Case M: Martin Intake Date March 2020 Demographic Data ✓ Solved

Case M CASE OF MARTIN INTAKE DATE: March 2020 DEMOGRAPHIC DATA

Case M: The case study of Martin details his background and current psychiatric condition, revealing key components of his mental health challenges, particularly related to substance use disorders. Martin, a 38-year-old African American male from Kansas City, Missouri, presents with complaints of stress and relationship issues stemming from his substance use. His intake reveals significant alcohol consumption and a history of recreational drug use, which has escalated particularly following a heart attack in December 2018.

The chief complaint is notable: Martin's wife expresses her unhappiness and desire to leave him. This marital strain is compounded by Martin's increased irritability and substance use, particularly of alcohol and prior use of cocaine and marijuana. Therapeutically, the focus is on understanding Martin's symptoms through a differential diagnosis approach as outlined by the DSM-5.

Diagnosis and Explanation

According to the DSM-5, Martin's symptoms suggest a diagnosis of Alcohol Use Disorder (AUD). The full diagnosis includes:

• Name of the Disorder: Alcohol Use Disorder
• ICD-10-CM Code: F10.20
• Severity: Moderate
• Z Codes: Z63.0 (Problems in relationship with spouse or partner)

To explain this diagnosis, the symptoms identified in the case are matched to the specific criteria for AUD. Martin exhibits significant distress and impairment, evidenced by his drinking habits and interpersonal conflicts. He routinely consumes alcohol to cope with anxiety, experiences withdrawal symptoms (irritability), and has failed to control his substance use.

Assessment and Validation

To validate Martin’s diagnosis and clarify missing information, I would employ the Alcohol Use Disorders Identification Test (AUDIT) and establish comprehensive screening for co-occurring disorders, such as anxiety or depression. Tracking his progress would necessitate repeated assessments and possibly standardized evaluations to monitor substance use and assess changes in his mental state.

Engagement and Cultural Considerations

Explaining the diagnosis to Martin should be done sensitively, framing the understanding of AUD in the context of its impact on health and relationships. Given his cultural background, it is crucial to acknowledge stigma around substance use and provide education on addiction as a medical condition rather than a personal failing. Engaging him in treatment would involve building rapport, offering a supportive environment, and facilitating a path for open communication about his struggles.

Initial Recommendations for Treatment

My initial recommendations for Martin's treatment would include a combination of Medication-Assisted Treatment (MAT) and counseling. The rationale for incorporating MAT, particularly naltrexone, is to help manage cravings and support his sobriety during this vulnerable period. Collaboration with a therapist specializing in addiction would also be beneficial in providing cognitive-behavioral strategies to enhance coping skills and address his relationship issues.

Resources and Referrals

Specific resources for Martin include outpatient treatment programs focusing on alcohol recovery, as well as support groups such as Alcoholics Anonymous (AA) tailored to his demographic. Referrals to services facilitating marital therapy could address relational difficulties. These recommendations consider his ethnic background and the societal pressures he faces, ensuring culturally sensitive support and fostering a sense of community.

Conclusion

Overall, it is essential to craft a personalized treatment approach for Martin, prioritizing his unique experiences and cultural context. This holistic strategy not only addresses his substance use but also aims to restore his familial relationships and improve his overall quality of life.

References

• Morrison, J. (2014). Diagnosis Made Easier (2nd ed.). New York, NY: Guilford Press.
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author.
• Capuzzi, D., & Stauffer, M. D. (2016). Foundations of Addictions Counseling (3rd ed.). New York, NY: Pearson Education, Inc.
• Substance Abuse and Mental Health Service Administration. (2020). Substance Use Disorder Treatment Engagement.
• Gowin, J. L., et al. (2017). Vulnerability for alcohol use disorder and rate of alcohol consumption. American Journal of Psychiatry, 174(11), 1094-1101.
• Reus, V. I., et al. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86–90.
• Stock, A.-K. (2017). Barking up the wrong tree: Why and how we may need to revise alcohol addiction therapy. Frontiers in Psychology, 8, 1-6.
• Best, D. et al. (2016). Overcoming alcohol and other drug addiction as a process of social identity transition. Addiction Research and Theory, 24(2), 111–123.
• Petrakis, I. L. (2017). The importance of identifying characteristics underlying the vulnerability to develop alcohol use disorder. American Journal of Psychiatry, 174(11), 1034–1035.
• Hom, M. A., et al. (2016). Insomnia brings soldiers into mental health treatment, predicts treatment engagement. Journal of Psychiatric Research, 79, 108–115.