Assignment: Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders

 
 Example Four
Patient Information:

Name: Bob

Age: 34

Sex: Male

Occupation: Unemployed

Education: High School

Marital Status: Single

Ethnicity: African American

Chief Complaint:

Bob complains of difficulty controlling his alcohol consumption.

HPI:

Bob reports that he started drinking heavily in college but was able to keep it under control until recently. He now drinks every day and cannot control the amount he consumes. He reports experiencing tremors in his hands and sweating when he does not drink.

Past Psychiatric History:

Bob reports a history of depression and anxiety for which he was prescribed medication but stopped taking it due to side effects.

Medication Trials and Current Medications:

Bob reports taking no current medications.

Psychotherapy or Previous Psychiatric Diagnosis:

Bob reports receiving a diagnosis of depression and anxiety in the past but has not received any psychotherapy.

Pertinent Substance Use, Family Psychiatric/Substance Use, Social, and Medical History:

Bob reports a family history of alcoholism. He also reports experiencing financial difficulties and losing his job due to his drinking.

Allergies:

Bob reports no known allergies.

ROS:

Bob reports no significant changes in his weight, appetite, or sleep patterns.

Mental Status Exam:

Bob presents as a disheveled and unkempt individual. He appears agitated and restless, frequently shifting in his seat. His speech is slurred, and he has difficulty focusing on the questions asked. He reports experiencing auditory hallucinations.

Assessment:

Based on Bob’s history and mental status exam, the following differential diagnoses are possible:

 	
Alcohol use disorder
 	
Major depressive disorder with psychotic features
 	
Schizophrenia

Alcohol use disorder is the highest priority diagnosis. The DSM-5 criteria for alcohol use disorder include a problematic pattern of alcohol use leading to clinically significant impairment or distress, such as drinking more than intended or being unable to stop or cut down on drinking. Bob meets these criteria, as he reports difficulty controlling his alcohol consumption and experiencing withdrawal symptoms when he attempts to stop.

Major depressive disorder with psychotic features is another possible diagnosis, as Bob reports a history of depression and currently experiences auditory hallucinations. However, his symptoms are more consistent with alcohol use disorder.

Schizophrenia is a less likely diagnosis, as Bob does not report a history of psychotic symptoms outside of his alcohol use.

The critical-thinking process that led to the primary diagnosis of alcohol use disorder was based on Bob’s history of heavy drinking, withdrawal symptoms, and difficulty controlling his alcohol consumption, which all meet the DSM-5 criteria for alcohol use disorder.

Reflection Notes:

If I could conduct the session over, I would focus more on exploring Bob’s feelings and motivations for drinking to gain a better understanding of his behavior. I would also address his auditory hallucinations and explore the possibility of comorbid psychiatric disorders. Legal and ethical considerations include ensuring informed consent and confidentiality, as well as addressing any potential risks associated with Bob’s heavy drinking, such as impaired judgment and increased risk of accidents. Health promotion and disease prevention would include addressing the long-term health consequences of alcohol use disorder and providing resources for quitting drinking. Factors such as Bob’s age, ethnicity, and socioeconomic background may also impact his treatment plan and should be taken into consideration.