Diagnosis

Alcohol use may lead to two alcohol-use disorders (abuse or dependence) and 11 alcohol-induced disorders (see section on clinical features). The fourth text revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) requires that three or more criteria for dependence occur at any time within a 12-month period. The necessity for occurrence of three or more criteria within a 12-month time frame is more diagnostically rigorous than the criteria of the DSM-III-R. In contrast to DSM-III-R, DSM-IV-TR lists only seven criteria under dependence; a former criterion—"substance often taken to relieve or avoid withdrawal symptoms"—has been subsumed under the withdrawal criteria; and the criteria on failure to fulfill major role obligations at work, school, or home have been shifted to the abuse criteria.

Alcohol abuse criteria have been expanded from two criteria in DSM-III-R to four criteria in DSM-IV-TR. Alcohol abuse requires at least one of the criteria to have occurred within a 12-month period.

Proper diagnosis requires adherence to these criteria. The distinctions between alcohol abuse and alcohol dependence (alcoholism) are clinically useful. For example, if only criteria for abuse are met, it can be assumed that the patient is not alcohol-dependent (and is, therefore, not an "alcoholic"). Such an individual is more likely to benefit from controlled drinking strategies and to be able to return to nonpathological use of alcohol than is the person who reaches criteria for dependence, where abstinence would be the preferred treatment goal. Higher rates of remission can be expected for clients with alcohol abuse compared to clients with alcohol dependence, even in the presence of a severe mental disorder.

The symptoms associated with alcohol abuse and alcohol dependence are far-ranging and involve biological, psychological, and social domains. The presenting symptoms vary from patient to patient, and such heterogeneity should be appreciated by the clinician making a diagnosis.

In assessing a patient for alcoholism, the clinician should consider problems related to the drinker, the family, and the community. Problems for the drinker may include declining job performance, joblessness, divorce, arrests (especially for driving while intoxicated and public intoxication), accidents, withdrawal symptoms, broken relationships, and associated medical and psychiatric illnesses. Assessment of family functioning may reveal marital discord, spousal abuse, child abuse, financial problems, depression or anxiety syndromes, child neglect, child developmental problems, school dropout, and delinquency. At the community level, manifestations may include violence, accidents, property damage, economic costs of welfare or health services, and decreased work productivity.

A diagnosis does not have to be rushed. Interviews with collateral sources are often necessary. Some patients will fall into a "gray zone," which means that it is unclear whether an alcohol use disorder is present. In such circumstances, obtaining further information and following the patient over time should clarify the diagnosis.

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