Introduction
The patient is a 45-year-old male presenting with a drinking problem. He works as a corporate lawyer at a local company. In this case, no clear information about his family is given, except that he has a wife who threatens to move out with their children if the man does not solve his alcohol dependence. His history of alcohol use began at the age of 17 and continued during his college, law school, and employment period. He takes at least six beers daily, but the number of drinks can increase to 14 in a day. The outcomes of his drinking habits are observed in all spheres: he arrives late at work, misses family events, stops playing tennis, and visits local bars regularly. The man can no longer ignore some disturbing factors concerning his physical and mental health. For example, almost every morning begins with a severe hangover, affecting his critical thinking abilities and performance. During the day, he cannot help but think about alcohol. The man admits he needs professional help to solve his problems with alcohol and is ready to begin his treatment.
Sometimes, people can control alcohol use and predict the development of negative outcomes affecting human health and interpersonal relationships. The Dietary Guidelines Advisory Committee (as cited in Chiva-Blanch & Badimon, 2019) identifies moderate consumption of alcohol, which is about 1-2 drinks for a person of legal drinking age. It means that if a person takes alcohol within the offered limits and does not overuse available opportunities, drinking from time to time is normal without serious harm. Unfortunately, more than 38.5 million Americans drink, and 6-7% report heavy alcohol use (Bohm et al., 2021; Kranzler & Soyka, 2018). Regular alcohol use tends to turn into alcohol use disorder (AUD) when the duration of consumption prevails 12 months and dependence is hardly controlled (American Psychiatric Association, 2012). Many physiological, emotional, and behavioral changes are observed, depending on demographic, environmental, and other factors.
Considering the information in the offered vignette, it is impossible to identify additional demographic or personal characteristics of the patient, including his race, ethnicity, nationality, income, or behaviors. He belongs to a group of middle-aged people who are at risk of moderate cognitive impairment because of alcohol (Chosy & et., 2022). According to Bohm et al. (2021), the prevalence of binge drinking (more than five standard drinks on the same occasion) is higher among males (22.5%) than among females (12.6%). About 25% report drinking weekly, and people older than 25 have a higher predisposition to this habit (Bohm et al., 2021). In addition to increased mortality rates, excessive alcohol use is characterized by co-occurring drug use disorders, depression, phobias, and somatic problems (Kranzler & Soyka, 2018). The patient under analysis has serious drinking problems, and he has to take several assessment tests to understand what kind of help should be offered to prevent the development of additional health complications.
Assessment
The patient reports repeated problems related to alcohol use, which requires the application of certain assessment tools to recognize his strengths and limitations in dealing with the situation. He takes the Alcohol Use Disorder Identification Test (AUDIT), which consists of ten simple questions with optional answers to obtain a particular score. If a person’s score is more than eight, an alcohol problem exists. The patient got 24 points, which served as definite evidence of alcohol use problems and the necessity of treatment.
Several core strengths may help the client improve his treatment outcomes. One of the major elements is his positive intention to apply for a treatment program. The patient has already tried to cut down his alcohol dependence on his own, but no success has been achieved. He has some insight into his problem and is ready to start treatment. At the same time, his family support can become a significant issue to rely on because the men understand his responsibilities as a husband and a father. He is aware of meaningful family events, but alcohol problems affect his memory. His recognition of employment obligations is another critical strength to be considered because he is a lawyer, and his job does not allow regular hangovers and lateness. Finally, the possibility of physical exercises in which he was previously involved should be mentioned. Instead of visiting a local bar, the patient needs to find the nearest tennis court and restore his skills.
Several limitations or the client’s weaknesses might affect a treatment process in the most unpredictable way. The man reports that he is constantly thinking about alcohol during the day, which proves the presence of intrusive thoughts and the inability to control them. No information about his medical history is given, and it is necessary to learn more if he takes any drugs to stabilize his health. Alcohol abuse and dependence cannot be ignored because it affects his emotional and behavioral patterns. Although the patient denies any psychiatric diagnosis, alcohol use might provoke mental changes asymptomatically. Thus, cognitive defects and memory problems are the limitations for successful treatment prognosis.
Diagnosis
A mental health provider must have personal communication, a psychological assessment, a physical examination, and lab tests to diagnose the patient. There are several self-report instruments for individuals to use, and the patient has seen his AUDIT results to continue screening. In the Diagnostic and Statistical Manual (DSM-5), a clinically significant impairment like AUD (is diagnosed if the patient meets at least two patterns (American Psychiatric Association, 2012). The man, in this case, admits to taking alcohol in larger amounts than intended, unsuccessful efforts/persistent desire to cut down, craving to use alcohol, and failures to fulfill his obligations at home (American Psychiatric Association, 2012). Social activities have been diminished due to alcohol, although the man is aware of his problems. These symptoms are not acute, and their development has been occurring for the last 28 years. The condition is severe (303.90 – F10.20) due to the presence of more than 6 DSM-5 symptoms in the patient.
