Date of Assessment: 1 November 2024
Identifying Information:
Patient is a 34-year-old male, single, presenting for mental health assessment related to substance use concerns.
Chief Complaint:
Patient states, "I can't seem to stop drinking, and it's ruining my life. I feel constantly anxious and can't sleep."
History of Present Illness:
Patient reports a progressive increase in alcohol consumption over the past 18 months, escalating to daily heavy drinking (approximately 10-12 units/day). He attributes the increase to job-related stress and a recent relationship breakup. Symptoms include daily anxiety, irritability, poor concentration, and recurrent insomnia. He has missed several days of work in the past month due to hangovers and feels a significant impact on his personal relationships and overall functioning.
Current Symptoms:
Mr. Smith presents with significant symptoms of generalised anxiety, including persistent worrying, restlessness, and difficulty concentrating. He experiences panic attacks approximately once a week, characterised by palpitations, shortness of breath, and a sense of impending doom. He also reports dysphoric mood, anhedonia, and feelings of guilt related to his substance use. Cognitive symptoms include impaired short-term memory and difficulty with executive functions. Physical manifestations include tremors, night sweats, and gastrointestinal upset.
Energy Levels:
Patient describes his energy levels as consistently low, rating them 3/10 compared to his baseline of 7/10 prior to the increase in alcohol use. He experiences significant fatigue throughout the day, which is worse in the mornings and slightly improves by late afternoon.
Sleep:
Mr. Smith reports severe insomnia, typically taking 2-3 hours to fall asleep. He experiences multiple nocturnal awakenings, often due to intrusive thoughts about his drinking or anxiety, and struggles to return to sleep. Total sleep duration is estimated at 4-5 hours per night, which he describes as unrefreshing. He notes vivid nightmares related to past events.
Identified Stressors:
Key stressors include high-pressure work environment, recent termination of a long-term relationship, and financial difficulties related to his inability to maintain consistent employment due to substance use. He also reports social isolation.
Past Psychiatric History:
No formal psychiatric diagnoses in the past. Patient reports a history of intermittent anxiety since early adulthood, which he previously managed with exercise. No history of hospitalizations for psychiatric reasons or suicide attempts.
Past Medical History:
History of hypertension, diagnosed 3 years ago, currently managed with medication. No history of significant surgeries or other major physical illnesses.
Current Medical Physical Conditions History:
Currently stable on lisinopril for hypertension. Review of systems reveals no fever, significant weight changes (reports a 5kg weight loss in the past 3 months due to poor appetite), or other acute physical complaints aside from withdrawal symptoms. Cardiovascular examination was regular in rhythm, and respiratory effort was unlaboured. No signs of hepatic enlargement on palpation.
Medical Investigations and Treatment Completed:
Patient presented to an urgent care clinic three weeks ago with severe tremors and received a prescription for benzodiazepines for acute withdrawal management, which he used for 5 days. He found them helpful but ceased use due to concern about dependence. No recent blood tests or imaging have been completed.
Current Medications:
Lisinopril 10mg once daily
Substance Use History:
Daily alcohol use (10-12 units/day) for 18 months, with a history of episodic heavy drinking since age 18. Reports past cannabis use (ages 16-20, occasional), but denies current use of illicit substances. No history of opioid or stimulant use. Smokes 10 cigarettes per day for 15 years.
Family History:
Patient's father had a history of alcohol dependence. Maternal aunt diagnosed with depression. No reported family history of suicide.
Social History:
Lives alone in a rented flat. Employed as a sales manager, but currently on sick leave due to substance-related issues. Completed a university degree in business. Reports a limited social support network since the breakup; primarily interacts with colleagues, but social engagements have decreased significantly.
Functional Capacity and ADLs:
Significant impairment in functional capacity. Struggles with maintaining personal hygiene regularly, often missing meals, and neglecting household chores. Has difficulty concentrating on work tasks and engaging in hobbies he once enjoyed, such as hiking and reading. Social engagement is minimal, contributing to feelings of isolation.
Mental Status Examination:
Appearance: Dishevelled, unkempt, appears older than stated age. Odor of alcohol faintly present.
Behavior: Restless, fidgety, poor eye contact, psychomotor agitation.
Speech: Normal rate and rhythm, soft volume, coherent.
Mood: "Anxious, low."
Affect: Constricted, anxious.
Thought Process: Linear, goal-directed, but occasionally tangential when discussing alcohol use.
Thought Content: Preoccupied with thoughts of drinking, guilt, and anxiety about the future. Denies paranoid ideation or obsessions.
Perceptual Disturbances: Denies hallucinations or delusions.
Cognition: Appears to have impaired recent memory and concentration during assessment.
Insight: Fair insight into the negative impact of alcohol on his life but struggles with a sense of control.
Judgment: Impaired judgment related to continued alcohol use despite negative consequences.
Risk Assessment:
Low immediate risk of suicide; denies current suicidal ideation, plans, or intent. Reports transient thoughts of wishing he "wasn't here" but no active desire to die. No history of self-harm. Denies homicidal ideation or plans. Safety concerns include potential for alcohol withdrawal seizures if consumption is abruptly stopped, and risk of relapse.
Clinical Impression:
Alcohol Use Disorder, Severe (F10.20)
Generalised Anxiety Disorder (F41.1)
Treatment Plan:
1. Begin outpatient detoxification with close monitoring and pharmacotherapy (e.g., chlordiazepoxide taper).
2. Refer to a structured addiction treatment program (e.g., intensive outpatient program).
3. Individual psychotherapy focusing on cognitive-behavioural strategies for anxiety and relapse prevention.
4. Consider selective serotonin reuptake inhibitor (SSRI) for anxiety symptoms once stable from acute withdrawal.
5. Psychoeducation on alcohol use disorder and anxiety management.
6. Encourage attendance at self-help groups (e.g., Alcoholics Anonymous).
Future Medical Plans:
Monitor liver function tests, complete full blood count, and electrolyte panel prior to and during detoxification. Review ongoing medication for hypertension and adjust as needed. Consider ECG if further cardiac concerns arise.
Future Medical Appointments:
Follow-up appointment with Addiction Medicine Specialist in 3 days. Initial appointment with therapist scheduled for next week. Group therapy orientation session within two weeks. Blood tests arranged for tomorrow.
