Chapter Four: Alcohol Dependence

1. Chapter Four: Alcohol Dependence

2. points to consider • Definitions • Disease concept • Natural history • Guidelines for diagnosis

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

4. definition: American Society of Addiction Medicine (ASAM) Alcoholism (dependence) is a “primary, chronicdisease with genetic, psychological and environmental factors... often progressive and fatal. …characterized by impaired control over drinking, preoccupation…, alcohol use despite adverse consequences…” 1993

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

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

7. 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

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

9. Jellinek’s phases of alcoholism Four stages • Pre-alcoholic Phase • Prodromal Phase - prodromal means signaling or warning • Crucial Phase • Chronic Phase

10. Jellinek phases of alcohol addiction

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

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

13. Jellinek’s phases of alcoholism Crucial Phase • Key symptom: loss of control • Drinking stands out • Drinking requires explanation • Adopt tactics to regain control • Life is alcohol-centered • Deteriorating relationships

14. Jellinek’s 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

15. phases of alcoholism some caveats • Product of era when developed • Some elements discounted 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

16. 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

17. species of alcoholismalpha 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” 

18. species of alcoholismbeta alcoholism • Physical problems of heavy drinking • Absence of psychological or physical dependence • Common in cultures with heavy drinking and inadequate diet 

19. species of alcoholismgamma alcoholism • Species identified in Phases of Alcoholism Addiction • Tolerance, loss of control • Psychological  physical dependence • Suggested to be most common type in US 

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

21. species of alcoholismepsilon alcoholism • Studied less intensively • Seen as different from other species • Described as “periodic alcoholism” • Marked by periodic binge drinking 

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

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

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

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

26. American Psychiatric Association APA’s Diagnostic & Statistical ManualThird Edition, 1980, a milestone • set forth explicit criteria for diagnosis • no longer dependent on theories of cause • created new category “Substance Use Disorders”

27. Criteria for Diagnosisof 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)

28. Criteria for Diagnosisof 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)

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

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

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

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

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

34. types of alcoholism (cont’d) model of secondaryalcoholism Note: Treatment required for both the psychiatric condition and the alcoholism stressexposure susceptibility primary psychiatric disorder self-medication with alcohol secondary alcoholism

35. 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 Caffeine Cannabis Cocaine Hallucinogens Inhalants Opiates Phencyclidine (PCP) diagnostic criteria for other substances