Everyone uses it, and is certain of what it means. However, no two
people seem to be able to agree on a clear definition. To some,
an alcoholic is a chronic inebriate living in the streets. To others,
it is anyone who has missed more than one day of work or school because of
over-drinking the night before. Members of the World Health Organization
had such a difficult time agreeing on a definition that they abandoned the
word completely in 1978 and replaced it with 'alcohol abuse and dependence'.
The American Psychiatric Association did the same two years later.
Below is some information that may help clarify the issue for you.
Diagnostic Criteria for Alcohol Abuse and Dependence
Diagnosis is the process of identifying and labeling specific conditions
such as alcohol abuse or dependence (1). Diagnostic criteria for alcohol abuse
and dependence reflect the consensus of researchers as to precisely which
patterns of behavior or physiological characteristics constitute symptoms
of these conditions (1). Diagnostic criteria allow clinicians to plan treatment
and monitor treatment progress; make communication possible between clinicians
and researchers; enable public health planners to ensure the availability
of treatment facilities; help health care insurers to decide whether treatment
will be reimbursed; and allow patients access to medical insurance coverage
(1-3).
Diagnostic criteria for alcohol abuse and dependence have evolved over time.
As new data become available, researchers revise the criteria to improve their
reliability, validity, and precision (4,5). This Alcohol Alert traces the
evolution of diagnostic criteria for alcohol abuse and dependence through
the current standards of the American Psychiatric Association's Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (6). For
comparison, the criteria found in the World Health Organization's International
Classification of Diseases, Tenth Revision (ICD-10) also are reviewed briefly,
although these are not often used in the United States (7).
Evolution of Diagnostic Criteria
Early Criteria
At least 39 diagnostic systems had been identified before 1940 (2). In 1941
Jlinek first published what is considered a groundbreaking theory of subtypes
of what was, until 1980, termed alcoholism (2,8). Jellinek associated these
subtypes with different degrees of physical, psychological, social, and occupational
impairment (2,9).
Formulations of diagnostic criteria continued with the American Psychiatric
Association's publication of the Diagnostic and Statistical Manual of Mental
Disorders, First Edition (DSM-I), and Second Edition (DSM-II) (10,11). Alcoholism
was categorized in both editions as a subset of personality disorders, homosexuality,
and neuroses (2,12).
In response to perceived deficiencies in DSM-I and DSM-II, the Feighner
criteria were developed in the 1970's to establish a research base for the
diagnostic criteria of alcoholism (5,13). These criteria were the first to
be based on research rather than on subjective judgment and clinical experience
alone (5). Though designed for use in clinical practice, they were primarily
developed to stimulate continued research for the development of even more
useful diagnostic criteria (5). Several years later, Edwards and Gross focused
solely on alcohol dependence (8). They considered essential elements of dependence
to be a narrowing of the drinking repertoire, drink-seeking behavior, tolerance,
withdrawal, drinking to relieve or avoid withdrawal symptoms, subjective awareness
of the compulsion to drink, and a return to drinking after a period of abstinence
(8)
The DSM Criteria
Researchers and clinicians in the United States usually rely on the DSM
diagnostic criteria. The evolution of diagnostic criteria for behavioral
disorders involving alcohol reached a turning point in 1980 with the publication
of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition
(14). In DSM-III, for the first time, the term "alcoholism" was dropped in
favor of two distinct categories labeled "alcohol abuse" and "alcohol dependence"
(1,2,12,15). In a further break from the past, DSM-III included alcohol abus
e and dependence in the category "substance use disorders" rather than as
subsets of personality disorders (1,2,12).
The DSM was revised again in 1987 (DSM-III-R) (16). In DSM-III-R, the category
of dependence was expanded to include some criteria that in DSM-III were considered
symptoms of abuse. For example, the DSM-III-R described dependence as including
both physiological symptoms, such as tolerance and withdrawal, and behavioral
symptoms, such as impaired control over drinking (17). In DSM-III-R, abuse
became a residual category for diagnosing those who never met the criteria
for dependence, but who drank despite alcohol-related physical, social, psychological,
or occupational problems, or who drank in dangerous situations, such as in
conjunction with driving (17). According to Babor, this conceptualization
allowed the clinician to classify meaningful aspects of a patient's behavior
even when that behavior was not clearly associated with dependence (18).
