Alcohol dependence and alcohol problems.
- Formulation of definitions of alcohol dependence: 1948–1974
- The alcohol dependence syndrome
- Clinical description
- Establishment of the validity of the alcohol dependence syndrome
- Individual elements of the alcohol dependence syndrome
- Influence of the alcohol dependence syndrome on later formulations of dependence
- Comparisons of the DSM-IIIR, DSM-IV, and ICD-10 definitions of alcohol dependence
- Non-addictive alcohol use disorders
- Alcohol abuse
- Harmful use
- Alcohol problems
- Types of alcohol-related problems
The problem of excessive alcohol consumption is a major cause of public health concern in most countries of the world today. Heavy consumption, which involves far more than ‘dependence', can cause untold misery to the individual, who is usually affected by other physical, psychological, and social disabilities as well.
As early as 1950, the World Health Organization ( WHO) viewed the lack of a commonly accepted terminology as a serious obstacle to international action in the alcohol field. (1)
Definitions of ‘alcoholism' have been proposed by a range of professional and other bodies, from biomedical scientists, medical doctors and psychiatrists, psychologists, sociologists, patients in treatment, to the general public. (2) Terms such as ‘alcoholism', ‘addiction', and ‘chemical dependence', have passed into everyday speech, becoming ‘popularly enriched' and ‘technically impoverished'. (2) These terms mean different things to different people and often have pejorative connotations. The lack of a precise definition of ‘drinking problems' has hampered interdisciplinary communication.
In this article the evolution of the term ‘alcohol dependence' will be traced and put into context as but one aspect of a wider spectrum of alcohol-related problems. The concept of the alcohol dependence syndrome (3) will be discussed. Its influence on the 10th revision of the International Classification of Diseases (4) and the most recent versions of the Diagnostic and Statistical Manual of Diseases (DSM-IIIR and DSM-IV) (5,6) will be reviewed. The terms ‘harmful use' (ICD-10) and ‘alcohol abuse' (DSM-IIIR/IV) will be discussed. Finally the issue of ‘alcohol problems' will be introduced.
Formulation of definitions of alcohol dependence: 1948–1974
From the time of its inception in 1948, WHO played a major role in formulating public health definitions of ‘alcoholism', ‘addiction', and ‘dependence' through a series of expert committees. Early definitions stressed the sociological rather than the physical aspects of dependence. (7) ‘Alcoholics' were defined as: (7)
those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance or an interference with their bodily and mental health, their inter-personal relations, and their smooth social and economic functioning; or who show the prodromal signs of such developments.
This definition had limited utility for biological research and psychiatric classification. (8) Therefore the 1955 Committee of Experts on Alcohol and Alcoholism highlighted the importance of physical criteria describing ‘alcoholism' as: (9,10)
a ‘chronic disease characterised by a fundamental disturbance of the nervous system which is manifested on a behavioural level by a state of physical dependence. The major forms of this dependence are either inability to stop drinking before drunkenness is achieved, or inability to abstain from drinking because of the appearance of withdrawal symptoms'.
‘Alcoholism' was classified under ‘Other non-psychotic mental disorders' in ICD-8. (11) This definition of ‘alcoholism' was generic, and included the subcategories of episodic excessive drinking, habitual excessive drinking, and alcohol addiction. Alcohol addiction was defined as: (11) a state of physical and emotional dependence on regular or periodic, heavy, and uncontrolled alcohol consumption, during which the person experiences a compulsion to drink. On cessation of alcohol intake there are withdrawal symptoms, which may be severe.
The alcohol dependence syndrome
In 1976, Edwards and Gross proposed the existence of alcohol dependence within a syndrome model. (3) Their description was based on the clinical observation that certain heavy drinkers manifested an interrelated clustering of signs and symptoms. They hypothesized that dependence was not an all-or-nothing phenomenon but existed in degrees of severity.The elements of the syndrome, as originally formulated, are summarized in Table 1. Not all the elements of the alcohol syndrome need always be present, nor always present with the same intensity. Edwards and Gross (3) also acknowledged the fact that not everyone who drinks too much is necessarily dependent on alcohol. They hypothesized that alcohol dependence should be conceptually distinguished from alcohol-related problems.
