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CASE STUDY Juan (alcohol use disorder)

Case study details.

Juan is a 34-year old Mexican-American construction worker. He reports having to work in extreme heat during interstate road repair and notes that his use of alcohol is comparable to others at the work-site. During a typical 10-hour workday, he may drink up to 8 cold beers to deal with the heat. He does not believe that it affects his work productivity in any way but admits that he has experienced a couple of minor injuries while under the influence. When he began this work a few years back, he recalls not drinking as much. Over time, he has increased his alcohol use and even requires it when returning home. He reports being a family man and had never had alcohol around his family until that time. He explains that his job is tiring and he has no energy left to engage with his children or wife when at home. He also admits to not being able to remember much of his off days because of his drinking. Before this job, he states that he remembers spending time with his three little girls and sometimes finds himself missing those times. He says that when he tries to cut back drinking during special events or during Lent, he finds that he is irritable and craves alcohol. He eventually returns to drinking a similar amount or more. His wife and he argue about how much of his paycheck is going to buying beers instead of their credit card bills and how he is too drunk to spend time with her or the kids. He believes that if he wanted to he could probably cut back.

Diagnoses and Related Treatments

2. substance and alcohol use disorders.

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Case Study and Treatment Plan: Major Depressive Disorder and Alcohol Use

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Alcohol Use Disorder: A Medical Perspective Case Study

Lukenotes, winter 2023.

Father Martin, age 42, was ordained a Catholic priest ten years ago. He served as parochial vicar in two parishes before being assigned to his current pastorate, where he is responsible for two parishes on the outer reaches of the diocese, far away from family and friends. In addition to being isolated from his previous support system, he found it challenging to build relationships with either parish community, as neither had a particularly healthy relationship with their prior pastor.

An intense feeling of loneliness set in, which he alleviated by drinking more in the evenings. At first, he enjoyed his after-dinner drink, as it gave him a feeling of euphoria and relaxation. He had something to look forward to after a taxing day of dealing with parishioners and staff.

Over time, he needed several bourbons to relax and fall asleep, and he would frequently awaken during the night. He became more irritable with the staff during the day. In the evenings, he felt depressed and agitated, ruminating about any minor negative experience from the day. He needed a drink to settle down, more often several drinks. Gradually, he developed a habit of finishing off half a bottle of bourbon in an evening. If he did not drink, he was absolutely miserable. Eventually, he began to think about his evening bourbons during the day. He became preoccupied with going to the liquor store and selecting new and different varieties of bourbon.

Father Martin did not consider his drinking a problem, nor had alcohol been a significant part of his upbringing. He remembered hearing stories of his maternal grandfather’s drunken behavior and his mother’s brothers, who often brawled in bars. He did not behave that way. He said daily Mass, heard confessions, visited the sick, and kept tabs on the parish finances. He was an attentive, responsible pastor. While he knew that he was often irritated and raised his voice with his staff, it did not strike him as unreasonable behavior.

Eventually the bishop got wind of Fr. Martin’s hostile outbursts and confronted him. Fr. Martin insisted he was within the bounds of being an effective leader. However, with the support of the administrative staff, a maintenance man presented the bishop with photos of the whiskey bottles in the recycle bin.

Fr. Martin arrived at Saint Luke Institute insisting his alcohol use was manageable. However, during his evaluation, his blood pressure and heart rate were significantly elevated, and he had a noticeable tremor. He was sent to an emergency room, where he was diagnosed with alcohol withdrawal syndrome. He was admitted to the hospital for a few days of detox and given IV fluids and a benzodiazepine for alcohol withdrawal. After his discharge, he resumed the evaluation at SLI.

Fr. Martin’s blood pressure and heart rate eventually returned to normal. His liver enzymes indicated a toxicity that lingered for several weeks. Cognitive tests indicated a mild memory problem, which could have been contributing to his frustrations in parish meetings. This appeared to be in the early stages and likely reversible, given time.

Fr. Martin entered the intensive outpatient program at Saint Luke Institute. He continued to notice intermittent cravings for alcohol, so his doctor prescribed daily naltrexone to decrease these urges. He also was treated for an underlying depression with an antidepressant. Gradually, his liver enzymes returned to normal, and his memory improved.

Fr. Martin received comprehensive treatment for his alcohol use disorder. In addition to the medical and psychiatric treatment he received, he also participated in group therapies. These included a general psychotherapy process group, psychoeducational groups, art therapy, psychodrama, and Case Study continued exercise. He participated in individual psychotherapy sessions twice per week, met with a spiritual integrator weekly, and attended spirituality groups.

Although Fr. Martin had developed an alcohol use disorder, it was discovered early enough for him to recover fully.

For confidentiality reasons, names, identifying data, and other details of treatment have been altered.

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case study for alcohol use disorder

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Alcohol Use Disorder: Case Study and Theory Analysis

Jennifer C. Rademacher

Alcohol Use Disorder is defined as a troublesome repetitive use of alcohol causing large amounts of impairment or distress, as shown by at least two of the following occurring within a twelve month period: alcohol is consumed in large amounts or for a long period of time, there is a want to quit drinking with failed attempts, a large amount of time and energy are spent trying to obtain the alcohol, a strong desire to drink alcohol, repetitive alcohol use causing one to not fulfill his/her life roles, repetitive alcohol use despite the alcohol causing relationship problems, stopping of regular and important activities, repetitive alcohol use despite health issues, repetitive alcohol use despite having knowledge of physical or mental issues caused by the alcohol, tolerance, and withdrawal. Severity of the Alcohol Use Disorder is determined by the number of symptoms present. Miguel is currently having the symptoms of drinking large amounts of alcohol as shown by his heavier drinking, repetitive alcohol use despite the alcohol worsening relationships as shown by his conflicts with his wife, no longer fulfilling his life roles as demonstrated him not being able to fulfill his role as a father to his children, repetitive alcohol use in situations which may be physically harmful as demonstrated by his punching walls, and tolerance as seen by his increase in more potent alcohol like whisky and an increase in the number of beers consumed. His fulfillment of five symptoms specifies him as having moderate Alcohol Use Disorder (Barlow and Durand, 2012, pg 402).

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Miguel father’s name is Tommy, his mother’s name is Susan, and he has two brothers and three sisters. His brother’s names are Bob and Mickey; his sister’s names are Tracy, Leah, and Maria. Miguel is the second oldest. Miguel’s father, Tom, had previously been diagnosed as having severe Alcohol Use Disorder . Tom worked as a pipe liner in the oil field, which required hazardous and difficult physical labor with him working long days and needing to travel frequently. Tom was unsure of how to cope with the stress and physical demands of his job since his schedule made it difficult to build a strong communication style with his wife, Susan. Tom often drank on his off time to cope with his stressors, while at home or away on business travels. Miguel often witnessed his father use drinking as a coping skill. Susan operated an after school day care at the home to help support the family. Miguel and his brothers and sisters were expected to either help with the day care or obtain jobs at the age of sixteen to help support the family. Miguel’s family was considered lower on the socioeconomic scale and his parents stressed doing well in school to urge their children to obtain a higher standard of living than their current state.

Miguel did well throughout high school and earned acceptance into a prestigious university where he majored in business. Miguel’s family placed a large amount of stress on Miguel’s academic performance throughout college since Miguel was a first generation college attendee. This caused Miguel to have frequent feelings of anxiety about his academic record and pleasing his family. Miguel was diagnosed with Generalized Anxiety Disorder and took an SSRI, specifically Paxil, for about a year. However, he discontinued his medication regimen when he felt the medication was no longer vital in his life. College is when Miguel first began drinking but he was seldom intoxicated except when he went to large parties. During Miguel’s senior year he met Ann. Miguel and Ann married when Miguel was twenty-four and had three children.

Post college Miguel entered into the business realm by working for a large firm. Within the last few years Miguel began drinking almost every weekend and would drink a few beers during the week as well. Two years ago he was promoted to a regional sales manager which involves him managing ten different company locations in his region and writing the quarterly reports. After the promotion, his intake of alcohol increased. This increase involved transitioning from beer to whiskey. During this period the relationship between Miguel and his wife began withering away as shown by an increase in the number of arguments. In addition, during more heated arguments Miguel would become so irate he would punch walls.

Miguel’s currently admits that he is consuming two to three drinks of whisky and six to eight beers on weekdays and the majority of a whisky bottle and twenty to three beers on weekends. Miguel decided to seek treatment after his wife separated from him. This separation led to Miguel living in a small apartment with minimal contact with his children. Miguel states the separation may have increased his intake of alcohol.

As seen in Miguel’s history and physical there was a job promotion and thus an increased number of stressors in life. This increase in stressors plus a combination of past anxiety issues (Grant et al., 2004), the high genetic risk of substance abuse (Ferguson & Goldberg, 1997), witnessing his father’s ineffective coping skills, and increased stress from his job promotion and relationship issues likely began his increase in drinking. The increase in number of drinks and more potent forms of alcohol may have contributed to the increase in arguments between his wife and him, therefore, increasing his stress and anxiety which could be part of the problem of the substance abuse. Miguel appears to lack healthy coping habits and thus his increase in stressors seems to be causing an increase in drinking.

Concerning Alcohol Use Disorder genetics and environment are known to play a large role. A study done by Ferguson and Goldberg looks closely at the genetic markers and alcohol abuse correlations. First Ferguson and Goldberg reviewed past studies concerning genetic vulnerability. A data collection and analysis done by Cotton (as cited in Ferguson and Goldberg, 1997) examined records to see ties between family members and alcoholism. Cotton collected and reviewed thirty-nine family case studies that were gathered over a forty year period with participants being 6,521 alcoholic participants and 4,083 non-alcoholic participants in order to theorize about the inheritability of alcoholism. Cotton’s analysis of the studies showed that out of the alcoholic participants, one of three was found to have a parent who had Alcohol Use Disorder. Cotton also noticed that the occurrence of Alcohol Use Disorder was dramatically lower when family members were non-alcoholics versus relatives who are alcoholics.

Another factor to take into consideration is that the environment is playing a role in offspring becoming alcoholics. A child may witness and model Alcohol Use Disorder behavior and symptoms. The learned behavior may increase the child’s vulnerability, not necessarily just the genes. In order to cancel out the environment factor and investigate just the genetic vulnerability, twin studies were conducted.

Twin studies try to prove genetic contributions to Alcohol Use Disorder by comparing the rates of alcoholism between monozygotic twins and dizygotic twins. A study done by Kendler, Heath, Neale, Kessler, and Eaves (as cited in Ferguson and Goldberg, 1997), involved 1,030 female-female twins and compared the rates of alcoholism using the diagnostic criteria from the DSM III-R. Interviews were conducted to assess the participants level, if any, of alcoholism. The results showed that monozygotic twins had higher rates of alcoholism in both twins versus dizygotic twins. The degree of inheritability was deemed 51-59% for monozygotic twins.

Ferguson and Goldberg discussed how previous studies, like the ones just discussed, place the degree of inheritability at around 50%. Ferguson and Goldberg’s study looks at genetic markers – specifically ADH, ALDH, and monoamine oxidase activity – to see how genetics may contribute to alcoholism. Samples of blood were taken from 46 alcoholic participants and 39 non-alcoholic participants to compare the genetic markers in their blood. The results of the study concluded that due to limitations of the DSM classification of alcoholism, the lack of ethinic diversity within subjects, and the fact that while there were differences in the level of the markers between the patients no single gene could be pinpointed as putting one at risk for developing alcoholism if higher or lower in abundance. MAO was seen to have a linkage to poorer mental health in general. In addition, ADH which affects tolerance to alcohol was shown to vary in quantity between the two groups of participants. But the correlation between tolerance ability and alcoholism could not be proven in the study. Overall, while specific genetic markers could not be concluded, genetic vulnerability still plays a strong role in one’s probability of developing Alcohol Use Disorder.

