Diagnostic Criteria for Alcohol Abuse and Dependence
Diagnosis is the process of identifying and labeling specific conditions such as alcohol abuse or dependence (1).
Diagnostic criteria for alcohol abuse and dependence reflect the consensus of researchers as to precisely which
patterns of behavior or physiological characteristics constitute symptoms of these conditions (1). Diagnostic
criteria allow clinicians to plan treatment and monitor treatment progress, make communication possible between
clinicians and researchers, enable public health planners to ensure the availability of treatment facilities, help
health care insurers to decide whether treatment will be reimbursed and allow patients access to medical
insurance coverage (1-3).
Diagnostic criteria for alcohol abuse and dependence have evolved over time. As new data become available,
researchers revise the criteria to improve their reliability, validity and precision (4, 5). This
Alcohol Alert traces
the evolution of diagnostic criteria for alcohol abuse and dependence through the current standards of the
American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV) (6). For comparison, the criteria found in the World Health Organization's International Classification of
Diseases, Tenth Revision (ICD-10) also are reviewed briefly, although these are not often used in the United
States (7).
Evolution of Diagnostic Criteria
Early Criteria
At least 39 diagnostic systems had been identified before 1940 (2).
In 1941, Jellinek first published what is considered a groundbreaking
theory of subtypes of what was, until 1980, termed alcoholism (2, 8).
Jellinek associated these subtypes with different degrees of physical,
psychological, social and occupational impairment (2, 9).
Formulations of diagnostic criteria continued with the American
Psychiatric Association's publication of the Diagnostic and Statistical
Manual of Mental Disorders, First Edition (DSM-I), and Second
Edition (DSM-II) (10, 11). Alcoholism was categorized in both
editions as a subset of personality disorders, homosexuality and
neuroses (2, 12).
In response to perceived deficiencies in DSM-I and DSM-II, the Feighner criteria were developed in the 1970s to
establish a research base for the diagnostic criteria of alcoholism (5, 13). These criteria were the first to be
based on research rather than on subjective judgment and clinical experience alone (5). Though designed for
use in clinical practice, they were primarily developed to stimulate continued research for the development of
even more useful diagnostic criteria (5). Several years later, Edwards and Gross focused solely on alcohol
dependence (8). They considered essential elements of dependence to be a narrowing of the drinking
repertoire, drink-seeking behavior, tolerance, withdrawal, drinking to relieve or avoid withdrawal symptoms,
subjective awareness of the compulsion to drink and a return to drinking after a period of abstinence (8).
The DSM Criteria
Researchers and clinicians in the United States usually rely on the DSM diagnostic criteria. The evolution of
diagnostic criteria for behavioral disorders involving alcohol reached a turning point in 1980 with the publication
of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (14). In DSM-III, for the first time, the
term "alcoholism" was dropped in favor of two distinct categories labeled "alcohol abuse" and "alcohol
dependence" (1, 2, 12, 15). In a further break from the past, DSM-III included alcohol abuse and dependence in
the category "substance use disorders" rather than as subsets of personality disorders (1, 2, 12).
The DSM was revised again in 1987 (DSM-III-R) (16). In DSM-III-R, the category of dependence was expanded to
include some criteria that in DSM-III were considered symptoms of abuse. For example, the DSM-III-R described
dependence as including both physiological symptoms, such as tolerance and withdrawal, and behavioral
symptoms, such as impaired control over drinking (17). In DSM-III-R, abuse became a residual category for
diagnosing those who never met the criteria for dependence, but who drank despite alcohol-related physical,
social, psychological or occupational problems, or who drank in dangerous situations, such as in conjunction
with driving (17). According to Babor, this conceptualization allowed the clinician to classify meaningful aspects of
a patient's behavior even when that behavior was not clearly associated with dependence (18).
The DSM was revised again in 1994 and was published as the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) (6). The section on substance-related disorders was revised in a coordinated
effort involving a working group of researchers and clinicians, as well as a multitude of advisers representing the
fields of psychiatry, psychology and the addictions (2). The latest edition of the DSM represents the culmination
of their years of reviewing the literature, analyzing data sets, such as those collected during the Epidemiologic
Catchment Area Study, conducting field trials of two potential versions of DSM-IV, communicating the results of
these processes and reaching consensus on the criteria to be included in the new edition (2, 19).
