Alcohol dependence, as described in the DSM-IV, is a psychiatric diagnosis (a substance related disorder DSM-IV) describing an entity in which an individual uses alcohol despite significant areas of dysfunction, evidence of physical dependence, and/or related hardship.
Definition and diagnosis
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)
History and epidemiology
About 12% of American adults have had an alcohol dependence problem at some time in their life. Alcohol dependence is acknowledged by the American Medical Association as a disease because it has a characteristic set of signs and symptoms and a progressive course.
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. This work began in 1976 when the British psychiatrist Griffith Edwards and his American colleague Milton M. Gross 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’.
Screening tools
The Alcohol Use Disorders Identification Test (AUDIT) is the most accurate alcohol screening tool for identifying potential alcohol misuse, including dependence. It was developed by the World Health Organisation, designed initially for use in primary healthcare settings with supporting guidance . Its use has replaced older screening tools such as CAGE but there are many shorter alcohol screening tools, 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.
Comparisons with other alcohol-related disorders
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.
- 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.
- In alcohol dependence, remission as defined within DSM-IV can be attained despite continued use of alcohol. That is, a patient can be in full sustained remission yet still be drinking alcohol so long as the patient does not meet the noted criteria. 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:
- Narrowing of the drinking repertoire.
- Increased salience of the need for alcohol over competing needs and responsibilities.
- An acquired tolerance to alcohol.
- Withdrawal symptoms.
- Relief or avoidance of withdrawal symptoms by further drinking.
- Subjective awareness of compulsion to drink.
- Reinstatement after abstinence.