Alcoholism Health Article

Diagnosis

Two different types of trouble with alcohol are identified. The first is called alcohol dependence, and refers to a person who is physiologically dependent on the use of alcohol. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), an individual must have three of the following traits to be diagnosed with alcohol dependence:

• Tolerance, meaning that a person becomes accustomed to a particular dose of alcohol and must increase the dose in order to obtain the desired effect.
• Withdrawal, meaning that a person experiences unpleasant physical and psychological symptoms when he or she does not drink alcohol.
• The tendency to drink more alcohol than one intends(i.e., once an alcoholic starts to drink, he or she finds it difficult to stop).
• Being unable to avoid drinking or stop drinking once started.
• Having large blocks of time taken up by alcohol abuse.
• Choosing to drink at the expense of other important tasks or activities.
• Drinking despite evidence of negative effects on one's health, relationships, education, or job.

Under DSM-IV, a diagnosis of alcohol abuse requires that one of the following four criteria is met within a 12-month period. Because of drinking, a person repeatedly:

• Fails to live up to his or her most important responsibilities.
• Physically endangers himself, herself, or others (e.g., by drinking when driving).
• Gets into trouble with the law.
• Experiences difficulties in relationships or jobs.

Diagnosis is often brought about when family members relate the alcoholic's difficulties to a physician. A physician may become suspicious when a patient suffers repeated injuries or begins to experience medical problems that seem related to alcohol abuse. Alcohol abuse is so widespread that some estimates suggest that about 20% of a physician's patients will be alcoholics.

Diagnosis is aided by the answers to questionnaires that try to determine what aspects of a person's life may be affected by his or her abuse of alcohol. Determining the exact quantity of alcohol that a person drinks is much less important than learning how drinking affects his or her relationships, jobs, educational goals, and family life. In fact, because the metabolism of alcohol (how the body

breaks down and processes alcohol) is so unique, the quantity of alcohol consumed is not a criterion for diagnosing either alcohol dependence or alcohol abuse.

One very simple tool for beginning to diagnose alcoholism is the CAGE questionnaire. It consists of four questions, with the first letters of each key word spelling the word CAGE:

• Have you ever tried to Cut down on your drinking?
• Have you ever been Annoyed by anyone's comments about your drinking?
• Have you ever felt Guilty about your drinking?
• Do you ever need an Eye-opener (a morning drink of alcohol) to start the day?

There are other, longer lists of questions that help to determine the severity and effects of a person's alcohol abuse. Given the evidence of genetic involvement in alcoholism, it is important to ascertain whether any relative of the person has ever suffered from alcoholism.

Physical examination may reveal signs suggestive of alcoholism: evidence of old injuries; a visible network of enlarged veins just under the skin around the navel (called caput medusae); fluid in the abdomen (ascites); yellowish tone to the skin; decreased testicular size; and poor nutritional status. Lab work may reveal an increase in the size of red blood cells; abnormalities in WBCs (responsible for fighting infection) and platelets (particles responsible for clotting); and an increase in certain liver enzymes.

Treatment

Treatment of alcoholism has two parts. The first step in the treatment of alcoholism, called detoxification, involves helping the person stop drinking and ridding his or her body of the harmful (toxic) effects of alcohol. Because the person's body has become accustomed to alcohol, he or she will need to be supported through withdrawal. Withdrawal will be different for different patients, depending on the severity of the alcoholism (as measured by the quantity of alcohol ingested daily and the length of time the patient has been an alcoholic). Withdrawal symptoms can range from mild to life-threatening. Mild withdrawal symptoms include nausea, aches, diarrhea, difficulty sleeping, sweats, anxiety, and trembling. This phase is usually over in about three to five days. More severe effects of withdrawal can include hallucinations, seizures, an unbearable craving for more alcohol, confusion, fever, fast heart rate, high blood pressure, and delirium (a fluctuating level of consciousness). Patients at highest risk for the most severe symptoms of withdrawal (referred to as delirium tremens) are those with other medical problems, including malnutrition, liver disease, or Wernicke's syndrome. Delirium tremens usually begins approximately three to five days after the patient's last drink, progressing from the more mild symptoms to the more severe, and may last a number of days.

Patients going through only mild withdrawal are simply monitored carefully to ensure that more severe symptoms do not develop. However, no medications are necessary. Treatment of a patient suffering the more severe effects of withdrawal may require sedating medications to relieve the discomfort of withdrawal and to avoid the potentially life-threatening complications of high blood pressure, fast heart rate, and seizures. Benzodiazepines are helpful in those patients suffering from hallucinations. If the patient is nauseated, fluids may need to be given through a vein (intravenously), along with some necessary sugars and salts. It is crucial that thiamin be included in the fluids, because of it is usually quite low in alcoholic patients. Further, thiamin deficiency can lead to Wernicke-Korsakoff syndrome.

After cessation of drinking has been accomplished, the next steps involve helping the patient avoid ever taking another drink. This phase of treatment is referred to as rehabilitation. The best programs incorporate the family into the therapy; it has no doubt been severely affected by the patient's drinking. Some therapists believe that family members, in an effort to deal with their loved one's drinking problem, sometimes develop patterns of behavior that unintentionally support or "enable" the patient's drinking. This situation is referred to as "codependence," and must be addressed in order to successfully treat a person's alcoholism.

Sessions led by peers, where recovering alcoholics meet regularly and provide support for each other's recoveries, are considered to be among the best methods of preventing a return to drinking (relapse). Perhaps the most well-known group of this kind is called Alcoholics Anonymous, which uses a "12-step" model to help people avoid drinking. These steps involve recognizing the destructive power that alcohol has held over the alcoholic's life, looking to a higher power for help in overcoming the problem, and reflecting on the ways in which the abuse of alcohol has hurt others and, if possible, making amends to those people.

There are also medications that may help an alcoholic avoid returning to drinking. These have been used with varying degrees of success. Disulfiram (Antabuse) is a drug that, when mixed with alcohol, causes a very unpleasant reaction that includes nausea and vomiting, diarrhea, and trembling. Naltrexone (Revia) and acamprosate (calcium acetylhomotaurinate) seem to be helpful in limiting the effects of a relapse. None of these medications would be helpful unless the patient is also willing to work very hard to change his or her behavior.

Alternative treatments can be a helpful adjunct for the alcoholic patient once the medical danger of withdrawal has passed. Because many alcoholics have very stressful lives (whether because of or leading to the alcoholism is sometimes a matter of debate), many of the treatments for alcoholism involve dealing with and relieving stress. These include massage, meditation, and hypnotherapy. The malnutrition of long-term alcohol abuse is addressed by nutrition-oriented practitioners, with careful attention being given to a healthy diet and the use of nutritional supplements, such as vitamins A, B complex, and C—as well as certain fatty acids, amino acids, zinc, magnesium, and selenium. Herbal treatments include milk thistle (Silybum marianum), which is thought to protect the liver against damage. Other herbs believed to be helpful for the patient suffering through withdrawal include lavender (Lavandula officinalis), skullcap (Scutellaria lateriflora), chamomile (Matricaria recutita), peppermint (Mentha piperita), yarrow (Achillea millefolium), and valerian (Valeriana officinalis). Acupuncture is believed to both decrease withdrawal symptoms and to help improve a patient's chances for continued recovery from alcoholism.