Table 1: Key elements of the alcohol dependence syndrome
- Narrowing of repertoire
- Salience of drinking seeking behaviour
- Increased tolerance to alcohol
- Relief or avoidance of further symptoms by further drinking
- Subjective awareness of compulsion to drink
- Reinstatement after abstinence
By drawing a clear distinction between the alcohol dependence syndrome and alcohol-related disabilities, Edwards and Gross introduced the concept of a biaxial model. This was described further in the report of a WHO scientific group published in 1977. (12) Alcohol-related disabilities are defined as comprising those physical, psychological, and social problems that are a consequence of excessive drinking and dependence. Consumption may be viewed on a third axis.
The alcohol dependence syndrome was proposed in the first instance as an empirical formulation. It was hoped that future research would allow a more detailed understanding of the ‘latent' processes that produced the covariance of signs, symptoms, prognosis, and response to treatment. Unlike previous models of ‘alcoholism' that had observational elements but no theoretical input, the alcohol dependence syndrome was influenced by psychological theory and proposed as a synthesis of both general learning theory and specific conditioning models of dependence. (13,14)
Establishment of the validity of the alcohol dependence syndrome
Since 1976, the alcohol dependence syndrome has assumed a position of increasing importance and has stimulated considerable research. Studies have focused on the degree to which the elements of the syndrome co-occur. (15,16,17,18 and 19) Other areas of research have included construct validity, (20) concurrent validity, (17,21,22) and predictive validity. (23,24) Field trials conducted as background to the preparation of ICD-10, DSM-IIIR, and DSM-IV, have all contributed to the body of research evidence. (6,25,26,27,28 and 29) Difficulties have been encountered in operationalizing elements such as narrowing of repertoire, subjective change, and reinstatement. (29)
These studies have shown a remarkable similarity in terms of the coherence and dimensionality of the syndrome, and are particularly impressive because of the diversity of methods and populations used. (13)
Individual elements of the alcohol dependence syndrome
Narrowing of the drinking repertoire
Most drinkers vary their alcohol consumption from day to day and week to week. The pattern of their drinking is influenced by a range of internal cues and external circumstances. Heavy drinkers may initially widen their drinking repertoire. As dependence advances, so a diminished variability in drinking behaviour emerges. The dependent person begins to drink in the same manner every day. The daily pattern established ensures that a relatively high blood-alcohol level is maintained and that symptoms of alcohol withdrawal are avoided. As drinking becomes stereotyped with advanced dependence, so dependent drinkers are able to describe their drinking day in minute detail.
Salience of drinking-seeking behaviour
With advancing dependence, individuals give priority to maintaining their alcohol intake. Alcohol consumption is maintained despite painful direct consequences such as physical illness, rejection by family, and lack of money. They will ‘beg, borrow, or steal' to obtain money for alcohol. (3)
Increased tolerance to alcohol
Regular drinkers become tolerant to the central nervous system effects of alcohol and can sustain blood alcohol levels that would incapacitate the non-tolerant drinker. In short, they can ‘drink others under the table'. Tolerance may decrease in the later stages of dependence, with individuals becoming intoxicated on much less alcohol than would previously have affected them. Cross-tolerance extends to other drugs, notably barbiturates and benzodiazepines.
The term ‘alcohol withdrawal' describes a broad range of symptoms and signs, from the relatively trivial to the life-threatening. At first the symptoms are intermittent and mild, but as the degree of dependence increases, so do the frequency and intensity of withdrawal symptoms. Symptoms vary from person to person and do not require abstinence to appear; they can occur when blood-alcohol concentrations are falling. When the picture is fully developed, the dependent drinker typically has severe multiple symptoms every morning on waking; these symptoms may wake him in the middle of the night. Those who are severely dependent usually experience mild withdrawal symptoms during the day whenever their alcohol levels fall.
Withdrawal symptoms cannot occur without a high degree of central nervous system tolerance, but tolerance can occur without clinically manifest withdrawal symptoms. (3)
The spectrum of symptoms is wide, but the four key symptoms are tremor, nausea, sweating, and mood disturbance. A range of other symptoms can also occur, including sensitivity to sound (hyperacusis), ringing in the ears (tinnitus), itching, muscle cramps, sleep disturbance, perceptual distortion, hallucinations, generalized (grand mal) seizures, and delirium tremens.
The four key symptoms will be described in further detail.
The first experience of alcohol withdrawal tremor may be recalled vividly: "One afternoon I went to cut the grass at a friend' house. She gave me a cup of tea and my hands kept shaking. I kept rattling the cup on the saucer and couldn'st put the cup to my mouth. I had to put them down and pretend that I had finished." Men often find it difficult to shave first thing in the morning and merely getting the first drink of the day to the mouth may be an ordeal in itself.
