Chapter Four: Alcohol Dependence

points to consider Definitions Definitions Disease concept Disease concept Natural history Natural history Guidelines for diagnosis Guidelines for diagnosis

definitions Earliest definitions Earliest definitions much variation much variation focus on different aspects example: descriptive only vs. causes focus on different aspects example: descriptive only vs. causes Efforts to promote uniformity Efforts to promote uniformity International Classification Diseases, WHO, 1977 International Classification Diseases, WHO, 1977 Diagnostic and Statistical Manual, APA, 1980 Diagnostic and Statistical Manual, APA, 1980

definition: American Society of Addiction Medicine (ASAM) Alcoholism (dependence) is a primary, chronic disease with genetic, psychological and environmental factors... often progressive and fatal. …characterized by impaired control over drinking, preoccupation…, alcohol use despite adverse consequences…

key points of ASAM definition Characterization as a disease that is chronic chronic primary primary progressive progressive

implications of disease concept Dictates attitudes Dictates attitudes Identifies care-givers Identifies care-givers Reduces stigma Reduces stigma Moves from punishment to treatment Moves from punishment to treatment

management of chronic disease Treatment of acute flare-ups Treatment of acute flare-ups Emotional support Emotional support Patient education Patient education Rehabilitation to live with limitations Rehabilitation to live with limitations Family involvement Family involvement Partnership of physician and patient Partnership of physician and patient

natural history a la EM Jellinek Natural history is how a disease unfolds Natural history is how a disease unfolds EM Jellinek first to describe natural history of alcoholism EM Jellinek first to describe natural history of alcoholism Based on survey of 2,000 early AA members Based on survey of 2,000 early AA members Identified pattern in emergence of symptoms Identified pattern in emergence of symptoms Grouped signs/symptoms into phases Grouped signs/symptoms into phases

Jellineks phases of alcoholism Four stages Four stages Pre-alcoholic Phase Pre-alcoholic Phase Prodromal Phase - prodromal means signaling or warning Prodromal Phase - prodromal means signaling or warning Crucial Phase Crucial Phase Chronic Phase Chronic Phase

Jellinek phases of alcoholaddiction

Jellineks phases of alcoholism Pre-alcoholic Phase Drinking socially motivated Drinking socially motivated Response to alcohol primes drinker offers psychological relief or release of tension Response to alcohol primes drinker offers psychological relief or release of tension Person seeks occasions where drinking is possible Person seeks occasions where drinking is possible Drinking behavior does not stand out Drinking behavior does not stand out Time: several months to 2 + years Time: several months to 2 + years

Jellineks phases of alcoholism Prodromal Phase Blackouts appear, the warning sign Blackouts appear, the warning sign Alcohol no longer just a beverage Alcohol no longer just a beverage Consumption heavy, but doesnt necessarily stand out Consumption heavy, but doesnt necessarily stand out Conscious effort to keep drinking inconspicuous Conscious effort to keep drinking inconspicuous Time: 6 months to 4 or 5 + years Time: 6 months to 4 or 5 + years

Jellineks phases of alcoholism Crucial Phase Key symptom: loss of control Key symptom: loss of control Drinking stands out Drinking stands out Drinking requires explanation Drinking requires explanation Adopt tactics to regain control Adopt tactics to regain control Life is alcohol-centered Life is alcohol-centered Deteriorating relationships Deteriorating relationships

Jellineks phases of alcoholism Chronic Phase Morning drinking common Morning drinking common Social & workplace functioning gone Social & workplace functioning gone Frequent intoxication Frequent intoxication Living on societys fringes Living on societys fringes Withdrawal symptoms without alcohol Withdrawal symptoms without alcohol Rationalization fails so open to treatment Rationalization fails so open to treatment Continued drinking likely, cant see way out Continued drinking likely, cant see way out

phases of alcoholism some caveats Product of era when developed Product of era when developed Some elements discounted by later research example: significance of blackouts Some elements discounted by later research example: significance of blackouts Also Jellinek Recognized some cases didnt fit model of phases Recognized some cases didnt fit model of phases Led to formulation of Species of Alcoholism Led to formulation of Species of Alcoholism

species of alcoholism Formulated by EM Jellinek Formulated by EM Jellinek Different varieties of alcoholism Different varieties of alcoholism Possibly product of different cultures Possibly product of different cultures Speculated that not all species may represent a disease Speculated that not all species may represent a disease Five species identified by a Greek letter Five species identified by a Greek letter

species of alcoholism alpha alcoholism Purely psychological dependence Purely psychological dependence Not loss of control nor inability to abstain Not loss of control nor inability to abstain Hallmark: drinking to handle problems Hallmark: drinking to handle problems Progression not inevitable Progression not inevitable Recognized as what others might call problem drinking Recognized as what others might call problem drinking

species of alcoholism beta alcoholism Physical problems of heavy drinking Physical problems of heavy drinking Absence of psychological or physical dependence Absence of psychological or physical dependence Common in cultures with heavy drinking and inadequate diet Common in cultures with heavy drinking and inadequate diet

