PSYC FPX 2300 Assessment 2 Whats Wrong a Short Assessment
Student Name
Capella University
PSYC FPX 2300 Introduction to Addiction Theories
Prof. Name
Date
PSYC FPX 2300 Assessment 2 Whats Wrong a Short Assessment
Assessing a client’s substance use requires careful consideration of their pattern of use, social environment, diagnostic symptoms, and potential risks. In Ann’s case, the information provided indicates a severe pattern of Alcohol Use Disorder (AUD), based on the DSM-5 criteria. Although Ann has strong family support and a willingness to seek treatment, her reported alcohol use and associated behavioral, social, and functional problems indicate the need for professional assessment and intervention.
Client Assessment Information
Client Name: Ann
Assessment Date: March 31, 2022
Substance Use History
Ann’s primary substance of concern is alcohol. According to the case information, she had not previously demonstrated a significant history of alcohol use but has developed a problematic pattern more recently. Her alcohol consumption has occurred daily, with her most recent use reported as the previous day.
| Substance | First Use | Pattern of Use Over Time | Frequency in Past Month | Most Recent Use |
|---|---|---|---|---|
| Alcohol | No previous history reported | Yes | Everyday | Yesterday |
The recent increase in alcohol use is particularly important because it appears to be associated with a significant stressor in Ann’s life. Understanding when the problematic use began, how frequently alcohol is consumed, and how it affects daily functioning can help clinicians determine the appropriate level of care.
Sociocultural Factors
Several social and environmental factors should be considered when assessing Ann’s substance use. She is employed and currently lives with her husband, children, and a parent who has relocated from another part of the country. The case does not identify any current or previous legal problems.
Ann also reports no known family history of substance use. This may be relevant when considering the broader circumstances surrounding the development of her alcohol use, although the absence of a family history does not eliminate the possibility of developing a substance use disorder.
Her social support system is an important protective factor. Ann’s husband recognizes the problem and is willing to support her in seeking treatment. Their shared recognition of the issue may help create a supportive environment for recovery.
Diagnostic Criteria for Alcohol Use Disorder
The DSM-5 identifies several criteria that clinicians consider when determining whether an individual meets the criteria for Alcohol Use Disorder. The severity of AUD is generally determined by the number of criteria present.
Based on the information provided in the case study, Ann demonstrates the following concerns:
- Alcohol is reportedly consumed in larger amounts or for longer than intended.
- Important social, occupational, or recreational activities have been reduced or affected.
- She has experienced difficulty controlling or reducing her alcohol use.
- Alcohol has been used in physically hazardous situations.
- Considerable time has been associated with obtaining, using, or recovering from alcohol.
- Alcohol use has continued despite awareness of physical or psychological problems.
- Alcohol use has contributed to social or interpersonal difficulties.
- Alcohol use has interfered with major responsibilities at home, work, or other areas of life.
- Tolerance is present.
- Withdrawal is present.
- She experiences craving or a strong desire to use alcohol.
When multiple DSM-5 criteria are present within the relevant diagnostic period, the individual may meet the criteria for Alcohol Use Disorder. The reported presence of all listed criteria in Ann’s case supports a severe classification.
DSM-5 Diagnosis
Diagnosis: Alcohol Use Disorder, Severe
DSM-5 Diagnostic Code: 303.90 (F10.20)
The diagnosis should ultimately be made by a qualified healthcare professional after a comprehensive clinical assessment. The case information, however, provides sufficient evidence for identifying severe Alcohol Use Disorder as the applicable diagnosis for this academic assessment.
Basis for the Diagnosis
Ann demonstrates a pattern of alcohol use that has produced significant problems across multiple areas of functioning. Her reported symptoms extend beyond occasional or social drinking and include impaired control, continued use despite negative consequences, interference with responsibilities, tolerance, withdrawal, and craving.
These characteristics are consistent with the DSM-5 diagnostic framework for Alcohol Use Disorder. The severity classification is supported by the number of diagnostic criteria identified in the case.
At the same time, Ann has several factors that may support treatment and recovery. She and her husband recognize that alcohol use has become a problem, and they are actively seeking therapeutic assistance. Her family support may provide an important resource during treatment.
A positive support system does not eliminate the need for treatment, but it can contribute to engagement with care and ongoing recovery efforts. Ann’s reported lack of a previous substance use history may also provide useful context when developing an individualized treatment plan.
Applicable Addictions Perspective
An appropriate perspective for understanding Ann’s situation is the concept of problematic substance use occurring in response to a difficult or stressful period. Because the case indicates that Ann did not have an established history of alcohol misuse before the current circumstances, her alcohol use may represent an attempt to cope with an environmental or psychological stressor.
Fetting and Fetting (2016) discuss how substance use can be understood within the context of an individual’s environment, experiences, and coping mechanisms. From this perspective, it is important to consider not only Ann’s alcohol consumption but also the circumstances that contributed to its development.
Early identification and intervention may help address the underlying stressors while reducing the risk of continued substance misuse. Treatment should therefore consider both the alcohol use itself and the factors that may be maintaining it.
Ethical Considerations in the Assessment
Confidentiality and protection of client information are essential components of substance use assessment and treatment. Addiction professionals have an ethical responsibility to protect sensitive information and comply with applicable federal and state requirements.
Following the NAADAC/NCC AP Code of Ethics, Ann’s assessment information should be handled securely and only accessed or disclosed in accordance with applicable laws, regulations, professional standards, and appropriate authorization.
Electronic records should be protected using appropriate security measures, while physical records should be stored in a secure location with access limited to authorized individuals. Maintaining confidentiality is particularly important in substance use treatment because disclosure of sensitive information without proper authorization can negatively affect a client’s privacy and well-being.
Treatment and Recovery Considerations
Ann’s assessment suggests that intervention should address both her alcohol use and the circumstances that contributed to it. A comprehensive treatment approach may include further clinical assessment, evaluation of withdrawal-related risks, appropriate substance use treatment, and support for healthier coping strategies.
Her willingness to seek help and the involvement of her husband are important considerations when developing a treatment plan. Family support can potentially strengthen treatment engagement while helping create a more supportive recovery environment.
Treatment planning should remain individualized and should be based on a qualified professional’s assessment of Ann’s physical, psychological, social, and substance-related needs.
Key Takeaway
Ann’s case demonstrates how a pattern of alcohol use can progress from problematic coping behavior to a condition that meets the diagnostic criteria for severe Alcohol Use Disorder. The reported presence of multiple DSM-5 criteria, including impaired control, continued use despite negative consequences, tolerance, withdrawal, and craving, supports the diagnosis identified in this assessment.
Her situation also demonstrates why substance use assessments should consider the client’s broader environment. Ann’s family support, willingness to seek assistance, and recognition of the problem are relevant protective factors that can be incorporated into an individualized approach to treatment and recovery.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425596
PSYC FPX 2300 Assessment 2 Whats Wrong a Short Assessment
Fetting, M., & Fetting, M. (2016). Perspectives on substance use, disorders, and addiction: With clinical cases. SAGE Publications. https://us.sagepub.com/
NAADAC, the Association for Addiction Professionals. (2021). NAADAC/NCC AP code of ethics. https://www.naadac.org/assets/2416/naadac_code_of_ethics_112021.pdf