Alcohol Abuse Diagnosis

  • Diagnosis

    Alcohol dependence (alcoholism) is a condition in which a person becomes physically dependent on alcohol Table 01. Physical or psychological repercussions from drinking, rather than the amount of alcohol consumed or frequency with which a person drinks, define alcohol abuse and dependence. With increased consumption, a person can develop a tolerance to alcohol, and will require greater quantities of alcohol to achieve a "high" feeling. A person with alcohol dependence may also experience symptoms of withdrawal with reduced alcohol intake.

    Alcohol abuse is the most common psychiatric disease in the US, with an estimated 13.7% to 23.5% of the general population experiencing problems with abuse or dependence during their lifetimes Table 02. Most people who have alcohol problems are employed and have families. Only 5% are stereotypical "Skid Row" drinkers. More men than women are affected by alcohol abuse, however the prevalence in women is rising. Professionals and executives, people under the age of 25, and elderly people are also at risk for alcohol abuse.

    Table 1. Continuum of Alcohol Abuse Severity

    Classification Behavior
    Social drinker Amount consumed and setting appear socially acceptable, but person has a propensity to overindulge or occasionally use alcohol to cope with stress
    Heavy social drinker Drinks in socially acceptable settings, but actively seeks occasions to drink, usually more than 2 drinks per day
    Problem drinker Heavy drinker, gets drunk, exhibits medical, legal, social, psychological consequences of excessive alcohol consumption; may have made attempts to cut down; variably functional
    Alcohol-dependent Tries to consume same excessive amount of alcohol regardless of mood or setting; alcohol is given top priority in all situations; tolerance develops and symptoms of withdrawal may be noted during the workday when alcohol levels drop; individual is aware of his compulsion, but is difficult to reach
    Severely deteriorated Constant state of intoxication; the person doesn't care for self or surroundings; many hospitalizations for detoxification and medical care after alcohol-related trauma or organ damage occur

    Table 2. Racial and Gender Difference In Alcohol Abuse and Related Problems

    Race or gender Comments
    White Largest number with alcohol problems
    Double the rate of driving under the influence of alcohol
    White women have higher rates of alcohol abuse and dependence than women of other races
    Black Higher rates of abstinence and lower rates of heavy use (especially in women)
    Higher rates of alcohol-related disease, injury, psychological problems, and homicide
    Greater alcohol-related problems among the socioeconomically deprived
    Hispanic Great diversity in drinking patterns among different groups
    Lower rates of use among women
    Heavier use and greater alcohol-related problems after age 30
    American Indian and Native Alaskan Great diversity in drinking patterns among tribal groups
    Highest prevalence of AA-D among all racial groups
    Highest consumption between ages 25 and 45 (75% of traumatic deaths and suicides are related to alcohol)
    Asian Lowest levels of alcohol consumption, alcohol abuse and dependence, and related problems
    Female Few studies prior to 1980; lower rates of heavy drinking and alcohol-related problems than men; heavier drinking among younger age groups (21-35 years), those living with heavy-drinking partner or spouse, those unmarried living with significant others, and those who are unemployed or employed part-time. Increased rates of drinking as gender roles approximate those in men. Heavy drinking tends to develop following medical or psychiatric illness

    Alcohol depresses the central nervous system, altering thinking, judgment, and behavior. People with alcohol problems crave a drink, and are not able to limit their intake. With increased consumption, the alcoholic loses his or her ability to think clearly and maintain normal coordination.

    Alcohol abuse is thought to occur when drinking repeatedly interferes with school, work, household responsibilities, and relationships with family and friends. Some people with alcohol problems are arrested for drinking and driving, or for displaying intoxicated behavior.

    Alcohol abuse can seriously endanger physical health Table 03. Liver, pancreas, and brain damage can occur with alcohol abuse, as can gastrointestinal inflammation, ulceration, and diarrhea. Chronic alcohol abuse is associated with an increased incidence of pneumonia and tuberculosis, and alcoholics are 10 times more likely to have cancer. Sleep, memory, and sexual performance disturbances can occur in alcoholics as well.

