Treating Clients With Impulsivity, Compulsivity, and Addiction

Impulsivity, Compulsivity, and Addiction in a 53 Year-Old Puerto Rican Female Diagnosed with Gambling Disorder and Alcohol Use Disorder (AUD): Pharmacotherapeutic Considerations

Psychiatric/ mental health problems sometimes manifest through a person’s unreasonable or repetitive actions that occur despite the same actions hurting the person. Included in this are impulsivity and compulsivity. Impulsivity can be defined as actions or behaviors that are not thought over, that are dangerous and risky to the person doing them, and that appear inappropriate to a reasonable person. The actions or behaviors lead to negative outcomes on the person performing the actions. Compulsivity on the other hand is the habit of repeating particular actions or habits despite the fact that the same actions/ habits bring about detrimental consequences to the performer (Chamberlain et al., 2018). Some of the diagnostic areas in which impulsivity and compulsivity are operational are addiction disorders like gambling and alcohol use (Sadock et al., 2015; APA, 2013). This paper is about the pharmacologic management of a 53 year-old female with alcohol use disorder and gambling disorder.Treating Clients With Impulsivity, Compulsivity, and Addiction

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Decision 1

The decision taken at this point was to prescribe for her naltrexone (Vivitrol) injection for the alcohol dependence as:

  • Start naltrexone (Vivitrol) 380 mg IM intragluteal every 4 weeks.

This decision was selected because naltrexone is approved by the Food and Drug Administration (FDA) for use in treating alcohol dependence. It is an evidence-based pharmacotherapeutic intervention for alcohol dependence in those diagnosed with alcohol use disorder such as Perez (Stahl, 2017). By selecting this decision, it was hoped that the Vivitrol would start triggering a reduction in alcohol consumption by Perez by the end of the first four weeks, or by the time she would be coming back for the next injection (Stahl, 2017). When she came back after four weeks, she reported that she has not drunk alcohol since the time she received her first injection of Vivitrol four weeks earlier. She is however still smoking and reports having increasing anxiety. There was no difference between what was expected and what the client presented with after the initial four weeks. It was expected that the injection would make her stop taking alcohol, and this came to pass. It was also expected that she might suffer one or more of the known side effects of naltrexone. Indeed, she reported having anxiety which is one of the known side effects of naltrexone (Stahl, 2017).

Decision 2

The decision taken at this point was to refer Mrs. Perez to a therapist/ counselor to receive psychotherapy and counseling for her gambling addiction (Sadock et al., 2015; APA, 2013). This decision was taken because there is no particular FDA-approved modality for treating gambling addiction. However, because this is a behavioral problem, it would make sense to surmise that psychoeducation and behavioral psychotherapy would be effective in disabusing the gambling addict of the impulsive compulsive behavior of gambling (Sadock et al., 2015). As a matter of fact, behavioral addictions such as gambling addiction have been shown through anecdotal and circumstantial evidence to be responsive to psychosocial support and behavioral therapies such as cognitive behavioral therapy or CBT (Hilliard, 2020). Cognitive behavioral therapy makes use of cognitive restructuring or remodelling. What this means is that the client is taken through therapy that is aimed at making them change the way they think. It is hoped that by changing their way of thinking around their behavioral addiction, they will eventually change their behavior concerning the detrimental habit they have such as gambling.Treating Clients With Impulsivity, Compulsivity, and Addiction

By making the above decision, it was hoped that Mrs. Perez would develop a therapeutic relationship with her counselor/ therapist so that the therapy would result in a reduction in the rate at which she is gambling. In the end, it was hoped that she would ultimately be disabused of the habit and completely stop engaging in it going forward. It was not expected that the behavioral treatment would be easy though. Challenges were expected and the fact that Mrs. Perez reported that she did not connect well with the therapist she was referred to was not entirely unexpected.

When Mrs. Perez came back after another four weeks for her subsequent appointment and naltrexone injection, she reported that the anxiety she had developed was gone. This was welcome news since the side effect of naltrexone appears to have resolved on its own without any intervention. Unfortunately, the client reported on this return visit that she met the therapist she was referred to but did not therapeutically connect with her. This was not good news since the client needed counseling and psychotherapy as the modalities that were expected to help her stop the habit of gambling. But behavioral therapy and counseling requires that the client and the therapist first develop a bond and a therapeutic relationship. If the two fail to develop a bond as happened in this case, then it would be very difficult to achieve any results and the outcomes will not be encouraging. Development of a bond and a therapeutic relationship between client and therapist/ counselor is dependent upon trust. When this is missing, there is no way that favorable outcomes can be realized. Mrs. Perez also reported during this visit that after she failed to establish a therapeutic rapport with the counselor she was referred to, she started attending meetings of her local chapter of gamblers anonymous. She has just started but says that she feels more at home in that setting and feels appreciated. She has even spoken in one if the meetings and feels that group therapeutic/ curative factors such as catharsis and altruism are in operation in this newfound group (Ezhumalai et al., 2018).Treating Clients With Impulsivity, Compulsivity, and Addiction

The difference between what was hoped and what was achieved by Mrs. Perez between the last visit and this one was that:

  • It was expected that she would develop a therapeutic relationship with her new counselor but this did not happen.
  • It was expected that she would still be having the anxiety caused as a side effect of the naltrexone, but she reported that she no longer had the symptom.

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It is not unusual for a client to fail to develop a therapeutic relationship with their therapist. Therefore, the reason for Mrs. Perez not liking the new counselor may be due to them having different personalities that clash. There could be other reasons too, including misinterpretation of the actions and intentions of the therapist. That the side effect of anxiety resolved itself can only be described as a result of Mrs. Perez’s body adjusting to the naltrexone in terms of pharmacokinetics and pharmacodynamics.

Decision 3

The decision taken was to try and explore the reasons behind the lack of rapport between Mrs. Perez and the counselor. Also, she was to be encouraged to continue attending the gamblers anonymous meetings as they appeared to help her heal. The reason for this was that psychoeducation and psychotherapy are important interventions for managing addictions and Mrs. Perez would be better off benefiting from it. What was hoped to be achieved by this decision was that the client would reconsider her decision to stop attending therapy sessions with the counselor. It was also hoped that the gamblers anonymous meetings would help her stop gambling in the long run. It is expected that the client may not return to the counselor, but will continue with the gamblers anonymous meetings. In any case, it is the end that justifies the means. If the meetings can help her stop gambling, then so be it. There is no expectation of there being a difference between what is expected and the outcomes. The client will also be encouraged to stop the habit of smoking. On this she may be given alternatives which are both behavioral in nature (educational) and pharmacologic. The naltrexone will be continued for a period not longer than one year for complete remission (Stahl, 2017). Treating Clients With Impulsivity, Compulsivity, and Addiction

 

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Chamberlain, S.R., Stochl, J., Redden, S.A., & Grant, J.E. (2018). Latent traits of impulsivity and compulsivity: Toward dimensional psychiatry. Psychological Medicine, 48(5), 810-821. http://dx.doi.org/10.1017/S0033291717002185

Ezhumalai, S., Muralidhar, D., Dhanasekarapandian, R., & Nikketha, B.S. (2018). Group interventions. Indian Journal of Psychiatry, 60(Suppl. 4), S514-521. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_42_18

Hilliard, J. (September 17, 2020). Gambling addiction. Addiction Center. https://www.addictioncenter.com/drugs/gambling-addiction/

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Treating Clients With Impulsivity, Compulsivity, and Addiction