I saw an awesome Rheumatologist who does NOT think that this is lupus, or fibromyalgia or any other specific autoimmune illness that is destined to worsen, but "adrenal fatigue" from being on steroids for thirty years, worsened by the cortisol output from trauma/PTSD reactions. She described it as "tug of war" on my immune system, and basically agreed with the neurologists that it's a clinical picture they often see in long term steroid takers. I certainly don't regret the steroids - I'm alive to complain about pain, after all! Seems like a pretty fair trade to me. :)
Dr. Keys is the first non-psychiatrist I've ever had who even KNEW about the trauma-cortisol link, let alone took a PTSD diagnosis as meaning anything other than "she's probably just imagining things" or "of course she's casting herself as some sort of medical victim" or just "batshit crazy, must be all in her head or an attempt to score narcotics." Plus I was seriously Vitamin D deficient and was prescribed Vit D, and calcium supplements to protect against osteoporosis in my arms - weight is extremely protective for feet, legs and spine because weight bearing exercise is protective no matter how it is acquired. Also, she said not to worry about weight, just eat a variety of foods and exercise like I always have.
Health At Every Size is gaining popularity with Dr.s who read the research - half of people are fit, no weight differences in that. Even the heaviest fit fat people have better health and live longer than unfit "ideal weight" people. (And "overweight" people live longest and are healthiest of all the weight groups. "Ideal weight" people come next, and underweight and obese people trail mildly.)
Gender is a much more important lifespan factor - women are sicker but live over a decade longer on average. Men have fewer illnesses, but those illnesses tend to come late in life and be acute and short rather than chronic and long. There's some thought that chronic illness might even be protective, but it's not established and we really have no idea why women live longer. And yet there's no "War on Maleness" and we don't advise men to have sex reassignment surgery to improve their health, the way some people are convinced to have their stomach and intestines mostly cut out so they can't absorb nutrients and will lose weight. I'm not convinced by the science that it's any more rational. :)
"Carrie" Assessment and Plans Assessment Carrie has a seven year old son, Joseph Jr. (JJ), whose imminent birth caused her to marry Joe despite misgivings. He has been diagnosed with ADHD, and his four year old sister Rachel appears to have it as well. Carrie's addiction and possibly the macho tendencies in Joe – she could hide her drugs in the diapers because he never performed the chore of changing either child. In any case, she is overwhelmed by her rambunctious children and has difficulty setting structure for them to help with the ADHD symptoms and provide a family routine. Carrie is also apparently sexually preoccupied, having multiple affairs as well as sexually charged arguments with Joe in which they "make up" by having passionate sex. Joe suspects the infidelity but Carrie will not confirm it for fear of breaking up the marriage. She will not consent to couples or family therapy because she fears the issue will come up, even though those therapies might help unify the family more. LEISURE/RECREATION Carrie's recreation involves drinking, smoking marijuana, snorting cocaine and having sexual affairs with multiple men including her drug dealer in a sex-for-drugs prostitution arrangement. The drugs and drinking were expected and frequent events in her family of origin, which may influence her lack of a role concept without substance abuse involved. Her sister in law uses drugs with Carrie as well, despite Joe's family image of being straight and narrow abstainers. It is normative for mothers of young children to derive some of their leisure/recreation with them, but this does not appear to be the case for either Carrie, Joe or both together. There do not appear to be any family activities going on, or attendance of JJ's or Rachel's school events. It appears that alcohol and drugs provide Carrie's only respite from her stressful, chaotic and powerless life as an isolated stay at home mom without non-using friendships. This area is deferred unless legal issues arise. AXIS II: 799.9 Diagnosis Deferred V61.20 Parent-Child Relational Problems Carrie was clearly suffering from physiological withdrawal symptoms including moodiness and shakes from cocaine dependence (DSM 4R AXIS I 304.2). I believe that Carrie has the strong motivation of potentially losing her children and the unpleasant withdrawal symptoms from cocaine. Carrie is admitted to residential treatment, but her insurance refuses to pay more than seven days. Since her family is wealthy they chose to self pay for the rest of the 30 day course of inpatient treatment. She plans to return to weekly individual therapy with me following