Insomnia, Anxiety and "Just Wine With Dinner": Uncovering Moderate Alcohol Use Disorder in a 52-Year-Old Attorney and Predicting Withdrawal Before She Stops
[Student Name]
University of Phoenix
PMH/501: Neuropsychiatric Disorders
Week 8 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Ms. P., a 52-year-old attorney, comes asking for help with sleep and anxiety. She wakes at 3 a.m. with a racing heart and cannot return to sleep, feels anxious in the mornings and has trouble concentrating at work. She asks for a sleeping pill. When I ask about alcohol, she says she has "just wine with dinner." This paper describes how the evaluation changed the diagnosis.
Screening
Saunders et al. (1993) developed the Alcohol Use Disorders Identification Test through a WHO collaborative project across six countries, designed to identify hazardous and harmful drinking in primary care. It covers consumption, dependence and harm. I administer it and ask for specifics. Ms. P. drinks a bottle of wine most evenings, sometimes more on weekends, has tried to cut down without success, has felt guilty and once could not remember parts of an evening. Her AUDIT score is 19, in the range suggesting harmful use and possible dependence.
Applying DSM-5 Criteria
DSM-5 defines alcohol use disorder by 11 criteria in the past year, with 2 or 3 indicating mild, 4 or 5 moderate and 6 or more severe disorder. Ms. P. describes finishing more wine than she planned, several failed attempts to cut back, whole mornings lost to recovering, craving, continued use despite anxiety and sleep problems that alcohol worsens and tolerance. Six criteria indicate severe alcohol use disorder; on careful review of timing, one item is marginal, and I record it as moderate to severe, with withdrawal symptoms to be clarified.
She asked for a sleeping pill; the question she had not been asked was how much wine made up her "just."
How Common This Is
Using the third wave of a large national survey of U.S. adults, Grant et al. (2015) estimated 12-month and lifetime prevalence of DSM-5 alcohol use disorder at 13.9% and 29.1% among U.S. adults, and found that most people with alcohol use disorder never received treatment. Ms. P.'s presentation, seeking care for a consequence rather than the drinking, is typical.
Sorting the Anxiety and Insomnia
Her early-morning awakening with a racing heart and morning anxiety are consistent with nightly withdrawal as blood alcohol falls. Alcohol also breaks up sleep in the early morning hours, after its sedating effect wears off. DSM guides the distinction: anxiety or insomnia that begins during heavy use and improves within about a month of abstinence is alcohol-induced, while symptoms that predate heavy drinking or persist after a period of sobriety suggest a primary disorder. Ms. P. reports that her anxiety began when her drinking increased three years ago. I defer diagnosing a primary anxiety or sleep disorder until after a period of abstinence.
Why Not Prescribe the Sleeping Pill
Sedative-hypnotics combined with alcohol increase the risk of respiratory depression, falls and accidents, and benzodiazepine receptor agonists can become a second dependence. Prescribing one would treat a symptom of her drinking while adding risk.
Predicting Withdrawal
If Ms. P. stops drinking, she may develop withdrawal. Sullivan et al. (1989) built the CIWA-Ar, a ten-item scale scored by a clinician, of withdrawal severity that guides symptom-triggered treatment. Her history of morning tremor and racing heart suggests she may have withdrawal; she has no history of seizures or delirium tremens, which would require medically supervised detoxification. We plan an outpatient reduction with daily check-ins, CIWA-Ar monitoring by a nurse and a clear plan for emergency care if severe symptoms occur.
Why Screening Questions Must Be Specific
Asking "Do you drink?" invites a vague answer. Asking how many drinks on a typical day, how many on the heaviest day in the past month and what size the glass is produces useful information. Ms. P.'s "glass" was a large goblet, and she refilled it several times. The AUDIT's structured items helped her report accurately without feeling accused (Saunders et al., 1993).
Work and Consequences
Ms. P. has noticed errors in her work and missed a filing deadline. Recognizing these consequences helps her see the link between drinking and the problems she came for, which increases motivation to change.
