Assessing and Diagnosing Substance-Related and Addictive Disorders: Comprehensive Psychiatric Evaluation Example (Alcohol Use Disorder)

Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis. Incorporate the following:

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination results. Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives.
• Reflection notes: What would you do differently with this client if you could conduct the session over? Include legal/ethical considerations (beyond confidentiality and consent for treatment), health promotion and disease prevention considering patient factors (age, ethnic group, PMH and other risk factors such as socioeconomic and cultural background).

Subjective

CC: “My wife and the judge both say I have a drinking problem. I guess I can’t keep going like this.”

HPI: R. G. is a 47-year-old Mexican American man referred for psychiatric evaluation after a second arrest for driving under the influence (DUI) three weeks ago. He reports drinking 8 to 10 beers daily on weekdays and up to 18 beers on weekends for at least four years, increasing over the past year after his father’s death. He describes cravings in the afternoon, failed attempts to cut down “at least five times,” drinking more than intended and continued drinking despite his wife’s threats to leave. He reports morning tremors, sweating and nausea relieved by drinking a beer, and he has missed work about twice a month due to hangovers. He reports low mood “most days” for about two months, poor sleep, low energy and guilt, but states that his mood improved during a 10-day period of abstinence last spring. He denies current suicidal or homicidal ideation, intent or plan.

Substance current use and history: began drinking at age 15; daily drinking for about four years; last drink 18 hours ago. He smokes half a pack of cigarettes per day and denies cannabis, opioids, stimulants or other drugs. He has never received treatment for substance use.

Past psychiatric history: no previous psychiatric diagnoses, hospitalizations, medication trials or psychotherapy. Denies history of suicide attempts or self-harm.

Family psychiatric/substance use history: father had alcohol use disorder and died of cirrhosis at age 70; a paternal uncle had depression; mother has no known psychiatric history.

Psychosocial history: born in Texas to parents from Michoacán, Mexico; bilingual, with English preferred for the interview; completed high school; works as a construction foreman. Married for 20 years with three children (ages 12–19). Catholic, attends Mass occasionally. Reports that drinking is common at family gatherings and at work and that his family “doesn’t talk about” mental health or addiction. Faces legal consequences, including possible jail time and license suspension.

Medical history: hypertension, untreated for the past year; gastroesophageal reflux. No known drug allergies. Current medications: omeprazole 20 mg over the counter as needed.

ROS: General: fatigue, 10-pound weight loss over six months. HEENT: denies vision changes. Skin: denies jaundice. Cardiovascular: reports palpitations during morning withdrawal; denies chest pain. Respiratory: morning cough. GI: heartburn, occasional nausea; denies hematemesis or melena. GU: denies symptoms. Neurological: morning tremors; denies seizures or blackouts in the past year. Musculoskeletal: denies pain. Hematologic: denies easy bruising. Endocrine: denies polyuria or polydipsia.

Objective

Vital signs: BP 152/94, HR 102, RR 18, T 98.9°F. Physical exam: fine bilateral hand tremor, diaphoresis, mild hepatomegaly on palpation, no jaundice or spider angiomas. Screening tools: AUDIT score 29 (probable alcohol dependence); CIWA-Ar score 11 (mild withdrawal); PHQ-9 score 13 (moderate depressive symptoms; item 9 = 0). Labs: GGT 142 U/L (elevated), AST 88 U/L and ALT 41 U/L (AST:ALT ratio about 2:1, consistent with alcohol-related liver injury), MCV 102 fL (macrocytosis), urine drug screen negative, breath alcohol 0.00 at the time of interview.

Assessment

Mental status examination: R. G. is a 47-year-old man who appears his stated age, casually dressed with fair hygiene and mild diaphoresis. He is cooperative with good eye contact, though he appears tense. Psychomotor activity shows a fine tremor and mild restlessness. Speech is normal in rate and volume. Mood is “down and stressed”; affect is constricted and congruent with mood. Thought process is linear and goal directed. Thought content is focused on guilt, legal problems and fear of losing his family; no delusions, obsessions, suicidal or homicidal ideation. He denies hallucinations and shows no signs of responding to internal stimuli. He is alert and oriented to person, place, time and situation; memory and concentration are grossly intact. Insight is fair, as he acknowledges a drinking problem, and judgment is fair to poor given repeated driving after drinking.