her residential treatment. A summary of our mutually agreed on formal treatment goals at intake follow. The first priority is that Carrie has been referred to her primary care physician for an examination today, including her potentially lethal asthma with prescriptions written in the customary way. Carrie seems to be in the action stage in this area of treatment. The physician will also consider a prescription to treat depressive symptoms. The agency, with Carrie's written consent, will keep a copy of all prescriptions and pass any medication scheduled during program hours. There is no risk for HIV infections as Ms.O has been celibate by choice for many years and has tested negative every year for work. Our nurse will track respiratory signs daily and as needed, and therapists will assess Carrie for worsening depression daily. The possible role of depression in her recent relapse will be explored in itself, as well as along with other psychosocial factors. Carrie identified her religious faith creating a positive outlook, limiting her social circle to "safe" and trusted individuals including a few close friends, 12 step sponsors and her church family as supports in her recovery. She identified a tendency to be "attracted to bad people" and lack of power over addiction with any use at all as addiction triggers that may or may not be se t off at work. Carrie was open to identifying triggers and using behavioral methods to dampen or eliminate them. Mary Heil, BS LBSW
Prof. Rodney Mulder
Carrie's medical history is minimal by her report, despite a ten plus year substance abuse history and domestic violence until her "after her first child was born." which would seem to imply that her husband physically abused her during pregnancy. She is not forthcoming with medical history details such as whether she practices safe sex when high or uses nicotine. She does not report taking any medication or practicing birth control methods of any kind. Carrie will be referred to a medical doctor for a gynecological exam to rule out AIDS and other STDs as well as cervical cancer potentiated by them. Weight is also an immediate concern - Carrie is severely underweight, only 3 pounds over the anorexia diagnostic level. Weight instability through rapid losses and cycling due to crack use may put her at risk for medical problems, although she reports no weight-associated illnesses in her family history or personal health indicators. Carrie reports that when she uses crack she simply has no appetite and does not eat. She reports no history of otherwise disordered eating. Carrie says that she experiences withdrawal symptoms from crack cocaine use, and her moodiness and jitters are evident. She has a history of blackouts from alcohol beginning at age 16, nine years ago. Crack withdrawal causes her labile mood and shakes, but cardiac effects of withdrawal are not always as evident in women as men. I have referred her to a local gynecologist for a medical examination. Carrie appears willing to seek medical care and take any prescribed medications while in our program.
General Observations: Carrie presents today with excellent self care but quiet and withdrawn demeanor. She avoids eye contact and is only getting the treatment she needs because her husband threatened to call CPS on her for neglect of their two children. Her memory, insight and orientation are intact and she poses no immediate danger to herself or others. Carrie gives the overall impression of numb, overwhelmed mood and poor insight into or denial of the serious nature of her substance abuse. She appears shocked, and agrees to my recommendation for inpatient treatment, when we explore how her children could be harmed if she is too intoxicated or crashed to respond to an emergency in the night. Carrie gives a "mild" trauma history of a forced abortion at age sixteen and domestic violence in her marriage, which she minimizes. Carrie reports that she has never had counseling or attended NA or AA, so we have arranged a beginning in her first residential substance abuse program: individual, group, and family available might raise her self esteem, helping the domestic issues.
We plan to provide individual outpatient treatment following her inpatient program, and Carrie feels that this will be adequate. Mood symptoms will be monitored by staff due to the link between depression and substance abuse or dependence, especially crack cocaine. There seems to be no need for a psychiatric referral, but inpatient will monitor symptoms. Carrie appears to have subclinical problems in several areas: mood disturbance, dangerously low (nearly anorexic level) .weight with risky weight cycling due to substance abuse. Formal psychiatric treatment is deferred at this time, but will be reconsidered should the depressive mood prove disruptive to Carrie's substance abuse treatment. If she is diagnosed with depression or another psychiatric illness, Carrie indicates a willingness to take medication if recommended by the physician.