    Alcohol abuse and dependence create a number of social and psychological problems: it is associated with the spread of sexually transmitted diseases, as well as increased rates of domestic abuse, violent crime, and suicide Table 04.

    Table 3. Medical Illness Associated With Chronic Alcohol Abuse

    Disorder Illness
    Metabolic Alcoholic ketoacidosis, alcoholic hypoglycemia, water and salt disorders
    Neurologic Chronic problems with thinking such as Wernicke's encephalopathy and Korsakoff's psychosis, alcoholic cerebellar degeneration, and central pontine myelinolysis leading to problems walking and other motor activities, acute and chronic dementia, alcoholic peripheral neuropathy
    Muscular Acute and chronic alcoholic muscle weakness
    Gastrointestinal Fatty liver, alcoholic hepatitis, alcoholic cirrhosis, alcoholic pancreatitis, poor pancreatic function, gastroesophageal reflux, esophageal carcinoma, erosive gastritis, chronic diarrhea, malabsorption, esophageal varices leading to bleeding into the GI tract
    Metabolic-endocrine High cholesterol, high levels of uric acid, low testosterone levels, impotence, testicular atrophy, gynecomastia, irregular menstrual periods, reversible Cushing's syndrome
    Blood Anemia due to poor production of blood cells or slow intestinal bleeding, poor white cell production, destruction of platelets, blood too thin to clot properly.
    Cardiac Decreased cardiac function, arrhythmias, dilated cardiomyopathy, high blood pressure
    Pulmonary Increased incidence of pneumonia, increased incidence of tuberculosis
    Other Increased incidence of severe intestinal infections, fetal alcohol syndrome, vitamin deficiency syndromes, trauma, sexual dysfunction, insomnia

    Table 4. Social Problems Associated With Alcohol Abuse and Dependence in the United States

    Accidental death and injury 50% of fatal car crashes
    25-fold increased risk of falls or drowning
    50% of fire-related burns or deaths
    20% to 30% of trauma seen in emergency rooms
    Crime Frequently involved in violent crime
    Suicide Involved in up to 35% of suicides
    Economic cost $148 billion annually (estimated); 15% for health care and treatment
    Other Associated with increased rates of spouse or child abuse and increased spread of sexually transmitted diseases

    Genetic, environmental, and sociocultural factors are all thought to contribute to alcohol abuse and dependence. The cause for alcohol abuse is not completely understood; biological, societal, psychological, and behavioral theories have been proposed as possible reasons. Studies of twins and of adopted children reveal that there is some genetic link to alcoholism. However, children also learn about and establish attitudes towards drinking by observing parents and peers, suggesting that social factors also play a role.

    Some studies indicate that people who abuse alcohol do not become intoxicated as easily as non-abusers. Some research shows that the brains of alcohol abusers tend to be less sensitive to the effects of the alcohol than non-abusers' brains. Therefore, alcohol abusers need to drink more than the average person in order to become intoxicated, which may lead to the physical problems of dependence.

    If you experience difficulties such as arguments, repeated missed deadlines or appointments, absenteeism, driving after drinking, and run-ins with the law after drinking, you may have an alcohol problem Table 05.

