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Alcohol dependence

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Alcohol dependence
SpecialtyPsychiatry
Women drinking during pregnancy can cause a fetal alcohol spectrum disorder.
The effects of alcohol has on the body.

Alcohol dependence is a previous (DSM-IV and ICD-10) psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol (also chemically known as ethanol).

In 2013, it was reclassified as alcohol use disorder in DSM-5,[1] which combined alcohol dependence and alcohol abuse into this diagnosis.

Definition

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Addiction and dependence glossary[2][3][4]
  • addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
  • addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence socially seen as being extremely mild compared to physical dependence (e.g., with enough willpower it could be overcome)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Diagnosis

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See also: Alcohol abuse § Diagnosis, and Alcoholism § Diagnosis

DSM: Alcohol dependence

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According to the DSM-IV criteria for alcohol dependence, at least three out of seven of the following criteria must be manifest during a 12-month period:

  • Tolerance
  • Withdrawal symptoms or clinically defined alcohol withdrawal syndrome
  • Use in larger amounts or for longer periods than intended
  • Persistent desire or unsuccessful efforts to cut down on alcohol use
  • Time is spent obtaining alcohol or recovering from effects
  • Social, occupational and recreational pursuits are given up or reduced because of alcohol use
  • Use is continued despite knowledge of alcohol-related harm (physical or psychological)[5]
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Because only 3 of the 7 DSM-IV criteria for alcohol dependence are required, not all patients meet the same criteria and therefore not all have the same symptoms and problems related to drinking. Not everyone with alcohol dependence, therefore, experiences physiological dependence. Alcohol dependence is differentiated from alcohol abuse by the presence of symptoms such as tolerance and withdrawal. Both alcohol dependence and alcohol abuse are sometimes referred to by the less specific term alcoholism. However, many definitions of alcoholism exist, and only some are compatible with alcohol abuse. There are two major differences between alcohol dependence and alcoholism as generally accepted by the medical community.

  1. Alcohol dependence refers to an entity in which only alcohol is the involved addictive agent. Alcoholism refers to an entity in which alcohol or any cross-tolerant addictive agent is involved.
  2. In alcohol dependence, reduction of alcohol, as defined within DSM-IV, can be attained by learning to control the use of alcohol. That is, a client can be offered a social learning approach that helps them to 'cope' with external pressures by re-learning their pattern of drinking alcohol. In alcoholism, patients are generally not presumed to be 'in remission' unless they are abstinent from alcohol.

The following elements are the template for which the degree of dependence is judged:

  1. Narrowing of the drinking repertoire.
  2. Increased salience of the need for alcohol over competing needs and responsibilities.
  3. An acquired tolerance to alcohol.
  4. Withdrawal symptoms.
  5. Relief or avoidance of withdrawal symptoms by further drinking.
  6. Subjective awareness of compulsion to drink.
  7. Reinstatement after abstinence.[6]

Screening

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See also: Alcohol abuse § Screening

AUDIT has replaced older screening tools such as CAGE but there are many shorter alcohol screening tools,[7] mostly derived from the AUDIT. The Severity of Alcohol Dependence Questionnaire (SAD-Q) is a more specific twenty-item inventory for assessing the presence and severity of alcohol dependence.

AUDIT

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The Alcohol Use Disorders Identification Test (AUDIT) is considered the most accurate alcohol screening tool for identifying potential alcohol misuse, including dependence.[8] It was developed by the World Health Organization, designed initially for use in primary healthcare settings with supporting guidance.[9]

CAGE

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The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used method of screening for alcohol dependence.

SADQ

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The Severity of Alcohol Dependence Questionnaire (SADQ or SAD-Q) is a 20 item clinical screening tool designed to measure the presence and level of alcohol dependence.[10]

Withdrawal

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Withdrawals from alcohol dependence is a common side effect that occurs when a person with the dependency stops drinking abruptly or even cuts back on their drinking after a prolonged period of indulgence. Withdrawal from alcohol dependence can vary from mild, moderate to severe, depending on several factors such as: how long the person has been drinking, whether they are a binge drinker, whether they relapse chronically, and how much they drink daily. All these factors can vary from one person to the next depending on psychological, environmental, and biological factors.[11] Some common withdrawal side effects are as listed:

Mild

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Severe

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Hallucinations from alcohol withdrawal.

The spectrum of alcohol withdrawal symptoms range from such minor symptoms as insomnia and tremulousness to severe complications such as withdrawal seizures and delirium tremens.[12] Alcohol withdrawal syndrome can be very tricky to diagnose, due to other preliminary conditions that may exist from individual to individual.

