2.2 Alcohol use disorder (AUD)

AUD is the term now used for the conditions formerly referred to as alcohol abuse and alcohol dependence. AUD is the diagnosis given to someone who is showing signs and symptoms of addiction to alcohol. This is often referred to as ‘alcoholism’ and the individual concerned may be called an ‘alcoholic’. Someone with AUD would show several characteristics common to all addictive behaviours, but there are three key features:

• Tolerance – this refers to increasing engagement with the object of addiction (in this case, the ‘object of addiction’ is alcohol) in order to keep achieving the same effects. For example, an individual who might have been drinking half a bottle of spirits per day in the past may gradually escalate their drinking to consuming a whole bottle of spirits per day.
• Withdrawal – this refers to the signs and symptoms that occur when an individual refrains from addictive behaviour. The withdrawal signs and symptoms of alcohol addiction can include irritability, insomnia, shaking, and changes in heart rate and body temperature.
• Craving – this refers to the persistent nagging desire to engage in the addictive behaviour.

Psychologists use a series of criteria to diagnose AUD on the basis of psychological and behavioural effects. The list of considerations is seen here in Figure 7 (taken from the Diagnosis and Statistical Manual from the American Psychiatric Association [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] ).

It is important for diagnostic criteria to be reliable because so much depends on the process. For example, for anyone attempting to understand the nature of a condition, the prevalence or incidence rates would be misleading if diagnosis of that condition were not reliable. For anyone who might receive treatment for a condition, the implications of unreliable diagnosis might be more extreme. They may be prescribed the wrong treatment, or a treatment, such as a drug, that they do not need and which may cause other problems. Diagnosis is therefore vital, but experts do not always get the criteria right and the criteria themselves constantly evolve. It is important to be aware of this issue.

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Figure 7 AUD diagnosis criteria (American Psychiatric Association, May 2013)

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The text in this table reads as follows: DSM-5. In the past year, have you: 1. Had times when you ended up drinking more, or longer, than you intended? 2. More than once wanted to cut down or stop drinking, or tried to, but couldn’t? 3. Spent a lot of time drinking? Or being sick or getting over other after-effects? 4. Wanted a drink so badly you couldn’t think of anything else? 5. Found that drinking - or being sick from drinking - often interfered with taking care of your home or family? Or caused job troubles? Or school problems? 6. Continued to drink even though it was causing trouble with your family and friends? 7. Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? 8. More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? 9. Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? 10. Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before? 11. Found that when the effects of alcohol were wearing off, you had withidrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there? The presence of at least 2 of these symptoms indicates as Alcohol Use Disorder (AUD). The severity of the AUD is defined as: Mild: The presence of 2 to 3 symptoms. Moderate: The presence of 4 to 5 symptoms. Severe: The presence of 6 or more symptoms.

Figure 7 AUD diagnosis criteria (American Psychiatric Association, May 2013)

AUD can be explained through several physiological and psychological conditions.

Firstly, ethanol affects many brain regions by altering the activity of neurons. This is the underlying reason for some of the acute effects of alcohol such as reduced coordination and reduced self-restraint which you discovered in Week 5. However, as you learned in Week 5, alcohol is also able to stimulate the brain’s reward system releasing dopamine – the brain’s ‘happy’ and ‘rewarding’ messenger molecule. With frequent consumption of something rewarding like alcohol, dopamine release can start to occur earlier, so is released at the point of anticipation that something rewarding is about to happen (i.e. before the alcohol is actually consumed). Over time therefore dopamine starts to act as more of a wanting signal. In psychology this is known as classical conditioning, but you may already be familiar with this concept due to the experiment carried out by the Russian scientist Pavlov in the 1890s.