Chapter Three: Alcohol Dependence

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

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

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  Primary  Progressive

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

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

natural history a la EM Jellinek  How a disease or condition unfolds  EM Jellinek first to describe  Based on survey of 2,000 early AA members  Identified pattern in emergence of symptoms  Grouped signs/symptoms into phases

Phases of alcoholism Four stages Four stages  Pre-alcoholic Phase  Prodromal Phase means “signaling” or “warning”  Crucial Phase  Chronic Phase

phases of alcoholism Pre-alcoholic Phase  Drinking socially motivated  Response to alcohol “primes” drinker psychological relief release of tension seeks occasions where drinking  Drinking behavior does not stand out  Time: several months to 2 + years

phases of alcoholism Prodromal Phase  Blackouts appear, the warning sign  Alcohol no longer just a beverage  Consumption heavy, doesn’t necessarily stand out  Conscious effort to keep drinking inconspicuous  Time: 6 months to 4 or 5 + years

phases of alcoholism Crucial Phase  Key symptom, loss of control  Drinking stands out  Drinking requires explanation  Adopts tactics to regain control  Life alcohol-centered  Deteriorating relationships

phases of alcoholism Chronic Phase  Morning drinking common  Social & workplace functioning gone  Frequent intoxication  Living on society’s fringes  Withdrawal symptoms without alcohol  Rationalization fails  so open to treatment  Continued drinking likely, can’t see way out

phases of alcoholism some caveats  Product of era when developed  Some elements countered by later research example: significance of blackouts Also  Jellinek recognized some cases didn’t fit model of Phases  Led to formulation of Species of Alcoholism

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

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

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

species of alcoholism gamma alcoholism  Species identified in Phases of Alcoholism Addiction  Tolerance, loss of control  Psychological  physical dependence  Suggested to be most common type in US” 

species of alcoholism delta alcoholism  Similar to gamma alcoholism  Psychological  physical dependence  Can control amount consumed on any occasion  But cannot cease drinking without withdrawal 

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

formalizing disease approach  Disease formulation garnered acceptance  If a disease  a need to formalize definitions  a need for guides to diagnosis  Actions by professional associations  National Council on Alcoholism  World Health Organization (ICD)  American Psychiatric Associations (Diagnostic and Statistical Manual)

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

National Council on Alcoholism  1972, published Criteria for Diagnosis  Identified signs and symptoms  Two types of datas  physiological/clinical  behavioral, psychological  within each track: major and minor criteria  Similarity to Jellinek, but external data

National Council on Alcoholism ( cont.)  Based on external verifiable data  Jellinek signs efforts to deceive  examples: alcohol or breathe at appointment  Characterizes disease as chronic  Suggests criteria for assessing post- treatment status

American Psychiatric Association APA’s Diagnostic & Statistical Manual 1980 edition, a milestone APA’s Diagnostic & Statistical Manual 1980 edition, a milestone  set forth explicit criteria for diagnosis  no longer dependent on theories of cause  created category “Substance Use Disorders”

Criteria for Diagnosis of Dependence (DSM-IV) 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)

Criteria for Diagnosis of Abuse (DSM-IV) 1. 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)  Other DSM-IV alcohol-related conditions  Examples: intoxication withdrawal alcohol-induced delirium alcohol-related dementia  Other substance use disorders (by drug class)

natural history a la Vaillant  Landmark study published in 1983  Longitudinal followed subject for 50 years  Information on pre-alcoholism state  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”  Typically, a progressive downward course  Essentially two outcomes people either became abstinence or died  Very few returned to non-problematic drinking