Finally, all patients should undergo a complete physical examination. During this examination, the clinician should pay attention to physical manifestations of heavy alcohol use, such as an enlarged, tender liver. The combination of positive results on laboratory tests and physical examination points strongly to a diagnosis of alcohol abuse or dependence.
This information can be used later on, when the physician presents his or her diagnosis to the patient and begins to confront the denial associated with the addiction Anthenelli If the clinician suspects a diagnosis of alcoholism is appropriate, the next step is to evaluate the psychiatric complaints in this context. Partly as a result of these direct brain effects, heavy alcohol use causes psychiatric symptoms and signs that can mimic most major psychiatric disorders. These changes occur both in the absence and presence of alcohol, and during the initial assessment the clinician should determine when in the patient's drinking cycle i.
Therefore, the clinician's job is to combine the data obtained from the multiple resources cited in the previous section and to establish a working diagnosis. This characteristic distinguishes them from the major independent psychiatric disorders they mimic.
In contrast, a patient who exhibits symptoms and signs of a psychiatric condition e. Establishing a timeline of the patient's comorbid conditions Anthenelli and Schuckit ; Anthenelli , using collateral information from outside informants and the data obtained from the review of the medical records, may be helpful in determining the chronological course of the disorders. In this context the clinician should focus on the age at which the patient first met the criteria for alcohol abuse or dependence rather than on the age when the patient first imbibed or became intoxicated.
This strategy provides more specific information about the onset of problematic drinking that typically presages the onset of alcoholism Schuckit et al. Further questioning should address whether the patient ever developed tolerance to the effects of alcohol or suffered from signs and symptoms of withdrawal when he or she stopped using the drug, both of which are diagnostic criteria for alcohol dependence.
After establishing the chronology of the alcohol problems, the patient's psychiatric symptoms and signs are reviewed across the lifespan. The patient's recollection of when these problems appeared can be improved by framing the interview around important landmarks in time e. This method not only ensures the most accurate chronological reconstruction of a patient's problems, but also, on a therapeutic basis, helps the patient recognize the relationship between his or her AOD abuse and psychological problems.
Thus, this approach begins to confront some of the mechanisms that help the patient deny these associations Anthenelli and Schuckit ; Anthenelli While establishing this chronological history, it is important for the clinician to probe for any periods of stable abstinence that a patient may have had, noting how this period of sobriety affected the patient's psychiatric problems. Using a somewhat conservative approach, such a probe should focus on periods of abstinence lasting at least 3 months because some mood, psychovegetative e.
By using this timeline approach, the clinician generally can arrive at a working diagnosis that helps to predict the most likely course of the patient's condition and can begin putting together a treatment plan. Considering Other Patient Characteristics. For example, it is well established that women are more likely than men to suffer from independent depressive or anxiety disorders Kessler et al.
Not surprisingly, alcoholic women are also more prone than alcoholic men to having independent mood or anxiety disorders Kessler et al. Alcoholic women and men also seem to differ in the temporal order of the onset of these conditions, with most mood and anxiety disorders predating the onset of alcoholism in women Kessler et al. Given these observations, it is especially important in female patients to perform a thorough psychiatric review that probes for major mood disorders i. Knowledge of the psychiatric illnesses that run in the patient's family also may enhance diagnostic accuracy.
For example, men and women with alcohol dependence and independent major depressive episodes have been found to have an increased likelihood of having a family history of major mood disorders Schuckit et al.
Alcoholism: A Review of its Characteristics, Etiology, Treatments, and Controversies
Thus, a family history of a major psychiatric disorder other than alcoholism in an individual may increase the likelihood of that patient having a dual diagnosis. Remaining Flexible with Diagnosis and Follow Up. Once a working diagnosis has been established, it is important for the clinician to remain flexible with his or her assessment and to continue to monitor the patient over time.
Like most initial psychiatric assessments, the basic approach described here is hardly foolproof.
Therefore, it is important to monitor a patient's course and, if necessary, revise the diagnosis, even if improvement occurs with abstinence and supportive treatment alone during the first weeks of sobriety. The importance of continued followup for several weeks also is supported by empirical data showing that most major symptoms and signs are resolved within the first 4 weeks of abstinence. Recognizing that this was an emergency situation and that alcoholics have an increased rate of suicide Hirschfeld and Russell , the emergency room clinician admitted the patient to the acute psychiatric ward for an evaluation.
