Moderate Alcohol Use Disorder and Treatment

Case Presentation

The patient’s racial identification is a white female at the age of 44. The female is cooperative, looks jovial, and maintains eye contact. However, she seems sad and tearful on some occasions. Her physical appearance is appropriate as she is adequately dressed and groomed. She exhibits several characteristics. Firstly, she does not portray abnormal motor activities, delusion thinking, and suicidal ideation. She has good, clear speech, and her thoughts are goal-oriented and logical. Cognitively, she portrays good concentration and memory, she is aware of her condition and is motivated to change her situation.

Diagnostic impression

Alcohol Use Disorder

The alcohol use disorder that the patient exhibited is Moderate Alcohol Use Disorder. This category of alcohol disorders is described as the maladaptive pattern in substance use that leads to distress or clinical impairment. Patients will exhibit several behaviors that are linked with the stage. Firstly the stage is connected with the intake of a large amount of alcohol for a long period. The patient outlines that she has a problem with drinking. She states that her drinking has increased, and she has been hospitalized several times to inhibit withdrawal symptoms. Secondly, the stage is characterized by the failure to reduce or control the use of alcohol. The patient states that she has been unsuccessful in controlling her intake of alcohol even though she has been hospitalized to stop her alcohol intake.

Thirdly individuals spend most of their time on activities that enable them to obtain alcohol. The patient has an intense craving to obtain alcohol in the activities she undertakes. Fourth the stage is characterized by the failure to maintain daily activities and carry out significant roles in an individual’s life due to the recurrent use of alcohol. The patient outlines that she was unable to retain her job position due to the use of alcohol, she is not able to financially provide for her child, and she depends on her father for financial support. The continuous use of alcohol characterizes the stage despite the use of alcohol having adverse effects on the individual’s life. The patient reports that she continues to use alcohol, although it has affected her job and financial situation. Lastly, the stage is associated with giving up on essential social and recreational activities. The patient says that she has become an introvert. She enjoys staying at home to drink rather than enjoying the company of her friends.

Major Depressive Disorder

For patients to be diagnosed with major depressive disorder, the patients must exhibit more than five symptoms that characterize the major depressive disorder for at least two weeks. The symptoms include guilt, loss of appetite or increased eating, insomnia, losing interest in pleasurable activities, lack of concentration, psychomotor retardation, and the feeling of suicide. The patients state that she has a problem with sleeping at night, she has lost interest in taking part in activities she used to do with her friends, she has lost concentration, and she exhibits guilt because she was unable to keep her job and financially support the child.

Generalized Anxiety Disorders

Patients with generalized anxiety disorders exhibit symptoms such as tension, lack of concentration, feeling tired, feeling worried, and fatigue that last more than six months. The patient exhibits all these symptoms. She is worried she is not a good mother to her son and worries about her job. She is unable to concentrate and frequently feels stressed out. She outlines that her symptoms began during the 2020 pandemic and have persisted since the pandemic.

Reflections

Case Formulation and Treatment Plan

Individuals who sought help when they exhibited alcohol disorders are few. According to NSDUH, at least 14 million individuals older than 17 exhibit an alcohol use disorder (Substance Abuse and Mental Health Services Administration, 2017). Approximately 8 percent of men and 7.7 percent of ladies from the population who exhibit the disorder sought help (Substance Abuse and Mental Health Services Administration, 2017). The patient is aware of her alcohol use disorder and outlines she attends AA meetings to receive support. She also needs to attend psychotherapy to help her deal with anxiety that has resulted from her financial situation, her brother’s use of opioids, and her mother’s death.

Anxiety and depression are mental disorders that inhibit the ability of an individual to incorporate healthy behaviors in their lives According to Healthy People 2030; there is a link between physical health and mental health (Carvalho et al., 2019). Physical health problems make it difficult for individuals to obtain treatment for mental health disorders. The goal of Healthy People 2030 is to ensure individuals that who suffer from substance use and mental illnesses can receive treatment that helps them recover from both disorders (Carvalho et al., 2019). I addressed the goal by recommending the patient to attend Psychotherapy, particularly cognitive behavior therapy, which would assist her in dealing with anxiety and depression. Coping mechanisms such as mediation and exercise were suggested to the patient. Pamphlets were provided to guide the patient with coping mechanisms.

Creating awareness of the risks of alcohol use was one strategy I would have incorporated. The patients should be informed about how alcohol use affects their learning and memory ability and the risk of developing cancer. The patients should be made aware that excessive use of alcohol leads to the development of Korsakoff’s syndrome (Volkow, 2020). Creating awareness of the patient would ensure she makes informed health decisions. I would have carried out an assessment of the history of alcohol before the pandemic.

Treatment

The patient was given Wellbutrin /Bupropion 150mg XRQHS to reduce the patient’s cravings for alcohol and assist the patient with mood disorders such as anxiety and depression. The patient was made aware of the adverse effects of the medication. The patient was informed to call if she experienced the side effects of the drug. The side effects include insomnia, headaches, dizziness, and constipation. Psychotherapy was suggested to the patients. She was instructed to attend cognitive behavior therapy to help her deal with the hardship she was experiencing. Lastly, the patient was exposed to coping strategies such as medication. The patient was given pamphlets with instructions on the healthy diets and coping strategies she would take part in a month.

References

Carvalho, A. F., Heilig, M., Perez, A., Probst, C., & Rehm, J. (2019). Alcohol use disorders. The Lancet, 394(10200), 781–792. Web.

Substance Abuse and Mental Health Services Administration. (2017). National survey on Drug Use and Health | CBHSQ. Samhsa.gov. Web.

Volkow, N. D. (2020). Personalizing the Treatment of Substance Use Disorders. American Journal of Psychiatry, 177(2), 113–116. Web.