Week #10 Assignment: Assessing and Treating Patients with Impulsivity, Compulsivity, and
Addiction
Name
College of Nursing-PMHNP, Walden University
NURS 6630: Psychopharmalogical Approaches to Treat Psychopathology
...
Week #10 Assignment: Assessing and Treating Patients with Impulsivity, Compulsivity, and
Addiction
Name
College of Nursing-PMHNP, Walden University
NURS 6630: Psychopharmalogical Approaches to Treat Psychopathology
Professor
Due date
2
Assessing and Treating Patients with Impulsivity, Compulsivity, and Addiction
Gambling disorder is a psychiatric disorder characterized by recurrent, maladaptive
gambling behavior leading to clinically distressing symptoms. In DSM 5, gambling disorder is
classified as a substance-related and addictive disorder. The categorization of gambling disorder
as a substance-related and addictive disorder was made because of the similarities between it and
substance use disorders. Menchon et al., (2018) wrote that numerous studies found that substance
use disorders and gambling disorders have analogous characteristics in reference to their
diagnostic criteria and symptomology, high comorbidity rates, genetic vulnerabilities, and their
relationship with cognitive deficits and biological markers. Martinac et al., (2019) added that up
to 73% of gamblers suffer from alcohol addiction and alcoholics are five to six times more
predisposed to developing a gambling disorder. Notably, the severity of gambling disorder is
directly associated with alcohol consumption levels.
Purpose statement
The purpose of this paper is to assess and treat Mrs. Maria Perez, a 53-year-old Puerto
Rican female who presented to the psychiatric clinic with what she termed as an “embarrassing
problem.” The patient admitted that she had alcohol use problems since her late teens when her
father died. She also stated that she has been on and off Alcoholics Anonymous for the past 25
years. In the past two years, she experienced difficulties maintaining her sobriety after a casino
near her home was opened. Mrs. Perez admitted to drinking alcohol while gambling to keep her
calm during high-stakes games, which leads to more reckless gambling and drinking. Although
she attempted quitting alcohol, her gambling habits made it difficult to quit. Her cigarette
smoking habits also increased. The patient is concerned about her spending habits as she
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borrowed $50,000 from her retirement account to pay off her gambling debts without her
husband’s knowledge. She is also worried about weight gain resulting from excessive alcohol
consumption as she has gained about 7lbs. Mental status exam findings show that the patient has
challenges with impulse control.
The goal for managing Mrs. Perez is to assist her in the gradual reduction of gambling
habits and substance abuse disorder. By the end of three months, the PMHNP aims to achieve at
least 75% symptom reduction as evidenced by reduced visits to the casino, reduced alcohol
consumption and cigarette smoking, and reduced financial expenses linked to gambling. While
managing this patient, specific factors should be considered. First, the patient abuses alcohol.
She has also gained weight, and she demonstrates impulsivity.
Decision #1
The initial decision in managing Mrs. Perez is to prescribe naltrexone 380mg IM on the
gluteus region every four weeks. This decision is informed by evidence from several clinical
trials confirming its efficacy in alleviating gambling and substance abuse habits. Kim et al.,
(2001) found that naltrexone 25mg/day reduced gambling symptoms measures considerably. For
instance, patient-rated and clinician-rated Clinical Global Impression (CGI) improved by p<.001,
Gambling symptom rating scale improved by p<.019. At the end of their study, 75% of
naltrexone-treated patients were much or very much improved than 24% of placebo-treated
patients. Additionally, Huang et al., (2006) found that naltrexone significantly reduced alcohol
craving among people with gambling disorder (p<.001). Grant et al., (2008) found that
naltrexone regardless of the dosage reduced gambling urges (p=.0053) and behavior in gambling
disorder (p=.0134). Besides, naltrexone-treated patients had greater improvements in gambling
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severity (p=.0080) than placebo-treated patients. Morley et al., (2006) also conducted a
randomized control trial to compare the efficacy of naltrexone and acamprosate and found that
naltrexone resulted in a significant reduction in alcohol dependence than acamprosate (p<0.05).
Maisel et al., (2013) found that naltrexone is efficacious in reducing heavy drinking and craving
while acamprosate resulted in statistically significant results in maintaining abstinence (p<.005).
The PMHNP did not prescribe disulfiram 250mg because the patient is currently taking
alcohol. Patkar et al., (2013) cite that disulfiram interferes with alcohol metabolism, thus, leading
to acetaldehyde accumulation which results in side effects such as tachycardia, flushing, and
sweating that may result in non-adherence. Besides, Grant et al., (2017) found that disulfiram did
not result in a beneficial response in reducing problem-gambling features while naltrexone did.
