Alcohol dependence

Alcohol dependence is a previous (DSM-IV and ICD-10) psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol (also chemically known as ethanol).

Alcohol dependence
SpecialtyPsychiatry

In 2013 it was reclassified as alcohol use disorder in DSM-5,[1] which combined alcohol dependence and alcohol abuse into this diagnosis.

Definition
Addiction and dependence glossary[2][3][4][5]
  • addiction – a biopsychosocial disorder characterized by compulsively seeking to achieve a desired effect, such as intoxication, despite harm and adverse consequences to self and others
  • addictive behavior – a behavior that is both rewarding and reinforcing
  • addictive drug – a drug that is both rewarding and reinforcing
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Diagnosis
See also: Alcohol abuse § Diagnosis, and Alcoholism § Diagnosis

DSM: Alcohol dependence

According to the DSM-IV criteria for alcohol dependence, at least three out of seven of the following criteria must be manifest during a 12-month period:

  • Tolerance
  • Withdrawal symptoms or clinically defined alcohol withdrawal syndrome
  • Use in larger amounts or for longer periods than intended
  • Persistent desire or unsuccessful efforts to cut down on alcohol use
  • Time is spent obtaining alcohol or recovering from effects
  • Social, occupational and recreational pursuits are given up or reduced because of alcohol use
  • Use is continued despite knowledge of alcohol-related harm (physical or psychological)[6]

ICD: Alcohol dependence syndrome

From the ICD-9 database:[7]

  • A chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking. A person with this disease also needs to drink greater amounts to get the same effect and has withdrawal symptoms after stopping alcohol use. Alcoholism affects physical and mental health, and can cause problems with family, friends, and work.
  • A disorder characterized by a pathological pattern of alcohol use that causes a serious impairment in social or occupational functioning.
  • A primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic. (morse & flavin for the joint commission of the national council on alcoholism and drug dependence and the American society of addiction medicine to study the definition and criteria for the diagnosis of alcoholism: in jama 1992;268:1012-4)
  • For most adults, moderate alcohol use is probably not harmful. However, about 18 million adult Americans are alcoholics or have alcohol problems. Alcoholism is a disease with four main features:
    • craving – a strong need to drink
    • loss of control – not being able to stop drinking once you've started
    • physical dependence – withdrawal symptoms, such as nausea, sweating, or shakiness when you don't drink
    • tolerance – the need to drink greater amounts of alcohol to feel the same effect
  • Temporary mental disturbance marked by muscle incoordination and paresis as the result of excessive alcohol ingestion.

Because only 3 of the 7 DSM-IV criteria for alcohol dependence are required, not all patients meet the same criteria and therefore not all have the same symptoms and problems related to drinking. Not everyone with alcohol dependence, therefore, experiences physiological dependence. Alcohol dependence is differentiated from alcohol abuse by the presence of symptoms such as tolerance and withdrawal. Both alcohol dependence and alcohol abuse are sometimes referred to by the less specific term alcoholism. However, many definitions of alcoholism exist, and only some are compatible with alcohol abuse. There are two major differences between alcohol dependence and alcoholism as generally accepted by the medical community.

  1. Alcohol dependence refers to an entity in which only alcohol is the involved addictive agent. Alcoholism refers to an entity in which alcohol or any cross-tolerant addictive agent is involved.
  2. In alcohol dependence, reduction of alcohol, as defined within DSM-IV, can be attained by learning to control the use of alcohol. That is, a client can be offered a social learning approach that helps them to 'cope' with external pressures by re-learning their pattern of drinking alcohol. In alcoholism, patients are generally not presumed to be 'in remission' unless they are abstinent from alcohol.

The following elements are the template for which the degree of dependence is judged:

  1. Narrowing of the drinking repertoire.
  2. Increased salience of the need for alcohol over competing needs and responsibilities.
  3. An acquired tolerance to alcohol.
  4. Withdrawal symptoms.
  5. Relief or avoidance of withdrawal symptoms by further drinking.
  6. Subjective awareness of compulsion to drink.
  7. Reinstatement after abstinence.[8]

Screening
See also: Alcohol abuse § Screening

AUDIT has replaced older screening tools such as CAGE but there are many shorter alcohol screening tools,[9] mostly derived from the AUDIT. The Severity of Alcohol Dependence Questionnaire (SAD-Q) is a more specific twenty-item inventory for assessing the presence and severity of alcohol dependence.

AUDIT

The Alcohol Use Disorders Identification Test (AUDIT) is considered the most accurate alcohol screening tool for identifying potential alcohol misuse, including dependence.[10] It was developed by the World Health Organisation, designed initially for use in primary healthcare settings with supporting guidance.[11]

CAGE

The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used method of screening for alcoholism.

SADQ

The Severity of Alcohol Dependence Questionnaire (SADQ or SAD-Q) is a 20 item clinical screening tool designed to measure the presence and level of alcohol dependence.[12]

Treatment

Treatments for alcohol dependence can be separated into two groups, those directed towards severely alcohol-dependent people, and those focused for those at risk of becoming dependent on alcohol. Treatment for alcohol dependence often involves utilizing relapse prevention, support groups, psychotherapy,[13] and setting short-term goals. The Twelve-Step Program is also a popular process used by those wishing to recover from alcohol dependence.[14]

Epidemiology
"The Drunkard’s Progress", 1846

About 12% of American adults have had an alcohol dependence problem at some time in their life.[15] In the UK the NHS estimates that around 9% of men and 4% of UK women show signs of alcohol dependence.[16]

History

The term 'alcohol dependence' has replaced 'alcoholism' as a term in order that individuals do not internalize the idea of cure and disease, but can approach alcohol as a chemical they may depend upon to cope with outside pressures.