Other Substances
I ask about other substances, including sedatives obtained from friends, cannabis and stimulants. She reports none. Screening for co-occurring substance use is part of every substance evaluation.
Safety
I ask about driving after drinking, which she admits has happened, and about suicidal thoughts, which she denies. We discuss not driving after any drinking.
Why Naltrexone
Naltrexone reduces the pleasurable effect of alcohol and cravings and has evidence for reducing heavy drinking. It requires normal or near-normal liver function and cannot be used with opioids. Acamprosate is an alternative that is cleared by the kidneys and may suit patients with liver disease. The choice depends on her liver tests and preferences.
Her Readiness
Ms. P. was surprised by the diagnosis and initially resisted it. Presenting the screening result and criteria as information rather than judgment, and linking them to her own goals of better sleep and work performance, helped her consider change. By the end of the visit, she agreed to try.
Follow-Up
I will see her in one week, with daily phone check-ins during reduction, and reassess anxiety and sleep after one month of abstinence to decide whether a primary disorder is present.
Nutrition
Heavy drinkers often have poor nutrition and low thiamine. I recommend thiamine supplementation during reduction to reduce the risk of Wernicke encephalopathy.
Family
She lives with her husband, who does not drink heavily. With her permission, he will help with the reduction plan and watch for withdrawal symptoms.
Relapse Prevention
Relapse is common in recovery from alcohol use disorder. We identify her high-risk times, evenings after stressful workdays, and plan alternatives, such as a walk or calling a friend, along with how to respond to a lapse without abandoning the goal.
Documentation
The note records her consumption pattern, the AUDIT score, each DSM criterion met, the withdrawal risk assessment and the plan, so that the reasoning behind withholding a sleeping pill is clear to other clinicians who see her.
Medical Evaluation
I check liver enzymes, complete blood count, metabolic panel and B vitamins and examine for signs of liver disease. Mean corpuscular volume and gamma-glutamyl transferase are elevated, consistent with heavy drinking.
Treatment Options
After discussion, she agrees to start naltrexone, which reduces heavy drinking, once her liver tests are reviewed, and to begin counseling. Mutual support groups are offered as an option.
Conclusion
Ms. P.'s request for help with insomnia and anxiety revealed, through the AUDIT and DSM-5 criteria, a moderate to severe alcohol use disorder, a common and undertreated condition. Her anxiety and insomnia are likely alcohol-induced, and diagnosing primary disorders must wait for abstinence. A sleeping pill was declined, and a plan for monitored reduction with the CIWA-Ar, medical evaluation and treatment for alcohol use disorder was put in place.
References
Grant, B. F., Goldstein, R. B., Saha, T. D., Chou, S. P., Jung, J., Zhang, H., Pickering, R. P., Ruan, W. J., Smith, S. M., Huang, B., & Hasin, D. S. (2015). Epidemiology of DSM-5 alcohol use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry, 72(8), 757-766. https://doi.org/10.1001/jamapsychiatry.2015.0584
Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction, 88(6), 791-804. https://doi.org/10.1111/j.1360-0443.1993.tb02093.x
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
How this PMH 501 Week 8 example is structured
The PMH/501 Week 8 work usually closes with substance-related disorders and an integrated diagnostic case. This paper shows how a common complaint conceals a substance disorder, how screening and criteria reveal it and how the diagnosis reorders the rest of the psychiatric picture. Students search this week as PMH 501 Week 8, PMH501 Wk 8 or PMH/501 Wk 8; all three are the same assignment.
PMH/501 Week 8 questions, answered
What does PMH/501 Week 8 usually ask for?
Many sections close with substance-related disorders and an integrated case requiring diagnosis of co-occurring conditions.
What is the AUDIT?
The Alcohol Use Disorders Identification Test, a 10-item WHO screening questionnaire on alcohol consumption, dependence symptoms and alcohol-related problems, scored from 0 to 40.
Can alcohol cause anxiety and insomnia?
Yes. Heavy drinking and withdrawal between drinks commonly cause anxiety and disrupted sleep, so these symptoms may improve with abstinence, and a primary disorder is diagnosed only if they persist.
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