Introduction
The case study concerns Juan, a 59-year-old commercial pilot who has come to visit a clinician at the urging of his son. He lives alone, having divorced his wife and had his children move away. He engages in extensive daily drinking of both beer and hard alcohol, which he has been able to sustain due to his high tolerance for the substance. However, recently, he has been experiencing symptoms such as memory loss and occasional loss of consciousness, followed by an inability to get up. Earlier, he has also suffered a heart attack, which his son attributes to his drinking habit. Juan himself claims that he does not have an alcohol-related problem, only drinking socially and in moderation. The purpose of this analysis is to evaluate his symptoms, produce a DSM-5 compliant diagnosis, and suggest treatment options.
Diagnosis
Juan describes some episodes that may be indicative of an inability to control himself with regard to alcohol, but overall, his drinking patterns seem consistent. His two-day period of not drinking after Guillermo’s departure may qualify as an unsuccessful attempt to stop drinking or cut down. He also spends a lot of time drinking, though he does not seem to suffer hangovers. Over the interview, Juan showed no signs of craving alcohol at any time, viewing it as entertainment rather than a necessity. Drinking does not appear to have interfered with his career or taking care of his family per se, though the health problems associated with it have placed him on leave. With that said, his drinking was at least a partial cause of Juan’s divorce from his wife.
Juan does not appear to have prioritized drinking over other activities, though he spends a lot of time at home engaging in it. He also gives no indication of having gotten into unsafe situations during or after drinking. With that said, he has kept drinking even after memory blackout episodes while knowing that it added to his existing health issues. Juan does not appear to have experienced diminished effects from alcohol, as he could always handle large amounts of it well. Lastly, from the conversation, it does not appear that he has experienced withdrawal effects when the alcohol was wearing off. As such, in total, Juan qualifies for four of the symptoms presented for determining the severity of alcohol use disorder in the DSM-5. This figure places him in the moderate category for the condition, represented by the code 303.90 (American Psychological Association, 2013). The diagnosis appears to be justified, as Juan does not seem to have other mental issues and has denied taking other substances or smoking emphatically.
Experienced Symptoms
From a chronological standpoint, the first symptom Juan has experienced is the heart attack that he had several years ago. The pathological nature of the symptom does not need an explanation, as it can potentially cause permanent disability or death. It should be noted that the degree of alcohol’s contribution to the heart attack is not necessarily clear. While Juan’s son and doctor assert that it was a direct cause, the lack of a recommendation to stop drinking from a physician should be noted. Juan was asked to quit smoking and did so successfully, which indicates that the role of substances in facilitating the problem was taken into consideration. With that said, the overall deterioration of his health described by his son, particularly the weight gain, is likely the result of alcohol.
More recent issues Juan has experienced are cases of memory loss and his blackout incident. Memory loss is pathological because it impedes Juan’s ability to operate normally, which is especially relevant in his job as a commercial pilot, where he is responsible for the lives of other people. Additionally, it may be indicative of broader damage to his nervous system that may develop into other issues if he continues drinking excessive amounts of alcohol. The blackout is pathological because it is also indicative of underlying issues. Moreover, Juan could not get up after regaining consciousness, which would have been highly problematic if his phone had not been within easy reach. Overall, Juan’s symptoms are substantial and require immediate attention as well as an intervention to ensure that they are mitigated.
Juan has likely continued drinking despite all of these issues due to how he has been socially and culturally conditioned throughout his life. At a relatively young age, he discovered his love of alcohol as well as his high tolerance for it. As he himself mentions, the ability to out-drink people made him popular, driving him to continue. With time, drinking became his principal form of entertainment, as is the prevailing theme in both fraternities and the Air Force. As a result, even after leaving both of these communities, he stayed reliant on alcohol as a way to spend time. Moreover, his endurance has led him to believe that the substance does not have any ill effects on him, as it has not impeded him from having a long and successful career. As a result, once it started failing him and causing issues, he refused to recognize the connection and kept drinking, partially out of stubbornness.
Treatment Options
Juan does not appear to have severe self-control issues and an overt dependence on alcohol. As such, an extensive medication-based intervention will likely not be necessary, and the focus should be on nonpharmacological options. With that said, he likely has a psychological reliance on alcohol, at the very least as his preferred way of alleviating boredom, though he is in partial denial about it. As such, in addition to a recommendation to quit drinking, behavioral therapy will likely be necessary. Cognitive-behavioral therapy (CBT) is one option that will help Juan recognize and avoid the triggers that drive him to drink excessively, though it is better suited to stress- and coping-related drinking. Motivational enhancement therapy may be a better fit, as it will help Juan find the strength to change his behavior in a purposeful manner.
Still, medication may deserve consideration, especially if, over time, Juan struggles to stop his drinking. The National Institute on Alcohol Abuse and Alcoholism (2019) outlines four FDA-approved medications: acamprosate calcium, disulfiram, and oral as well as extended-release injectable forms of naltrexone. Of these, disulfiram is not suitable for treatment because it is used for different situations than Juan’s. Oral naltrexone may be the best immediate option in the case that it is necessary, blocking the receptors that produce pleasure due to alcohol. If Juan proves to be able to stay abstinent for extended periods, the other two medications may also be considered. Extended-release naltrexone is easier to manage because it is injected once a month, while acamprosate has to be taken three times a day, creating nonadherence opportunities. Moreover, acamprosate is better suited for patients who are already abstinent at the treatment’s beginning, which is not the case for Juan.
Overall, Juan’s treatment should begin with motivational enhancement therapy. He will undergo four sessions with a qualified provider, who will help him understand the necessity of not drinking as much, develop a plan, and learn the skills needed to adhere to it. Then, Juan will implement that plan while living normally, with occasional check-ins with the care provider. If he is unable to maintain the regimen and relapses into drinking, he should be prescribed oral naltrexone. If he is able to abstain but complains about craving alcohol, the extended-release version should be used instead. The treatment will be considered finished when Juan has been able to abstain from alcohol for three months and improve his overall health.
Conclusion
Despite Juan’s remarkable ability to handle alcohol, it ultimately started having significant adverse effects on him. Though he denies that and tries to defend his drinking habit, the decision to visit a medical care provider with his son shows that he has taken the first step toward recovery. Based on the analysis of his symptoms and relationship with alcohol, the diagnosis of alcohol use disorder was made. His symptoms are substantial but not permanent, assuming he quits alcohol or reduces his consumption of it significantly. Therefore, the focus of the treatment should be on persuading him to do so and providing him with the help he needs. Motivational enhancement therapy can help achieve this goal, and naltrexone in both oral and extended-release injectable forms can aid in removing his alcohol dependency in the case where such assistance is needed.
References
American Psychological Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing.
National Institute on Alcohol Abuse and Alcoholism. (2019). Medication for the treatment of alcohol use disorder: A brief guide. U.S. Department of Health and Human Services.