THE CASE OF NICHOLAS
Nicholas Underwood, a 41-year-old married software engineer, entered an alcohol
treatment program with this chief complaint: “I need to stop drinking or my wife will
divorce me.”
At the time of admission, Mr. Underwood stated that he was drinking approximately 1
liter of vodka per day, every day, and had not had an alcohol-free day in over 2 years. For
many years, Mr. Underwood had drunk alcohol only after work, but about a year prior to
the evaluation he had begun to routinely drink in the morning whenever he had the day
off. More recently, he had begun to feel “shaky” every morning and would sometimes
treat that sensation with a drink, followed by more alcohol during the day.
Mr. Underwood experienced a number of problems related to drinking. His wife was “at
the end of her rope” and considering divorce. His diminished ability to concentrate at
work was “sinking” his once-promising career. He was spending more time trying to
recover from the effects of drinking and found himself planning strategies both for
abstinence and for surreptitiously taking his next drink.
Mr. Underwood first tried alcohol in high school and said that he had always been able
to hold his liquor more than his friends could. In college, he was one of the heaviest
drinkers in a fraternity known as “Animal House” around campus. Through his 30s, he
gradually increased the frequency of his drinking from primarily on weekends to daily.
Over the prior year, he had switched from being exclusively a beer drinker to drinking
vodka. He had gone to many Alcoholics Anonymous meetings over the years but tended
to drink as soon as the meeting ended. He had received no formal treatment.
The patient denied recent use of other substances; he had smoked marijuana and
snorted cocaine several times during college but never since. He had used no other illicit
drugs and took no medications. He did not smoke cigarettes. He had experienced
blackouts on several occasions during college but not since then. He had no history of
seizures and no other medical problems. Family history was significant for alcohol use
disorder in his father and paternal grandfather.
Mr. Underwood entered the alcohol treatment program at approximately 3:00 p.m.,
having not had a drink since the evening before. He was diaphoretic and exhibited
significant tremulousness in his hands. He complained of anxiety, restlessness,
irritability, nausea, and recent insomnia.
Clinical evaluation revealed a casually groomed, diaphoretic man who was cooperative
but anxiously pacing and who immediately said, “I’m getting ready to jump out of my
skin.” Speech was of normal rate, rhythm, and tone. He denied depression. There was no
evidence of psychotic thinking, and he denied auditory, visual, or tactile hallucinations.
He was alert and oriented to person, place, and date. He had no gross memory deficits,
but his attention and concentration were noted to be reduced.
Notable features of his physical examination were marked diaphoresis, a blood pressure
of 155/95, a heart rate of 104 beats/minute, severe tremulousness in his upper
extremities, and hyperactive deep tendon reflexes throughout. Laboratory test findings
were within normal limits except for aspartate aminotransferase and alanine
aminotransferase, which were approximately 3 times normal. Nicholas Underwood, a 41-
year-old married software engineer, entered an alcohol
treatment program with this chief complaint: “I need to stop drinking or my wife will
divorce me.”
At the time of admission, Mr. Underwood stated that he was drinking approximately 1
liter of vodka per day, every day, and had not had an alcohol-free day in over 2 years. For
many years, Mr. Underwood had drunk alcohol only after work, but about a year prior to
the evaluation he had begun to routinely drink in the morning whenever he had the day
off. More recently, he had begun to feel “shaky” every morning and would sometimes
treat that sensation with a drink, followed by more alcohol during the day.
Mr. Underwood experienced a number of problems related to drinking. His wife was “at
the end of her rope” and considering divorce. His diminished ability to concentrate at
work was “sinking” his once-promising career. He was spending more time trying to
recover from the effects of drinking and found himself planning strategies both for
abstinence and for surreptitiously taking his next drink.
Mr. Underwood first tried alcohol in high school and said that he had always been able
to hold his liquor more than his friends could. In college, he was one of the heaviest
drinkers in a fraternity known as “Animal House” around campus. Through his 30s, he
gradually increased the frequency of his drinking from primarily on weekends to daily.
Over the prior year, he had switched from being exclusively a beer drinker to drinking
vodka. He had gone to many Alcoholics Anonymous meetings over the years but tended
to drink as soon as the meeting ended. He had received no formal treatment.
The patient denied recent use of other substances; he had smoked marijuana and
snorted cocaine several times during college but never since. He had used no other illicit
drugs and took no medications. He did not smoke cigarettes. He had experienced
blackouts on several occasions during college but not since then. He had no history of
seizures and no other medical problems. Family history was significant for alcohol use
disorder in his father and paternal grandfather.
Mr. Underwood entered the alcohol treatment program at approximately 3:00 p.m.,
having not had a drink since the evening before. He was diaphoretic and exhibited
significant tremulousness in his hands. He complained of anxiety, restlessness,
irritability, nausea, and recent insomnia.
Clinical evaluation revealed a casually groomed, diaphoretic man who was cooperative