In most cases, it is enough to use DSM-5 to diagnose AUD appropriately. Attention should also be paid to physical changes and the results of lab tests. Nausea, vomiting, anxiety, restlessness, and rapid heartbeat are usually the signs of alcohol withdrawal, which may be relevant to AUD. The patient might have an unsteady gait, tremors, and erectile dysfunction; in men, decreased testicular size and reduced testosterone levels provoke feminizing effects (American Psychiatric Association, 2012). Memory loss, depression, and cardiovascular problems can be observed, including high blood pressure or stroke. The elevation of gamma-glutamyltransferase levels, more than 20 units in the carbohydrate-deficient transferrin test, and at least 150 mg of ethanol in the blood are laboratory proofs of AUD (American Psychiatric Association, 2012). Sometimes, additional liver function tests and diagnostic markers are implemented, but the above-mentioned tests and observations create a solid picture of the patient having a serious mental health disorder to be treated.
Treatment
Treatment for the AUD patient depends on several factors, including the severity of the condition, the level of social support, and physiological issues. The combination of cognitive-behavioral therapy (CBT) with behavioral techniques and medications is one of the most effective psychosocial interventions for severe alcohol use (Kranzler & Soyka, 2018). The main treatment goal, in this case, is to achieve abstinence from drinking. Motivational enhancement and cognitive control are the means to consider and focus on developing social skills, stopping alcohol intake, and replacing alcohol with harmless activities (Kranzler & Soyka, 2018). Individual counseling with the patient is an important step to show how to improve self-control and learn how to recognize situations when drinking is preferred. The patient needs additional explanations for avoiding provocative situations with drinking triggers like visiting local bars. Education about alternatives (e.g., regular physical activities and tennis) for the patient and coping with circumstances plays a crucial role. The man should be ready to talk about his feelings and desires with an expert and listen to recommendations.
Because the patient has already taken several unsuccessful steps to stop drinking, pharmacological interventions become inevitable to control his behaviors and decisions and predict symptom deterioration. Oral and injectable medications like disulfiram (250-500 mg/day), naltrexone (50 mg/day), or acamprosate (1998 mg/day) are approved by the Food and Drug Administration (FDA) to prevent drinking behaviors (Kranzler & Soyka, 2018). Some drugs might directly reduce the drinking urge, while others provoke the necessary physical reaction (nausea or headache) to stop drinking. Unfortunately, many recent studies on pharmacological interventions are characterized by high dropout rates, and psychiatrists prefer to follow CBT interventions (Kranzler & Soyka, 2018). Proper motivation, family support, and restrictions should be properly identified to show the patient the benefits and harms of drinking and help him enhance self-control. Relapse prevention is also critical not to allow the patient to return to bars or find another reason for drinking.
Conclusion
Despite various preventive programs, many people of both genders tend to relapse. The environment affects the decision to drink or not to drink in a particular situation. Positive outcomes will be expected if the patient is interested in a program and wants to use professional help. This 45-year-old patient has several motivational factors like family support, employment, and sports engagement. These issues can be enough to achieve short-term goals of drinking abstinence for some period. Long-term goals based on no alcohol intake in the future are hard to predict, and the patient needs to continue visiting a counselor. The man needs to talk about his feelings and share his thoughts and intentions. His approaches to stopping drinking did not bring positive outcomes, and the success of the current treatment prognosis depends on his cooperation with healthcare practitioners, psychiatrists, and family members. Relapse risks should not be neglected because they are regularly in people with AUD. It will not be easy for a man with more than 25 years of drinking history to quit drinking, but his health improvement and stable family relationships should motivate him to make the right decision.
References
American Psychiatric Association. (2012). DSM-V: Diagnostic and statistical manual (5th ed.). American Psychiatric Association.
Bohm, M. K., Liu, Y., Esser, M. B., Mesnick, J. B., Lu, H., Pan, Y., & Greenlund, K. J. (2021). Binge drinking among adults, by select characteristics and state – United States, 2018. Morbidity and Mortality Weekly Report, 70(41), 1441-1446. Web.
Chiva-Blanch, G., & Badimon, L. (2019). Benefits and risks of moderate alcohol consumption on cardiovascular disease: Current findings and controversies. Nutrients, 12(1). Web.
Chosy, E. J., Edland, S., Launer, L., & White, L. R. (2022). Midlife alcohol consumption and later life cognitive impairment: Light drinking is not protective and APOE genotype does not change this relationship. PloS One, 17(3). Web.
Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: A review. JAMA, 320(8), 815-824. Web.