Alcohol use disorder (AUD) is the current diagnosis for what may also be called chronic alcoholism, alcohol addiction, alcohol abuse, dipsomania, and alcohol dependence. We can define unhealthy drinking behaviors in a variety of ways, but problems are the common denominator. That is, our friend/enemy/frenemy alcohol (technically ethanol) is a psychoactive drug that can cause serious problems in our lives. But how do you know when your drinking habits are harmful? And is it possible to predict who can drink recreationally without becoming addicted? And if you do find yourself thinking about alcohol all the time, what are you supposed to do about it? Show
This comprehensive look at alcohol use disorder will seek to answer these questions, and many more. The subject of alcohol tends to elicit strong reactions. Most of us have deliberated about how much to drink, and what, and when, and why. We have turned down glasses of wine and we have stared into empty bottles. We might associate alcohol with friends and fun times, or with guilt, loss, and shame. Often, our feelings are mixed. Bearing this in mind, we will try to give you the facts without embellishing or editorializing. Everyone’s relationship with alcohol is deeply personal, which is why successful AUD treatment can run the gamut. In this article, we aim to offer a compassionate, clinical framework in which to think about drinking and its effects on our well-being. What Is Alcohol Use Disorder?Alcohol use disorder (AUD) is the term that the American Psychiatric Association (APA) uses to describe a harmful drinking pattern, as defined in the Diagnostic and Statistical Manual of Disorders, Fifth Edition (DSM-5). (In the United States, the DSM-5 is considered the bible of mental health issues.) An earlier version of that manual, the DSM-IV, distinguished between alcohol abuse and alcohol dependence. Those disorders have now merged into AUD. So that’s the background, but what’s the big picture? Is alcohol use disorder a mental illness? AUD is both a medical condition and a mental health condition. The DSM-5 categorizes AUD as a substance use disorder. People use and misuse substances like drugs and alcohol all the time, but when they begin to suffer significant problems as a result, and continue to use those substances despite the significant problems, their behavior pattern becomes a disorder. The word “addiction” has fallen out of favor in mental health circles, but substance use disorders often (but not always) include an element of physical dependency. So a person with alcohol use disorder might experience unpleasant withdrawal symptoms when they’re not drinking. Their brain circuitry might come to rely on alcohol, which intensifies cravings and makes relapse more likely. What are the DSM-5 criteria for an alcohol use disorder? Let’s take a deeper look. Alcohol Use Disorder DSM-5 CriteriaThere are 2,048 potential ways to have the symptoms of alcohol use disorder. This is because a DSM-5 diagnosis of AUD requires at least two symptoms out of 11, which can be combined in various ways over the course of a year. And the exact combination of symptoms is significant. For example, if someone exhibits only number 10 (tolerance) and number 11 (withdrawal), but not symptoms 1-9, then their AUD interventions will probably look different from those of the drinker who frequently misses work due to hangovers and has multiple DUIs on their record. You can think of the DSM-5 symptoms of AUD as stand-alone, or categorize them in groups. To be diagnosed with the disorder, an individual demonstrates at least two of the following over a 12-month period: [Criteria grouping A: Impaired control over substance use]
[Criteria grouping B: Social impairment]
[Criteria grouping C: Risky use]
[Criteria grouping D: Pharmacological
The DSM-5 also breaks down AUD by severity:
And finally, DSM-5 criteria can specify whether someone is:
Alcohol Use Disorder ICD 11Though clinicians in the United States primarily use the DSM-5 for diagnosing mental health conditions, clinicians across the world tend to favor the International Classification of Diseases (ICD), which is in its 11th edition. The ICD-11, published by the World Health Organization (WHO), does not use the term “alcohol use disorder.” Instead, this global health manual distinguishes between three kinds of alcohol problems:
What Does Alcohol Use Disorder Look Like?Clinical criteria can help make a formal diagnosis, but what does alcohol use disorder look like in daily life? Does it mean that you often drink alone? Does it mean that you routinely have whiskey for breakfast? Does it mean that you own t-shirts that say “Wine O’Clock,” or that you hit rock bottom and lose everything? It all depends on the severity and symptomatology of the disorder. The following real-world signs may indicate that you’re struggling with alcohol use. Warning Signs of Alcohol Use Disorder