The studies reviewed in Ferguson and Goldberg’s article showing the inheritability degree of alcoholism of around 50% are important because Miguel had an alcoholic father. Miguel’s genetic vulnerability could have placed him at an increased risk of becoming an alcoholic. In addition, Miguel witnessed his father use alcohol as a coping skill. The combination of nature and nurture could have contributed to Miguel’s diagnosis.

Also concerning Miguel’s environment, Miguel felt his parent’s placed extreme standards on him growing up which caused him anxiety. A study done by Grant et al. (2004) examined the dual diagnosis of anxiety disorders paired with substance use disorders (pg 807-816). The study involved 43,093 participants who were classified as having substance use disorders and any one of the nine mood or anxiety disorders according to the DSM IV. The methods use to collect information was a face to face survey by trained interviewers from the National Epidemiological Survey on Alcohol and Related Conditions. The results of the study first stated rates of mood disorder (9.21% ), anxiety disorder (11.08%) and substance use disorders (9.35%) separately for the general US population. The percentage of people with substance use disorder and at least one mood disorder was 18% while the percentage of people with substance use disorder and at least one anxiety disorder was 20% for the general US population. However, when looking just at individuals who currently were getting treatment for alcohol use disorder 40.7 % of those individuals had at least one mood disorder and 33% had at least one anxiety disorder. Thus the percentages for people seeking treatment were higher versus the general population. The correlation between the two diagnosis was deemed positive with a rate of .05 and thus being significant. (Grant et al., 2004, pg. 807 – 816).

The positive correlation and increase in percentages of dual diagnosis for people who seek treatment are relevant to Miguel because he diagnosed as having GAD while in college. Miguel’s previous diagnosis and lack of effective coping skills could be considered an integral part of his development of Alcohol Use Disorder.

For treatment Miguel would be placed in a short term stabilization unit for detoxification where he will receive one hour of recreational therapy, one hour chemical dependency counseling, and one hour of psychotherapy per day Monday through Sunday. Short term in-patient treatment would be used because this is the current standard of care. In addition, having the inpatient care will ensure the patient in unable to obtain alcohol for at least 3 to 5 days. Then Miguel should seek out-patient therapy in order to continue learning skills/ways to prevent relapse. Out-patient therapy will consist mostly of psychotherapy.

The Recreational Therapy groups offered at the in-patient stabilization unit will focus learning new coping skills, activity involvement, and leisure awareness in order for the patient to decrease triggers for drinking such as boredom, develop a coping method and achieve flow (Malkin & Benshoff, 1996). A theory by Francis (1991) (as citied in Malkin and Benshoff, 1996) states that individuals with alcoholism often experience increased stress, low self-esteem, leisure dissatisfaction, and boredom. Then Francis explains Czikszentmihalyi’s theory of flow which states that nirvana or leisure satisfaction can be reached when one’s skill level matches the challenge of the activity. Francis then states that leisure awareness which helps one find flow through recreation can help alleviate the negative symptoms alcoholics experience and reduce the urge to use alcohol.

Another study focusing on recreation in the aid of alcoholism was done by Nation et al. (1996) which focused on goals achieved through recreational therapy groups according to Certified Therapeutic Recreation Specialists at different facilities (pg. 10 – 16). A twenty question questionnaire was sent to Recreational Therapist at 250 substance abuse help centers, including in-patient and out-patient facilities, which focused on the goals achieved through the program and recreational therapy groups. The achievable goals listed as most important from the responsive Recreational Therapists included improving one’s ability to socialize (90%), increasing self-esteem (87%), bettering one’s ability to trust and cooperate with others (84%), bettering one’s leisure awareness and developing recreation skills (68%), and increase one’s idea of responsibility (66%). Developing these goals through RT groups can help the patient develop new, more positive habits (Nation et al., 1996, pg 10-16).

The drug and alcohol counseling group will focus on informing patients about the cycle of addiction, negative thought patterns, support groups in the area including AA, and the harmful side effects of drug and alcohol on mental and physical health.

Cognitive Behavioral Theory will also be a component of in-patient care because CBT can help teach the individual socialization skills and news ways to cope with stressors. One of the main goals of CBT is to help the person better express their feelings and thoughts in an appropriate, healthy way. Learning these new skills can help reduce the urge to drink by decreasing anxiety and stress. (Libal, 2003, pg. 116)

The outpatient care will consist of Cognitive Behavioral Therapy, Motivational Interviewing Therapy, and daily intake of Naltrexone to prevent relapse because these methods have shown to help samples of alcohol abuse participants in previous studies (Anton et al., 1999). In a study conducted by Anton et al. (1999) 131 recently detoxed alcohol dependent persons were treated in an outpatient setting for 12 weeks with the interventions being Cognitive Behavior Therapy and either Naltrexone or a placebo pill. The study was double blind and randomized. Progress was tracked throughout the study in two ways. At the end of each week participants were evaluated using the timeline follow-back calendar method to track amount of drinks consumed per day, the Obsessive Compulsive Drinking Scale, the analog craving scales, and a checklist of any physical symptoms experienced. The second method of data collection was a physician administering a more physical health aimed evaluation at weeks 1, 4, 8, and 12. In addition, the participant’s blood was tested for indications of alcohol intake throughout the study. The most central result from the study was that 62% of the experimental group, the one receiving Naltrexone, did not relapse during the 12 week study. The control group, the one receiving the placebo, had a 40% success rate of not relapsing. Both groups’ relatively high amounts of participants resisting alcohol during the study could point to the success of Cognitive Behavioral Therapy used during the study. However, the experimental group data proves that the pairing of Naltrexone and therapy had a higher success rate. Therefore, Anton et al. (1999) believe that the patient will experience the most value out of outpatient care by pairing the medication along with Cognitive Behavioral Therapy.

Libal (2003) states that a patient’s willingness to change can be a barrier in treatment, and when this issue occurs Motivation Interviewing Therapy should be utilized. This form of therapy focuses on helping the individual realize he has a problem and find ways to become intrinsically motivated to achieve change. This therapy has the potential to be beneficial for Miguel because it can increase his motivation to stick to his medication schedule and help him problem solve on ways he can motivate himself to change. His own readiness and desire for recovery is important since his former support system, his wife and family, may no longer what to be involved with him. Therefore, the triad of therapies proposed – Cognitive Behavioral therapy, Motivational Interviewing Therapy, and Naltrexone – has the potential to be of high therapeutic worth to Miguel concerning outpatient care.

The goals of treatment for Recreation Therapy include help the patient identify healthy activities that helps him achieve flow and develop coping skills and frustration management skills (Malkin & Benshoff, 1996). The goals for Motivation Interviewing therapy involve helping the client become self motivated to change lifestyle towards sobriety. The goals of Cognitive Behavioral Therapy incorporate changing thinking/behavior patterns that are associated with substance abuse. Finally, the goals of the Chemical Dependency Groups include learning of information about Alcohol Use Disorder, support groups in the area including AA, and other community resources.

Anton, R., Moak, D., Waid, R., Latham, P., Malcom, R., & Dias, J. (1999). Naltrexone and cognitive behavioral therapy for the treatment of outpatient alcoholics: results of a placebo-controlled trial.The American Journal of Psychiatry,156(11), 1758-1764.

Barlow, D. H., & Durand, V. M., (2012). Abnormal psychology: an integrative approach (7th ed.). Stamford, CT: Cengage Learning.

Ferguson, R. A., & Goldberg, D. M. (1997). Genetic markers of alcohol abuse. Clinica Chimica Acta , 257 (2), 199-250.

Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., Dufour, M. C., Compton, W., & Kaplan, K. (2004). Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry , 61 (8), 807-816.

Libal, J. (2003). Chapter 7: Alternative and supplementary treatments. Drug Therapy & Substance-Related Disorders , 116.

Malkin, M. J., & Benshoff, J. J. (1996). Therapeutic recreation interventions in substance abuse. Parks & Recreation , 31 (10), 26.

Nation, J. M., & Benshoff, J. J. (1996). Therapeutic recreation programs for adolescents in substance abuse treatment facilities. Journal Of Rehabilitation , 62(4), 10-16.

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Alcoholism Disorder Case Study Analysis

Assessment findings.

The client in the case study exhibits symptoms of alcoholism. Also called alcohol use disorder, alcoholism is a disorder that is associated with traits such as dependence on alcohol, preoccupation with alcohol drinking and repetition of alcohol drinking even after experiencing detrimental effects of alcoholism (Lehne, 2013). The client in the case study has developed the disorder since he is very dependent on alcohol and continues to use it even after experiencing negative effects of its consumption. An alcoholism diagnosis criterion is currently described in the DSM-5. As explained under the criterion, people that have developed the alcohol use disorder exhibit traits such as craving appetite for alcohol, loss of control after drinking and development of tolerance and physical dependence to alcohol (Lehne, 2013). The client in the case study exhibits the traits mentioned above. He loses control after drinking alcohol to the extent that he uses violence against his marriage partners and sometimes, he does not remember what he did after he becomes sober. When he is not drunk, he develops withdrawal symptoms, implying that he has developed physical dependence to alcohol. He has a craving appetite for alcohol.

Under the DSM-5 criteria, a person who has developed alcoholism disorder usually continues taking it despite the fact that it is causing problems in his or her life (Lehne, 2013). The client in the case study exhibits that characteristic since he has continued taking alcohol despite the fact that it led him to lose construction job. Also, the client continued taking alcohol despite the fact that it led to a break-up of his family. In fact, the disorder has led to break-up of two marriages. Due to the disorder, he is not allowed to see his son. After the break-up of the two marriages, he got a girlfriend. However, the girlfriend left him because of alcoholism and use of violence when he is drank. The problems caused by alcoholism can be in the form of harm on physical or psychological health. The disorder has an impact on his health because when he is not drunk, his right knee shakes constantly and he becomes restless. He also developed feelings of anxiety. Even after realizing about such negative effects of alcoholism, he has continued drinking.

Another trait in the DSM-5 is the failure to fulfill important obligations due to over-dependence on alcohol (Lehne, 2013). A person that has developed that disorder can use the money meant for paying bills on alcohol. The client in the case study exhibits that trait since he does not provide support to his child. He has also failed to pay for important bills, including rent. In fact, he is being evicted because of the failure to pay the rent. He is even unable to purchase medications for hypertension. Another trait described in the DSM-5 criteria is that alcohol use disorder affects ability to work optimally (Lehne, 2013). Although the client in the case study tries to work harder than the workmates, the disorder makes him very unreliable. Sometimes, the effects of alcohol makes arrive at work late. He also goes to work with hangovers because of drinking, which affect his ability to work effectively. Also, people that have developed the alcohol use disorder tend to use it in dangerous situations, as explained in the DSM-5 criteria (Lehne, 2013). The client in the case study continued driving when drunk even after being arrested. Last, alcohol use disorder is associated with tolerance. Tolerance occurs when a person takes more drinks than before in order to get satisfied. The client stated that he takes more alcohol than when he was in the army in order to get satisfied.

Referral Recommendations

The client in the case study has not reached to a point where it is difficult to treat his condition. However, there is a need for thorough diagnosis of his condition in order to determine the best treatment options to use. The councilor has noted that he is unable to treat the client and that the client requires additional, more effective screening and care. Subsequently, a self-administered form for evaluating substance abuse was applied on the client. The results derived from the assessment indicated that the client needs moderate to high intervention for alcohol abuse. The client’s diagnosis results suggest that different types of effective treatments should be applied to him. First, he should be referred to a psychiatrist or psychologist who has knowledge on how to use behavioral therapy treatment approaches. One of the common behavioral therapies that are effective in treating the alcohol use disorder is the cognitive-behavioral therapy (CBT) (Dupuy, 2013). When applying CBT, the psychiatrist determines the fundamental causes of alcoholism and lets the client acknowledge them. The client is then taken through a step-by-step process after which he/she accepts to take an active role in reducing or stopping intake of alcohol. The client in this case, for instance, can be taught to overcome memories of deaths he witnessed when he was in the army and factors that lead his to continue drinking. The client can be made to understand that he has a great future if he stops the drinking habit. In case of a need, the client can be supported to get a new job. Considering his situation, the client should also be referred to a medical doctor to be treated using medications that help in detoxification of the body. The client can also be referred to rehabilitation programs, such as 12-step and Alcoholics Anonymous programs to be provided with treatment for a specific period of time (Dupuy, 2013). The behavioral therapy should continue until the client is fully healed.


