Excessive usage of marihuana and intoxicant, particularly within the last 2 old ages. “ Kurt ” began imbibing and utilizing marihuana at age 14 and by age 15 referred to the
use as “ heavy ” . Despite late being caught for the larceny of his parents TYME card and $ 400, which resulted in him being forced to fall in an AODA group, he still
continues to “ usage ” on a regular footing. He has besides gone to work while drunk and attended a school dance under the influence of marihuana. As a consequence he was
fired from his occupation and had to undergo a urine screen in order to once more be allowed back into his peculiar school. Regardless of these effects, 17-year-old “ Kurt ” still uses.
Background Information
Demographic: Male, age 17, white.
Early life: The youngest boy in a two parent household, one older brother, one deceased brother, and a younger sister. The oldest boy was killed in a “ freak accident ” about six old ages ago. “ Kurt ” expresses that since the accident ( which he doesn ’ t retrieve ) place life as been hard. His ma has psychological and AODA issues and has been diagnosed with Munchausen syndrome. He had a good relationship with his male parent. Relationship with brother non really good.
Current place life: Lives at place with both parents and younger sister in a individual household house. Staying older brother moved out, late. Average middle-class vicinity. Social life: Many friends with three to four being near. He enjoys being around people most of the
clip.
Education: Currently attends a parochial school, is on agenda for graduation. He ’ s in the 11th class and acquiring go throughing classs ( C-average ) .
Employment: Presently working part-time after school and weekends. Previous job-he was fired for demoing up drunk, nevertheless, has managed to maintain a “ summertime ” occupation for the last two old ages.
Military: N/A
Health: He rated current wellness as hapless, saying bad lungs from old turns with pneumonia, and a bad back due to a 17 % curvature of the spinal column doing musculus cramps in his lower dorsum.
Restrictions: None
Temper: No history of depression or passion.
Sleep: Occasional incubuss ( 2 to 3 times monthly ) .
Appetite: No jobs.
Sexual map: N/A
History of lost consciousness: Has passed out while imbibing.
Hospitalization: Twice for pneumonia.
Medicine: None
A
lcohol/drug usage: Heavy usage of marihuana and frequent usage
of intoxicant. Has besides experimented with narcotics which were stolen from his female parent. Hallucinogens, including “ acid ” and “ shrooms ” . He is besides a pack-a-day coffin nail
tobacco user.
Observations and Behaviors
Attitude: Good resonance during interview, really concerted,
Frank, and unfastened.
Appearance: Everyday.
Motor: Position slumped, seemed nervous, a small agitated,
but held oculus contact.
Address: Adequate and norm.
Language: Good vocabulary, normal.
Attention: Adequate.
Memory: Could non retrieve exact twelvemonth his brother died. Otherwise, memory seemed all right, with accurate item.
Temper: No depression or passion. Has had occasional ideas of self-destruction, but ne’er attempted. In the yesteryear has had anger- direction job, and saw a healer ( after ailments by instructors ) from 1987 to 1990.
Affect: Appropriate and normal.
Self-appraisal: Adequate.
Penetration: Consistent with abilities.
Judgment: Adequate.
Ideas: Appropriate to content, no phobic disorder, compulsions, etc.
Percept: Normal.
Attitude towards unwellness: Recognizes he has a job, but doesn ’ t see it as serious, therefore is non really motivated to repair, or work on the job.
Diagnosis
Axis I: Substance maltreatment, peculiarly intoxicant and hemp, surrounding on substance dependance.
Axis II: N/A
Axis III: Curvature of the spinal column.
Axis IV: Mother with important psychological jobs combined with AODA issues due to decease of oldest boy.
Axis V: 90
Support for diagnosing
Substance abuse-Despite being caught legion times for imbibing and drug usage, and enduring the resulting effects, “ Kurt ” refuses to abstain from take parting in these illegal activities. I ab initio thought that “ oppositional defiant upset ” may be a more appropriate diagnosing, but the negative, noncompliant, and hostile facets are non truly present. “ Kurt seems noncompliant merely in order to obtain the intoxicant or drugs he wants. This attitude doesn ’ t carry over into other facets of his life.
Treatment
I recommend continued AODA group therapy, but besides think
single talk therapy would profit. I feel that the substance maltreatment is a symptom of an implicit in job,
likely the consequence of the stressors at place. He may besides
be sing some mild depression and suffer from low self-pride.
