National Albuterol Shortage

 

My husband has had asthma his whole life and depends on respiratory drugs like albuterol to keep himself healthy. Right now, there's a national shortage, and I've already been informed by two different pharmacies that they can't get it and don't know when they will get it. Luckily, he has lots of Hispanic friends who willingly pick up medication for him when they travel to Mexico. We keep a backup supply for times like this. But, I'm scared for the people who don't have that option. They will end up in the hospital unnecessarily or die. This is a disgraceful example of what's happening in our medical/pharmaceutical system. And real people are suffering as a result.

Dawn Pisturino

May 12, 2023

Copyright 2023 Dawn Pisturino. All Rights Reserved.

Adjustment Disorder and Internet Gaming Disorder

 

Photo by Fredrick Tendong on Unsplash

The final project for my Online Digital Obsessions class asked us to create a fictitious patient with an electronic addiction, adopt the role of a college counselor, and create a treatment plan for this patient's therapeutic intervention. In the end, we were required to predict the challenges and outcomes for this patient. At this time, there is no official diagnosis, "Internet Gaming Disorder." The proposed diagnosis was referred for further study by the American Psychiatric Association. However, it is expected to be adopted in the future. Playing video games is only a problem when it becomes the dominant interest in somebody's life and undermines their normal functioning in day-to-day living.

Adjustment Disorder and Internet Gaming Disorder

by Dawn Pisturino

Thomas Edison State University

Introduction

       Jeremy Reed is an 18-year-old Caucasian male who was referred to counseling by his academic advisor for depression.  He says that adjusting to university life has been difficult, and he has been feeling increasingly depressed.  He began playing World of Warcraft on his computer to relieve stress and cope with his depressed feelings.  He became so involved in the game that he began neglecting his homework, and his grades are suffering.  His academic advisor referred him to counseling so he does not lose his full-ride scholarship to the university. 

       The client says that playing World of Warcraft makes him “feel good,” and he does not want to stop.  He has made new friends and become a “top player.”  He admits to feeling more depressed and irritable when he is not playing the game.  I explain to Jeremy—who is a biology major—that he feels good when he plays World of Warcraft because the activity activates the reward system in his brain and stimulates the release of dopamine.  The more he activates this system, however, the more he craves the gratifying pleasure produced by the game.  He needs to spend more hours playing the game to reach that same level of pleasure and craves playing the game when he is not able to do so.  Playing the game has become more important to him than his academic performance, so he is neglecting his schoolwork and falling behind.  As he loses control over his impulse to play, I explain, his life will spiral more and more out of control.  He is at great risk for not sleeping and eating, neglecting his hygiene, alienating his roommate, and losing his scholarship and admission to the university if he does not reduce his game playing and start improving his academic performance.  Jeremy agrees that this is true but also states that he does not want to completely give up playing the game (Gros et al., 2020, pp. 2-4; Tavormina & Tavormina, 2017, pp. 422-424).

Clinical Assessment

       For this assessment, I am using the Therapist Clinical Assessment/Psychosocial Assessment tools used routinely at Flagstaff Medical Center Behavioral Health Unit in Flagstaff, Arizona, and the PHQ-9 questionnaire because I am familiar with these forms.  The PHQ-9 is used to screen clients for symptoms of depression and has a proven track record of accuracy and reliability.  Clients who fill out the form are scored based on their responses.  Scores equal to or greater than 10 can indicate a depressive disorder (American Psychological Association, 2020, para. 1-2).

       The client, Jeremy Reed, presents as withdrawn with a flat affect and a disheveled appearance.  His thought processes are linear and logical with organized thinking.  He is alert and oriented.  His speech is coherent and clear, but he is delayed in his responses.  His psychomotor activity appears normal, but he makes poor eye contact.  His thought content is realistic, but he exhibits poor insight into his excessive video game activity even though his memory and judgment are within normal limits.  He denies hearing voices, having hallucinations, or experiencing extreme mood swings.

       Jeremy denies any current suicidal and homicidal ideation.  He denies any actual self-harm or harm to others.  He denies any thoughts of suicide/homicide in the past or making any gestures or threats of violence against others.