One of the most important ethical standards in healthcare profession is confidentiality. According to the standard, the information about the health of a patient should be kept confidential at all times. The information should only be shared with the client and other healthcare providers that are involved in the treatment process (Dupuy, 2013). In case of a need, the information can be given only to people that are close to a patient, such as close relatives or friends.

To adhere to the standard of confidentiality, the reports about the health situation of the client in the case study should not be shared with people that are not involved in the treatment process. The report derived from the self-administered test should be shared between the client, the medical professional and the psychiatrist involved in the treatment (Dupuy, 2013). The information can be shared with other people that are not related to the client only upon his consent.

If the client is enrolled in a rehabilitation program, the reports about his health can only be shared with the health professional that will be directly involved in treating him. Even the other healthcare professionals that are not involved in the treatment should not have access to that information.

Also Study: Alcohol Patient Case Study Analysis


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Alcohol Use Disorders: A Case Study

case study for alcohol use disorder

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Related Topics

Alcohol use disorder is a pattern of alcohol use that involves problems controlling your drinking, being preoccupied with alcohol or continuing to use alcohol even when it causes problems. This disorder also involves having to drink more to get the same effect or having withdrawal symptoms when you rapidly decrease or stop drinking. Alcohol use disorder includes a level of drinking that's sometimes called alcoholism.

Unhealthy alcohol use includes any alcohol use that puts your health or safety at risk or causes other alcohol-related problems. It also includes binge drinking — a pattern of drinking where a male has five or more drinks within two hours or a female has at least four drinks within two hours. Binge drinking causes significant health and safety risks.

If your pattern of drinking results in repeated significant distress and problems functioning in your daily life, you likely have alcohol use disorder. It can range from mild to severe. However, even a mild disorder can escalate and lead to serious problems, so early treatment is important.

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Alcohol use disorder can be mild, moderate or severe, based on the number of symptoms you experience. Signs and symptoms may include:

Alcohol use disorder can include periods of being drunk (alcohol intoxication) and symptoms of withdrawal.

What is considered 1 drink?

The National Institute on Alcohol Abuse and Alcoholism defines one standard drink as any one of these:

When to see a doctor

If you feel that you sometimes drink too much alcohol, or your drinking is causing problems, or if your family is concerned about your drinking, talk with your health care provider. Other ways to get help include talking with a mental health professional or seeking help from a support group such as Alcoholics Anonymous or a similar type of self-help group.

Because denial is common, you may feel like you don't have a problem with drinking. You might not recognize how much you drink or how many problems in your life are related to alcohol use. Listen to relatives, friends or co-workers when they ask you to examine your drinking habits or to seek help. Consider talking with someone who has had a problem with drinking but has stopped.

If your loved one needs help

Many people with alcohol use disorder hesitate to get treatment because they don't recognize that they have a problem. An intervention from loved ones can help some people recognize and accept that they need professional help. If you're concerned about someone who drinks too much, ask a professional experienced in alcohol treatment for advice on how to approach that person.

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Genetic, psychological, social and environmental factors can impact how drinking alcohol affects your body and behavior. Theories suggest that for certain people drinking has a different and stronger impact that can lead to alcohol use disorder.

Over time, drinking too much alcohol may change the normal function of the areas of your brain associated with the experience of pleasure, judgment and the ability to exercise control over your behavior. This may result in craving alcohol to try to restore good feelings or reduce negative ones.

Risk factors

Alcohol use may begin in the teens, but alcohol use disorder occurs more frequently in the 20s and 30s, though it can start at any age.

Risk factors for alcohol use disorder include:


Alcohol depresses your central nervous system. In some people, the initial reaction may feel like an increase in energy. But as you continue to drink, you become drowsy and have less control over your actions.

Too much alcohol affects your speech, muscle coordination and vital centers of your brain. A heavy drinking binge may even cause a life-threatening coma or death. This is of particular concern when you're taking certain medications that also depress the brain's function.

Impact on your safety

Excessive drinking can reduce your judgment skills and lower inhibitions, leading to poor choices and dangerous situations or behaviors, including:

Impact on your health

Drinking too much alcohol on a single occasion or over time can cause health problems, including:

Early intervention can prevent alcohol-related problems in teens. If you have a teenager, be alert to signs and symptoms that may indicate a problem with alcohol:

You can help prevent teenage alcohol use:

Alcohol use disorder care at Mayo Clinic

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Case Study: Alcohol Abuse with Co-Occurring Anxiety

Table of contents.

Our client was a male in his early 20s and presented for treatment for alcohol use disorder and reported he had been drinking daily for 2 years. He was on short term disability and employed. This was his first-time seeking treatment.

The Process

Initially, client was using justification (cognitive distortion) for his alcohol use due to presenting as “functioning” externally. He justified his alcohol use by his ability to maintain employment, have a savings account, and having a good relationship with his family. Therapy was focused on how this client functions internally. Client was able to get honest about his mental health, specifically feeling increasing anxiety for the past 2 years. Client was able to make connections that he drank alcohol to cope with his anxiety.

The Outcome

Client addressed his anxiety in collaboration with the psychiatrist and therapist. Through the client’s course of treatment, he was able to recognize the need to stop drinking and follow the psychiatrist’s recommendation of incorporating anti-anxiety medications into his treatment.  The therapist executed clinical interventions utilizing Motivational Interviewing, Cognitive Behavioral Therapy as well as providing psychoeducation on the 12-step of Alcoholics Anonymous.  The client was able to return to his job following completion of treatment, secured a sponsor and a home group, and worked with a psychiatrist for ongoing follow up with his medication.

The client reported that he has been working on his steps with a sponsor and is accessing supports he has developed in his home group to maintain sobriety.

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Substance Use Disorders During the COVID-19 Pandemic: Case Study 

alcohol, beer, bottles, alcoholism, substance use disorder

This is the fourth installment of our 6-part series on mental health issues exacerbated by the COVID-19 pandemic. In this installment, we will discuss identifying and treating substance use disorders in adolescents and adults in the aftermath of the COVID-19 pandemic in primary care.

A 45-year-old man presents to his primary care office at 9:00 am after he was asked to leave work the day before because he smelled of alcohol and had been acting erratically. He is told that he will need to be evaluated prior to returning to work. His behavior includes running back in forth at the shop yelling, “the holy spirit is in me.” He has been at his current employment for 3 months after being fired from his previous job after backing a forklift into loaded shelves at a nearby warehouse.

He reports he started drinking beer when he was 14 years old. In the past 2 years during the COVID-19 pandemic, his alcohol intake has increased to a 12-pack of beer nightly to get the “same effect” as he did last year. He notes that his drinking is now affecting his work and relationship with his wife. He states he knows that he needs to stop but feels ill (vomits and shakes) when he tries to lower his intake. He states, “when I was 22 years old, I had to be hospitalized after I tried to quit cold turkey and I was talking out of my head.” Several days a week he consumes 1 to 2 beers when he first awakes to “calm his nerves.”

His last drink was last night around midnight but he states, “I could use one right now.” He states, “I start off thinking I will only drink 1 or 2 beers but time gets away from me.” He further reports, “the pills my friend has been giving me have been helping me stay awake throughout the day.” He is unsure of the name of the medication but reports taking the pills almost daily over the last year.

Laboratory results show high levels of ammonia, glucose, carbohydrate-deficient transferrin, ethyl alcohol, and mean corpuscular volume (Table 1). 1-4 Low white blood cell count, platelet count, and folic acid level are noted. Liver function tests are all elevated. Urine toxicology is positive for alcohol, cannabis, and amphetamine, and electrocardiography shows tachycardia (112 beats/min) with no ST segment abnormalities. Liver ultrasonography reports are pending.

Table 1. Laboratory Results of Markers of Alcohol Consumption 1-4

ALT , alanine transaminase; AST , aspartate aspartate aminotransferase; EtOH , ethyl alcohol; GGT , gamma-glutamyl transferase

Alcohol Use Disorder Screening Tools

Screening tools used to diagnose alcohol use disorder include the CAGE 5 , which is based on the 4 questions that ask:

The patient has a positive response to 3 out of 4 CAGE questions. The Drug Abuse Screening Test (DAST-10) was also completed by the patient and he scored 6 indicating a need for further assessment. 5,6

Another alcohol use screening tool that can be used is the AUDIT-C 5 , a shortened version of the AUDIT (Alcohol Use Disorders Identification Test) that includes 3 questions:

Significant Medical/Psychiatric History

The patient has a history of hypertension and is prescribed lisinopril 10 mg daily but is rarely compliant with taking medication. The patient admits to being diagnosed with COVID-19 approximately 1 month ago, but only experienced mild symptoms, which included headache and nonproductive cough for 3 days. He has increased his alcohol consumption over the last 2 years.

Table 2. Vital Signs

Family history.

The patient’s family history includes a parental grandfather with alcohol use disorder; brother currently using methamphetamine and cocaine. The patient’s mother has type 2 diabetes and the patient’s father has hypertension and alcohol use disorder.

Mental Status Examination

The patient presents with unkempt hair, dirty clothes, and a scruffy beard. He continuously clinches his fists and taps his feet, appearing anxious. He is mildly diaphoretic and wipes sweat from his forehead every couple of minutes. Mild bilateral hand tremors a noted as he held out his return to work form. He is alert and oriented to person, place, and time. He voices frustration that he must be cleared before returning to work since he has gone to work after drinking in the past and it was never a big deal. He acknowledges he may be drinking a bit more recently but states, “I am getting these pills from a friend that keep me wired for hours and sometimes days. I really don’t function well without them.”

He describes his mood as “frustrated” and reports he has been more irritated lately. He reports having a lot of energy after taking the pills. His thoughts are organized and logical. He denies any hallucinations and does not appear to be responding to internal stimuli currently. He does not verbalize anything that could be considered delusional. He denies suicidal or homicidal ideations and has not had these thoughts in the past. He reports a period of euphoria associated with “the pills” that may last up to 3 days. His attention is intact but his judgment is impaired due to showing up to work smelling of alcohol. His speech is loud at times but with normal rate and nonpressured speech. He has fair insight into his alcohol use and wants to quit but has limited insight into the substances he is taking from his friend.


The patient in this case is diagnosed with alcohol use disorder (Table 3), 7 severe alcohol, withdrawal, amphetamine use, macrocytosis, and elevated liver enzymes. 8 He agrees to sign a formal voluntary admission form and wants to attend a 28-day program after detoxification.

