Diagnosis of Alcohol Abuse

Friends and family members of the alcoholic are often the first to notice problems and seek professional help. Many times, the alcoholic does not realize the severity of the problem or denies it. Some signs cannot go unnoticed, such as loss of a job, family problems, or citations for driving under the influence of alcohol. Dependence is indicated by symptoms such as withdrawal, injuries from accidents, or blackouts.

The American Psychiatric Association has developed the criteria for the clinical diagnosis of abuse and dependence. The Diagnostic and Statistical Manual-V (DSM-V) defines abuse and dependence as:

  • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by two (or more) of the following, occurring within a 12-month period:
    1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
    2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
    3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
    4. craving or a strong desire or urge to use a substance

    [DSM-V, Diagnostic and Statistical Manual of Mental Disorders, ed. V. Washington DC: American Psychiatric Association (AMA). 2013.]

    Most often, abuse is diagnosed in individuals who recently began using alcohol. Over time, abuse may progress to dependence. However, some alcohol users abuse alcohol for long periods without developing dependence.

    Dependence is suspected when alcohol use is accompanied by signs of the following:

    The DSM-IV separated the diagnosis of substance abuse and dependence; however DSM-V does not make this distinction. DSM-IV defined dependence as:

    • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
      1. tolerance, as defined by either of the following:
        • a need for markedly increased amounts of the substance to achieve intoxication or desired effect
        • markedly diminished effect with continued use of the same amount of substance
      2. withdrawal, as manifested by either of the following:
        • the characteristic withdrawal syndrome for the substance
        • the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
      3. the substance is often taken in larger amounts or over a longer period than was intended
      4. there is a persistent desire or unsuccessful efforts to cut down or control substance use
      5. a great deal of time is spent in activities to obtain the substance, use the substance, or recover from its effects
      6. important social, occupational or recreational activities are given up or reduced because of substance use
      7. 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 (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

    [DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington DC: American Psychiatric Association (AMA). 1994.]

    Alcohol Assessment

    The clinician relies on interviews and self-report questionnaires to assess quantity and frequency of drinking. Questions focus on two aspects:

    • Consequences of drinking
    • Perceptions of drinking behavior

    Clinicians determine risk for abuse and dependence based on how much and how often the patient drinks. The definition of moderate drinking differs for men and women:

    Men 4 to 14 drinks per week
    Women 3 to 7 drinks per week

    A drink is 12 grams of alcohol (e.g., 12 ounces of beer; 5 ounces of wine; 1.5 ounces of 80-proof liquor). Typical risk-assessment questions include:

    • How many days a week do you drink alcohol?
    • On a typical day when you drink, how many drinks do you have?
    • What is the maximum number of drinks you had on any given occasion during the last month?

    The CAGE questionnaire is commonly used to determine the risk of alcohol-related problems:

    C - Have you ever felt that you should Cut down on your drinking?
    A - Have people Annoyed you by criticizing your drinking?
    G - Have you ever felt bad or Guilty about your drinking?
    E - Have you ever had an Eye opener - a drink first thing in the morning to steady your nerves or get rid of a hangover?

    One "yes" answer indicates a risk for abuse and/or dependence alcohol use problems; more than one "yes" indicates a high likelihood.

    The Alcohol Use Disorders Identification Test (AUDIT) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) are based on the CAGE. The five-question Trauma Scale targets problem drinking in both men and women. The T-ACE and the TWEAK are designed to identify alcoholism in pregnant women.

    Because these less formal interviews and questionnaires have the risk of underreporting, additional tests are used to solicit information, especially if the patient is evasive or intoxicated at the time of the interview:

    • Short Michigan Alcoholism Screening Test (S-MAST) determines general alcohol abuse.
    • Short Alcohol Dependence Data Questionnaire (SADD) determines dependence severity.

    Once abuse or dependence is verified, the clinician administers a comprehensive assessment to develop a treatment plan. The assessment includes detailed medical and psychological histories from the individual. The clinician may request copies of medical records and may interview family members.

    Publication Review By: Debra Emmite, M.D., Stanley J. Swierzewski, III, M.D.

    Published: 02 Apr 2001

    Last Modified: 28 Aug 2015