Example SA Assessment Diagnosis

Part 5/5 Example Diagnosis

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SUBSTANCE ABUSE EVALUATION

Name: Casey Jones Date of Evaluation: 2-15-14
Referring Party: Court DOB: 2/3/84 Age: 30


A. DEMOGRAPHICS
Casey is a 30 year old Caucasian male who presents for a drug and alcohol evaluation.

B. PRESENTING PROBLEM / PRIMARY COMPLAINT
Casey comes in for a drug and alcohol evaluation as a result of a driving while under the influence of a
controlled substance charge. Casey reported that he had been taking large amounts of Tramadol and
was driving his car when he ran off the road and into a cornfield. He doesn’t remember the accident and
likely blacked out. He has had previous legal problems related to his substance use and had a previous
driving under the influence charge that was reduced to a reckless driving offense. Casey readily admits
that he has a substance use problem and it is causing him great difficulty in his life.

C. MEDICAL HISTORY
Casey indicates that he is generally healthy, however he does complain of frequent headaches. He was
prescribed Tramadol seven years ago for the headaches and this is the medication he was abusing when
he had his car accident. He acknowledges that he took more of it than prescribed to get high. He also
reports he is on Xanax for anxiety. He takes .5 mg two times a day as needed. He has been on
antidepressants in the past but feels that they don’t work for him. Casey has a history of asthma but
doesn’t take any medication for that. Casey reports 5 months ago he had a seizure and blacked out while
driving and 2 years ago he passed out and hit his head while working and had a concussion. He took his
girlfriend’s Darvocet at that time which likely caused the black out. Casey’s physician is Dr. Chuck at
the Medical Clinic.

D. WORK / SCHOOL / MILITARY HISTORY
Casey graduated from high school in 2002 and attended community college for about 6 months at two
different schools. He did not graduate. While in high school he participated in sports and earned good
grades. He remembers his high school years as the best years of his life. He dropped out of community
college to work and make more money. Casey is currently unemployed. He had been working for his
grandfather in the family used car dealer business however this has been sporadic due to the economy.
Casey’s longest employment was working at Perkins as a server. He liked that job and wants to go
back. He has also worked at various other restaurants, a telemarketing company, and bartending. Casey
has had difficulty on the job due to his substance use. While working at one job where he was a
bartender he passed out from taking his girlfriend’s Darvocet. Casey supports his daughter and himself
on his income and he receives ADC and food stamps as a means of support. Casey is also supported by
his grandparents; he currently lives with them and they provide him some basic necessities. He has
never been in the military.

E. ALCOHOL / DRUG HISTORY SUMMARY
Alcohol and drug history was obtained by clinical interview, the Substance Abuse Subtle Screening
Inventory (SASSI-3), and collateral contact. Casey was a reliable historian during the interview portion.
Results on the independent inventories for self report were valid.

Casey reports that he has used alcohol and various other illegal and legal drugs.

2. Casey reports that he has used alcohol since the age of 15. During high school he reports that he drank
with his friends about every weekend. He would drink more during the summer months. He remembers
that in the beginning it would take about 6-8 beers to feel the effects of the alcohol. His drinking
increased when he left home to attend community college in Lincoln and has continued to increase since
that time. Currently Casey reports that he can’t drink enough beer to feel the effects. He has switched
to drinking Vodka or other hard liquor so that he can feel the effects. He denies any symptoms of
withdrawal such as nausea, shaking, or sweating when he doesn’t drink. Based on the increasing
amounts and decreasing effects of the alcohol, Casey is experiencing physical signs of tolerance. Casey
reports he currently drinks a pint of vodka about twice a week. He does experience cravings and urges
to drink stating he feels obsessed with it sometimes. He will drink with friends and then drink alone
after they leave.

Casey started smoking marijuana at about age 14 or 15. He states that he didn’t like it at first but that he
started to like it more and increased to smoking every day when he was 19 or 20. He acknowledges that
it affected his motivation, his grades and work performance. Casey was caught several times smoking
however the consequences did not deter him for continuing to smoke. Casey currently indicates he is
smoking about one time a month or “whenever it is around”. He reports that it helps him focus and
concentrate but that it also decreases his motivation.

Casey has used several other illegal drugs. He reports using methamphetamine when he was age 20 and
that he used it about 10 times. He also used cocaine several times but reports that he didn’t like the way
they made him feel. He states he is “not interested” in these drugs because they don’t do much for him.
He denies any IV drug use. He has also used mushrooms.