The clinician also obtained the patient's permission to speak with his wife. Laboratory tests showing an elevated GGT level supported the diagnosis. Moreover, a review of the patient's medical records showed a previous hospitalization for suicidal ideation and depression 2 years earlier, after the patient's mother had died.
First, the patient had stated that his depression started about 1 week before admission, after his wife and family members confronted him about his drinking. This confrontation triggered a more intense drinking binge that ended only hours before his arrival in the emergency room. The patient complained of irritable mood and increased feelings of guilt during the past week, and he admitted he had been drinking heavily during that period.
However, he denied other symptoms and signs of a major depressive episode during that period. Second, the medical records indicated that the patient's previous bout of depression and suicidal ideation had improved with abstinence and supportive and group psychotherapy during his prior hospitalization. At that time, the patient had been transferred to the hospital's alcoholism treatment unit after 2 weeks, where he had learned some of the principles that had led to his longest abstinence of 18 months. Third, both the patient and his wife said that during this period of prolonged abstinence the patient showed gradual continued improvement in his mood.
During the first week of the current hospitalization, the patient's suicidal ideation disappeared entirely and his mood gradually improved. He was transferred to the open unit and participated more actively in support groups. Three weeks after admission, he continued to exhibit improvement in his mood but still complained of some difficulty sleeping.
However, he felt reassured by the clinician's explanation that the sleep disturbance was likely a remnant of his heavy drinking that should continue to improve with prolonged abstinence. Nevertheless, the clinician scheduled followup appointments with the patient to continue monitoring his mood and sleep patterns.
Alcoholism: A Review of its Characteristics, Etiology, Treatments, and Controversies
Alcohol abuse can cause signs and symptoms of depression, anxiety, psychosis, and antisocial behavior, both during intoxication and during withdrawal. At times, these symptoms and signs cluster, last for weeks, and mimic frank psychiatric disorders i. Parts of this paper were previously presented in: Anthenelli, R.
A basic clinical approach to diagnosis in patients with comorbid psychiatric and substance use disorders. In: Miller, N. Principles and Practice of Addictions in Psychiatry. Philadelphia: W. Saunders, , pp.
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Clinical differences between antisocial and primary alcoholics. Diagnosis of depression in alcohol dependence: Changes in prevalence with drinking status. Psychopathology in hospitalized alcoholics. Assessment and treatment of suicidal patients. KOOB, G. Neurobiology of addiction.
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Listen to full episodes on iTunes , Spotify , and Google Play. Jellinek is often called the father of the disease theory or model of alcoholism. His theory listed alcoholism as having stages that drinkers progressively passed through. Alcohol works largely as a depressant on the central nervous system and due to the relatively small size of alcohol molecules, it can affect many parts of the brain and body simultaneously. As the tolerance to alcohol increases, the abuser must take in more in order to feel the effects, which further damages both the body and brain.
The National Council on Alcoholism and Drug Dependence likens alcohol dependence — alcoholism — to a medical illness through the disease model. The disease model of alcoholism depends on it being a physical addiction that cannot be controlled, distinguishable by specific symptoms and requiring specialized medical treatment. Cycles of physical cravings and withdrawal symptoms, including shaking, sweating, nausea and dizziness, are part of the reason alcoholism has been classified as a physical disease.
As alcoholism is an addiction, it is considered a disease of the brain. The brain has been physically altered by extended exposure to alcohol, causing it to function differently and therefore creating addictive behavior. Tweet This. This disease model may not take into account the reasons some people become addicted and others do not. Cultural and environmental factors need to be considered, as do traumatic events.
Principles of Effective Treatment | National Institute on Drug Abuse (NIDA)
Compounding on this disease model, the theory of addiction being genetic or hereditary was born. This theory states that addicts may have certain predispositions to addiction, or genes that may help determine whether or not a person becomes an alcoholic. Many believe that it is a combination of genes and environmental stimuli that actually lead to addiction. Still others argue that addiction is a psychological symptom and not necessarily a physical disease.
Labeling alcoholism as a disease instead of merely deviant behavior can make medical treatment more accessible.
Many medical facilities as well as insurance carriers recognize addiction as a physical malady that needs to be treated. It also implies that, like many other diseases, relapse is common and nothing to be ashamed of. According to The New York Times , 80 to 90 percent of people treated for alcohol dependency relapse at some point.
The initial disease model also indicates that alcoholism is incurable and irreversible with abstinence being the only answer.