ADC 630 Module 1 Diagnosing Substance Use Disorders Example

From Screening to Severity: Diagnosing a Substance Use Disorder After a Drunk-Driving Arrest

Student Name

Psychology and Addiction Studies Program, Aspen University

ADC 630: Diagnosis and Treatment of Substance Abuse Disorders

Instructor Name

Month Day, Year

From Screening to Severity: Diagnosing a Substance Use Disorder After a Drunk-Driving Arrest

Sam, thirty-eight, is a roofer referred by the court to an outpatient clinic in Portland, Maine, after his first arrest for driving under the influence. His counselor, Brooke, has three sessions to complete an assessment and recommend a level of care. None of them is real; the clinic and its people were created to teach the material. At intake, Sam said, "I'm not an alcoholic. I just got unlucky." This paper sets out how Brooke moves from screening to diagnosis.

Screening and Diagnosis

Screening identifies people who may have a problem and need fuller assessment. Diagnosis determines whether a disorder is present, using established criteria. Screening tools are brief and sensitive; diagnosis requires a clinical interview and judgment.

Screening Tools

Saunders et al. (1993) developed the Alcohol Use Disorders Identification Test, known as the AUDIT, for the World Health Organization, drawing on patients from six countries. Its ten questions cover the amount and frequency of drinking, signs of dependence and alcohol-related problems. Scores of eight or more generally indicate hazardous or harmful drinking, and higher scores suggest possible dependence. Its brevity and international validation made it widely used. Sam scored 19.

Humeniuk et al. (2008) validated the WHO Alcohol, Smoking and Substance Involvement Screening Test, or ASSIST, in several countries. The ASSIST asks about a range of substances, including tobacco, alcohol, cannabis, cocaine, stimulants, sedatives and opioids, and produces a risk score for each. It showed good validity in distinguishing between people who use substances at low risk, those with harmful use and those with dependence. On the ASSIST, Sam's alcohol score fell in the high-risk range and his cocaine score, which he had not mentioned, in the moderate range.

The DSM-5 Criteria

Hasin et al. (2013) laid out what changed for substance problems in the current edition of the American diagnostic manual. Earlier editions separated substance abuse and substance dependence, a distinction research did not support: the criteria formed a single dimension of severity. So the new edition folded both into a single substance use disorder judged on eleven criteria. Trouble with the law was removed from the list, since few people met it alone and it told clinicians little; craving took its place, since it is common and matters clinically. Severity follows the count of criteria met within a year, from mild at two or three, through moderate, to severe at six or more. Tolerance and withdrawal are not counted for medications taken as prescribed.

Applying the Criteria to Sam

Brooke interviewed Sam over two sessions and, with his consent, spoke with his partner.

The Diagnosis

Sam met nine criteria for alcohol use disorder, well above the threshold of six for the severe level. For cocaine, which he used on about half of weekends, he met two criteria: using more than intended and using in hazardous situations, meeting the threshold for mild cocaine use disorder. Brooke recorded both diagnoses with their severity and noted that withdrawal symptoms required medical assessment before any reduction in drinking.

Why Severity Matters

The severity rating is not a formality. It informs the level of care, the urgency of medical assessment and the goals of treatment. A mild alcohol use disorder might be addressed with brief intervention and a goal of reduced drinking; a severe disorder with withdrawal symptoms calls for medical oversight and, usually, a goal of abstinence. Rating each substance separately also matters: Sam's mild cocaine use disorder calls for attention but not the same intensity as his alcohol use.

The Role of Collateral Information

Brooke's conversation with Sam's partner, with his consent, changed the picture. Sam had described drinking "a few beers most nights"; his partner described eight or more on weekends and morning shakiness Sam had not mentioned. Court-referred clients often minimize, sometimes deliberately and sometimes because heavy use has come to feel normal. A second account helps the diagnosis reflect the actual pattern.

Common Errors

Brooke avoided several common errors. She did not count the arrest as a criterion, since legal problems were dropped; instead, the behavior behind it, driving after drinking, counted under hazardous use. She rated each substance separately rather than combining them. She sought collateral information, since Sam's initial account minimized his drinking. And she treated the screening scores as prompts for assessment, not as diagnoses.

Co-Occurring Conditions

Diagnosis also means looking beyond substances. Sam's low mood since his father's death, noted during the interview, could reflect grief, a depressive disorder or effects of heavy drinking, which itself causes low mood. Brooke recorded the symptoms and planned to reassess after several weeks of reduced drinking, when alcohol's effects would be clearer, rather than diagnosing depression at intake. Many clients with substance use disorders have co-occurring mental health conditions, and separating them takes time.

Explaining the Diagnosis

Brooke showed Sam the criteria and his answers, explaining that the diagnosis described a pattern, not a character. Sam was quiet, then said, "I didn't think about it like that." The conversation opened the motivational work that later modules describe.

Conclusion

Screening tools such as the AUDIT and ASSIST identify people who need assessment, and the ASSIST revealed a substance Sam had not mentioned. The DSM-5 criteria, as Hasin and colleagues explain, define a single disorder rated by severity. Applied criterion by criterion with evidence, they showed a severe alcohol use disorder and a mild cocaine use disorder, a result Sam could understand and begin to accept.

References

Hasin, D. S., O'Brien, C. P., Auriacombe, M., Borges, G., Bucholz, K., Budney, A., Compton, W. M., Crowley, T., Ling, W., Petry, N. M., Schuckit, M., & Grant, B. F. (2013). DSM-5 criteria for substance use disorders: Recommendations and rationale. American Journal of Psychiatry, 170(8), 834-851. https://doi.org/10.1176/appi.ajp.2013.12060782

Humeniuk, R., Ali, R., Babor, T. F., Farrell, M., Formigoni, M. L., Jittiwutikarn, J., de Lacerda, R. B., Ling, W., Marsden, J., Monteiro, M., Nhiwatiwa, S., Pal, H., Poznyak, V., & Simon, S. (2008). Validation of the Alcohol, Smoking And Substance Involvement Screening Test (ASSIST). Addiction, 103(6), 1039-1047. https://doi.org/10.1111/j.1360-0443.2007.02114.x

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction, 88(6), 791-804. https://doi.org/10.1111/j.1360-0443.1993.tb02093.x