Chapter Four: Alcohol Dependence. points to consider Definitions Definitions Disease concept Disease...
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Transcript of Chapter Four: Alcohol Dependence. points to consider Definitions Definitions Disease concept Disease...
Chapter Four: Alcohol Dependence
points to consider
DefinitionsDefinitions Disease conceptDisease concept Natural historyNatural history Guidelines for diagnosisGuidelines for diagnosis
definitions
Earliest definitionsEarliest definitions much variationmuch variation focus on different aspects focus on different aspects
example: descriptive only vs. causes example: descriptive only vs. causes
Efforts to promote uniformityEfforts to promote uniformity International Classification Diseases, International Classification Diseases,
WHO, 1977WHO, 1977 Diagnostic and Statistical Manual, Diagnostic and Statistical Manual,
APA, 1980APA, 1980
definition: American Society of Addiction Medicine (ASAM)
Alcoholism (dependence) is a “Alcoholism (dependence) is a “primaryprimary, , chronicchronic diseasedisease with genetic, psychological with genetic, psychological and environmental factors... often and environmental factors... often progressiveprogressive and fatal. …characterized by and fatal. …characterized by impaired controlimpaired control over drinking, over drinking, preoccupationpreoccupation…, alcohol …, alcohol use despiteuse despite adverse consequences…” adverse consequences…”
19931993
key points of ASAM definitionCharacterization as a disease that is Characterization as a disease that is chronicchronic primaryprimary progressiveprogressive
implications of disease concept
Dictates attitudes Dictates attitudes Identifies care-giversIdentifies care-givers Reduces stigma Reduces stigma Moves from punishment to treatmentMoves from punishment to treatment
management of chronic disease
Treatment of acute flare-upsTreatment of acute flare-ups Emotional supportEmotional support Patient educationPatient education Rehabilitation to live with limitationsRehabilitation to live with limitations Family involvementFamily involvement Partnership of physician and patientPartnership of physician and patient
natural history a la EM Jellinek
Natural history is how a disease unfoldsNatural history is how a disease unfolds EM Jellinek first to describe natural history ofEM Jellinek first to describe natural history of
alcoholism alcoholism Based on survey of 2,000 early AA membersBased on survey of 2,000 early AA members Identified pattern in emergence of symptoms Identified pattern in emergence of symptoms Grouped signs/symptoms into phasesGrouped signs/symptoms into phases
Jellinek’s phases of alcoholism
Four stagesFour stages Pre-alcoholic PhasePre-alcoholic Phase Prodromal PhaseProdromal Phase
- - prodromal means prodromal means signalingsignaling or or warningwarning Crucial PhaseCrucial Phase Chronic PhaseChronic Phase
JellinekJellinek
phases ofphases of
alcohol alcohol
addictionaddiction
Jellinek’s phases of alcoholism Pre-alcoholic Phase
Drinking socially motivatedDrinking socially motivated Response to alcohol “primes” drinkerResponse to alcohol “primes” drinker
offers psychological relief offers psychological relief or release of tensionor release of tension
Person seeks occasions where Person seeks occasions where drinking is possibledrinking is possible
Drinking behavior does not stand outDrinking behavior does not stand out Time: several months to 2Time: several months to 2++ years years
Jellinek’s phases of alcoholism Prodromal Phase
Blackouts appear, Blackouts appear, thethe warning sign warning sign Alcohol no longer just a beverageAlcohol no longer just a beverage Consumption heavy, but doesn’tConsumption heavy, but doesn’t
necessarily stand outnecessarily stand out Conscious effort to keep drinkingConscious effort to keep drinking
inconspicuous inconspicuous Time: 6 months to 4 or 5Time: 6 months to 4 or 5++ years years
Jellinek’s phases of alcoholism Crucial Phase
Key symptom: loss of controlKey symptom: loss of control Drinking stands outDrinking stands out Drinking requires explanationDrinking requires explanation Adopt tactics to regain controlAdopt tactics to regain control Life is alcohol-centeredLife is alcohol-centered Deteriorating relationshipsDeteriorating relationships
