CASE

STUDY
ACKNOWLEDGEMENT
I would like to express my special thanks of
gratitude to my teacher Vibha Nath as well
who gave me the golden opportunity to do this
wonderful Case Study, which also helped me in
doing a lot of Research and I came to know
about so many new things I am really thankful
to them.
Secondly I would also like to thank my parents
and friends who helped me a lot in finalizing
this project within the limited time frame.

CASE STUDY
In the social sciences and life sciences, a case study is a
research method involving an up-close, in-depth, and detailed
examination of a subject of study (the case), as well as its related
contextual conditions.
Case studies can be produced by following a
formal research method. These case studies are likely to appear
in formal research venues, as journals and professional
conferences, rather than popular works. The resulting body of
'case study research' has long had a prominent place in many
disciplines and professions, ranging from psychology,
anthropology, sociology, and political science to education,
clinical science, social work, and administrative science.
In doing case study research, the "case" being studied may be an
individual, organization, event, or action, existing in a specific time
and place. For instance, clinical science has produced both well-
known case studies of individuals and also case studies of clinical
practices. However, when "case" is used in an abstract sense, as
in a claim, a proposition, or an argument, such a case can be the
subject of many research methods, not just case study research.
Case studies may involve both qualitative and quantitative
research methods.

ALCOHOLISM
Alcoholism, also known as alcohol use disorder (AUD), is a broad term for
any drinking of alcohol that results in mental or physical health problems. It
was previously divided into two types: alcohol abuse and alcohol
dependence. In a medical context, alcoholism is said to exist when two or
more of the following conditions is present: a person drinks large amounts
over a long time period, has difficulty cutting down, acquiring and drinking
alcohol takes up a great deal of time, alcohol is strongly desired, usage
results in not fulfilling responsibilities, usage results in social problems,
usage results in health problems, usage results in risky
situations, withdrawal occurs when stopping, and alcohol tolerance has
occurred with use. Risky situations include drinking and driving or
having unsafe sex among others. Alcohol use can affect all parts of the
body but particularly affects the brain, heart, liver, pancreas, and immune
system. This can result in mental illness, WernickeKorsakoff syndrome,
an irregular heart beat, liver failure, and an increase in the risk of cancer,
among other diseases. Drinking during pregnancy can cause damage to
the baby resulting in fetal alcohol spectrum disorders. Generally women are
more sensitive to alcohol's harmful physical and mental effects than men.
Both environmental factors and genetics are associated with alcoholism
with about half the risk attributed to each. A person with a parent or sibling
with alcoholism is three to four times more likely to be alcoholic
themselves. Environmental factors include social, cultural, and behavioral
influences. High stress levels, anxiety, as well as inexpensive easily
accessible alcohol increases risk. People may continue to drink partly to
prevent or improve symptoms of withdrawal. A low level of withdrawal may
last for months following stopping. Medically, alcoholism is considered both
a physical and mental illness. Both questionnaires and certain blood tests
may detect people with possible alcoholism. Further information is then
collected to confirm the diagnosis.
Prevention of alcoholism may be attempted by regulating and limiting the
sale of alcohol, taxing alcohol to increase its cost, and providing
inexpensive treatment. Treatment may take several steps. Because of the
medical problems that can occur during withdrawal, alcohol
detoxification should be carefully controlled. One common method involves
the use of benzodiazepinemedications, such as diazepam. This can be
either given while admitted to a health care institution or occasionally while
a person remains in the community with close
supervision. Other addictions or mental illness may complicate
treatment. After detoxification support such as group therapy or support
groups are used to help keep a person from returning to drinking. One
commonly used form of support is the group Alcoholics Anonymous. The
medications acamprosate, disulfiram, or naltrexone may also be used to
help prevent further drinking.
Early signs
The risk of alcohol dependence begins at low levels of drinking and
increases directly with both the volume of alcohol consumed and a pattern
of drinking larger amounts on an occasion, to the point of intoxication,
which is sometimes called "binge drinking". Young adults are particularly at
risk of engaging in binge drinking.
Alcoholism is characterized by an increased tolerance to alcoholwhich
means that an individual can consume more alcoholand physical
dependence on alcohol, which makes it hard for an individual to control
their consumption. The physical dependency caused by alcohol can lead to
an affected individual having a very strong urge to drink alcohol. These
characteristics play a role decreasing an alcoholic's ability to stop
drinking.[25] Alcoholism can have adverse effects on mental health, causing
psychiatric disorders and increasing the risk of suicide. A depressed
mood is a common symptom of heavy alcohol drinkers.

