DSM-IV Multi-Axial Diagnosis for SMASHED

Axis I 303.90 Alcohol Dependence, With physiological dependence

Axis II V71.09 No Diagnosis

Axis III None

Axis IV Problems Related to the Social Environment

Axis V GAF=60

Explanation of the Diagnosis

Axis I
303.90 Alcohol Dependence, With physiological dependence
Koren’s maladaptive pattern of substance use led to clinically important distress and impairment, as manifested by the following symptoms, shown in a single 12-month period:
1. Tolerance: With continued use, the same amount of the substance has markedly less effect
a. “When too much never seems to be sufficient anyway” (p. 157).
b. “All the Malibu I am drinking isn’t having an effect on me” (p. 287).
c. “Even as my tolerance for alcohol goes sky high…” (P. 256).

2. The amount or duration of use is often greater than intended
a. “After two beers there is no question as to whether I should have two more after four…” (pg. 158).
b. “I expect to limit my drinking to a few nights a week but that doesn’t happen” (pg 281).

3. Patient tries without successes to control or reduce substance use
a. On multiple occasions Koren attempts to stop drinking
b. “The month I took off doesn’t slow down my drinking at all” (p. 252).

4. Patient spends much time using the substance, recovering from its effects, or trying to obtain it
a. “It isn’t possible to exceed normal when my drinking feels normal to being with” (p. 157).
b. “Drinking becomes my full-time summer occupation. I devote increased hours to it. I give it increased effort” (p. 239).
c. “I spend the rest of the semester drinking at a bar called Chubby’s with Elle. In fact we are there so often that the owner starts to call us “the twin birds” because we’re always at the bar” (p. 193).
d. “Paul was living in an eternal state of hangover just like me” (p. 293).

5. The patient reduces or abandons important work, social or leisure activities because of substance use
a. Koren became more interested in going to parties than practicing for the cheerleading team which resulted in her being cut from the team
b. Koren spent more time at the campus bars than at the gym library or dinning hall.

Axis II V71.09 No Diagnosis
There is no evidence in the book that Koren has a personality disorder

Axis III none

Axis IV Problems related to the social environment
• Availability of access to alcohol, lack of non-substance using activities, lack of substance-using peers

Axis V GAF=60 Koren shows moderate symptoms pertaining to depression, panic attacks and suicidal ideations. Koren continues to attend college and is able to make and keep friends though relationships usually revolve around alcohol use.

DRY - Treatment

Augusten requested to attend a specialized rehab that was designed for people who are gay and lesbian. This seemed to motivate him to attend and take part in treatment.

DRY fails to provide much detail about Augusten’s treatment, although there seemed to be a lot of group therapy, which is typical of most rehab facilities. His extensive history of childhood abuse, although identified as a factor in his drinking, is not discussed as part of his treatment.

Augusten talks a lot about AA attendance when he returns to New York. AA seemed helpful for him, but unfortunately, he also met at the meetings, a person with whom he became romantically involved. Given this person’s addiction to crack cocaine, Augusten eventually ended up relapsing on both alcohol and crack cocaine. He continued to have a problem with both substance for two years until he returned to AA and became sober on a permanent basis.

Eliciting and Amplifying Strengths DRY

These questions from Solution-Focused Therapy and Motivational Interviewing could be used to find out more about Augusten's strengths and resources and how these could be used to tackle his substance abuse.


1. How were you able to have such a successful career, despite dropping out of school so young and only having a GED? What qualities did you draw upon to reach your level of employment? How did you convince your employer that you were able to do this kind of work? How have you been able to be a success?
2. How were you able to survive the kind of childhood you had and rise above it?
3. The pain of this problem can affect many areas of your life. What aspects of your life are still intact despite the problem, such as relationships, hobbies, interests, employment, academics?
4. When have you been able to give up drinking or drugs, or cut down your use? How were you able to do that?
5. How have you been able to attract the friendships you have? What about you would they say you have going for you? How are you able to rely on them for support?
6. Motivational interviewing- What do you get out of drinking/What do you like about it? What are the not so good things?
7. What will your life look like when you are past this? What will you be doing/What will you be saying?/How will other people react to you?


