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II. Diagnosis

What is the DSM-IV?

What is alcohol dependency?

What is alcohol abuse?


What is the DSM-IV?

DSM-IV and DSM-IV-TR are the abbreviations for Diagnostic and Statistical Manual of Mental Disorders (IV refers to the 4th edition, and TR stands for text revised). This is considered the standard diagnostic manual for establishing the diagnosis of various mental disorders. In its introduction, a few caveats are outlined. First, the term "mental disorder" implies a distinction from "physical" disorders that is a relic of mind/body dualism. Second, the term "mental disorder' lacks a consistent operational definition that covers all situations." Third, the categorical approach has limitations in that discrete entities are assumed when in fact there are no absolute boundaries dividing one disorder from another. Fourth, the criteria for each disorder serve as guidelines only and should not be applied in either a "cookbook fashion" or in an "excessively flexible" manner. Finally, the purpose of the manual is primarily to enhance agreement among clinicians and investigators, and it does not imply that any "condition meets legal or other nonmedical criteria for what constitutes mental disease, mental disorder, or mental disability" (see the Introduction and Cautionary Statement of DSM-IV-TR).

You should keep these caveats in mind, as it is easy to get caught up in a physicians diagnosis, believing that it is set in stone, which it is not. As new information is acquired about treatments, the diagnoses and treatment plans are very likely to change. Additionally, it is not uncommon for clinicians to disagree on the diagnosis because of the previously mentioned caveats. After an initial assessment, when reading the various criteria individually, it may be easy to assume accuracy and jump to the conclusion that criteria have identified the condition. Only time and the guidance of a skilled clinician, who is probing and comprehensive in his or her questioning, will help to establish a diagnosis that leads to an effective treatment plan.

Any set of psychological symptoms must either impair functioning or cause significant distress in order to qualify as a psychiatric disorder. It is easy to make assumptions and/or come to false conclusions with this last criterion as a guide. What constitutes distress or disability is often a quality-of-life issue. If a Harvard-educated MBA holds a midlevel job in a small company, does that mean that he or she has not risen to an expected potential? Consequently, he or she may be labeled as "disabled" or "distressed" because of the perceived lack of success. If he or she is a daily drinker, was it the drinking that led to his or her lack of progress? Was it simply a lifestyle choice of wanting to leave the rat race? Ultimately, only that individual can answer such questions; however, with the guidance of a good therapist, honest answers may be found. Unfortunately, we live in a culture that increasingly stresses material wealth as the final measure of success. This can and has led to a lot of "distressed" individuals in our society who all too often search for "therapeutic" solutions for their misguided sense of "failure."

What is alcohol dependency?

According to the ASAM, addiction and dependency are interchangeable terms (see Question 7). In the mid-1980s, the WHO operationalized the concept of dependence syndrome, adapted by both the DSM and

According to the ASAM, addiction and dependency are interchangeable terms (see Question 7).

ICD (International Classification of Diseases) this is the World Health Organization's manual for classifying all diseases, including mental illness and substance abuse.

ICD (International Classification of Diseases) committees. The syndrome refers to a cluster of physiological, behavioral, and cognitive processes. The DSM-IV-TR delineates these processes with the following specific criteria as described in Table 2.

Because only three of seven criteria are required to meet the diagnostic requirement for dependence, whereas tolerance and withdrawal are prominently featured, they are not necessary to meet the definition of dependency. Therefore, there is the possibility that an individual can be dependent without developing tolerance or withdrawal. There is also the possibility that a person can develop tolerance and withdrawal without actually being dependent. This is an important concept that requires further explanation.

Table 2 DSM-IV-TR Criteria for Alcohol Dependence

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


Tolerance, as defined by either of the following:

• There is a need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

• There is a markedly diminished effect with continued use of the same amount of alcohol.


Withdrawal, as defined by either of the following:

• For the characteristic withdrawal syndrome for alcohol, refer to DSM-IV.

• Alcohol is taken to relieve or avoid withdrawal symptoms.


Alcohol is often taken in larger amounts or over a longer period than was intended.


There is a persistent desire, or there are unsuccessful efforts to cut down or control alcohol use.


A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.


Important social, occupational, or recreational activities are given up or reduced because of alcohol use.


Alcohol 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 alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

Source: The American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV-TR, p. 197). Washington, DC: Author.

Dependency's distinction from tolerance and withdrawal is one of the greatest sources of confusion with respect to drugs in general and alcohol more specifically. Many prescription and nonprescription medications on the market can cause tolerance and withdrawal syndromes. The most obvious drug that people think about in terms of dependency includes the prescription pain medications called opiates. Everyone who takes these medications on a regular basis will develop some level of tolerance and withdrawal, and therefore, the medications must be tapered in order to avoid withdrawal symptoms. As the criteria demonstrate, the experience of tolerance and withdrawal alone does not mean that a person has developed an addiction or dependency to medication.

Many medications that cause tolerance and withdrawal are never thought of as addictive, including some antihypertensive medications, anticonvulsant medications, steroids, and antidepressant medications. Physicians have never regarded any of these as addictive. Alternatively, many street drugs do not cause any measurable physiological changes in the body that could be labeled as tolerance or withdrawal, but nevertheless, these are some of the most highly addictive substances known to humans. This then leads to a humorous irony. When certain medications are prescribed for their psychotropic effects rather than any other effects they might have, such as antidepressants and antianxiety agents for depression and anxiety as opposed to migraines or seizures, evidence of tolerance and withdrawal is immediate proof of addiction, despite the fact that no other criteria of dependence are met while using these medications. At the same time, many argue that because some street drugs show no evidence of tolerance or withdrawal, they are absolutely not addictive.

Again, as the criteria explicitly state, if the drug does not become a central activity in people's daily lives (the other five criteria delineated essentially fall under the concept of "loss of control"), then they are not addicted or dependent on the drug. There is, however, another source of unending confusion, which is semantic in nature. Conflating the DSM definition of dependency with the common definition of dependency can only be thought of in a pejorative way. This only further confuses the concept. People depend on all kinds of things that are specific to their individual needs. A diabetic, for example, is dependent on his or her insulin, a paraplegic on his or her wheelchair, and a person with schizophrenia on his or her antipsychotic medication. Under these circumstances, being dependent on something on a daily basis to restore one's health and allow one to improve his or her ability to function in the world is a good, not bad, thing. Unfortunately, the pejorative term for dependency has led many patients to refuse or stop necessary treatments simply because of the belief that it is an addiction and a sign of weakness or moral failing. Again, the larger culture is at work on this issue, where any form of reliance on anything or anyone outside of oneself is a sign of weakness.

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