Long-term Effects
Drinking more than one drink a day for women or two drinks for men
increases the risk of heart disease, high blood pressure, atrial fibrillation,
and stroke. Risk is greater in younger people due to binge drinking who
may result in violence or accidents. About 3.3 million deaths (5.9% of all
deaths) are believed to be due to alcohol each year. Alcoholism reduces a
person's life expectancy by around ten years and alcohol use is the third
leading cause of early death in the United States. No professional medical
association recommends that people who are nondrinkers should start
drinking wine. Long-term alcohol abuse can cause a number of physical
symptoms, including cirrhosis of the
liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart
disease, nutritional deficiencies, peptic ulcers and sexual dysfunction, and
can eventually be fatal. Other physical effects include an increased risk of
developing cardiovascular disease, malabsorption, alcoholic liver disease,
and cancer. Damage to the central nervous system and peripheral nervous
system can occur from sustained alcohol consumption A wide range of
immunologic defects can result and there may be a generalized skeletal
fragility, in addition to a recognized tendency to accidental injury, resulting
a propensity to bone fractures.

Psychiatric
Long-term misuse of alcohol can cause a wide range of mental
health problems. Severe cognitive problems are common; approximately
10 percent of all dementia cases are related to alcohol consumption,
making it the second leading cause of dementia. Excessive alcohol use
causes damage to brain function, and psychological health can be
increasingly affected over time. Social skills are significantly impaired in
people suffering from alcoholism due to the neurotoxic effects of alcohol on
the brain, especially the prefrontal cortexarea of the brain. The social skills
that are impaired by alcohol abuse include impairments in perceiving facial
emotions, prosody perception problems and theory of mind deficits; the
ability to understand humour is also impaired in alcohol
abusers. Psychiatric disorders are common in alcoholics, with as many as
25 percent suffering severe psychiatric disturbances. The most prevalent
psychiatric symptoms are anxiety and depression disorders. Psychiatric
symptoms usually initially worsen during alcohol withdrawal, but typically
improve or disappear with continued abstinence. Psychosis, confusion,
and organic brain syndrome may be caused by alcohol misuse, which can
lead to a misdiagnosis such as schizophrenia. Panic disorder can develop
or worsen as a direct result of long-term alcohol misuse.
Alcohol Withdrawal
As with similar substances with a sedative-hypnotic mechanism, such
as barbiturates and benzodiazepines, withdrawal from alcohol dependence
can be fatal if it is not properly managed. Alcohol's primary effect is the
increase in stimulation of the GABAA receptor, promoting central nervous
system depression. With repeated heavy consumption of alcohol, these
receptors are desensitized and reduced in number, resulting
in tolerance and physical dependence. When alcohol consumption is
stopped too abruptly, the person's nervous system suffers from
uncontrolled synapse firing. This can result in symptoms that
include anxiety, life-threatening seizures, delirium tremens, hallucinations,
shakes and possible heart failure. Other neurotransmitter systems are also
involved, especially dopamine, NMDA and glutamate.
Severe acute withdrawal symptoms such as delirium tremens and seizures
rarely occur after 1-week post cessation of alcohol. The acute withdrawal
phase can be defined as lasting between one and three weeks. In the
period of 36 weeks following cessation increased anxiety, depression, as
well as sleep disturbance, is common; fatigue and tension can persist for
up to 5 weeks as part of the post-acute withdrawal syndrome; about a
quarter of alcoholics experience anxiety and depression for up to 2 years.
These post-acute withdrawal symptoms have also been demonstrated in
animal models of alcohol dependence and withdrawal. A kindling
effect also occurs in alcoholics whereby each subsequent withdrawal
syndrome is more severe than the previous withdrawal episode; this is due
to neuroadaptations which occur as a result of periods of abstinence
followed by re-exposure to alcohol. Individuals who have had multiple
withdrawal episodes are more likely to develop seizures and experience
more severe anxiety during withdrawal from alcohol than alcohol-
dependent individuals without a history of past alcohol withdrawal
