CASE STUDY 1
Addictions Case Study Part 3: Marci
Derrick L. Smith
School of Behavioral Sciences, Liberty University
Case Conceptualization
This case presented Marci, a 22-year-old female student. Marci’s presenting problems
include alcohol use, smoking marijuana, tobacco use, other drug experimentation. Marci also
reports having feelings of anxiety and depression. Currently living with her parents, Marci
CASE STUDY 2
admits that her substance abuse has caused tensions between her and her family. It has also
caused issues in school and on the job as she has lost motivation and can no longer keep a job.
Marci’s substance abuse has led to her being arrested for DWI and marijuana possession. This
resulted in her license being suspended, for which she applied for and received a hardship license
in order to travel to work and school.
After completing a genogram, Marci’s family shows a history of alcohol abuse as well as
anxiety and depression. Her family also shows a history of tobacco and marijuana use. She has
admitted to experimenting with Lysergic acid diethylamide (LSD) and Cocaine. Her friends
have also given her Xanax, which she stated she had not yet tried. Marci noted a dry, hacking
cough she recently developed. Marci also has a concern that she may be pregnant due to missing
her menstrual cycle. If she does not make changes, she risks being arrested again and possibly
injury or death due to her drinking and driving. Marci is at a greater risk for suicide attempts as
her family relationships may leaving her feeling as if she has no one to turn to. Marci scored a
27 on the AUDIT, which indicates a possible dependence.
Marci has been referred to Mount Sinai Wellness Center located in Dahlonega, Georgia,
an in-patient alcohol and substance abuse program. Her family has also been referred to a family
therapist to help mend the broken family relationship. After this, it is advised that Marci seek
out an employability skills and life skills program; she will be referred by this office. Finally,
there is a recommendation to take time off from school in order to assist in helping her get the
proper care without the added stress of school.
CASE STUDY 3
Diagnostic Impression
Primary Diagnosis
The primary diagnosis for Marci is Alcohol Use Disorder F10.229 moderate or severe
alcohol use disorder with alcohol intoxication (American Psychiatric Association, 2013). Marci
met eight of the criteria for this diagnosis; one of them being that Alcohol use is continued
despite knowledge of having a persistent or recurrent physical or psychological problem that is
likely to have been caused or exacerbated by alcohol (American Psychiatric Association, 2013,
p. 491). The prevalence rate of this disorder is estimated to be 4.6% among 12- to 17-year-olds
and 8.5% among adults age 18 years and older in the United States (American Psychiatric
Association, 2013). The rate is higher in men as opposed to women. On the other hand,
courtesy of the stereotypical female characteristics, girls tend to have reduced alcohol
involvement. In adulthood, sex difference in response to alcohol is more dramatic (Ceylan-Isik
et al., 2010). There is an increased rate of suicidal behavior as well as of completed suicide
among individuals with the disorder (American Psychiatric Association, 2013, p. 493).
Alcohol use disorder carries with it a myriad of functional consequences. These include
driving and operating machinery, school and work, interpersonal relationships and
communication, and health (American Psychiatric Association, 2013). Alcohol-related disorders
contribute to absenteeism from work, job-related accidents, and low employee productivity.
Comorbidity issues include bipolar disorders, schizophrenia, and antisocial personality disorder
are associated with a markedly increased rate of alcohol use disorder, and several anxiety and
depressive disorders may relate to alcohol use disorder as well (American Psychiatric
Association, 2013). In most cultures, alcohol is the most frequently used intoxicating substance
and contributes to considerable morbidity and mortality. An estimated 3.8% of all global deaths
CASE STUDY 4
and 4.6% of global disability-adjusted life-years are attributable to alcohol (American Psychiatric
Association, 2013).
Secondary Diagnosis 1
Marci’s secondary diagnosis is Cannabis Use Disorder, with a severity of 304.30 F12.20,
moderate. Marci meets five of the criteria for this disorder, one being that Cannabis is often
taken in larger amounts or over a longer period than was intended (American Psychiatric
Association, 2013, p.509). The 12-month prevalence of cannabis use disorder (DSM-IV abuse
and dependence rates combined) is approximately 3.4% among 12- to 17-year-olds and 1.5%
among adults age 18 years and older. Rates of cannabis use disorder are greater among adult
males (2.2%) than among adult females (0.8%) and among 12- to 17-year-old males (3.8%) than
among 12- to 17-year-old females (3.0%) (American Psychiatric Association, 2013).