Dependent drinkers commonly say that their bodies want to vomit first thing in the morning, but that they have nothing to bring up. This may be described as ‘dry retching' or ‘the dry heaves'. Typically they find it difficult to eat breakfast and to brush their teeth. The first drink of the day is often vomited back.
Dependent drinkers commonly describe waking up in the early morning (3 a.m. or 4 a.m.) to find the bed sheets ‘drenched'. In the earlier stages of dependence they may report feeling clammy.
This is an important feature of the withdrawal syndrome. Mildly dependent individuals may feel ‘a bit edgy'. Severely dependent individuals may present with clinically significant symptoms of anxiety and depression.
Relief or avoidance of withdrawal symptoms by further drinking
In the early stages of dependence individuals may find that they need a lunchtime drink to alleviate discomfort. As dependence progresses there emerges the need for an early morning drink to relieve the symptoms of alcohol withdrawal coming on after a night's abstinence. Later, individuals may wake in the middle of the night for a drink, and alcohol is often kept by the bed. If they have to go for 3 or 4 h without a drink during the day, they value the next drink for its relief effect.
Clues to the degree of dependence can be obtained by taking a detailed history of the first drink of the day. The person drinking from a bottle kept by the side of the bed before they get up is more dependent than the person who has breakfast and reads the paper first. The woman who pours whisky into her first cup of tea is more dependent than the librarian who slips out to the lavatory at midday to drink from a quarter bottle of vodka hidden in her handbag.
Subjective awareness of compulsion to drink
This describes an altered subjective experience of an inability to limit drinking to an acceptable level. Although the familiar term ‘loss of control' has been used to denote this element, it is more likely that control has been ‘impaired' rather than lost.
Another complex experience is that of ‘craving', the subjective experience of which is greatly influenced by environment. Individuals can experience craving of very different intensities on different occasions. Cues for craving include the experience of intoxication, the withdrawal syndrome, mood (anger, depression, elation), or situational cues (being in a pub (bar), passing an off-licence (liquor store)).
Here the key experience may best be described as a compulsion to drink. The desire for a further drink is seen as irrational, and is resisted, but despite this a further drink is taken.
Reinstatement after abstinence
Alcohol dependent individuals who begin to drink again after a period of abstinence invariably relapse back into the previous stage of the dependence syndrome. This process occurs over a variable time course, with moderately dependent individuals perhaps taking weeks or months and severely dependent individuals taking a couple of days.
Influence of the alcohol dependence syndrome on later formulations of dependence
The concept of the alcohol dependence syndrome presented a significant challenge to researchers and clinicians, requiring them to re-think many fundamental concepts and definitions. In ICD-9 the term ‘alcoholism' was dropped in favour of the ‘alcohol dependence syndrome'. (30) It was, however, still classified under the category ‘Other non-psychotic mental disorders'. The ICD-9 definition of alcohol dependence may have been somewhat premature, because the theoretical process was still evolving at that time. (2)
At the same time as WHO was formulating public health definitions of ‘alcoholism', ‘addiction', and ‘dependence', a trend towards formal diagnostic criteria was emerging in the United States. This was driven by practical consideration such as the need for better communication between clinicians, researchers, and the general public. Other influential factors included the growing need to categorize persons in an objective fashion for legal, medical, or psychiatric reasons, to collect and communicate accurate public health information, and to standardize practice nationally and internationally. The first two editions of the Diagnostic and Statistical Manual classified ‘alcoholism' as a subcategory of personality disorder. In DSM-III, (31) it was included under a new and separate category of ‘Substance use disorders'. The terms ‘alcoholism' and ‘addiction' were dropped and the terms ‘dependence' and ‘alcohol abuse' used instead. Dependence was distinguished from abuse by the presence of tolerance or withdrawal symptoms.
By the mid-1980s DSM-III and ICD-9 were undergoing reviews for the purposes of revision. (32) The diagnostic criteria for dependence were broadened in DSM-IIIR (5) to incorporate the elements of the alcohol dependence syndrome as hypothesized by Edwards and Gross. (3) Here, nine items were included in the diagnostic criteria for dependence, the majority focusing on evidence of loss of control, overuse of the substance, a willingness to give up important events in order to take the substance, and consumption of alcohol despite consequences. Out of the nine items, three related to the presence of tolerance or withdrawal, but these were not required for a diagnosis as they had been in DSM-III. To meet the criteria for dependence, individuals had to fulfil three of the nine items for a period of at least 1 month.