AUD Symptom GlossaryAlcohol abuse: According to Elizabeth Fiser, Psychiatric Mental Health Nurse Practitioner (PMHNP) at Thriveworks, alcohol abuse and alcohol misuse can be interchangeable with alcohol use. She defines alcohol abuse as “a deleterious situation for the one using and for those who love and care for them. It is a mosaic of drinking frequently. It impedes a person’s day-to-day quality of life.” Binge drinking: Both the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) define binge drinking as consuming 5+ alcoholic drinks for men, or 4+ alcoholic drinks for women, within a few hours. This brings someone’s blood alcohol concentration (BAC) to 0.08 percent or higher. Drinking in moderation: For men, drinking in moderation is defined by consuming two drinks or fewer per day, and for women, one drink or less per day. This can also be called controlled drinking or nonproblematic drinking. Hangover: A hangover is an unpleasant bouquet of symptoms that emerge in the immediate wake of alcohol consumption. Hangovers vary from person to person, but they may include headaches, stomach upsets, irritability, anxiety, and fatigue. Heavy alcohol use: For men, healthy alcohol use means consuming 14+ drinks per week, and for women, consuming 7+ drinks per week. Heavy alcohol use can also be defined as binge drinking for more than five days in the past month. Sobriety: Sobriety is a human’s natural state of being, when someone doesn’t have any measurable psychoactive substances in their body. Withdrawal: When someone suffers specific physical and mental symptoms when they discontinue a substance, the phenomenon is called withdrawal. Alcohol withdrawal is a DSM-5 diagnosis. Are There Different Types of AUD?Alcohol use disorder can be mild, moderate, or severe according to DSM-5 criteria. But some clinicians have attempted to categorize people with AUD or alcohol dependence according to subtype. For example, a survey from the NIAAA determined that there were five types of people with alcohol dependence:
The NIAAA called its typology the “five-cluster solution.” But this is certainly not the only way of classifying problem drinkers. There are also the four subtypes of alcoholism defined by Robert Zucker in 1987:
And the two subtypes proposed by Thomas Babor in 1992:
Informally, there are countless names for different types of drinkers. For example, a dry drunk is what the founder of Alcoholics Anonymous (AA) christened someone who was technically sober, but hadn’t addressed any of the underlying issues that motivated them to drink. Because there’s been no real change, the dry drunk is vulnerable to relapse. Are There Stages of Alcoholism?Alcohol use disorder can have a variable course. For some people, AUD might begin in the teen years and worsen at a steady pace. Other people may quit drinking, then relapse multiple times. And others may go into remission forever. So there’s no one way an individual can develop AUD. Some researchers have attempted to outline progressive phases of alcoholism, however. For example, E. Morton Jellinek posited five phases that form what’s known as the Jellinek curve:
The 2016 “Surgeon General’s Report on Alcohol, Drugs, and Health” specifies three stages in the addiction cycle:
AUD relapse and recovery can also have stages. For example, one medical doctor who specializes in addiction refers to the emotional, mental, and physical stages of relapse. Recognizing these stages and intervening early can be crucial in maintaining recovery. The same doctor also describes the stages of recovery: abstinence, repair, and growth. What Causes Alcohol Use Disorder?There are many ways to think about how and why someone develops alcohol use disorder. One camp believes that anyone who drinks alcohol will eventually become addicted because that’s the nature of the drug. So it’s not a matter of if, but when. Other camps believe that only certain factors encourage AUD, and without this alchemy, some moderate drinkers can basically remain immune. But the bottom line is that alcohol use disorder is a heterogeneous disease, meaning it’s pretty different for everyone. There’s no single origin story for the affliction. So experts think in terms of risk factors. Research has shown that the following elements can contribute to the development of AUD. Risk Factors for Alcoholism
Alcohol Use Disorder and Other Mental Health ConditionsHarmful drinking patterns are associated with a large number of other mental health conditions, especially depressive disorders and anxiety disorders. Alcohol can also directly trigger certain psychiatric disorders. These are called alcohol-induced disorders and they typically resolve when the individual stops drinking. Alcohol-induced Disorders
Most Common AUD ComorbiditiesAlcohol use disorder can be present at the same time as other psychiatric disorders. When this happens, we call them comorbid disorders. More common AUD comorbidities include the following:
Alcohol As Coping MechanismPicture a young woman with social anxiety. When she pours herself a glass of wine or a shot of liquor before going out with friends or on a date, she feels more at ease. This is because alcohol can act as an anxiolytic agent, meaning it can temporarily reduce anxiety. The young woman had been experiencing some nervousness, some dysphoria, and wine seemed to alleviate those negative feelings. Now that she feels slightly sedated and happy, she’s more easy-going and sociable. Where’s the harm? The harm comes if the young woman develops a pattern of turning to alcohol every time she feels anxious. Not only can this prevent her from finding the internal resources to cope with her emotions, but over time alcohol acts on the brain as a stressor. The young woman thought that she was relieving stress, but in reality, her wine consumption is causing a stress response. The longer she drinks, the more her brain’s reward system and stress system become dysregulated, and it becomes harder and harder for her to maintain control over alcohol – and her own well-being. As in the above example, alcohol is frequently used as a maladaptive coping mechanism. Feeling depressed? You drink. Feeling stressed? You drink. Worried about your marriage? You drink. Instead