History of Alcohol Use Disorder
Alcoholism, also called alcoholic disorder is defined as the inability to control the consumption of alcohol because of both, emotional as well as physical dependence on alcohol. Generally, the use of alcohol is defined in terms of using alcohol that is associated with problems caused by the adverse effect of alcohol, or something having alcohol, injurious to health. Binge drinking, defined as a dinking pattern in which a male is having five or more than five drinks in the time span of two hours or a female is found to be having at least four drinks within the same time span. There are several terrifying health concerns associated with Binge drinking, taking into account that people are taking the initiative to overcome this impact. Medication-assisted therapy is one of the options that is used to treat opioid disorder, considering that there are very few people who know that alcoholism can be treated or somewhat reduced with the help of therapy or counseling, as compared to self-initiatives actions of overcoming addiction. Therefore, the purpose of this paper is to evaluate the patient's diagnosis with alcohol use disorder. It will describe the demographics and background of the patient, as well as the disease process, sign, and symptoms, treatment options and pharmacology.
Case History on Alcohol Use Disorder
BB is a 64 years old male, Indian American male with history of alcohol use disorder. BB was brought into the emergency room by emergency medical services. Patient was hospitalized at Jamaica Medical Center for his erratic behavior due to alcohol use and depression. Patient has no past psychiatric hospitalizations. No history of MH treatment. No history of suicide or self-harm. No history of violence or arrests. No legal issues. No history of trauma. Migrated to the USA 40 years ago, he lives with wife and family in a private house.
BB has two sons aged 28 and 30 years, his highest level of education is high school. He identifies himself as a businessman and stated that he runs a liquor business with his wife and children. According to BB, the business is not as profitable as it used to be years ago when the business was established, and he decided to close the business. Currently, he is unemployed, he expressed emotions about his fear and anxiety and depression due to his inability to support his family financially. BB was diagnosed with Alcohol Use Disorder when she was 45. BB developed thoughts of hopelessness, worthlessness, which led to suicidal ideations.
This led to two inpatient psychiatric hospitalizations, where he overdoses both times on medications. On this first admission, BB was started on PO Antabuse, Ativan and referred to rehabilitation and detoxification program. He reports stopping the medication and discontinues his rehabilitation program after three months of feeling sober. The second hospitalization was six months ago, which may have been caused due to another episode of binge drinking. During the second admission, BB shared that he has tried to reduce his habit of consuming alcohol before getting ended in a residential treatment option. He shared that he was unable to continue his attempts for more than 30 days and he just tried to "white knuckle” his way. Also, BB has shared some major withdrawal symptoms such as excessive sweating and shivering as two of the major hurdles in sustained sobriety.
Before getting admitted to the residential treatment, BB has attended some Alcoholics Anonymous meetings that he never found as effective and supporting him in sustained sobriety. BB has also reported that he had full 120 days of assistance from alcohol when he was undergoing treatment in a residential treatment facility. BB was referred to a psychiatrist and psychotherapist and started to see the psychiatrist once a month and psychotherapist twice in a week. The therapy sessions according to BB paved the way for recovery by increasing more adherence to abstinence support and medications, collaborated by education and referral of the supporting groups.
He expresses frustration for relapsing two weeks ago and is disappointed in the way his family views his alcohol abuse. He feels as though his family does not respect him anymore due to his alcohol abuse and is motivated to quit on his own. BB denies any history of blackouts, seizures, diabetes, and hypercholesterolemia.
As per the data collected from the CDC, alcoholism is one of the disorders that plays a central role in causing disability in the United States of America. According to the same report, about 62% of the adults who were older than 18 years were suffering from alcoholism, making up 15.1 million people. It also included 9.8 million men and about 5.3 million women, making up 84% of the adult men and 4.3% of the adult women. every year, it is calculated that 88,000 people making up 62000 men and 26000 women die because of alcohol-related diseases. it is highlighted that, as per information collected in 2014, alcohol abuse or alcohol-related aspects as the third major cause of death in the United States of America. There were about 9,967 deaths because of alcohol-driven impacts. Different studies have highlighted that alcoholism majorly contributes to cardiovascular problems along with atrial fibrational, hypertension and different types of strokes, particularly hemorrhagic.