Casey acknowledges a dependence on prescription pills. He most recently has been using Tramadol,
darvocet, oxycontin, vicodin, Valium, Ultram, and other pills when they are available. Casey was
prescribed the Tramadol for headaches and he would stock pile the pills and take several at a time to get
a high. He has also been prescribed various other painkillers for medical purposes, seeking out doctors
to prescribe to him. He has taken other’s pills and has bought pills to abuse. Casey indicates he has had
seizures and black outs when he takes too many pills. Casey acknowledges that he has a problem with
pills, thinks about them obsessively and has urges and cravings to get high. He was high when he had
his most recent car accident leading to this evaluation.

Casey denies any other addictive behavior such as gambling or pornography. Casey’s preferred
substances are alcohol and prescription pills. He has had a previous evaluation which led to him
attending an Intensive Outpatient Program. He reports that he completed the program but had no
intentions of stopping his substance use. He remembers this treatment occurring when he was 20. He
was also on probation at the time for his substance use related legal charges. Casey has experienced
multiple consequences from his use including legal problems, family and relationship problems, health
problems, and financial and occupational problems. Casey has continued to use despite these problems.
Casey reports that there is a family history of substance use including his mother, father, and his brother
whom died at age 23 from substance abuse. Casey’s significant other, whom he has been involved with
for several years, and with whom him he has a daughter with is also addicted and is currently in
treatment.

F. LEGAL HISTORY
Casey currently has a charge of driving under the influence for which he will be going to court on April
2nd. He has a history of legal issues related to substance use. He had a driving under the influence
charge in 2004; he reports this was dropped to a reckless driving charge. He was on probation and
completed the requirements of him. Casey also had a sexual assault charge and contributing to the
delinquency of a minor for being involved with a 15 year old when he was 19. Casey was put on the sex
offender registry for this offense and will be on it until he is 30. He also completed jail time as a result

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of the sexual assault charge. Casey indicates this has made his life extremely difficult in the areas of
housing and employment. Casey reports he had an MIP charge but denied any other legal charges such
as possession of paraphernalia or controlled substances.

G. FAMILY / SOCIAL / PEER HISTORY
Casey and his three and a half year old daughter currently live with his grandparents in Peach Town.
Prior to this he was living in Appleton with his girlfriend and their daughter. He reports having
difficulty finding housing due to being on the sexual offender registry.

Casey grew up in Peach Town and lived with his parents until they divorced when he was in the 7th
grade. This was very hard on Casey by his report. He was about 12 or 13. He got to choose whom he
wanted to live with and he picked his father whom he describes as his best friend. Casey had a brother
who passed away just a few years ago at the age 23 due to substance abuse. Casey’s mother lives in
Appleton and he has a stepsister from her remarriage. He reports he gets along with his mother and
visits her frequently. He shared that his mother has mental health issues and is on medication. He
believes she has bipolar disorder and depression. He reports his dad drinks heavily and uses marijuana.
His father just recently moved to Oklahoma and Casey would like to be able to go to Oklahoma to live
close to him when he gets his legal problems taken care of. Casey spends a lot of time with his paternal
grandparents whom he lives with. They support him and he has a good relationship with them according
to Casey.

Casey has many friends and he likes to spend time with them. He likes to golf and this is an important
part of his life. While he golfs he likes to drink. Casey is separated from his daughter’s mother as she is
in treatment and he reports that they are not good for each other. They use together and this has created
more problems for them. He likes to hang with his friends, play video games, and he reports that his
friends don’t “pressure” him to use but they do use substances. Casey indicates that he has faith but
does not go to church regularly.

H. PSYCHIATRIC / BEHAVIORAL HISTORY
Casey states that he has never been in counseling and doesn’t believe he needs any counseling however
he is on medication for anxiety and depression. He does report a significant amount of anxiety and
depression in the past and currently. He believes that he started to feel depressed around the time he
graduated from high school. Casey has a poor appetite and he does not sleep very well. He reports that
has been occurring for several years and he is “used to it”. Since he has been on sexual offender registry
he has been feeling that he is not accepted by others and he has a very poor concept of what he is
capable of stating he doesn’t like it well every get better for him especially if he doesn’t stop his
substance use. During the interview he frequently made comments that he is not a very good father or a
very good person for the choices he has made. Casey denies any suicide attempts or suicidal ideation.
There is a history of mental health issues in his family on his mother’s side.

I. COLLATERAL INFORMATION
Jamison, Casey’s father, was contacted as a collateral contact with Casey’s permission. A phone call
was placed to Jamison who returned the call several days later. Jamison shared that he has been
concerned about his son for along time but that he is “following in the old man’s footsteps” so he should
be fine in the long run. He did verify that Casey has been using multiple substances.

