NRNP 6635 Week 8 Substance-Induced Analysis Example

Substance-Induced Presentation Analysis: Low Mood That Began Before the Heaviest Drinking, and Morning Anxiety That Eases With the First Drink

Student Name

College of Nursing, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Instructor Name

Month Day, Year

Substance-Induced Presentation Analysis: Low Mood That Began Before the Heaviest Drinking, and Morning Anxiety That Eases With the First Drink

Use History as a Timeline

Composite patient: a woman of about 55, a hospital pharmacy purchasing manager, divorced, living alone. Drinking began socially in her twenties, one or two glasses of wine at weekends. After her divorce 4 years ago, she drank a bottle of wine most evenings for about a year, then cut back to two or three glasses most evenings for 2 years with no withdrawal symptoms. Eighteen months ago her mother moved into memory care; low mood began about then, by her account and her sister's. Heavier drinking followed about 4 months later: a bottle and a half of wine most nights for the past year. She has not had a period of abstinence longer than 2 days in the past year. Her last drink was 14 hours before this visit.

Her sister, interviewed by phone with permission, confirms the sequence: "She was down about Mom before the drinking got bad. The drinking got bad around the holidays." Collateral is recorded as a second source for the timing, because the timing is what the diagnosis depends on.

Symptoms Taken in Groups

Mood: low mood most days, loss of interest in gardening, guilt about her mother's placement, poor concentration at work; onset about 18 months ago, 4 months before the heaviest drinking; worsened as drinking increased.

Anxiety: shakiness, sweating, a racing heart, and dread on waking most mornings for about 6 months, easing within 30 minutes of a first drink, which she has started to take at 07:00 on weekends. No panic attacks at other times.

Sleep: falls asleep quickly after drinking but wakes at 02:00 or 03:00 unable to return to sleep.

The Manual's Induced-Disorder Logic

DSM-5-TR asks three questions of a substance-induced mental disorder: whether the symptoms developed during or soon after intoxication or withdrawal, whether the substance is capable of producing them, and whether the picture is better explained by an independent disorder, as shown by symptoms that began before the substance use, persisted for a substantial period (such as about a month) after cessation of acute withdrawal or severe intoxication, or a history of independent episodes (American Psychiatric Association, 2022).

Applied to her mood symptoms: they began before the heaviest drinking, about 4 months earlier, during a period of moderate use; alcohol is capable of producing depressive symptoms; she has had no abstinence since, so persistence after cessation has never been observed. The onset before heavy use points toward an independent depressive disorder; the absence of any abstinence period means the question cannot yet be answered with confidence. Depressive symptoms in heavy drinkers often improve quickly with abstinence: in one study of men in inpatient alcohol treatment, 42% had clinically significant depression at admission but only 6% remained depressed at week 4 (Brown & Schuckit, 1988).

Applied to her morning anxiety: the timing, on waking after overnight abstinence, with relief from alcohol, fits withdrawal rather than a primary anxiety disorder.

Withdrawal, Given Its Own Section

She has morning withdrawal symptoms after a night without drinking and is drinking in the morning on weekends to relieve them. Today, 14 hours after her last drink, she has a fine tremor, sweating, and a heart rate of 104. On the CIWA-Ar, the shortened 10-item version of the withdrawal scale built to quantify severity at the bedside (Sullivan et al., 1989), she scores 12. She has no history of withdrawal seizures or delirium. Her withdrawal must be managed before any mood diagnosis can be settled, because treating it is both a safety need and the only route to the abstinence period that the mood question requires. Plan: medically supervised withdrawal, with a referral to the addiction medicine clinic today.

Verdicts That Can Be Revised

Alcohol use disorder, severe, based on tolerance, withdrawal, drinking to relieve withdrawal, drinking more than intended, and continued use despite worsening mood: confirmed.

Alcohol withdrawal, current: confirmed.

Anxiety: attributed to alcohol withdrawal; revisited if it persists beyond the withdrawal period.

Mood: provisional. Alcohol-induced depressive disorder and major depressive disorder are both live. The onset before heavy drinking favors an independent disorder; the verdict is revisited after 4 weeks of abstinence. If her depressive symptoms persist then, major depressive disorder is diagnosed and treated; if they resolve, the induced label stands.

What the case does not say: whether she has ever had a depressive episode before this one, which would support an independent disorder, and whether she uses any other substance; both are asked at the next visit.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Brown, S. A., & Schuckit, M. A. (1988). Changes in depression among abstinent alcoholics. Journal of Studies on Alcohol, 49(5), 412-417. https://doi.org/10.15288/jsa.1988.49.412

Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353-1357. https://doi.org/10.1111/j.1360-0443.1989.tb00737.x