Adan is a 28 year old, married, heterosexual, Hispanic male. He has had a history of substance abuse since he was 16 years old. Adan states that he prefers the use of alcohol or marijuana, but has no issue using other substances; if offered to him or when he cannot obtain his preferred substance of choice. He has had a history of using alcohol, amphetamines, cocaine, hallucinogens, marijuana, nicotine, opiates, and barbiturates; separately and in conjunction with each other.
Adan states that he does not feel as though he needs treatment for his substance use; he uses as a means of relaxation. He states that his reason for entering treatment was based on his probation, as the court mandated him to admit himself into an in-patient substance treatment facility. Furthermore, this is his first-time he has been admitted, voluntary or involuntary into a substance treatment facility. He has, however, been treated at a facility for Attention Deficit Hyperactivity Disorder (ADHD) from age 7 – 10 years old. Adan does not remember the name of the facility and his time there ended prematurely due to his mothers passing at the time.
At the time of admittance, Adan reported, that he had no current medical conditions that were affecting him. For the safety of the clients and staff, all clients are sent to the county medical facility within the first three days of admittance. Adans' evaluation indicated that he had no evidence of physical complications, but was diagnosed with “General Anxiety Disorder” and was prescribed medication for his anxiety. It is not unheard of, that the county medical facility accidentally “misdiagnosis” clients from the treatment facility, due to the number of patients and lack of time they have for a proper evaluation. It is my clinical opinion that Adans' symptoms, result from his tendency to self medicate, when stressors enter into his life; further evaluation is needed to rule out any differential diagnoses.
All though, Adan entered treatment due to external motives; he states that he would like to use his time in therapy to work on his feelings of anxiety and fits of anger. When asked if he could go into more detail he explains:
“It is like a circle; at times my thoughts begins to race, until I begin to feel overwhelmed; which then makes me feel frustrated. When this happens all I want to do is try to calm down and slow down my thoughts, otherwise I get angry really quick. So to calm myself down I drink a beer and maybe smoke a bud or two.”
During the his initial assessment, he was wearing an oversize white T-shirt, with blue basketball shorts, and white basketball shoes. His hair was cut short in a Burr style, with a slight five o'clock shadow. Adans' mannerism was fairly normal with a slight indication of anxiety. He maintained good eye contact; his speech was loud and pressured; displayed psychomotor agitation, as he would often grip at his wrist or hand, and his right leg would shake. He...