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Diagnosing an Active Disorder

Addiction is a chronic situation that is hard to identify and treat; while the symptoms appear clearly, diagnosis depends entirely on the individual with an addiction issue. Majority of individuals suffering from addiction associate with drug abuse disorders, which negatively influence their lives and choices. According to (Godleski et al., 2019), substance use ailment is a multifaceted situation where an individual has an uncontrolled utilization of drugs despite their dangerous consequences. Individuals with drug abuse issues have an intense concentration on drugs, excess pain medicines, or any other harmful drugs leading to interference in the person’s daily activities. Hence, the need for intervention in treatment and counseling in case the addicted individual admits to it so that they receive the necessary help.


I decided to focus on Martha’s case study for seven weeks to help examine her situation closely. Martha is a 72-year-old woman of African American origin who lately is widowed as she lost her husband to a severe heart attack. Martha’s marriage lasted for forty-five years with three kids and six grandchildren who stayed in different nations. After asking for several pain medication refills within a short time, Martha was referred to me by her primary doctor. She also tried to convince the doctor’s assistant to prescribe her more prescriptions after receiving the previous ones from the doctor. After analyzing Martha’s condition, it remains clear that she has been in pain for the longest time. Her pain comes from various causes; a hip injury that occurred in a car accident, migraines, and a thyroid condition. Although Martha disclosed taking more than the recommended medication, she rapidly shifted the conversation.

In the past, Martha also had been on pain drugs for a long time since her surgeries failed to help minimize the hip pain. Ever since, Martha has always been in pain, which causes her to look for more medication to ease her pain. Martha displays numerous signs of sadness, defensiveness, and agitation when talking. Martha’s condition requires Percocet medication to help her n recovering, but she ends up taking more than the required amount. Even after talking to Martha about her health concerns and her misusing the given drugs, Martha responded negatively, suggesting that she does not care about the danger of the drugs because nobody will miss her when she dies. In Martha’s case, she has been lonely most of the time since her husband’s death, and she misses his company around. Although her children would like to visit them frequently, Martha remains unmotivated to see them, causing her to stay alone mostly.

Initial Questions

The first appropriate question to ask Martha is, “When did you start to seek more medication than the prescribed dosage?” This question is an excellent opportunity for the counselor to examine Martha’s source of addiction to the pain medicines and what drove her into them whenever she faced any issue ahead. Moreover, the question establishes Martha’s dependency and possible ways to deal with the addiction. The question helps formulate Martha’s triggers that cause her to use the Percocet. According to Randall et al. (2018), most addicts have triggers that stimulate them to abuse drugs; hence, identifying the trigger helps them relapse.

The second essential question is, “How do you feel when you use Percocet, and what motivates you to continue using them? The question allows us to look deeper into Martha’s image and the sensation she likes, which she only feels that Percocet medicine can provide. Looking at Martha, one can quickly notice her need for love, affection, acceptance, and family around her. However, asking to determine the facts is essential since most inexperienced counselors would assume that treating an addict is a natural process from what they only see (Randall et al., 2018). Martha says that she feels like nobody cares about her and that nobody will miss her when she dies.

The third appropriate question is, “How long have you been using Percocet, and how do you feel about yourself? The question is significant because talking about one’s addiction journey and how they honestly think of themselves is difficult to steer when all they have experienced in life is neglect. Heartbreaks, disappointments, and rejection from loved ones threaten individuals’ self-worth, causing them to look for other alternatives to reinforce their worth (Godleski et al., 2019). It is essential to analyze Martha’s relationship with her family and the effect of her husband’s loss in her life.

The final question is, “What would you like to change in your life patterns after this therapy?” The question offers Martha an opportunity of choice and a sensation of optimism that she can change her life for the better. Juhnke (2017) stated that transformation operates as the injunction in any therapy session; counselors work with clients to help transform their attitudes for a better cause. My responsibility as a counselor is to ensure that I identify Martha’s intentions and her dedication to therapy to help her formulate specific objectives for her life improvement.