of dealing with these negative feelings head-on, someone with alcohol use disorder might feel motivated to pick up a bottle. And eventually, all those bottles can disrupt the brain’s ability to generate happiness on its own. Alcohol in SocietyAlcohol has been part of human society for a long time – almost 10,000 years. Historically, various temperance movements and teetotalers (never-drinkers) have tried to make people abstain from alcohol altogether, but they’ve hardly achieved global success. Beer only trails water and tea as the most popular beverage in the world! In the United States, we tend to accept alcohol consumption as a part of life. But there are still safeguards in place meant to protect people from harm. For example, the minimum drinking age is 21. And it’s illegal to drive a car while intoxicated. But alcohol still exacts a heavy cost on society in terms of public health and the economy. In the US alone, excessive alcohol use is responsible for $249 billion in losses every year, and is a leading risk factor for death and disability. The World Health Organization (WHO) has made several recommendations to limit this harm:
Interestingly, research has found that social, cultural, and personal expectations can play a significant role in how people feel and behave when they drink. For example, someone who expects to feel positive when they drink is more likely to feel positive when they drink. And someone who expects to feel socially outgoing when they drink might become more extroverted when intoxicated. So alcohol expectations can be a self-fulfilling prophecy, and understanding someone’s beliefs about alcohol can be an important step in changing drinking behaviors. Women and AlcoholSome interesting research points to sex and gender differences in drinking patterns and alcohol use disorder. Not only are women’s bodies more vulnerable to the negative health consequences of alcohol, but women are also more likely to hide their drinking problems because they fear being judged. This can prevent them from seeking the psychosocial support they need to recover from AUD. Teens and AlcoholStudies show that the earlier someone is initiated into drinking behaviors, the more likely they are to develop alcohol use disorder in young adulthood. Heavy drinking in adolescence can also disrupt normal brain development, both accelerating a reduction in gray matter and slowing the growth of white matter. Weakened executive functions can lead to more impulsivity and more drinking, which can lead to weaker executive functions, and so on in a vicious cycle. Finally, underage drinking is a common contributing factor in car crashes, accidents, overdoses, and suicide. How Does Alcohol Affect the Body?Alcohol can affect the body both directly, on a cellular level; and indirectly, in terms of leading to accidents, violence, injuries, and risky behaviors. All in all, alcohol use disorder can reduce someone’s lifespan by 10 years. The “Surgeon General’s Report on Alcohol, Drugs, and Health” cites 88,000 deaths in the US every year due to alcohol misuse. This section will look at the short- and long-term effects of alcohol use on human health. What Are the Short-term Effects of Alcohol Use?The short-term effects of alcohol depend on how much a person drinks, what their tolerance is, what their expectations are (related to the placebo effect), and other complex variables. In small amounts, alcohol can cause someone to feel mildly euphoric, talkative, relaxed, or uninhibited. In greater amounts, alcohol can lead to anger, mood swings, sleep deprivation, slurred speech, unconsciousness, and even death. The DSM-5 distinguishes between alcohol use disorder and alcohol intoxication. What Are the Long-term Effects of Alcohol Use?Alcohol is associated with hundreds of long-term health problems, including the following:
Alcohol use in pregnant women can also lead to fetal alcohol syndrome (FAS) and various pre-term birth complications. *The Environmental Protection Agency (EPA) classifies acetaldehyde, the chief metabolite of ethanol, as a probable human carcinogen. Neurobiology of AlcoholAlcohol primarily works on the brain by impeding the activity of the central nervous system. What’s the mechanism for this? Alcohol boosts the effects of gamma-aminobutyric acid, or GABA, an inhibitory neurotransmitter. Alcohol also affects other neurotransmitters like serotonin, endocannabinoids, opioid peptides, and dopamine, which are all part of the brain’s reward pathways. So people keep drinking because of this positive reinforcement, but also because not drinking can cause them to feel bad (negative reinforcement) due to hyperactivity and dysfunction in the nervous system. This is what’s known as the addiction cycle. How Does Alcohol Use Disorder Affect Relationships?Frequently, alcohol problems don’t just affect the drinker, but everyone close to them: kids, friends, family members, coworkers, etc. Alcohol abuse can lead to dysfunction within a couple or a family, but relationship dysfunction can also increase someone’s alcohol use. The reciprocal nature of these issues is why people in recovery from AUD often benefit from family therapy and/or marriage counseling. Parental alcoholism can also have a damaging effect on children’s mental health, leading to low self-esteem, externalizing disorders, and/or trust issues. There’s even a 12-step support group for children who have grown up with alcoholic parents: Adult Children of Alcoholics (ACA) & Dysfunctional Families World Support Organization. What Happens When You Quit Alcohol?If your