episodes. The kindling effect leads to persistent functional changes in brain
neural circuits as well as to gene expression. Kindling also results in the
intensification of psychological symptoms of alcohol withdrawal. There are
decision tools and questionnaires which help guide physicians in evaluating
alcohol withdrawal.
Causes
A complex mixture of genetic and environmental factors influences the risk
of the development of alcoholism. Genes that influence the metabolism of
alcohol also influence the risk of alcoholism, and may be indicated by a
family history of alcoholism. One paper has found that alcohol use at an
early age may influence the expression of genes which increase the risk of
alcohol dependence. Individuals who have a genetic disposition to
alcoholism are also more likely to begin drinking at an earlier age than
average. Also, a younger age of onset of drinking is associated with an
increased risk of the development of alcoholism, and about 40 percent of
alcoholics will drink excessively by their late adolescence. It is not entirely
clear whether this association is causal, and some researchers have been
known to disagree with this view.
Severe childhood trauma is also associated with a general increase in the
risk of drug dependency. Lack of peer and family support is associated with
an increased risk of alcoholism developing. Genetics and adolescence are
associated with an increased sensitivity to the neurotoxic effects of chronic
alcohol abuse. Cortical degeneration due to the neurotoxic effects
increases impulsive behaviour, which may contribute to the development,
persistence and severity of alcohol use disorders. There is evidence that
with abstinence, there is a reversal of at least some of the alcohol induced
central nervous system damage. The use of cannabis was associated with
later problems with alcohol use. Alcohol use was associated with an
increased probability of later use of tobacco, cannabis, and other illegal
drugs.
Diagnosis
Misuse, problem use, abuse, and heavy use of alcohol refer to improper
use of alcohol which may cause physical, social, or moral harm to the
drinker. Moderate use is defined by The Dietary Guidelines for
Americans as no more than two alcoholic beverages a day for men and no
more than one alcoholic beverage a day for women. Some drinkers may
drink more than 600 ml of alcohol per day during a heavy drinking
period. The National Institute on Alcohol Abuse and Alcoholism (NIAAA)
defines binge drinking as the amount of alcohol leading to a blood alcohol
content (BAC) of 0.08, which, for most adults, would be reached by
consuming five drinks for men or four for women over a two-hour period.
According to the NIAAA, men may be at risk for alcohol-related problems if
their alcohol consumption exceeds 14 standard drinks per week or 4 drinks
per day, and women may be at risk if they have more than 7 standard
drinks per week or 3 drinks per day. It defines a standard drink as one 12-
ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled
spirits.[94] Despite this risk, a 2014 report in the National Survey on Drug
Use and Health found that only 10% of either "heavy drinkers" or "binge
drinkers" defined according to the above criteria also met the criteria for
alcohol dependence, while only 1.3% of non-binge drinkers met the criteria.
An inference drawn from this study is that evidence-based policy strategies
and clinical preventive services may effectively reduce binge drinking
without requiring addiction treatment in most cases.

Brief History of the Subject

The subject is a 44 years old Hindu, male, literate and married, hailing from
a middle socio-economic background of urban area of Ghaziabad, Uttar
Pradesh .Predominantly subject was well adjusted and very responsible
person, he has a history of 19 years of alcohol intake. As alcohol abuse
and family functioning are linked; there are several family problems that are
likely to co-occur with an individual's alcohol abuse and often required
psycho social care and intervention. Family dysfunctions (conflict, poor
interpersonal relationship, communication problems, unpredictability,
breakdown in rituals and traditional family rules, emotional and physical
abuse, stress, care burden, stigma etc) is very common problem
associated with alcohol dependence, further, alcoholic behavior in the
family can lead to various communication problems may be characterized
as highly critical, involving considerable amounts of nagging, judgments,
blame, complaints, and guilt. There may be family burden (care burden and
financial burden), associated with alcoholic behavior.