Cannabis use has inherent functional consequences. Cognitive function, particularly
higher executive function, appears to be compromised in cannabis users, and this relationship
appears to be dose dependent (both acutely and chronically) (American Psychiatric Association,
2013). Comorbidity use has been associated with poorer life satisfaction; increased mental
health treatment and hospitalization; and higher rates of depression, anxiety disorders, suicide
attempts, and conduct disorder (American Psychiatric Association, 2013). Cannabis use disorder
denotes a lower cognitive performance as well as physical issues for users. It has been shown
that cannabis is known to cause antisocial syndrome and issues with anxiety. Cultural factors
(acceptability and legal status) that might impact diagnosis relate to differential consequences
across cultures for detection of use (i.e., arrest, school suspensions, or employment suspension).
The general change in substance use disorder diagnostic criteria from DSM-IV to DSM-5 (i.e.,
CASE STUDY 5
removal of the recurrent substance-related legal problems criterion) mitigates this concern to
some degree (American Psychiatric Association, 2013, p. 514).
Secondary Diagnosis 2
Marci exhibits five of the criteria for a diagnosis of Tobacco Use Disorder, with a
severity level of 305.1 F I7.200, moderate. In the United States, 57% of adults have never been
smokers, 22% are former smokers, and 21% are current smokers. Approximately 20% of current
U.S. smokers are nondaily smokers. The prevalence of smokeless tobacco use is less than 5%,
and the prevalence of tobacco use in pipes and cigars is less than 1% (American Psychiatric
Association, 2013). The 12-month prevalence of DSM-IV nicotine dependence in the United
States is 13% among adults age 18 years and older. Rates are similar among adult males (14%)
and females (12%) and decline in age from 17% among 18- to 29-year-olds to 4% among
individuals age 65 years and older (American Psychiatric Association, 2013).
Tobacco is used by all cultures. Non-Hispanic white smokers appear to be more likely to
develop tobacco use disorder than are smokers. Some ethnic differences may be biologically
based. African American males tend to have higher nicotine blood levels for a given number of
cigarettes, and this might contribute to greater difficulty in quitting (American Psychiatric
Association, 2013). The most common medical diseases from smoking are cardiovascular
illnesses, chronic obstructive pulmonary disease, and cancers. Smoking also increases perinatal
problems, such as low birth weight and miscarriage. The most common psychiatric
comorbidities are alcohol/substance, depressive, bipolar, anxiety, personality, and attention-
deficit/hyperactivity disorders. Research has shown that among current regular smokers, self-
reported numbers of both hyperactive–impulsive and inattentive ADHD symptoms significantly
CASE STUDY 6
predicted the number of cigarettes smoked per day (McClernonF&FKollins, 2008, p. 4). Tobacco
use can also produce withdrawal symptoms in those admitted to treatment facilities.
Treatment Plan Problem/Symptom 1
Client shows marked symptoms of alcohol use disorder. This is shown through excessive
drinking, unsafe activities such as driving under the influence, and has a history of arrest.
Long-Term Goal 1
Client will acquire the necessary 12-step skills to maintain long-term sobriety from all
mood-altering substances, and live a life free of substance abuse
Short-Term Goal/Objective 1
Attend Alcoholics Anonymous/Narcotics Anonymous (AA/NA) meetings as frequently
as necessary to support sobriety.
Short-Term Goal/Objective 2
Cooperate with exploration of increasing satisfaction in areas of life that can support
sobriety such as employment, recreation, and relationships.
Long-Term Goal 2
Utilize behavioral and cognitive coping skills to help maintain sobriety. Identifying high
risk situations for use such as liquor stores or areas where drugs are commonly sold and
encouraging the patient to avoid such situations (McHugh et al., 2010)
Short-Term Goal/Objective 1
Agree to make amends to significant others who have been hurt by the life dominated by
substance abuse.
CASE STUDY 7
Short-Term Goal/Objective 2
Verbalize an understanding of factors that can contribute to development of chemical
dependence and pose risks for relapse. There are an extensive number of risk factors that may
contribute to the onset of substance use. Risk factors for substance use are divided into three
primary categories: familial, social, and individual (Whitesell et al., 2013).
Treatment Plan Problem/Symptom 2
Client displays symptoms of cannabis use disorder. This is characterized by the client
demonstrating a maladaptive pattern of substance use, manifested by increased tolerance and
withdrawal. The client denies that chemical dependence is a problem, despite feedback from
significant others that the use of the substance is negatively affecting her and others. She has
continued substance use despite knowledge of experiencing persistent physical, legal, financial,
vocational, social, and/or relationship problems that are directly caused by the use of the
substance. Demonstrates increased tolerance for the drug, as there is the need to use more to
become intoxicated or to recall the desired effect.
Long-Term Goal 1
Accept the powerlessness and unmanageability over mood-altering substances, and
participate in a recovery-based program.