Table 3. DSM-5 Signs and Symptoms of Alcohol Use Disorder 7

The effects of COVID-19 on mental health and substance use can be compared with the effects of a disaster (natural or environmental), war, or traumatic event. 9-11  For example, following the September 11th terrorist attack, 30% of New York City residents reported increased use of alcohol, marijuana, and cigarette use. 12

When experiencing psychological distress, some people may initially rely on drugs, alcohol, gambling, or overeating. 13 According to Avena et al, more than 50% of adults in the United States reported that the COVID-19 pandemic negatively affected their mental health since. 13 During the COVID-19 pandemic, the increase in substance use led to the highest drug overdose rates since 2019 with an increase from 31% between 2019 and 2020. 14 In the period from September 2020 to September 2021, overdose deaths exceeded 100,000, representing a 50% increase over the previous 2 years. 15 The increased death rate by overdose is primarily attributed to the rising rates of synthetic opioid use such as illicitly manufactured fentanyl. 16 A 38.4% increase in synthetic overdose deaths was reported between June 2019 and May 2020. 16 Most overdoses occur when the person is home alone, 17 and only 13% of people with substance use disorder seek treatment. 18

At the beginning of the COVID-19 pandemic, many clinics and community-based programs closed, which initially caused an increase in the amount of alcohol consumption and sleep aid use among people unable to obtain medical cannabis. 17,19 However, a shift toward telemedicine use occurred when most insurance companies lifted telehealth restrictions on substance use and mental health visits. 17 Additionally, community-based programs like Alcoholics Anonymous and Narcotics Anonymous started meeting virtually. 17

Higher alcohol consumption risk levels are associated with lower socioeconomic classes in both the general population and people with a history of alcohol use disorder. 11 Additionally, stress and anxiety increased alcohol consumption during the COVID-19 pandemic. 10 In a systematic review, Roberts et al found mixed findings on the effects of the COVID-19 pandemic on alcohol use with some studies showing an increase in alcohol use ranging from 21.7% to 72.9% while others reported a decrease in alcohol use and some reported a variation. 20 However, the overall finding among all the reviewed articles showed at least some increase in alcohol consumption during the COVID-19 pandemic. 20 A survey conducted by the Research Triangle Institute in May 2020 concluded that the average monthly alcohol consumption increased from 36% to 39% and binge drinking increased from 26% to 30% during the pandemic. 11

Substance use among adolescents was also affected by the COVID-19 pandemic. Temple et al examined 1188 ethnically diverse adolescents and found that if adolescents did not limit their socialization during the pandemic, they were more likely to use alcohol, marijuana, hard drugs, prescription drugs, and e-cigarettes. 22 Addiction can begin as early as childhood so screening in the primary care setting is imperative. 22

Treatment for Substance Use Disorders

Treatment for substance use disorders depends on the agent being used. 23-27  

Alcohol Use Disorder

Cannabis Use Disorder

Cocaine Use Disorder

Opioid Use Disorder

Stimulant Use


The patient will follow up after he completes his 28-day residential program. At that time, the provider will evaluate his medication regimen to see if it meets his long-term goals.

During the COVID-19 pandemic, increased use of alcohol and other substances lead to an increase in overdose rates. During this time, patients with occasional drug and alcohol use may have developed substance use disorders. Substance abuse is a complex treatable disease that involves identifying the problem using assessment and screening tools. The first step of the treatment process is detoxification, which may require hospitalization. Once safely detoxed, initiating or continuing medication and ensuring referral to treatment is based on patient needs.

Shirley Griffey, DNP, PMHNP , is a psychiatric nurse practitioner at Baton Rouge General Medical Center and an instructor at Southeastern Louisiana University School of Nursing in Baton Rouge, Louisiana.

Jennifer Allain, DNP, MSN, APRN, FNP-C , is the NP program coordinator and master teacher of mental health psychiatric nursing at The LHC Group, Myers School of Nursing of the University of Louisiana at Lafayette College of Nursing and Health Sciences.

Christy Cook-Perry,  DNP, PMHNP, ANP , is an assistant professor at Southeastern Louisiana University College of Nursing and Health Sciences.

The next installment in the mental health series will be on nonsuicidal ideation. Previous articles include:

Anxiety in Children and Adults Ballooned in US at Start of COVID-19 Pandemic Depression After COVID-19: Identification and Treatment in Primary Care Suicide Awareness During the COVID-19 Pandemic

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Deep brain stimulation of the nucleus accumbens in treatment-resistant alcohol use disorder: a double-blind randomized controlled multi-center trial

Translational Psychiatry volume  13 , Article number:  49 ( 2023 ) Cite this article

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Treatment resistance in alcohol use disorders (AUD) is a major problem for affected individuals and for society. In the search of new treatment options, few case studies using deep brain stimulation (DBS) of the nucleus accumbens have indicated positive effects in AUD. Here we report a double-blind randomized controlled trial comparing active DBS (“DBS-EARLY ON”) against sham stimulation (“DBS-LATE ON”) over 6 months in n  = 12 AUD inpatients. This 6-month blind phase was followed by a 12-month unblinded period in which all patients received active DBS. Continuous abstinence (primary outcome), alcohol use, alcohol craving, depressiveness, anxiety, anhedonia and quality of life served as outcome parameters. The primary intention-to-treat analysis, comparing continuous abstinence between treatment groups, did not yield statistically significant results, most likely due to the restricted number of participants. In light of the resulting limited statistical power, there is the question of whether DBS effects on secondary outcomes can nonetheless be interpreted as indicative of an therapeutic effect. Analyses of secondary outcomes provide evidence for this, demonstrating a significantly higher proportion of abstinent days, lower alcohol craving and anhedonia in the DBS-EARLY ON group 6 months after randomization. Exploratory responder analyses indicated that patients with high baseline alcohol craving, depressiveness and anhedonia responded to DBS. The results of this first randomized controlled trial are suggestive of beneficial effects of DBS in treatment-resistant AUD and encourage a replication in larger samples.


Alcohol use disorder (AUD) is among the most frequent and devastating diseases globally [ 1 ]. Currently approved pharmacological and non-pharmacological treatments leave much room for improvement. Even when treated according to current guidelines, the majority of AUD patients relapse within a short period [ 2 ]. New treatments are needed, especially for the group of treatment-resistant AUD patients who respond poorly to currently available treatment options [ 3 ]. Treatment-resistant AUD has been associated with increased incentive sensitization to alcohol-associated cues, accompanied by attentional bias towards such cues, as well as increased craving [ 4 ]. Regarding the neurobiological basis of these processes, animal models demonstrated that ethanol intake and the anticipation of ethanol both trigger a phasic dopamine release in the Nucleus accumbens (NAc). This dopamine release, in turn, modulates activation in the mesocorticolimbic system implicated in craving, reward and behavioral control [ 5 , 6 , 7 , 8 ]. Although a wide range of brain areas have been implicated in the development and maintenance of addictive behaviors, the NAc has been identified as a key region in animal and human models of AUD [ 9 , 10 ]. Past neuroimaging studies have uncovered evidence of alcohol-cue exposure increasing brain activation in the NAc and striatum [ 11 , 12 , 13 , 14 ]. Brain activation in these areas has been repeatedly demonstrated to be correlated to subjective alcohol craving [ 11 , 15 ], to predict relapse in AUD patients after withdrawal treatment [ 16 , 17 ] and to be associated with a better treatment response to naltrexone, an opioid antagonist [ 18 , 19 , 20 ].

In recent years efforts have been undertaken to develop innovative interventions to modulate NAc activation and assess the clinical effects of such interventions. One such intervention is Deep Brain Stimulation (DBS). DBS is an approved treatment for several movement disorders (e.g. Parkinson’s disease, tremor, and dystonia) and epilepsy in various brain targets and has been used in clinical practice for more than 25 years [ 21 ]. Under its Human Device Exemption, the U.S. Food and Drug Administration has approved of DBS targeting the anterior limb of the internal capsule (ALIC) neighboring the NAc as an option for treating patients with refractory obsessive-compulsive disorder (OCD) [ 22 ]. Initial translational studies on DBS and optogenetic stimulation of the NAc have yielded promising results in animal models of addiction [ 23 , 24 , 25 , 26 ].

Using DBS to treat addiction in humans has been documented in the literature for more than 15 years. It can be traced back to a first incidental finding of a patient with severe treatment-resistant anxiety disorder and comorbid AUD consuming much less alcohol while being treated with NAc stimulation [ 27 ]. In the following years, several human studies and case reports have investigated the effects of DBS in various substance-use disorders. In AUD results from nine patients altogether have been published to date [ 27 , 28 , 29 , 30 , 31 ]. A recent open-label study in six AUD patients provided further support for the beneficial effects of DBS in AUD [ 32 ]. Patients reported a reduction in alcohol consumption, alcohol craving, and anxiety after 12 months of stimulation. In addition, reduced NAc metabolism during positron emission tomography (PET) studies and a reduced NAc activation and connectivity during functional magnetic resonance imaging (fMRI) were observed. Even though these studies reported positive effects, open-label, non-randomized study designs leave open the question of whether or not the observed effects are attributable to DBS. In the intention to close this gap, we conducted a randomized controlled double-blind multi-center trial (“Deep Brain Stimulation in Treatment-Resistant Alcoholism” - DeBraSTRA) investigating the effects of NAc DBS in a sample of heavily dependent AUD patients over a period of 18 months.

Methods and materials

Study design and procedures.

The study was preregistered (German clinical trials database: DRKS00003206, EUDAMED ID: CIV-11-05-000663) and conducted in three German centers (Cologne, Magdeburg, and Mannheim/Heidelberg) as a double-blind randomized controlled trial (RCT). After baseline assessment and randomization all participants received bilateral stereotactic implantation of DBS electrodes in the NAc with sub-clavicular implantation of the pulse generator (see Supplements for details on the surgical procedure and Supplementary Fig. 1 ). After surgery, patients were randomized to either receive sham (DBS-LATE ON) or active stimulation (DBS-EARLY ON) during the first 6 months of the study. The first 6 months of active or sham stimulation were followed by a 12-month open-label period of active stimulation in all patients (see Fig. 1 ). Safety and outcome measures were assessed for a total of 18 months (see Fig. 1 ). A block-wise randomization was conducted within the study centers with a randomly varied block size between 2 and 4. Both, clinical investigators and patients were blinded to whether patients received active treatment or not.

figure 1

Of the 30 planned patients, only 12 patients were ultimately enrolled ( n  = 4 per center) (2013 – 2016). One reason for the lower-than-expected inclusion rate was the strict inclusion and exclusion criteria, which followed those used in previous studies and were approved by the applicable ethics committees. For the primary outcome “time to first alcohol use”, data was available for all n  = 12 participants from baseline until the end of the blinded study period at month 6 (100%). For the secondary outcomes, data was available at baseline for all participants and for 9 participants at months 6 and 18. After 18 months, 75% of included participants ( n  = 9) had completed the study.

The trial was conducted in accordance to Good Clinical Practice guidelines (ICH-GCP) and the Declaration of Helsinki. All study procedures were approved by the German Federal Institute for Drug Safety and the German Federal Office for Radiation Protection as well as the local ethics committees of all study centers. The Institute of Biometry and Medical Informatics of the University Hospital Magdeburg provided biometrical support for the RCT. Independent and steady monitoring was provided by the coordination center for clinical studies of the University of Magdeburg and by an external data safety and monitoring board.

Surgical procedure and stimulation parameters

The surgical procedure followed a predefined protocol in all study centers. Treatment planning for stereotactic bilateral implantation of quadripolar DBS-brain electrodes (3387, Medtronic, Minneapolis, MN, USA) was based on high-resolution pre- or intraoperative MRI images (1.5T or 3.0T MRI-scanner). The target for electrode implantation (translating to the inferior border of the most distal electrode contact) was defined by a combination of indirect coordinate-based and direct anatomical targeting. Standard coordinates in relation to the midsagittal plane were: X  = 6–8 mm lateral to the midline, Y  = 2 mm rostral to the anterior border of the anterior commissure, and Z  = 3–4 mm ventral [ 33 , 34 ]. From here targeting was refined by anatomical means. In coronal MRI images (T1 or proton density weighted T2 images) the slice that most clearly outlined Broca’s diagonal band (a gray matter tract encapsulating the NAc medially and inferiorly) was chosen. Herein the target was defined to be 2.0–2.5 mm lateral to the vertical limb of Broca’s diagonal band and dorsal to the Tuber olfactorius. A deep frontolateral position for the entry point in relation to the coronal suture was used to enable a trajectory running parallel to and inside the ALIC. Targeting this way aimed at placing the two distal contacts of the DBS-electrode into the caudo-medial NAc, the third contact at the transitional border between the NAc and the ALIC and the fourth contact into the most ventral part of the ALIC or in transition to the Caudate nucleus.