    Table 5. Indicators of Possible Problem Drinking

    Acute symptoms Chronic symptoms Other signs
    Recurrent intoxication
    Amnesic episodes (blackouts)
    Nausea
    Sweating
    Tachycardia
    Tremor
    Fatigue
    Grand mal seizures
    Hallucinations
    Delirium tremens
    Mood swings
    Depression
    Anxiety
    Insomnia
    Dyspepsia
    Nausea
    Diarrhea
    Bloating
    Hematemesis
    Jaundice
    Unsteady gait
    Paraesthesia
    Memory loss
    Erectile dysfunction
    Heavy, regular alcohol consumption
    Other substance abuse, either illegal or prescription
    Heavy cigarette smoking
    Poor nutrition
    Inability to articulate feelings
    Multiple psychosomatic problems
    Spontaneous abortion
    Child with fetal alcohol syndrome
    Domestic violence and abuse
    Frequent falls or minor trauma (especially in the elderly)
    Absenteeism from work
    Interpersonal, financial, and legal problems
    Accidents, burns, violence; suicide attempts
    Unexpected response to medication

    An inability to stop drinking, having symptoms of withdrawal, and compulsive consumption indicate alcohol dependence. An arrest for drinking and driving, being sent home from work for smelling like alcohol, or physically or verbally abusing your family after a few drinks serve as strong warnings that you may have an alcohol problem.

    Having an alcoholic parent increases your risk of developing alcohol problems.

    Close relatives of people who are dependent on alcohol are three to four times more likely than the general population to develop alcohol problems themselves. While the disease tends to run in families, not every child of an alcoholic parent will develop alcohol-related problems. In addition, people with no family history can become dependent upon alcohol as well.

    Growing up in a troubled household may increase your risk of becoming an alcoholic, as may feelings of isolation, depression, and anger. Many alcoholics watched parents fight and separate. Some have low self-esteem, or suffer from bouts of depression and anxiety that may be temporarily alleviated by the "high" feeling one gets from alcohol.

    Gender, age, and race influence your risk for alcoholism. Men, younger people, and whites experience more alcohol-related problems than women, older people, or other racial groups, respectively.

    While men have more problems with alcohol than women, substance-related physical ailments sometimes progress more quickly in women than they would in men because of differences in body composition and alcohol metabolism.

    Elderly patients sometimes start drinking to manage stress, induce sleep, or deal with the loss of a loved one.

    Young people under the age of 25 are at risk of developing alcohol problems in high school or college.

    Professionals and executives who drink socially during the day are at an increased risk of developing alcohol dependence or abuse.

    Your doctor will ask questions about possible job, school, or family difficulties that you may have that are related to alcohol. He or she will also look for biological markers that indicate heavy alcohol use, and will ask about how much alcohol you normally consume Table 06. When taking a medical history, your doctor will ask about any disruptions in your social or work life that may have stemmed from alcohol problems.

    Blood tests indicating elevated liver enzymes or changes to blood cells signal heavy alcohol intake. Acute increase in acetate and ethanol levels in the blood may indicate acute intoxication. Alcohol can be measured in the blood for up to 24 hours. Changes in albumin levels in the blood also can suggest an alcohol problem, as can a nutritional deficiency.

    Table 6. Safety of Various Drinking Levels

    ? Men Women
    Safe levels Up to 2 drinks per day Up to 1 drink per day
    At-risk levels More than 14 drinks per week or more than 4 drinks per occasion More than 7 drinks per week or more than three drinks per occasion
    Heavy drinking More then 5 or 6 drinks a day More than three or four drinks per day

    A series of questions called the CAGE screening tool can help determine if you have a problem with alcohol Table 07. The questions of the CAGE screening tool ask about your desire to cut back on alcohol consumption, annoyance at other peoples' opinions about your drinking habits, guilty feelings about alcohol intake, and whether or not you've ever started the day with an alcoholic beverage to combat a hangover, or to steady your nerves. A "yes" to any of the questions suggests increased risk. Two or more positive responses indicate a need to seek assistance.

    Table 7. CAGEa Screening Exam

    A positive answer to any of these questions signals an increased risk for alcohol problems
    Have you ever felt you should cut down on your drinking?
    Have people annoyed you by criticizing your drinking?
    Have you ever felt bad or guilty about your drinking?
    Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

    aCAGE: Cut down, annoyed by criticism, guilty about drinking, eye-opener drinks.