The subject in the present case has been denied supportive, intimate and
long lasting relationships. Subjects wife left the subject several times not
able to withstand his alcohol intake behavior, which affected his major
source of support and social acceptance. He has been neglected by his
sibling; there was lack of support from their side. In the present case
alcohol abuse has affected the couples relationships in a variety of
negative ways, including communication problems, increased conflict,
nagging, poor sexual relations, and domestic violence. Subject was not
able to perform a role as a father because of his drinking behaviour; he was
inconsistent, unpredictable, and lacking in clear rules and limits. As it has
found in the research that children of alcoholic parents commonly
experience poor parenting and poor home environments, conflict,
interpersonal problems during significant developmental periods and its
effect their physical mental and cognitive health. In the case study the wife
of the subjects, is especially affected in this way, often becoming
emotionally inaccessible not only to the husband alcoholic behaviour but to
her children as well, due to the need to try to block out the overwhelming
emotional climate. Children notice this when they see behavioural changes,
crying, and physical or affective distancing by mother. while emotional
distancing is evidenced by such things as mothers talking to their children
less, answering only basic questions and being more inclined to silence .In
the case we found that staying alone and working out of his home town
without any supervision of medication as the subjects own lack of insight
into his symptoms and contributes into the treatment non-compliance as
the subject does not feel the need to take any medications and refuses to
do so.

About His Family

Father: Subjects father died at the age of 73 years. Subjects age at
fathers death was 43 years. Cause of death was natural. His father was a
graduate and a teacher by profession. He was a social and responsible
person.

Mother: Subjects mother died at the age of 62 years. Subjects age at the
time of mothers death was 41 years. His mother was educated till higher
secondary. She was a teacher by profession and extrovert by nature.

Wife: Subjects wife is 40 years old, a master degree holder in Assamese,

she is a home maker, and takes responsibility of taking care of their
children. Subjects relationship with his wife is not cordial.

Family interaction pattern

Interaction between parents: Subject mother and father shared a cordial
relationship when they were alive. They used to discuss most of the issues
regarding family affairs and decisions were taken with mutual consent.
Conflicts are rare, and mother used to obey the father in most of the
matters, mother is very submissive person and hence will always go by the
fathers words.

Interaction between subject and parents: There was cordial and loving
relationship between the subject and parents until the subject started
drinking and causing troubles at home. Since the time subject started
drinking heavily and comes home late the relations and interaction between
them became strained.

Interaction between subject and wife: Interaction with the wife was
adequate; they do interact well and have a healthy relationship until the
subject develops his symptoms. As subjects was taking alcohol regularly
and that has affected their relationship and due to his alcoholic behavior
interaction pattern changed. He becomes aggressive and violent towards
his wife. Since then there is conflict and frequent arguments which leads to
marital problem.

Interaction between subject and children: The interaction between

subject and children was cordial and each member was supportive to each
other. However, after the illness of the subject the interaction of the children
was strained with the subject. They are not very closed towards their father
.They are scared, having minimal interaction with their father because of
his alcohol intake behavior.

Support system
Primary support system: Primary support system is not adequate. Unable
to withstand the alcohol intake behavior of the subject, his wife often goes
off to her house with their children leaving the subject alone.

Secondary support system: Secondary social support from close

relatives is not adequate in terms of emotional support.

Tertiary support system: Subject tertiary support is adequate. The family

used to seek support from different health institutions in and around the
district.

Social Status of the Family: Subject belongs to a middle socioeconomic

family. The main source of the familys income is from the service of the
subject. The present living condition ok and they have a concrete house of
their own. All the basic facilities are available in the house.

Personal information

Birth order: Subject is the 3rd among 5 siblings

Early development: The development milestones were age appropriate

and achieved normally

Education history: Subject started going to school at the age of 3 years.

The highest educational qualification the subject completed is his Masters
in Computer Application. He used to participate in the co-curricular
activities in school and had no disciplinary complains in school

Occupation: Subject started working at the age of 25 years as a computer

technician. There is no history of work change. His work position is static
with a satisfactory work record. Although he took leave of absence from his
work many times while he have to be in de-addiction centre.

Social status of the family: Subject belongs to a middle socioeconomic

family. The main source of income is the subjects earning as a service
holder.

