Could some of his other symptoms (restlessness, stress) be caused by his substance use?

Question

DSM Diagnosis
305.00 Alcohol Use Disorder, Severe
305.20 Cannabis Use Disorder, Mild
314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type, Mild
300.02 Generalized Anxiety Disorder
995.81 Spouse or Partner Violence, Physical, Confirmed
V15.81 Noncompliance with Treatment
493.90Asthma, unspecified
V62.5 Other problems related to the legal system

Rationale
The information for Larry’s diagnosis was based only on his self-report, and he could be minimizing the amount and extent of his alcohol and drug use. He admits that he has not stopped drinking at any point. The fact that he has not abstained during treatment efforts might indicate that he is unable to stop, although Larry would probably argue that he is not motivated to do so (but could if he wanted to). In any event, it is unknown whether he would suffer from withdrawal. He does state that he drinks daily, and says that, for him, a twelve-pack of beer during a weekend is a substantial reduction in his drinking. As a result, we may assume that he experienced tolerance to alcohol. Despite the fact that he denies his drinking or marijuana use is problematic, Larry has suffered some severe consequences for drinking. There are legal consequences in that he has lost his license to drive, which, in turn, has affected his ability to do his job. Other legal consequences involve his arrests for family violence, and he admits that these episodes occur while he is drinking. His drinking is also one of the contentions between Larry and his girlfriend.
The cannabis use, he claims, occurs about twice a week, but since it is the “only thing that helps with the stress,” it is possible that he is under-reporting his use. He admits to a regular pattern of use for years. Although he has not had consequences directly attributable to the marijuana use, he says that when he has been smoking, he has also often been drinking, as well. Therefore, some of the above-named consequences of his drinking may also involve marijuana use. Additionally, one would presume that marijuana smoking might result in health consequences as Larry has been diagnosed with asthma. However, he does not appear to compulsively use it and does not spend an inordinate amount of time, money or energy pursuing marijuana use.
Larry was diagnosed with ADHD as a child (criterion B involves some impairing symptoms that were present before age 12), and currently meets six symptoms for “inattention.” In examining his current impairment, he seems to be using substances to manage these symptoms. The substance use, as already discussed, has led to other impairments. Larry believes his work performance is compromised because of his difficulties concentrating and being organized. His girlfriend complains about his forgetfulness and his inability to listen to her, and this has contributed to their conflict.
For the diagnosis of Generalized Anxiety Disorder, Larry reports anxiety and worry every day for at least six months (“as long as he can remember”). The worry is related to a number of areas of his life: his job, his children, his relationship with his girlfriend, and his required attendance at a substance abuse treatment facility. Further, the anxiety and worry are associated with the following symptoms (three of a possible six are required):
? Restlessness
? Difficulty concentrating
? Irritability
? Sleep disturbance (difficulty staying asleep and restless unsatisfying sleep)
He suffers distress from his symptoms and in order to cope with his symptoms, he reports using alcohol and marijuana.
A couple of V codes were also offered. Larry admits to having been physical with his girlfriend and being arrested for family violence. Non-compliance with treatment also seems to be an important clinical issue. Despite his losing his license, Larry has not complied with the necessary treatment to get his license reinstated. He realizes that this has serious repercussions on his work as a real estate agent. Finally, a code for his various legal problems – the lost license and the arrests for DUI and domestic violence – was given.

Additional Information Required
In considering Larry’s anxiety symptoms, one possible contributing factor is that some inhalers can cause anxiety; this should be explored with Larry’s doctor before a definitive anxiety diagnosis is given. In addition, collateral reports are often necessary for the valid assessment of ADHD, substance use disorders, and family violence. Interviews with Larry’s girlfriend and his mother might shed more light on his symptom patterns.

Treatment
Because of Larry’s belief that the alcohol and marijuana use are not a problem for him, motivational interviewing should be the first-line approach. Motivational interviewing would diffuse some of his defensiveness and allow for a collaborative relationship between Larry and the helping person. The strengths identified above should also be explored more fully so that they can be directed at some of his current struggles.
A clinician may be able to start Larry with cognitive-behavioral therapy in order to help him build skills in managing his ADHD and anxiety symptoms, as well as his anger. These skills include relaxation training/mindfulness, problem solving, organization/planning, and cognitive restructuring. Because Larry starting substance use as a teenager, he may not have developed many skills for coping with life stressors. Having some coping strategies in place may make it easier for him to stop using. Then cognitive-behavioral therapy might be employed to treat the substance abuse.
His intimate partner violence is another critical area to address. For this, it may be necessary for him to attend a program that specializes in family violence intervention.
In addition, Larry may need to be assessed for possible psychotropic medication. However, medication use will require him to be sober from marijuana and alcohol. One of the stimulants may be appropriate for the treatment of his ADHD, although it should be used cautiously given his substance use history. An antidepressant may address both his anxiety and his ADHD.

Critical Perspective
This case points to some of the confusion present when substance use disorders are concurrent with symptoms for other disorders. Perhaps the substance use is causing some of his symptoms, for example, his irritability, anxiety, restlessness, difficulty concentrating, and sleep problems. Optimally, Larry would be assessed again after a period of sobriety (i.e., six weeks), and the pattern of co-morbidity would become clearer.
Another potential problem that this case study brings to light is the extent to which the ADHD diagnostic criteria are relevant for adults. Larry’s impulsivity may be expressed through his substance use and violent outbursts, but the diagnostic criteria do not capture these possible adult representations. The reader will also note the symptom overlap between ADHD and anxiety. For example, restlessness and difficulty concentrating are common to both Generalized Anxiety Disorder and symptoms of inattention for ADHD. At the same time, anxiety can be co-morbid to ADHD. For example, in a quarter of childhood cases of ADHD, anxiety disorders are concurrent (Pliszka, 2000).

Answer 1

This is difficult to tell without a period of time for the substances to clear his system.
Again, the best position is to re-assess the client after he has been abstinent for a few weeks. Of note is that Larry has recently quit smoking cigarettes; perhaps some of these symptoms result from withdrawal from nicotine. However, this does not explain the past history of these symptoms. In addition, Larry uses an inhaler to control his asthma, which is known to cause anxiety in some people.