The patient, a 35-year-old male, presents with concerns about increased alcohol consumption and difficulty controlling his drinking.

The patient, a 35-year-old male, presents with concerns about increased alcohol consumption and difficulty controlling his drinking. He reports consuming six to eight drinks daily for the past year, leading to multiple consequences, including conflicts at work and in his personal relationships. The patient acknowledges that he has tried to reduce his drinking but has repeatedly failed. Symptoms include cravings, increased tolerance, and occasional withdrawal symptoms, such as shakiness and irritability when abstaining.

History of Present Illness (HPI)

The patient describes his drinking patterns as progressively worsening over the past few years, especially following a stressful family event. He first began drinking socially in his late teens, but his usage increased over time. He reports a history of alcohol use in his family, specifically in his father, who struggled with alcoholism. The patient denies illicit drug use but occasionally uses nicotine. He has not previously sought treatment or counseling for substance use.

Past Psychiatric History

The patient denies any previous psychiatric diagnoses or treatments. He reports experiencing stress and mild depressive symptoms but has not received formal mental health care. He occasionally experiences sleep disturbances and low mood.

Family History

The patient reports a family history of alcohol use disorder in his father and maternal uncle. No family history of other mental illnesses is noted.

Social and Occupational History

The patient is employed full-time and lives with his partner. He describes his work environment as high-stress, contributing to his increased alcohol use as a coping mechanism. He maintains some social support through friends and family but mentions that alcohol often features prominently in his social gatherings.

Cultural Background

The patient identifies as part of a cultural group in which alcohol use is socially normalized, and abstinence is sometimes stigmatized. This may have contributed to his reluctance to seek treatment or reduce his consumption independently.

Interview Questions

• How does alcohol fit into your social and family life?
• Have you experienced any physical or mental symptoms when you have tried to reduce or stop drinking?
• Do you feel that alcohol has impacted your work or relationships?
• What challenges do you foresee if you were to pursue treatment or reduction in drinking?

Objective

Observations During Psychiatric Assessment

The patient appears well-groomed and maintains good eye contact. He is alert and oriented to person, place, and time. His speech is coherent and at a normal rate, though he appears tense when discussing his alcohol use. He demonstrates mild hand tremors and is somewhat fidgety, which may be related to mild withdrawal symptoms.

Mental Status Examination (MSE)

• Appearance: Well-groomed, casually dressed.
• Behavior: Cooperative but slightly anxious when discussing his drinking habits.
• Speech: Normal rate and tone.
• Mood/Affect: Reports feeling anxious and guilty about his drinking; affect is congruent with mood.
• Thought Process: Logical and coherent.
• Thought Content: No delusions, hallucinations, or suicidal ideation noted.
• Cognitive Functioning: Intact, alert, and oriented.
• Insight and Judgment: Limited insight into the need for professional help; judgment impaired related to alcohol use.

Assessment

Differential Diagnoses

1. Alcohol Use Disorder (AUD) (Primary Diagnosis): According to DSM-5, AUD is characterized by problematic alcohol use leading to significant impairment or distress. The patient meets several criteria for AUD, including increased tolerance, unsuccessful attempts to cut down, cravings, and persistent use despite interpersonal problems (American Psychiatric Association, 2013). These criteria strongly support AUD as the primary diagnosis.
2. Adjustment Disorder with Depressed Mood: Adjustment disorder could be considered due to the patient’s reported stress and mild depressive symptoms following a significant life event. However, these symptoms appear to be secondary to the patient’s alcohol use, as they exacerbate with drinking patterns rather than standalone depressive symptoms. DSM-5 criteria for adjustment disorder do not fully align with the patient’s experience, ruling this out as the primary condition (First, 2013).