Of the substance disorders, alcohol-related disorders are the most prevalent even though only a small percentage of individuals actually receive help. Recidivism in the substance treatment world is also very high. As research into treatment has developed, more and more evidence shows that genes for alcohol-metabolizing enzymes can vary by genetic inheritance. Women have been identified as particularly vulnerable to the impacts of alcohol. Native Americans, Asians, and some Hispanic and Celtic cultures also have increased vulnerability to alcohol misuse.
Even with these developments, treatment continues to spark debate. For many years, the substance use field itself has disagreed with mental health experts as to what treatments are the most effective for substance use disorders and how to improve outcomes. The debate is often over medication-assisted treatment (MAT) versus abstinence-based treatment (ABT). Recently the American Psychiatric Association has issued guidelines to help clinicians consider integrated solutions for those suffering with these disorders. In this Discussion, you consider your treatment plan for an individual with a substance use disorder.
To prepare: Read the case provided by your instructor for this week’s Discussion and the materials for the week. Then assume that you are meeting with the client as the social worker who recorded this case.
Post a 300- to 500-word response in which you address the following:
Morrison, J. (2014). Diagnosis made easier (2nd ed.). New York, NY: Guilford Press.
Chapter 15, “Diagnosing Substance Misuse and Other Addictions” (pp. 238–250)
American Psychiatric Association. (2013r). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm16
Gowin, J. L., Sloan, M. E., Stangl, B. L., Vatsalya, V., & Ramchandani, V. A. (2017). Vulnerability for alcohol use disorder and rate of alcohol consumption. American Journal of Psychiatry, 174(11), 1094–1101. doi:10.1176/appi.ajp.2017.16101180
Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., … Hong, S.-H. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86–90. doi:10.1176/appi.ajp.2017.1750101
Stock, A.-K. (2017). Barking up the wrong tree: Why and how we may need to revise alcohol addiction therapy. Frontiers in Psychology, 8, 1–6. doi:10.3389/fpsyg.2017.00884
CASE OF BRANDON
INTAKE DATE: May 2018
This is a voluntary admission for this 26 year old African-American male. This is
Brandon’s first psychiatric hospitalization. Brandon has been married for 2 years
and has been separated from his husband for the past three months. He has
currently been living with his sister in Atlanta, GA., where his husband and son
reside. Brandon has a two year degree in nursing. Brandon works as an RN.
Religious affiliation is agnostic.
“I need to learn to deal with losing my husband and son.”
HISTORY OF ILLNESS:
This admission was precipitated by Brandon’s increased depression and agitation
which has been steadily increasing over the past year. In the past three months
prior to admission, it was unbearable. He identifies a major stressor of his husband
and son leaving him three months ago. Brandon reports that in the past three
months since separating from his husband, he has experienced sad mood and
Brandon reports his dedication to working out. He has used a cycle of steroids to
increase his body mass. During his most ambitious cycle, approximately 1 year
ago, he used testosterone cypionate, 600 mg per week; nandrolone decanoate, 400
mg a week; stanozolol (Winstrol), 12 mg a day; and oxandrolone (Anavar), 10 mg
a day. During each of the cycles Brandon has noted euphoria, irritability, and
grandiose feelings. These symptoms were most prominent during his most recent
cycle, when he felt “invincible.” During this cycle he also noted a decreased need
for sleep, racing thoughts, and a tendency to spend excessive amounts of money.
For example, he impulsively purchased a $2,700 stereo system when he
realistically could not afford to spend more than $500. He also became
uncharacteristically irritable with his husband and on one occasion put his fist
through the side window of their car during an argument, an act inconsistent with
his normally mild-mannered personality.