       The client denies any history of sexual, verbal, emotional, or physical abuse.  He does not recall witnessing any extreme acts of violence.  He reports that his parents argue sometimes but always resolve their differences amicably.  He is an only child and has no half-siblings or step-siblings.

       Jeremy confirms that he is a healthy heterosexual male with little sexual experience.  He is currently single and not sexually active.  Although he would like to have a girlfriend, he believes it would interfere even more with his studies.

       The client says he is a nominal Protestant and only attends church at Christmas and Easter.  He has experimented with yoga and meditation in the past to live a healthier lifestyle.  He does not routinely pray or engage in spiritual practices.

       Jeremy currently lives on campus in a dorm and has no housing needs.  He is unemployed at the moment but worked part-time at Burger King in high school.  He is studying biology and plans a career as a biologist.  Since he has a full-ride scholarship to the university, his parents help out with his expenses.  He says he does not want to lose his scholarship or disappoint his parents.

       The client has no military experience and no legal difficulties.  He has never been arrested or suspended from school. As far as he knows, his developmental history was normal.

       Jeremy says he played basketball in high school and still enjoys playing when he can find the time and other players.  He has no significant medical history, no known allergies, and takes no prescribed medications. The client appears well-nourished and physically fit.  His tonsils were removed at age 10.  He broke his arm when he fell off his bike at age 12.  He is already registered with the university’s student health services.  Currently, he reports staying up late playing video games, feeling tired the next day, and eating too much junk food.  He says he lacks the motivation and concentration to study.

       The client denies any mental health history.  He states that his depression and anxiety began a couple of months ago when he began his freshman year of college.  This is his first time living away from home, and he is having trouble adjusting to university life, living with a roommate, and being away from his family.  He is carrying a full load of credits and feels stressed out and overwhelmed by all the homework, expectations, and pressure.

       Jeremy believes his paternal grandfather was a heavy smoker and alcohol drinker.  His father drinks alcohol occasionally, mostly on holidays.  His mother takes Vistaril occasionally for anxiety.  He admits to trying cannabis twice but did not like it.  He denies all other substance use except alcohol, which he uses occasionally on the weekends.  His only source of caffeine is Coca-Cola.

       The client states that his main form of recreation right now is playing Internet video games, i.e., World of Warcraft.  He wants to cut back and resume his studying, but he derives a lot of satisfaction from the game and does not want to stop playing the game completely.  He admits that he loses track of time while on the game.  He is not fully motivated to quit.

       Jeremy describes his strengths as being goal-oriented and a good student.  He is strongly motivated to complete his college degree and start work as a biologist.  He describes his weaknesses as being too introverted and serious.  He believes he has poor coping skills when it comes to stress.  He wants help overcoming his depression and anxiety but says he is not interested in taking medication.  Although he does not see playing video games as a serious problem, he admits that it has already affected his grades and academic standing.  His PHQ-9 score is 13, with 4 boxes checked in the gray areas.  His score indicates moderate depression that is making it difficult for him to function at his normal baseline (American Psychological Association, 2020, para. 1-3).

Probable Diagnoses and Treatment Plan

Probable Diagnoses

Problem #1 – Adjustment Disorder with Mixed Anxiety and Depressed Mood (ICD Code   F43.23) ( ICD-10 Coded, 2022, para. 1)          

       Adjustment disorder occurs when a person is faced with a stressful life situation, such as going away to school.  Jeremy describes having a difficult time adjusting to university life and

being away from home.  He has no prior history of depression, anxiety, or other mental health issues.  His symptoms appeared less than three months ago after arriving on campus for his freshman year, meeting the DSM-V criteria.  He reports increasing depression and anxiety that are affecting his ability to cope with his new situation.  If Jeremy agrees with the assessment and treatment plan, his prognosis looks good. (American Psychiatric Association, 2015, pp. 120-121; Kenardy, 2014, para. 1-3; Mayo Clinic, 2023, para. 1-13).

