RISK AND PROTECTIVE FACTORS

Any substance use disorder is a biopsychosocial phenomenon with risk and protective at these various levels interacting. At the biological level, Koren did not have a familial history of alcoholism. She also possessed a number of social influences that were protective. She came from a middle-to upper class two-parent household, and her parents were supportive. She was a good student in school and was involved in variety of extra-curricular activities, such as ballet camp, horseback riding, piano lessons, young writers, and diplomacy camp. Koren maintained a religious connection (Catholic) and attended Sunday School. On the risk side, her parents were fairly permissive about teenage experimentation and the use of alcohol. Psychologically, Koren struggled to fit in with her peers and drinking provided that venue.

These issues only intensified when she started college. Depression, anxiety and loneliness spurred the use of drinking to cope. The college environment was also conducive to alcohol as a way of socializing.

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.

SMASHED

SMASHED: STORY OF A DRUNKEN GIRLHOOD, is Koren Zailcka’s memoir detailing her nine- year battle with alcohol, which began when she first tried alcohol at the age of 14 and ended with her choice to abstain from alcohol at the age of 23. Koren was raised in a white middle-class family and grew up in the Northeast. The oldest of two girls, she lived with both parents until she moved away to college. Koren’s first experience with alcohol was at the age of 14 with her best friend while her friend’s parents were at work. Once Koren entered high school, she continued to drink infrequently on the weekends with friends, but during one of her drinking episodes, she over-dosed at a party and was found unconscious lying in her own vomit. She was taken back to a friend’s house where her father was called. He immediately rushed her to the hospital. Tests reported that the 5’2”, 105 pound, 16-year old had a blood alcohol content (BAC) of 0.25.

After graduating high school, Koren attended Syracuse University where her drinking intensified. As a way to make friends, Koren started attending parties and drinking with girls from her dorm. By the end of the first semester of her freshman year, she had fallen into a pattern of frequent drinking, and her life revolved around obtaining, using and being hung over from alcohol. During this year, Koren joined the school cheerleading team and rushed a sorority. Both of these peer groups encouraged the heavy consumption of alcohol.

By her second year of school, Koren was drinking at least four nights a week. Koren’s dating life also began to center around her substance use; she dated guys who heavily used alcohol and drugs. Koren’s first sexual experience was against her will when she was blacked out after a night of drinking. Due to these experiences Koren developed sleeping problems and a hatred of men, which, in turn, fueled her desire to drink. She also began feeling depressed and uninterested in many things that she had previously enjoyed.

At the end of her second year, Koren realized her drinking was out of control and attempted to stop, but by the summer she had found a group of friends that she bonded with over drinking. By Koren’s third year in school, her depression had worsened, and she started having anxiety attacks. She moved into a sorority house which proved to be detrimental because there, she always found people to drink with. a constant opportunity to find people to drink with. She was soon drinking five or six nights a week, which led to risky behaviors, such as promiscuity and driving while intoxicated. During a portion of both her third and fourth year of college, Koren attempted to take a break from drinking but was never able to stop for an extended period of time.

After graduating, Koren moved to Manhattan and lived with a drinking buddy from college. She continued to drink heavily and was hungover to the point of spitting up black specks (which she later discovered was indicative of stomach bleeding). While living in New York, she attempted to quit drinking again after she and her friend woke up in a strange apartment after a night of partying. Neither she nor her friend had a clue how they had ended their night at this apartment.
Koren was very conflicted about her drinking. On one hand, she felt that she didn’t have a problem. She didn’t think her body was physically addicted and didn’t see her use as any more extreme than the next college student or graduate. On the other hand, she believed her use of alcohol held her back from fully maturing into adulthood.

Koren attempted to attend an Alcoholics Anonymous (AA) meeting but changed her mind before she walked in the door, telling herself that she didn’t need help and could quit on her own. After that, Koren attempted to limit her consumption, but, as with previous attempts, she began drinking again. Finally, after a night of heavy drinking, it struck her that as long as she continued to drink, she would not be able to live the life she wanted. She realized she had not developed the ability to hold conversations or make friends with people outside of alcohol. She then made the decision that abstinence was the best way for her and was able to quit without any formal treatment process.

