1

Alcohol-related disorders.
DIAGNOSIS AND CLINICAL FEATURES

Alcohol use disorders are among the most common of the serious life-
threatening behavioral or psychiatric syndromes, and the diagnosis of
alcohol dependence or abuse requires a high index of suspicion for the
disorder in any patient. The average man or woman presenting with
severe and repetitive alcohol problems is likely to be neatly dressed, to
show no signs of severe alcohol withdrawal, to have a job and a family,
and to complain of a variety of physical conditions or temporary but
potentially severe psychiatric complaints. Thus, the clinician must
gather a history of alcohol-related life problems from the patient and,
whenever possible, a resource person and must try to determine whether
alcohol has caused or contributed to the psychiatric or physiological
syndrome. Table 11.2-3 lists the alcohol-related disorders in DSM-IV-
TR and also presents a comparable listing from ICD-10.
This section offers an overview of clinical characteristics and diag-
nostic criteria for a wide range of phenomena relevant to alcohol use
disorders, beginning with a brief overview of comorbid psychiatric
symptoms and clinically relevant thoughts on how to approach them.
The section then progresses to a discussion of more general relevant
diagnostic criteria, including alcohol dependence, abuse, and so on.

Diagnosing Substance-Induced Conditions

For men and women presenting with psychiatric symptoms (e.g.,
anxiety, depression, or psychoses) as well as evidence of alcohol-related
problems, the first step is to obtain a careful history from both the
 2

patient and a resource person. Second, the clinician must emphasize

syndromes that meet diagnostic criteria for major depressive disorder or
full anxiety syndromes or other disorders, not just symptoms such as
sadness or nervousness. Third, a timeline of relevant events from
childhood to the present should be established noting (1) the
approximate age of onset of alcohol problems severe and repetitive
enough to justify a diagnosis of alcohol dependence (note: this is not the
age of first drink or first sign of difficulty), (2) periods of abstinence of
several months or more, and (3) the ages at which the patient met the
criteria for any major psychiatric disorders, taking care to emphasize
full-blown psychiatric clinical conditions, not isolated symptoms. If a
review of the timeline reveals no evidence that the additional
psychiatric syndromes either clearly antedated the severe alcohol
problems or persisted for 4 or more weeks during a period of
abstinence, alcoholism is the major disorder. The other psychiatric
syndromes are likely to be important but temporary conditions that
occurred during alcohol intoxication or withdrawal (i.e., are alcohol
induced) 3
Depressive, anxiety, and psychotic symptoms are often seen in people
with alcohol-related disorders. However, even if the psychiatric
symptoms are intense, they do not indicate a separate psychiatric
syndrome when seen only during intoxication or withdrawal. In an
effort to encourage clinicians and researchers to consider the entire span
of. clinical conditions that might be relevant to any syndrome being
observed, in DSM-IV-TR, all important diagnostic entities related to a
specific phenomenon (e.g., depressive disorders, anxiety iciest, psychotic
 3

disorders) are now listed within the clinically relevant sections (e.g., the
mood disorder section). For the sake of clarity, conditions associated
with substances are now labeled as substance-induced disorders.
The diagnostic. criteria further list the specific substances involved and
ask that , if possible, the clinician specify whether the condition had an
onset during intoxication or withdrawal. These latter modifiers are
important to indicate to the clinician when additional medical and
psychiatric treatment might be required. For alcohol-induced mood
disorders, diagnoses can also be subtyped regarding the presents or
absence of depressive, manic, or mixed features. Anxiety conditions can
be further subdivided regarding the relevance of generalized
anxiety symptoms, repetitive panic attacks, obsessive-compulsive
: symptoms, or phobic symptoms.

Alcohol Dependence DSM-IV-TR provides general criteria for

all substance use disorders. These are stated in broad terms to be
applied to all substances of abuse and to be flexible enough to guide
the clinician's diagnoses of people from divers cultures, both
genders, and different age groups. Dependence concerns a history of
an array of problems, including compulsive intake of alcohol, an
increasingly important place in life occupied by the substance, and
possibly evidence of physical withdrawal symptoms. Dependence
criteria also concern life impairment related to the substance.
Physical dependence is a phenomenon that overlaps greatly with
tolerance. As the body changes to resist the effects of alcohol, it is
likely to reach a condition in which it cannot function optimally
 4

unless the brain depressant is present and in which rebound or

withdrawal symptoms develop if the depressant drug is stopped
quickly.