Problem #2 – Internet Gaming Disorder (no ICD code until ICD-11) ( Petry et al., 2015, pp. 1,7)

       Internet gaming disorder (IGD) appears in the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-V) in Section III under the heading of “Conditions for Further Study.”  The DSM-V provides criteria for IGD that closely align with the criteria for other addictive disorders, like substance use disorder and gambling disorder.  Clients who meet at least five of the criteria could be considered suffering from or at high risk for Internet gaming disorder (Petry et al., 2015, pp. 1-5).

       Jeremy has been playing Internet video games to relieve stress, anxiety, and depression.  He has been spending increasing amounts of time playing video games and spending less time sleeping and studying.  As a result, his academic performance has declined, and he risks losing his full-ride scholarship.  Currently, Jeremy meets six of the criteria on the DSM-V list of criteria: preoccupation, tolerance, neglecting other activities, escapism, and risking losing his

educational opportunities.  He has only been playing for a couple of months and is not fully motivated to quit, even though he recognizes that he needs to make some changes in his life.  If

he agrees with the assessment and treatment plan, however, his prognosis looks good (Petry et al., 2015, pp. 2-3).                                           

Treatment Plan

Goals and Objective

       Jeremy’s primary concern is protecting his full-ride scholarship and earning his biology degree.  His second goal is to learn new coping skills to deal with his depression, anxiety, and stress.  His third goal is to achieve more balance in his life between studying and recreation.  His fourth goal is to reduce his time playing video games and participate in more physical activities, like basketball.  Overall, the client’s objective is to return to his normal baseline status before going away to college.  He wants the same self-confidence and control over his life that he had before.  He wants to regain his motivation and commitment to studying and succeeding in school.  He wants a positive outcome that will help him grow as a person and mature into adulthood.

Action Plan

       Psychotherapy is the primary evidence-based treatment for both adjustment disorder and Internet gaming disorder (IGD).  The client will benefit from weekly psychotherapy sessions to discuss how and why leaving home and starting college has made such a huge impact on his well-being, including his use of video games to relieve stress.  If psychotherapy is insufficient to stabilize the client, a course of medication may be helpful.  The client, however, is unwilling to try medication at this time (American Psychiatric Association, 2015, pp. 63, 121; Gros et al.,

2020, p. 15; Kenardy, 2014, para. 4, 6-7, 10; Mayo Clinic, 2023, para. 22-23; Petry et al., 2015, p. 6; Tavormina & Tavormina, 2017, p. 424; Torres-Rodriguez et al., 2017, pp. 1003, 1005-1006, 1010-1011).

Interventions

       Cognitive behavioral therapy (CBT) is effective in helping clients to recognize and re-frame harmful patterns of thought and behavior.  The client will be referred to a therapist who is proficient in CBT since it has been proven successful in treating both adjustment disorder and IGD.  I will encourage the client to continue seeing me on a weekly basis at the clinic for one-to-one motivational and support counseling and provide him with opportunities to participate in clinical workshops that will help him to learn new skills in stress management, anger management, relaxation activities, mindfulness and resilience training, and goal-focused solutions.  With Jeremy’s cooperation, we will devise a schedule that maps out times for study, recreation, and playing video games that supports his class schedule and enhances his goals and objective.  I will suggest that he join a campus support group for new students.  I will refer him to mental health peer support services for monitoring and help.  If the client requires medication, I will refer him to a psychiatrist or psychiatric nurse practitioner for evaluation and prescriptions. 

I will get consent from the client to speak to his parents, make them aware of the situation, and offer them support.  Since Jeremy is in a vulnerable age group, he needs intense support to get through this temporary setback.  Otherwise, this could turn into an ongoing issue (American Psychiatric Association, 2015, pp. 63, 121; Gros et al., 2020, p. 15; Kenardy, 2014, para. 4, 6-7, 10; Mayo Clinic, 2023, para. 22-23; Petry et al., 2015, p. 6; Tavormina & Tavormina, 2017, p. 424; Torres-Rodriguez et al., 2017, pp. 1003, 1005-1006, 1010-1011).

