For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background. Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis. Incorporate the following into your responses in the template:

Assessment of Substance-Related and Addictive Disorders: A Case Study

Introduction

Substance-related and addictive disorders are significant public health concerns, affecting individuals from various backgrounds and cultures. Accurate assessment and diagnosis are essential for effective treatment planning and implementation. This assignment aims to assess and diagnose a patient experiencing a substance-related or addictive disorder using a comprehensive psychiatric evaluation.

Case Study

The patient in this case study is a 32-year-old male named John. He is of Caucasian background and has a history of heavy alcohol use for the past ten years. John reports experiencing difficulties at work and in his personal relationships due to his alcohol consumption. He admits to drinking alcohol on a daily basis, often starting early in the morning and continuing throughout the day. John states that he has unsuccessfully attempted to reduce or stop drinking in the past but has been unable to do so.

Psychiatric Evaluation

1. Reason for Referral

John was referred for an assessment due to concerns about his alcohol use and its impact on his functioning at work and in relationships.

2. Presenting Problem

The primary presenting problem is John’s alcohol dependence, which has resulted in negative consequences in various areas of his life.

3. History of Present Illness

John reports that his alcohol use started during his college years as a way to socialize and alleviate social anxiety. Over time, his drinking escalated to the point where he became dependent on alcohol to function. Despite experiencing negative consequences such as job instability, strained relationships, and declining physical health, he has been unable to stop or control his drinking.

4. Past Psychiatric History

John has never sought psychiatric treatment in the past but acknowledges that he has felt down and anxious at times. He denies any previous suicidal or homicidal ideation or attempts.

5. Family History

John reports a family history of alcoholism, with both his father and paternal grandfather struggling with alcohol use disorders. He also mentions that his maternal uncle had a history of substance use issues.

6. Medical History

John has a history of chronic pancreatitis, a condition commonly associated with heavy alcohol use. He takes medications for pain management but otherwise reports no significant medical issues.

7. Social History

John is employed as a construction worker but has recently been struggling to maintain steady employment due to his drinking. He is unmarried and has no children. He admits to experiencing strained relationships with family and friends, primarily due to conflicts arising from his alcohol use.

8. Substance Use History

John’s primary substance of abuse is alcohol. He reports consuming an average of ten standard drinks per day, escalating to twelve or more on weekends. He denies any current or past use of illicit substances or non-medical use of prescription medications.

Differential Diagnosis

Based on the information provided, a differential diagnosis for John’s condition may include:

1. Alcohol Use Disorder: John’s heavy and compulsive alcohol consumption, unsuccessful attempts to control or quit drinking, and negative consequences associated with his drinking behavior suggest a potential diagnosis of alcohol use disorder.

2. Social Anxiety Disorder: John’s disclosure of using alcohol as a coping mechanism for social anxiety during his college years indicates the possibility of a comorbid social anxiety disorder. However, further assessment is necessary to confirm this diagnosis.

3. Major Depressive Disorder: John’s admission of feeling down at times suggests the possibility of comorbid depressive symptoms. Proper evaluation is required to determine the severity and persistence of these symptoms.

Critical-Thinking Process

The critical-thinking process used to arrive at the primary diagnosis involves considering John’s presenting problem, history of present illness, family and medical history, social context, and substance use history. The primary diagnosis of alcohol use disorder is based on the DSM-5 criteria, which include impaired control, social impairment, risky use, and pharmacological criteria indicative of tolerance and withdrawal.

Conclusion

Assessing and diagnosing substance-related and addictive disorders require a comprehensive psychiatric evaluation considering various factors, including the patient’s history, presenting problem, family history, and social context. In this case study, a differential diagnosis for alcohol use disorder, social anxiety disorder, and major depressive disorder was considered. The critical-thinking process involved examining the patient’s symptoms, comorbid conditions, and relevant diagnostic criteria.