Treatment

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Treatments for alcohol dependence can be separated into two groups, those directed towards severely alcohol-dependent people, and those focused for those at risk of becoming dependent on alcohol. Treatment for alcohol dependence often involves utilizing relapse prevention, support groups, psychotherapy,[13] and setting short-term goals.[14] The Twelve-Step Program is also a popular faith-based process used by those wishing to recover from alcohol dependence.[15]

The ultimate goal when it comes to treating alcohol dependence or as the DSM-5 now calls it alcohol use disorder, is to help with establishing abstinence from drinking. There are several other benefits that come along with treatment. For some, it is reconnecting with themselves and obtaining self-esteem and confidence, a healthier lifestyle (physically and mentally), creating new relationships with other like-minded people as well as rekindling or mending old relationships if possible. The treatment process consists typically of two parts short-term and long-term. First, there is the path to abstinence and/or recovery. There are several reasons why someone with alcohol use disorder or alcohol dependency would seek treatment. This can either be a personal reason or because of law enforcement. There is a series of different levels of treatment processes depending on the severity subtype. Some would or could benefit from medication treatment with psychosocial treatment, while others could just benefit from psychosocial treatment. Listed below are some different types of treatments that are used with treating alcohol dependency/alcohol use disorder depending on several factors that vary from person to person.[16]

Treatment and support

Types of treatments:

Acceptance and mindfulness-based interventions show evidence of efficacy in being used to target Alcohol Use Disorder. These types of interventions are often most effectively delivered in group settings, however, they are also proven effective in individual therapy contexts. Overall, this is crucial in helping individuals who are dependent on alcohol because it raises awareness, provides a non-judgemental environment for people to express their thoughts, and allows individuals to be heard and accepted in the present moment. [17]

Epidemiology

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"The Drunkard's Progress", 1846

About 12% of American adults have had an alcohol dependence problem at some time in their life.[18] In the UK the NHS estimates that around 9% of men and 4% of UK women show signs of alcohol dependence.[19]

Genetic factors

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A 2015 study found that alcohol dependency may have genetic risk factors. Linkage disequilibrium between an AD-associated GABA receptor gene cluster, GABRB3/GABRG3, and eye color genes, OCA2/HERC2, as well as between AD-associated GRM5 and pigmentation-associated TYR, were all associated with alcohol dependency.[20] GABA downregulation may decrease sensitivity to the toxic effects of alcohol, leading to increased alcohol consumption in blue-eyed individuals.[21]

History

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The term 'alcohol dependence' has replaced 'alcoholism' as a term in order that individuals do not internalize the idea of cure and disease, but can approach alcohol as a chemical they may depend upon to cope with outside pressures.

The contemporary definition of alcohol dependence is still based upon early research. There has been considerable scientific effort over the past several decades to identify and understand the core features of alcohol dependence.[22] This work began in 1976, when the British psychiatrist Griffith Edwards and his American colleague Milton M. Gross [23] collaborated to produce a formulation of what had previously been understood as 'alcoholism' – the alcohol dependence syndrome.

The alcohol dependence syndrome was seen as a cluster of seven elements that concur. It was argued that not all elements may be present in every case, but the picture is sufficiently regular and coherent to permit clinical recognition. The syndrome was also considered to exist in degrees of severity rather than as a categorical absolute. Thus, the proper question is not 'whether a person is dependent on alcohol', but 'how far along the path of dependence has a person progressed'.

See also

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[24]