The essential feature of the DSM-IIIR dependence category is defined in the text as a ‘cluster of cognitive, behavioural, and physiological symptoms, indicating that the person has impaired control over drinking and continues to drink despite adverse consequences' ( Table 2).
Table 2 DSM-IIIR criteria for substance dependence DSM-IV (6)
In view of the major changes in criteria that had occurred between 1980 and 1987, the DSM-IV Substance Use Disorders Work Group was reluctant to make any additional major changes. The nine items in DSM-IIIR were reduced to seven (two separate DSM-IIIR items, those referring to withdrawal and the use of drugs to treat withdrawal were combined into one item; another item was moved from the dependence to the abuse section). The repetitive nature of the problem was highlighted in that three or more of the items should have occurred during the same 12-month period and the associated difficulties must have led to clinically significant impairment or distress. DSM-IV also uniquely allows for the subtyping of dependence with and without physiological dependence ( Table 3).
Table 3 DSM-IV criteria for substance dependence ICD-10 (4)
ICD-10 includes six items under dependence, most of which are similar to DSM-IV. For a diagnosis of dependence, three or more items should have occurred in the past year. The ‘strong desire or sense of compulsion to take the substance' is viewed as a central descriptive characteristic of dependence in ICD-10. This compulsive-use indicator is not included in the DSM-IIIR or DSM-IV concept of dependence (Table 4).
Table 4 ICD-10 criteria for substance dependence
Although the DSM-IIIR, DSM-IV, and ICD-10 diagnostic approaches have drawn on the original concept of the alcohol dependence syndrome, and are of value in standardizing psychiatric practice nationally and internationally, they picture dependence as an all-or-nothing phenomenon rather than as a dimensional state. (33)
Comparisons of the DSM-IIIR, DSM-IV, and ICD-10 definitions of alcohol dependence (32)
- ICD-10 collapses four of the DSM-IIIR and DSM-IV dependence criteria into two: a. the two DSM impaired-control criteria are combined in ICD-10; b. the ‘important recreational activities' and ‘great deal of time spent drinking' from DSM are combined into progressive neglect of alternative pleasures.
- ICD-10 includes compulsive use, not included in DSM-IIIR or DSM-IV.
- DSM-IV and ICD-10 combine withdrawal and avoidance of withdrawal criteria, which are separate items in DSM-IIIR.
- The inability to fulfil role obligations and hazardous-use criteria of DSM-IIIR are moved to the DSM-IV abuse category and dropped from ICD-10.
- The ‘continued use despite problems' category of DSM-IV and ICD-10 includes physical and psychological problems; the DSM-IIIR category is broader, including social problems.
- The duration of threshold criteria differs across the systems. In DSM-IIIR some symptoms must have persisted for at least 1 month or occurred repeatedly over a longer period. DSM-IV and ICD-10 do not specify a duration criterion. However, several dependence criteria in DSM-IV must occur repeatedly.
- DSM-IV allows for subtyping of dependence diagnoses with and without physiological dependence.
Research shows that agreement between the three systems on diagnosis of alcohol dependence is good to excellent for ‘past year, prior to past year, and life-time diagnoses, for men and women, different ethnic groups and older and younger respondents'. (32) Thus the international effort to integrate the two major classification systems has been successful with respect to the dependence category. The DSM-IIIR classification is the most inclusive, requiring three of nine positive criteria for diagnosis, and the ICD-10 classification the most exclusive, requiring three of six positive criteria. The DSM-IV classification is intermediate, requiring three of seven positive criteria for diagnosis.
Non-addictive alcohol use disorders
The term ‘alcohol abuse' appeared infrequently in the American literature before 1970, when the United States National Institute on Alcohol Abuse and Alcoholism was formed. It was adopted as a formal diagnostic category by DSM-III, (31) which defined abuse as a behavioural concept: ‘A pattern of pathological use for at least a month that causes impairment in social or occupational functioning'. Although enshrined in DSM-IIIR and DSM-IV, the term ‘abuse' has been variously regarded as ‘unscientific and pejorative' (34) and ‘oppobrious' and ‘vindictive'. (35)
The broadening of diagnostic criteria for alcohol dependence in DSM-IIIR relegated ‘abuse' to a residual less serious category. The two criteria for DSM-IIIR abuse are also DSM-IIIR dependence criteria; fulfilment of either criterion leads to a positive diagnosis of dependence, rendering the abuse category residual to the dependence category in this system. (32) The abuse diagnosis also required that the symptoms ‘persist for at least one month or occur repeatedly over a longer period of time'.