species of alcoholism gamma alcoholism Species identified in Phases of Alcoholism Addiction Species identified in Phases of Alcoholism Addiction Tolerance, loss of control Tolerance, loss of control Psychological physical dependence Psychological 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 Psychological physical dependence Psychological physical dependence Can control amount consumed on any occasion Can control amount consumed on any occasion But cannot cease drinking without withdrawal But cannot cease drinking without withdrawal

species of alcoholism epsilon alcoholism Studied less intensively Studied less intensively Seen as different from other species Seen as different from other species Described as periodic alcoholism Described as periodic alcoholism Marked by periodic binge drinking Marked by periodic binge drinking

emergence of disease approach Disease formulation garnered acceptance Disease formulation garnered acceptance If a disease If a disease a need to formalize definitions a need to formalize definitions a need for guides to diagnosis, i.e. diagnostic criteria a need for guides to diagnosis, i.e. diagnostic criteria

formalizing disease concept ( cont.) Actions by professional associations National Council on Alcoholism National Council on Alcoholism World Health Organization (ICD) World Health Organization (ICD) American Psychiatric Associations (Diagnostic and Statistical Manual) American Psychiatric Associations (Diagnostic and Statistical Manual)

National Council on Alcoholism 1972, published Criteria for Diagnosis 1972, published Criteria for Diagnosis Identified signs and symptoms Identified signs and symptoms Two types of data Two types of data physiological/clinical physiological/clinical behavioral, psychological behavioral, psychological For each type of data: major and minor criteria For each type of data: major and minor criteria

National Council on Alcoholism ( cont.) Based on external verifiable data Based on external verifiable data Example: alcohol on breath at appointment Example: alcohol on breath at appointment Jellinek signs were subjective and included efforts to deceive Jellinek signs were subjective and included efforts to deceive Characterizes disease as chronic Characterizes disease as chronic Offers criteria to assess post-treatment status Offers criteria to assess post-treatment status

American Psychiatric Association APAs Diagnostic & Statistical Manual Third Edition, 1980, a milestone APAs Diagnostic & Statistical Manual Third Edition, 1980, a milestone set forth explicit criteria for diagnosis set forth explicit criteria for diagnosis no longer dependent on theories of cause no longer dependent on theories of cause created new category Substance Use Disorders created new category Substance Use Disorders

Criteria for Diagnosis of Dependence (DSM-IV TR) 1. Tolerance 2. Withdrawal 3. Drinking more than intended 4. Desire to or inability to control drinking 5. Considerable time spent drinking 6. Important activities given up due to drinking 7. Continued drinking despite known negative consequences (3 or more = diagnostic) consequences (3 or more = diagnostic)

Criteria for Diagnosis of Abuse (DSM-IV TR) 1. Recurrent drinking leads to failing to fill major roles 2. Recurrent drinking when it is physically hazardous 3. Recurrent alcohol-related legal problems 4. Continued drinking despite persistent social or interpersonal problems (1 or more = diagnostic) (1 or more = diagnostic)

other alcohol-related diagnoses (DSM-IV TR) Other DSM-IV alcohol-related conditions Other DSM-IV alcohol-related conditions Include: intoxication withdrawal alcohol-induced delirium alcohol-related dementia Include: intoxication withdrawal alcohol-induced delirium alcohol-related dementia Other substance use disorders (by drug class) Other substance use disorders (by drug class)

natural history a la Vaillant Landmark study published in 1983 Landmark study published in 1983 Longitudinal study followed subjects for 50 years Longitudinal study followed subjects for 50 years Information on pre-alcoholic state Information on pre-alcoholic state Able to sort out results of alcoholism from pre-existing factors Able to sort out results of alcoholism from pre-existing factors

findings: natural history a la Vaillant No support for then-popular theory of alcoholic personality No support for then-popular theory of alcoholic personality Typically, a progressive downward course Typically, a progressive downward course Essentially two outcomes: people became abstinent or died Essentially two outcomes: people became abstinent or died Very few returned to non-problematic drinking Very few returned to non-problematic drinking

factors associated with recovery Identified by Vaillant Identified by Vaillant Presence of vital interest Presence of vital interest External reminders External reminders Unambivalent social support Unambivalent social support Source of hope and inspiration Source of hope and inspiration

types of alcoholism Primary Alcoholism Primary Alcoholism no psychological condition that leads to development of alcoholism no psychological condition that leads to development of alcoholism Secondary Alcoholism Secondary Alcoholism grows out of major psychological problem or psychiatric illness grows out of major psychological problem or psychiatric illness also called Reactive Alcoholism also called Reactive Alcoholism Familial vs. Non-familial Familial vs. Non-familial

types of alcoholism (contd) model of secondary alcoholism Note: Treatment required for both the psychiatric condition and the alcoholism primary psychiatric disorder stress exposure susceptibility self-medication with alcohol secondary alcoholism

diagnostic criteria for other substances Conditions Addressed Dependence Abuse Intoxication from DSM-IV TR Note: Clear withdrawal syndrome not established for all drugs. For those drugs a diagnosis of dependence is based on behavioral features. Organized by Drug Amphetamines Amphetamines Caffeine Caffeine Cannabis Cannabis Cocaine Cocaine Hallucinogens Hallucinogens Inhalants Inhalants Opiates Opiates Phencyclidine (PCP) Phencyclidine (PCP)