2012’s most popular posts #10 – Almost Alcoholic

~ Jason Schwartz

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

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Published by Jason Schwartz

I have been an addiction professional and social worker since 1994. I started blogging in 2005 as the Clinical Director at Dawn Farm. I no longer work at Dawn Farm and am now the Director of Behavioral Medicine at a community hospital, and a lecturer at Eastern Michigan University’s School of Social Work. Views expressed here are my own. Keep in mind that the field, the contexts in which the field operates, and my views have changed over time.

2 thoughts on “2012’s most popular posts #10 – Almost Alcoholic”

  1. The DSM criteria serve a specific purpose:categorization.Not as an infallible defining instrument but as a working tool necessary to insure that those diagnosing patients are ALL reading from the same page. Literally! In order to do this a line in the sand has to be made. Somewhere. I don’t think professionals view the criteria as absolute.
    The abuse phase you refer to talks about pain,damage to self/others.If these loss of control items are present and the client continues drinking despite these then he falls clearly into the alcoholic category.No?
    A third category or degree of alcoholism/drug-dependence might be useful and include the “career” or chronic individuals who manifest symptoms of withdrawal when deprived of alcohol/drugs.
    Are not chronic users “dependent” by definition.Here dependence would refer,also, to the presence of withdrawal symptoms upon discontinuation.
    I think all of this is splitting unnecessary hairs.People who treat alcoholics are,I believe, well aware of the shortcomings of diagnostic criteria. I think professionals and common folk realize that “the map is not the territory.”
    Dr Jellenik,the physician/father of the alcoholism as a disease concept developed a chart that could be used to determine where in the progressive path of decline an individual was.”Jellinik’s curve” also clearly demonstrated the predictability of alcoholism. Adding that alcoholism was primary as well he gave us the “Three P’s.”
    Alcoholism is primary,predictable and progressive.
    People may not be able to define alcoholism but they”know it when they see it!” There are many working definitions of alcoholism/drug-dependence.
    Using one or another really doesn’t matter in the treatment of individuals.

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  2. “The abuse phase you refer to talks about pain,damage to self/others.If these loss of control items are present and the client continues drinking despite these then he falls clearly into the alcoholic category.No?”

    Part of the problem is that there is no alcoholic category.

    Why does it matter? Some of us may know this is simply a limited tool, but tools shape our thinking and imagination.

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