Differential diagnoses (highest to lowest priority):

1. Alcohol use disorder, severe (F10.20), with alcohol withdrawal without perceptual disturbances (F10.230). Primary diagnosis. The DSM-5-TR requires at least 2 of 11 criteria within 12 months; six or more indicate severe disorder (American Psychiatric Association [APA], 2022). R. G. meets at least eight: drinking more than intended, unsuccessful efforts to cut down, craving, failure to fulfill work obligations, continued use despite relationship problems, recurrent use in hazardous situations (driving), tolerance and withdrawal. Pertinent positives include his daily heavy drinking, tremor, diaphoresis, CIWA-Ar of 11, AUDIT of 29 and elevated GGT and MCV. Pertinent negatives include no other substance use and a negative drug screen.

2. Alcohol-induced depressive disorder. This diagnosis applies when a depressive disturbance develops during or soon after intoxication or withdrawal and the substance is capable of producing the symptoms (APA, 2022). Supporting evidence includes depressive symptoms that began during a period of heavy drinking and improved during his brief abstinence. Because DSM-5-TR codes this diagnosis together with the use disorder, it is listed as a strong consideration; it will be confirmed or ruled out by reassessing mood after about four weeks of sustained abstinence.

3. Major depressive disorder, single episode, moderate. R. G. reports depressed mood, sleep problems, low energy and guilt for about two months, and he has a family history of depression. However, MDD is less likely because the DSM-5-TR requires that the episode not be attributable to the physiological effects of a substance, and his symptoms closely track his drinking and improved with abstinence. If symptoms persist after a month of sobriety, MDD would move higher on the list.

Ruled out: generalized anxiety disorder, because his anxiety is limited to withdrawal periods and legal stress rather than excessive worry about many areas for six months; and alcohol withdrawal delirium, because he is fully oriented with no hallucinations or disturbance of attention.

Critical-thinking process: I prioritized alcohol use disorder because it explains the largest number of symptoms, has objective supporting evidence and carries immediate safety risks (withdrawal, liver disease and impaired driving). Because alcohol can cause depressive symptoms, I used the timeline of his mood in relation to drinking and abstinence to distinguish a substance-induced disorder from an independent depressive disorder, consistent with DSM-5-TR guidance. Cultural factors, including normalized drinking at family events and stigma around mental health, were considered when interpreting his delayed help-seeking rather than as evidence of pathology in themselves.

Plan (brief): withdrawal monitoring with CIWA-Ar and a symptom-triggered benzodiazepine protocol if scores rise; thiamine supplementation; referral for medically supervised outpatient detoxification or a higher level of care if withdrawal worsens. Discuss FDA-approved medications for AUD, such as naltrexone (after confirming liver function) or acamprosate, as recommended for patients with moderate to severe AUD (Reus et al., 2018). Refer for counseling, such as cognitive behavioral therapy and motivational interviewing, and mutual-help groups, including Spanish-language or culturally specific options if he prefers.

Reflection notes

What I would do differently: I would spend more time early in the session using motivational interviewing to explore his own reasons for change rather than focusing first on legal consequences, which may have increased his defensiveness. I would also ask, with his permission, to include his wife in part of the evaluation to obtain collateral information about drinking patterns and blackouts.

Legal and ethical considerations: Because he is court-referred, I must clarify what information will be shared with the court and obtain specific written consent; records related to substance use disorder treatment in federally assisted programs are protected under 42 CFR Part 2, which requires specific consent for most disclosures. His repeated impaired driving raises a public safety concern; I would counsel him not to drive after drinking, document the discussion and review state laws on reporting impaired drivers, balancing beneficence and justice for the public with his autonomy. I must also respect his right to choose treatment while ensuring that a court mandate does not undermine voluntary informed consent.

Health promotion and disease prevention: Alcohol use disorder affects an estimated 27.9 million people aged 12 and older in the United States, including about 5.0 million Hispanic or Latino people (National Institute on Alcohol Abuse and Alcoholism [NIAAA], n.d.). For R. G., priorities include liver evaluation and screening for hepatitis B and C with vaccination as indicated, blood pressure treatment, smoking cessation, depression and suicide-risk monitoring, and age-appropriate screenings such as colorectal cancer screening. Culturally responsive care, such as involving family if he wishes, offering bilingual resources and addressing stigma, can improve engagement.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

National Institute on Alcohol Abuse and Alcoholism. (n.d.). Alcohol use disorder (AUD) in the United States: Age groups and demographic characteristics. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics

Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., Mahoney, J., Pasic, J., Weaver, M., Wills, C. D., McIntyre, J., Kidd, J., Yager, J., & 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. https://doi.org/10.1176/appi.ajp.2017.1750101

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.