general medical history to analyze, however Axis IV is diagnosed with Substance Dependence.  Substance dependence is different from substance abuse in that dependence demonstrates a compulsive use of a substance with total disregard to the problems often associated with its use (American Psychiatric Association, 2000).  The person will continue using the substance even though they have verbally or consciously promised to cut down or attempt to regulate their use.  Gradually over time, the person will realize that he or she is using more of the product or using the product more often than in the past (Lowinson, Ruiz, Millman,  Langrod, 2005).  Lara has indicated that she has often tried to regulate her usage to just weekends or at parties, but has found herself using at home during the week.  She also admitted to now shooting up cocaine, which is a more serious form of drug use.  It is not uncommon for Substance Dependency to be comorbid to other more serious mental disorders.  Patients often fall into drug or alcohol use as a means to stop certain feelings or thoughts (Back, 2010).  Seeking or being mandated into a drug or alcohol treatment program is usually when the other mental disorders are discovered.

Treatment
Hospitalization
It would be viable to suggest to this client the need of a temporary inpatient hospitalization in order to safely perform a detoxification from the chemicals and to stabilize the patient due to the PTSD and BPD.  This patient has recently been involved in a domestic violence situation whereby the patient physically caused damage to her partners vehicle.  The patient has also admitted to stalking-like behavior by sitting parked in front of her partners residence.  This patient admits to being depressed as well, which given the diagnosis of BPD and history of substance dependency, makes her a threat to herself and or someone else.  Other staff members should be made aware of the circumstances and intention to admit the patient because of the possibility of the patient emotionally splitting (Zanarini, 2008).  An involuntary hospitalization should be sought if the patient does not voluntarily agree to enter the hospital for treatment.

Therapy
Once the patient is admitted to the hospital and successfully completed the chemical dependency detoxification, therapy and medications can be administered to address the PTSD and BPD.  Cognitive Behavioral Therapy (CBT) would be conductive in treating the chemical dependency and PTSD.  The CBT would challenge the illogical beliefs and thoughts of the patient (National Institute of Health, 2010).  Classical conditioning can be used to reshape and redevelop the cognitive coping strategies that the patient is lacking (Back, 2010).  This is often done through relaxation training and systematic desensitization through the use of imagined and actual stimuli (Back, 2010).  An in hospital Narcotics Anonymous (NA) group would be mandated to get the patient in touch with an outside source of emotional support.  A Client Centered Therapy (CCT) would be beneficial to the conditions of PTSD and BPD.  This type of therapy would enable the patient to develop a rapport and sense of trust with the therapist.  This would also be beneficial to the patient since the BPD indicates long-term therapy as a form of treatment.  It is important in treating a patient with BPD to maintain open communication and emotional distance from the patient (Zanarini, 2008).  It may be necessary to develop a behavior contract with the patient, but the therapist must always be aware of the fact that emotional splitting could occur if the patient began to reject the primary therapist.  Dialectical Behavioral Therapy is most recommended in treating BPD.  This form of therapy teaches the patient
interpersonal skill, helps the patient to reshape the cognitive thought process, and increases the patients self-image. Even with therapy, the level of success in treating the BPD is moderate at best (American Psychiatric Association, 2000).

Medication
Medications are a part of many treatments of mental disorders.  In treating PTSD, clinicians often use anti-depressants or anti-anxiety medications.  These medications help the patient to resolve depressive symptoms with Imipremine or Zoloft and feelings of panic with medications like Valium or Xanax (National Institute of Health, 2010).  These medications are also useful in helping the patient to overcome some feelings associated with Substance Dependency (Back, 2010).  In treating the mental disorder of BPD, the area becomes gray.  Anti-anxiety drugs and anti-depressants are commonly used to aid in the symptoms associated with BPD, but there is no one pill or kind of pill known to effectively treat BPD (Zanarini, 2008).  Depending on the patients presenting condition, some clinicians may choose to go with a mood-stabilizer or an anti-psychotic drug (American Psychiatric Association, 2000).  The rationale really depends on the patients mental condition at that time.

Discussion and Conclusion
Therapies and medications are to be determined and prescribed by a licensed psychiatrist.  The information provided in the simulation case study was limited, and it is very difficult to make any determinations without critical assessments and test being performed first.  The behaviors of Lara do indicate an immediate need for hospitalization due to the threat that she poses not only to herself, but to others around her.  There is much research being done in reference to the Borderline Personality Disorder.  Often times, when there is a history of substance abuse or mental illness, the children end up pre-disposed and eventually develop some addiction or mental illness.  It has yet to be determined if this is a genetic condition or just mere coincidence.  Chemical dependency is often the first sign and symptom of a mental disorder, as it does co-morbidly exist with many mental disorders.  More research is needed in all three diagnoses in order to have a better understanding of effective treatments and the earlier detection of such disorders.