The DSM was revised again in 1994 and was published as the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (6). The section
on substance-related disorders was revised in a coordinated effort involving
a working group of researchers and clinicians as well as a multitude of advisers
representing the fields of psychiatry, psychology, and the addictions (2).
The latest edition of the DSM represents the culmination of their years of
reviewing the literature; analyzing data sets, such as those collected during
the Epidemiologic Catchment Area Study; conducting field trials of two potential
versions of DSM-IV; communicating the results of these processes; and reaching
consensus on the criteria to be included in the new edition (2,19).
DSM-IV, like its predecessors, includes nonoverlapping criteria for dependence
and abuse. However, in a departure from earlier editions, DSM-IV provides
for the subtyping of dependence based on the presence or absence of tolerance
and withdrawal (6). The criteria for abuse in DSM-IV were expanded to include
drinking despite recurrent social, interpersonal, and legal problems as a
result of alcohol use (2,4). In addition, DSM-IV highlights the fact that
symptoms of certain disorders, such as anxiety or depression, may be related
to an individual's use of alcohol or other drugs (2).
The ICD Criteria
While the American psychiatric community was formulating its editions of
diagnostic criteria for mental disorders, the World Health Organization was
developing diagnostic criteria for the purpose of compiling statistics on
all causes of death and illness, including those related to alcohol abuse
or dependence, worldwide (1,4,20). These criteria are published as the International
Classification of Diseases (ICD). The first ICD classification of substance-related
problems, published in 1967 in ICD-8 (21), classified what was then called
alcoholism with personality disorders and neuroses, as had DSM-I and DSM-II.
In ICD-8, alcoholism was a separate category that included episodic excessive
drinking, habitual excessive drinking, and alcohol addiction that was characterized
by the compulsion to drink and by withdrawal symptoms when drinking was stopped
(1).
Although ICD-9 (22,23) included separate criteria for alcohol abuse and
dependence, this revision defined them similarly in terms of signs and symptoms
(1). According to Babor, an important assumption in ICD-9 was that alcohol
use in the absence of dependence "merits a separate category by virtue of
its detrimental effects on health" (1, p. 87).
The category of alcohol dependence was central to the current revision,
ICD-10 (1,2,7). Alcohol dependence is defined in this classification in a
way that is similar to the DSM. The diagnosis focuses on an interrelated
cluster of psychological symptoms, such as craving; physiological signs,
such as tolerance and withdrawal; and behavioral indicators , such as the
use of alcohol to relieve withdrawal discomfort (1). However, in a departure
from the DSM, rather than include the category "alcohol abuse," ICD-10 includes
the concept of "harmful use." This category was created so that health problems
related to alcohol and other drug use would not be underreported (1). Harmful
use implies alcohol use that causes either physical or mental damage in the
absence of dependence (1).
Moving Toward Agreement Between Diagnostic Criteria
The DSM diagnostic criteria for psychiatric disorders are the criteria primarily
used in the United States. The ICD is an international diagnostic and classification
system for all causes of death and disability, including psychiatric disorders
(4). Earlier editions of these two major diagnostic criteria dealing with
alcohol abuse and dependence were criticized for being too dissimilar (2).
Therefore, the DSM-IV and the ICD-10 were revised in a coordinated effort
among researchers worldwide to develop criteria that were as consistent with
one another as possible (1,2).
Although some differences between the two major diagnostic criteria still
exist, they have been revised by consensus as to how alcohol abuse and dependence
are best characterized for clinical purposes (18). Clinicians, international
health agencies, and researchers are now better able to categorize people
with alcohol dependence, abuse, and harmful use to plan treatment, collect
statistical data, and communicate research results (18).
Diagnostic Criteria--A Commentary by
NIAAA Director Enoch Gordis, M.D.
The research community has long found standardized diagnostic criteria useful.
Such criteria provide agreement as to the constellation of symptoms that indicate
the alcohol dependence syndrome and allow researchers all over the world
to communicate clearly as to what kinds of disorders are being studied.
Standardized diagnostic criteria are equally important and useful to clinicians.