J. OTHER DIAGNOSTIC / SCREENING TOOLS -- SCORE & RESULTS
Casey completed the Substance Abuse Subtle Screening Inventory (SASSI-3) and a clinical interview.
On the SASSI-3 Casey scored as having a high probability of a substance abuse disorder on both the
face valid items and the subtle attributes indicating that Casey acknowledges his substance abuse and

4. holds beliefs consistent with substance abuse. Of note is his high score on the correctional scale, which
indicates a probable likelihood of future legal involvement due to his substance use.

SASSI Results:
Face Valid Alcohol: 15
Face Valid Other Drug: 22
Symptoms: 8
Obvious Symptoms: 5
Subtle Attributes: 4
Defensiveness: 2
Supplemental Addiction Measure: 9
Family vs. Control: 7
Correctional: 12
Random Answering Pattern: 0

K. CLINICAL IMPRESSION
Casey is a 30-year-old, unemployed, Caucasian male who presents for a drug and alcohol evaluation.
He is charged with driving under the influence of a controlled substance. He takes large amounts of
tramadol, which caused him to blackout and ran off the road into a cornfield. Five moths ago he had a
seizure and blacked out while driving. Two years ago he passed out at work and had a concussion. He
has had previous legal problems due to his substance use and previous reckless driving charges Casey
abuses prescribed medications (Tramadol, Darvocet, oxycontin, vicodin, Valium, Ultramand Xanax,
anxiety medication and other pills when available). Casey was prescribed Tramadol for headaches; he
takes more than the prescribed amount to get high. He is obsessed with pills and finds ways to get them.
Casey currently is also on antidepressants and feels anxious, has poor appetite and cannot sleep well.
This has been a constant pattern, which he has become accustomed to. He admits he has a substance use
problem that interferes with his life. His drug history includes his current prescribed medication abuse as
well as alcohol since he was 15. He has high alcohol tolerance and liquor. Casey currently drinks a pint
of vodka twice a week. He drinks socially, alone and has constant cravings, urges and obsessive
thoughts about drinking. At the age of 15 Casey started smoking cannabis and did not like it, but by age
19 or 20 he was smoking it everyday. Currently he smokes it once a month or when available, although
it decreases his motivation it helps him concentrate. At age 20 he used methamphetamine and has used it
about 10 times. He also used cocaine, but did not like it, has used mushrooms as well. Casey also has
sexual assault charge for being with a 15-year-old when he was 19. Casey’s family has a substance
abuse history as well, his brother passed away at age 23 from substance abuse. His father drinks
habitually and smokes cannabis. His mother has mental health issues (possibly bipolar disorder), has
depression and is on medication. Due to the aforementioned statements and his addictive behavior,
Casey has been in treatment, (but admits he had no intention of quitting his addictive habits), probation,
has faced legal, relationship, self-image, health, financial, housing and occupational problems. Casey
regrets his past and current choices and seems to feel guilty about not being a better parent to his almost
four-year-old daughter.

Diagnosis:

303.90 (F10.20) Alcohol Use Disorder, Severe
304.00 (F11.20) Opioid (Tramadol) Use Disorder, Severe
300.4 (F34.1) Persistent Depressive Disorder (Dysthymia), With anxious distress, early onset with pure
dysthymic syndrome, moderate


L. RECOMMENDATIONS (include level of care)

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Casey would benefit from seeking treatment in an inpatient residential prescription drug recovery center. He
qualifies for this level of care based on ASAM criteria. In this level of care he can receive a combination of
individual and group counseling sessions to understand his addictions and learn new ways of coping with
problems including his mental health issues. Treatment would need to address his individual multiple needs
and focus on recovery from his substance use.


M. TREATMENT PLAN (include needs list; 2 Goals with 2 Objectives each and the intervention)
Needs List
1. Evaluate for Detoxification and locate a residential prescription drug recovery center
2. Treat alcohol and drug disorder
3. Employment

Goal #1: Casey seems to need treatment for the alcohol and the prescribed medication abuse within a week.
Treating this will help with the neurocognitive disorder.
Objective/s: 1. Get the referral put in and make an appointment with physician
2.Intiate Detoxification assessment
Intervention: Individual Therapy

Goal #2: Casey will enter a recovery program
Objective/s: Cognitive Behavioral Therapy and complete long-term treatment (90 days).
Intervention: Enter a residential prescription drug recovery center. Attend individual and group counseling
sessions weekly.