Alcohol Abuse The DSM-IV-TR diagnostic criteria for abuse focus

on the impairment of social, legal, interpersonal, and occupational
functioning in a person who is not alcohol dependent (Table 11.1-8).
ICD-10 presents a diagnosis of harmful use that is only approximately
similar to DSM-IV-TR, as the international system is limited to
physical or psychological problems.
A categorical approach (e.g., abuse or dependence) has many benefits
in clinical settings, including the relative ease of use while evaluating
patients. However, almost by definition, there are some patients who
report one or more of the dependence problems but who do not meet
criteria for abuse. These men and women, sometimes referred to as
diagnostic orphans, appear to have a clinical course that is distinct
from both individuals with no alcohol-related problems and those with
alcohol dependence. The patterns of problems both in the past and as
established in 1- to 5-year follow-ups more closely resemble
individuals with abuse, although only 10 percent of these "orphans" go
on to meet criteria for abuse, and less than 5 percent go on to
dependence. Future studies preparing for DSM-V-TR need to more
carefully evaluate these individuals to determine whether their level of
problems is significant enough to warrant altering the diagnostic
 5

system.

Alcohol Intoxication (The DSM-IV-TR diagnostic criteria for

alcohol intoxication are based on evidence of recent ingestion of
ethanol, maladaptive behavior, and at least one of six possible physio-
logical correlates of intoxication (Table 11.2-4). The ICD-10 criteria for
acute alcohol intoxication are generally similar to DSM-IV-TR, listing
seven physiological signs of intoxication, some of which, such as
conjunctival injection, are not seen in DSM-IV-TR.

Alcohol Withdrawal In people who have been drinking heavily over a

prolonged period, a rapid decrease in blood alcohol levels might
produce a variety of physical symptoms. Typical of brain
depressants, including barbiturates and benzodiazepines, this
withdrawal or abstinence syndrome is characterized by a group of|
symptoms that are the opposite of what was initially experienced
with intoxication. These include a coarse tremor of the hands,
insomnia, anxiety, and increased blood pressure, heart rate, body
temperature, and respiratory rate—a condition labeled in DSM-IV-TR
as alcohol withdrawal and described. In ISD-10 the criteria for
alcohol withdrawal are similar to those listed in DSM-IV-TR, with
some differences in the specific items listed and the number of signs
required (i.e., three) to make a diagnosis. The DSM-IV-TR criteria for
alcohol withdrawal also require that the symptoms must cause
clinically significant distress or impairment . Although 95 percent or
 6

more of withdrawals are limited to these mild or moderate

symptoms, for 3 to 5 percent, the symptoms include convulsions or
delirium.
Withdrawal phenomena are likely to begin within approximately 8
hours of abstinence, reach a peak intensity on the second or third
day, and markedly diminish by the fourth or fifth day. The symptoms
persist in a more mild form for as many as 3 to 6 months or more as
part of a protracted withdrawal syndrome, which might contribute to
relapse.

Alcohol Withdrawal Delirium

For the small proportion of intoxications and withdrawals that are

accompanied by severe cognitive symptoms, both DSM-IV-TR
and ICD-10 list criteria for alcohol intoxication delirium and
alcohol withdrawal delirium . When this agitated confusion is
associated with tactile or visual hallucinations, the diagnosis of
alcohol withdrawal delirium (also called delirium tremens) can be
made. During withdrawal , some alcoholic people show one or
several grand mal convulsions, sometimes called rum fits..

Alcohol - Induced Persisting Amnestic Disorder

 7

One of the most intensely studied alcohol-related CNS syndromes

is SM-IV-TR diagnosis of alcohol-induced persisting amnestic
disorder Table 10.4-2), which is the result of a relatively severe in
the B vitamin thiamine. Similar criteria are offered in an amnesic
syndrome. As mentioned briefly earlier in the section on effects of
alcohol on the body, some people are at higher risk for this syndrome
than are others because of a genetically influenced transketolase
deficiency. The condition has been historically into (1) Wernicke's
encephalopathy, with prominent ataxia and palsy of the sixth
cranial nerve, a condition that tends to reverse fairly rapidly with
vitamin supplementation; and (2) Korsakoff's syndrome, which is
permanent in at least a partial form in perhaps 50 to 70 percent of the
people affected. Korsakoff's syndrome is characterized by a
pronounced anterograde and retrograde amnesia and potential
impairment in visuospatial, abstract, and other types of learning. In
most cases, the level of recent memory is out of proportion to the
global level of cognitive impairment

Alcohol-Induced Persisting Dementia

A poorly studied, heterogeneous long-term cognitive problem that can

develop in the course of alcoholism is alcohol-induced persisting
dementia. Similar syndromes are described in ICD-10 as residual and
late-onset psychotic disorder or as other persisting cognitive
impairment. Global decreases in intellectual functioning, cognitive
abilities, and memory are observed, but recent memory difficulties are
 8

consistent with the global cognitive impairment, an observation that

helps to distinguish the syndrome from alcohol-induced persisting
amnestic disorder. Brain functioning tends to improve with abstinence,
but perhaps one-half of all affected patients have long-term and even
permanent memory and thinking disabilities.

