Diagnosis

Definition

Misuse, problem use, abuse, and heavy use of alcohol refer to improper use of alcohol, which may cause physical, social, or moral harm to the drinker. The Dietary Guidelines for Americans defines "moderate use" as no more than two alcoholic beverages a day for men and no more than one alcoholic beverage a day for women. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as the amount of alcohol leading to a blood alcohol content (BAC) of 0.08, which, for most adults, would be reached by consuming five drinks for men or four for women over a two-hour period. According to the NIAAA, men may be at risk for alcohol-related problems if their alcohol consumption exceeds 14 standard drinks per week or 4 drinks per day, and women may be at risk if they have more than 7 standard drinks per week or 3 drinks per day. It defines a standard drink as one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits. Despite this risk, a 2014 report in the National Survey on Drug Use and Health found that only 10% of either "heavy drinkers" or "binge drinkers" defined according to the above criteria also met the criteria for alcohol dependence, while only 1.3% of non-binge drinkers met the criteria. An inference drawn from this study is that evidence-based policy strategies and clinical preventive services may effectively reduce binge drinking without requiring addiction treatment in most cases.

Alcoholism

The term alcoholism is commonly used amongst laypeople, but the word is poorly defined. Despite the imprecision inherent in the term, there have been attempts to define how the word alcoholism should be interpreted when encountered. In 1992, it was defined by the National Council on Alcoholism and Drug Dependence (NCADD) and ASAM as "a primary, chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking." MeSH has had an entry for "alcoholism" since 1999, and references the 1992 definition.

The WHO calls alcoholism "a term of long-standing use and variable meaning", and use of the term was disfavored by a 1979 WHO expert committee.

In professional and research contexts, the term "alcoholism" is not currently favored, but rather alcohol abuse, alcohol dependence, or alcohol use disorder are used. Talbot (1989) observes that alcoholism in the classical disease model follows a progressive course: if a person continues to drink, their condition will worsen. This will lead to harmful consequences in their life, physically, mentally, emotionally and socially. Johnson (1980) explores the emotional progression of the addict's response to alcohol. He looks at this in four phases. The first two are considered "normal" drinking and the last two are viewed as "typical" alcoholic drinking. Johnson's four phases consist of:

1. Learning the mood swing. A person is introduced to alcohol (in some cultures this can happen at a relatively young age), and the person enjoys the happy feeling it produces. At this stage, there is no emotional cost.
2. Seeking the mood swing. A person will drink to regain that feeling of euphoria experienced in phase 1; the drinking will increase as more intoxication is required to achieve the same effect. Again at this stage, there are no significant consequences.
3. At the third stage there are physical and social consequences, i.e., hangovers, family problems, work problems, etc. A person will continue to drink excessively, disregarding the problems.
4. The fourth stage can be detrimental, as Johnson cites it as a risk for premature death. As a person now drinks to feel normal, they block out the feelings of overwhelming guilt, remorse, anxiety, and shame they experience when sober.

DSM and ICD

In the United States, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the most common diagnostic guide for substance use disorders, whereas most countries use the International Classification of Diseases (ICD) for diagnostic (and other) purposes. The two manuals use similar but not identical nomenclature to classify alcohol problems.

Manual	Nomenclature	Definition
DSM-IV	Alcohol abuse, or Alcohol dependence	Alcohol abuse - repeated use despite recurrent adverse consequences. Alcohol dependence - alcohol abuse combined with tolerance, withdrawal, and an uncontrollable drive to drink. The term "alcoholism" was split into "alcohol abuse" and "alcohol dependence" in 1980's DSM-III, and in 1987's DSM-III-R behavioral symptoms were moved from "abuse" to "dependence". Some scholars suggested that DSM-5 merge alcohol abuse and alcohol dependence into a single new entry, named "alcohol-use disorder".
DSM-5	Alcohol use disorder	"A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by two or more symptoms out of a total of , occurring within a 12-month period ...."
ICD-10	Alcohol harmful use, or Alcohol dependence syndrome	Definitions are similar to that of the DSM-IV. The World Health Organization uses the term "alcohol dependence syndrome" rather than alcoholism. The concept of "harmful use" (as opposed to "abuse") was introduced in 1992's ICD-10 to minimize underreporting of damage in the absence of dependence. The term "alcoholism" was removed from ICD between ICD-8/ICDA-8 and ICD-9.
ICD-11	Episode of harmful use of alcohol, Harmful pattern of use of alcohol, or Alcohol dependence	Episode of harmful use of alcohol - "A single episode of use of alcohol that has caused damage to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others ...." Harmful pattern of use of alcohol - "A pattern of alcohol use that has caused damage to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others ...." Alcohol dependence - "Alcohol dependence is a disorder of regulation of alcohol use arising from repeated or continuous use of alcohol. The characteristic feature is a strong internal drive to use alcohol ... The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if alcohol use is continuous (daily or almost daily) for at least 1 month."

Social barriers

Attitudes and social stereotypes can create barriers to the detection and treatment of alcohol abuse. This is more of a barrier for women than men. Fear of stigmatization may lead women to deny that they are suffering from a medical condition, to hide their drinking, and to drink alone. This pattern, in turn, leads family, physicians, and others to be less likely to suspect that a woman they know is an alcoholic. In contrast, reduced fear of stigma may lead men to admit that they are suffering from a medical condition, to display their drinking publicly, and to drink in groups. This pattern, in turn, leads family, physicians, and others to be more likely to suspect that a man they know is an alcoholic.

Screening

Screening is recommended among those over the age of 18. Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self-reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.

The CAGE questionnaire, named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further.

The questionnaire asks the following questions:

1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

The CAGE questionnaire has demonstrated a high effectiveness in detecting alcohol-related problems; however, it has limitations in people with less severe alcohol-related problems, white women and college students.

Other tests are sometimes used for the detection of alcohol dependence, such as the Alcohol Dependence Data Questionnaire, which is a more sensitive diagnostic test than the CAGE questionnaire. It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use. The Michigan Alcohol Screening Test (MAST) is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses, driving under the influence being the most common. The Alcohol Use Disorders Identification Test (AUDIT), a screening questionnaire developed by the World Health Organization, is unique in that it has been validated in six countries and is used internationally. Like the CAGE questionnaire, it uses a simple set of questions – a high score earning a deeper investigation. The Paddington Alcohol Test (PAT) was designed to screen for alcohol-related problems amongst those attending Accident and Emergency departments. It concords well with the AUDIT questionnaire but is administered in a fifth of the time.

Urine and blood tests

There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC). These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:

• Macrocytosis (enlarged MCV)
• Elevated GGT
• Moderate elevation of AST and ALT and an AST: ALT ratio of 2:1
• High carbohydrate deficient transferrin (CDT)

With regard to alcoholism, BAC is useful to judge alcohol tolerance, which in turn is a sign of alcoholism. Electrolyte and acid-base abnormalities including hypokalemia, hypomagnesemia, hyponatremia, hyperuricemia, metabolic acidosis, and respiratory alkalosis are common in alcoholics.

However, none of these blood tests for biological markers is as sensitive as screening questionnaires.