DSM-IV, like its predecessors, includes nonoverlapping criteria for dependence and abuse. However, in a
departure from earlier editions, DSM-IV provides for the subtyping of dependence based on the presence or
absence of tolerance and withdrawal (6). The criteria for abuse in DSM-IV were expanded to include drinking
despite recurrent social, interpersonal and legal problems as a result of alcohol use (2, 4). In addition, DSM-IV
highlights the fact that symptoms of certain disorders, such as anxiety or depression, may be related to an
individual's use of alcohol or other drugs (2).
The ICD Criteria
While the American psychiatric community was formulating its editions of diagnostic criteria for mental disorders,
the World Health Organization was developing diagnostic criteria for the purpose of compiling statistics on all
causes of death and illness, including those related to alcohol abuse or dependence, worldwide (1, 4, 20). These
criteria are published as the International Classification of Diseases (ICD). The first ICD classification of
substance-related problems, published in 1967 in ICD-8 (21), classified what was then called alcoholism with
personality disorders and neuroses, as had DSM-I and DSM-II. In ICD-8, alcoholism was a separate category that
included episodic excessive drinking, habitual excessive drinking and alcohol addiction that was characterized
by the compulsion to drink and by withdrawal symptoms when drinking was stopped (1).
Although ICD-9 (22, 23) included separate criteria for alcohol abuse and dependence, this revision defined them
similarly in terms of signs and symptoms (1). According to Babor, an important assumption in ICD-9 was that
alcohol use in the absence of dependence "merits a separate category by virtue of its detrimental effects on
health" (1, p. 87).
The category of alcohol dependence was central to the current revision, ICD-10 (1, 2, 7). Alcohol dependence is
defined in this classification in a way that is similar to the DSM. The diagnosis focuses on an interrelated cluster
of psychological symptoms, such as craving; physiological signs, such as tolerance and withdrawal; and
behavioral indicators, such as the use of alcohol to relieve withdrawal discomfort (1). However, in a departure
from the DSM, rather than include the category "alcohol abuse," ICD-10 includes the concept of "harmful use."
This category was created so that health problems related to alcohol and other drug use would not be
underreported (1). Harmful use implies alcohol use that causes either physical or mental damage in the absence
of dependence (1).
Moving Toward Agreement Between Diagnostic Criteria
The DSM diagnostic criteria for psychiatric disorders are the criteria primarily used in the United States. The ICD
is an international diagnostic and classification system for all causes of death and disability, including psychiatric
disorders (4). Earlier editions of these two major diagnostic criteria dealing with alcohol abuse and dependence
were criticized for being too dissimilar (2). Therefore, the DSM-IV and the ICD-10 were revised in a coordinated
effort among researchers worldwide to develop criteria that were as consistent with one another as possible (1, 2).
Although some differences between the two major diagnostic criteria still exist, they have been revised by
consensus as to how alcohol abuse and dependence are best characterized for clinical purposes (18). Clinicians,
international health agencies and researchers are now better able to categorize people with alcohol
dependence, abuse and harmful use to plan treatment, collect statistical data and communicate research
results (18).
Diagnostic Criteria - A Commentary by NIAAA Director Enoch Gordis, M.D.
The research community has long found standardized diagnostic criteria useful.
Such criteria provide agreement as to the constellation of symptoms that indicate
the alcohol dependence syndrome and allow researchers all over the world to
communicate clearly as to what kinds of disorders are being studied.
Standardized diagnostic criteria are equally important and useful to clinicians. In the
alcohol field, there have been many different ways by which clinical staff might arrive
at a diagnosis - sometimes differing among staff within the same program. Although
the use of standard diagnostic criteria may seem somewhat burdensome, it
provides many benefits: more efficient assessment and placement, more
consistency in diagnoses between and within programs, enhanced ability to
measure the effectiveness of a program and provision of services to people who
most need them. As we move more and more into a managed health care arena,
third-party payers are requiring more standardized reporting of illnesses; they want
to know what conditions they are paying for and that these conditions are the same
from program to program. The standardized diagnostic criteria presented in this
Alert are based on the newest research, have been developed based on field trials
and extensive reviews of the literature and are continually revised to reflect new findings. Although clinical
judgment will always play a role in diagnosing any illness, alcohol treatment programs that use standardized
diagnostic criteria will be in the best position to select appropriate treatment and to justify their selection to
third-party payers.