In the alcohol field, there have been many different ways by which clinical
staff might arrive at a diagnosis--sometimes differing among staff within
the same program. Although the use of standard diagnostic criteria may seem
somewhat burdensome, it provides many benefits: more efficient assessment
and placement, more consistency in diagnoses between and within programs,
enhanced ability to measure the effectiveness of a program, and provision
of services to people who most need them. As we move more and more into a
managed health care arena, third-party payors are requiring more standardized
reporting of illnesses; they want to know what conditions they are paying
for and that these conditions are the same from program to program. The standardized
diagnostic criteria presented in this Alert are based on the newest research,
have been developed based on field trials and extensive reviews of the literature,
and are continually revised to reflect new findings. Although clinical judgment
will always play a role in diagnosing any illness, alcohol treatment programs
that use standardized diagnostic criteria will be in the best position to
select appropriate treatment and to justify their selection to third-party
payors.
(1) Babor, T.F. Substance-related problems in the context of international
classificatory systems. In: Lader, M.; Edwards, G.; & Drummond, D.C.,
eds. The Nature of Alcohol and Drug Related Problems. New York: Oxford University
Press, 1992.
(2) Schuckit, M.A. DSM-IV: Was it worth all the fuss? Alcohol and Alcoholism.
(Supp. 2):459-469, 1994.
(3) Vaillant, G.E. The Natural History of Alcoholism Revisited. Cambridge:
Harvard University Press, 1995.
(4) Rounsaville, B.J.; Bryant, K.; Babor, T.; Kranzler, H.; & Kadden,
R. Cross system agreement for substance use disorders: DSM-III-R, DSM-IV and
ICD-10. Addic tion 88(3):337-348, 1993.
(5) Feighner, J.P.; Robins, E.; Guze, S.B.; Woodruff, R.A., Jr.; Winokur,
G.; & Munoz, R. Diagnostic criteria for use in psychiatric research. Archives
of General Psychiatry 26(1):57-63, 1972.
(6) American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition. Washington, D.C.: the Association, 1994.
(7) World Health Organization. The ICD-10 Classification of Mental and Behavioural
Disorders: Clinical Descriptions and Diagnostic Guidelines, Tenth Revision.
Geneva: World Health Organization, 1992.
(8) Edwards, G., & Gross, M.M. Alcohol dependence: Provisional description
of a clinical syndrome. British Medical Journal 1:1058-1061, 1976.
(9) Jellinek, E.M. The Disease Concept of Alcoholism. New Brunswick: Hillhouse
Press, 1960.
(10) American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, First Edition. Washington, D.C.: the Association, 1952.
(11) American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, Second Edition. Washington, D.C.: the Association, 1968.
(12) Nathan, P.E. Substance use disorders in the DSM-IV. Journal of Abnormal
Psychology 100(3):356-361, 1991.
(13) Keller, M., & Doria, J. On defining alcoholism. Alcohol Health
& Research World 15(4):253-259, 1991.
(14) American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, Third Edition. Washington, D.C.: The Association, 1980.
(15) Cottler, L.B.; Schuckit, M.A.; Helzer, J.E.; Crowley, T.; Woody, G.;
Nathan, P.; & Hughes, J. The DSM-IV field trial for substance use disorders:
Major results. Drug and Alcohol Dependence 38:59-69, 1995.
(16) American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, Third Edition, Revised. Washington, D.C.: the Association,
1987.
(17) Hasin, D.S.; Grant, B.; & Endicott, J. The natural history of alcohol
abuse: Implications for definitions of alcohol use disorders. American Journal
of Psychiatry 147(11):1537-1541, 1990.
(18) Babor, T.F. The road to DSM-IV: Confessions of an erstwhile nosologist.
Commentary No. 2. Drug and Alcohol Dependence 38:75-79, 1995.
(19) Schuckit, M.A. Familial alcoholism. In: Widiger, T.; Frances, A.; Pincus,
H.; First, M.; Ross, R.; & Davis, W., eds. DSM-IV Sourcebook. Vol. 1.
Washington, D.C.: American Psychiatric Association, 1994. pp. 159-167.
(20) Grant, B.F. DSM III-R and ICD 10 classifications of alcohol use disorders
and associated disabilities: A structural analysis. International Review of
Psychiatry 1:21-39, 1989.
(21) World Health Organization. Manual of the International Statistical
Classification of Diseases, Injuries, and Causes of Death, Eighth Revision.
Geneva: World Health Organization, 1967.
(22) World Health Organization. Manual of the International Statistical
Classification of Diseases, Injuries, and Causes of Death, Ninth Revision.
Vol. 1. Geneva: World Health Organization, 1977.
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