eMedicine Specialties > Psychiatry > Addiction

Alcoholism: Differential Diagnoses & Workup

Author: Warren Thompson, MD, FACP, Associate Professor, Department of Internal Medicine, Mayo Medical School
Coauthor(s): R Gregory Lande, DO, FACN, Clinical Consultant, Army Substance Abuse Program, Department of Psychiatry, Walter Reed Army Medical Center; Raj K Kalapatapu, MD, Fellow in Geriatric Psychiatry, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: Aug 19, 2008

Differential Diagnoses

Anxiety Disorders
Panic Disorder
Bipolar Affective Disorder
Social Phobia
Depression
Dysthymic Disorder
Insomnia

Other Problems to Be Considered

The relationship between alcohol and bipolar disorder is an important dual diagnosis. In fact, a substance abuse disorder is seen in nearly 60% of individuals with bipolar disorder.15 Any individual who presents with significant mood fluctuations must be screened for an alcohol use disorder.

Panic disorder, generalized anxiety disorder, social phobia, dysthymic disorder, major depression, bipolar mania, or primary (idiopathic) insomnia: Alcohol abuse or dependence might reflect self-treatment for these conditions.

Other drug abuse (both prescription drugs and street drugs): Consider the possibility of other drug abuse, both prescription drugs and street drugs.

Comorbid disorders: Also consider comorbid psychiatric conditions such as anxiety and depression. Depression, anxiety, and antisocial personality all are more common in persons with alcoholism than in the general population (20.5% vs 7.2%, 23.5% vs 11.1%, and 18.3% vs 3.6%, respectively).

Of particular importance is the common concurrence of posttraumatic stress disorder (PTSD) and alcohol abuse. The activating symptoms of alcohol withdrawal aggravate the PTSD, which inevitably increases the risk of relapse.16 A number of studies examined alcohol use in the aftermath of the attacks on the World Trade Center. A survey conducted 9 months after the terrorist attack found a 17.5% increase in alcohol use when compared with consumption patterns in the month preceding the attack. The same study noted that PTSD declined during those 9 months, but alcohol use remained elevated.17 Individuals glued to the television experienced higher rates of PTSD. Nationwide estimates of PTSD in the 2 months following 9/11 varied according to the television viewing time, ranging between 2.7-4.3%.18

Another study examined combat veterans of the first Gulf War. Six years after that brief war, a significant correlation still existed between alcohol use disorders and PTSD.19 The co-occurring disorders of PTSD and alcohol abuse are expressed differently between the genders. Men are much more likely to experience irritability as they drink excessively.20 Women with PTSD also abuse alcohol, but are more likely to suffer from vague physical complaints and depression.21

Workup

Laboratory Studies

Biomarkers

Alcohol biomarkers are physiological indicators of alcohol exposure or ingestion and may reflect the presence of an alcohol use disorder. These biomarkers are not meant to be a substitute for a comprehensive history and physical examination by an appropriate health professional. Instead, alcohol biomarkers should be a complement to self-reported measures of drinking.23

In a population of psychiatric patients, research evidence has shown the usefulness of biological measures in the detection of alcohol use disorders when compared with patient self-report. A 2007 study of 486 consecutively admitted psychiatric patients showed a low correlation between self-reported consumption of alcohol and illicit drugs and biological measures; 52% of the patients underreported their consumption of illicit drugs when compared with urine toxicology screening results; 56% of patients underreported alcohol use as evaluated by carbohydrate-deficient transferrin (CDT), and 37% of patients underreported alcohol use as evaluated by CDT + gamma glutamyltransferase (GGT).22 Replication of such research in a primary care population is needed to show that biological measures aid the primary care clinician in detecting alcohol use disorders.

Alcohol biomarkers are generally divided into indirect and direct biomarkers.23

Indirect alcohol biomarkers
Indirect biomarkers suggest heavy alcohol use by detecting the toxic effects that alcohol may have had on organ systems or body chemistry.23

  • Indirect alcohol biomarkers include aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyltransferase (GGT), mean corpuscular volume (MCV), and carbohydrate-deficient transferrin (CDT).23
  • GGT, AST, and MCV are the most frequently used indirect biomarkers.24 As a screen for alcohol dependence, the sensitivity/specificity of CDT is generally higher than AST, ALT, GGT, or MCV.23,25,26 (See Table 2 below.) CDT is less sensitive/specific in women than men.27
  • CDT is a collection of various isoforms of the iron transport protein transferrin.24 Alcohol consumption above 50-80 g/d for 2-3 weeks appears to increase serum concentrations of CDT.26,25 CDT tends to distinguish chronic heavy drinkers from light social drinkers.24  A number of different ways are available to measure CDT; some may be better than others, depending on factors such as the type of alcohol consumption and gender.28
  • The combination of GGT and CDT compared with GGT or CDT alone shows a higher diagnostic sensitivity, a higher diagnostic specificity, and a stronger correlation with the actual amounts of alcohol consumption (see Table 2 below).25,26 Combination GGT/CDT values appear to increase after the daily alcohol consumption exceeds a threshold of 40 g.26 This approach is cost-effective, easy to manage in hospital laboratories, and should be suitable for routine clinical care.26
  • Other indirect alcohol biomarkers of emerging interest include total serum sialic acid (TSA), 5-hydroxytryptophol (5-HTOL), N-acetyl-beta-hexosaminidase (Beta-Hex), plasma sialic acid index of apolipoprotein J (SIJ), and salsolinol.29

