29 Mar 2018
Alcohol Use Disorder is defined as a troublesome repetitive use of alcohol causing large amounts of impairment or distress, as shown by at least two of the following occurring within a twelve month period: alcohol is consumed in large amounts or for a long period of time, there is a want to quit drinking with failed attempts, a large amount of time and energy are spent trying to obtain the alcohol, a strong desire to drink alcohol, repetitive alcohol use causing one to not fulfill his/her life roles, repetitive alcohol use despite the alcohol causing relationship problems, stopping of regular and important activities, repetitive alcohol use despite health issues, repetitive alcohol use despite having knowledge of physical or mental issues caused by the alcohol, tolerance, and withdrawal. Severity of the Alcohol Use Disorder is determined by the number of symptoms present. Miguel is currently having the symptoms of drinking large amounts of alcohol as shown by his heavier drinking, repetitive alcohol use despite the alcohol worsening relationships as shown by his conflicts with his wife, no longer fulfilling his life roles as demonstrated him not being able to fulfill his role as a father to his children, repetitive alcohol use in situations which may be physically harmful as demonstrated by his punching walls, and tolerance as seen by his increase in more potent alcohol like whisky and an increase in the number of beers consumed. His fulfillment of five symptoms specifies him as having moderate Alcohol Use Disorder (Barlow and Durand, 2012, pg 402).
Miguel father's name is Tommy, his mother's name is Susan, and he has two brothers and three sisters. His brother's names are Bob and Mickey; his sister's names are Tracy, Leah, and Maria. Miguel is the second oldest. Miguel's father, Tom, had previously been diagnosed as having severe Alcohol Use Disorder . Tom worked as a pipe liner in the oil field, which required hazardous and difficult physical labor with him working long days and needing to travel frequently. Tom was unsure of how to cope with the stress and physical demands of his job since his schedule made it difficult to build a strong communication style with his wife, Susan. Tom often drank on his off time to cope with his stressors, while at home or away on business travels. Miguel often witnessed his father use drinking as a coping skill. Susan operated an after school day care at the home to help support the family. Miguel and his brothers and sisters were expected to either help with the day care or obtain jobs at the age of sixteen to help support the family. Miguel's family was considered lower on the socioeconomic scale and his parents stressed doing well in school to urge their children to obtain a higher standard of living than their current state.
Miguel did well throughout high school and earned acceptance into a prestigious university where he majored in business. Miguel's family placed a large amount of stress on Miguel's academic performance throughout college since Miguel was a first generation college attendee. This caused Miguel to have frequent feelings of anxiety about his academic record and pleasing his family. Miguel was diagnosed with Generalized Anxiety Disorder and took an SSRI, specifically Paxil, for about a year. However, he discontinued his medication regimen when he felt the medication was no longer vital in his life. College is when Miguel first began drinking but he was seldom intoxicated except when he went to large parties. During Miguel's senior year he met Ann. Miguel and Ann married when Miguel was twenty-four and had three children.
Post college Miguel entered into the business realm by working for a large firm. Within the last few years Miguel began drinking almost every weekend and would drink a few beers during the week as well. Two years ago he was promoted to a regional sales manager which involves him managing ten different company locations in his region and writing the quarterly reports. After the promotion, his intake of alcohol increased. This increase involved transitioning from beer to whiskey. During this period the relationship between Miguel and his wife began withering away as shown by an increase in the number of arguments. In addition, during more heated arguments Miguel would become so irate he would punch walls.
Miguel's currently admits that he is consuming two to three drinks of whisky and six to eight beers on weekdays and the majority of a whisky bottle and twenty to three beers on weekends. Miguel decided to seek treatment after his wife separated from him. This separation led to Miguel living in a small apartment with minimal contact with his children. Miguel states the separation may have increased his intake of alcohol.
As seen in Miguel's history and physical there was a job promotion and thus an increased number of stressors in life. This increase in stressors plus a combination of past anxiety issues (Grant et al., 2004), the high genetic risk of substance abuse (Ferguson & Goldberg, 1997), witnessing his father's ineffective coping skills, and increased stress from his job promotion and relationship issues likely began his increase in drinking. The increase in number of drinks and more potent forms of alcohol may have contributed to the increase in arguments between his wife and him, therefore, increasing his stress and anxiety which could be part of the problem of the substance abuse. Miguel appears to lack healthy coping habits and thus his increase in stressors seems to be causing an increase in drinking.
Concerning Alcohol Use Disorder genetics and environment are known to play a large role. A study done by Ferguson and Goldberg looks closely at the genetic markers and alcohol abuse correlations. First Ferguson and Goldberg reviewed past studies concerning genetic vulnerability. A data collection and analysis done by Cotton (as cited in Ferguson and Goldberg, 1997) examined records to see ties between family members and alcoholism. Cotton collected and reviewed thirty-nine family case studies that were gathered over a forty year period with participants being 6,521 alcoholic participants and 4,083 non-alcoholic participants in order to theorize about the inheritability of alcoholism. Cotton's analysis of the studies showed that out of the alcoholic participants, one of three was found to have a parent who had Alcohol Use Disorder. Cotton also noticed that the occurrence of Alcohol Use Disorder was dramatically lower when family members were non-alcoholics versus relatives who are alcoholics.