Carrie reports that she started drinking as a young adolescent, and snorted cocaine only after she married into wealth. Her report today was enough data to diagnose her with Cocaine Dependence. She had been using cocaine daily for six months, and is visibly experiencing cocaine withdrawal after two days clean with obvious jitters, moodiness and general malaise. She reports use triggers being the kids' behavior, high stress and being at family parties with alcohol. Carrie has tried several times to quit on her own without success. Carrie experienced her first alcohol blackout at age 16 following a forced abortion. Carrie noted heavy alcohol and drug abuse in several generations of her family of origin. Carrie's social roles and functioning have been seriously impaired by her substance abuse: she is neglecting her children, prostituting herself for cocaine and having affairs, there is hostility and tension in her marriage, and her use as a teen cut off her schooling and she has no GED and virtually no job experience as a result. Carrie realized for the first time the potential of hurting her children by using heavily after they are asleep. She consents to attend our residential treatment program for the 30 days her insurance covers. We agree that she will try the very intensive residential treatment first, re-entering this individual program afterward for further intervention. She has private insurance that will cover part of the residential treatment, and the family agrees to self pay for 16 days of inpatient treatment.
FAMLY & SOCIAL
Carrie tells me that she is the middle sister of three, with no brothers. She felt sibling rivalry keenly and acted out with substance abuse and sex from early adolescence to get attention from her parents. Carrie's family is distant at this time, but not intensely hostile. However, she must attend "raucous parties" with drug and alcohol use rampant to get any time with her family at all when they come to New Jersey twice annually. They will not forsake the parties to visit with Carrie. Her present family seems dysfunctional to a moderate degree. Joe was twenty years old when he started to date Carrie at only fifteen, and coupled with the physical abuse early in marriage, resistance to parenting equally, and his family's enmeshed approach with Carrie, there seems to be a dominance issue in their relationship. Emotional abuse is evident, including the threat to call child protective services on Carrie unless she met with me. Carrie feels that she has no privacy in Joe's enmeshed family, which includes the secretary at the family business as well as Joe's intimidating father. Her sister in law Maureen was told by Joe's father to move in to help with the children, but Carrie and Maureen ended up doing drugs together and had the same dealer. The family always sides with Joe, who shares even the most private details of their marriage with his family.
Carrie, who comes from a working class background, feels out of place in her upper class neighborhood and avoids forming relationships with neighbors. She does not have friends or family (except Joe and his dad) who don't use substances at this point in her life. Carrie feels confined as a stay at home mother but her lack of a high school diploma or GED severely limits her ability to get jobs. This may be part of the dominance issue in her marriage, since Joe instigated her high school dropping out. She has thoughts of leaving Joe, and they once separated, but the only work she could find was a cocktail waitress job, which paid next to nothing and certainly would not let her raise the children. It also gave her frequent opportunities to drink, if it was a typical tavern job. She does not want to lose custody of her children, which is likely if she divorces Joe given his superior ability to support them and lack of formal substance abuse history.
LEGAL & MILITARY
Carrie has no family or personal military background, and no she legal issues relating to substance abuse at least yet. Joe has threatened to turn her in to child protective services for neglect, and even if he doesn't, a divorce and custody battle seem likely.
AXIS I: 304.2 Cocaine Dependence with Physiological Dependence
AXIS III: Deferred
AXIS IV: V61.10 Partner Relational Problems
AXIS V: Current GAF: 45
GAF over the past year: 60
Carrie is a 25 year old European American woman who presents today requesting substance abuse treatment following six months of daily powder cocaine use. She agreed to seek treatment because her husband Joe threatened to report her to child protective services for neglect of their children.
