Case Example: Substance Use Disorder and Anxiety Disorder (Follow-Up) NRNP 6635 – Week Assignment
Case Example: Substance Use Disorder and Anxiety Disorder (Follow-Up)
A 33-year-old Caucasian male with Alcohol Use Disorder and Generalized Anxiety Disorder returned for follow-up. He reports continued cravings for alcohol, especially during stressful situations, and describes increased anxiety when unable to use alcohol as a coping mechanism. He notes feeling nervous and restless throughout the day, which exacerbates his urge to drink.
Preceptor Plans include continuing participation in outpatient rehabilitation for alcohol use, starting cognitive-behavioral therapy (CBT) to address anxiety and coping strategies, and implementing relaxation techniques to manage stress without alcohol. Follow-up is scheduled in two weeks to monitor progress and assess treatment effectiveness.
1. Introduction
Patient: 33‑year‑old Caucasian male.
Diagnoses: Alcohol Use Disorder (AUD) and Generalized Anxiety Disorder (GAD).
Clinical Context: Follow‑up visit after initial diagnosis and treatment planning.
Presenting Concerns:
Continued cravings for alcohol, especially during stress.
Increased anxiety when unable to use alcohol as coping mechanism.
Nervousness and restlessness throughout the day, exacerbating urge to drink.
Preceptor Plan:
Continue outpatient rehabilitation for alcohol use.
Initiate Cognitive Behavioral Therapy (CBT) for anxiety and coping.
Implement relaxation techniques.
Follow‑up in two weeks to monitor progress.
2. Alcohol Use Disorder (AUD)
Definition
A problematic pattern of alcohol use leading to clinically significant impairment or distress.
Characterized by impaired control, social impairment, risky use, and pharmacological criteria (tolerance, withdrawal).
Clinical Features
Cravings and strong urge to drink.
Loss of control over intake.
Continued use despite negative consequences.
Tolerance and withdrawal symptoms.
Functional impairment in work, relationships, health.
Risk Factors
Genetic predisposition.
Family history of substance use.
Co‑occurring psychiatric disorders (e.g., anxiety, depression).
Stressful life events.
Early onset of alcohol use.
Assessment Tools
AUDIT (Alcohol Use Disorders Identification Test).
CAGE Questionnaire.
DSM‑5 diagnostic criteria.
Treatment
Pharmacological:
Naltrexone (reduces cravings).
Acamprosate (restores neurotransmitter balance).
Disulfiram (aversive therapy).
Psychotherapy:
CBT for coping skills.
Motivational interviewing.
Relapse prevention therapy.
Rehabilitation:
Outpatient or inpatient programs.
12‑step groups (AA).
Lifestyle:
Structured routine.
Stress management.
Social support.
3. Generalized Anxiety Disorder (GAD)
Definition
Excessive anxiety and worry occurring more days than not for at least 6 months, difficult to control, associated with physical and cognitive symptoms.
Clinical Features
Restlessness, feeling keyed up.
Fatigue.
Difficulty concentrating.
Irritability.
Muscle tension.
Sleep disturbance.
Persistent worry across multiple domains.
Risk Factors
Genetic predisposition.
Family history of anxiety.
Personality traits (neuroticism).
Stressful life events.
Co‑occurring substance use.
Assessment Tools
GAD‑7 (Generalized Anxiety Disorder scale).
HAM‑A (Hamilton Anxiety Rating Scale).
DSM‑5 diagnostic criteria.
Treatment
Pharmacological:
SSRIs (sertraline, escitalopram).
SNRIs (venlafaxine, duloxetine).
Buspirone.
Psychotherapy:
CBT (gold standard).
Relaxation training.
Mindfulness‑based therapy.
Lifestyle:
Sleep hygiene.
Exercise.
Nutrition.
4. Comorbidity: AUD and GAD
Interaction:
Anxiety increases urge to drink as coping mechanism.
Alcohol temporarily reduces anxiety but worsens long‑term symptoms.
Withdrawal exacerbates anxiety.
Clinical Implications:
Must treat both disorders concurrently.
Integrated approach essential.
Challenges:
Risk of relapse during stress.
Difficulty differentiating withdrawal anxiety from baseline GAD.
Need for strong therapeutic alliance.