Both, frame-based stereotactic implantation of the brain electrodes and implantation of the non-rechargeable pulse generator (ACTIVA®PC, Medtronic; Minneapolis, MN, USA) in the subclavicular area were performed as a single surgery under general anesthesia. All patients underwent post- or intraoperative CT- or MRI scans for verification and documentation of final electrode placement (see Fig. 2 for depiction of electrode localizations) and to exclude intracerebral hemorrhage. All study participants were treated as inpatients for at least one week after surgery.

figure 2

All electrodes, colored by center, were reconstructed from preoperative magnetic resonance imaging and postoperative computer tomography, following the default pipeline of the LEAD-DBS software [ 75 ]. In the left image, the target area, i.e. the nucleus accumbens, is depicted as white mesh. The right image displays the projection on 2D slices for each contact level. All images are superimposed on slices of a 7 Tesla brain scan in MNI space [ 76 ].

Initial stimulation parameters were empirically chosen and carried over from the previous case studies and series of NAc DBS for psychiatric disorders under which patients experienced significant improvement of symptoms without encountering any stimulation-induced side effects [ 35 , 36 ]. Stimulation was started at 130 Hz, 90 µs, and 3.5 V with the two most distal contacts being activated for cathodic monopolar stimulation aiming to cover a large portion of the NAc volume. Adjustment of the stimulation amplitude by 0.5 V each (culminating in a maximum amplitude of 4.5 V) could be performed at 2 and 4 weeks after initiating stimulation (both after baseline in the DBS-EARLY ON group and after 6 months in the DBS-LATE ON group) if no stimulation-induced side effects were observed or suboptimal treatment response was seen during a standardized interview. Patients were evaluated for changes in mood, calmness, anxiety, and craving. Other changes in stimulation parameters were not permitted.

Study visits

Study visits were conducted at baseline, in weeks 2, 4, 6, 8 and then monthly. Visits included assessment of adverse events and primary and secondary outcome measures. Alcohol use and abstinence were assessed through patient reports using the validated Form-90 interview [ 37 ]. Alcohol craving was measured using the Obsessive-Compulsive-Drinking-Scale (OCDS), which assesses alcohol craving over the last seven days [ 38 , 39 ] and the Alcohol Urge Questionnaire (AUQ) [ 40 ], which assesses momentary craving. Depressive symptoms were investigated using the Beck Depression Inventory (BDI-II) [ 41 ] and the Hamilton Depression Scale (HAMD) [ 42 ]. In addition, anhedonia was assessed using the Snaith-Hamilton-Pleasure-Scale (SHAPS) [ 43 ] and the Chapman Anhedonia Scale [ 44 ]. The Young Mania Rating scale was used to assess euphoria and symptoms of (hypo-)mania throughout the trial [ 45 ]. For Quality of Life we used the German version of the World Health Organization’s quality of life questionnaire (WHOQOL-BREF) [ 46 ]. Psychosocial functioning was assessed using the Global Assessment of Functioning scale (GAF) [ 47 ]. Adverse events were recorded at every study visit and between study visits, if reported by the participants. Before study inclusion, after electrode implantation and at 6 months follow-up (end of sham-stimulation) a full neurological and psychiatric examination was conducted and blood samples were drawn to determine indirect measures of alcohol use (e.g., Carbohydrate Deficient Transferrin). Control of the stimulation parameters was done by an unblinded researcher at each site who was independent and not involved in any other assessment.


The local ethics committees requested only male AUD patients to be included into the trial. Patients were enrolled if they met all following inclusion criteria: (i) age between 25 and 60 years, (ii) diagnosis of alcohol dependence for at least 10 years according to the Diagnostic and Statistical Manual of Mental Disorders 4th revision (DSM-IV-TR) and the International Classification of Disease 10th revision (ICD-10), (iii) completion of at least 9 years of school education, (iv) capacity to understand study procedures and provide informed written consent, (v) meet criteria of “treatment resistance”. This was defined as alcohol dependence for at least 10 years, at least 2 inpatient or day-care rehabilitation treatments of a total duration of at least 6 months and unsuccessful treatment with acamprosate or naltrexone, and (vi) consumption of at least 30 standard drinks (14 grams pure alcohol) per week over a 30-day period within the last 3 months.

Exclusion criteria were: (i) abuse of or addiction to other substances (other than nicotine and alcohol) with a positive urine screening, (ii) other DSM-IV-TR axis-I disorders (excluded via a full SCID-I interview [ 48 ]), (iii) antisocial personality disorder (i.e. score >20 on the psychopathy check list [ 49 ]), (iv) brain damage, diagnosed on MRI-scan by a neuroradiologist, v) severe neurological or medical conditions, as well as vi) any general contraindication for surgery and/or anesthesia.

The inclusion and exclusion criteria matched those used during previous trials [ 29 ]. During the three years of recruitment (2013-2015), a total of about 750 patients were treated at the three study sites with a diagnosis of an alcohol addiction or alcohol-related disease (ICD-10: F10.2, F10.3 and F10.4) and a duration of inpatient treatment at least one week. Most of these patients however did not meet the strict inclusion and exclusion criteria. Specifically, the majority of these patients did either not meet the inclusion criterion of treatment resistance (see above) or presented with a psychiatric (e.g., other addiction diagnoses) or somatic comorbidity. In addition, a relevant proportion of patients declined to participate in the study because of the surgical procedure involved.

Because of medical detoxification as inpatients, all participants were abstinent at the time of surgery.

Primary outcome

Continuous abstinence from alcohol, i.e. the time to first alcohol use within the first 6 months after randomization served as the primary outcome and was assessed using the validated Form-90 interview [ 37 ]. The choice of the primary outcome followed German treatment guidelines and recommendations by the European Medicines Agency (EMA/CHMP/EWP/20097/2008).

Secondary Outcomes

Alcohol consumption (i.e. proportion of abstinent days, proportion of heavy drinking days, mean daily alcohol use) during the 6 months after randomization (blinded phase) and the following 12 months (unblinded ON phase).

Alcohol craving, depressive symptoms, anhedonia, anxiety, quality of life, and global functioning at months 6 and 18 after randomization.

Safety was assessed by means of occurrence of any adverse or serios adverse events throughout the 18-month study period.

We hypothesized that DBS-EARLY ON versus DBS-LATE ON results in a longer abstinence from alcohol during the first 6 months after randomization (primary outcome). Secondary hypotheses: DBS-EARLY ON versus DBS-LATE ON results in lower relative proportions of drinking days and heavy drinking days, as well as mean alcohol use at month 6 after randomization.

Statistical analyses and sample size estimation

The primary analysis included all randomized patients, following an intention-to-treat principle. The primary endpoint was compared between both treatment arms using a log-rank test. For the power analyses we assumed a relapse rate (i.e. any alcohol use) of 90% in the DBS-LATE ON group vs. a relapse rate of 67% in the DBS-EARLY ON group, according to previous studies [ 27 , 28 , 29 , 30 ]. Sample sizes estimation indicated that n  = 13 patients per group yield a power of 80% for a log-rank-test ( α  = 0.05, two-sided) comparing time to first alcohol use between both arms. To account for drop-outs, we aimed to recruit n  = 15 patients per group, in order to yield a sample size of n  = 30. The effect of DBS-EARLY ON was further quantified as hazard ratio (HR) using a proportional hazards Cox-regression model with 95% confidence interval. Secondary endpoints were compared between DBS-EARLY ON and DBS-LATE ON at month 6 after study randomization using Mann-Whitney U-tests. Within-group differences between baseline and after 6 and 18 months were compared using Wilcoxon-matched-pairs signed-rank tests. Furthermore, we conducted exploratory responder analyses to identify patient characteristics linked to DBS efficacy. Since a reduction of alcohol use by at least two WHO risk-drinking levels has been identified as an important outcome in clinical AUD trials by the European Medicines Agency (EMA) and has been substantiated by multiple clinical studies [ 50 , 51 , 52 , 53 ], we classified patients as responders (i.e. reduction at least two WHO risk drinking levels) and non-responders (i.e. reduction of less than two WHO risk-drinking levels) accordingly, based on the trajectories of their alcohol use from baseline to the last study visit (month 18).

A total of 12 patients were enrolled in the trial ( n  = 4 per center). For the primary outcome, data was available for all participants. For the secondary outcomes, data was available at baseline for all subjects and at months 6 and 18 for 9 participants (see Fig. 1 ). At baseline, there were no significant differences between the DBS-EARLY ON and DBS-LATE ON groups with the exception of a higher physical anhedonia score in the DBS-LATE ON group (see Table 1 ).

Primary outcome parameter – time to first alcohol use

Overall, 11 out of 12 patients used alcohol during the first 6 months after randomization. In the DBS-EARLY ON group, one patient remained abstinent throughout the study and one patient remained abstinent for 5 months, while all patients in the DBS-LATE ON group had used alcohol by the end of month 6. The mean time to first alcohol use was 70.5 days (DBS-EARLY ON) and 29.7 days (DBS-LATE ON). There was no significant difference in terms of time to first alcohol use between the DBS-LATE ON and DBS-EARLY ON groups after the first 6 months of treatment (two-sided Log-Rank-Test, p  = 0.619, see Fig. 3 ). Cox regression revealed a non-significant reduction in alcohol use risk for the DBS-EARLY ON group (HR = 0.73; 95%CI 0.20–2.62; p  = 0.625). This HR would translate to a number needed to treat (NNT) of 9.6 [95%CI 1.9–16.4] [ 54 ]. The results remained unchanged when dependence severity and recency of alcohol use were included as covariates in the Cox regression model.

figure 3

Kaplan–Meier curves illustrating the time until first alcohol use after randomization (primary outcome) in the active stimulation group (DBS EARLY-ON) and sham stimulation group (DBS LATE-ON), which did not differ significantly between both groups (95%CI = 95% Confidence Interval).

Secondary outcomes

Alcohol use.

In accordance with the study protocol, the comparison of both study groups at month 6 after randomization revealed a significantly higher proportion of abstinent days in the DBS-EARLY ON group ( p  = 0.048, see Table 2A ). Analyses of the means of the secondary outcome variables, calculated across the eight study visits that took place over the 6 months following randomization, corroborated this finding. Here, the DBS-EARLY ON group showed a significantly higher mean proportion of abstinent days ( p  = 0.032, see Table 2B and Fig. 4B ) and fewer heavy drinking days ( p  = 0.041, see Table 2B and Fig. 4C ). Comparison of other alcohol-use indices showed a lower mean alcohol consumption per day in the DBS-EARLY ON group (see Fig. 4A ), although this comparison was not statistically significant. Comparing both groups at 18 months after randomization, i.e. after all patients had been stimulated for 12 months following the end of the double-blind study phase, revealed no significant differences between both study groups (all p values ≥ 0.05; see Table 2C ). This descriptive observation was mirrored by longitudinal analyses in the whole study group and in both groups separately, comparing baseline against study visits 8 after 6 months (6 M) and 20 after 18 months (18 M). DBS treatment resulted in a significantly higher proportion of abstinent days at the end of the study ( n  = 9, baseline: 27.6% ± 11.6, 18 M: 74.2% ±31.3, Z  = −2.547, p  = 0.004) and lower proportion of heavy drinking days ( n  = 6, baseline: 69.6% ± 12.6, 18 M: 35.5% ± 29.9, Z  = −1.992, p  = 0.031), as well as a lower mean daily alcohol use ( n  = 9, baseline: 207.4 g/d ± 162.2, 18 M: 62.7 g/d ± 72.5, Z  = −1.836, p  = 0.037, see Fig. 4 ). A significant increase in the proportion of abstinent days was also observed when comparing baseline against the 6-month visit across both study groups ( n  = 12, baseline: 27.6% ± 11.6, 6 M: 56.0% ±31.1, Z  = −2.191, p  = 0.014), as well as a significant decrease in the proportion of heavy drinking days ( n  = 9, baseline: 69.6% ± 12.6, 6 M: 47.4% ± 27.6, Z  = −2.073, p  = 0.020) and mean daily alcohol use ( n  = 9, baseline: 207.4 g/d ± 162.2, 6 M: 85.3 g/d ± 69.7, Z  = −2.192, p  = 0.014, see Fig. 4 ).

figure 4

Depiction of median values and of significant longitudinal changes and group differences in A mean alcohol use (mean over last 30 days), B proportion of abstinent days, and C the proportion of heavy drinking days, at baseline, at the 6-month visit (i.e., end of blinded phase), and at 18 months (after all patients had been actively stimulated for at least 12 months). *Significant differences between time points or study groups, as indicated, at p  < 0.05, determined using Wilcoxon tests and Mann–Whitney U tests.

