Alcoholism Clinical Presentation

Diagnosis

The diagnosis of an alcohol problem is best made by the history. Laboratory tests have a sensitivity of no better than 50%, and physical examination is helpful only after the consequences of alcoholism are apparent. Early diagnosis based on a careful history can prevent such consequences. Physicians should use terms such as "person with an alcohol problem" rather than "alcoholic" or "addict," which are commonly used but demeaning shorthand terms.

Although the dangers of alcoholism are well known, data suggest that physicians frequently fail to make the diagnosis. Less than 50% of people who went to their doctor because of alcohol-related issues were asked about the problem. Multiple studies on medical inpatients and surgical patients in university and community hospitals, as well as outpatients in internal medicine and family medicine practices, show a low recognition rate and an even poorer treatment rate. The following are possible reasons that alcohol-related problems are missed during diagnosis.

• Patient factors contribute to the failure to diagnose alcohol problems. Patients frequently deny they have a problem. They might not link alcohol with its consequences. Patients may be unaware that a positive family history increases their risk for the disease. They might fear being reported to their employers. Patients might be too ashamed to report their problem.
• Physicians frequently share the responsibility for the failure to diagnose alcoholism. Many physicians have a negative attitude toward persons with alcohol problems. They view these patients as demanding and feel that they waste society's resources.
• Recognized substance abuse patients tend to have an antisocial personality disorder (type 2 alcoholism, characterized by an association with criminal behavior [sociopathy], onset in teen years, and drinking to get high), while those whose diagnosis is missed tend to have depression or anxiety. During residency training, physicians see a fair number of persons with type 2 alcoholism; these patients are often not truthful and have a poorer prognosis. This contributes to the belief among many physicians that alcoholism is not treatable, despite good evidence to the contrary (see Treatment). Also, physicians might hesitate to label a patient as alcoholic because of negative consequences. Physicians who have a problem with alcohol themselves are less likely to discuss alcoholism and its consequences with patients.
• Physicians might not know how to screen for and diagnose alcoholism. However, screening for alcoholism is important (see CAGE questionnaire and AUDIT).
• "How much do you drink?" is probably the question asked most commonly by doctors. This question has less than 50% sensitivity for alcohol problems. Blood tests, such as liver function tests and mean corpuscular volume, are not particularly effective; even the best test, gamma glutamyl transferase, has a sensitivity of only approximately 50%. Recently, sialic acid and carbohydrate-deficient transferrin levels have been touted as possible tests, but the sensitivities of both appear to be too low to be useful.

Screening The CAGE ([need to] cut down [on drinking], annoyance, guilt [about drinking], [need for] eye-opener) questionnaire is the best-known and most-studied short screening test for alcohol problems. The CAGE questions should be given face-to-face (not as a paper and pencil test) and should be asked before questions on quantity and frequency (the sensitivity of the questions drops if quantity questions precede them).

The following 4 questions make up the CAGE questionnaire:

• Have you ever felt the need to cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Patients who answer affirmatively to 2 questions are 7 times more likely to be alcohol dependent than the general population. Those who answer negatively to all 4 questions are one-seventh as likely to have alcoholism as the general population.

The sensitivity of the CAGE questionnaire was thought to be 75%. More recent studies, however, show that the sensitivity is lower, particularly in populations with a lower prevalence, such as among female and elderly populations. The CAGE questionnaire also may fail to identify binge drinkers and cannot identify those who have not experienced the consequences of alcoholism. Nevertheless, the CAGE questionnaire is brief and easy to administer

The CAGE questions are not useful for diagnosing hazardous drinking. Women should consume no more than 3 standard alcohol drinks on any one occasion and no more than 7 drinks per week^[14] and men younger than 65 years should consume no more than 4 drinks on any one occasion and no more than 13 standards drinks per week. Men older than 65 years should follow recommendations for women. Other drinking considered hazardous is any use of alcohol by children, teens, by those with a personal or family history of alcohol dependence, women who are pregnant or breastfeeding, and use before or during situations requiring attention or skill (eg, driving)

By itself, the CAGE questionnaire is not an adequate screening for alcohol problems.

