Adam's Case Study
Aside from the detailed history, and physical examination, I chose to use the Mental Status Examination for screening, the ICD-10 checklist for psychoactive substance use syndrome module and the DSM-5 for assessment and diagnosis. Adam’s case meets the ICD-10 criteria for dependence syndrome (heroin), based on the following criteria: (a) strong desire or compulsion to take the substance; (b) difficulty in controlling substance-use behavior; (c) physiological withdrawal on discontinuation of or reduction of substance intake; (d) evidence of tolerance (need for increasing doses of medication to achieve the initial effect of the drug); (e) progressive neglect of other interests; (f) persistence with substance use despite evidence of harmful consequences.
Narrowing of the personal repertoire of pattern of substance misuse (for example, always injecting with friends as opposed to be at home) is also present. Currently, he seems to be in Heroin withdrawal and is on the Dependent/Compulsive stage of the Continuum of drug use. It is also determined that on Coding based on current severity, he is on level 304.00 (F11.20): Severe: Presence of 6 or more symptoms.
On DSM-5, This young man has the diagnosis of Heroin Use Disorder due to his use of heroin and he has at least two of the following symptoms within a 12 month period: Taking more opioid drugs than intended; Wanting or trying to control opioid drug use without success; Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs; Cravings opioids; Failing to carry out important roles at home, work or school because of opioid use; Continuing to use opioids, despite use of the drug causing relationship or social problems; Giving up or reducing other activities because of opioid use; Using opioids even when it is physically unsafe; Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway; Tolerance for opioids; and Withdrawal symptoms when opioids are not taken (American Psychiatric Association, 2013).
Narrowing of the personal repertoire of pattern of substance misuse (for example, always injecting with friends as opposed to be at home) is also present. Currently, he seems to be in Heroin withdrawal and is on the Dependent/Compulsive stage of the Continuum of drug use. It is also determined that on Coding based on current severity, he is on level 304.00 (F11.20): Severe: Presence of 6 or more symptoms.
On DSM-5, This young man has the diagnosis of Heroin Use Disorder due to his use of heroin and he has at least two of the following symptoms within a 12 month period: Taking more opioid drugs than intended; Wanting or trying to control opioid drug use without success; Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs; Cravings opioids; Failing to carry out important roles at home, work or school because of opioid use; Continuing to use opioids, despite use of the drug causing relationship or social problems; Giving up or reducing other activities because of opioid use; Using opioids even when it is physically unsafe; Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway; Tolerance for opioids; and Withdrawal symptoms when opioids are not taken (American Psychiatric Association, 2013).