Clinical symptoms

The DBS-EARLY ON group reported significantly lower alcohol craving at the end of the blinded study phase, during study visit 8 (AUQ score, p  = 0.020, see Table 2A and Fig. 5 ) and lower anhedonia scores on two scales (SHAPS, p  = 0.028, and the Chapman Anhedonia scale, p  = 0.008) compared to the DBS-LATE ON group. Longitudinal analyses across both groups showed a significant reduction in alcohol craving (OCDS) from baseline to month 6 ( n  = 10, baseline: 21.0 ± 7.0, 6 M: 10.5 ± 7.2 Z  = −2,191, p  = 0.014) and month 18 ( n  = 8, baseline: 21.0 ± 7.0, 18 M: 5.9 ± 6.4 Z  = −2,371, p  = 0.008). Mirroring these findings, we also found decreases in alcohol craving (AUQ) although these were not statistically significant (see Supplementary Table 2 ). We further observed a reduction in depressive symptoms (HAMD, BDI) and anhedonia (SHAPS) as well as increases in quality-of-life indices (WHOQOL-BREF) and global functioning (GAF) that were larger in the DBS-EARLY ON compared to the DBS-LATE ON group (see Supplementary Table 2 ). However, these descriptive differences were not statistically significant, most likely due to limited power.

figure 5

Depiction of median values and of significant longitudinal changes and group differences in A anhedonia (SHAPS), B , C alcohol craving (OCDS and AUQ), and D quality of life (WHOQOL-BREF) at baseline, at the 6-month visit (i.e., end of blinded phase), and at 18 months (after all patients had been actively stimulated for at least 12 months). *Significant differences between time points or study groups, as indicated, at p  < 0.05, determined using Wilcoxon tests and Mann–Whitney U tests.

Within the first 6 months, a total of 38 adverse events (AEs) occurred in 6 patients, including 24 AEs and 7 serious adverse events (SAEs) in 4 patients in the DBS-EARLY ON group and 14 AEs and 7 SAEs in 2 patients in the DBS-LATE ON group. During the following 12 months, a total of 82 AEs were recorded in 9 patients. Of all of the AEs, 68.9% were rated as mild to moderate. SAEs were mostly related to alcohol relapse and re-admission for detoxification, as any case of inpatient treatment had to be considered by law as SAE. Six AEs were related to a surgical procedure (DBS-EARLY ON: n  = 5; DBS-LATE ON: n  = 1). Some AEs were related to the stimulation device itself: in one case, the AE was interpreted to be causally related to the stimulation device (premature battery depletion), while in 9 cases the stimulation device was considered as possibly related to the AE (for details see Supplementary Table 3 ). One patient experienced a premature battery depletion 11 months after randomization, leading to the replacement of the pulse generator. During the first 6 study months, 26 AEs required treatment, while 65 AEs required treatment during the following 12 months. Of AEs occurring within the first six study months, 85.7% were resolved, compared to 88.9% during the following 12 months. Within the 18-month study period, no deaths or lasting disabilities were reported. Both study groups (DBS-EARLY ON and DBS-LATE ON) did not differ significantly on the Young Mania rating scale (range 0–60) at any time point throughout the study period with scores ranging from 0 to a maximum of 7 points ( p min  ≥ 0.690). In addition, the scores on the Young Mania rating scale across both groups did not show a significant increase or decrease over time ( p  = 0.301), suggesting absence of clinically relevant (hypo-)mania in the current sample.

Exploratory responder analyses

Based on the trajectories of their alcohol use, three patients were classified as responders (i.e. reduction of mean alcohol use by two or more WHO risk drinking levels) and 8 as non-responders. The mean reduction in daily alcohol use from baseline to the last study visit (month 18) was 43.4 g/d (±226.7) in non-responders and 198.1 g/d (±52.7) in responders. At baseline, responders showed a significantly higher craving for alcohol ( p  = 0.042), significantly more depressive symptoms ( p  = 0.018), anxiety ( p  = 0.042) as well as higher anhedonia scores ( p  = 0.036, see Supplementary Table 4 ).

We present the first double-blind RCT investigating the effects of DBS on abstinence and alcohol use in AUD patients. The primary intention-to-treat analysis suggested an abstinence-promoting effect of DBS. However, the results were not statistically significant, most likely due to limited power resulting from the small sample size and the categorial primary outcome. Descriptively, the observed HR of 0.73 would translate to a NNT of 9.6, which – in the light of the NNTs observed for other relapse-preventing treatments and the sample of treatment resistant patients – is suggestive of a potential effect of DBS in AUD [ 55 , 56 , 57 ]. Obviously, the significance and robustness of this effect would need to be confirmed in larger samples. Further evidence for an abstinence-promoting effect was provided by the significant effects of active DBS (DBS-EARLY ON) on secondary parametric outcomes. Considering alcohol use at 6 months after randomization, the proportion of abstinent days for the DBS-EARLY ON group was significantly higher than that of the DBS-LATE ON group. In addition, the DBS-EARLY ON group reported fewer heavy drinking days. These findings are in line with preclinical animal models, which demonstrated significant effects of NAc DBS on alcohol use [ 25 , 26 ]. Following case reports and a recent open-label trial in six patients investigating NAc DBS reported noteworthy abstinence rates and reductions of alcohol craving for patients with treatment-resistant AUD [ 27 , 29 , 32 , 58 , 59 ] and other substance-use disorders (for review see [ 60 ]). In the current trial, we observed a prominent decrease in alcohol use within two weeks of activated DBS in the DBS-EARLY ON group (see Supplementary Fig. 2 ). A similar effect also occurred in the DBS-LATE ON group receiving sham stimulation. These observations are in line with DBS studies in depression [ 61 , 62 , 63 ], obsessive compulsive disorder [ 64 ] and Parkinson’s disease [ 65 ] that reported significant non-stimulation-related effects of DBS on clinical symptoms in the sham stimulation groups early after onset of the intervention. It has been suggested that placebo effects, motivational effects and micro-lesion effects (due to electrode insertion, microtrauma and local edema without active stimulation) may account for these observations. Regarding the effects of micro-lesioning, animal models demonstrated that DBS induced neuro-inflammation at the target site and data in humans showed that acute antidepressant effects were reduced in those patients taking anti-inflammatory medication after surgery, linking non-stimulation-related effects of DBS to local inflammation [ 66 ]. In addition, it can be speculated that local electrode insertion at the NAc might lead to transient silencing of adjacent neurons, which might contribute to the effects, which we observed in the DBS-LATE ON group. Beyond that, placebo and motivational effects could have contributed to the acute effects observed in both groups. Even though the relative contribution of the different non-stimulation-related effects of DBS cannot be disentangled based on current data, any putative placebo effect would likely explain short-term effects but not long-term DBS effects as observed in our study. Significant differences between the two DBS groups emerged 5 months after randomization (see Supplementary Fig. 2 ) and alcohol use was significantly attenuated in the DBS-LATE ON group after stimulation was activated in the open-label phase (month 6–18). These observations indicate stimulation-specific effects of DBS on alcohol use and support the potential beneficial effects of NAc DBS in treatment resistant alcohol dependence.

In addition, we observed alcohol craving – a hallmark symptom of AUD that can act as a trigger for alcohol use – to be significantly reduced in the DBS-EARLY ON group after 6 months [ 67 ]. Even beyond the initial 6-month follow-up period, our data show a continued significant reduction in alcohol craving up to the end of the study, indicating that DBS might exert at least a part of its abstinence-promoting effects by attenuating alcohol craving. This finding suggests that patients experiencing high craving for alcohol might particularly benefit from NAc DBS treatment. Our exploratory responder analyses support this speculation by demonstrating that responders to DBS treatment were the ones exhibiting high alcohol craving at baseline. Positive effects of DBS on alcohol craving are in line with previous research investigating DBS in AUD [ 27 , 29 , 31 ] and other substance-use disorders [ 68 , 69 , 70 , 71 ].

Our responder analyses also indicated that responders to NAc DBS are those with higher depressiveness, anxiety and anhedonia scores at baseline. NAc DBS resulted in significantly lower anhedonia scores in the DBS-EARLY ON group versus DBS-LATE ON group. It is conceivable that the effects of DBS on alcohol use are also mediated in part by its positive impact on anhedonia, a common symptom in depression and anxiety, as well as in addiction. The positive effect of NAc DBS on anhedonia might also – at least in part – explain the observed positive effects on alcohol use during the open-label phase of the trial, when alcohol craving (OCDS and AUQ) did not show significant decreases, while alcohol use and anhedonia were attenuated. This finding is interesting in several ways: The NAc is considered a key brain region for regulating behaviors related not only to addiction, but also to depression. Previous studies in depressed patients reported significant effects of NAc DBS on depressive symptoms, including anhedonia [ 72 , 73 , 74 ]. Furthermore, neuroimaging studies in AUD showed that alcohol-cue-induced brain response in the NAc and the striatum can predict both relapse risk [ 16 ] as well as treatment response to naltrexone [ 18 , 19 ].

Regarding the safety of DBS, we did not observe any adverse events or serious adverse events resulting in lasting disability or death over the 18-month trial period, and most AEs were mild to moderate. This is in line with previous research on DBS [ 60 ]. The available data underscore the importance of carefully balancing the risks of DBS against the risks of uncontrolled alcohol use in treatment-resistant AUD. Future research could focus on investigating patients with comorbid depression and addiction. For this population, the combined morbidity and mortality risks resulting from treatment-resistant depression and addiction are substantial, supporting demand for new unconventional treatment approaches.

Strengths and limitations

The presented results have to be considered against the backdrop of the strengths and limitations of previously published work. Due to the strict inclusion and exclusion criteria, the study was unable to yield the expected sample size of 30 patients in the allotted time. Such a sample size would have been necessary to provide sufficient statistical power for the primary intention-to-treat analysis which was not statistically significant, most likely due to the limited power originating from the small sample size and the categorial nature of the primary outcome parameter. Post-hoc estimates of statistical power indicated that the power to detect effect sizes corresponding to a HR of 0.73 was <15%. To illustrate the magnitude of the effect of DBS in treatment resistant AUD, we calculated the corresponding NNT, which indicated a medium effect of DBS in AUD. The wide confidence interval of the estimate for the NNT, however, indicates a high degree of uncertainty regarding the size of the true effect and should therefore be interpreted with caution. Inclusion of a parametric primary outcome could have provided higher power. Unfortunately, the use of such outcomes (e.g. mean alcohol use, proportion of heavy drinking days) had not yet been approved by the European Medicines Agency (EMA) when we planned and received funding for our study, and thus were not approved by the ethics boards. Future studies should consider outcomes beyond abstinence rates, such as number of heavy drinking days, which captured significant effects of NAc DBS in the current study. The sample of our study can still be considered as sizable in the light of the very low sample sizes of previous DBS AUD studies in the literature (range n  = 1 to 6; for a review, see [ 60 ]). The start of the sham stimulation phase directly after surgery leaves open the possibility that non-stimulation-related effects (e.g. placebo effects and micro-lesioning effects), as well ongoing optimization of stimulation parameters in some patients might have contributed to the observed efficacy of DBS in the early trial phase. In addition, even though the targeting procedures were standardized across all patients and centers and a thorough review process of the implanted electrodes after the operation did not identify any major violations of the implantation protocol that would require repositing of electrodes, slight variations of the electrode positions between patients and centers cannot be ruled out. This, together with minimal changes of the stimulation parameters (3.5–4.5 V) during the early stimulation phase, may have resulted in stimulation of slightly different brain networks. While it was beyond the scope of the presented work, application of MRI-based tractography could contribute to the refinement of electrode placement and a better characterization of the stimulated networks in future studies that might also promote a better understanding of the observed variable treatment responses. Our exploratory responder analyses indicated that especially patients with higher scores in depression, anxiety and anhedonia might be those responding to DBS in treatment-resistant AUD. This conclusion however is limited by the low overall scores and the fact that the current study did not enroll patients meeting the diagnostic criteria of a depressive disorder or anxiety disorder.

