Client Description.
The client is a 19-year-old single male who was referred for treatment by his parents who are concerned that his use of alcohol is interfering with his grades in college. The client reportedly had all A grades in high school and had been placed in a program for gifted students. However, he has reportedly flunked out of college in his first year. Following this he was also recently arrested for his second DUI offense, the first offense occurring when he was a senior in high school.
According to his parents, the client was born at full term with no complications occurring in the pregnancy and delivery of the baby. He met all of his developmental milestones ahead of expectation and has experienced no major health issues although his last physical examination was several years ago. He excelled in school and was placed in a program for gifted and talented students. According to his parents the client maintained an A average throughout high school even while being in a more challenging gifted program. He went to college with ambitions to go into chemical engineering, but "flunked out" after his first year, an event totally uncharacteristic of his past. His father is a neurosurgeon and his mother is a research scientist. Family history is significant for anxiety disorders in his father and both grandfathers and possible alcohol abuse in both grandfathers.
In addition, the client and his parents report that he has a history of experiences of anxiety and worry present over a three-year period. His parents report he has always been "high strung," but that he began to display physical signs of anxiety such as (dizziness, palpitations, etc.), cognitive signs (a strong sense of worry over his everyday life issues), and behavioral signs (few social contacts, missing school, etc.) while in high school. The anxiety that the client experiences is not limited to specific or discrete situations and does not appear to consist of panic attacks (although this is also a consideration; American Psychiatric Association [APA], 2000). His parents described him as a "functional alcoholic" and that they were unsure if his drinking behaviors occurred before or after his difficulties with anxiety; however, they do know he was drinking alcohol regularly while he was in high school.
B. Assessment
The client's parents contacted the clinic for treatment for their son for his difficulties with suspected alcohol abuse. Both the client and the client's parents (with the permission of the client) participated in a standard clinical interview process designed to coincide with the diagnostic criteria from the DSM -- IV -- TR for axis I and axis II disorders.
The client agreed to enter treatment for issues with anxiety and substance abuse. Both the client and the therapist discussed the goals of treatment for the client. These included designing a program to manage the client's anxiety, attending AA meetings, and individual therapy and that helping the client control his anxiety and his use of alcohol. In addition, the client expressed a wish to return back to school and later sessions will be devoted to specific issues with college, anxiety, and methods of coping with the pressures of college designed specifically for the client.
C. Measurement.
The client underwent a clinical interview that investigated the presence of any DSM -- IV -- TR axis I or axis II disorders. In addition, the counselor plans to administer the Structural Clinical Interview for the DSM (SCID-1 and SCID-2; First, Spitzer, Gibbons, Williams, & Benjamin, 1996; First, Spitzer, Gibbons, & Williams, 1997) for further clarification and quantification of these issues. The SCID-1 and 2 are semi-structured clinical interviews to determine DSM diagnoses on axis I or axis II. The SCID for the new DSM-5 is not yet available, so the DSM-IV-TR was used in this case. In addition to this data a thorough and complete history will be taken regarding the onset of the client's drinking and onset of his difficulties with anxiety in order to determine as best as possible which one preceded the other. This information will be used to determine the focus of treatment (anxiety or substance abuse). The preliminary results of the clinical interview resulted in the following DSM -- IV -- TR diagnosis:
Axis I: 300.02. Generalized Anxiety Disorder
305.00. Alcohol Abuse
Axis II: V71.09. No diagnosis on Axis II
Axis III: No significant medical issues.
Axis IV: Two DUI arrests; flunked out of college; reports feeling isolated from friends and family.
AXIS V: GAF = 51-55. Symptoms of impaired social and interpersonal relationships. Alcohol Abuse. Severe symptoms of anxiety.
The client agreed to maintain a behavioral journal to document the daily instances where...
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