References
(1) Babor, T.F. Substance-related problems in the context of international classificatory systems. In: Lader, M.;
Edwards, G.; & Drummond, D.C., eds. The Nature of Alcohol and Drug Related Problems. New York: Oxford
University Press, 1992.
(2) Schuckit, M.A. DSM-IV: Was it worth all the fuss? Alcohol and Alcoholism.
(Supp. 2):459-469, 1994.
(3) Vaillant, G.E. The Natural History of Alcoholism Revisited. Cambridge: Harvard
University Press, 1995.
(4) Rounsaville B.J.; Bryant, K.; Babor, T.; Kranzler, H.; & Kadden, R. Cross system
agreement for substance use disorders: DSM-III-R, DSM-IV and ICD-10. Addic tion 88(3):337-348, 1993.
(5) Feighner, J.P.; Robins, E.; Guze, S.B.; Woodruff, R.A., Jr.; Winokur, G.; & Munoz, R. Diagnostic criteria for
use in psychiatric research. Archives of General Psychiatry 26(1):57-63, 1972.
(6) American Psychiatric
Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.: the
Association, 1994.
(7) World Health Organization. The ICD-10 Classification of Mental and Behavioural
Disorders: Clinical Descriptions and Diagnostic Guidelines, Tenth Revision. Geneva: World Health Organization,
1992.
(8) Edwards, G., & Gross, M.M. Alcohol dependence: Provisional description of a clinical syndrome.
British Medical Journal 1:1058-1061, 1976.
(9) Jellinek, E.M. The Disease Concept of Alcoholism. New
Brunswick: Hillhouse Press, 1960.
(10) American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, First Edition. Washington, D.C.: the Association, 1952.
(11) American Psychiatric
Association. Diagnosti and Statistical Manual of Mental Disorders, Second Edition. Washington, D.C.: the
Association, 1968.
(12) Nathan, P.E. Substance use disorders in the DSM-IV. Journal of Abnormal Psychology
100(3):356-361, 1991.
(13) Keller, M., & Doria, J. On defining alcoholism. Alcohol Health & Research World
15(4):253-259, 1991.
(14) American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Third Edition. Washington, D.C.: The Association, 1980.
(15) Cottler, L.B.; Schuckit, M.A.; Helzer,
J.E.; Crowley, T.; Woody, G.; Nathan, P.; & Hughes, J. The DSM-IV fiel trial for substance use disorders: Major
results. Drug and Alcohol Dependence 38:59-69, 1995.
(16) American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, D.C.: the Association, 1987.
(17) Hasin, D.S.; Grant, B.; & Endicott, J. The natural history of alcohol abuse: Implications for definitions of
alcohol use disorders. America Journal of Psychiatry 147(11):1537-1541, 1990.
(18) Babor, T.F. The road to
DSM-IV: Confessions of an erstwhile nosologist. Commentary No. 2. Drug and Alcohol Dependence 38:75-79,
1995.
(19) Schuckit, M.A. Familial alcoholism. In: Widiger, T.; Frances, A.; Pincus, H.; First, M.; Ross, R.; &
Davis, W. eds. DSM-IV Sourcebook. Vol. 1. Washington, D.C.: American Psychiatric Association, 1994. pp.
159-167.
(20) Grant B.F. DSM III-R and ICD 10 classifications of alcohol use disorders and associated
disabilities: A structural analysis. International Review of Psychiatry 1:21-39, 1989.
(21) World Health
Organization. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death,
Eighth Revision. Geneva: World Health Organization, 1967.
(22) World Health Organization. Manual of the
International Statistical Classification of Diseases, Injuries, and Causes of Death, Ninth Revision. Vol. 1.
Geneva: World Health Organization, 1977.
(23) World Health Organization. Manual of the International
Statistical Classification of Diseases, Injuries, and Causes of Death, Ninth Revision. Vol. 2. Geneva: World
Health Organization, 1978.
