Chapter Three: Alcohol Dependence. points to consider Definitions Disease concept Natural history...
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Transcript of Chapter Three: Alcohol Dependence. points to consider Definitions Disease concept Natural history...
Chapter Three: Alcohol Dependence
points to consider
DefinitionsDefinitions Disease conceptDisease concept Natural historyNatural history Guidelines for diagnosisGuidelines for diagnosis
definitions
Earliest definitionsEarliest definitions much variationmuch variation focus on different aspects focus on different aspects
example: descriptive only vs. causes example: descriptive only vs. causes
Efforts to promote uniformityEfforts to promote uniformity WHO 1977WHO 1977
International Classification DiseasesInternational Classification Diseases APA 1980APA 1980
Diagnostic and Statistical ManualDiagnostic and Statistical Manual
definition: American Society of Addiction Medicine (ASAM)
Alcoholism (dependence) is a “Alcoholism (dependence) is a “primaryprimary, , chronicchronic diseasedisease with genetic, psychological with genetic, psychological and environmental factors... often and environmental factors... often progressiveprogressive and fatal. …characterized by and fatal. …characterized by impaired controlimpaired control over drinking, over drinking, preoccupationpreoccupation…, alcohol …, alcohol use despiteuse despite adverse consequences…” adverse consequences…”
19931993
key points of ASAM definition
Characterization as a disease that is Characterization as a disease that is ChronicChronic PrimaryPrimary ProgressiveProgressive
implications of disease concept
Dictates attitudesDictates attitudes Identifies care-giversIdentifies care-givers Moves from punishment to treatmentMoves from punishment to treatment Reduces stigmaReduces stigma
management of chronic disease
Treatment of acute flare-upsTreatment of acute flare-ups Emotional supportEmotional support Patient educationPatient education Rehabilitation to live with limitationsRehabilitation to live with limitations Family involvementFamily involvement Partnership of physician and patientPartnership of physician and patient
natural history a la EM Jellinek
How a disease or condition unfoldsHow a disease or condition unfolds EM Jellinek first to describeEM Jellinek first to describe Based on survey of 2,000 early AA Based on survey of 2,000 early AA
membersmembers Identified pattern in emergence of symptoms Identified pattern in emergence of symptoms Grouped signs/symptoms into phasesGrouped signs/symptoms into phases
Phases of alcoholism
Four stagesFour stages Pre-alcoholic PhasePre-alcoholic Phase Prodromal PhaseProdromal Phase
means “signaling” or “warning” means “signaling” or “warning” Crucial PhaseCrucial Phase Chronic PhaseChronic Phase
phases of alcoholism Pre-alcoholic Phase
Drinking socially motivatedDrinking socially motivated Response to alcohol “primes” drinkerResponse to alcohol “primes” drinker
psychological reliefpsychological relief release of tension release of tension
seeks occasions where drinkingseeks occasions where drinking Drinking behavior does not stand outDrinking behavior does not stand out Time: several months to 2Time: several months to 2++ years years
phases of alcoholism Prodromal Phase
Blackouts appear, Blackouts appear, thethe warning sign warning sign Alcohol no longer just a beverageAlcohol no longer just a beverage Consumption heavy, doesn’t necessarily Consumption heavy, doesn’t necessarily
stand outstand out Conscious effort to keep drinkingConscious effort to keep drinking
inconspicuous inconspicuous Time: 6 months to 4 or 5Time: 6 months to 4 or 5++ years years
phases of alcoholism Crucial Phase
Key symptom, loss of controlKey symptom, loss of control Drinking stands outDrinking stands out Drinking requires explanationDrinking requires explanation Adopts tactics to regain controlAdopts tactics to regain control Life alcohol-centeredLife alcohol-centered Deteriorating relationshipsDeteriorating relationships
phases of alcoholism Chronic Phase
Morning drinking commonMorning drinking common Social & workplace functioning goneSocial & workplace functioning gone Frequent intoxicationFrequent intoxication Living on society’s fringesLiving on society’s fringes Withdrawal symptoms without alcoholWithdrawal symptoms without alcohol Rationalization fails Rationalization fails so open to treatment so open to treatment Continued drinking likely, can’t see way outContinued drinking likely, can’t see way out
phases of alcoholism some caveats
Product of era when developedProduct of era when developed Some elements countered by later research Some elements countered by later research
example: significance of blackoutsexample: significance of blackouts
AlsoAlso Jellinek recognized some cases didn’t fit Jellinek recognized some cases didn’t fit
model of Phasesmodel of Phases Led to formulation of Led to formulation of Species of AlcoholismSpecies of Alcoholism
species of alcoholism
Formulated by EM JellinekFormulated by EM Jellinek Different “varieties” of alcoholismDifferent “varieties” of alcoholism Possibly product of different culturesPossibly product of different cultures Speculated that not all species may Speculated that not all species may
represent a diseaserepresent a disease Five species identified by aFive species identified by a
Greek letterGreek letter
species of alcoholism alpha alcoholism
Purely psychological dependencePurely psychological dependence Not loss of control nor inability to abstainNot loss of control nor inability to abstain Hallmark: drinking to handle problemsHallmark: drinking to handle problems Progression not inevitableProgression not inevitable Recognized as what others might callRecognized as what others might call
“problem drinking”“problem drinking”