The AUDIT (alcohol use disorders identification test) is the best test for screening because it detects hazardous drinking and alcohol abuse. Furthermore, it has a greater sensitivity in populations with a lower prevalence of alcoholism. One study suggested that questions 1, 2, 4, 5, and 10 were nearly as effective as the entire questionnaire. If confirmed, AUDIT would be easier to administer.

Table 1. AUDIT Questions and Scoring System (Open Table in a new window)

The AUDIT can be administered as a paper-and-pencil test, but the CAGE questionnaire should be administered face to face. The CAGE questionnaire is less reliable when given after asking questions on frequency. If the patient answers questions on the CAGE questionnaire or AUDIT affirmatively, following up with additional questions about circumstances and reasons is important. Additional useful questions are found below (see Additional questions).

The diagnosis of alcohol dependence relies more on the consequences of alcohol use and less on the amount of alcohol consumed. Thus, if one suspects alcohol problems from answers to screening questions, attempt to determine what consequences of alcohol abuse the patient has experienced.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria are required to make the diagnosis of alcohol dependence. The diagnosis requires 3 of the following criteria in the DSM-IV-TR.

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 or more of the following, occurring at any time in the same 12-month period:

• Tolerance, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount of the substance
• Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) or the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
• The substance is often taken in larger amounts or over a longer period than was intended
• There is a persistent desire or unsuccessful efforts to cut down or control substance use
• A great deal of time is spent in activities necessary to obtain the substance (eg, visiting multiple doctors or driving long distances), use the substance (eg, chain-smoking), or recover from its effects
• Important social, occupational, or recreational activities are given up or reduced because of substance use
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (eg, current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption). Specify if with physiological dependence - Evidence of tolerance or withdrawal (ie, either item 1 or 2 is present) or without physiological dependence - No evidence of tolerance or withdrawal (ie, neither item 1 nor 2 is present).

The following reasons illustrate the importance of screening for alcohol and drug abuse.

• Alcoholism is common and serious.
• Failure to screen leads to misdiagnosis. Approximately 50-90% of alcohol problems are missed in the office.
• Effective and simple screening tests are available.
• Effective treatments are available, especially if the diagnosis is made early.
• Early identification can prevent physical and psychosocial problems.

Additional questions, as present below, may be helpful when screening for alcoholism.

• Have you ever had a drinking problem?
• When was your last drink? (Less than 24 h is a red flag.)
• Do you use alcohol to relieve pain, anxiety, or insomnia?
• Have you ever been arrested for drinking, such as driving under the influence?
• Have you ever lost friends or girlfriends/boyfriends because of your drinking?
• Have you ever been to an Alcoholics Anonymous (AA) meeting?
• The following are additional questions specific to the geriatric population: Did your drinking increase after someone close to you died? Does alcohol make you sleepy so that you often fall asleep in your chair?
• The following are additional questions specific to the adolescent population: Do you drink alone? Do you ever miss school to go drinking or because you have a hangover?

The following are signs and symptoms of alcohol withdrawal:

• Nausea and vomiting
• Diaphoresis
• Agitation and anxiety
• Headache
• Tremor
• Seizures
• Visual and auditory hallucinations: Many patients who are not disoriented, and who therefore do not have delirium tremens, have hallucinations.

The following are signs of delirium tremens (ie, alcohol withdrawal delirium):

• Tachycardia and hypertension
• Temperature elevation
• Delirium

The following are signs of chronic alcoholism:

• Gynecomastia
• Spider angiomata
• Dupuytren contractures (also may be congenital)
• Testicular atrophy
• Enlarged or shrunken liver
• Enlarged spleen

Ataxia, ophthalmoplegia (usually lateral gaze palsy), and confusion indicate Wernicke encephalopathy.

Anterograde and retrograde amnesia, often with confabulation and preceded by Wernicke encephalopathy, indicates Korsakoff syndrome.

Asterixis and confusion suggest hepatic encephalopathy.

Patients commonly use a psychiatric disorder to deny alcohol abuse. Unless strong evidence indicates that the psychiatric disorder clearly precedes the alcoholism or is present during a long period of sobriety, the best plan is to proceed as if alcoholism is the primary diagnosis. Arrange a consultation with a psychiatrist for difficult cases because some patients who are treated for psychiatric conditions stop drinking and do very well.