    This test is not recommended for the elderly.

    The Michigan Alcoholism Screening Test (MAST) is another self-test that can help you determine if you have a drinking problem Table 08.

    Table 8. Michigan Alcoholism Screening Test (MAST)

    Question Yes or No Points
    Do you enjoy a drink now and then? ? 1 for Yes
    Do you feel you are a normal drinker (drink less or as much as others)? ? 2 for No
    Have you ever awakened in the morning after some drinking the night before and found that you could not remember a part of the evening? ? 2 for Yes
    Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking? ? 1 for Yes
    Can you stop drinking without a struggle after one or two drinks? ? 2 for No
    Do you ever feel guilty about your drinking? ? 1 for Yes
    Do friends or relatives think you are a normal drinker? ? 2 for No
    Are you able to stop drinking when you want to? ? 2 for No
    Have you ever attended a meeting of Alcoholics Anonymous (AA)? ? 5 for Yes
    Have you ever gotten into physical fights when drinking? ? 1 for Yes
    Has your drinking ever created problems between you and your wife, husband, a parent, or other relative? ? 2 for Yes
    Has your wife or husband (or other family members) ever gone to anyone for help about your drinking? ? 2 for Yes
    Have you ever lost friends because of drinking? ? 2 for Yes
    Have you gotten into trouble at work or school because of drinking? ? 2 for Yes
    Have you ever lost a job because of drinking? ? 2 for Yes
    Have you ever neglected your obligations, your family, or your work for two or more days in a row because of drinking? ? 2 for Yes
    Do you drink before noon fairly often? ? 1 for Yes
    Have you ever been told you have liver trouble? Cirrhosis? ? 2 for Yes
    After heavy drinking, have you ever had delirium tremens (DTs) or severe shaking, or heard voices or seen things that weren't really there? ? 2 for Yes (5 for DTs)
    Have you ever gone to anyone for help about your drinking? ? 5 for Yes
    Have you ever been in a hospital because of drinking? ? 2 for Yes
    Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was a part of the problem that resulted in hospitalization? ? 2 for Yes
    Have you ever been at a psychiatric or mental health clinic or gone to any doctor, social worker, or clergyman for help with any emotional problems, where drinking was part of the problem? ? 2 for Yes
    Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages? (If "yes," how many times?) ? 2 for each arrest
    Have you ever been arrested or taken into custody for a few hours because of other drunken behavior? ? 2 for each arrest
    Total points ? ?

    Scoring: 3 points or less, nonalcoholic; 4 points, suggestive of alcoholism; 5 points, alcoholic category.

    Avoid habitual alcohol consumption, and establish and maintain friendships with people who do not drink. When stressed or facing a challenging situation, talk to a friend rather than turning to the bottle.

    Join a support group to help yourself work through challenging temptations to drink. Alcoholics Anonymous (AA) has helped countless individuals stay sober. At meetings, members support each other and talk about their struggles to avoid alcohol. The organization's 12-step program fosters self-esteem and helps build confidence. Becoming involved, serving as a sponsor, and actively participating in meetings increases success rates.

    Al-Anon is a support group intended to help spouses deal with the challenges of living with an alcoholic. Children of alcoholics can also join a support group, such as Al-Ateen.

  • Prevention and Screening

    Avoid habitual alcohol consumption, and establish and maintain friendships with people who do not drink. When stressed or facing a challenging situation, talk to a friend rather than turning to the bottle.

    Join a support group to help yourself work through challenging temptations to drink. Alcoholics Anonymous (AA) has helped countless individuals stay sober. At meetings, members support each other and talk about their struggles to avoid alcohol. The organization's 12-step program fosters self-esteem and helps build confidence. Becoming involved, serving as a sponsor, and actively participating in meetings increases success rates.

    Al-Anon is a support group intended to help spouses deal with the challenges of living with an alcoholic. Children of alcoholics can also join a support group, such as Al-Ateen.

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