Direct alcohol biomarkers
Direct biomarkers are analytes of alcohol metabolism.23

  • Direct alcohol biomarkers include alcohol itself and ethyl glucuronide (EtG).23
  • A blood alcohol level might be helpful in the office if the patient appears intoxicated but is denying alcohol abuse. A blood alcohol level in excess of 300 mg/dL, a blood alcohol level of greater than 150 mg/dL without gross evidence of intoxication, or a blood alcohol level of greater than 100 mg/dL upon routine examination indicates alcoholism with a high degree of reliability. The short half-life of alcohol limits its use widely as a biomarker.26 As the blood alcohol level detects alcohol intake in the previous few hours, it is not necessarily a good indicator of chronic excessive drinking.24
  • EtG is a minor, nonoxidative, water-soluble, stable, and direct metabolite of alcohol that is formed by the conjugation of ethanol with activated glucoronic acid.24,25,26 Shortly after alcohol intake, even in small amounts, EtG becomes positive.24 After complete cessation of alcohol intake, EtG can be detected in urine for up to 5 days after heavy binge drinking29,26 , making EtG an important biomarker of recent alcohol consumption.24 A 2006 report by the Substance Abuse and Mental Health Services Administration states that the use of EtG should be considered as a potential valuable clinical tool, but the use of EtG in forensic settings is premature.23
  • Other direct alcohol biomarkers of emerging interest include acetaldehyde, fatty acid ethyl esters (FAEE), Ethyl Sulfate (EtS), and Phosphatidylethanol (PEth).23,29

Table 2. Sensitivity and Specificity of Alcohol Biomarkers*

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Table
BiomarkerSensitivity (%)Specificity (%)
AST15-6947-68
ALT18-5850-57
GGT34-8511-95
MCV34-8926-95
CDT39-9482-100
CDT + GGT90 † 98
Alcohol0-1000-100
EtG76-9177-92
BiomarkerSensitivity (%)Specificity (%)
AST15-6947-68
ALT18-5850-57
GGT34-8511-95
MCV34-8926-95
CDT39-9482-100
CDT + GGT90 † 98
Alcohol0-1000-100
EtG76-9177-92


*Values vary considerably according to gender, age, drinking pattern, prevalence of alcohol abuse/dependence, and prevalence of comorbidity, among other factors.25,26,30,31,27

† The sensitivity comes from one study in Finland, which uses a special formula. This study needs to be replicated.32

Other Tests

The possibility of polysubstance abuse/dependence justifies performing a blood/urine toxicology screen for other substances of abuse.

More on Alcoholism

Overview: Alcoholism
Differential Diagnoses & Workup: Alcoholism
Treatment & Medication: Alcoholism
Follow-up: Alcoholism
References
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Further Reading

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Keywords

alcoholism, alcohol dependence, alcohol abuse, Alcoholics Anonymous, AA, chronic alcohol use, chronic alcohol abuse, substance abuse, ethanol abuse, binge drinking, bender

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Contributor Information and Disclosures

Author

Warren Thompson, MD, FACP, Associate Professor, Department of Internal Medicine, Mayo Medical School
Warren Thompson, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Heart Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

R Gregory Lande, DO, FACN, Clinical Consultant, Army Substance Abuse Program, Department of Psychiatry, Walter Reed Army Medical Center
R Gregory Lande, DO, FACN is a member of the following medical societies: American Osteopathic Academy of Addiction Medicine and American Osteopathic Association
Disclosure: Nothing to disclose.

Raj K Kalapatapu, MD, Fellow in Geriatric Psychiatry, Mount Sinai School of Medicine
Raj K Kalapatapu, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Denis F Darko, MD, Executive Director, Clinical Research and Development, Neuroscience Global Licensing Medical Director, Clinical Neuroscience Therapy Area and CNS and Pain Control Research Area, AstraZeneca LP
Denis F Darko, MD is a member of the following medical societies: American College of Physicians and American Psychiatric Association
Disclosure: AstraZeneca Salary Management position

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other; Pfizer Honoraria Speaking and teaching

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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