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Substance/Medication-Induced Bipolar and Related DisorderPrincipal DSM-5Diagnosis (Focus of treatment): 304.20 (F14.20) Stimulant Use Disorder, Moderate (Cocaine)Additional DSM-5Diagnoses: 292.89(F14.229) Stimulant Intoxication, Moderate (Cocaine)292.84 (14.24) Substance/Medication-Induced Bipolar and Related Disorder Relevant Medical Diagnoses (if known): None at this timeNote: Refer the client to a detoxification program, collaborate with detox center for a treatment plan, evaluate and track the progress of the client.Other Conditions That May Be a Focus of Clinical Attention:V62.29 (Z56.9) Other Problem Related to EmploymentV62.89 (Z60.0) Phase of Life ProblemV62.4 (Z60.5) Target of (Perceived) Adverse Discrimination or PersecutionV69.9 (Z72.9) Problem Related to LifestyleMeasures of Symptom Severity/Disability The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is an assessment for adults that measures disability in ages 18 and up (American Psychiatric Association, 2013). There are six domains measured within the WHODAS that are scored on a 5-point scale, these domains include 1) understanding and communicating, 2) getting around, 3) self-care, 4) getting along with people, 5) life activities, and 6) participation in society (AmericanPsychiatric Association, 2013). There are 36 items listed on the WHODAS. The domain of
ASSESSMENT9cognition may provide information on how Derek responds to daily problems and his responses to those problems. The domain of getting around provides information on Derek leaving the house, neighborhood, and vacationing. The domain of self-care looks at Derek’s physical appearance, hygiene, cleanliness of clothing, eating habits, and sleeping patterns. The domain of getting along with people can provide insights on how Derek is maintaining his current relationships, including family, intimate, and friendships. The domain of life activities can provide information on how Derek is handling his home and work responsibilities and if they arebeing done well and on time. The domain of participation in society can explore the problems Derek is experiencing when interacting with others. Diagnosis FormulationDerek meets several criteria for the primary diagnosis of stimulant use disorder. Based upon the vignette, Derek’s partner found a small bag of white powder in Derek’s luggage. William believed the powder to be methamphetamine (Capella, n.d.). Angel, Derek’s brother, suspected Derek of hanging around people known to be methamphetamine users (Capella, n.d.). The behaviors that Derek has displayed are congruent with symptoms of substance use, according to the DSM-5 (American Psychiatric Association, 2013). Derek also shows signs of stimulant intoxication due to the drug causing behavioral and psychological changes, such as anger, belligerence, and impaired judgment (American Psychiatric Association, 2013). Finally, symptoms of substance/medication-induced bipolar and related disorder include a persistent disturbance in disposition that is categorized by episodes of elevated or irritable mood (AmericanPsychiatric Association, 2013).