Chapter Three: Alcohol Dependence

points to consider

DefinitionsDefinitions Disease conceptDisease concept Natural historyNatural history Guidelines for diagnosisGuidelines for diagnosis

definitions

Earliest definitionsEarliest definitions much variationmuch variation focus on different aspects focus on different aspects

example: descriptive only vs. causes example: descriptive only vs. causes

Efforts to promote uniformityEfforts to promote uniformity WHO 1977WHO 1977

International Classification DiseasesInternational Classification Diseases APA 1980APA 1980

Diagnostic and Statistical ManualDiagnostic and Statistical Manual

definition: American Society of Addiction Medicine (ASAM)

Alcoholism (dependence) is a “Alcoholism (dependence) is a “primaryprimary, , chronicchronic diseasedisease with genetic, psychological with genetic, psychological and environmental factors... often and environmental factors... often progressiveprogressive and fatal. …characterized by and fatal. …characterized by impaired controlimpaired control over drinking, over drinking, preoccupationpreoccupation…, alcohol …, alcohol use despiteuse despite adverse consequences…” adverse consequences…”

19931993

key points of ASAM definition

Characterization as a disease that is Characterization as a disease that is ChronicChronic PrimaryPrimary ProgressiveProgressive

implications of disease concept

Dictates attitudesDictates attitudes Identifies care-giversIdentifies care-givers Moves from punishment to treatmentMoves from punishment to treatment Reduces stigmaReduces stigma

management of chronic disease

Treatment of acute flare-upsTreatment of acute flare-ups Emotional supportEmotional support Patient educationPatient education Rehabilitation to live with limitationsRehabilitation to live with limitations Family involvementFamily involvement Partnership of physician and patientPartnership of physician and patient

natural history a la EM Jellinek

How a disease or condition unfoldsHow a disease or condition unfolds EM Jellinek first to describeEM Jellinek first to describe Based on survey of 2,000 early AA Based on survey of 2,000 early AA

membersmembers Identified pattern in emergence of symptoms Identified pattern in emergence of symptoms Grouped signs/symptoms into phasesGrouped signs/symptoms into phases

Phases of alcoholism

Four stagesFour stages Pre-alcoholic PhasePre-alcoholic Phase Prodromal PhaseProdromal Phase

means “signaling” or “warning” means “signaling” or “warning” Crucial PhaseCrucial Phase Chronic PhaseChronic Phase

phases of alcoholism Pre-alcoholic Phase

Drinking socially motivatedDrinking socially motivated Response to alcohol “primes” drinkerResponse to alcohol “primes” drinker

psychological reliefpsychological relief release of tension release of tension

seeks occasions where drinkingseeks occasions where drinking Drinking behavior does not stand outDrinking behavior does not stand out Time: several months to 2Time: several months to 2++ years years

phases of alcoholism Prodromal Phase

Blackouts appear, Blackouts appear, thethe warning sign warning sign Alcohol no longer just a beverageAlcohol no longer just a beverage Consumption heavy, doesn’t necessarily Consumption heavy, doesn’t necessarily

stand outstand out Conscious effort to keep drinkingConscious effort to keep drinking

inconspicuous inconspicuous Time: 6 months to 4 or 5Time: 6 months to 4 or 5++ years years

phases of alcoholism Crucial Phase

Key symptom, loss of controlKey symptom, loss of control Drinking stands outDrinking stands out Drinking requires explanationDrinking requires explanation Adopts tactics to regain controlAdopts tactics to regain control Life alcohol-centeredLife alcohol-centered Deteriorating relationshipsDeteriorating relationships

phases of alcoholism Chronic Phase

Morning drinking commonMorning drinking common Social & workplace functioning goneSocial & workplace functioning gone Frequent intoxicationFrequent intoxication Living on society’s fringesLiving on society’s fringes Withdrawal symptoms without alcoholWithdrawal symptoms without alcohol Rationalization fails Rationalization fails so open to treatment so open to treatment Continued drinking likely, can’t see way outContinued drinking likely, can’t see way out

phases of alcoholism some caveats

Product of era when developedProduct of era when developed Some elements countered by later research Some elements countered by later research

example: significance of blackoutsexample: significance of blackouts

AlsoAlso Jellinek recognized some cases didn’t fit Jellinek recognized some cases didn’t fit

model of Phasesmodel of Phases Led to formulation of Led to formulation of Species of AlcoholismSpecies of Alcoholism

species of alcoholism

Formulated by EM JellinekFormulated by EM Jellinek Different “varieties” of alcoholismDifferent “varieties” of alcoholism Possibly product of different culturesPossibly product of different cultures Speculated that not all species may Speculated that not all species may

represent a diseaserepresent a disease Five species identified by aFive species identified by a

Greek letterGreek letter

species of alcoholism alpha alcoholism

Purely psychological dependencePurely psychological dependence Not loss of control nor inability to abstainNot loss of control nor inability to abstain Hallmark: drinking to handle problemsHallmark: drinking to handle problems Progression not inevitableProgression not inevitable Recognized as what others might callRecognized as what others might call

