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Carlos Gonzalez Case

Carlos Gonzalez Case

Abstract
The subject of this paper is the case that describes Carlos Gonzalez, a 40 year old Latino male (Mexican ancestry), born in the United States. Carlos been diagnosed with Kaposi’s sarcoma and an AIDS. He is addicted to Methamphetamine (“Crystal Meth”), cocaine, ecstasy and alcohol. He also has hallucinations of bugs crawling his body and symptoms of paranoia.

The major problem for the case manager is Carlos’s distrust as it may prevent effective communications and his treatment. This paper reviews literature with respect of each case component to provide explanation of their interrelationship, effects on the client and draw corresponding conclusion regarding his treatment.

A. Introduction
The subject of this paper is the case that describes Carlos Gonzalez, a 40 year old Latino male (Mexican ancestry), born in the United States. Carlos been diagnosed with Kaposi’s sarcoma and an AIDS. He is addicted to Methamphetamine (“Crystal Meth”), cocaine, ecstasy and alcohol. He also has hallucinations of bugs crawling his body and symptoms of paranoia.

The major problem for the case manager is Carlos’s distrust as it may prevent effective communications and his treatment. In order to effectively manage the case one should understand the root causes of the potential problems, i.e. it might be a problem to convince distrustful patient to continue treatment as he may be convinced that you act not in his interests. Therefore source of the clients distrust should be identified. Potentially the client’s distrust may be related to his paranoia and hallucinations as well as to the drug abuse and illness (AIDS and Kaposi’s sarcoma).

Accordingly, this paper reviews literature with respect of each case components (AIDS, Kaposi’s sarcoma, cocaine and methamphetamine abuse, hallucinations and paranoia). This review will enable providing explanation of interrelationship between case components, their impact on the client and draw corresponding conclusion regarding his treatment.

B. Literature Review
AIDS and Kaposi’s sarcoma
Kaposi’s sarcoma is a tumor caused by Kaposi’s sarcoma-associated herpes virus (KSHV), also referred to precisely Human herpes virus 8 (HHV8) which was originally described by a Hungarian dermatologist Moritz Kaposi. This herpes virus is not uncommon, but in most cases it remains latent, however in patients with AIDS, whose immune system is weakened, it often cause Kaposi’s sarcoma. Accordingly Kaposi’s sarcoma is often a symptom presenting AIDS diagnosis, for example in 1981 about 48% of AIDS diagnosis were made as a result of Kaposi’s sarcoma. While AIDS is considered to be a terminal disease (some researchers prefer term “malignant” as appropriate AIDS treatment can prolong life for many years) and Kaposi’s sarcoma in such cases among major immediate causes of death (National Cancer Institute, 2009).

In her book Mental Disorders, Medications and Clinical Social Work Austrian (2000) provides evidences that HIV-related dementia occurs in 40 – 50 % of persons with AIDS. This phenomenon can be observed as neurological complications resulting from direct effects of the virus on the central nervous system and of the neurological conditions that opportunistically affect the person (Frierson 1997, Weiner, Tintner, and Goodkin 1991). Observed impairments relate to one or several of the following: including poor concentration, impaired cognitive processes, memory deficits, motility problems, and emotional and personality changes. Weiner and Svetlik (1991) also argue that the majority of people being at late stage of AIDS will develop dementia with no predictable pattern and in 90% delirium has place. As these disorders progress often the primitive defenses, as well as denial, delusional projection, paranoia and hallucinations may occur. While there are no specific medications for such organic mental disorders, antidepressants, antipsychotics and minor tranquilizers can sometimes used to alleviate secondary symptoms, however it might be problematic considering extreme sensitivity of patients with AIDS and their possible interaction with other necessary medication (Austrian, 2000).

MA and Cocaine abuse
Another research, conducted by Washton, Gold, and Pottash, (1984) revealed the following frequency of psychological effects reported in the results of a survey of 500 callers to the 800-COCAINE hot line: panic attacks – 50%, lack of sexual interest – 53%, memory problems – 57%, paranoia – 65%, difficulty concentrating – 65%, apathy and laziness – 66%, irritability – 82%, depression – 83%, anxiety – 83%..
Booth et al. (2006) conducted a research aiming to determent impact of cocaine and MA use (separately and together) on psychological distress. They draw data from BSI index compiled by Derogatis (1993).

As is clear from, adjusted scores for all three groups were greater than 50, indicating higher distress as compared to the general population. The adjusted means were the most high for psychoticism and paranoid ideation and for the overall Global Severity Index. Comparing the groups of stimulant users (MA only, cocaine only and both), the adjusted means were for all distress types the highest for the combined use.

Accordingly it can be said that persons abusing cocaine or MA, and especially both, a prone to mental disorders, including paranoia.

One of the particular symptoms described in the case is the client “believes that he has ‘bugs’ crawling on him” was specifically described in literature as an implication of drug abuse and is referred to as “formication.” Brown (1989) wrote that continued use of cocaine may be a reason of hallucination. In particular it can cause a hallucinatory “cocaine bugs”. Formication is condition being a form of paresthesia, a tactile hallucination often reported by long-term cocaine abusers. The basis of formication according to Brown (1989) may lie in “stimulation of nerve endings in the skin, the action of cocaine on the noradrenergic innervation of the somatosensory cortex in humans, or drug-induced degradation of pyramidal cells in the sensory motor cortex” (1989). Brown (1989) also claimed that in some cases intensity of this tactile hallucination may be so significant that a patient may attempt to cut out the imagined insects from his skin.

