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Feb 20, 2024

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What's Wrong, A Short Assessment Assessment Case Studies Directions : Choose one of the individuals described in Chapter 6 of your textbook: Ann (page 61), Daniel (page 65), Sam (page 67), or Dean (page 72). Based on the information in the textbook, complete the following form. Client Name: Dean Assessment Date: January 15, 2024 Substance Use History Drug First Use: Yes or No Pattern of use over time? Frequency of use in past month? Date/amount of most recent use? Alcohol ( Fetting, 2016) No ( Fetting, 2016) The client has engaged in frequent use of drinking. ( Fetting, 2016) The client has not had a drink within the past 2 weeks. ( Fetting, 2016) The client had a drink today. ( Fetting, 2016) Sociocultural Factors Educational level The client’s education level was not disclosed. ( Fetting, 2016) Employment status The client is unemployed. ( Fetting, 2016) Current living situation The client’s living situation is unknown. ( Fetting, 2016) Current or past legal problems There is no disclosure of history of any legal problems. ( Fetting, 2016) Describe family history of substance use No family history of substance abuse was disclosed. ( Fetting, 2016) Describe client’s social support system The client has become distant from both friends and family. Despite the potential support that his mother could offer, the client is not willing to involve her. ( Fetting, 2016) 1

Diagnostic Criteria Checklist Criteria Yes No Criteria Yes No Was the substance taken in larger amounts or over a longer period of time than intended? x Were important social, occupational, or recreational activities given up or reduced because of substance use? x Is there a persistent desire or unsuccessful efforts to cut down or control substance us? x Has the substance been used recurrently in physically hazardous situations? x Was a great deal of time spent in activities necessary to obtain or use the substance, or recover from the substance? x Has use continued despite knowing of having a persistent or recurrent physical or psychological problem that is caused or exacerbated by substance use? x Have they continued to use the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the substance use? x Has recurrent use of the substance resulted in a failure to fulfill major role obligations at work, school, or home? x Is tolerance present? x Is withdrawal present? x Is there a craving or strong desire or urge to use the substance? x DSM-5-TR Diagnosis: Alcohol Use Disorder, Alcohol Induced Mental Disorder (American Psychiatric Association, 2022) DSM-5-TR Diagnostic Code: F10.20, F10.99 (American Psychiatric Association, 2022) 2

Basis of Diagnosis (A 2–4 sentence explanation of why you chose this diagnosis.) The client has been diagnosed with a severe substance use disorder (SUD), with a history of alcohol use spanning 14 years. There was one attempt to stop drinking, lasting two weeks, followed by a relapse. The client has experienced withdrawal and has distanced himself from family and friends, avoiding phone calls, missing multiple sessions, and presenting at the Emergency Department with symptoms such as gastritis, elevated liver enzymes, and a pancreatic issue—all indicative of significant alcohol misuse. ( Fetting, 2016) Applicable Addictions Perspective (A 2–4 sentence description of a theoretical perspective that would explain this client’s substance use history.) The client, aged 27, initiated alcohol use at the age of 13. Over the past 14 years, various developmental milestones have not been achieved. Presently, the client exhibits psychological issues and faces challenges in maintaining healthy relationships with both family and friends. Additionally, there are concerns related to financial management. ( Fetting, 2016) Ethical Considerations (Based on NAADAC code of ethics, describe how will you store and protect assessment information. Cite the NAADAC code of ethics.) I am bound by the NAADAC code of ethics, requiring me to prioritize client confidentiality and safety. All records will be meticulously kept in compliance with HIPAA guidelines, and any disclosure of information will strictly adhere to established protocols. This commitment ensures a secure and confidential environment for clients seeking support for substance use issues. (NAADAC, 2021) 3

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