Another factor to take into consideration is that the environment is playing a role in offspring becoming alcoholics. A child may witness and model Alcohol Use Disorder behavior and symptoms. The learned behavior may increase the child's vulnerability, not necessarily just the genes. In order to cancel out the environment factor and investigate just the genetic vulnerability, twin studies were conducted.
Twin studies try to prove genetic contributions to Alcohol Use Disorder by comparing the rates of alcoholism between monozygotic twins and dizygotic twins. A study done by Kendler, Heath, Neale, Kessler, and Eaves (as cited in Ferguson and Goldberg, 1997), involved 1,030 female-female twins and compared the rates of alcoholism using the diagnostic criteria from the DSM III-R. Interviews were conducted to assess the participants level, if any, of alcoholism. The results showed that monozygotic twins had higher rates of alcoholism in both twins versus dizygotic twins. The degree of inheritability was deemed 51-59% for monozygotic twins.
Ferguson and Goldberg discussed how previous studies, like the ones just discussed, place the degree of inheritability at around 50%. Ferguson and Goldberg's study looks at genetic markers - specifically ADH, ALDH, and monoamine oxidase activity - to see how genetics may contribute to alcoholism. Samples of blood were taken from 46 alcoholic participants and 39 non-alcoholic participants to compare the genetic markers in their blood. The results of the study concluded that due to limitations of the DSM classification of alcoholism, the lack of ethinic diversity within subjects, and the fact that while there were differences in the level of the markers between the patients no single gene could be pinpointed as putting one at risk for developing alcoholism if higher or lower in abundance. MAO was seen to have a linkage to poorer mental health in general. In addition, ADH which affects tolerance to alcohol was shown to vary in quantity between the two groups of participants. But the correlation between tolerance ability and alcoholism could not be proven in the study. Overall, while specific genetic markers could not be concluded, genetic vulnerability still plays a strong role in one's probability of developing Alcohol Use Disorder.
The studies reviewed in Ferguson and Goldberg's article showing the inheritability degree of alcoholism of around 50% are important because Miguel had an alcoholic father. Miguel's genetic vulnerability could have placed him at an increased risk of becoming an alcoholic. In addition, Miguel witnessed his father use alcohol as a coping skill. The combination of nature and nurture could have contributed to Miguel's diagnosis.
Also concerning Miguel's environment, Miguel felt his parent's placed extreme standards on him growing up which caused him anxiety. A study done by Grant et al. (2004) examined the dual diagnosis of anxiety disorders paired with substance use disorders (pg 807-816). The study involved 43,093 participants who were classified as having substance use disorders and any one of the nine mood or anxiety disorders according to the DSM IV. The methods use to collect information was a face to face survey by trained interviewers from the National Epidemiological Survey on Alcohol and Related Conditions. The results of the study first stated rates of mood disorder (9.21% ), anxiety disorder (11.08%) and substance use disorders (9.35%) separately for the general US population. The percentage of people with substance use disorder and at least one mood disorder was 18% while the percentage of people with substance use disorder and at least one anxiety disorder was 20% for the general US population. However, when looking just at individuals who currently were getting treatment for alcohol use disorder 40.7 % of those individuals had at least one mood disorder and 33% had at least one anxiety disorder. Thus the percentages for people seeking treatment were higher versus the general population. The correlation between the two diagnosis was deemed positive with a rate of .05 and thus being significant. (Grant et al., 2004, pg. 807 - 816).
The positive correlation and increase in percentages of dual diagnosis for people who seek treatment are relevant to Miguel because he diagnosed as having GAD while in college. Miguel's previous diagnosis and lack of effective coping skills could be considered an integral part of his development of Alcohol Use Disorder.
For treatment Miguel would be placed in a short term stabilization unit for detoxification where he will receive one hour of recreational therapy, one hour chemical dependency counseling, and one hour of psychotherapy per day Monday through Sunday. Short term in-patient treatment would be used because this is the current standard of care. In addition, having the inpatient care will ensure the patient in unable to obtain alcohol for at least 3 to 5 days. Then Miguel should seek out-patient therapy in order to continue learning skills/ways to prevent relapse. Out-patient therapy will consist mostly of psychotherapy.
The Recreational Therapy groups offered at the in-patient stabilization unit will focus learning new coping skills, activity involvement, and leisure awareness in order for the patient to decrease triggers for drinking such as boredom, develop a coping method and achieve flow (Malkin & Benshoff, 1996). A theory by Francis (1991) (as citied in Malkin and Benshoff, 1996) states that individuals with alcoholism often experience increased stress, low self-esteem, leisure dissatisfaction, and boredom. Then Francis explains Czikszentmihalyi's theory of flow which states that nirvana or leisure satisfaction can be reached when one's skill level matches the challenge of the activity. Francis then states that leisure awareness which helps one find flow through recreation can help alleviate the negative symptoms alcoholics experience and reduce the urge to use alcohol.
