Multi-axial diagnosis of alcohol abuse and adjustment disorder in Al

Substance Abuse Case Study: Multi-Axial Diagnosis

Substance Abuse

Substance Abuse Case Study: DSM-V-TR Multi-Axial System Diagnosis

Substance Abuse Case Study: DSM-V-TR Multi-Axial System Diagnosis

Al (A.L.) is obviously in enough distress that his family felt the need to drag him, kicking and screaming, to the emergency room. Despite having a normal appetite, concentration, energy levels, interest, and sleep patterns, the alcohol abuse, deep despondency, and acute family concern suggest that this behavior is abnormal for Al and the family as a whole. This type of behavior would also be abnormal for the general public, therefore a multi-axial system diagnosis is warranted.

Axis I: 305.00 alcohol abuse; 309.28 adjustment disorder with mixed anxiety and depressed mood, acute; 309.21 separation anxiety disorder

Axis II: 317 mild mental retardation

Axis III: none

Axis IV: marital difficulties

Axis V: GAF = 55, current.

Axis I

When Al was brought to the emergency department (ED) for evaluation, he smelled of alcohol and appeared intoxicated. The wife's report that Al had been drinking more heavily since they began to have marriage problems, together with the DUI, was deemed sufficient to diagnose Al with alcohol abuse (305.00).

The Axis I adjustment disorder (309.28) diagnosis is based in part on the Axis II diagnosis of mild mental retardation. Although the DSM recommends that a diagnosis of adjustment disorder not be given when the criteria are met by an axis II diagnosis, the description of mild mental retardation is sufficiently vague to warrant further elaboration on the symptoms. Al's depressive and anxious symptoms developed within 3 months of the onset of marriage difficulties, the main stressor, which satisfies one of the diagnostic criteria. In addition, the stressor is being blamed as the cause for alcohol abuse and three consecutive days of tearful hopelessness. Based on these symptoms, Al seems to be having a difficult time adjusting to the reality that his marriage is in trouble.

Al could be experiencing the beginnings of a major depressive disorder, single episode, but not enough information is provided in the vignette to determine whether Al meets the necessary diagnostic criteria. Al had experienced 3 days of tearful hopelessness concerning his marriage before presenting in the ED, but the only mood-related history provided by the family is that Al had been increasing the amount of alcohol consumed during the preceding two months. Since the diagnostic criteria for a major depressive disorder, single episode, requires the symptoms to be present for at least two weeks Al does not meet the criteria for this diagnosis. In addition, Al's appetite, concentration, interest, energy levels, and sleep patterns are reportedly normal, which is inconsistent with a depressive episode. If this is a depressive episode, it is very likely that it was precipitated in part by Al's alcohol consumption; however, the degree of contribution that alcohol is making to the mood change cannot be established until Al has stopped drinking. The relatively recent onset of these symptoms rules out dysthymia and the symptoms do not meet the criteria for anxiety disorders.

The Axis I diagnosis of separation anxiety disorder (309.21) is also provided to help describe the symptoms Al presented with upon arrival in the ED. Even though Al fails to meet the age criteria of 18 or younger, if he is suffering from mild mental retardation then at age 20 he would probably be developmentally under 18 years of age. A diagnosis of separation anxiety disorder is given when excessive anxiety is produced in anticipation of, or after, separation from a place or person. A significant impairment in daily activities is another criterion that must be met for this diagnosis. A person with mild mental retardation would be predicted to have a hard time adapting to major changes in their life and the onset of marriage difficulties could qualify as a major change sufficient to induce separation anxiety.

A differential diagnosis for separation anxiety disorder is mainly based on the presence of psychotic symptoms, pervasive developmental disorder, or a panic disorder with agoraphobia. Based on Al's symptoms, there is no evidence of psychosis, avoidance of crowded or public places, or an inability to socialize and communicate with others.

Axis III

Axis III is intended to provide information about a general medical condition that could be relevant to the Axis I and II diagnosis and planned treatment. Since Al seems to be otherwise physically healthy, no entry was made for this axis.

Axis IV

Axis IV is intended to provide relevant information about the psychosocial and environmental problems that may have contributed to Al's symptoms. Since the wife's report indicates that Al began to drink more heavily after his marriage problems began and he seemed hopeless for three tearful days before presenting in the ED, the marriage difficulties were judged to be the primary stressor that triggered Al's substance abuse and anxious symptoms. The axis IV entry was limited to marriage difficulties, since he seemed to be receiving significant support from both family and wife.

Axis V

Axis V is provided to communicate the physician's assessment of Al's overall level of psychological, social, and occupational functioning. By the time Al had presented in the ED he had been experiencing two months of heavy drinking, was caught driving under the influence, and had spent three tearful days feeling hopeless about his marriage. Based on the information provided in the vignette, Al was judged to be experiencing moderate symptoms and social difficulties. This is equivalent to a Global Assessment of Functioning (GAF) score between 51 and 60. Al was therefore given a score of 55, which represents his level of function when he arrived in the ED.