Alcohol Abuse

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Diagnosis

Friends and family members of the alcoholic are often the first to notice problems and seek professional help. Many times, the alcoholic does not realize the severity of the problem or denies it. Some signs cannot go unnoticed, such as loss of a job, family problems, or citations for driving under the influence of alcohol. Dependence is indicated by symptoms such as withdrawal, injuries from accidents, or blackouts.

The American Psychiatric Association has developed strict criteria for the clinical diagnosis of abuse and dependence. The Diagnostic and Statistical Manual-IV (DSM-IV) defines abuse as:

• A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
  1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
  4. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
• The symptoms have never met the criteria for Substance Dependence for this class of substances.

[DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington DC: American Psychiatric Association (AMA). 1994.]

Most often, abuse is diagnosed in individuals who recently began using alcohol. Over time, abuse may progress to dependence. However, some alcohol users abuse alcohol for long periods without developing dependence.

Dependence is suspected when alcohol use is accompanied by signs of the following:

• Abuse
• Compulsive drinking behavior
• Tolerance
• Withdrawal

DSM-IV defines dependence as:

• A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
  1. tolerance, as defined by either of the following:
     • a need for markedly increased amounts of the substance to achieve intoxication or desired effect
     • markedly diminished effect with continued use of the same amount of substance
  2. withdrawal, as manifested by either of the following:
     • the characteristic withdrawal syndrome for the substance
     • the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  3. the substance is often taken in larger amounts or over a longer period than was intended
  4. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  5. a great deal of time is spent in activities to obtain the substance, use the substance, or recover from its effects
  6. important social, occupational or recreational activities are given up or reduced because of substance use
  7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

[DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington DC: American Psychiatric Association (AMA). 1994.]

Assessment
The clinician relies on interviews and self-report questionnaires to assess quantity and frequency of drinking. Questions focus on two aspects:

• Consequences of drinking
• Perceptions of drinking behavior

Clinicians determine risk for abuse and dependence based on how much and how often the patient drinks. The definition of moderate drinking differs for men and women:

A drink is 12 grams of alcohol (e.g., 12 ounces of beer; 5 ounces of wine; 1.5 ounces of 80-proof liquor). Typical risk-assessment questions include:

• How many days a week do you drink alcohol?
• On a typical day when you drink, how many drinks do you have?
• What is the maximum number of drinks you had on any given occasion during the last month?

The CAGE questionnaire is commonly used to determine the risk of alcohol-related problems:

One "yes" answer indicates a risk for abuse and/or dependence alcohol use problems; more than one "yes" indicates a high likelihood.

The Alcohol Use Disorders Identification Test (AUDIT) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) are based on the CAGE. The five-question Trauma Scale targets problem drinking in both men and women. The T-ACE and the TWEAK are designed to identify alcoholism in pregnant women.

Because these less formal interviews and questionnaires have the risk of underreporting, additional tests are used to solicit information, especially if the patient is evasive or intoxicated at the time of the interview:

• Short Michigan Alcoholism Screening Test (S-MAST) determines general alcohol abuse.
• Short Alcohol Dependence Data Questionnaire (SADD) determines dependence severity.

Once abuse or dependence is verified, the clinician administers a comprehensive assessment to develop a treatment plan. The assessment includes detailed medical and psychological histories from the individual. The clinician may request copies of medical records and may interview family members.

Differential Diagnosis
The clinician must rule out medical problems that cause symptoms similar to intoxication and withdrawal, such as the following conditions:

• Brain trauma
• Hypoglycemia
• Electrolyte imbalance
• Diabetic acidosis and ketoacidosis
• Meningitis
• Neurological conditions such as multiple sclerosis
• Pneumonia
• Stroke

If a patient has one of these conditions, he or she may be disoriented, unable to hold a conversation, have a short attention span, or may have trouble walking or maintaining balance. In the case of brain trauma and stroke, the patient may be unconscious.

Diagnosis also includes evaluations for depression and anxiety disorders, which often coexist with alcoholism. Abuse of other intoxicants, such as benzodiazepines and barbiturates, is common. The presence of a mixed drug and alcohol problem must be determined.

Alcohol Abuse, Diagnosis reprinted with permission from mentalhealthchannel.net
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