Notes

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  1. ^ "Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5". November 2013. Retrieved 9 May 2015.
  2. ^ Malenka RC, Nestler EJ, Hyman SE (2009). "Chapter 15: Reinforcement and Addictive Disorders". In Sydor A, Brown RY (eds.). Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. pp. 364–375. ISBN 9780071481274.
  3. ^ Nestler EJ (December 2013). "Cellular basis of memory for addiction". Dialogues in Clinical Neuroscience. 15 (4): 431–443. PMC 3898681. PMID 24459410. Despite the importance of numerous psychosocial factors, at its core, drug addiction involves a biological process: the ability of repeated exposure to a drug of abuse to induce changes in a vulnerable brain that drive the compulsive seeking and taking of drugs, and loss of control over drug use, that define a state of addiction. ... A large body of literature has demonstrated that such ΔFosB induction in D1-type [nucleus accumbens] neurons increases an animal's sensitivity to drug as well as natural rewards and promotes drug self-administration, presumably through a process of positive reinforcement ... Another ΔFosB target is cFos: as ΔFosB accumulates with repeated drug exposure it represses c-Fos and contributes to the molecular switch whereby ΔFosB is selectively induced in the chronic drug-treated state.41. ... Moreover, there is increasing evidence that, despite a range of genetic risks for addiction across the population, exposure to sufficiently high doses of a drug for long periods of time can transform someone who has relatively lower genetic loading into an addict.
  4. ^ Volkow ND, Koob GF, McLellan AT (January 2016). "Neurobiologic Advances from the Brain Disease Model of Addiction". New England Journal of Medicine. 374 (4): 363–371. doi:10.1056/NEJMra1511480. PMC 6135257. PMID 26816013. Substance-use disorder: A diagnostic term in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) referring to recurrent use of alcohol or other drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Depending on the level of severity, this disorder is classified as mild, moderate, or severe.
    Addiction: A term used to indicate the most severe, chronic stage of substance-use disorder, in which there is a substantial loss of self-control, as indicated by compulsive drug taking despite the desire to stop taking the drug. In the DSM-5, the term addiction is synonymous with the classification of severe substance-use disorder.
  5. ^ "DSM-IV Criteria for Alcohol Abuse and Alcohol Dependence". Archived from the original on 2005-03-24.
  6. ^ Clark, David, Background Briefing, Alcohol Dependence, Drink and Drug News, 7 February 2005, p. 11
  7. ^ "Alcohol use screening tests – GOV.UK". www.gov.uk. Retrieved 8 April 2018.
  8. ^ "AUDIT – Alcohol Use Disorders Identification Test". Alcohol Learning Centre. 28 June 2010. Archived from the original on 17 March 2012. Retrieved 3 June 2012.
  9. ^ "World Health Organization" (PDF). World Health Organization. Archived from the original (PDF) on April 23, 2004. Retrieved 8 April 2018.
  10. ^ "SADQ or SAD-Q Questionnaire – find out if you are dependent on alcohol". www.markjayalcoholdetox.co.uk. Archived from the original on 2017-07-07. Retrieved 2017-09-26.
  11. ^ Becker, Howard C. (2008). "Alcohol Dependence, Withdrawal, and Relapse". Alcohol Research & Health. 31 (4): 348–361. ISSN 1535-7414. PMC 3860472. PMID 23584009.
  12. ^ Bayard, Max; McIntyre, Jonah; Hill, Keith; Woodside, Jack (2004-03-15). "Alcohol Withdrawal Syndrome". American Family Physician. 69 (6): 1443–1450. ISSN 0002-838X. PMID 15053409.
  13. ^ "Alcohol Dependence and Treatment". ICAP Blue Book. International Center for Alcohol Policies. Archived from the original on 27 February 2013. Retrieved 2 June 2012.
  14. ^ "Alcohol use disorder". Mayo Clinic. Retrieved 4 October 2020.
  15. ^ "What is Alcohol Addiction: What Causes Alcohol Addiction?". MedicalBug. 6 January 2012. Archived from the original on 19 May 2012. Retrieved 2 June 2012.
  16. ^ "UpToDate". www.uptodate.com. Retrieved 2021-05-18.
  17. ^ Witkiewitz, K.; Litten, R.; Leggio, L. (2019-09-25). "Advances in the science and treatment of Alcohol Use Disorder". Science Advances. 69 (6): 1443–1450. ISSN 0002-838X. PMID 15053409.
  18. ^ Hasin D; et al. (2007). "Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United States". Archives of General Psychiatry. 64 (7): 830–42. doi:10.1001/archpsyc.64.7.830. PMID 17606817.
  19. ^ "Alcohol dependence and withdrawal".
  20. ^ Sulovari, Arvis; Kranzler, Henry R.; Farrer, Lindsay A.; Gelernter, Joel; Li, Dawei (July 2015). "Eye color: A potential indicator of alcohol dependence risk in European Americans". American Journal of Medical Genetics Part B: Neuropsychiatric Genetics. 168 (5): 347–353. doi:10.1002/ajmg.b.32316. ISSN 1552-4841.
  21. ^ Eissenberg, Joel C. (2024-03-14). "More than Meets the Eye: Eye Color and Alcoholism". Missouri Medicine. 113 (2). Missouri State Medical Association. PMID 27311215. Retrieved 2024-05-21.
  22. ^ Irving B. Weiner; Donald K. Freedheim; George Stricker; Thomas A. Widiger (2003). Handbook of Psychology: Clinical psychology. John Wiley and Sons. pp. 201–. ISBN 978-0-471-39263-7. Retrieved 16 April 2010.
  23. ^ Edwards G. & Gross MM, Alcohol dependence: provisional description of a clinical syndrome, BMJ 1976; i: 1O58-106
  24. ^ Alcohol Recovery Program
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