Substance abuse overview and treatment approaches

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 II

There are several signs justifying an Axis II diagnosis of mental retardation. The first is poor academic performance in high school, which was severe enough to justify enrollment in special education classes. The second is the family feeling the need to admit Al to the ED, which suggests a reduced ability for self-care. Al's mental retardation could not be too severe, because he is able to drive an automobile, was educable, and capable of socializing to the extent that it resulted in a marriage. Based on this assessment Al suffers from mild mental retardation (317).

A diagnosis of mild mental retardation would explain all the other symptoms and behaviors that Al exhibited. Although Al experienced significant academic difficulty in high school, he was still capable of participating in special education classes. The late onset of mental retardation symptoms (high school) is also consistent with this diagnosis. Persons with this disorder are able to develop normal social and communication skills at an early age, which would explain the marriage. In terms of self-efficacy, persons with mild retardation are usually self-sufficient up to a point. In situations of unusual stress, such as marriage difficulties, a person with mild retardation would likely require significant emotional support from family and friends. This would explain why the marriage difficulties triggered an acute episode of alcohol abuse, the DUI, and the family's felt need to intervene by bringing Al to the ED against his wishes.

The wife's behavior is also telling. She was willing to accompany the family to the ED and explain what she thought triggered the acute onset of alcohol abuse. This behavior suggests that the wife still cares deeply about Al, but has not reacted to the marriage difficulties with the same level of anxiety expressed by Al. This disparity is consistent with a deficit in adaptive function common to individuals with mild retardation.