Challenges

       Since Jeremy is highly motivated to protect his full-ride scholarship and complete his degree, his prognosis is good as long as he follows the treatment plan.  Challenges include ongoing depression, anxiety, and stress that may undermine his motivation, time constraints due to carrying a full load, and relapsing on playing video games.  I will provide him with literature and books that will help him to understand the biological, neurological, and psychological nature of his problems.  This may pique his interest as a biology student and keep him involved in his

therapy.  I will suggest that he drop any extra credits that he is taking.  The client will be given positive encouragement and reinforcement to stick to his goals.  I will work with his assigned peer support person to monitor his progress and participation.

Conclusion

       Eighteen-year-old Jeremy Reed was referred to my office for depression, anxiety, and excessive playing of video games by his academic advisor.  Jeremy’s symptoms began when he moved into the campus dorm to start his freshman year of college a few months ago.  Since then, he has been spending more time playing video games and less time studying.  His academic performance has suffered, putting his full-ride scholarship at risk.

       This client is positive for symptoms of adjustment disorder and Internet gaming disorder.  His age makes him a high risk for long-term mental health issues, including suicide, if he does not participate in treatment.  If he cannot control, reduce, or eliminate his video game activity, he will continue to decline academically, which will impact other areas of his life (Kenardy, 2014, para. 2).

 References

American Psychiatric Association. (2015). Understanding mental disorders: Your guide to

       dsm-5. Washington: American Psychiatric Publishing.

American Psychological Association. (2020). Patient health questionnaire. American

       psychological association. Retrieved from

       http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/

       patient-health.

Gros, L., Debue, N., Lete, J., van de Leemput, C. (2020). Video game addiction and emotional

       states: Possible confusion between pleasure and happiness. Frontiers in psychology.

       doi: 10.3389/fpsyg.2019.02894.

ICD-10 Coded. (2022). ICD-10-cm code f43.23. ICD-10 coded. Retrieved from

       http://www.icd10coded.com/cm/F43.23/

Kenardy, J. (2014). Treatment guidance for common mental health disorders: Adjustment

       disorder. Australian psychological society inpsych 2014, 36(5). Retrieved from

       http://www.psychology.org.au/inpsych/2014/october/kenardy.

Mayo Staff Writers. (2023). Adjustment disorders. Mayo clinic. Retrieved from

       http://www.mayoclinic.org/diseases-conditions/adjustment-disorders/diagnosis-treatment/

       drc-20355230.

Petry, N.M., Rehbein, F., Ko, C., O’Brien, C.P. (2015). Internet gaming disorder in the dsm-5.

       Current psychiatry reports, 17(72). doi: 10.1007/s11920-015-0610-0.

Tavormina, M.G.M., Tavormina, R. (2017). Playing with video games: Going to a new

       addiction. Psychiatria danubina, 29(3), 422-426.

Torres-Rodriguez, A., Griffiths, M.D., Carbonell, X. (2017). The treatment of internet gaming

       disorder: A brief overview of the pipatic program. International journal of mental health

       addiction. doi: 10.1007/s11469-017-9825-0.  

February 19, 2023

Copyright 2023 Dawn Pisturino. All Rights Reserved.

      

      

 

 

 

 

 

Electronic Addictions, Las Vegas Style

 

(Photo from Unsplash)

Electronic Addictions, Las Vegas Style

When people go into a casino, they are mesmerized by the colors, bright lights, and dinging bells of slot machines that, nowadays, look suspiciously like video games. In fact, the video game craze has influenced what kinds of games casinos offer to their customers. The live-action table games are slowly being replaced with interactive video games. Not only is this cost-effective for casinos, but machines can be manipulated to take more of the customer’s money.

But why are people so attracted to the Las Vegas type of bells and whistles that they find in casinos, amusement parks, and video arcades? Why are they mesmerized by these same effects on their video games, computers, and smartphones? Are consumers being trained to use electronic devices like toys – and not just tools for business and communication?

According to an article posted on the Psychology Today website, “the typical American spends about 1460 hours per year on their smartphone” (Brooks, 2019, para. 2). The author attributes this behavior to the variable ratio reinforcement schedule, a conditioning process that draws users over and over again to their electronic devices, and in particular, video games. With the right psychological rewards in place, users can quickly become hooked (Brooks, 2019, para. 3).