Alcohol-Induced Conditions Reflecting the emphasis on

understanding alcohol use disorders in psychiatric practice, this is an
appropriate place to return to specific comorbid psychiatric conditions.
Of course, individuals with alcohol use disorders have at least the same
rate of most psychiatric conditions as do others in the general
population and have an elevated risk for associated independent
schizophrenia, manic-depressive disease, and, possibly, several of the
anxiety disorders. Even more prevalent are the temporary, but
potentially severe, substance-induced disorders that are distinguished
from independent psychiatric conditions using the timeline method
described previously. This section presents the criteria and clinical
examples of some of the more common alcohol-induced conditions .

Alcohol-Induced Mood Disorder

In the context of heavy and repetitive intake of any brain depressant,
symptoms of severe depression are common and may be labeled as an
alcohol-induced mood disorder (Table 13.6-18). Like DSM-III-R, ICD-
10 retains this and most related substance-induced syndromes in the
section on organic mental disorders labeled as an organic mood
[affective] disorder. For long-lasting mood disturbances, ICD-10 also
 9

has the labels of other persistent mood [affective] disorders and

persistent mood [affective] disorder. The diagnosis in DSM-IV-TR or
ICD-10 focuses on either sadness or mania-like symptoms severe
enough to impair functioning that occur only in the context of
repeated heavy drinking and continue for several days to 4 weeks after
abstinence.

Alcohol-Induced Anxiety Disorder Anxiety symptoms fulfilling the

diagnostic criteria for alcohol-induced anxiety disorder are also
common in the context of acute and protracted alcohol withdrawal. In
ICD-10, these are listed as organic anxiety disorders resembling
generalized anxiety or panic disorders. Almost 80 percent of alcoholic
people report panic attacks during acute withdrawal; their complaints
can be intense enough for the clinician to consider diagnosing a panic
disorder. Similarly, during the first 4 to 6 weeks of abstinence, people
with severe alcohol problems are likely to avoid some social situations
for fear of being overwhelmed by anxiety (i.e., they have symptoms
resembling social phobia); their problems can at times be severe
enough to resemble agoraphobia. However, when psychological or
physiological symptoms of anxiety are observed in alcoholic people
only in the context of heavy drinking or within the first several weeks
or months of abstinence, the symptoms are likely to diminish and
subsequently disappear with time alone. Only two anxiety disorders
may be more closely tied to alcoholism: panic disorder and social
phobia.
 10

Alcohol-Induced Psychotic Disorder

Approximately 3 percent of alcoholic people have auditory
hallucinations or paranoid delusions in the context of heavy drinking
and withdrawal In DSM-III-R those problems are labeled organic
hallucinosis or delusional disorders. In ICD-10, they are presented as
organic delusional disorders in the organic section and as a psychotic
substance use disorders section. Many of the symptoms resemble those
seen in schizophrenia, but when the psychotic features develop only in
the context of alcohol problems, they are likely to clear spontaneously..
The syndromes are likely to recur only if heavy alcohol intake resumes.

Alcohol-Related Disorder Not Specified

DSM-IV-TR allows for the diagnosis of alcohol-related disorder not
otherwise specified for alcohol-related disorders that do not meet the
diagnostic criteria for any of the other diagnoses(Table 11.2-7). ICD-10
offers the listings of other or unspecified mental and behavioral
disorders induced by alcohol.

TREATMENT
The elements of treatment appropriate for patients with severe alcohol
problems are fairly straightforward. The core of these involves steps to
maximize motivation for abstinence, helping alcoholics to restructure
their lives without alcohol, and taking steps to minimize a return, or
relapse, to substance-using behaviors.This cognitive and behavioral
approach is similar to efforts appropriate for any long-term disorder that
 11

requires changes in lifestyles such as diabetes or hypertension. Much

of the clinical challenge comes recognizing how prevalent the
alcohol-related disorders are ,how often those conditions present with
temporary symptoms of other psychiatric syndromes, and how to use
clinical clues ,physical findings , and laboratory tests to identify
alcoholism.
Three general steps are involved in treating the alcoholic person
once the disorder has been diagnosed: intervention, detoxification ,
and rehabilitation. Those approaches assume that all possible efforts
have been made to optimize medical functioning and to address
psychiatric emergencies. Thus, for example, the alcohol persons with
symptoms of depression severe enough to be suicidal requires inpatient
hospitalization for at least several days until the suicidal ideation
disappears, even if it is a temporary alcohol-induced mood disorder.
Similarly, the person presenting with cardiomyopathy , liver difficulties,
or GI bleeding first needs adequate attention paid to the medical
emergency.
The patient with alcohol abuse or dependence must then be brought
face to face with the reality of the disorder (intervention), be
detoxified if needed, and begin rehabilitation. The essentials of these
three steps for alcoholic people with and without independent
psychiatric syndromes are quite similar. However, in the former case,
the treatments are often applied after the psychiatric disorder has been
stabilized to the maximum degree possible.
12