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This Month’s Expert: Alcoholism in DSM-IV and DSM-5 by Mark Willenbring, MD

This Month’s Expert Alcoholism in DSM-IV and DSM-5 Mark Willenbring, MDTCPR: Dr. Willenbring, there is a proposal to rename and reorganize substance abuse and substance dependence disorders in DSM-5. Please tell us about this.

Dr. Willenbring: Some people, especially those who deal primarily with opioid addiction, felt that the word “dependence” rather than “addiction” in DSM-IV has led to a lot of confusion. For example, people taking opioids for chronic pain would of course become physiologically dependent, but this is not the same thing as addiction. “Addiction” more accurately implies compulsive, destructive drug use, and so there is a proposal that in DSM-V the whole substance use category should be called “Addiction and Related Disorders.”

TCPR: What will happen to the term “alcohol abuse”?

Dr. Willenbring: Substance abuse would be eliminated as a separate category, and the disorder would be renamed “substance use disorder.” The reasoning here is that over 20 years ago, at the time of planning for DSM-IV, alcohol abuse was thought to be a milder form of alcohol dependence, or perhaps even something separate involving more episodic, as opposed to daily or near daily, drinking. However, new research has proven this is not so. There is no clear categorical distinction between substance abuse and substance dependence.

TCPR: Which research are you referring to in particular?

Dr. Willenbring: The NIAAA (National Institute on Alcohol Abuse and Alcoholism) Epidemiological Study on Alcohol and Related Conditions (NESARC). This is the largest epidemiologic study of substance abuse and psychiatric disorders ever done, and was a random sample of the U.S. adult population, involving 43,000 people, age 18 and older. The first set of interviews was in 2000/2001, the second set was in 2004/2005, and we are currently in the third round.

TCPR: And what have we learned from this study so far?


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Dr. Willenbring: It has shown that a lot of what we thought we knew about alcohol dependence was wrong. For example, most abuse symptoms only occur in severe late stage addiction, and abuse is not a less severe form of alcohol involvement. NESARC has also found that about three-quarters of people who have DSM-IV alcohol dependence in their lifetimes have only a single episode lasting on average three or four years. It is relatively mild, they don’t become seriously dysfunctional, and it then goes away and never recurs. This is in great contrast to what we thought we knew about alcoholics—many would have predicted that most of these people would have long, chronic courses and would be extremely dysfunctional.

TCPR: I understand that recent studies have identified three main categories of problematic alcohol users. Can you describe them?

Dr. Willenbring: If you look at the subtyping data from NESARC and from other research, you find that about a third, 30 percent, of people who have an episode of alcohol dependence have what I call age-limited heavy drinking, which takes place between ages 18 and 25. Any problems they have at age 20 are usually gone by 25 or 30. This is a group that very seldom seeks any kind of substance-specific help. The second group, about 40 percent, has what I call variable onset. This is similar to sporadic cases of asthma with no family history. The average age of onset for this group is about 35, although it is highly variable. And again, these people are mild to moderate, three to four mainly internal criteria of substance dependence, and most of it is eventually resolved without any clinical intervention. The final 30 percent have an early age of onset, often in the mid teens. This is basically what I would call familial or early onset alcohol dependence. This is characterized by a strong family history, often multigenerational, early onset, and chronicity or recurrence. The worst of these alcohol users—only about 10% to 12% of those with addiction—are the ones who end up going to rehab.

TCPR: And these are the users that have formed the basis of most treatment studies?

Dr. Willenbring: Yes, which is why our understanding of treatment has become so distorted. Consider that the average age of onset for alcohol dependence in the U.S. is 21, the average age of first treatment is about 30, but the average age of people in just about every U.S. treatment trial for alcoholism is 40. So we have been routinely studying this very severe slice of people who have been ill for a couple of decades or more. For years, we have been studying samples of convenience—people who were either in treatment programs or who sought participation in a treatment study. Focusing on people who are in alcohol rehab programs to study alcoholism is equivalent to studying hospitalized asthmatics in order to understand asthma. If you were to only study hospitalized asthmatics and you thought, “This is what asthma is,” you would end up with a very distorted picture.

TCPR: I understand that recent studies have identified three main categories of problematic alcohol users. Can you
describe them?

Dr. Willenbring: If you look at the subtyping data from NESARC and from other research, you find that about a third, 30 percent,
of people who have an episode of alcohol dependence have what I call age-limited heavy drinking, which takes place between
ages 18 and 25. Any problems they have at age 20 are usually gone by 25 or 30. This is a group that very seldom seeks any kind
of substance-specific help. The second group, about 40 percent, has what I call variable onset. This is similar to sporadic cases of asthma with no family history. The average age of onset for this group is about 35, although it is highly variable. And again, these people are mild to moderate, three to four mainly internal criteria of substance dependence, and most of it is eventually resolved without any clinical intervention. The final 30 percent have an early age of onset, often in the mid teens. This is basically what I would call familial or early onset alcohol dependence. This is characterized by a strong family history, often multigenerational, early onset, and chronicity or recurrence. The worst of these alcohol users—only about 10% to 12% of those with addiction—are the ones who end up going to rehab.