The first assessment instrument to use is an interview, which requires more sensitivity from my end and ample time to help analyze Martha. An assessment interview starts our therapeutic association that will help set the foundation for our treatment. I will understand Martha’s history and background contributing to her addiction through this. Schneider et al. (2021) stated that a regulated biophysical history interview is obtained using the Psychosocial History (PSH) assessment tool. Martha said that she feels neglected, lonely, and abandoned by her family, understanding that part of her life is essential for her treatment. The device will help incorporate Martha’s modification that examines her history and the necessity for using excess Percocetd while in treatment. According to Schneider et al. (2021), the PSH tool helps establish one’s family associations, relationships, love entanglements, and children’s responsibilities, which is essential for assisting clients with their issues.

The second assessment instrument is the Addiction Severity Index (ASI), an essential tool in a clinical setting. The device is administered in a conducted interview that helps to collect a client’s data from different categories (Ljungvall et al., 2020). The instrument addresses seven main issues in a client’s addiction; drug abuse, legal rank, family rank, medical status, job status, support, and psychiatric condition rather than concentrating on one issue alone. The ASI will effectively help me examine Martha’s problems, the triggers, and the best treatment option Martha requires moving forward. Martha has many issues surrounding her that need a comprehensive picture of her struggle with pain management. The ASI will assist in coming up with an effective plan, but it will also help formulate the best treatment option.

Preliminary Diagnosis

The preliminary diagnosis for Martha would be extreme substance use disorder and depression. Given her long history of pain medications and her husband’s loss, Martha resolves to this to help ease her pain whenever she feels any pain in her hip. Martha’s depression plays a huge factor in her prescription usage because her husband’s loss has created a massive turn in her life. Moreover, her children and grandchildren live in different cities; hence, denying her the love and association with family around her would ease her situation. My primary diagnosis for Martha would be the 304.10 moderate Percocet utilization condition. I selected moderate because Martha’s actions need several prescriptions to help her.

The reoccurring illness here is depression, which happens as a side effect of Martha’s medication. Although grieving alone does not qualify to identify someone with a depressive condition, additional issues must be considered, like how long someone remains lonely and unmotivated and mental illness history. Crunelle et al. (2018) stated that stress about withdrawal or any unmanaged pain could cause one to look for more drugs to help calm them, resulting in unusual attitudes during treatment. A thorough history of Martha’s mental health and the family association will provide a more precise diagnosis of her substance misuse and depression.


Martha requires special aid to assist her in returning to her everyday life and family. Her treatment plan should come with a primary caregiver with the participation of a pain professional. Martha has suffered a lot from her injured hip and her husband’s loss, which may take longer for her to recover, as she was accustomed to the pain and drugs as her survival means. Outmost patience and a judgment-free zone are necessary for her recovery, and she is hoping that everything will return to normal.


Crunelle, C. L., van den Brink, W., Moggi, F., Konstenius, M., Franck, J., Levin, F. R., … & Matthys, F. (2018). International consensus statement on screening, diagnosis, and treatment of substance use disorder patients with comorbid attention-deficit/hyperactivity disorder. European addiction research24(1), 43-51.

Godleski, S. A., Eiden, R. D., Kachadourian, L., & Lucke, J. F. (2019). Etiological pathways to rejection sensitivity in a high-risk sample. Personality and Social Psychology Bulletin45(5), 715-727.

Juhnke, G. A. (2017). Substance abuse assessment and diagnosis: A comprehensive guide for counselors and helping professionals. Psychology Press.

Ljungvall, H., Persson, A., Åsenlöf, P., Heilig, M., & Ekselius, L. (2020). Reliability of the Addiction Severity Index self-report form (ASI-SR): a self-administered questionnaire based on the Addiction Severity Index composite score domains. Nordic Journal of Psychiatry74(1), 9-15.

Randall, J., Cunningham, P. B., & Henggeler, S. W. (2018). The development and transportability of multisystemic therapy-substance abuse: A treatment for adolescents with substance use disorders. Journal of Child & Adolescent Substance Abuse27(2), 59-66.

Schneider, L. H., Pawluk, E. J., Milosevic, I., Shnaider, P., Rowa, K., Antony, M. M., … & McCabe, R. E. (2021). The diagnostic assessment research tool in action: A preliminary evaluation of a semistructured diagnostic interview for DSM-5 disorders. Psychological Assessment.


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