Jellinek’s phases of alcoholism Chronic Phase
Morning drinking commonMorning drinking common Social & workplace functioning goneSocial & workplace functioning gone Frequent intoxicationFrequent intoxication Living on society’s fringesLiving on society’s fringes Withdrawal symptoms without alcoholWithdrawal symptoms without alcohol Rationalization fails Rationalization fails so open to treatment so open to treatment Continued drinking likely, can’t see way outContinued drinking likely, can’t see way out
phases of alcoholism some caveats
Product of era when developedProduct of era when developed Some elements discounted by later research Some elements discounted by later research
example: significance of blackoutsexample: significance of blackouts
Also Jellinek Also Jellinek Recognized some cases didn’t fit Recognized some cases didn’t fit
model of phasesmodel of phases Led to formulation of Led to formulation of Species of AlcoholismSpecies of Alcoholism
species of alcoholism
Formulated by EM JellinekFormulated by EM Jellinek Different “varieties” of alcoholismDifferent “varieties” of alcoholism Possibly product of different culturesPossibly product of different cultures Speculated that not all species may Speculated that not all species may
represent a diseaserepresent a disease Five species identified by aFive species identified by a
Greek letterGreek letter
species of alcoholism alpha alcoholism
Purely psychological dependencePurely psychological dependence Not loss of control nor inability to abstainNot loss of control nor inability to abstain Hallmark: drinking to handle problemsHallmark: drinking to handle problems Progression not inevitableProgression not inevitable Recognized as what others might callRecognized as what others might call
“problem drinking”“problem drinking”
species of alcoholism beta alcoholism Physical problems of heavy drinkingPhysical problems of heavy drinking Absence of psychological or Absence of psychological or
physical dependencephysical dependence Common in cultures with heavy drinkingCommon in cultures with heavy drinking
and inadequate dietand inadequate diet
species of alcoholism gamma alcoholism Species identified in Species identified in
Phases of Alcoholism AddictionPhases of Alcoholism Addiction Tolerance, loss of controlTolerance, loss of control Psychological Psychological physical dependence physical dependence Suggested to be most common type in USSuggested to be most common type in US
species of alcoholism delta alcoholism Similar to gamma alcoholism Similar to gamma alcoholism PsychologicalPsychological physical dependence physical dependence Can control amount consumed on any Can control amount consumed on any
occasionoccasion ButBut cannot cease drinking without cannot cease drinking without
withdrawalwithdrawal
species of alcoholism epsilon alcoholism
Studied less intensivelyStudied less intensively Seen as different from other speciesSeen as different from other species Described as “periodic alcoholism”Described as “periodic alcoholism” Marked by periodic binge drinkingMarked by periodic binge drinking
emergence of disease approach
Disease formulation garnered acceptanceDisease formulation garnered acceptance If a diseaseIf a disease
a need to formalize definitionsa need to formalize definitions a need for guides to diagnosis, i.e.a need for guides to diagnosis, i.e.
diagnostic criteriadiagnostic criteria
formalizing disease concept (cont.)
Actions by professional associationsActions by professional associations National Council on AlcoholismNational Council on Alcoholism World Health Organization (World Health Organization (ICDICD)) American Psychiatric Associations American Psychiatric Associations
( (Diagnostic and Statistical Diagnostic and Statistical Manual)Manual)
National Council on Alcoholism
1972, published 1972, published Criteria for DiagnosisCriteria for Diagnosis Identified signs and symptomsIdentified signs and symptoms Two types of dataTwo types of data
physiological/clinicalphysiological/clinical behavioral, psychologicalbehavioral, psychological
For each type of data: major and minor For each type of data: major and minor criteria criteria
National Council on Alcoholism (cont.)
