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What is alcohol abuse?

Abuse is the self-administration of any drug in a culturally disapproved manner that causes adverse consequences. The National Institute on Alcohol Abuse and Alcoholism defines alcohol abuse as "a maladaptive drinking pattern that repeatedly causes life problems." The DSM-IV-TR defines alcohol abuse in Table 3.

Abuse is often diagnosed in individuals who recently began using alcohol. Over time, abuse may progress to dependence; however, some alcohol users abuse alcohol for long periods without developing dependence. The difference between dependence and abuse is most obvious in terms of the issue of tolerance and withdrawal. As was earlier pointed out, however, tolerance and withdrawal are not necessary to the diagnosis of dependence. Using ever-increasing amounts of alcohol and spending ever-increasing time in pursuit of alcohol (along with the negative consequences as defined in abuse) are sufficient issues to warrant the diagnosis of dependence. Thus, someone may periodically misuse alcohol in a way that gets him or her into trouble, but his or her use never escalates to the point of dependence.

Abuse is the selfadministration of any drug in a culturally disapproved manner that causes adverse consequences.

Table 3 DSM-IV-TR Criteria for Alcohol Abuse

• A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

1.

Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

2.

Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3.

Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

4.

Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights )

• The symptoms have never met the criteria for substance dependence for this class of substances.

Source: American Psychiatric Association. (1994). DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision, p. 199). Washington, DC: Author.

Using ever-increasing amounts of alcohol and spending ever- increasing time in pursuit of alcohol (along with the negative consequences as defined in abuse) are sufficient issues to warrant the diagnosis of dependence.

How do you know whether you are an alcoholic?

As noted Questions 14 and 15, alcoholism refers to the two DSM-IV-TR categories of alcohol abuse and dependence. The simple answer, therefore, is that if an individual fits either of those categories, then he or she is an alcoholic. The more complex answer takes into consideration the caveats noted in the previous answer about the limitations of the DSM-IV-TR. Should the following criteria be used to define alcoholism: "an inability to fulfill a major role" or "recurrent use despite social or interpersonal problems such as arguments with one's spouse about the consequences of intoxication"? What does "often" mean? One patient reported that her alcohol counselor compared her high level of functioning despite her "alcoholism" to Winston Churchill's alcoholism. Her response to the comparison was curt, but to the point, "And where would England be today if he had been forced into a rehab during the war?"

It is important to distinguish between quantitative and qualitative differences. A quantitative difference between a regular drinker and an alcoholic suggests a slippery slope downward. The line must be drawn somewhere along that slippery slope between the normal, regular drinker; the heavy but functional drinker; and the abnormal, pathological alcoholic. The qualitative difference between a drinker and an alcoholic suggests that these two different individuals represent distinct types or categories. Nothing in the diagnostic and medical literature actually represents such clear distinctions. Where should the line be drawn between normal blood pressure and hypertension? Between being merely overweight and obese? Between precancerous tissue and cancer? Between heavy drinking and alcoholism? Clearly there are types, according to diagnostic criteria, that everyone can agree on as representing hypertension, obesity, cancer, and alcoholism; however, that still does not capture a large number of people who fall somewhere in between. The line is drawn depending on risk. For example, when looking at hypertension, studies demonstrate that blood pressure higher than 140/90 for people over the age of 18 years has a dramatically increased risk of heart attacks or strokes compared with those with blood pressures that are lower than those numbers. Increased risk is not a guarantee, just a higher probability. How many drinks you consume daily can also be measured against risk but offers no guarantee either. The easiest way to understand this is to think of buying a lotto ticket. Buying two tickets may double your chances of winning, but the odds still remain infinitesimal.

Consider the example of a person who drinks three drinks five times a week and on two occasions up to six drinks. Clearly this person's alcohol use is heavy, but what if this person has never missed work, has never had relationship difficulties, has never had an eye opener, has never shown up to an important engagement intoxicated or endangered himself or herself because of intoxication, but noticed after stopping for a couple of days some mild withdrawal symptoms such as tremors and insomnia. Out of concern, he or she sees the doctor for a physical examination, including laboratory studies, and everything is found to be entirely normal. This person clearly demonstrates tolerance and withdrawal, but this person does not meet the criteria for either alcohol abuse or dependence! Contrast this with a person who drinks only on weekends but drinks to the point of passing out every time and has no idea how much he or she consumes, has had several DWIs, and has been told by the physician that he or she has alcohol-induced liver disease. Despite these consequences, the person can neither control the amount that he or she drinks nor stop drinking. This person has never experienced withdrawal symptoms. Nevertheless, this person does meet the criteria for alcohol dependence!

DWI a legal acronym for driving while Intoxicated.

To reiterate, alcoholism does not depend on the amount orfrequency of alcohol used!

To reiterate, alcoholism does not depend on the amount or frequency of alcohol used! A third scenario includes those people who call themselves alcoholics but have absolutely no objective pathological evidence to support their belief. Their livers are fine. They have never needed hospitalization or detoxification. They have never shown up to work drunk. Nobody has ever witnessed them misusing alcohol. For them, however, they felt that alcohol was playing a role in their life that was leading them down a path toward eventual self-destruction. They somehow understood their vulnerabilities and headed them off at the pass or at least believed strongly enough that that is what they needed to do. Are they really alcoholics who stopped their disease dead in its tracks? Many people who are alcoholic remit spontaneously. They decide one day to stop, and that is the end of it.

 
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