“problem drinking”“problem drinking”

species of alcoholism beta alcoholism Physical problems of heavy drinkingPhysical problems of heavy drinking Absence of psychological or Absence of psychological or

physical dependencephysical dependence Common in cultures with heavy drinkingCommon in cultures with heavy drinking

and inadequate diet”and inadequate diet”

species of alcoholism gamma alcoholism Species identified in Species identified in

Phases of Alcoholism AddictionPhases of Alcoholism Addiction Tolerance, loss of controlTolerance, loss of control Psychological Psychological physical dependence physical dependence Suggested to be most common type in US”Suggested to be most common type in US”

species of alcoholism delta alcoholism Similar to gamma alcoholism Similar to gamma alcoholism PsychologicalPsychological physical dependence physical dependence Can control amount consumed on any Can control amount consumed on any

occasionoccasion ButBut cannot cease drinking without cannot cease drinking without

withdrawalwithdrawal

species of alcoholism epsilon alcoholism

Studied less intensivelyStudied less intensively Seen as different from other speciesSeen as different from other species Described as “periodic alcoholism”Described as “periodic alcoholism” Marked by periodic binge drinkingMarked by periodic binge drinking

formalizing disease approach Disease formulation garnered acceptanceDisease formulation garnered acceptance If a diseaseIf a disease

a need to formalize definitionsa need to formalize definitions a need for guides to diagnosisa need for guides to diagnosis

Actions by professional associationsActions by professional associations National Council on AlcoholismNational Council on Alcoholism World Health Organization (World Health Organization (ICDICD)) American Psychiatric Associations American Psychiatric Associations

( (Diagnostic and Statistical Diagnostic and Statistical Manual)Manual)

formalizing disease approachs

Actions by professional associationsActions by professional associations National Council on AlcoholismNational Council on Alcoholism World Health Organization (World Health Organization (ICDICD)) American Psychiatric Associations American Psychiatric Associations

( (Diagnostic and Statistical Diagnostic and Statistical Manual)Manual)

National Council on Alcoholism

1972, published 1972, published Criteria for DiagnosisCriteria for Diagnosis Identified signs and symptomsIdentified signs and symptoms Two types of datasTwo types of datas

physiological/clinicalphysiological/clinical behavioral, psychologicalbehavioral, psychological within each track: major and minor within each track: major and minor

criteriacriteria Similarity to Jellinek, but external dataSimilarity to Jellinek, but external data

National Council on Alcoholism (cont.)

Based on external verifiable dataBased on external verifiable data Jellinek signs efforts to deceiveJellinek signs efforts to deceive examples: alcohol or breathe at examples: alcohol or breathe at

appointmentappointment Characterizes disease as chronic Characterizes disease as chronic Suggests criteria for assessing post-Suggests criteria for assessing post-

treatment statustreatment status

American Psychiatric Association

APA’s APA’s Diagnostic & Statistical ManualDiagnostic & Statistical Manual1980 edition, a milestone1980 edition, a milestone

set forth explicit criteria for diagnosisset forth explicit criteria for diagnosis no longer dependent on theories of causeno longer dependent on theories of cause created categorycreated category

“Substance Use Disorders” “Substance Use Disorders”

Criteria for Diagnosisof Dependence (DSM-IV)

1. Tolerance1. Tolerance

2. Withdrawal2. Withdrawal

3. Drinking more than intended3. Drinking more than intended

4. Desire to or inability to control drinking4. Desire to or inability to control drinking

5. Considerable time spent drinking5. Considerable time spent drinking

6. Important activities given up due to drinking6. Important activities given up due to drinking

7. Continued drinking despite known negative7. Continued drinking despite known negativeconsequencesconsequences (3 or more = diagnostic)(3 or more = diagnostic)

Criteria for Diagnosisof Abuse (DSM-IV)

1. Drinking leads to failing to fill major roles1. Drinking leads to failing to fill major roles

2. Recurrent drinking when it is physically 2. Recurrent drinking when it is physically hazardoushazardous

3. Recurrent alcohol-related legal problems3. Recurrent alcohol-related legal problems

4. Continued drinking despite persistent 4. Continued drinking despite persistent social or interpersonal problemssocial or interpersonal problems

(1 or more = diagnostic)(1 or more = diagnostic)

other alcohol-related diagnoses (DSM-IV)

Other DSM-IV alcohol-related conditionsOther DSM-IV alcohol-related conditions Examples:Examples:

intoxicationintoxicationwithdrawalwithdrawalalcohol-induced deliriumalcohol-induced deliriumalcohol-related dementiaalcohol-related dementia

Other substance use disorders Other substance use disorders (by drug class) (by drug class)

natural history a la Vaillant

Landmark study published in 1983Landmark study published in 1983 LongitudinalLongitudinal

followed subject for 50 years followed subject for 50 years Information on pre-alcoholism stateInformation on pre-alcoholism state Able to sort out results of alcoholism fromAble to sort out results of alcoholism from

pre-existing factors pre-existing factors

findings: natural history a la Vaillant

No support for then popular theory of No support for then popular theory of “alcoholic personality”“alcoholic personality”

Typically, a progressive downward courseTypically, a progressive downward course Essentially two outcomesEssentially two outcomes

people either became abstinence or died people either became abstinence or died Very few returned to non-problematic Very few returned to non-problematic

drinkingdrinking