Based on external verifiable dataBased on external verifiable data Example: alcohol on breath at Example: alcohol on breath at
appointmentappointment Jellinek signs were subjective andJellinek signs were subjective and
included efforts to deceive included efforts to deceive Characterizes disease as chronic Characterizes disease as chronic Offers criteria to assess post-treatment statusOffers criteria to assess post-treatment status
American Psychiatric Association
APA’s APA’s Diagnostic & Statistical ManualDiagnostic & Statistical Manual Third Edition, 1980, a milestoneThird Edition, 1980, a milestone set forth explicit criteria for diagnosisset forth explicit criteria for diagnosis no longer dependent on theories of causeno longer dependent on theories of cause created new categorycreated new category
“Substance Use Disorders” “Substance Use Disorders”
Criteria for Diagnosisof Dependence (DSM-IV
TR) 1. Tolerance1. Tolerance2. Withdrawal2. Withdrawal3. Drinking more than intended3. Drinking more than intended4. Desire to or inability to control drinking4. Desire to or inability to control drinking5. Considerable time spent drinking5. Considerable time spent drinking6. Important activities given up due to drinking6. Important activities given up due to drinking7. Continued drinking despite known negative7. Continued drinking despite known negative
consequencesconsequences (3 or more = diagnostic)(3 or more = diagnostic)
Criteria for Diagnosisof Abuse (DSM-IV TR)
1. 1. Recurrent drinking leads to failing to fill major Recurrent drinking leads to failing to fill major rolesroles
2. Recurrent drinking when it is physically 2. Recurrent drinking when it is physically hazardoushazardous
3. Recurrent alcohol-related legal problems3. Recurrent alcohol-related legal problems
4. Continued drinking despite persistent 4. Continued drinking despite persistent social or interpersonal problemssocial or interpersonal problems
(1 or more = diagnostic)(1 or more = diagnostic)
other alcohol-related diagnoses (DSM-IV
TR) Other DSM-IV alcohol-related conditionsOther DSM-IV alcohol-related conditions Include:Include:
intoxicationintoxicationwithdrawalwithdrawalalcohol-induced deliriumalcohol-induced deliriumalcohol-related dementiaalcohol-related dementia
Other substance use disorders Other substance use disorders (by drug class) (by drug class)
natural history a la Vaillant
Landmark study published in 1983Landmark study published in 1983 Longitudinal study Longitudinal study
followed subjects for 50 yearsfollowed subjects for 50 years Information on pre-alcoholic stateInformation on pre-alcoholic state Able to sort out results of alcoholism fromAble to sort out results of alcoholism from
pre-existing factorspre-existing factors
findings: natural history a la Vaillant
No support for then-popular theory of No support for then-popular theory of “alcoholic personality”“alcoholic personality”
Typically, a progressive downward courseTypically, a progressive downward course Essentially two outcomes:Essentially two outcomes:
people became abstinent or diedpeople became abstinent or died Very few returned to non-problematic Very few returned to non-problematic
drinkingdrinking
factors associated with factors associated with recoveryrecovery Identified by VaillantIdentified by Vaillant
Presence of vital interestPresence of vital interest External remindersExternal reminders Unambivalent social Unambivalent social support support Source of hope andSource of hope and inspiration inspiration
types of alcoholism
Primary AlcoholismPrimary Alcoholism no psychological condition that leads tono psychological condition that leads to
development of alcoholismdevelopment of alcoholism
Secondary AlcoholismSecondary Alcoholism grows out of major psychological grows out of major psychological
problem or psychiatric illness problem or psychiatric illness also called Reactive Alcoholismalso called Reactive Alcoholism
Familial vs. Non-familialFamilial vs. Non-familial
types of alcoholism (cont’d)
model of model of secondarysecondaryalcoholismalcoholism
Note: Treatment required for Note: Treatment required for both the psychiatric both the psychiatric condition and the alcoholismcondition and the alcoholism
primary psychiatric disorder
stress exposure susceptibility
self-medication with alcohol
secondary alcoholism
diagnostic criteria for other substances
Conditions Addressed Conditions Addressed
DependenceDependence AbuseAbuse IntoxicationIntoxication
from from DSM-IV TRDSM-IV TRNote: Clear withdrawal syndrome not Note: Clear withdrawal syndrome not
established for all drugs. For those established for all drugs. For those drugs a diagnosis of dependence drugs a diagnosis of dependence is based on behavioral features.is based on behavioral features.
Organized by DrugOrganized by Drug
AmphetaminesAmphetamines CaffeineCaffeine CannabisCannabis CocaineCocaine HallucinogensHallucinogens InhalantsInhalants OpiatesOpiates Phencyclidine (PCP)Phencyclidine (PCP)