Psych Note 13 Alcoholism

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School

University of Notre Dame *

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5111

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Nursing

Date

Nov 24, 2024

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1 Psych Notes: Alcoholism Student’s Name Institutional Affiliation Course Professor’s Name Date

2 Pysch Notes: Alcholism Demographics: Sebastian is a fifty-seven-year-old man in Washington Chief Complaint: The patient arrives at the addiction treatment facility looking for assistance with his excessive alcohol use and its detrimental effects on his life. History of Current Illness: The client claims to have a long history of alcohol misuse, which has gotten worse recently. He talks about having frequent episodes of binge drinking, where he frequently drinks a lot of alcohol quickly. The patient admits drinking has harmed his interpersonal interactions, professional performance, and general functioning. He states that he is motivated to stop drinking and regain control of his life. The client has also admitted that their family has a history of drug abuse, as his mother had been diagnosed with cirrhosis due to excessive drinking of alcohol. Psychiatric history from the past: The client has never received a mental health diagnosis or treatment. Medical History: The patient has a history of hypertension, which is being treated with medication right now. He denies having any more serious medical issues or ongoing ailments. Family History: The patient has admitted that he comes from a family that has a problem with alcoholism. The patient has depicted that his uncles and father have been struggling with alcohol abuse for many years. Social History: The patient has been divorced for 5 years and lives alone with his dog. The patient indicated he is a full-time worker in a fast food joint, and he indicated the job is very stressful. In furtherance, the patient indicated that he has not been on good terms with his

3 parents, and together with the stressful job, the patient has been experiencing anxiety and depression, and this has made the patient sink into alcoholism. Mental Status Examination Appearance and Behavior: The patient's appearance has been disheveled, showing signs of malaise and fatigue. Motor Activity: The motor activity of the patient is slow. Speech: Although the patient's speech is coherent, it sometimes becomes slurred, showing the level of the patient's alcoholism. Mood: The patient looks depressed and shows guilt and remorse due to alcohol abuse. Thought Content: The patient shows a strong need to change as he is very well aware of some of the negative implications affiliated with alcohol abuse. Thought Processes: There are no substantial abnormalities notable in the thought processes of the patient. Perceptual Disturbances: The patient does not have any notable perceptual disturbances. Cognition: The patient is oriented to person, place, and time and is very alert. Suicidal Thoughts: The patient has denied any suicidal thoughts. Case Formulation: J.K., the client, has a severe case of alcohol use disorder (AUD), which is defined by a protracted history of binge drinking, unpleasant side effects in a number of areas of life, and a strong desire to stop. Self-medication for episodes of depression and anxiety and a family history of drinking may impact the individual's alcoholism (Kranzler & Soyka, 2018).

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4 His illness may have worsened due to recent increases in alcohol intensity and stress from his job. Detoxification, pharmacological intervention, psychotherapy, patient education, and referrals to support groups for continuing recovery and relapse prevention are all part of the treatment strategy. Diagnosis: Alcohol Use Disorder - Severe - 303.90 (F10.20) Treatment Plan Pharmacology:  Disulfriam 50 mg daily  Naltrexone 30 mg daily to block the good feelings caused by alcohol abuse (Campbell et al.,2018).  Acamprosate 40 mg Detox and Withdrawal: The patient can undergo detox that is medically managed for 2-7 days. Evidence-Based Non-Pharmacological Interventions:  Family Therapy  Individual Therapy  Group Therapy Referrals  Recommend the patient to local addiction treatment centers  Refer the patient to various support groups in the community.

5 References Campbell, E. J., Lawrence, A. J., & Perry, C. J. (2018). New steps for treating alcohol use disorder. Psychopharmacology , 235 , 1759-1773. Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. Jama , 320 (8), 815-824.