We report a prospective double-blind randomized controlled trial investigating DBS in treatment-resistant AUD patients. While the primary intention-to-treat analysis did not produce a statistically significant result, the findings are nonetheless suggestive of a beneficial effect of DBS. This conjecture is supported by significant effects of DBS on important secondary outcomes, including the proportion of abstinent days, heavy drinking days, alcohol craving and anhedonia during the blinded study phase. We were able to provide evidence for the specificity of the observed effects using a double-blind lead-in phase. Additionally, we conducted an exploratory responder analysis, which indicated that patients suffering from high craving, depression and anhedonia might stand to benefit particularly from DBS.

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This study was supported by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation Bo 799/8-1). JCB is funded by the Else Kröner-Fresenius-Stiftung (grant number 2022_EKES.23) and receives funding from the German Research Foundation (CRC-1451).

Open Access funding enabled and organized by Projekt DEAL.

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These authors contributed equally: Patrick Bach, Mathias Luderer, Ulf Joachim Müller, Bernhard Bogerts, Jens Kuhn, Karl Mann.

Authors and Affiliations

Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

Patrick Bach & Karl Mann

Feuerlein Center on Translational Addiction Medicine (FCTS), University of Heidelberg, Heidelberg, Germany

Patrick Bach

Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital, Goethe University, Frankfurt, Germany

Mathias Luderer

Department of Psychiatry and Psychotherapy, University Hospital, Otto-v.-Guericke University, Magdeburg, Germany

Ulf Joachim Müller & Bernhard Bogerts

Division for Stereotactic Neurosurgery, Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany

Martin Jakobs & Karl Kiening

Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany

Juan Carlos Baldermann, Joachim Klosterkötter, Daniel Huys & Jens Kuhn

Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany

Juan Carlos Baldermann

Department of Stereotactic Neurosurgery, University Hospital, Otto-v.-Guericke University, Magdeburg, Germany

Jürgen Voges

Institute of Biometry and Medical Informatics of the University Hospital Magdeburg, Magdeburg University, Magdeburg, Germany

Department of Stereotactic Neurosurgery, University Hospital Cologne, Cologne, Germany

Veerle Visser-Vandewalle

Department of Psychiatry, Psychotherapy and Psychosomatics, Johanniter Hospital, Oberhausen, Germany

Institute of Psychopharmacology, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany

Wolfgang Sommer

AHG hospital Wilhelmsheim, Wilhelmsheim, Germany

Tillmann Weber

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Bach, P., Luderer, M., Müller, U.J. et al. Deep brain stimulation of the nucleus accumbens in treatment-resistant alcohol use disorder: a double-blind randomized controlled multi-center trial. Transl Psychiatry 13 , 49 (2023).

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case study for alcohol use disorder

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Substance Use Disorder Case Study

This is a hypothetical example based on our experiences. Our clients’ information is held in strict confidence as a condition of our agreements in every case.

Thomas is a 41-year-old partner at a leading financial firm who is struggling with his  alcohol use . Thomas has tried multiple times to reduce or stop drinking but has yet to succeed. His alcohol use has started to affect his work performance and is straining his relationship with his wife and children. Thomas’ wife contacted OPG for support around creating a treatment plan and helping to find Thomas appropriate and high-quality care that would give him the best chance for success. OPG conducted a consultation with Thomas and his wife, assessing the history of Thomas problems as well as an understanding of his current struggles. With input from the family, OPG staff constructed a consultation report containing a multi-phase treatment plan to put Thomas on the road to recovery. This plan included:

Thomas attended one of the recommended residential faculties for thirty days. Upon completing this program, Thomas worked with an OPG Case Manager while his wife consulted with an OPG Family Coach. Each learned how to best support Thomas in his recovery, with Thomas learning the steps he needed to take to continue his care while his wife learned how best to help him (without enabling and while taking care of herself). Thomas began to see a therapist who specialized in substance use disorders. He also met regularly with an addiction psychiatrist. Thomas’ case manager met with him several times each week in the community, helping him work through the struggles of early recovery.

Thomas was able to achieve sobriety for several months, but, did have one instance where he relapsed while in a high-stress environment (several difficult assignments piled up at work and Thomas struggled, out of pride, to reach out for help). During this time, Thomas’ OPG case manager coordinated with his treatment team and implemented a swift response, increasing the frequency of meetings with Thomas’ case manager as well as with his therapist. Thomas was able to re-engage and was soon back on the path to recovery. Thomas continued to work with his case manager as he became more confident in his sobriety and overtime services were reduced to promote Thomas’ independence.

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Alcohol Use Disorder: Case Study and Theory Analysis

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Understanding alcohol use disorders and their treatment

People with alcohol use disorders drink to excess, endangering both themselves and others. This question-and-answer fact sheet explains alcohol problems and how psychologists can help people recover.

Understanding alcohol use disorders and their treatment

For many people, drinking alcohol is nothing more than a pleasant way to relax. People with alcohol use disorders, however, drink to excess, endangering both themselves and others. This question-and-answer fact sheet explains alcohol problems and how psychologists can help people recover.

When does drinking become a problem?

For most adults, moderate alcohol use — no more than two drinks a day for men and one for women and older people — is relatively harmless. (A "drink" means 1.5 ounces of spirits, 5 ounces of wine, or 12 ounces of beer, all of which contain 0.5 ounces of alcohol.

Moderate use, however, lies at one end of a range that moves through alcohol abuse to alcohol dependence:

Alcohol abuse is a drinking pattern that results in significant and recurrent adverse consequences. Alcohol abusers may fail to fulfill major school, work, or family obligations. They may have drinking-related legal problems, such as repeated arrests for driving while intoxicated. They may have relationship problems related to their drinking.

People with alcoholism — technically known as alcohol dependence — have lost reliable control of their alcohol use. It doesn't matter what kind of alcohol someone drinks or even how much: Alcohol-dependent people are often unable to stop drinking once they start. Alcohol dependence is characterized by tolerance (the need to drink more to achieve the same "high") and withdrawal symptoms if drinking is suddenly stopped. Withdrawal symptoms may include nausea, sweating, restlessness, irritability, tremors, hallucinations and convulsions.

Although severe alcohol problems get the most public attention, even mild to moderate problems cause substantial damage to individuals, their families and the community.

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) , 6.2 percent of adults in the United States aged 18 and older had alcohol use disorder. 1 For example, a government survey revealed that about one in five individuals aged 12 to 20 were current alcohol users and about two in five young adults, aged 18 to 25, were binge alcohol users and about one in 10 were heavy alcohol users. 2

What causes alcohol-related disorders?

Problem drinking has multiple causes, with genetic, physiological, psychological,and social factors all playing a role. Not every individual is equally affected by each cause. For some alcohol abusers, psychological traits such as impulsiveness, low self-esteem and a need for approval prompt inappropriate drinking. Some individuals drink to cope with or "medicate" emotional problems. Social and environmental factors such as peer pressure and the easy availability of alcohol can play key roles. Poverty and physical or sexual abuse also increase the odds of developing alcohol dependence.

Genetic factors make some people especially vulnerable to alcohol dependence. Contrary to myth, being able to "hold your liquor" means you're probably more at risk — not less — for alcohol problems. Yet a family history of alcohol problems doesn't mean that children will automatically grow up to have the same problems. Nor does the absence of family drinking problems necessarily protect children from developing these problems.

Once people begin drinking excessively, the problem can perpetuate itself. Heavy drinking can cause physiological changes that make more drinking the only way to avoid discomfort. Individuals with alcohol dependence may drink partly to reduce or avoid withdrawal symptoms.

How do alcohol use disorders affect people?

While some research suggests that small amounts of alcohol may have beneficial cardiovascular effects, there is widespread agreement that heavier drinking can lead to health problems.

Short-term effects include memory loss, hangovers, and blackouts. Long-term problems associated with heavy drinking include stomach ailments, heart problems, cancer, brain damage, serious memory loss and liver cirrhosis. Heavy drinkers also markedly increase their chances of dying from automobile accidents, homicide, and suicide. Although men are much more likely than women to develop alcoholism, women's health suffers more, even at lower levels of consumption.

Drinking problems also have a very negative impact on mental health. Alcohol abuse and alcoholism can worsen existing conditions such as depression or induce new problems such as serious memory loss, depression or anxiety.

Alcohol problems don't just hurt the drinker. Spouses and children of heavy drinkers may face family violence; children may suffer physical and sexual abuse and neglect and develop psychological problems. Women who drink during pregnancy run a serious risk of damaging their fetuses. Relatives, friends and strangers can be injured or killed in alcohol-related accidents and assaults.

When should someone seek help?

Individuals often hide their drinking or deny they have a problem. How can you tell if you or someone you know is in trouble? Signs of a possible problem include having friends or relatives express concern, being annoyed when people criticize your drinking, feeling guilty about your drinking and thinking that you should cut down but finding yourself unable to do so, or needing a morning drink to steady your nerves or relieve a hangover.

Some people with drinking problems work hard to resolve them. With the support of family members or friends, these individuals are often able to recover on their own. However, those with alcohol dependence usually can't stop drinking through willpower alone. Many need outside help. They may need medically supervised detoxification to avoid potentially life-threatening withdrawal symptoms, such as seizures. Once people are stabilized, they may need help resolving psychological issues associated with problem drinking.

There are several approaches available for treating alcohol problems. No one approach is best for all individuals.

How can a psychologist help?

Psychologists who are trained and experienced in treating alcohol problems can be helpful in many ways. Before the drinker seeks assistance, a psychologist can guide the family or others in helping to increase the drinker's motivation to change.

A psychologist can begin with the drinker by assessing the types and degrees of problems the drinker has experienced. The results of the assessment can offer initial guidance to the drinker about what treatment to seek and help motivate the problem drinker to get treatment. Individuals with drinking problems improve their chances of recovery by seeking help early.

Using one or more of several types of psychological therapies, psychologists can help people address psychological issues involved in their problem drinking. A number of these therapies, including cognitive-behavioral coping skills treatment and motivational enhancement therapy, were developed by psychologists. Additional therapies include 12-Step facilitation approaches that assist those with drinking problems in using self-help programs such as Alcoholics Anonymous (AA).

These therapies can help people boost their motivation to stop drinking, identify circumstances that trigger drinking, learn new methods to cope with high-risk drinking situations, and develop social support systems within their own communities.

