The primary diagnoses in Jon’s case are substance-related and addictive disorders, but he should also be assessed for impulse-control disorders. Although Jon reported experimenting with hallucinogens, he does not use them frequently and did not report using them within the past 12 months, so the most appropriate diagnoses based on the information provided are severe alcohol use disorder (303.90 [F10.20]) and mild cannabis use disorder (305.10 [F12.10]). Substance use is often a consequence of another root disorder, so additional diagnoses have to be explored (American Psychiatric Association, 2013). The most appropriate diagnosis based on Jon’s background information would be moderate adolescent-onset type conduct disorder (312.82 [F91.2]), possibly with limited prosocial emotions.
Alcohol use disorder is clearly Jon’s problem because he reported withdrawal symptoms in the absence of alcohol (Criterion A11), occupational impairment (Criterion A7), continued use despite violent behavior (Criterion A6), dropping out of school because of alcohol use (Criterion A5), and spending time to obtain alcohol (Criterion A3). Because Jon reported experiencing “the shakes” and spending his time and money primarily on obtaining alcohol, it is also possible to suggest that he has strong cravings to consume it (Criterion A4). It is possible to ask for more information pertaining to his tolerance of alcohol or efforts to control use, but Jon already satisfies six criteria, which indicates that the disorder is severe.
Jon’s cannabis use disorder is mild based on the provided information. He continues cannabis use despite its harmful effects on his functions (Criterion A5) and social problems (Criterion A6). Based on the provided information, is not clear whether other criteria (e.g., developed tolerance, cravings, physical hazard) are satisfied. Assuming that his withdrawal symptoms can be attributed to alcohol alone, the most probable diagnosis in Jon’s case is mild cannabis use disorder.
The information provided confirms this diagnosis of severe alcohol use disorder because alcohol abuse is the reason Jon is in treatment, and he admits to having severe withdrawal symptoms while he was in prison. However, more information is required to determine whether his cannabis use disorder is mild. Jon was charged with possession of marijuana, but it is possible that he is telling the truth when he says that he does not engage in frequent marijuana use. It is important to determine whether the marijuana in his possession was for personal use because that would mean that he does spend time obtaining cannabis and perhaps even needs to satisfy his cravings. It is also currently assumed that alcohol is solely responsible for Jon’s withdrawal symptoms, and it is not clear how he would feel without using cannabis. If it proves that he uses marijuana more frequently than reported, the disorder could prove to be moderate or severe.
Jon should also be asked about his cannabis use timeline within the past year. At the moment, the only information available for substance use within the past 12 months pertains to hallucinogens. Therefore, the use of other hallucinogens can be ruled out from the diagnosis, but Jon’s cannabis use habits within the past year are not completely clear. The criteria for diagnosing cannabis use disorder state that the client’s behavior must occur within the past 12 months. Assuming that Jon uses both alcohol and marijuana frequently, it is highly likely that he has been using marijuana more frequently within the past year than he was willing to admit. If Jon did not use marijuana within the past 3 months, it will be important to specify that he is in the early remission phase.
The majority of impulse-control disorders listed in the DSM-V are not applicable to Jon’s case because his violent behavior at the time of the arrest can be explained by the physiological effects of substances he was using, most likely both alcohol and marijuana (American Psychiatric Association, ). Nevertheless, Jon could be diagnosed with conduct disorder based on the information provided because he initiates physical fights (Criterion A1) and because he reported stealing in order to obtain money for alcohol (Criteria A10 and A12). His behavior affected his academic and occupational performance, so he also satisfies Criterion B. However, with the current information, it is not possible to determine whether Jon satisfies Criterion C, which states that the client’s behavior cannot be explained by antisocial personality disorder (301.7 [F60.2]).
Additional information will be required to confirm the presence of conduct disorder and perform a differential diagnosis. For example, it is possible that alcohol use in adolescence was a response to a traumatic event or to a mood disorder, but the current information about Jon does not suggest that either of those diagnoses are warranted. It is also not clear how Jon stole money to obtain alcohol. If he confronted the victims of his robberies, that would make his conduct disorder severe.
Jon’s past before he started drinking is also relevant to determine whether his problematic behavior started before adolescence. Understanding his behavior before high school is important to perform a differential diagnosis and rule out or diagnose antisocial personality disorder. If his problematic behavior started before the age of 15, it would be possible to consider antisocial personality disorder as an alternative. Based on Jon’s background, his alcohol use disorder did not begin immediately during freshman year. If his behavior developed after the age of 15, it will be possible to rule out antisocial personality disorder and confirm the presence of adolescent-onset type conduct disorder.
Based on the information provided and the diagnoses, Jon needs inpatient care to ensure both his safety and adherence to treatment. According to Hayashida (1998), both outpatient and inpatient treatment methods are effective if patient have mild or moderate withdrawal symptoms. It was also estimated that approximately 90% of alcohol disorder patients can manage withdrawal symptoms as outpatients (Abbott, Quinn, & Knox, 1995). However, Jon already reported experiencing severe withdrawal symptoms. As a person who experienced seizure in prison because of alcohol withdrawal, Jon needs to be referred to inpatient care, where he can receive benzodiazepines that outperform other medications for withdrawal-induced seizures (Amato, Minozzi, & Davoli, 2011). Therefore, based on the provided information and the American Society of Addiction Medicine (2001) patient placement criteria, it is recommended that Jon is placed in Level III.7-D care (i.e., medically monitored inpatient detoxification).
Recommending Level III.7-D is justified because residential detoxification emphasizes peer support to overcome withdrawal symptoms, but Jon’s symptoms are severe and need medical interventions. A higher level of care will not be warranted unless acute care is required. In addition to severe withdrawal seizures and delirium tremens, several considerations indicate that inpatient treatment is required. First, it is not clear whether Jon is capable of providing informed consent because of his history of substance abuse, so a protective environment is necessary. Second, it is expected that Jon will not be able or willing to adhere to the treatment outside of a protective and supervised environment. Finally, the provided information does not disclose other medical conditions Jon has, so he might have contraindications to outpatient detoxification, such as hypertension.
References
Abbott, P. J., Quinn, D., & Knox, L. (1995). Ambulatory medical detoxification for alcohol. The American Journal of Drug and Alcohol Abuse, 21(4), 549-563.
Amato, L., Minozzi, S., & Davoli, M. (2011). Efficacy and safety of pharmacological interventions for the treatment of the Alcohol Withdrawal Syndrome. Cochrane Database of Systematic Reviews, 6. doi:10.1002/14651858.CD008537.pub2
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed.). Washington, DC: American Psychiatric Publishing.
American Society of Addiction Medicine. (2001). Patient Placement Criteria for the Treatment of Substance-Related Disorders: ASAM PPC-2R. (2nd ed.). Chevy Chase, MD: American Society of Addiction Medicine.
Hayashida, M. (1998). An overview of outpatient and inpatient detoxification. Alcohol Health and Research World, 22, 44-46.