AXIS II was coded 799.9 Diagnosis Deferred, because Carrie functions very successfully socially when uninfluenced by substances and no signs of personality disorder were present. Axis III was also deferred because Carrie is apparently in good health, but she was referred to a medical doctor because her probable unsafe sex practices during prostitution and affairs, long term alcohol and drug use and physiological withdrawal from cocaine pose numerous health risks. The AXIS IV Diagnosis of Partner Relational Problems and Parent-Child Relational Problems reflects Carrie's addiction related hostility and anger in her relationship with Joe and impaired ability to care for and provide structure to her children JJ and Rachel. Therefore on AXIS V, Carrie seems to fall in the severely impaired Global Assessment of Functioning range of 45, compared with a GAF of 60 in the past year, before she added daily cocaine use to her pre-existing alcohol and marijuana use, which do not appear to rise to the level of dependence at this time.
The second treatment priority addresses the psychosocial path from recovery to relapse and will focus on the substance abuse itself: to help Carrie identify possible triggers for this binge relapse. It appears that she is in the preparation stage and has recently had enough difficulty to produce relapse. She appears to be regrouping and making progress, recognizing the need for treatment and actually seeking it immediately is a positive sign. Initially it appears that depressed mood with less attention to self care and prevention, loosened standards for forming social ties and possibly an unusual vulnerability to known psychological and physiological addiction relapse triggers at work may be the major contributors. Carrie plans to explore these matters during individual and groups therapy.
The third main treatment goal is psychological: to restore Carrie's self esteem and self-confidence through individual and group treatment. She appears quite devastated emotionally by this relapse, although intellectually she recognizes it as part of an episodic illness. Carrie reported feeling discouraged, hypocritical and even incompetent in her professional addictions treatment provider role, which she highly values. These statements point to the contemplation stage, with a need to rebuild Carrie's confidence, self esteem and re-acceptance of existing strengths the goals that can move her toward emotional and physical addiction recovery. Obliquely assigning Carrie leadership roles in the educational portions of treatment may boost her confidence, and reinforcing her naturally emerging leadership role in groups will counter these false beliefs. Individually exploring relapse as a teacher and something that happens to virtually everyone with an addiction may help her accept the event emotionally and neutralize it.
The fourth goal employs Carrie's leisure time and activities, increasing time spent in her supportive, drug-free church activities and daily or more often 12 step group attendance with her few very close friends. Carrie stated that expanding her social circle too much contributed to her relapse because, "I'm attracted to bad people." She will identify strategies and implement a plan of strengthening positive leisure activities.
Carrie is supported by her employer socially and administratively by the 70% of her coworkers who are in addiction recovery themselves. She has an uncharacteristically accepting workplace where she can be open about the need for leave and the purpose. The only treatment issues here are to assist her in filing for FMLA and identify potential work triggers creating plans to manage them during vulnerable times of life.
With respect to Carrie's goal to earn and online Social Work Administration master's degree, exploration of her readiness to start and the effect of stress versus the stress relieving enjoyment of studying will be examined. It does not appear that education has triggered relapse in the past, but this issue still warrants exploration and setting up coping strategies.
Since Carrie has never served in the military and has not experienced legal issues for many years, these areas of treatment are deferred.
I believe that Carrie's treatment prognosis is excellent. She is a professional substance abuse counselor, very educated and aware of the components of treatment. She was sober for 16 years before this relapse and comes to the program immediately following a four day relapse binge. Carrie is strongly motivated for change, has a deeply held personal faith and a drug-free church family for help, and attends 12 step programs daily. Given her quick action, insight, and willingness to participate in treatment, it seems likely that intensive outpatient therapy will resolve the issues surrounding this brief relapse. If the need emerges for more intensive treatment, Carrie is eligible for our residential treatment program.
"Carrie" Assessment and Plans
AXIS II: 799.9 Diagnosis Deferred
Mary Heil, BS LBSW