body is dependent on alcohol and you stop drinking, you will likely experience short-term physical and mental discomfort due to withdrawal. These symptoms usually fade or at least become more manageable after 72 hours. This process is often called an alcohol detox, and for severe drinkers, it can be dangerous. Within weeks, months, and years of not drinking, your body and mind will slowly recover from the drug. You’ll feel healthier and more energized after you get over these hurdles. But physical detox is only the first step in overcoming AUD. You also have to figure out the emotional side of the equation as well. With the right tools, it’s very possible to undo alcohol’s damage to your nervous system – and to your life. Alcohol WithdrawalAlcohol withdrawal can include a number of extremely unpleasant symptoms like depression, anxiety, sweating, tremors, insomnia, nausea, gastrointestinal (GI) issues, and cravings. Because none of this feels good, and the only cures are time (several hours to a few days), medication, or more alcohol, many people choose to resume drinking. And to make matters worse, the more times you withdraw from alcohol and then relapse, the worse your withdrawal symptoms can be. This is due to the kindling effect. There are two specific subtypes of alcohol withdrawal worth mentioning here:
Alcohol Use Disorder Screening and DiagnosisMost people diagnose themselves with AUD. Research indicates that only 1 in 6 American adults are asked about their drinking behaviors in health care settings. The CAGE questionnaire is a popular screening for AUD. It asks people the following:
Other assessments include the Alcohol Use Disorders Identification Test (AUDIT), the Alcohol Dependence Data Questionnaire, the Michigan Alcoholism Screening Test (MAST), or one of the MAST derivatives. Lab tests and imaging are not required for an AUD diagnosis. If you receive the diagnosis in a clinical setting, your provider may provide brief counseling and prescribe a medication like naltrexone, then recommend therapy, harm reduction approaches, or a mutual support group. Alcohol Use Disorder TreatmentAs we’ve emphasized throughout this article, alcohol use disorder is different for everyone. This means that interventions should be customized for each drinker. But – and this is crucial – every drinker should have hope that they can find a path to recovery. Though AUD is a chronic health condition that can last for years or a lifetime, the majority of people with AUD recover over time, whether on their own, with medication, or with plenty of psychosocial support. Success rates are high, and there are countless options for effective interventions. You may choose complete abstinence (zero tolerance) or take a harm reduction approach. Well-being can look different to different people. But you have to be ready to change. And because alcohol has hijacked your brain’s reward systems for so long, you’ll need to learn how to be happy without alcohol. Sometimes this can mean learning to be comfortable with being uncomfortable. You may have to “.” This period of personal growth can be something to look forward to, rather than dread. After all, we tend to overestimate the pleasures of drinking, and underestimate its penalties. Alcohol Use Disorder TherapyMany mental health professionals are specially trained to help people with alcohol use disorder. They might be certified addiction counselors (CACs), licensed clinical social workers (LCSWs), psychologists, licensed professional counselors (LPCs), psychiatrists, or another kind of experienced therapist. Here are some of the most effective psychosocial interventions for alcohol use disorder:
Alcohol Use Disorder MedicationsThe Food and Drug Administration (FDA) has approved three drugs for the treatment of alcohol use disorder. These medications are underutilized in the AUD population, only being prescribed to about 10% of people who seek help.
Off-label medications that might hold promise for the treatment of AUD include topiramate, ondansetron, gabapentin, and varenicline. Future Treatment DirectionsEvidence-based alcohol use disorder treatment options are expanding as researchers learn more about the condition. But we’ve already come a long way. In the late 19th century, Sigmund Freud treated alcohol addiction with cocaine! Today’s novel treatments are more likely to involve smart watches and electrodes than asylums and controlled substances. For example, evidence-based AUD interventions of tomorrow may include the following:
An AUD Action PlanHow do you go from a self-diagnosis of alcohol use disorder to a full recovery? Start by feeling some compassion for yourself. This means accepting, without judgment, that you have struggled to master a potent drug. Self-compassion is the direct opposite of shame and depression, both of which tend to be part and parcel of alcohol abuse. So the first step is often to be kinder to yourself and more mindful of your hardships and your common humanity. Therapy can frequently help with this process. At the same time, you explore what protects you from drinking. What are your positive motivators? Alcohol use disorder tends to make people seek “highly salient alcohol rewards” over more meaningful things like strong relationships and long-term health. So recovery should include not just an absence of alcohol, but the presence of deeper, more abstract rewards. Think of recovery as a restoration of what makes you feel happy and whole. It may take some time to find yourself again, but this courageous adventure can begin with sobriety. |