BB is a good historian, well-groomed in clean casual clothing and he was healthy in appearance much like dishevel African American man. He is quick enough to respond to person, place situation or the time, also with better communication skills accompanied by angry and irritable mood swings. Some major signs in BB are, BP, 130/88 (in sitting position and of the left arm), HR is 104, RR is 22 and Temperature is 98.8 Fahrenheit. His facial gestures are glassy with bilaterally constricted pupils, highly reaction to lights round in shape with the red sclera and teary eyes. He has normal ears with a normal ear canal and an adequately functioning tympanic membrane. He has a running nose with no erythema of the nostrils with a normal septum, BB has a dry oral mucous membrane with a poor dentation and has his back tooth missing. The heart rate of BB is regular with mild tachycardia recorded as 104. He has bilateral extremities with different tattoos and a fresh mark of a needle in the antecubital areas. He has space in the lower extremities. His bilateral hand tremors with extended arm, noting there is no edema observed on the upper as well as lower extremities. He has bilateral feet with cracking, dry and peeling skin, where BB usually itch at times. He maintains eye contact most of the time during interview, he was articulate, and the thought process was clear and concise. BB reports that his father was alcoholic, Also, his son who is 30 years has also been treated with alcoholism in the past. According to him, alcohol abuse or addiction runs in the family, but he feels that he has observed a change in his drinking habit because he takes his medication regularly. This disease contributed to a lack of concentration and coordination in his liquor business, reduces productivity, which in turn impacts business goals and objectives. His addiction to alcohol led to the downfall of his liquor business which he operated for 25 years. He admits to drinking7 to 10 bottles of alcohol daily, and sometimes throw upon himself.
Patient reports that when there are negative feelings or thoughts, he listens to soft music and sometimes takes a long walk.
Counseling is done for substance abuse and its impact on patient's health. Patient was advised against the mixing of substance use with any prescription/over the counter herbal medications. He was educated on the illness, and signs and symptoms of withdrawal and how to contact his providers or the emergency room if it is after hours. BB was given information about support groups such as Alcoholics Anonymous (AA) and other programs are helpful for the patient.
According to BB, he has endorsed multiple diagnostic criteria in his initial process of assessment. As per his memory, within the time span of last year, he has consumed more alcohol as compared to the past. Also, he found difficulty in reducing his total alcohol consumption and because of this habit of alcohol consumption, he has restrained from his friends and family members. BB also had strong cravings for alcohol which resulted in lack of attention in the recreational activities. He also quoted that he kept on drinking alcohol, despite knowing that alcohol can cast a negative impact on diabetes. Also, he has developed a strong tolerance towards alcoholism, with an ability to drink one gallon each day which as one liter in the past years, BB has also experienced severe symptoms of withdrawal from the last few months such as sweating, mood disturbance and shaking.
According to BB medical records, he was diagnosed with alcoholism at the age of 25. Alcoholism is a chronic, relapsing disease that affects millions of Americans of all ages and is more common among men (American Psychiatric Association, 2018). Various factors contribute to alcohol use disorder, they include genetics, environment, trauma, mental illness, and peer pressure (APA, 2018). BB said that his parents were addicted to alcohol and other drugs, and he had some belief that this caused him to be addicted to alcohol. He stated that his older brother had pancreatitis and dementia, he died two years ago. BB also shares that he has faced a lack of communication and companionship with his friend because of alcoholism, taking into account that he was not able to reciprocate. BB shares that he was conscious about making new friends because he was fearful of being let down by his friends because of drinking.
Diagnosis: DSM-5 Diagnosis
Diagnostic and Statistical Manual of Mental Disorders highlights a criterion that must be met by the individual who is diagnosed with AUD. Under DSM-5, anyone who is meeting any two of the criteria out of 11 during the time span of 1 year, he would be eligible for receiving a diagnosis of AUD. Meeting criteria defined the severity of AUD, either to be mild, server or moderate. In order to assess, if someone has AUD, there are some questions that must be asked, calculating information from the past year
There were times when either there was a complete withdrawal or more urge to drink as compared to the normal routine?
Once you feel that you should drink then you wanted to give up drinking or you were tired of it but were not able to?
You have spent a lot of time drinking or trying to overcome the after effects of drinking?
You had strong cravings for drinking?
You came to know that the urge or craving of drinking interfered with familial responsibilities or alcoholism has caused some school problems or issues related to employment.
You continued to drink, knowing that it can cause trouble with the friends or family members?
The urge of drinking was so strong that you tried to cut back from all the actions that were somehow imported or interesting to you in the past. It also includes your recreational activities?
You have been caught in a situation where drinking or the after-effects of drinking has caused to some life risks such as while driving, using any machine or swimming. It may also include a situation in which you are drunk and you are walking in a dangerous area or you are having unsafe sex?
