Chapter 17

Substance-Related Disorders: Alcohol

Description of the Disorder

• Shift in the public perception of alcoholism from moral transgression to disease

• Role of genetics, social, and cultural factors in the development of alcoholism

• Research refuting popular misconceptions– Recovering without treatment– Development of dependence– Progression of the disorder

Clinical Picture and Diagnostic Considerations

• Ambivalence about quitting/denial of a problem

• Motivational interviewing• Commonly co-occurs with other psychiatric

disorders– Poorer treatment outcome– Changes in drug use in the course of treatment

• Withdrawal symptoms after restricting alcohol

Epidemiology

• Alcohol is the second-most-used psychoactive substance

• Considerable economic cost– Causes 1.8 million deaths worldwide

• Lifetime prevalence – Alcohol dependence: 13.3%; alcohol use

disorders: 7.35%– More common among men– Differences across ethnic groups

Critical Issues in Assessment

• Self-report of drinking behavior is generally accurate when:– Interviewed in a clinical/research setting– Patient is alcohol-free– Confidentiality is assured– Still subject to biases and other issues inherent in

self-reports• Accurate assessment of drinking behavior is

vital to treatment outcome

Assessment of Alcohol Use and Consequences

• Consists of both quantity and frequency of past and present use

• Major assessment instruments of alcohol use– Retrospective method versus self-monitoring

• Assessments of consequence help place patients along a continuum of severity

Assessment of High-Risk Situations and Self-Efficacy

• Relapse rates among alcoholics are influenced by situational factors – Important to assess and monitor during treatment

• Self-efficacy to resist drinking across different situations also important to monitor and discuss in treatment

Neurological Functioning

• Several neuropsychological functions are negatively impacted by both acute and chronic alcohol use – Attention, verbal processing, reaction time,

auditory working memory, and spatial processing, among others

• Assessing neuropsychological functioning may help identify potential barriers to treatment

Barriers to Change

• Can be both practical and motivational– Little or no motivation to change drinking

habits–Refusal to adopt treatment goals– Entrenched in an environment where alcohol

is constantly available–May also consist of difficulties with finding

child care or obtaining transportation to treatment

Biochemical Assessment Measures

• Intentional and unintentional recall biases may lead to inaccurate assessments of use

• Biochemical assessments provide objective means of achieving convergent validity – Also subject to error

• Strengths and weaknesses of different methods– Urinalysis– Breath analyzer– Hair analysis– Medical examination of liver function

Etiological Considerations

• Behavioral and molecular genetics– Risk for AUD equally influenced by genetic and

environmental influences – Endophenotypes with strong genetic influences– Other genetic risk factors• Absence or limited production of alcohol-metabolizing

enzymes• Low response level to alcohol• Specific genes (ADH and ALDH)

Etiological Considerations cont.

• Neuroanatomy and neurobiology– Hypothalamic-pituitary-adrenal (HPA) axis• System stimulated by alcohol consumption• Some evidence that individuals with greater

HPA reactivity find alcohol consumption more reinforcing

– Endogenous opioid system• Also stimulated by alcohol consumption• Increased dopamine in the nucleus accumbens

Etiological Considerations cont.

• Learning, modeling, and life events– Learning theory suggests that drinking behavior, in

all of its extremes, is largely learned – Classical conditioning and operant conditioning

models– Alcohol expectancies• Effects (positive and negative) attributed to alcohol that

an individual anticipates experiencing when drinking• Highly related to drinking behavior

– Tension-reduction hypothesis of alcohol consumption

Etiological Considerations cont.

• Cognitive influences– Attentional Allocation Model• Capacity for effortful information processing• Alcohol myopia

– Appraisal-Disruption Model• Alcohol interferes with the cognitive process of

appraisal• Information organization

Etiological Considerations cont.

• Sex and racial/ethnic factors– Women tend to drink less and have fewer drinking-

related problems • Gender differences in the metabolism of alcohol• Sex roles and social influences

– Ethnic differences in alcohol and alcohol-related morbidity and mortality• Dependence more persistent in African

Americans and Hispanics

Course and Prognosis

• Alcohol problems may occur at any age • Progression of severity varies across

individuals – Does not always worsen without treatment

• Reducing probability of remission– Reduced depressive symptoms– Improved stress coping– Enhanced social support

DSM-5

• Alcohol use problems are best conceptualized as a unitary construct

• Eliminated the biaxial distinction between alcohol abuse and dependence

• Eliminated legal problems criterion and added alcohol craving

• Use of a severity continuum