The contemporary definition of alcohol dependence is still based upon early research. There has been considerable scientific effort over the past several decades to identify and understand the core features of alcohol dependence.[17] This work began in 1976, when the British psychiatrist Griffith Edwards and his American colleague Milton M. Gross [18] collaborated to produce a formulation of what had previously been understood as ‘alcoholism’ – the alcohol dependence syndrome.

The alcohol dependence syndrome was seen as a cluster of seven elements that concur. It was argued that not all elements may be present in every case, but the picture is sufficiently regular and coherent to permit clinical recognition. The syndrome was also considered to exist in degrees of severity rather than as a categorical absolute. Thus, the proper question is not ‘whether a person is dependent on alcohol’, but ‘how far along the path of dependence has a person progressed’.

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See also

Notes
  1. "Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5". November 2013. Retrieved 9 May 2015.
  2. Malenka RC, Nestler EJ, Hyman SE (2009). "Chapter 15: Reinforcement and Addictive Disorders". In Sydor A, Brown RY (eds.). Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. pp. 364–375. ISBN 9780071481274.
  3. Nestler EJ (December 2013). "Cellular basis of memory for addiction". Dialogues in Clinical Neuroscience. 15 (4): 431–443. PMC 3898681. PMID 24459410. Despite the importance of numerous psychosocial factors, at its core, drug addiction involves a biological process: the ability of repeated exposure to a drug of abuse to induce changes in a vulnerable brain that drive the compulsive seeking and taking of drugs, and loss of control over drug use, that define a state of addiction. ... A large body of literature has demonstrated that such ΔFosB induction in D1-type [nucleus accumbens] neurons increases an animal's sensitivity to drug as well as natural rewards and promotes drug self-administration, presumably through a process of positive reinforcement ... Another ΔFosB target is cFos: as ΔFosB accumulates with repeated drug exposure it represses c-Fos and contributes to the molecular switch whereby ΔFosB is selectively induced in the chronic drug-treated state.41. ... Moreover, there is increasing evidence that, despite a range of genetic risks for addiction across the population, exposure to sufficiently high doses of a drug for long periods of time can transform someone who has relatively lower genetic loading into an addict.
  4. "Glossary of Terms". Mount Sinai School of Medicine. Department of Neuroscience. Retrieved 9 February 2015.
  5. Volkow ND, Koob GF, McLellan AT (January 2016). "Neurobiologic Advances from the Brain Disease Model of Addiction". New England Journal of Medicine. 374 (4): 363–371. doi:10.1056/NEJMra1511480. PMC 6135257. PMID 26816013. Substance-use disorder: A diagnostic term in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) referring to recurrent use of alcohol or other drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Depending on the level of severity, this disorder is classified as mild, moderate, or severe.
    Addiction: A term used to indicate the most severe, chronic stage of substance-use disorder, in which there is a substantial loss of self-control, as indicated by compulsive drug taking despite the desire to stop taking the drug. In the DSM-5, the term addiction is synonymous with the classification of severe substance-use disorder.
  6. http://www.alcoholcostcalculator.org/business/about/dsm.html
  7. "ICD-9-CM Diagnosis Codes 303.* : Alcohol dependence syndrome". www.icd9data.com.
  8. Clark, David, Background Briefing, Alcohol Dependence, Drink and Drug News, 7 February 2005, p. 11
  9. "Alcohol use screening tests – GOV.UK". www.gov.uk. Retrieved 8 April 2018.
  10. "AUDIT – Alcohol Use Disorders Identification Test". Alcohol Learning Centre. 28 June 2010. Retrieved 3 June 2012.
  11. "World Health Organization" (PDF). World Health Organization. Retrieved 8 April 2018.
  12. "SADQ or SAD-Q Questionnaire – find out if you are dependent on alcohol". www.markjayalcoholdetox.co.uk. Archived from the original on 2017-07-07. Retrieved 2017-09-26.
  13. "Alcohol Dependence and Treatment". ICAP Blue Book. International Center for Alcohol Policies. Archived from the original on 27 February 2013. Retrieved 2 June 2012.
  14. "What is Alcohol Addiction: What Causes Alcohol Addiction?". MedicalBug. 6 January 2012. Archived from the original on 19 May 2012. Retrieved 2 June 2012.
  15. Hasin D; et al. (2007). "Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United States". Archives of General Psychiatry. 64 (7): 830–42. doi:10.1001/archpsyc.64.7.830. PMID 17606817.
  16. "Alcohol dependence and withdrawal".
  17. Irving B. Weiner; Donald K. Freedheim; George Stricker; Thomas A. Widiger (2003). Handbook of Psychology: Clinical psychology. John Wiley and Sons. pp. 201–. ISBN 978-0-471-39263-7. Retrieved 16 April 2010.
  18. Edwards G. & Gross MM, Alcohol dependence: provisional description of a clinical syndrome, BMJ 1976; i: 1O58-106
Classification
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