Brandon is 69 inches tall and presently weighs 204 pounds, with a body fat of 11
percent. He reports that he began lifting weights at age 17, at which time he
weighed 155 pounds. About 2 years after beginning his weight lifting, he
began taking steroids, which he obtained through a friend at his gymnasium. His
first “cycle” of steroids lasted for 9 weeks and involved methandienone
(Methanabol), 30 mg a day, orally, and testosterone cypionate, 600 mg a week,
intramuscularly. During these 9 weeks, he gained 20 pounds of muscle mass. He
was so pleased with these results that he took five further cycles of steroids over
the course of the next 6 years. Brandon exhibits characteristic features of muscle
PAST PSYCHIATRIC HISTORY:
Brandon was seen on an outpatient basis by Dr. S for a period of two months prior
to admission. He was being seen for individual counseling because of the marital
problems. Brandon reported to Dr S. that he was using steroids to increase his
body mass. He noted that after the most recent cycle ended, he became mildly
depressed for about 2 months. Brandon has used a number of drugs to lose weight
in preparation for bodybuilding contests. These include ephedrine, amphetamine,
triiodothyronine, and thyroxin. Recently, he has also begun to use the opioid
agonist–antagonist nalbuphine intravenously (IV) to treat muscle aches from
weight lifting. He also used oral opioids, such as controlled-release oxycodone
(OxyContin), at least once a week. He uses oral opioids sometimes to treat muscle
aches, but often simply to get high. He reports that use of nalbuphine and other
opioids is widespread among weight lifters.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY:
Father and grandfather have a history of cardiovascular disease.
PSYCHOSOCIAL AND DEVELOPMENTAL HISTORY:
Brandon reports that while growing up his parents maintained a satisfactory
relationship. Father reportedly worked nights and slept during the day. Brandon did
not have much contact with his father but now enjoys a close relationship with
him. He states he has always had his parents support.
During Brandon’s school years, he reports he was an underachiever in elementary
school. He denies having had a history of discipline problems or hyperactivity. He
states he did well in high school and earned grades of A’s and B’s. Brandon played
football in HS. After completing high school, Brandon furthered his education and
earned his license as a registered nurse. He states he graduated at the top of his
class from nursing school.
CURRENT FAMILY ISSUES AND DYNAMICS:
Brandon’s husband reports that Brandon’s difficulties began to get worse a few
months ago when he decided to move out of the house due to Brandon’s increasing
erratic behavior. He moved into his parents’ house and Brandon is living with his
sister. Husband states that Brandon has been suffering from mood swings where he
is “very up” and feeling great, firm in his direction and then within the next few
hours, he is often out of control, arguing, throwing temper tantrums, pushing and
shoving, and becoming verbally abusive.
Husband describes Brandon as “extremely depressed” now and says Brandon
states, “life is over…I wish I was dead…don’t send my son over to visit because I
don’t want him to find my dead body…everything I touch turns to garbage.”
Husband adds that Brandon suffers from poor self-esteem. In terms of strengths,
he is a good father, compassionate, creative, and can be an outstanding person.
Brandon has been married for 2 years and has recently been separated for the past
three months. Brandon and his husband have one adopted son, age 4. Brandon
states he feels invested as a parent and feels close to his son.
Leisure time activities Brandon has enjoyed in the past include playing softball,
reading, playing poker, and watching football. Now his main focus is
weightlifting. Brandon states he has several close friends.
Brandon presents as a casually dressed male who appears his stated age of 26.
Posture is relaxed. Facial expressions are appropriate to thought content. Motor
activity is appropriate. Speech is clear and there is no speech impediments noted.
Thoughts are logical and organized. There is no evidence of delusions or
hallucinations. Brandon denies any hallucinations. Brandon denies suicidal or
homicidal ideation at the present time. His husband has observed a history of
notable mood swings. No manic-like symptoms are observed at the time of this
On formal mental status examination, Brandon is found to be oriented to three
spheres. Fund of knowledge is appropriate to educational level. Recent and
remote memory appear intact. Brandon was able to calculate serial 7’s. He reports
checking his appearance dozens of times a day in mirrors, or when he sees his
reflection in a store window or even in the back of a spoon. He becomes anxious if
he misses even one day of working out at the gym, and acknowledges that his
preoccupation with weight lifting has cost him both social and occupational
opportunities. Although he has a 48-inch chest and 19-inch biceps, he has
frequently declined invitations to go to the beach or a swimming pool for fear that
he would look too small when seen in a bathing suit. He is anxious because he has
lost some weight since the end of his previous cycle of steroids and is eager to
resume another cycle in the near future.