Assessing And Treating Patients With Impulsivity, Compulsivi ✓ Solved

Assessing and Treating Patients With Impulsivity, Compulsivity

Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction Impulsivity, compulsivity, and addiction are challenging disorders for patients across the lifespan. Impulsivity is the tendency to act upon sudden urges without considering consequences; patients often describe impulsivity as living in the present moment without regard to the future. These disorders frequently manifest as negative behaviors, leading to adverse outcomes. Compulsivity involves performing driven behaviors to relieve anxiety. Such behaviors may contribute to addiction, representing a progression from impulsive to compulsive behaviors.

As a psychiatric nurse practitioner (PNP), one plays a vital role in identifying and addressing the underlying causes of these behaviors and assisting patients in overcoming them. This involves comprehensive assessment and personalized treatment planning. Pharmacologic intervention is often necessary and should be tailored considering individual patient factors, including life span, comorbidities, and specific health conditions.

Assessment and Treatment Considerations

Assessment involves understanding patient history, behavioral patterns, and potential contributing factors such as comorbid psychiatric conditions or substance use disorders. Treatment may encompass psychopharmacologic approaches, psychotherapy, and behavioral therapies. Pharmacological options include medications such as selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, naltrexone, acamprosate, and agents targeting specific pathways involved in impulsivity and compulsivity.

When prescribing medications, it is essential to evaluate pharmacokinetic and pharmacodynamic processes, especially when dealing with diverse age groups and health statuses. Factors like hepatic and renal function, drug interactions, and previous medication responses influence medication choice and dosing.

Examining a Case Study: A Puerto Rican Woman With Comorbid Addiction

A 53-year-old Puerto Rican woman presents with gambling disorder and alcohol use disorder. She reports a history of alcohol problems starting in her late teens, with recent escalation in gambling behaviors following exposure to a local casino, especially when combined with alcohol consumption. She has significant financial debts and has borrowed from her retirement fund. The patient exhibits impaired impulse control and reports feelings of sadness, with ongoing problematic behaviors. Her case exemplifies the complexity of treating impulsivity, compulsivity, and addiction in a patient with multiple substance use disorders and behavioral addictions.

Introduction to the Case

Mrs. Perez is a middle-aged woman with a long-standing history of alcohol use disorder and recent developing gambling addiction, exacerbated by environmental factors such as the opening of a new casino. Her comorbidities include increased smoking, weight gain, and financial jeopardy. Her age and cultural background influence her treatment approaches, pharmacodynamics, and pharmacokinetics—for example, hepatic function may impact medication metabolism. Her impaired impulse control and ongoing addictive behaviors necessitate a nuanced, individualized treatment plan integrating medication and psychosocial interventions.

Decision Point One

Choice: Vivitrol (naltrexone) injection, 380 mg IM every 4 weeks.

Rationale for the Choice

The administration of Vivitrol, an extended-release injectable form of naltrexone, is supported by evidence showing effectiveness in reducing alcohol cravings and relapse rates (O'Malley et al., 2014). It is particularly advantageous for patients with adherence challenges because of its once-monthly administration, ensuring consistent medication delivery. Furthermore, naltrexone has shown efficacy in reducing gambling behaviors and alcohol consumption (Grant et al., 2014), making it suitable for Mrs. Perez’s comorbid disorders.

It is also beneficial because it lacks sedative properties, reducing the risk of further impairment or interactions with other substances. Additionally, this medication minimally affects hepatic function, which is relevant given Mrs. Perez’s possible liver impacts from alcohol use.

Why Not the Other Options?

• Disulfiram (Antabuse): Disulfiram requires strict abstinence from alcohol before initiation and adherence, which Mrs. Perez struggles with due to her environmental triggers and cravings. Its potential for adverse reactions with alcohol, possibly accidental, also makes it less appropriate for her case.
• Acamprosate (Campral): While effective for maintaining alcohol abstinence, it does not address gambling behaviors directly and requires multiple daily doses, which may challenge compliance in a patient with impulsivity.

Goals of This Decision

Administering Vivitrol aims to decrease alcohol cravings, reduce relapse risk, and potentially diminish gambling urges by targeting shared neurobiological pathways involved in impulsivity and addiction, supporting overall behavioral stabilization.

Ethical Considerations

Using Vivitrol aligns with beneficence and nonmaleficence principles by providing a safe, evidence-based intervention. Ensuring informed consent, discussing potential side effects (e.g., liver enzyme elevation, headache), and monitoring are vital. Respecting the patient's autonomy involves explaining the benefits and risks clearly and including her in decisionmaking, especially given her financial and emotional distress.

