Using the *Biopsychosocial Addiction Assessment* create a case presentation to share with your classmates. Please use a narrative form that lines up with the same way that you use to document your patient’s visits in your clinical rotations.
Patient Name: John Smith Date of Assessment: October 6, 2023 Presenting Concerns: John Smith is a 34-year-old male who has sought addiction assessment and treatment due to his increasing alcohol dependence and its negative impact on his personal and professional life.
Biopsychosocial Assessment:
Biological Factors:
- Physical Health: John reports a history of frequent alcohol use since his early twenties. He currently consumes approximately 10-12 alcoholic beverages per day. He experiences withdrawal symptoms when attempting to cut down or quit drinking, including tremors, nausea, and anxiety.
- Genetic Predisposition: John’s father had a history of alcohol dependence.
Psychological Factors:
- Mental Health: John reports feeling anxious and depressed, especially during hangovers or when he is unable to access alcohol. He has a history of using alcohol as a coping mechanism for stress and emotional distress.
- Cognitive Functioning: John acknowledges that his alcohol use has led to impaired decision-making and memory lapses.
- Motivation for Change: John expresses a desire to quit drinking due to the negative consequences it has had on his relationships and work.
Social Factors:
- Family and Relationships: John’s alcohol use has strained his relationship with his partner, who has threatened to leave if he doesn’t seek help. His social circle predominantly consists of heavy drinkers, which contributes to his continued alcohol use.
- Employment: John’s job performance has deteriorated recently, resulting in warnings from his employer. He fears losing his job if he doesn’t address his alcohol dependence.
- Financial Situation: John’s excessive spending on alcohol has led to financial difficulties.
Assessment Summary:
John Smith presents with a severe alcohol use disorder characterized by biological factors such as withdrawal symptoms, a genetic predisposition, and compromised physical health. Psychologically, he exhibits symptoms of anxiety and depression, as well as impaired cognitive functioning. His motivation for change is driven by a desire to salvage his relationships and employment.
Socially, John’s relationships and work have been adversely affected by his alcohol use. His social network largely consists of heavy drinkers, contributing to the perpetuation of his addiction. Financial difficulties have also arisen due to excessive spending on alcohol.
Recommendations:
- Medical Assessment: John should undergo a thorough medical assessment to evaluate his physical health, assess withdrawal risks, and develop a plan for detoxification if necessary.
- Psychological Assessment: A mental health evaluation should be conducted to address his anxiety and depression. Individual therapy, such as cognitive-behavioral therapy (CBT), may be beneficial.
- Substance Abuse Treatment: John should engage in a comprehensive substance abuse treatment program, which may include outpatient or inpatient rehabilitation, group therapy, and counseling.
- Social Support: Encourage John to distance himself from his social circle of heavy drinkers and seek out support from friends and family who are supportive of his recovery.
- Employment Assistance: John should seek assistance from an Employee Assistance Program (EAP) or vocational counseling to address work-related issues.
- Financial Counseling: A financial counselor can help John develop a budget and financial plan to address his financial difficulties.
Follow-up:
John will be scheduled for a follow-up assessment in one week to monitor his progress and adjust the treatment plan as necessary. A multidisciplinary approach involving medical professionals, therapists, and support groups will be essential for addressing his biopsychosocial addiction needs effectively.