Case of Richard Richard is a 22-year-old college senior who presents with a five

Case of Richard
Richard is a 22-year-old college senior who presents with a five-year history of alcohol use disorder and a little over one-year history of sedative, hypnotic, and anxiolytic use disorder (i.e., Xanax). In addition, Richard presents with a long-term history of generalized anxiety disorder and panic disorder. Richard presented to outpatient treatment only for anxiety issues. He has never been in any form of substance use or mental health disorder treatment before. He was referred by his girlfriend and his parents, who grew concerned regarding his recent increase in anxiety over the past few days. Neither the parents nor girlfriend knew of his Xanax use.
Anxiety History
Richard reports having “anxiety issues” for as far back as he can recall. Relevant to his adulthood (since approximately age 18), Richard can recall numerous instances in college where he experienced anxiety that he could not understand.
I would wake-up and just feel anxious. Worried. And it bothered me that I did not know why I was anxious. I was doing fine in school. No problems. Had a summer job lined-up. All good. But, it was like I had some huge weight of worry on me. And, this is the messed-up part, I started getting anxious cause I was anxious and did not know why. It just sort of kept spinning.
Richard also noted that over the course of his college years, he would experience numerous instances of feeling “on-edge.” For example, if the phone would ring Richard would be convinced the call was going to impart bad news or result in a conflict. Richard would screen phone calls and reported feeling “ridiculous” when he found the calls were just his parents, friends, or others calling to say “hello” or actually impart good news. In one case, Richard did not check a voice mail from a professor all weekend in fear it was bad news. In reality, it was the professor awarding Richard a partial scholarship based on academic merit.
Richard also noted how his anxiety impeded his concentration. Richard devised a studying scheme where he would need to start 1-2 weeks before others because of his struggles focusing.
It sucked. I am a great student with a 3.7 GPA but it took so much work. And not the normal work others do. I would get so worried. Doubt what I knew was true – that being I knew the material. But, I would get so anxious. I just couldn’t focus. I would need to go so slow over everything. Repeat, repeat, repeat. I got the work done well but it was draining.
Richard discussed having multiple panic attacks that were entirely unexpected.
I would just get slammed upside the head with a crash of panic and worry. My heart would pound, I’d be sweating, dizzy. My chest hurt. I couldn’t breathe or swallow. I’d feel all flushed. I was so dizzy, so out of control I thought I was going crazy or dying from anxiety. It made no sense. I once had an attack in the library stacks. I’d been in the library, and that aisle of books in particular, about a few hundred times by the time this attack occurred my junior year. I couldn’t understand how or why I would get one there. Weird thing was, I was so worried after the attack about going back to the library I almost gave myself another attack. But, I forced myself to go to the stacks a few weeks later and nothing. I was fine. That made it all worse. There was no logic or predictability to it all.
Richard reviewed his fear of the attacks, because he did not know when they would strike. At times in college he would have an attack in a public space. The subsequent embarrassment of his public attack only further fueled his worry regarding an upcoming attack. Richard reports he would spend 4-6 weeks worrying—almost every day—about the attacks and when he may have another panic attack. After another attack, he would worry immediately about the onset of the next one.
Alcohol Use History
Richard reported a frequent use of alcohol that started in his latter high school years and progressed throughout college. Richard noted that at first drinking was only a “social thing” but he slowly realized that his drinking would help him “calm down.”
I got to college and the anxiety was off the charts crazy. It seemed like any little thing would set me off and make me anxious. I once went the wrong way to the student center and even though it only took me an extra five minutes and I had nowhere to go and wasn’t late or anything, I almost hyperventilated due to the worry. One night right around that incident my friends invited me to a party. I figured I’d go to get my mind off my anxiety. While there I had a few drinks, mixed stuff in a solo cup with fruit punch. No idea what was in it but it was strong. I did remember, despite being buzzed, that I felt a lot less anxious and more relaxed. A few days later I was nervous before my public speaking class ‘cause I was due to give a 5 minute talk on some political issue I didn’t give a shit about. But, talking in front of 50 people was getting me close to a panic attack. I could feel it. My roommate had a bottle of whiskey that was opened. I did 3 quick shots right before I left for class. I felt so much better about 30 minutes later when it was my turn to talk. I can still remember doing the talk while thinking to myself holy crap I’m not anxious! Guess from there it just got a little more out of hand and common for me every day.
Richard reviewed a drinking history in college that consisted of beer and hard liquor consumption approximately 4-5 days per week. On any given day over the past 12 months, Richard would report having about 2-3 cans of beer and “a bunch” of shots of liquor usually mixed in with juice. Richard was unable to quantify his exact usage.
Xanax Use History
Approximately, 14 months ago, Richard started taking Xanax illegally. He began when his friend at college, who also experiences anxiety, offered two of his Xanax prescribed by a physician. Richard found the Xanax just as beneficial for his anxiety as the alcohol, but he was able to take these “out in plain site.”
The alcohol made me go behind closed doors. Open container laws. If you’re seen drinking out of a beer bottle or whiskey bottle in a classroom, you will get your ass tossed out of the class and in a world of trouble. But, if I am anxious in a long three hour class, I can easily open a personal pill carrier, take 2 pills and a bottle of water, and nobody thinks anything of it. It’s not like I was taking Molly’s or ‘shrooms in class and I’d be freaking out. I was just some guy who took 2 pills in class, if anybody was even really watching.
Richard would borrow or steal Xanax from a few friends as well as purchase illegally from a dealer on-campus. At his peak, Richard was taking 2-3 Xanax per day, about 4-5 days per week. Richard reported that he never bothered to examine the bottle to check the dosage, nor could he read the dosage stamped on the pills he purchased. Richard was also not aware there were extended release forms of Xanax which he may easily have taken at some point. Richard discussed he would typically consume the Xanax and drink alcohol within the same 24-hour period.
Richard’s Presentation
Richard reported that he read an online article about the dangers of Xanax approximately three days ago and stopped taking the Xanax “cold turkey.” Richard reports he stopped drinking as well because he “read about how alcohol is a bad thing mixed with Xanax.” Richard does present in session as very jittery, with rapid speech, an inability to stay on task, and an increased degree of reported anxiety. Richard also reports he “thinks I sometimes hear footsteps or whispering” over the past 2-3 days. Richard reports difficulty sleeping the past few nights and he demonstrates moderate hand tremors when filling out intake paperwork. Richard reports he feels “overwhelming” anxiety and fears another panic attack is imminent. When pressed regarding any context for his anxiety, Richard cannot clarify why he feels such overwhelming anxiety.
Questions to Consider:
Richard clearly presented to counseling ONLY for anxiety issues. Consequently, how do you educate Richard on his appropriate immediate level of care as per the ASAM Criteria? Where do you see the levels of care progressing following the initial treatment level?
Even though Richard does present with a clear co-occurring non-substance-related history of anxiety disorders, how do you conceptualize his current anxiety symptoms in the context of his rapid “cold-turkey” cessation of Xanax and alcohol?
How does Richard’s anxiety, alcohol, and Xanax histories perhaps influence his abilities to accurately provide the typical data required during an intake session?
Does this case require the counselor to break confidentiality under the harm-to-self stipulation so that his parents (and maybe girlfriend) can become involved in the process of persuading him to enter into the appropriate level of care you discussed in question #1?
At the appropriate time, what do you think would be a good battery of measures to use to understand Richard?