TCPR: And these are the users that have formed the basis of most treatment studies?

Dr. Willenbring: Yes, which is why our understanding of treatment has become so distorted. Consider that the average age of
onset for alcohol dependence in the U.S. is 21, the average age of first treatment is about 30, but the average age of people in just about every U.S. treatment trial for alcoholism is 40. So we have been routinely studying this very severe slice of people who have been ill for a couple of decades or more. For years, we have been studying samples of convenience—people who were either in
treatment programs or who sought participation in a treatment study. Focusing on people who are in alcohol rehab programs
to study alcoholism is equivalent to studying hospitalized asthmatics in order to understand asthma. If you were to only study hospitalized asthmatics and you thought, “This is what asthma is,” you would end up with a very distorted picture.

TCPR: So most past studies looked at people who are already full blown alcoholics while the NESARC study looks at the general population, instead.

Dr. Willenbring: Yes. And as you move more into community samples, you discover that there is a much broader continuum of severity, and the lines of demarcation are not clearly written in nature. So we have learned that most alcohol dependence is mild to moderate. I call it functional alcohol dependence.

TCPR: What are the most common symptoms of such patients—how would I recognize such a patient in my office?

Dr. Willenbring: The most common symptoms are what you might call the internal symptoms of addiction—that is, repeatedly setting limits and exceeding them. For example, saying, “I am only going to have two drinks tonight,” and then having eight. There is a persistent desire to quit or cut down without success. Internal symptoms also include things like continuing to use in spite of symptoms like hangover, nausea, and insomnia. And a very common pattern that I see clinically in this group is that the drinking is sequestered. These are people who get up on time in the morning, take care of their families, and go to work. And then after their kids go to bed, for example, they drink a pint of vodka or one or two bottles of wine and fall asleep on the couch. The thing clinical psychiatrists should focus on is impaired control, these things like going over limits and desire to cut down or quit.

TCPR: So this would be a so-called functioning alcoholic, who has an alcohol disorder and who needs treatment but whose problem is less severe than alcoholics who end up in rehab.

Dr. Willenbring: Right, and the big lesson from NESARC is that we need to be thinking about substance use on a continuum, rather than dichotomously. It is actually very similar to bipolar disorder or depression, in that some people have a relatively mild episode and it goes away and never comes back.

TCPR: Does that imply that these people don’t really need treatment?

Dr. Willenbring: No, I don’t think so. Take the analogy of depression, which often also occurs as a single, selflimiting episode. We still treat that episode in order to reduce its length and severity. The same holds true for alcohol use.

TCPR: So to sum it up, you think that instead of viewing people as “you are an alcoholic or you are not an alcoholic,” we should view substance use disorder as a continuum, and we should treat more of these patients in an office-based setting rather than referring them to rehab for treatment.

Dr. Willenbring: That is right. And now we have medications that have similar efficacy as SSRI antidepressants, so treating alcohol disorders in the office is much easier.

TCPR: Can you recommend any published guidelines for implementing this updated understanding of substance use disorders?

Dr. Willenbring: Yes, you can find guidelines for treatment in the NIAAA Clinician Guide at www.NIAAA.NIH.gov/guide, which is completely free and downloadable. Screening based on the recommendations here is very easy—it is a single question to screen for nondependent heavy drinking: how many times in the past year have you had five or more drinks in a day for a man or four or more drinks in a day for a woman? Any positive answer is a positive screen. From there, the guide takes you through a decisional process, and it is extremely practical in use, and includes how to prescribe medications for alcohol dependence.

TCPR: Thank you, Dr. Willenbring.

This Month’s Expert: Alcoholism in DSM-IV and DSM-5 by Mark Willenbring, MD

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This article was published in print 9/2011 in Volume:Issue 9:9.

 

APA Reference
Willenbring,, M. (2013). This Month’s Expert: Alcoholism in DSM-IV and DSM-5 by Mark Willenbring, MD. Psych Central. Retrieved on September 19, 2019, from https://pro.psychcentral.com/this-months-expert-alcoholism-in-dsm-iv-and-dsm-5-by-mark-willenbring-md/

 

Scientifically Reviewed
Last updated: 9 Oct 2013
Last reviewed: By John M. Grohol, Psy.D. on 9 Oct 2013
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