According to Platt (1997) a significant number of descriptive studies and even laboratory induction was performed with respect to paranoid symptomatology resulting from stimulant use. Most of these studies relate to suspiciousness and other symptomatology associated with use of amphetamine, however Platt (1997) relates to the effects of cocaine use – Sherer et al (1988). Sherer et al in course of the experimental induction found that symptomatology following cocaine infusion suggests that they are not very different from those of amphetamine use.

However according to Satel, Southwick and Gawing (1991) paranoia induced by cocaine is usually transient or “binge”-limited form, which is confined to the period time immediate to the use of a drug and not lasting after emergence of hypersomnia occurring after binge (“crash”). While amphetamine induced paranoia may be of a persisting nature, which is sustained for days, weeks, or even longer.

Stimulant Abuse Treatment
The treatment of stimulant abuse, including cocaine, has two primary goals: initiation of abstinence and relapse prevention. They may be achieved by a number of means, such as pharmacotherapy, psychotherapy, and other therapies. Non-pharmacological treatment may elaborate on a number of approaches, such as behavioral, cognitive behavioral, psychodynamic and supportive approaches (Platt, 1999). While treatment for stimulant abuse should be carried out independently from alcohol problems and more general drugs, as combined treatment may fail to address the stimulant-specific problems, such as anhedonia and significant craving ( Gawin and Ellinwood, 1988 ), however it still should take into account other addictions ( Condelli et al., 1991 ).

Once stabilization has been achieved after the acute withdrawal period any rehabilitation effort should include three general strategies as outlined by Schuckit (1994):
1. development and maintenance of high levels of motivation for abstinence;
2. helping the stimulant abuser to rebuild a drug-free life;
3. relapse prevention.

Successful treatment of the stimulant addiction, as well as other drugs abuse, requires an understanding of broad range of the patient’s issues, not only stimulant addiction but addiction in general, as well as other issues he faces. As Gawin, Khalsa, and Ellinwood admit “the knowledge needed before the clinical presentation by a drug-abusing individual can be adequately understood and interpreted and effective treatment implemented should include an understanding of recent cultural changes and older historical forces, characteristics of both acute stimulant euphoria and acute post-use euphoria, the significance of the route of administration, neurochemical effects, and medical consequences, as well as the clinical characteristics of the transition to dependence, abstinence rates and symptoms, and interactions with psychiatric disorders” (1994). Important note is that, while both psychotherapeutic and pharmacological interventions, have demonstrated certain efficacy in drug abuse treatment, neither of them “has been found to be a solution in itself to the problem of substance abuse” (Platt, 1999).

C. Conclusion
Review of the literature regarding AIDS and Kaposi’s sarcoma reveal the following facts. Kaposi’s sarcoma is caused by Kaposi’s sarcoma-associated herpes virus (KSHV), also referred to precisely Human herpes virus 8 (HHV8), which is not a common disease in humans with healthy immune system.

However, weak immune system, resulting from AIDS gives an opportunity for Kaposi’s sarcoma development, which in absence of proper treatment leads to death. Accordingly it is important that Carlos Gonzales receives medical care, which would suppress AIDS and Kaposi’s sarcoma development.

Gonzales’s mental state – specifically distrust and paranoia – may cause him to reject medical treatment. Accordingly, in order to prevent the client from rapid death due to Kaposi’s sarcoma a root cause of his paranoid state should be identified and addressed.

Literature review on AIDS and substance abuse lead to the conclusion that both of these factors could lead to Carlos’s mental state. From one hand HIV not only cause deterioration of immune system but may have multiple negative implication on mental health. In majority of cases at a late stage of AIDS dementia and/or delirium may occur. Mental health of the person with AIDS may diminish resulting in the primitive defenses, denial, delusional projections, paranoia and hallucinations.

From the other hand there are evidences that abuse of stimulants, such as methamphetamine and cocaine may also lead to mental disorders, including paranoia. Especially in case of long-term methamphetamine abuse. Sensation of crawling bugs experienced by Carlos is a formication, a condition being a form of paresthesia, a tactile hallucination often reported by long-term cocaine abusers. This fact confirms the fact that Carlos is a long-term abuser and his paranoia may result from use of stimulants.

Accordingly, Carlos’s paranoia may be caused either by HIV or substance abuse, or both. Treatment of his paranoia should be performed based on deeper examination of its causes or imply contribution of both factors, elaborating common stimulant abuse treatment strategies and HIV-related dementia treatment. With respect to HIV-related dementia it should be considered that due to cognitive functions impairment, Carlos’s paranoia can be difficult to treat with non-pharmaceutical methods.

Carlos Gonzales case demonstrates that selecting successful treatment strategy should elaborate on investigation of the causes of both mental and physical health. However, as literature review demonstrates, it might be difficult to determine root cause of the problem as many factors can contribute to its development. Accordingly deeper investigation may be required or comprehensive treatment strategy addressing multiple causes should be developed in order to achieve success.

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