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.

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?