~Kristen Dubin

GIRL, INTERRUPTED

Girl, Interrupted is Susanna Kaysen’s memoir. In this book she writes about her experience as a psychiatric patient in the 1960s. Susanna was an 18-year-old female admitted to McLean Hospital, in Belmont, Massachusetts, after making a suicide attempt. Susanna was born and raised in Cambridge, Massachusetts. She attended high school at the Commonwealth School in Boston and Cambridge School. She was a daughter of the economist Carl Kaysen, a professor at MIT and former advisor to President John F. Kennedy. Her mother was sister of architect Richard Neutra. Susanna also had a sister.

Susanna was about to finish high school when she had a sexual relationship with her high school English teacher and ran away with him to New York. After returning, Susanna woke up one morning with the decision to commit suicide. “It was my task: my job for the day. I lined them up on my desk and took them one by one, counting” (Kaysen, 1993, p.17). Altogether, she took 50 aspirin, but beforehand, she called her (same-age) boyfriend and told him she was going to kill herself. When she went out to get some milk, realizing the attempt was a mistake, the police arrived at her home (the boyfriend had alerted them). She collapsed at the store, and was taken to the emergency room.

The doctor who forcefully advocated her committal to a mental hospital interviewed Susanna for only twenty minutes. He sent a letter to McLean Hospital stating that his evaluation was three hours long. He described her as having the following symptoms: immersion in fantasies; a chaotic lifestyle with no plans for the future; decompensation; sleep problems; depression; suicidality; immersion in fantasy; and progressive withdrawal and isolation. At the hospital, she was assessed as profoundly depressed, suicidal, and promiscuous, with no direction to her life.

During her stay at the hospital, Susanna described the difficulty she had making visual sense of patterns in objects like Oriental rugs, tile floors, and print curtains. Supermarkets were especially bad, because of the long, hypnotic checkerboard aisles. When she looked at these patterns, she saw other things within them. She adamantly denied that she hallucinated. She knew she was “looking at a floor or a curtain. But all the patterns seemed to contain potential representations, which in a dizzying array would flicker briefly to life.”

She also had some perceptual challenges with people’s faces. She stated “once you start parsing a face, it’s peculiar item: squishy, pointy, with lots of air vent and wet spots. This was the reverse of my problem with patterns. Instead of seeing too much meaning, I didn’t see any meaning” (Kaysen, 1993, p. 40).
Furthermore, she stated, “The world, whether dense or hollow, provoked only my negations. When I was supposed to be awake, I was asleep; when I was supposed to speak, I was silent; when a pleasure offered itself to me, I avoided it. My hunger, my thirst, my loneliness and boredom and fear were all weapons aimed at my enemy, the world” (Kaysen, 1993, p. 42).

During her two-year stay at the hospital, she experienced one, six-hour episode of depersonalization, where she bit open the flesh of her hand after becoming terrified that she had "lost her bones.” She talked about wanting to cut herself to see whether she would bleed to prove to herself that she was a real person. She mentioned she would like to see an x-ray of herself to see if she had any bones or anything else inside.

Throughout her stay, she had periods of depression and believed her parents did not understand what she was going through. They communicated little to her, and she felt as if they weren’t to be trusted. Susanna received psychoanalysis at the hospital but didn’t appear to get much out of work with her therapist. She talked about the “us against them” mentality of the residents and the nurses, but Susanna described as being close to one of the nurses. Her closest – and longest-lasting – relationships were with her fellow residents.

Question: If you have seen the movie or already read the book, do you remember the diagnosis she was given? Did this seem appropriate?

If you don't have familiarity with this memoir, what other information might you need to provide an appropriate DSM diagnosis? What diagnosis would you lean toward?

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