5. Cognitive Behavioral Therapy (CBT)
Definition
Structured, time‑limited psychotherapy focusing on identifying and modifying maladaptive thoughts and behaviors.
Application in GAD
Identify cognitive distortions (catastrophizing, overgeneralization).
Challenge irrational thoughts.
Teach relaxation and coping skills.
Behavioral experiments to reduce avoidance.
Application in AUD
Identify triggers for drinking.
Develop alternative coping strategies.
Relapse prevention planning.
Strengthen motivation for sobriety.
6. Relaxation Techniques
Deep Breathing Exercises: Reduce physiological arousal.
Progressive Muscle Relaxation: Release tension.
Mindfulness Meditation: Increase awareness, reduce rumination.
Guided Imagery: Promote calmness.
Yoga/Exercise: Improve mood and reduce cravings.
7. Outpatient Rehabilitation
Structured program with therapy, group support, and medical monitoring.
Allows patient to maintain daily responsibilities.
Provides accountability and relapse prevention.
Focus on long‑term sobriety and coping skills.
8. Monitoring and Follow‑Up
Two‑week follow‑up: Assess cravings, anxiety, coping skill use, adherence to rehab.
Progress Indicators:
Reduced alcohol cravings.
Improved anxiety management.
Engagement in CBT.
Use of relaxation techniques.
Adjustments:
Medication initiation if needed.
Intensify therapy if relapse risk high.
Family involvement if appropriate.
9. Nursing and Clinical Implications
Assessment: Monitor cravings, anxiety, sleep, nutrition.
Intervention: Support CBT, teach relaxation, encourage rehab participation.
Education: Explain risks of alcohol use, benefits of sobriety.
Support: Encourage social support, family involvement.
Safety: Monitor for withdrawal, suicidality, relapse risk.
10. Ethical and Cultural Considerations
Confidentiality: Respect patient privacy.
Consent: Informed consent for treatment.
Stigma: Address stigma of addiction and anxiety.
Cultural Sensitivity: Respect patient’s background and beliefs.
11. Summary
Patient presents with comorbid AUD and GAD.
Cravings and anxiety reinforce each other.
Integrated treatment plan includes outpatient rehab, CBT, relaxation techniques.
Follow‑up scheduled to monitor progress.
Goal: Reduce cravings, manage anxiety, prevent relapse, improve functioning.
📝 Quiz (15 Questions)
Multiple Choice – Select the best answer.
What are the patient’s diagnoses? a) PTSD and OCD b) Alcohol Use Disorder and GAD c) Depression and Bipolar Disorder d) ADHD and Panic Disorder
What symptom exacerbates the patient’s urge to drink? a) Fatigue b) Increased anxiety c) Headache d) Appetite changes
What therapy is planned to address anxiety? a) Psychoanalysis b) CBT c) ECT d) Dialysis
What relaxation technique involves tensing and releasing muscles? a) Guided imagery b) Progressive muscle relaxation c) Yoga d) Deep breathing
What is the patient’s age? a) 30 b) 33 c) 35 d) 40
Which medication reduces alcohol cravings? a) Naltrexone b) Clozapine c) Lithium d) Haloperidol
Which tool screens for generalized anxiety? a) GAD‑7 b) AUDIT c) Y‑BOCS d) CAPS‑5
Which therapy is gold standard for GAD? a) CBT b) Psychoanalysis c) EMDR d) DBT
Which program allows patient to maintain daily responsibilities while receiving treatment? a) Inpatient rehab b) Outpatient rehab c) Detox only d) Emergency care
Which neurotransmitter system is targeted by SSRIs? a) Dopamine b) Serotonin c) GABA d) Acetylcholine
What is the primary outcome goal of treatment? a) Immediate cure b) Reduce cravings and manage anxiety c) Avoid medical care d) Relocate patient
Which assessment tool screens for alcohol use severity? a) AUDIT b) GAD‑7 c) PHQ‑9 d) ADOS‑2
Which trauma history is relevant in Lisa Tremblay’s case but not in this patient? a) Childhood sexual abuse b) Combat exposure c) Divorce d) None
What is scheduled in two weeks? a) Hospitalization b) Follow‑up appointment c) Family therapy d) Court hearing
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