The DSM-IV Substance Use Disorders Workgroup carried out extensive analysis in an effort to define abuse more precisely. Accordingly, in DSM-IV, four separate items, not included in dependence, are listed for the diagnosis of abuse, focusing on social, physical, legal, and interpersonal problems associated with alcohol use. These problems must have occurred repeatedly over a 12-month period, and caused ‘clinically significant impairment or distress' (Table 5).
Table 5 Criteria for abuse or harmful use of substances
The ICD-10 criteria for harmful use of alcohol differ significantly from the DSM-IIIR and DSM-IV abuse classifications. An ICD-10 diagnosis of harmful drinking requires a pattern of drinking that has caused actual physical or psychological harm to the user. This definition is overly restrictive and does not overlap with DSM-IIIR and DSM-IV definitions of alcohol abuse.
Not everyone experiencing an alcohol problem or alcohol-related disability will be suffering from alcohol dependence. Both dependent and non-dependent drinkers, particularly binge drinkers, are at risk of problems related to heavy alcohol consumption. Indeed, epidemiological evidence supports the view that most alcohol-related harm in the general population occurs in heavy non-dependent drinkers.
Alcohol problems are extremely diverse. They have been defined as ‘those problems that may arise in individuals around their use of beverage alcohol, and that may require an appropriate treatment response for their optimum management'. (36) The phrases ‘alcohol problems' or ‘alcohol-related problem' contain an assumption of causality. (37) This issue is a complex one, involving individual differences and the social context of drinking as well as the pattern, duration, and intensity of alcohol use.
Alcohol problems can be related to the acute or chronic consumption of alcohol. A fractured ankle sustained by falling over while acutely intoxicated is an example of the former category. Cirrhosis of the liver is an example of a chronic problem. An individual who drinks in binges will experience different problems compared with someone who drinks the same amount of alcohol spread out over a week or a month or a year. The way in which a person behaves while intoxicated is another important factor determining the nature of alcohol-related problems. The social consequences of drinking such as job loss, imprisonment, marital and family break-up, and drink-driving have profound effects on the well being of the drinker, their family, and society. (37)
Types of alcohol-related problems
Although somewhat artificial, it is helpful to classify alcohol-related problems in individuals into physical, psychological, and social categories. There is often considerable overlap between these three areas. The more severe the dependence, the greater the likelihood of problems of all three kinds. (22)
Alcohol-related physical and psychological problems are discussed in the next section. Some of the social problems can be included here, for example the acute adverse consequences of drinking such as trauma resulting from road traffic accidents, injuries from fights, and death from overdose. (37)
The social problems that can result from drinking are legion. Alcohol is involved in all types of accidents and contributes to 15 per cent of traffic deaths. It is implicated in 26 to 54 per cent of home and leisure injuries (37) and is associated with domestic violence, child abuse, crime, homicide, and suicide. Alcohol is also related to poor work performance, dismissal, unemployment, debt and housing problems, and crimes of violence.
There is a continuity between moderate and excessive drinking and between harmless drinking and drinking that results in harm or in problems. Such problem-clustering may reflect alcohol dependence, certainly amongst a proportion of these drinkers. Given this heterogeneity, no one form of treatment is likely to be effective for all individuals with alcohol problems. (36) A range of treatments is required and it should be possible for non-specialists to offer brief interventions.
The study of alcohol-related problems remains underdeveloped, compared with the study of alcohol dependence. (38) There may be several reasons for this, not least the difficulties inherent in measuring alcohol-related problems. (39) Another important issue, central to these difficulties, is the extent to which alcohol is causally related to the problem.(38)
Several questionnaires, measuring a variety of alcohol-related problems, have been developed. (38,40) The Alcohol Problems Questionnaire (APQ) (38) is a standardized inventory, which includes 46 items covering eight problem domains: physical, psychological, friends, finances, police, marital, children, and work. All questions apply to the 6-month period prior to the completion of the questionnaire. The shorter version includes the first five domains. This questionnaire can make a useful contribution to the overall assessment, and is of potential value in outcome research.
An understanding of the concepts of alcohol dependence and alcohol problems is central to the therapeutic process with individual patients. The development of diagnostic criteria has helped to standardize practice nationally and internationally, and aided interdisciplinary communication. The diagnostic criteria for dependence are imperfect because they view the syndrome as an all-or-nothing phenomenon rather than as a dimensional state. The concepts of abuse and harmful use need further classification. The totality of alcohol problems is a vast area with major implications for the general population, not just dependent drinkers.
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