Assessment and Treatment Plan Homework

Assessment and Treatment Plan

Caniesha presents as a 30 year old Caucasian female who meets the diagnostic crtieria for F15.20 Amphetamine-type substance use disorder, severe as evidenced by substance is taken in larger amounts over a longer period of time than intended, there is a persistent desire to use, there have been unsuccessful efforts made to cut down/control use, continued cravings, continued use despite having family/social problems, increased tolerance, recurrent use resulting in failure to fulfill major work or family obligations, recurrent use in situations which create a physical hazard and the substance use is continued to avoid withdrawal. Caniesha also has a current diagnosis for Tourette’s Disorder (F95.2) with multiple motor and one or more vocal tics. She was diagnosed at an early age. It is suspected that the Tourette’s Disorder is substance-induced due to Caniesha being exposed to Methamphetamines beginning as an infant. There is also a diagnosis of ADHD which is common with Tourtette’s Disorder.

Caniesha’s parents were heavy Methamphetamine users and Canisha’s maternal grandparents sought and gained custody of Caniesha when she was 7 years old. Caniesha reports her parents were physically and verbally abusive and that she was told her mother used both Meth and Marijuana while pregnant. Caniesha’s was raised by her grandparents but then reestablished contact with her parents upon graduating from high school. She fell back into the drug use lifestyle as an IV user and continued to use with her parents on a daily basis. At age 25, Caniesha gave birth to a baby boy and moved back in with her grandparents so she wouold have help caring for her son. Caniesha continued to use Methamphetamines and left her grandparents babysitting for days while she was out partying. The grandparents reported her to CPS and filed for guardianship of the boy. There is a court order in place keeping Caniesha away from her son except for weekly visits of one hour each under CPS supervision.

Medical: Caniesha reports having a prolapsed heart valve (meaning it doesn’t close all the way) and she suffers from Vasovagal Syncope. Vasovagal syncope (vay-zoh-VAY-gul SING-kuh-pee) occurs when you faint because your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress. It may also be called neurocardiogenic syncope. The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly. That leads to reduced blood flow to your brain, causing you to briefly lose consciousness.

. She denies taking medication for either condition.

Other MH: Caniesha reports hearing voices that no one else hears and seeing objects that no one else sees.

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