1. How were you able to have such a successful career, despite dropping out of school so young and only having a GED? What qualities did you draw upon to reach your level of employment? How did you convince your employer that you were able to do this kind of work? How have you been able to be a success?
2. How were you able to survive the kind of childhood you had and rise above it?
3. The pain of this problem can affect many areas of your life. What aspects of your life are still intact despite the problem, such as relationships, hobbies, interests, employment, academics?
4. When have you been able to give up drinking or drugs, or cut down your use? How were you able to do that?
5. How have you been able to attract the friendships you have? What about you would they say you have going for you? How are you able to rely on them for support?
6. Motivational interviewing- What do you get out of drinking/What do you like about it? What are the not so good things?
7. What will your life look like when you are past this? What will you be doing/What will you be saying?/How will other people react to you?

BIOPSYCHOSOCIAL RISK AND RESILIENCE ASSESSMENT FOR DRY

Onset of the Disorder
Biological
RISK
• Family history of substance abuse (father)
• Family history of mental disorder (mother)
• Male
PROTECTIVE
Good Physical health

Psychological
PROTECTIVE
Lack of co-occurring disorder

Social
RISK
Physical abuse from father
Ongoing sexual abuse starting at 13
Maternal abandonment
Gay

PROTECTIVE
Was able to obtain his GED and have a high paying job

Course of the Disorder

Biological
PROTECTIVE
Good physical health

Social
RISK
Lack of family support
Gay

PROTECTIVE
Boss and co-worker are supportive of intervention
Has close relationships with friends
Continues to hold a well-paying job
Access to specialized treatment for people who are gay

Rationale for DSM Diagnosis for DRY

Axis 1: 303.90 Alcohol Dependence with physiological dependence

Augusten has displayed a maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by the following symptoms, occurring in the last year:
1. tolerance: a need for markedly increased amounts of the substance to achieve intoxication or desired effect (one liter a day of whiskey).
2. withdrawal (he is given Librium while detoxing to avoid physical shock)
3. the substance is often taken in larger amounts or over a longer period than was intended time (begins with intention to drink until midnight but keeps going until bottle is finished)
4. there is a persistent desire or unsuccessful efforts to cut down or control substance use (even when he has to attend to work responsibilities, Augusten is unable to stop his use)
5. a great deal of time is spent in activities to obtain the substance, use the substance, or recover from its effects (drinks every night and is unable to meet work responsibilities due to lack of sleep and hangovers)
6. important social, occupational or recreational activities are given up or reduced because of substance use (occupational problems due to use, threatened with job loss)
7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (drinks even though he is allergic to alcohol and has to consume large amounts of Benadryl to prevent a reaction from alcohol)
• With physiological dependence is specified due to the evidence of tolerance and withdrawal

Axis II: V71.09 No Diagnosis
No evidence, at least in DRY, of a personality disorder, although this could be assessed further.

Axis III: Allergy to alcohol

Axis IV: Problems with Primary support: Poor relationship with parents who seemed to have abandoned him as a child; mother now suffers from a stroke

Problems with the social environment: enabling drinking friends, living alone, friend with terminal illness

Occupational problems: is threatened with job loss if he does not participate in treatment

Axis 5: 50

Augusten shows a serious impairment in social and occupational functioning, which indicates a GAF of 50. This would be lower if he did not continue to have a job that provides adequate income.

MULTI-AXIAL DIAGNOSIS FOR DRY

Axis 1: 303.90 Alcohol Dependence with physiological dependence

Axis II: V71.09 No Diagnosis

Axis III: Allergy to alcohol

Axis IV:
Problems with Primary support: Poor relationship with parents who seemed to have abandoned him as a child; mother now suffers from a stroke
Problems with the social environment: enabling drinking friends, living alone, friend with terminal illness
Occupational problems: is threatened with job loss if he does not participate in treatment

Axis 5: 50

Grateful acknowledgement to the contributions of Will Hayden, Erika Paz, and Dallas Williams.