The physician should, nonetheless, perform a brief mental status exam to help guide the referral process. Basic elements that should be covered in the mental status exam include an assessment of mood, perceptual problems such as hallucinations, and a safety screen. The use of a standardized instrument helps ensure important questions are asked and the results transmitted with some degree of objectivity. Several validated instruments exist, including The Patient Health Questionnaire from the Primary Care Evaluation of Mental Disorders (PRIME-MD)^[15] and the Cornell Psychiatric Screen.^[16]

Genetic psychiatric disorders, such as schizophrenia and bipolar disorder, are associated with alcoholism.^[17] The presence of both a serious, persistent mental illness and alcoholism is called dual diagnosis. The physician must address both. Family history commonly reveals members with bipolar disorder, alcoholism, or both. Despite this and despite an intensive search for a gene for alcoholism, study results remain inconclusive. Nevertheless, some evidence indicates that genetics plays a major role in alcohol abuse.

Twin studies

Identical twins have a higher concordance for drinking behavior and possibly alcoholism than fraternal twins.

In a well-conducted twin study of 542 families, a single underlying trait for conduct disorder, antisocial personality, alcohol dependence, and drug dependence was found, which was highly heritable and was observed in both sexes.^[18] Additionally, the study found that maximal alcohol consumption of fathers was predictive of their children having behavior and substance abuse problems (>24 drinks in 24 h yielded especially high risk). Not all at-risk children developed substance use or behavior problems. The environment seemed to determine which, if any, manifested. Deviant peers and poor parent-child relationships predicted early use (age < 15 y) of alcohol, which predicted later alcohol abuse and antisocial personality. This study applies to early-onset alcoholism and type 2 alcoholism. More work is needed on later-onset alcoholism and type 1 alcoholism.

Adoption studies

Whether reared by biologic or adoptive parents, sons of males with alcoholic problems are 4 times more likely to have problems with alcohol than sons of persons who are not.

Two Swedish studies have suggested the following 2 types of male alcoholism:

• Type 1 characteristics include (1) onset in adulthood (early twenties), (2) drinking to relieve anxiety, and (3) inherited but requires an environmental trigger.
• Type 2 characteristics include (1) an association with criminal behavior (sociopathy), (2) onset in teen years, and (3) drinking to get high.
• Sons of persons with type 2 alcoholism are 7 times more likely to develop type 2 alcoholism compared with the general population.
• The theories suggested from these studies are controversial and require confirmation in additional populations.

Data from adoption studies on daughters of persons with alcohol problems are less clear. Daughters might be at increased risk if the biological mother has alcoholism. A recent twin study in women found higher concordance in monozygotic twins than in dizygotic twins.

Experimental studies

Schuckit and Smith found that sons of persons with alcoholism respond differently to an alcohol challenge.^[19] They report decreased subjective ratings for feeling intoxicated, and they objectively have less body sway when given the same amount of alcohol as sons of persons without alcoholism. The study population consisted of white, male college students who drank alcohol but were not alcohol dependent themselves. The fathers in this study could not have psychopathology other than alcoholism (ie, no sociopathy, no bipolar illness).

Ten-year follow-up data have been published recently for the first half of this cohort. Of the sons of persons with alcoholism, 26% were alcohol dependent by age 30 years, as opposed to 9% of the control group. Furthermore, 56% of the sons of persons with alcoholism with lesser objective and subjective responses to alcohol became alcohol dependent, as opposed to 14% of the sons of persons with alcoholism who did not demonstrate these decreased responses. This also held true for the sons of fathers who did not have alcoholism, although the numbers were small.

Positive family history and lesser response to alcohol increased the likelihood of later development of alcohol dependence.

Psychological studies

Behavioral models explain alcohol abuse in terms of learning theory. Through operant conditioning, the reinforcing elements of alcohol use become habitual.

Cognitive models explain alcohol abuse in terms of “automatic thoughts,” which precede the person’s more identifiable feelings about alcohol. For example, an automatic thought might be “I deserve a drink because I’ve had a rough day."

Psychoanalytic models explain alcohol abuse in terms of ego defenses and intrapsychic conflicts. The alcohol serves as a way to escape the uncomfortable internal conflict.