INTRODUCTION

Project Overview

The following case study project involves the treatment of an individual, known here as George J. (This is not the individual's true name). George was initially presented to treatment for chronic alcoholism. The patient was brought into the treatment facility by his parents. His parents stated that despite numerous treatment attempts, George had been unable to maintain any significant length of abstinence from alcohol. Prior to entering treatment, George had been treated at a local hospital for injuries sustained when he drove his bicycle over an embankment while intoxicated. His parents stated that George had been in the ditch overnight, and that he was found the following morning by a passing pedestrian. George was treated at a local hospital for his immediate medical conditions. After George's stabilization, the hospital recommended that he be referred to a treatment center for his alcoholism. During the initial intake screening process, George stated that he was a forty-two year old medical doctor, who had been unable to practice medicine for the past three years due in part to his alcoholism. George stated that he had had four previous treatment episodes for his alcoholism. He had been hospitalized two times in 1993, once in 1994, and once in 1995. The patient stated that he had also been hospitalized in a psychiatric hospital in 1993 for a period of ten days, following a failed suicide attempt. At that time George had been given two DSM IV Axis I Diagnostic codes -- Axis-I 296.3x -Major Depression Recurrent, and 303.90 - Alcoholism. Upon admission into detox, George was receiving 25 mg. doses of Librium four times per day as a preventative step down for severe alcohol withdrawal. George was also taking one 100 mg. dose of Doxopin per day, for depression. George stated that he had only taken his Doxepin on an intermittent basis since he was first prescribed the medication in 1993.

An effective treatment approach was required in order to deal with George's specific needs. Because George had two separate Axis I Diagnosis', the theoretical approach selected for this case was the Integrative Dual Diagnosis Treatment Approach.

Chapter 2 of this project will examine a review of the literature related to the clinical problems of dealing with alcoholism, and alcoholism with co-existing mental illness. Chapter 2 will review the literature for various theoretical frameworks of alcoholism, its etiology, and treatment approaches. The theoretical approaches that will be reviewed in Chapter 2 are:

1.) Alcoholics Anonymous

2.) Psychoanalytic

3.) The Medical Model

4.) Family Interaction Concept

5.) The Behavioral Model

6.) Sociological Concept

7.) Transactional Analysis

8.) Models of Treatment for the Dually Disordered Population

9.) An Integrative Dual Diagnosis Approach

Chapter 2 will also include an overview of the dually diagnosed population, i.e. individuals with substance abuse coupled with mental health problems. Because the focus of this project concerns itself with the case study of an individual with alcoholism and depression, Chapter 2 will also include an overview of the current literature on depression, and depression as it relates to alcoholism.

REVIEW OF THE LITERATURE

Theories of Etiology

In trying to identify the causes of problem drinking, some researchers have stressed the role of genetic and biochemical factors; others have pointed to psychosocial factors, viewing problem drinking as a maladaptive pattern of adjustment to the stress of life; still others have emphasized sociocultural factors, such as the availability of alcohol and the social approval of excessive drinking. As with most other forms of maladaptive behavior, it appears that there may be several types of alcoholic dependence, each with somewhat different patterns of biological, psychosocial, and sociocultural causal factors. Recently, a committee of experts from the National Academy of Sciences (Institute of Medicine, 1990) concluded that identifying a single cause for all types of alcohol problems is unlikely.

Biological Factors

In an alcohol dependent person, cell metabolism has adapted itself to the presence of alcohol in the bloodstream and now demands it for stability. When the alcohol in the bloodstream falls below a certain level, withdrawal symptoms occur. These symptoms may be relatively mild -- including a craving for alcohol, tremors, perspiration, and weakness -- or more severe; with nausea, vomiting, fever, rapid heart beat, convulsions, and hallucinations. The shortcut to ending them is to take another drink. Once this point is reached, each drink serves to reinforce alcohol seeking behavior because it reduces the unpleasant symptoms. An unusual craving could result from a genetic vulnerability. The possibility of a genetic predisposition to developing alcohol abuse problems has been widely researched. Cotton, (1979) in a review of 39 studies of families of 6251 alcoholics and 4083 non-alcoholics who had been followed over 40 years, reported that almost one third of alcoholics had at least one parent with an alcohol problem. More recently, a study of children of alcoholics by Cloninger et al. (1986) reported strong evidence for the inheritance of alcoholism. They found that for males, having one alcoholic parent increased the rate of alcoholism from 11.4 percent to 29.5 percent, and having two alcoholic parents increased the rate to 41.2 percent. For females with no alcoholic parents, the rate was 5.0 percent; for those with one alcoholic parent the rate was 9.5 percent, and for those with two alcoholic parents it was 25.0 percent. However, it should be kept in mind that the majority of individuals in the study did not have alcoholic parents. Also, such studies do not rule out environmental influences such as modeling.

One approach to understanding the precursors to alcoholism is to study the behavior of individuals who are at high risk for substance abuse but who are not yet affected by alcohol -- prealcoholic personalities. An alcohol-risk personality has been described by Finn (1990), as an individual (usually the child of an alcoholic) who has an inherited predisposition toward alcohol abuse and who is impulsive, prefers taking high risks, is emotionally unstable, has difficulty planning and organizing behavior, has problems in predicting the consequences of his or her actions, has many psychological problems, finds that alcohol is helpful in coping with stress, does not experience hangovers, and finds alcohol rewarding.

Finn et al. (1990) found that pre-alcoholic men show different physiological patterns than non-alcoholic men in several respects. Pre-alcoholic men are more sensitive to stress-response dampening (lessened experience to stress) with alcohol ingestion than nonalcoholic men. They also show different alpha wave patterns on EEG (Stewart, Finn, and Pihl, 1990). Pre-alcoholic men as defined by the personality characteristic, were found to show larger conditioned physiological responses to alcohol cues than were individuals who were...