Alcohol Use Disorders - The Case of Shane Flashcards
What does DSM-IV say of alcohol dependence and abuse?
A maladaptive pattern of substance use resulting in clinically significant impairment or distress.
Abuse is considered LESS severe than dependence
To receive a diagnoses of alcohol DEPENDENCE, THREE or more of the following seven criteria must be present in the 12 months prior to evaluation:
(Growing) The Wine Vines Take Courage and Patience.
Tolerance
Withdrawal
Volume - Drinking more over longer periods than intended
Time - Spending significant amounts of time obtaining, consuming and recovering from the effects of alcohol
Control - Inability to control drinking
Activities - Giving up activities not related to drinking
Problems - Continued drinking despite exacerbated psychological or physical problems.
To receive a diagnoses of alcohol ABUSE, ONE or more more of the following criteria must be present in the 12 months prior to evaluation:
Please Review Drinking Laws
Problems - Drinking despite relationship problems worsened by the drinking
Responsibilities - Not meeting home, school or work responsibilities
Danger - Drinking in situations where it could be physically dangerous
Legal - Alcohol related legal trouble
Is any single treatment for AUD considered superior to others?
no
What are some of the empirically supported treatments for AUDs?
CBT (eg social skills training, etc)
Contingency management (use of reinforcers, be they positive or negative)
Cue exposure therapy - (social learning, classical conditioning)
Community reinforcement approach - build an environment that discourages substance use and reinforces sobriety
Behavioural Couples and Family Treatments - interventions to facilitate abstinence, interventions to teach partner skills, and strategies to improve relationship functioning.
Brief interventions -
Motivational Interviewing and Motivational Enhancement therapy
12 step based programs -
What can you say about relationship and therapist factors WRT the treatment of alcohol abuse and disorders?
Hersen and Sturmey (2012)
Importance of therapist and relationship factors cannot be underestimated.
Therapist warmth, empathy and the TA contribute more to the prediction of client out comes than do technique-specific factors such as treatment modality.
Less directive therapy produces lesser drinking at 1 year follow up. Increased confrontation leads to increased resistance, which leads to more alcohol use - so don’t be too confrontational.
What are some general comments about the treatment of AUDs
They are largely imperfect - even the best EBPs produce only modest improvements in outcomes.
When clients have multiple needs, a Case Management approach is recommended. When partners are involved, a relationship based approach is recommended.
Less impaired patients respond better to less structured treatment modalities.
What were some of the key therapeutic goals for Shane?
Take responsibility for his DUI charge, and violence towards his wife while drunk
Increase his awareness of his drinking
Motivational interviewing IOT get him to address his ambivalence and assess the costs/benefits
How to proceed when assessing/treating an AUD?
Use MI techniques to motivate for change. Take full clinical history and functional analysis Use psychometrics (such as AUDIT) to assess frequency, amount of consumption; associated problems; etc
Describe the AUDIT
The AUDIT is a simple screen which can detect risky and high risk drinking. It contains three questions on alcohol consumption (q1 to q3), three questions on drinking behaviour/dependence (q4 to q6) and four questions on problems related to drinking (q7 to q10).
Does Shane meet DSM-IV diagnostic criteria?
Shane meets the criteria for Alcohol Use Disorder, as described in DSM-5. Diagnostic criteria indicates a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of listed criteria, occurring within a 12 month period.
The criteria that Shane currently conforms to include:
- Alcohol is often taken in larger amounts or over a longer period than was intended (Shane reported that “I don’t go to the pub meaning to get pissed… before I know it I’ve had about ten”).
- Recurrent alcohol use reulsting in a failure to fulfill major role obligations at work, school or home (Shane reported that both business and family life are suffering as a result of his drinking; being caught drink driving).
- Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (fighting with wife including physical violence; fights at the local hotel).
- Important social, occupational, or recreational activities are given up or reduced because of alcohol use (Shane has difficulty applying himself at work if he has had a “really big one the night before”).
- Recurrent alcohol use in situations in which it is physically hazardous (Shane has been drink driving for four to five months).
Part 2 - What is the utility of diagnosing an individual in this manner?
Provides a framework for intervention.
Aids differential diagnosis and consideration of additional diagnoses.
Aids communication between professionals.
Discussion of diagnosis may increase client’s motivation to change.
Helps to identify relevant research literature.
Helps access evidence-based ‘best-practice’ treatment guidelines.
Helps to guide broad approach to treatment (e.g., detox required?).
Indicates specific areas of concern to focus on.
Assists with formulation.
May assist with identification of etiological and prognostic factors.
May increase access to specialist treatment options.
Provides information relevant to epidemiological studies.
Diagnostic criteria and instrument scores provide baseline data to compare with
progress and outcome data.
Formal diagnosis may be necessary for insurance purposes.
Part 3 - Outline your formulation of Shane’s case thus far.
a) Presenting problem
- “wife thinks I have a drinking problem”
- fighting with wife
- driving whilst drunk
b) Predisposing factors
- Familial alcohol abuse (father and grandfather)
- History of binge drinking since age 16
- Cannabis use from age 15-18
- Parents divorced
- Not close to dad
c) Precipitating factors
- Got caught drink driving
- Interpersonal difficulties with, and concern from, wife
- Work stress associated with consequences of drinking
d) Perpetuating factors
- Drinking used to relax
- Drinking facilitates social connectedness with friends
- Drinking allows him escape from the cycle of fighting with his wife
- Ambivalent about the seriousness of his drinking problem
e) Prognosistic factors
Positive
- Social support in change from his wife/family
- Insight into the impact his drinking has on his business (“notably slowed in the last four months”)
- Insight into the impact his loss of license may have on his business
Negative
- Ambivalence about change
- Social contacts through football are entrenched in drinking culture
Define Substance Use Disorder as per DSM-5
The DSM-5 defines a substance use disorder as the presence of at least 2 of 11 criteria, which are clustered in four groups:
- Impaired control: (1) taking more or for longer than intended, (2) unsuccessful efforts to stop or cut down use, (3) spending a great deal of time obtaining, using, or recovering from use, (4) craving for substance.
- Social impairment: (5) failure to fulfill major obligations due to use, (6) continued use despite problems caused or exacerbated by use, (7) important activities given up or reduced because of substance use.
- Risky use: (8) recurrent use in hazardous situations, (9) continued use despite physical or psychological problems that are caused or exacerbated by substance use.
- Pharmacologic dependence: (10) tolerance to effects of the substance, (11) withdrawal symptoms when not using or using less.*
What sorts of interventions were used for Shane?
Cognitive Techniques
modify beliefs/attitudes that play a role in substance abuse
address cognitive processes such as self-efficacy, outcome expectancies
Behavioural Techniques Self monitoring Stimulus control Counter-conditioning Cue exposure Activity monitoring and scheduling
C-B
Recognising conditioned craving and modify behaviour accordingly
Functional analysis of substance abuse
