Chapter Four: 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 International Classification Diseases, International Classification Diseases,

WHO, 1977WHO, 1977 Diagnostic and Statistical Manual, Diagnostic and Statistical Manual,

APA, 1980APA, 1980

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 definitionCharacterization as a disease that is Characterization as a disease that is chronicchronic primaryprimary progressiveprogressive

implications of disease concept

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

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

Natural history is how a disease unfoldsNatural history is how a disease unfolds EM Jellinek first to describe natural history ofEM Jellinek first to describe natural history of

alcoholism alcoholism Based on survey of 2,000 early AA membersBased on survey of 2,000 early AA members Identified pattern in emergence of symptoms Identified pattern in emergence of symptoms Grouped signs/symptoms into phasesGrouped signs/symptoms into phases

Jellinek’s phases of alcoholism

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

- - prodromal means prodromal means signalingsignaling or or warningwarning Crucial PhaseCrucial Phase Chronic PhaseChronic Phase

JellinekJellinek

phases ofphases of

alcohol alcohol

addictionaddiction

Jellinek’s phases of alcoholism Pre-alcoholic Phase

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

offers psychological relief offers psychological relief or release of tensionor release of tension

Person seeks occasions where Person seeks occasions where drinking is possibledrinking is possible

Drinking behavior does not stand outDrinking behavior does not stand out Time: several months to 2Time: several months to 2++ years years

Jellinek’s 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, but doesn’tConsumption heavy, but doesn’t

necessarily stand outnecessarily stand 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

Jellinek’s phases of alcoholism Crucial Phase

Key symptom: loss of controlKey symptom: loss of control Drinking stands outDrinking stands out Drinking requires explanationDrinking requires explanation Adopt tactics to regain controlAdopt tactics to regain control Life is alcohol-centeredLife is alcohol-centered Deteriorating relationshipsDeteriorating relationships

Jellinek’s 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 discounted by later research Some elements discounted by later research

example: significance of blackoutsexample: significance of blackouts

Also Jellinek Also Jellinek Recognized some cases didn’t fit 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 dietand 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 USSuggested 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

emergence of 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 diagnosis, i.e.a need for guides to diagnosis, i.e.

diagnostic criteriadiagnostic criteria

formalizing disease concept (cont.)

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 dataTwo types of data

physiological/clinicalphysiological/clinical behavioral, psychologicalbehavioral, psychological

For each type of data: major and minor For each type of data: major and minor criteria criteria

National Council on Alcoholism (cont.)

Based on external verifiable dataBased on external verifiable data Example: alcohol on breath at Example: alcohol on breath at

appointmentappointment Jellinek signs were subjective andJellinek signs were subjective and

included efforts to deceive included efforts to deceive Characterizes disease as chronic Characterizes disease as chronic Offers criteria to assess post-treatment statusOffers criteria to assess post-treatment status

American Psychiatric Association

APA’s APA’s Diagnostic & Statistical ManualDiagnostic & Statistical Manual Third Edition, 1980, a milestoneThird Edition, 1980, 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 new categorycreated new category

“Substance Use Disorders” “Substance Use Disorders”

Criteria for Diagnosisof Dependence (DSM-IV

TR) 1. Tolerance1. Tolerance2. Withdrawal2. Withdrawal3. Drinking more than intended3. Drinking more than intended4. Desire to or inability to control drinking4. Desire to or inability to control drinking5. Considerable time spent drinking5. Considerable time spent drinking6. Important activities given up due to drinking6. Important activities given up due to drinking7. Continued drinking despite known negative7. Continued drinking despite known negative

consequencesconsequences (3 or more = diagnostic)(3 or more = diagnostic)

Criteria for Diagnosisof Abuse (DSM-IV TR)

1. 1. Recurrent drinking leads to failing to fill major Recurrent drinking leads to failing to fill major rolesroles

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

TR) Other DSM-IV alcohol-related conditionsOther DSM-IV alcohol-related conditions Include:Include:

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 Longitudinal study Longitudinal study

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

pre-existing factorspre-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 outcomes:Essentially two outcomes:

people became abstinent or diedpeople became abstinent or died Very few returned to non-problematic Very few returned to non-problematic

drinkingdrinking

factors associated with factors associated with recoveryrecovery Identified by VaillantIdentified by Vaillant

Presence of vital interestPresence of vital interest External remindersExternal reminders Unambivalent social Unambivalent social support support Source of hope andSource of hope and inspiration inspiration

types of alcoholism

Primary AlcoholismPrimary Alcoholism no psychological condition that leads tono psychological condition that leads to

development of alcoholismdevelopment of alcoholism

Secondary AlcoholismSecondary Alcoholism grows out of major psychological grows out of major psychological

problem or psychiatric illness problem or psychiatric illness also called Reactive Alcoholismalso called Reactive Alcoholism

Familial vs. Non-familialFamilial vs. Non-familial

types of alcoholism (cont’d)

model of model of secondarysecondaryalcoholismalcoholism

Note: Treatment required for Note: Treatment required for both the psychiatric both the psychiatric condition and the alcoholismcondition and the alcoholism

primary psychiatric disorder

stress exposure susceptibility

self-medication with alcohol

secondary alcoholism

diagnostic criteria for other substances

Conditions Addressed Conditions Addressed

DependenceDependence AbuseAbuse IntoxicationIntoxication

from from DSM-IV TRDSM-IV TRNote: Clear withdrawal syndrome not Note: Clear withdrawal syndrome not

established for all drugs. For those established for all drugs. For those drugs a diagnosis of dependence drugs a diagnosis of dependence is based on behavioral features.is based on behavioral features.

Organized by DrugOrganized by Drug

AmphetaminesAmphetamines CaffeineCaffeine CannabisCannabis CocaineCocaine HallucinogensHallucinogens InhalantsInhalants OpiatesOpiates Phencyclidine (PCP)Phencyclidine (PCP)