Richard is a 32-year-old single man who has episodically worked part time as a computer programmer but who has been unemployed much of the time since dropping out of college a decade earlier. He was referred for a psychiatric evaluation after his parents had become increasingly frustrated by his behavior, threatening to “kick him out” of their house if he didn’t’ “get sober, get a job,, and get a life.” The patient reports he “has been a mess” his whole life, with a persistent inability to function effectively at work, at school, and with friends. He has dated “a little” but the relationships “fizzle out” within weeks or months. He believes his biggest problem is his cocaine use. Richard describes an intensifying use in the 6 months since he was most recently fired. He describes spending $200-300 (about 1-3 grams) every weekend in a binge patterns in which he would sleep most of the day and play video games at night. Since he was never moved away from home, this behavior was quite noticeable and worrisome to his parents, who insisted he seek treatment.
Richard reports a chronic history of inattention, impulsivity, and procrastination. He was diagnosed with ADHD in seventh grade. A several-month trial of immediate-release methylphenidate at that time led to significant clinical improvement (according to his Mother) and to significant side effects (according to Richard). He specifically denies recalling any behavioral improvement on the methylphenidate, adding that all he recalls was “feeling jittery” and “tunnel vision.”
Richard began to smoke marijuana during high school, increasing to daily use during college. He quit cannabis 2 years earlier and now only smokes occasionally. He also drinks alcohol socially, but “not like at college,” when he would have 10-15 drinks on weekends and 2-5 drinks every night during the week. He experimented with oral opioids such as OxyContin but never sustained a regular pattern of use. He describes some other “random experimentation” during college, including LSD, mushrooms, and crystal methamphetamine, but denies having used any other drugs in over 10 years. In his view, his only “problem drug” is the cocaine. He believes the cocaine hurt his motivation and ability to sustain school and work, but he also feels ambivalent about cutting down or staying abstinent, stating “nothing in my life is as good as cocaine.”
In regard t a more detailed social history, Richard is an only child born to middle-class parents. He and his parents agree that he graduated from high school with mediocre grades and poor attendance. He attended several semesters at a local community college before dropping out. While he had a knack for computer science he was often unable to concentrate and complete assignments even in subjects that he found interesting. He has worked part time as a computer programmer but has spent most of the last decade playing video games in his parents’ basement.
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*** 1. What diagnoses would you consider for this client? Explain your rationale with scholarly sources and describe information that supports these findings based on assessment information.
*** 2. What are medical concerns that you have for this client?
*** 3. What modes/levels of treatment would you recommend for this client? Be sure to list them in the priority in which they need to be addressed.