Another study focusing on recreation in the aid of alcoholism was done by Nation et al. (1996) which focused on goals achieved through recreational therapy groups according to Certified Therapeutic Recreation Specialists at different facilities (pg. 10 - 16). A twenty question questionnaire was sent to Recreational Therapist at 250 substance abuse help centers, including in-patient and out-patient facilities, which focused on the goals achieved through the program and recreational therapy groups. The achievable goals listed as most important from the responsive Recreational Therapists included improving one's ability to socialize (90%), increasing self-esteem (87%), bettering one's ability to trust and cooperate with others (84%), bettering one's leisure awareness and developing recreation skills (68%), and increase one's idea of responsibility (66%). Developing these goals through RT groups can help the patient develop new, more positive habits (Nation et al., 1996, pg 10-16).
The drug and alcohol counseling group will focus on informing patients about the cycle of addiction, negative thought patterns, support groups in the area including AA, and the harmful side effects of drug and alcohol on mental and physical health.
Cognitive Behavioral Theory will also be a component of in-patient care because CBT can help teach the individual socialization skills and news ways to cope with stressors. One of the main goals of CBT is to help the person better express their feelings and thoughts in an appropriate, healthy way. Learning these new skills can help reduce the urge to drink by decreasing anxiety and stress. (Libal, 2003, pg. 116)
The outpatient care will consist of Cognitive Behavioral Therapy, Motivational Interviewing Therapy, and daily intake of Naltrexone to prevent relapse because these methods have shown to help samples of alcohol abuse participants in previous studies (Anton et al., 1999). In a study conducted by Anton et al. (1999) 131 recently detoxed alcohol dependent persons were treated in an outpatient setting for 12 weeks with the interventions being Cognitive Behavior Therapy and either Naltrexone or a placebo pill. The study was double blind and randomized. Progress was tracked throughout the study in two ways. At the end of each week participants were evaluated using the timeline follow-back calendar method to track amount of drinks consumed per day, the Obsessive Compulsive Drinking Scale, the analog craving scales, and a checklist of any physical symptoms experienced. The second method of data collection was a physician administering a more physical health aimed evaluation at weeks 1, 4, 8, and 12. In addition, the participant’s blood was tested for indications of alcohol intake throughout the study. The most central result from the study was that 62% of the experimental group, the one receiving Naltrexone, did not relapse during the 12 week study. The control group, the one receiving the placebo, had a 40% success rate of not relapsing. Both groups’ relatively high amounts of participants resisting alcohol during the study could point to the success of Cognitive Behavioral Therapy used during the study. However, the experimental group data proves that the pairing of Naltrexone and therapy had a higher success rate. Therefore, Anton et al. (1999) believe that the patient will experience the most value out of outpatient care by pairing the medication along with Cognitive Behavioral Therapy.
Libal (2003) states that a patient’s willingness to change can be a barrier in treatment, and when this issue occurs Motivation Interviewing Therapy should be utilized. This form of therapy focuses on helping the individual realize he has a problem and find ways to become intrinsically motivated to achieve change. This therapy has the potential to be beneficial for Miguel because it can increase his motivation to stick to his medication schedule and help him problem solve on ways he can motivate himself to change. His own readiness and desire for recovery is important since his former support system, his wife and family, may no longer what to be involved with him. Therefore, the triad of therapies proposed – Cognitive Behavioral therapy, Motivational Interviewing Therapy, and Naltrexone – has the potential to be of high therapeutic worth to Miguel concerning outpatient care.
The goals of treatment for Recreation Therapy include help the patient identify healthy activities that helps him achieve flow and develop coping skills and frustration management skills (Malkin & Benshoff, 1996). The goals for Motivation Interviewing therapy involve helping the client become self motivated to change lifestyle towards sobriety. The goals of Cognitive Behavioral Therapy incorporate changing thinking/behavior patterns that are associated with substance abuse. Finally, the goals of the Chemical Dependency Groups include learning of information about Alcohol Use Disorder, support groups in the area including AA, and other community resources.
Anton, R., Moak, D., Waid, R., Latham, P., Malcom, R., & Dias, J. (1999). Naltrexone and cognitive behavioral therapy for the treatment of outpatient alcoholics: results of a placebo-controlled trial.The American Journal of Psychiatry,156(11), 1758-1764.
Barlow, D. H., & Durand, V. M., (2012). Abnormal psychology: an integrative approach (7th ed.). Stamford, CT: Cengage Learning.
Ferguson, R. A., & Goldberg, D. M. (1997). Genetic markers of alcohol abuse. Clinica Chimica Acta,257(2), 199-250.
Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., Dufour, M. C., Compton, W., & Kaplan, K. (2004). Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.Archives of General Psychiatry,61(8), 807-816.
Libal, J. (2003). Chapter 7: Alternative and supplementary treatments.Drug Therapy & Substance-Related Disorders, 116.
Malkin, M. J., & Benshoff, J. J. (1996). Therapeutic recreation interventions in substance abuse.Parks & Recreation,31(10), 26.
Nation, J. M., & Benshoff, J. J. (1996). Therapeutic recreation programs for adolescents in substance abuse treatment facilities. Journal Of Rehabilitation, 62(4), 10-16.
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