Alcohol Dependence (303.90)

DSM-IV-TR criteria

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1) Tolerance, as defined by either of the following:

  • A need for markedly increased amounts of the substance to achieve intoxication or desired effect
  •  Markedly diminished effect with continued use of the same amount of the substance

(2) Withdrawal, as manifested by either of the following:

  • The characteristic withdrawal syndrome for the substance (refer to criteria A and B of the criteria sets for Withdrawal from the specific substances)
  • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(3) The substance is often taken in larger amounts or over a longer period than was intended

(4) There is a persistent desire or unsuccessful efforts to cut down or control substance use

(5) A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6) Important social, occupational, or recreational activities are given up or reduced because of substance use

(7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Specify if:

  • With Physiological Dependence
  • Without Physiological Dependence
  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • In a Controlled Environment

Associated features

  • Statistics show that: in the United States about one out of ten people are alcohol dependent; there is either an intoxicated driver or pedestrian involved in approximately one half of all highway fatalities; and among individuals with alcohol dependence, approximately ten percent commit suicide (this is shown to be related to Substance Induced Mood Disorders) . Other studies show a connection between long term heavy alcohol use and the development of Dementia and Wernicke’s disease. In pregnant women alcohol dependence can also cause different birth defects such as Fetal Alcohol Effects (FAE) and Fetal Alcohol Syndrome (FAS).Fetal Alcohol Syndrome is more severe and usually causes some form of mild Mental Retardation and physical defects leading to intellectual deficiencies and learning disabilities. The statistics concerning FAS are staggering. It is estimated that out of every 1000 infants born alive, approximately 1.5 has FAS. Not only is Fetal Alcohol Syndrome the primary preventable cause of Mental Retardation in the United States, it is also the third leading cause of birth defects.
  • Regarding tolerance, it is a sign that the liver has been damaged when reverse tolerance, that is, the need of less alcohol to produce the desired effect, appears.

Child vs. Adult presentation

Having hyperactive ADHD increases teenagers’ chances of using alcohol. Children who come from families that sanction drinking have a higher risk of becoming alcohol users. Adolescents and teenagers who first use alcohol are starting the experimentation process. Adults who first use alcohol are doing so because of some positive or negative influence in their lives.

Gender and Cultural differences in presentation

  • Religion is a large factor in the rates of alcohol abuse and dependence in different cultures. Part of that influence is the context in which the alcohol is being used. There tends to be lower rates of Alcohol Dependence in cultures that use alcohol in religious ceremonies. Rates of Alcohol Dependence are higher in cultures where religion uses alcohol as a social lubricant.
  • Alcohol dependence is more prominent among Native Americans and Irish or Irish Americans. For Native Americans this stems from the history of being deprived of their lands and denied the stability of economic success. Because their homes are usually too small and crowded to get together with friends and family, the pub is usually the social center of the Irish way of life.
  • Men represent a larger population of alcohol dependent’s than do women. Numerous studies have shown that men will be less likely to abstain from using alcohol, and hence more often become dependent on the substance. Men generally consume more alcohol and abuse alcohol more frequently than women (Homila 2004). From culture to culture the size of this discrepancy varies, and more research is needed to explain why these cultural differences exist.

Epidemiology

Ninety percent of the population has used alcohol at some point in their lives. Alcohol has the effects of positive reinforcement by changing brain and body chemistry. Alcohol also has a negative reinforcement effect of removing inhibitions and anxiety. It is at least three times as likely for a primary biological relative to have Alcohol Dependence if a first degree biological relative has the same disorder. The environment of where individuals live and their Socio Economic Status also play a role in developing Alcohol Dependence. There is also a new theory being studied that connects Alcohol Dependence to abnormally low serotonin levels.

Etiology

  • There are many various factors that influence whether or not an individual develops alcohol dependence. From a psychoanalyst perspective, Alcohol Dependence would be seen as a result of anxiety, repressed emotions, or neurotic conflict, and could also be used as a way to boost self esteem. Having an oral fixation has also been connected to Alcohol Dependence. There can also be a genetic connection. A key factor is that the individual must hold a positive attitude towards alcohol. Peer pressure during adolescence and the media portrayal of alcohol (having sex appeal) throughout life are also strong influential factors. Once an individual gives into the pressure he will start to experiment with alcohol. These experiments may have positive or negative effects. If the individual has a positive opinion about alcohol and enjoys drinking then he will continue to drink. If he steadily increases the amount of alcohol he drinks it could eventually lead to complications of his everyday life. Ads for alcoholic beverages are increasigly targeted at the youth, especially young men, sending the message that drinking beer may, for example, cause scandalously clad women to flock to one’s location. The individual then begins to experiment with alcohol, usually with a peer group, and continues use through school. Problems occur and worsen the heavier the alcohol use becomes.
  • Two key etiological factors are generally agreed upon. First, the individual must have a positive attitude toward alcohol.

Empirically supported treatments

  • It is much easier to treat and stop the alcohol abuse before it becomes dependence. There are many proposed treatments for an individual with Alcohol Dependence. Psychotherapy, ketamine-enhanced psychotherapy (Kolp, Friedman, Young & Krupitsky, 2006), medications such as Disulfiram (Mustard, May & Phillips,2006; Obholzer, 1974), 12-step programs (Gomes & Hart, 2009), and religious programs are all empirically supported treatments for individuals with Alcohol Dependence. It is not uncommon for two or more of these methods to be used in treating individuals with Alcohol Dependence. Spirituality is suggested to be inversely related to alcohol use, therefore, increasing one’s spirituality is an approach taken by many substance-abuse professionals in an attempt at treatment of the Substance-Related Disorders (Johnson, Sheets & Kristeller, 2008). Twelve-step programs such as Alcoholics Anonymous or Narcotics Anonymous are examples of commonly used spirituality-based treatments for Substance-Related Disorders. It is suggested that use of a 12-step program in combination with psychotherapy is quite effective (Knack, 2009). Groh, Jason, Ferarri, & Davis (2009) examined the effectiveness of 12-step involvement in combination with the use of an Oxford House (group recovery living) in 150 substance-dependent individuals. Groh (2009) and his colleagues found that in the 12-step/Oxford house combination condition, 87.5% of individuals with “high 12-step involvement” were abstinent at 24 months. Abstinence rates at 24 months for individuals with “low 12-step involvement” were fairly similar across both conditions; 12-step/Oxford combination = 31.4%, 12-step alone = 21.2% (Groh, Jason, Ferarri, & Davis, 2009)
  • The Disease Model sees Alcohol dependence as a medical condition. This model ties into the genetic factor. If Alcohol Dependence is seen as a biological condition then the only successful way to treat it, is to completely abstain from drinking alcohol. The self help group Alcoholics Anonymous (AA) recognizes the disease model. It is unsafe for an individual that is dependent on alcohol to stop “cold turkey”. The alcohol must be removed from the system in a slow process of detoxification. To prevent sever withdrawal complications, the individual will be given some form of anti-anxiety medications. Medications such as Antabuse may also be used in an attempt to maintain abstinence. Severe Alcohol Dependence can have a spontaneous remission with about twenty percent never experience drinking problems again.

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