All three of these therapies have demonstrated their effectiveness. One analysis  of cognitive-behavioral approaches, for instance, found that 58 percent of patients receiving cognitive-behavioral treatment fared better than those in comparison groups. 3 In another study , motivational interventions reduced how often and how much adolescents drank following alcohol-related emergency room treatment. 4 And an intervention called Making Alcoholics Anonymous Easier significantly increased participants' odds of abstaining from alcohol. 5 Many individuals with alcohol problems suffer from other mental health conditions, such as severe anxiety and depression, at the same time. Psychologists can also diagnose and treat these "co-occurring" psychological conditions. Further, a psychologist may play an important role in coordinating the services a drinker in treatment receives from various health professionals.

Psychologists can also provide marital, family, and group therapies, which often are helpful for repairing interpersonal relationships and for resolving problem drinking over the long term. Family relationships influence drinking behavior, and these relationships often change during an individual's recovery. The psychologist can help the drinker and significant others navigate these complex transitions, help families understand problem drinking and learn how to support family members in recovery, and refer family members to self-help groups such as Al-Anon and Alateen.

Because a person may experience one or more relapses and return to problem drinking, it can be crucial to have a trusted psychologist or other health professional with whom that person can discuss and learn from these events. If the drinker is unable to resolve alcohol problems fully, a psychologist can help with reducing alcohol use and minimizing problems.

Psychologists can also provide referrals to self-help groups. Even after formal treatment ends, many people seek additional support through continued involvement in such groups.

Alcohol-related disorders severely impair functioning and health. But the prospects for successful long-term problem resolution are good for people who seek help from appropriate sources.

The American Psychological Association gratefully acknowledge the assistance of Peter E. Nathan, PhD, John Wallace, PhD, Joan Zweben, PhD, and A. Thomas Horvath, PhD, in developing this fact sheet . 

1 National Institute on Alcohol Abuse and Alcoholism. (2018). "Alcohol Use Disorder."

2 Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from

3 Magill, M., & Ray, L.A. (2009). "Cognitive-behavioral treatment with adult alcohol and illicit drug users: A meta-analysis of randomized controlled trials." Journal of Studies on Alcohol and Drugs, 70 (4): 516-527.

4 Spirito, A., Sindelar-Manning, H., Colby, S.M., Barnett, N.P., Lewander, W., Rohsenow, D.J., & et al. (2011). "Individual and family motivational interventions for alcohol-positive adolescents treated in an emergency department." Archives of Pediatrics and Adolescent Medicine, 165 (3): 269-274.

5 Kaskutas, L.A., Subbaraman, M.S., Witbrodt, J., & Zemore, S.E. (2009). "Effectiveness of Making Alcoholics Anonymous Easier: A group format 12-step facilitation approach." Journal of Substance Abuse Treatment, 37 (3): 228-239.

Updated Sept. 2018

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Once the alcoholic chooses their treatment program or once the program is chosen for them (in some cases), you are starting your journey. There are several options out there for treatment which was specified by, Alcoholics Anonymous. A short-term treatment that helps alcoholics deal with similar issues would be the 28-day in-patient treatment. The 28-day in-patient treatment would make the patient go to a treatment facility for a duration period between three weeks to one month to cleanse their bodies from all of the alcohol they digested over a short to long period of time. Other treatment methods seem to last a longer period of time, typically lasting for about six months according to Alcoholics Anonymous. These treatments include residential

Stricter Federal Requirements Of Detox Facilities

First of all, any person with an alcohol issue, no matter how large their issue is, will deny it. Denial protects the alcoholic from dealing with the problem that they have. According to "Addiction and Denial”, "Those who are addicted to alcohol or drugs can have little insight into their own condition as a result of denial" (1). This means they are avoiding the problem for a reason, and they will not and can not make the step to admitting their problem to themselves and others. Admitting to an issue is very important though, because admitting to the issue is the only way and the first step to regaining a normal life and defeating the disease of alcoholism. Detox facilities cannot force any person to go into treatment, so the person needs to have admitted their problem and signed into a treatment center while sober if they want to get better. This is very controversial because many alcoholics use many different excuses about their problem and will not admit it. Some

Marijuana Methadone Treatment

The principle of treatment therapy is to helping the patients to reduce problematic drinking, deterring relapse back to heavy drinking and achieving and maintaining abstinence from alcohol (Edmunds, 2014). An oral naltrexone (ReVia) or injectable Vivitrol, Acamprosate and Disulfiram are used for the treatment of alcohol abuse (Edmunds, 2014). Disulfiram are used more often if unpleasant physical symptoms when alcohol is ingested but is reported to be more expensive and have reported to have adverse reaction to the patients (Edmunds, 2014). Benzodiazepines such as Lorazepam and Diazepam are also widely used for treatment of alcohol withdrawal. With the side effects and overdosing of benzodiazepines remains controversial in treating alcohol withdrawal and is always in need to monitor the patient for abuse (SAMHSA, 2013). Additionally, social detoxification and lifestyle management would benefit the whole treatment process such as referring the patient to social support groups and encouraging the family to support the patient during the treatment

Alcohol Use Disorder Case Study

Client meets the diagnosis of severe alcohol use disorder (F10.20). Due to his continuous problems associated with alcohol use, along with lack of sober support system and relapse prevention skills, client can benefit from the alcohol and drug treatment.

The Medical Model Of Addiction

Drug and Alcohol Treatment in America has been based on the Medical Model of Treatment. According to Wikipedia, the medical model of addiction is rooted in the philosophy that addiction is a disease and has biological, neurological, genetic, and environmental sources of origin. Treatment includes potential detox with a 28 day or more stay at a residential treatment facility. The continuum of care can include an additional 28 days at the partial hospitalization level, followed by another 6 weeks of Intensive Outpatient.

Alcohol Ruins Lives: as Shown by Raymond Carver’s Short Stories

With the possibility of drugs capable of suppressing the urge to consume alcohol in addicts, many people who normally would not be helped by a simple 12 step program, could use such drugs in combination with standard treatment in the future to help combat their addiction.

The Benefits Of Alcoholic Behavioral Therapy

Physicians have several options for treating alcohol use disorders. Behavioral therapy can help alcoholics recognize and avoid high-risk situations, and referral to programs that provide peer support, such as Alcoholics Anonymous, can increase a person’s chance of recovery. Therapists can also prescribe medications that decrease the appeal of alcohol. Studies show disulfiram, acamprosate and naltrexone help most people abstain from alcohol. Disulfiram causes unpleasant side effects such as sweating, nausea, headache, vomiting and chest pain when patients consume alcohol. The severity of the effects differs among patients, and is correlated with the amount of alcohol consumed. Naltrexone inhibits euphoric effects or feelings of intoxication

Explain How People Use Substances

People use substances as a way to deal with life stressors by self-medicating physical and emotional pain. Many people who suffer from anxiety, depression, trauma and other disorders, turn to drugs of alcohol for relief. Although this may provide some relief– temporarily it usually brings along with is a host of other problems.

Avoid Drinking: A Case Study

A treatment plan for a single female problem drinker who has sought to modify her drinking

Aversion Therapy Essays

“Aversion therapy can be used with alcoholics. Alcohol is paired with an emetic drug (a drug which causes nausea and vomiting). Over time the alcoholic associate’s alcohol with being sick and does not

The Social Science Perspectives Of Sociologists And Social Marketers

It is inevitable that at some stage in an individual’s life, they are going to use drugs and or alcohol and some point. In the entirety of this report alcohol refers to a liquid or brew containing alcohol as the active agent and drugs refer to a substance that is used as a medicine or narcotic. (Hornby, A.S. and Wehmeier, S., 1995)

Related Topics


Understanding Alcohol Use Disorder

Image highlighting that alcohol use disorder can be mild, moderate, or severe

Alcohol use disorder (AUD) is a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. It encompasses the conditions that some people refer to as alcohol abuse, alcohol dependence, alcohol addiction, and the colloquial term, alcoholism. Considered a brain disorder, AUD can be mild, moderate, or severe. Lasting changes in the brain caused by alcohol misuse perpetuate AUD and make individuals vulnerable to relapse. The good news is that no matter how severe the problem may seem, evidence-based treatment with behavioral therapies, mutual-support groups, and/or medications can help people with AUD achieve and maintain recovery. According to a national survey, 14.1 million adults ages 18 and older 1 (5.6 percent of this age group 2 ) had AUD in 2019. Among youth, an estimated 414,000 adolescents ages 12–17 1 (1.7 percent of this age group 2 ) had AUD during this timeframe.

What Increases the Risk for AUD?

A person’s risk for developing AUD depends, in part, on how much, how often, and how quickly they consume alcohol. Alcohol misuse, which includes binge drinking * and heavy alcohol use ,** over time increases the risk of AUD. Other factors also increase the risk of AUD, such as:

What Are the Symptoms of AUD?

Healthcare professionals use criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), to assess whether a person has AUD and to determine the severity if the disorder is present. Severity is based on the number of criteria a person meets based on their symptoms—mild (2–3 criteria), moderate (4–5 criteria), or severe (6 or more criteria).

A healthcare provider might ask the following questions to assess a person’s symptoms.

In the past year, have you:

Any of these symptoms may be cause for concern. The more symptoms, the more urgent the need for change.

What Are the Types of Treatment for AUD?

Several evidence-based treatment approaches are available for AUD. One size does not fit all and a treatment approach that may work for one person may not work for another. Treatment can be outpatient and/or inpatient and be provided by specialty programs, therapists, and doctors.


Three medications are currently approved by the U.S. Food and Drug Administration to help people stop or reduce their drinking and prevent relapse: naltrexone (oral and long-acting injectable), acamprosate, and disulfiram. All these medications are non-addictive, and they may be used alone or combined with behavioral treatments or mutual-support groups.

Behavioral Treatments

Behavioral treatments, also known as alcohol counseling or “talk therapy,” provided by licensed therapists are aimed at changing drinking behavior. Examples of behavioral treatments are brief interventions and reinforcement approaches, treatments that build motivation and teach skills for coping and preventing relapse, and mindfulness-based therapies.

Mutual-Support Groups

Mutual-support groups provide peer support for stopping or reducing drinking. Group meetings are available in most communities, at low or no cost, at convenient times and locations—including an increasing presence online. This means they can be especially helpful to individuals at risk for relapse to drinking. Combined with medications and behavioral treatment provided by health professionals, mutual-support groups can offer a valuable added layer of support.

Please note: People with severe AUD may need medical help to avoid alcohol withdrawal if they decide to stop drinking. Alcohol withdrawal is a potentially life-threatening process that can occur when someone who has been drinking heavily for a prolonged period of time suddenly stops drinking. Doctors can prescribe medications to address these symptoms and make the process safer and less distressing.

Can People With AUD Recover?

Many people with AUD do recover, but setbacks are common among people in treatment. Seeking professional help early can prevent relapse to drinking. Behavioral therapies can help people develop skills to avoid and overcome triggers, such as stress, that might lead to drinking. Medications also can help deter drinking during times when individuals may be at greater risk of relapse (e.g., divorce, death of a family member).

If you are concerned about your alcohol use and would like to explore whether you might have AUD, please visit the Rethinking Drinking website .

To learn more about alcohol treatment options and search for quality care near you, please visit the NIAAA Alcohol Treatment Navigator .

For more information about alcohol and your health, please visit:

* The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 percent—or 0.08 grams of alcohol per deciliter—or higher. For a typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours.

** NIAAA defines heavy alcohol use as consuming more than 4 drinks on any day for men or more than 3 drinks for women.

1 Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality. 2019 National Survey on Drug Use and Health. Table 5.4A—Alcohol Use Disorder in Past Year Among Persons Aged 12 or Older, by Age Group and Demographic Characteristics: Numbers in Thousands, 2018 and 2019. . Accessed November 6, 2020.

2 SAMHSA, Center for Behavioral Health Statistics and Quality. 2019 National Survey on Drug Use and Health. Table 5.4B—Alcohol Use Disorder in Past Year Among Persons Aged 12 or Older, by Age Group and Demographic Characteristics: Percentages, 2018 and 2019.


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