8.21: Alcohol Abuse

Name: Lila Blewitt

Source: Lila: An Inquiry into Morals by Robert M. Pirsig (book, 1991)

Background Information

Lila Blewitt is a Caucasian female and presumed to be middle aged, although her actual age is unknown. She is currently riding on a sailboat with a man she met the previous night in a bar located along side a river on the East Coast. Lila does not have an occupation. In the past, Lila has been a prostitute as well as a waitress. Lila’s mother was critical of her. As a child, when Lila did something good, the mother said nothing; but when she did something bad, her mother mentioned the incident repeatedly. Lila was previously married to a trucker and had a daughter. Her husband and daughter are deceased. Lila’s daughter died by smothering in her blanket, and her husband died in a car accident. She likes to dress very provocatively, but with no originality.

Description of the Problem

Lila has very little direction in life, and her mental processes and conversations are very surface. She dresses overtly sexual, and believes that with enough alcohol, relations with men are reduced to pure biology where they belong. Lila does not moderate her intake of alcohol, and drinks often and to the point of complete intoxication. She takes medication called Empirin whenever she begins to sense a psychotic episode is coming on. These episodes appear to be induced by social stressors, such as disagreements or arguments. Lila also suffers from severe delusions, odd ideations, and catatonia. Lila’s medication was stolen from her purse; she ended up lost in New York City and thought that taking all of her clothes off would be a good idea because then somebody would “see” her and help her. Lila’s social life greatly suffers due to impulsively rapid shifts between seeing individuals as either a rescuing friend, or as an enemy out to get her. Also while she was lost in New York City, Lila ordered three rum and cokes, although she didn’t end up being able to pay for them, and then thought that her childhood pet and dead husband were giving her directions on how to get back to the sailboat she had been riding on. Once back at the sailboat, Lila saw a doll floating in the river and believed it to be a human baby. Also at times, Lila’s speech is highly disorganized, described by the author as “word salad.”

Diagnosis

The diagnosis for Lila that seems to fit appropriately is Schizophrenia, Disorganized Type (295.10) with a comorbidity of alcohol abuse (305.00).

A. To be diagnosed with schizophrenia, two or more of the following characteristics must be present:

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms, i.e., affective flattening, alogia, or avolition

Lila displayed all of these characteristics throughout the book.

B. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.

• Lila was unable to hold down a job, drifting through life without goals or direction. Her interpersonal relationships suffered drastically. Everywhere that she went, people would end up wanting to get and stay away from her. Lila was unable to maintain stability in her life, with no home or occupation. She had to rely on others to take care of her.

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms that meet Criterion A and may include periods of prodromal or residual symptoms.

• The author indicated from conversations with a childhood friend of Lila’s that she had suffered from the above stated symptoms throughout her adult life.

D. Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

• Lila did not seem to display symptoms of mood disorders. Other than during a psychotic episode, Lila’s mood remained relatively stable throughout the book. She did not display depression, but she did display catatonia. Any time that she displayed anxiety, it would be involving a break from reality.

E. The disturbance is not due to the direct physiological effects of a substance or a general medical condition.

• Lila’s substance abuse involved heavy drinking, but her above symptoms were never consequences of being under the influence of alcohol at that time.

F. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month.

• There is no history of either of the above listed disorders present in Lila.

To fit the Diagnostic Criteria for 295.10 Disorganized Type, the following criteria are met:

1. Disorganized speech.
   • The author would describe the way Lila conversed as being “word salad.” It would make sense to Lila, but not to the listener.
2. Disorganized behavior.
   • Lila got lost in New York City because she was not paying attention to the direction that she was walking in, nor the direction that she would need to later return. She also thought that it would be acceptable to take her clothes off in order to get somebody to “see” her. She often needs others to rescue her from situations that she got herself into.
3. Flat and inappropriate affect.
   • During a psychotic episode, Lila’s affect became completely flat. She would not speak or respond to any outside stimulus for an entire day.

To fit the diagnosis for Alcohol Abuse (305.00)

1. Recurrent substance use in situations in which it is physically hazardous and continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
   • Lila would drink to the point of being intoxicated in public places where she did not know anybody, when she did not have the money to pay for the drinks, and did not even know her own whereabouts. As a result of her behavior while intoxicated, Lila would behave inappropriately and aggressively towards others. These behaviors would cause Lila to be an outcast in her social circle.
2. The symptoms have never met the criteria for Substance Dependence for this class of substance
   • Lila does not meet the criteria for Substance Dependence. Although drinking alcohol did cause Lila the above stated problems, Lila did not drink as frequently as is required to be considered dependent.

Accuracy of Portrayal

The average person reading this book would see an accurate portrayal of a person whose behavior qualifies for alcohol abuse. The author does not make Lila out to be dependent on alcohol, but he does show how Lila overconsumes alcohol to the point of causing her problems in her social life, as well as putting herself in hazardous situations. The comorbidity of her alcohol abuse with her schizophrenia is also an accurate portrayal for someone with less severe schizophrenia, occurring in episodes rather than ongoing. The book also illustrates for the reader accurately what may be going on inside the mind of a person during a schizophrenic episode as well as while abusing alcohol.

Treatment

To treat Lila’s alcohol abuse, the first step would be to provide treatment for her Schizophrenia. No long term success for treatment of her alcohol abuse could occur while Lila was suffering from a psychotic disorder without treatment. Once Lila was in treatment for Schizophrenia, you would then address her alcohol abuse. Lila would have to realize and admit that she was abusing alcohol. The fact that alcohol abuse was causing social problems for Lila as well as putting herself in dangerous situations could be presented to Lila so that she would correlate alcohol abuse with its negative consequences. While her treatment for schizophrenia could involve medication, it would be important to look at possible drug interactions before prescribing her any medication to help her stop drinking. Next, Lila could start cognitive behavioral therapy to explore her emotional reaction to events in her life and her ensuing behaviors and their further consequences, while emphasizing alcohol abuse throughout this process. Last, Lila could attend Alcoholics Anonymous to learn more about alcohol abuse and to have a social environment that is supportive of her while she is learning to change her behaviors involving alcohol abuse.