In a variable ratio reinforcement schedule, rewards are delivered randomly so that the electronic device user has to use the device more and more in order to get the psychological reward. If the user stops using the device, he gets no reward. But if he keeps going, the reward will eventually be delivered, hooking the user even more (Brooks, 2019, para. 4-5).

Why does this happen? Dopamine is released by the brain when the reward system is activated. A random reward reinforces the reward system further, leading the electronic device user to unconsciously look for the stimulus that delivers the reward (Brooks, 2019, para. 7).

The anticipation and expectation of reward entice the device user to keep using the device and receiving the reward once more . . . over and over again . . . until the user has lost control over his own impulses. Unless the user has strong sales resistance and self-discipline, he may find himself glued to his device, drawn there like a bee to honey. This is why the diagnosis of impulse control has become so pertinent to the abuse and overuse of electronic devices (Brooks, 2019, para. 8).

Reference

Brooks, M. (2019). The “vegas effect” of our screens. Psychology Today. Retrieved from

       http://www.psychologytoday.com/us/blog/tech-happy-life/201901/the-vegas-effect-our-

       screens.

Dawn Pisturino

January 7, 2023

Copyright 2023 Dawn Pisturino. All Rights Reserved.

Christmas Humor

 

My cat knocked over the Christmas tree three times this year before she finally got the message to leave it alone. She likes to chew on the ends of the branches, but the flocking always makes her sick. Luckily, she didn't break any ornaments. Do your pets mess around with the Christmas tree?

MERRY CHRISTMAS!

Dawn Pisturino

December 22, 2022

Thanksgiving Prayer

 

Happy Thanksgiving!

October Prayer for Children and Parents

 

October Prayer for Children and Parents:

Father, we pray that the heart of the parents will be toward their children, and the heart of the children will be toward their parents. Give our children obedient hearts that they may obey their parents in the Lord, for this is right. Grant them the will to honor their father and mother that it may go well with them and that they may enjoy long life on the earth in the name of Jesus. Amen.

Based on Ephesians 6:1–3. 

From Prayers.org

Dawn Pisturino

Starry, Starry Night

 

I’ve visited many art galleries and museums, including the De Young Museum in San Francisco, the Getty Museum in Los Angeles, and the Metropolitan Art Museum in New York City, and seen many wonderful and inspiring paintings, but what really stands out in my mind is Vincent Van Gogh’s The Starry Night. Its brilliant blue and yellow colors, active night sky, and peaceful ambience (in spite of the strong brush strokes and turbulent sky) provoke speculation, mystery, and fascination, in my mind. What was Van Gogh thinking? What was he feeling? Most importantly, what was he seeing?

It’s well known that he suffered from mental illness and attempted to commit suicide by shooting himself in the chest. He later died of the wound. His death surprised people who believed that he was actually in a more positive frame of mind at the time of his death. But who knew what was really going on in his mind and in his heart?

(People who have decided to kill themselves often appear more positive and energetic because they have made the final decision and no longer feel conflicted about their actions. In fact, people can feel so depressed that they lack the energy to actually harm themselves. Appearances are deceiving, and it’s important to remember this if you are dealing with someone in your life who suffers from depression and suicidal ideation.)

Sometimes, people ask if persons who are mentally ill are more artistic than others. When I worked in mental health, I met scores of patients who were phenomenal artists. Not only did they possess an exceptional natural talent for art, but engaging in art helped them to concentrate their attention, focus their thoughts, freely express their ideas and emotions, make sense of the larger world around them, distract them from troubling thoughts and feelings, and help them to cope with anxiety and depression. (When I worked in Flagstaff, we had an actual art therapist who would come in and do art projects with the patients.) I cannot say that their mental illness made them more artistic. In some cases, their lack of self-esteem and confidence actually caused them to suppress their talent. On the other hand, people who are intimately in touch with their emotions make great artists because they can freely express themselves without regard to social convention and self-constraint. But people who are over-sensitive and cannot manage their own emotions can be more susceptible to mental health issues.

So, it’s a conundrum. Did Vincent Van Gogh’s mental illness make him a great artist – or did his mental illness interfere with his natural artistic talent? I don’t know.

What do you say?

Dawn Pisturino, RN

Copyright 2022 Dawn Pisturino. All Rights Reserved.