Almost alcoholic?

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

4 thoughts on “Almost alcoholic?

  1. One could drive themselves crazy splitting hairs with the DSM definitions. But they are necessary for insurance coverage.

    Alcoholism is a self-diagnosis.

    1. At the individual level, as a recovering person, I agree with your sentiment.

      At another level, it’s important that we do a decent job of distinguishing well so that professionals can determine how to respond. We don’t want counselors telling non-chronic DSM dependent college students that they have an incurable illness and that lifelong abstinence is the only reasonable course of action. We also don’t want counselors assuming that a chronic/relapsing type dependent college student sill mature out of it and moderate.

      We can’t always tell the difference, but a well-informed counselor can have a candid conversation with the person about the two types, the difficulty distinguishing, characteristics of each type and so that they have the right info to self-diagnose…and revisit they diagnosis if they get into trouble again.

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