You were in a situation where you continued to drink, knowing that it will make you anxious or depressed or it can add to your health problem? It also includes a situation of having a memory blackout?
You want to drink more and more as compared to your drinking schedule to get the effect that you want? Or you found that the number of drinks is less to cast an effect on you?
You found that when the effect of alcohol was wearing off, you were facing the withdrawal symptoms. These symptoms are irritability, restlessness, trouble in sleeping, nausea or excessive sweating. Also, you seem to sense things that were not part of reality?
In the time of remission, BB meets all the diagnostic criterion, applied to alcoholism. it is highlighted that the proponent of disease model hypothesized that continuous exposure to substance abuse is driven by some neurological hangs that are the product of some chemical interaction between the brain of an individual and the substance that is consumed. There are some additions in the disease model, in recent past, such as genetics, social and environmental factors. (Volkow, et al. 2016). BB also shared that he faced some interpersonal difficulties since the time of elementary education. He highlighted his assumptions of not being normal by the time he was nine years old.
According to Erikson, children who are 9 years old are found to be struggling with industry vs inferiority. one of the key features of this developmental stage is developing trust in others as well as being industrial, referring to self-confidence. Erikson also proposed that the children who feel inferior about themselves, or who are unable to develop self-confidence are unable to manage their life activities, considering themselves as not normal. As per BB's report, there is a possibility that he did not develop self-confidence in developmental stage and it was influencing his social connection, leading to an inferiority complex. He also added that he has always longed for a strong social network. The integration of data from BB’s report as well as assessment from the conceptual framework proposed by the disease model and Erikson inferred the significance of interpersonal support that can be used for BB’s ongoing support.
In a nutshell, it can be said that BB found himself different from other who are 9 years old. This assumption of difference kept him at a distance from everyone around, posing hurdles in development leading to inferiority. His concept of being inferior was the reason that he started drinking. A fall in business life added to his inferiority giving him more reason for drinking and isolation.
The adherence to Treatment Plan based on contextual conceptualization, the treatment schedule of BB emphasized increased social support to align with a growing sense of being industrious. There are some overarching goals associated with the guide such as permeant withdrawal from alcohol parallel to the time span of treatment as measured in the self-report by client.
There are some interventions that will be used for the achievement of health goals, such as induction of physical health schedule that can help to know how substance abuse by Kevin has impacted his physical health. The collaboration of Kevin’s physical health with that of mental health. Also, this will include an evaluation for the pharmacotherapy to be summed up in synchronization with the physicians and medical compliance management. This will be addressed in the form of weekly counseling sessions. These goals will also include increasing Kevin’s social support. Some cognitive-behavioral anxiety management techniques will also be used such as though banning, mindfulness as well as deep breathing.
Ideally, the goal will be quoted in the SMART formula. Also, the interpersonal approach will be used for empathizing with the counselor’s use of immediacy that can help Kevin get social feedback. Kevin will also be motivated to participate in weekly interpersonal process groups that will incorporate interpersonal feedback and social contact (Teyber & Teyber, 2011). An increase in Kevin’s sense of industry with the help of social support and participation in manual work will also be emphasized. Kevin will also be proposed with a set of social assessment along with career assessments so that Kevin can develop career interest. Also, some career counseling strategies will be used to help Kevin in developing the skills that can help him return to professional life.
There are three medicines the rea approved and will be used to treat AUD.
Disulfiram: this medicine can cause unpleasant symptoms such as skin flushing and nausea after drinking. These feelings can help to abstain from alcohol.
Naltrexone: It blocks the receptors that can help to feel good when drinking alcohol. This medicine is also capable of reducing cravings for alcohol, which can help overcome drinking.
Acamprosate: This drug helps to prevent alcohol driving. This medicine works on different brain systems with an aim to reduce cravings right after quit drinking.
Referrals and consultation
PCP for a physical exam
Patient will attend Alcohol detoxification Program daily from M-F, will meet with NP for medication management minimum of once weekly but will be checked on for symptom management daily. Alcohol detoxification program is limited to six weeks but can be of shorter duration if it is determined that a lower level of care is appropriate. Upon finishing the Partial Program, the next level of care will be determined, and referrals made.
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Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences, clinical psychiatry. Philadelphia: Lippincott Williams & Wilkins
Stahl, S. M. (2013). Stahl' s essential psychopharmacology: Neuroscientific basis and practical applications (4 ed.). New York: Cambridge University Press.
Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016) Neurobiological Advances from the Brain Disease Model of Addiction. The New England Journal of Medicine, 374(4), 363-371. doi: 10.1056/NEJMra1511480.
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