species of alcoholism beta alcoholism Physical problems of heavy drinkingPhysical problems of heavy drinking Absence of psychological or Absence of psychological or
physical dependencephysical dependence Common in cultures with heavy drinkingCommon in cultures with heavy drinking
and inadequate diet”and inadequate diet”
species of alcoholism gamma alcoholism Species identified in Species identified in
Phases of Alcoholism AddictionPhases of Alcoholism Addiction Tolerance, loss of controlTolerance, loss of control Psychological Psychological physical dependence physical dependence Suggested to be most common type in US”Suggested to be most common type in US”
species of alcoholism delta alcoholism Similar to gamma alcoholism Similar to gamma alcoholism PsychologicalPsychological physical dependence physical dependence Can control amount consumed on any Can control amount consumed on any
occasionoccasion ButBut cannot cease drinking without cannot cease drinking without
withdrawalwithdrawal
species of alcoholism epsilon alcoholism
Studied less intensivelyStudied less intensively Seen as different from other speciesSeen as different from other species Described as “periodic alcoholism”Described as “periodic alcoholism” Marked by periodic binge drinkingMarked by periodic binge drinking
formalizing disease approach Disease formulation garnered acceptanceDisease formulation garnered acceptance If a diseaseIf a disease
a need to formalize definitionsa need to formalize definitions a need for guides to diagnosisa need for guides to diagnosis
Actions by professional associationsActions by professional associations National Council on AlcoholismNational Council on Alcoholism World Health Organization (World Health Organization (ICDICD)) American Psychiatric Associations American Psychiatric Associations
( (Diagnostic and Statistical Diagnostic and Statistical Manual)Manual)
formalizing disease approachs
Actions by professional associationsActions by professional associations National Council on AlcoholismNational Council on Alcoholism World Health Organization (World Health Organization (ICDICD)) American Psychiatric Associations American Psychiatric Associations
( (Diagnostic and Statistical Diagnostic and Statistical Manual)Manual)
National Council on Alcoholism
1972, published 1972, published Criteria for DiagnosisCriteria for Diagnosis Identified signs and symptomsIdentified signs and symptoms Two types of datasTwo types of datas
physiological/clinicalphysiological/clinical behavioral, psychologicalbehavioral, psychological within each track: major and minor within each track: major and minor
criteriacriteria Similarity to Jellinek, but external dataSimilarity to Jellinek, but external data
National Council on Alcoholism (cont.)
Based on external verifiable dataBased on external verifiable data Jellinek signs efforts to deceiveJellinek signs efforts to deceive examples: alcohol or breathe at examples: alcohol or breathe at
appointmentappointment Characterizes disease as chronic Characterizes disease as chronic Suggests criteria for assessing post-Suggests criteria for assessing post-
treatment statustreatment status
American Psychiatric Association
APA’s APA’s Diagnostic & Statistical ManualDiagnostic & Statistical Manual1980 edition, a milestone1980 edition, a milestone
set forth explicit criteria for diagnosisset forth explicit criteria for diagnosis no longer dependent on theories of causeno longer dependent on theories of cause created categorycreated category
“Substance Use Disorders” “Substance Use Disorders”
Criteria for Diagnosisof Dependence (DSM-IV)
1. Tolerance1. Tolerance
2. Withdrawal2. Withdrawal
3. Drinking more than intended3. Drinking more than intended
4. Desire to or inability to control drinking4. Desire to or inability to control drinking
5. Considerable time spent drinking5. Considerable time spent drinking
6. Important activities given up due to drinking6. Important activities given up due to drinking
7. Continued drinking despite known negative7. Continued drinking despite known negativeconsequencesconsequences (3 or more = diagnostic)(3 or more = diagnostic)
Criteria for Diagnosisof Abuse (DSM-IV)
1. Drinking leads to failing to fill major roles1. Drinking leads to failing to fill major roles
2. Recurrent drinking when it is physically 2. Recurrent drinking when it is physically hazardoushazardous
3. Recurrent alcohol-related legal problems3. Recurrent alcohol-related legal problems
4. Continued drinking despite persistent 4. Continued drinking despite persistent social or interpersonal problemssocial or interpersonal problems
(1 or more = diagnostic)(1 or more = diagnostic)
other alcohol-related diagnoses (DSM-IV)
Other DSM-IV alcohol-related conditionsOther DSM-IV alcohol-related conditions Examples:Examples:
intoxicationintoxicationwithdrawalwithdrawalalcohol-induced deliriumalcohol-induced deliriumalcohol-related dementiaalcohol-related dementia
Other substance use disorders Other substance use disorders (by drug class) (by drug class)
natural history a la Vaillant
Landmark study published in 1983Landmark study published in 1983 LongitudinalLongitudinal
followed subject for 50 years followed subject for 50 years Information on pre-alcoholism stateInformation on pre-alcoholism state Able to sort out results of alcoholism fromAble to sort out results of alcoholism from
pre-existing factors pre-existing factors
findings: natural history a la Vaillant
No support for then popular theory of No support for then popular theory of “alcoholic personality”“alcoholic personality”
Typically, a progressive downward courseTypically, a progressive downward course Essentially two outcomesEssentially two outcomes
people either became abstinence or died people either became abstinence or died Very few returned to non-problematic Very few returned to non-problematic
drinkingdrinking