The PMHNP did not also select acamprosate because it is efficacious in abstinence instead of
reducing gambling urges, which the patient is suffering from.
The aim of prescribing naltrexone IM is to reduce the number of visits by the patient to
the casino, alcohol abuse, and cigarette smoking by 35% by the end of four weeks. According to
Kovanen et al., (2016), naltrexone-treated participants demonstrated a 38% reduction in
gambling urges in a month.
Some of the ethical issues impacting Mrs. Perez’s treatment plan and communication
include seeking informed consent by educating the patient about her condition and available
treatment options. The PMHNP should also educate the patient on concerns while using
naltrexone. For example, concomitant use of opioids such as morphine and codeine may not be
effective while using naltrexone (Toneatto et al., 2009). This allows the patient to make informed
choices. The PMHNP also upheld beneficence by choosing an evidence-based option whose
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safety and efficacy is confirmed by clinical trials. Communication with the patient should uphold
patient confidentiality.
Decision #2
The next decision in managing Mrs. Perez was informed by outcomes after administering
naltrexone 380mg IM. The patient reported that she did not drink any alcohol in the past four
weeks. She also reported a reduced frequency of visiting the casino but considerable spending,
anxiety, and continued cigarette smoking. Therefore, the next decision was to continue
naltrexone administration and refer the patient to a counselor for psychotherapy. According to
Choi et al., (2017), there is no FDA-approved medication for gambling disorder. Psychotherapy
for gambling disorder utilizes similar principles as those used in addiction because they have
shared themes, including loss of control, continued gambling despite knowledge of its
deleterious effects, and preoccupation. Psychotherapeutic approaches commonly employed for
gambling disorder include cognitive-behavioral therapy and motivational interviewing that
change the patient’s cognitions about gambling and allow them to adopt adaptive behaviors and
promote motivation for change (Choi et al., 2017).
The PMHNP did not add diazepam to manage Mrs. Perez’s anxiety because it is a
benzodiazepine. Benzodiazepines are contraindicated among patients with alcohol use disorders
because of the risk of dependence, overdose, and death. Schimtz (2016) also wrote that alcohol
enhances the sedative effects of benzodiazepines, and their combination is linked to fatal
consequences such as coma and death induced by respiratory depression. Diazepam in this case
is suggested as an option to alleviate the patient’s anxiety, which is a side effect of naltrexone.
Stahl (2013) asserts that medications should not be added to a patient’s regimen to manage
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another medication’s side effects. The PMHNP did not also add Chantix despite its known
efficacy in smoke cessation. The standard starting dose of Chantix is 0.5mg rather than 1mg.
However, it can be titrated gradually to 2mg/day (Hajek et al., 2015). By prescribing 1mg/day of
Chantix, the PMHNP predisposes the patient to unwanted side effects such as nightmares, severe
nausea and vomiting, and agitation.
The aim of referring Mrs. Perez to a counselor for psychotherapy is to reduce gambling
by 75% based on baseline behaviors and maintain alcohol cessation. Besides, the PMHNP aims
at reducing the patient’s cigarette smoking habits by at least 25%. Since psychotherapy teaches
patients about how to identify maladaptive thoughts and behaviors and motivates them to
change, the PMHNP aims to improve all behaviors linked to lack of impulse control.
In this phase, some of the ethical considerations impacting the patient’s treatment plan
and communication are issues of consent, maintaining patient confidentiality, and veracity. The
PMHNP should seek Mrs. Perez’s consent to refer her to a counselor and demonstrate
truthfulness when communicating with the patient by informing her that the mainstay of
management for gambling disorder is psychotherapy. The PMHNP should also seek the patient’s
consent to share her information with the counselor.
Decision #3
Four weeks later, the patient returned stating that her anxiety had gone and she did not
like her counselor. She also began attending a local meeting of Gamblers Anonymous and that
she felt supported in the group. The next decision is to explore the issue Mrs. Perez is having
with her counselor and encourage her to continue attending the Gamblers Anonymous meetings.
Exploring issues in the therapeutic relationship between Mrs. Perez and her counselor is crucial
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to promoting the attainment of patient goals. A therapeutic relationship is the quality of the bond
between a therapist and a client and the overall approach to therapy. The therapeutic relationship
is a reliable and substantial contributor to client goal attainment (Stargell, 2017). A break in the
therapeutic alliance is attributed to the discontinuation of th
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