Marital history: Marital adjustment of the subject is not satisfactory. Intake

of alcohol was present in the subject before his marriage. He was on
abstinence for 2 years. But it was not disclosed to the spouse family.
Marriage took place within 15 days after both the family came to know each
other. One year of the marriage life went on smoothly. Marital adjustment
was cordial at the initial years. But the subjects relapse on the day of his
sons hair cutting ceremony. He had consumed alcohol on that occasion.
After that he started showing abusive and assaultative behavior towards his
family members and his alcohol intake behavior was increased. This
incident has affected their marital life. Knowing that wife went back to
home. She was at home for 45 days. Family members from the subjects
home went to bring her back from home for 17 times. At last when the
subject promise to quit alcohol she came back. But the subject could not
maintain it and relapse. Wife went to home again. And after giving many
chances to the subject to quit alcohol and maintain a stable life she has lost
all her hope. And currently she is planning to get divorced and is more
concerned towards both of her children.

Problems Identified
i. Familys lack of knowledge regarding illness and
treatment
ii. Alcohol dependence
iii. Poor coping skills
iv. Marital conflicts
v. Poor support system
vi. Poor motivation.
Progress of Therapy
Counseling: The subjects were admitted to the hospital for his alcohol
problems. The family members were provided admission counseling. Brief
psycho social assessment was done. Brief education regarding the
subjects illness to the family members was provided. They were explained
the nature of the illness and its causes. In this session the caregivers were
provided information regarding the rules and regulations of the hospital,
duration of stay of the subject, mode of family visit after admission and
regarding the deposit of money and its utilization. Apart from these address
verification was also done.

Family assessment was done with the subjects wife and uncle to come
through the psychosocial issues of the family and also to investigate the
level of knowledge regarding mental illness due to prolong period of alcohol
abuse of the subject. During the session different issues on the marital
conflict also arise. The support system and expressed emotion were found
not adequate between the family members. Knowledge regarding the
illness to the family members was imparted, so that a better understanding
is present in knowing and maintaining the illness. The family members
were educated about the illness, importance of drug compliance and early
warning signs were discussed. In the further sessions subjects wife was
provided supportive therapy.

Discussion with Subjects wife

The subjects wife is often subjected to various forms of physical,
psychological, and emotional problems. The spectrum of problems varies
from mild emotional insults to physical violence. The subjects wife reported
anxiety and mental disturbance owing to the drinking problems of her
husbands. Anxiety, depression, and poor adjustment are commonly
reported problems of the wife of the in subject.

Questionnaires Attached:-
1. Alcoholism
2. Stress
Interpretation of results on the basis of alcoholism
questionnaire:-
As far as the subjects case is concerned, according to the answers marked
by the subject it can be easily seen that the subject was highly addicted to
alcohol and alcohol became a part of his life.(Discussed Above)

Interpretation of results on the basis of stress

questionnaire:-
In the second questionnaire the subject has marked the answers of
questions in such a way that one can easily make out that how stressful his
life would be. In personal life the subjects stress is basically because of
alcohol dependence and also he does not have any support of his family.
His economic condition is also becoming worse so this is also a cause of
stress to him.

Conclusion
Subject had gained insight regarding his illness. Subjects
motivation has been enhanced. Family members have better
understanding about subjects illness. Thus it can be said that
Psycho-social interventions play an important role in
determination of treatment outcomes. It has been shown to
improve subject compliance to medication and the retention of
subjects in treatment. It has also been shown to increase alcohol
abstinence rates and quality of life in persons with alcohol
dependence. Psychiatric social work can play a key role in
working with person with alcohol dependence syndrome,
educating, enhancing motivation and teaching skill for recovery
and also working with the family. So we can conclude that
treatment and rehabilitation of subjects with alcohol dependence
has been an important area of psychiatric social work.
Psychosocial intervention can enhance pharmacological
treatment efficacy by increasing medication compliance,
maintenance in treatment, and attainment of skills.
References:-
1. www.acknowledgementsample.com
2. en.wikipedia.org
3. www.psychologytoday.com
4. www.cebglobal.com
5. www.humanstress.ca
6. www.stress.org
7. NCERT Psychology Book