Decision Point Two

Choice: Add on Valium (diazepam) 5 mg TID/PRN for anxiety

Rationale for the Choice

Benzodiazepines like diazepam can provide immediate relief from anxiety symptoms, which are common during early phases of addiction treatment (Hulvershorn et al., 2015). Mrs. Perez reports significant improvement initially, indicating a positive response. Use in this context aims to improve her overall stability and compliance with therapy, which could facilitate engagement in behavioral interventions.

Why Not the Other Options?

• Increase the dose or frequency: Given her history of substance dependence, increasing benzodiazepine dosage risks dependence, respiratory depression, and worsening addiction. Long-term benzodiazepine use is discouraged, especially in patients with substance use histories.
• Discontinue benzodiazepines altogether: Complete withdrawal might precipitate severe anxiety and withdrawal symptoms, risking relapse or withdrawal complications.

Goals of This Decision

Initial use of diazepam aims to manage acute anxiety, supporting her ability to undergo other therapies. However, plans should include tapering and monitoring for dependence, with alternative interventions considered for long-term anxiety management.

Ethical Considerations

Administering benzodiazepines to a patient with substance use disorder requires balancing the relief of suffering (beneficence) versus the risk of harm (nonmaleficence). Transparent conversations about risks, dependency potential, and the importance of adhering to the tapering plan are crucial.

Decision Point Three

Choice: Continue Vivitrol while decreasing Valium to 5 mg TID and planning discontinuation

Rationale for the Choice

This approach aligns with best practices for minimizing dependency risks associated with benzodiazepines in patients with substance use disorders (Hulvershorn et al., 2015). Continuing Vivitrol supports alcohol abstinence and reduces relapse risk, while tapering benzodiazepines mitigates dependence development. Referral to counseling enhances behavioral strategies, and addressing smoking cessation further improves health outcomes.

Why Not the Other Options?

• Increase Valium dose: Escalating doses would heighten dependence risk and exacerbate impulsivity and addiction issues.
• Maintain current dose without tapering: Prolonged benzodiazepine use contradicts best practices in substance use disorder management.

Goals of This Decision

Achieve symptom control while reducing medication dependency, promote long-term behavioral change, and address comorbid health risk factors such as smoking. Psychosocial interventions complement this pharmacologic management.

Ethical Considerations

Prioritizing safety (nonmaleficence) and promoting autonomy through informed consent remain critical. Transparent communication on the tapering plan, side effects, and referral supports ethical, patient-centered care.

Conclusion

In managing Mrs. Perez’s complex presentation, a comprehensive, phased pharmacological plan targeting her alcohol and gambling disorders is essential. Initiating Vivitrol offers evidence-based benefits for reducing cravings and relapse. Combining this with cautious benzodiazepine use to manage acute anxiety, followed by tapering and adjunctive behavioral therapy, aligns with best practices for reducing dependency risks. Engaging her in psychosocial support such as counseling and support groups like Gamblers Anonymous enhances her chances of sustainable recovery. Addressing health behaviors like smoking cessation further promotes holistic care and improves long-term outcomes.

References

• Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381.
• Hulvershorn, L. A., Schroeder, K. M., Wink, L. K., Erickson, C. A., & McDougle, C. J. (2015). Psychopharmacologic treatment of children prenatally exposed to drugs of abuse. Human Psychopharmacology, 30(3), 164–172.
• O'Malley, S. S., et al. (2014). Efficacy of long-acting naltrexone for alcohol dependence: A systematic review. Journal of Substance Abuse Treatment, 46(1), 31–37.
• U.S. Food and Drug Administration. (2014). Vivitrol (naltrexone) prescribing information. FDA.
• Hulvershorn, L. A., Schroeder, K. M., Wink, L. K., et al. (2015). Psychopharmacologic treatment of children prenatally exposed to drugs of abuse. Human Psychopharmacology, 30(3), 164–172.
• Rohde, P., et al. (2014). Pharmacotherapy for impulsivity and compulsivity. Current Psychiatry Reports, 16, 464.
• Sanches, M., et al. (2014). Impulsivity in mood disorders. Comprehensive Psychiatry, 55(6), 1337-1341.
• Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders. Treatment Improvement Protocol (TIP) Series, No. 32.
• University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control. Journal of Psychosocial Nursing & Mental Health Services, 54(4), 15.
• Loreck, D., et al. (2016). Managing opioid abuse in older adults. Journal of Gerontological Nursing, 42(4), 10–15.