To make a diagnosis,  use the criteria listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. (Order a copy from the American Psychiatric Association,  1400 K Street,  NW,  Washington,  D.C.  20005.)  A new edition comes out every few years, so there will be changes in the criteria from time to time. The 2000 criteria for Psychoactive Substance Use Disorder are listed in Appendix 5. If you are unsure of your abilities to use the diagnostic criteria, an instrument such as the Structured Clinical Interview for DSM-IV-TR (First, Spitzer, Gibbon, & Williams, 2001) is the most readily available battery used in clinical evaluation.

Following is the DSM-IV-TR criteria for diagnosing Alcohol Abuse and Alcohol Dependence:

Diagnosis: Alcohol Abuse
A.  A maladaptive pattern of psychoactive substance use leading to clinically significant impairment or distress indicated 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 or 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 use in situations in which use is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use).
3.  Recurrent substance-related legal problems.
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).

B.  The symptoms never met the criteria for Psychoactive Substance Dependence for this class of substance (DSM-IV-TR, p. 199).

If you are unable to diagnose abuse, check with the family. This patient may be in denial, and you may get more of the truth from someone else.

Family members, particularly a spouse or a parent, may give you a more accurate clinical picture of the problems.

If you diagnose abuse, move on to the dependency questions:

Diagnosis: Alcohol Dependence

A maladaptive pattern of substance (alcohol) use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
A.  Tolerance, as defined by either of the following:

1.  A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
2.  Markedly diminished effect with continued use of the same amount of the substance.

B.  Withdrawal, as manifested by either of the following:
1.  The characteristic withdrawal syndrome for the substance.
2.  The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

C.  The substance is often taken in larger amounts or over a longer period of time than was intended.
D.  There is a persistent desire or one or more unsuccessful efforts to cut down or control substance use.
E.  A great deal of time spent in activities necessary to get the substance, use the substance, or recover from its effects.
F.  Important social, occupational, or recreational activity given up or reduced because of substance use.
G.  The substance use is continued despite knowledge of having a persistent or recurrent psychological or physical problem that is likely to have caused or been exacerbated by the use of the substance (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption; DMS-IV-TR, p. 197).

Specify if:
•  With physiological dependence: evidence of tolerance or withdrawal.
•  Without physiological dependence:  no evidence of tolerance or withdrawal.

Explain to patients that the diagnosis is your best professional judgment.  It is important that patients make up their own minds.  Patients need to collect evidence and get accurate in their thinking. Do they have a problem or not? This is a good time to explain denial and how it keeps patients from seeing the truth.

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Robert R. Perkinson,  PHD
Helping Your Clients Find the Road to Recovery

Alcoholism - Treatment.  I.  Title.
RC565.P375 - 2004
616.86’10651- dc22