Short-Term Goal/Objective 1
Explore and resolve ambivalence associated with commitment to change behaviors
related to substance use and addiction.
CASE STUDY 8
Interventions
Conduct Motivational Interviewing to assess the client's stage of preparation for change;
intervene accordingly, moving from building motivation, through strengthening commitment to
change, to participation in treatment (see Motivational Interviewing by Miller and Rollnick;
Motivational Interviewing and Enhancement by DiClemente, Van Orden, and Wright).
Short-Term Goal/Objective 2
Commit self to an action plan directed toward termination of substance use.
Interventions
Assign the client to write a list of reasons to be abstinent from addiction (or assign
"Alternatives to Addictive Behavior" in the Addiction Treatment Homework Planner by Finley
and Lenz).
Long-Term Goal 2
Establish and maintain total abstinence, while increasing knowledge of the disease and
the process of recovery.
Short-Term Goal/Objective 1
Identify level of happiness in various areas of life.
Interventions
Approaching the client with empathy and genuine caring, administer the Happiness Scale
(see A Community Reinforcement Approach to Addiction Treatment by Meyers and Miller);
review results in session.
Short-Term Goal/Objective 2
Verbalize the results of turning problems over to God each day.
CASE STUDY 9
Interventions
Using a Step 3 exercise, teach the client about the recovery concept of turning it over;
then assign turning over problems to a higher power each day; ask the client to record the event
and discuss the results.
Treatment Plan Problem/Symptom 3
Client displays symptoms of tobacco use disorder. This is characterized by the client’s
continued use of cigarettes despite experiencing persistent or recurring physical problems that
are caused or exacerbated by smoking. Use of tobacco in larger amounts and for longer periods
than intended. Increased tolerance for nicotine, manifested by either the absence of nausea or
dizziness despite using substantial amounts or by the need for an increased amount to achieve the
desired effect. Inability to quit smoking or decrease use of cigarettes, despite a verbalized desire
to do so and/or previous unsuccessful attempts to quit.
Long-Term Goal 1
Enhance confidence in ability to quit smoking, while increasing awareness of both the
benefits of quitting and the health risks associated with continued smoking.
Short-Term Goal/Objective 1
List alternative behavioral activities to be used when the urge to smoke is strong.
Interventions
Assign patient to generate a list of alternative activities and behaviors (e.g., chewing
gum, exercising, talking to someone about urge, practicing deep breathing and relaxation) to
utilize in response to the urge to smoke.
CASE STUDY 10
Short-Term Goal/Objective 2
Identify and utilize sources of positive social support in facilitating and maintaining
abstinence from cigarette use.
Interventions
Assist patient in identifying people and situations that encourage or trigger smoking and
discuss ways to cope with or avoid these situations.
Long-Term Goal 2
Develop coping strategies to deal with nicotine cravings and smoking cues in order to
continue abstinence from smoking cigarettes.
Short-Term Goal/Objective 1
Identify negative, distorted self-talk that mediates anxiety, lack of confidence, or low
self-esteem that can in turn trigger smoking.
Interventions
Assist patient in identifying and modifying negative, distorted cognitions in response to
stressors that contribute to negative effect.
Short-Term Goal/Objective 2
Agree to regular follow-up sessions to review progress and to discuss any further relapse
prevention that may be necessary.
Interventions
Assist patient in constructing a hierarchy of settings and situations that trigger smoking.
Assign patient to progressively eliminate smoking in each of these settings, starting with the
easiest situation and gradually incorporating more difficult situations.
CASE STUDY 11
References
American Psychiatric Association. (2013).FDiagnostic and statistical manual of mental
disorders. Arlington: American Psychiatric Publishing.
Ceylan-Isik, A. F., McBride, S. M., & Ren, J. (2010). Sex difference in alcoholism: who is at a
greater risk for development of alcoholic complication?.FLife sciences,F87(5-6), 133–138.
https://doi.org/10.1016/j.lfs.2010.06.002
Finley, J. R., & Lenz, B. S. (2017).FAddiction treatment homework planner.
McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for
substance use disorders.FThe Psychiatric clinics of North America,F33(3), 511–525.
https://doi.org/10.1016/j.psc.2010.04.012
Miller, W. R., Rollnick, S., Reuß, J., & Trunk, C. (2015).FMotivational interviewing.
Parkinson, R. R., Jongsma, A. E., Bruce, T. J. (2014). The Addiction Treatment Planner. New
Jersey: Wiley.
Whitesell, M., Bachand, A., Peel, J., & Brown, M. (2013). Familial, social, and individual factors
contributing to risk for adolescent substance use.FJournal of addiction,F2013, 579310.
https://doi.org/10.1155/2013/579310
