Alcohol Use Disorder – are we making the right diagnosis?

Do you and your friends enjoy the occasional cocktail or two over the weekend? Maybe we know someone who enjoys the more-than-occasional cocktail. But, at what point do our drinking habits significantly affect our health? Recent studies suggest that 6% of adults in the United States report heavy or high-risk consumption of alcohol, which is defined as an average of more than 7 drinks/week for women and more than 14 drinks/week for men. This high risk-consumption may lead to Alcohol Use Disorder (AUD) if it is repeated for one year or more. AUD is associated with a number of medical and psychiatric problems, and can even increase risk of death in patients who have cancer and cardiovascular disease.

To diagnose AUD, medical and mental health professionals use the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which explores 11 criteria, including alcohol-related cravings, strains on relationships caused by alcohol use, feeling unable to cut back or stop drinking, dangerous or risky behavior when under the influence of alcohol, etc. Unlike previous versions of the DSM, these AUD diagnoses are divided based on severity, where people who experience 0 or 1 of the diagnostic criteria do not have AUD (no-AUD), 2-3 criteria have mild AUD, 4-5 criteria have moderate AUD, and 6+ have severe AUD. However, it’s not well understood whether other factors like the extent of alcohol use, the degree of cravings or impairments, etc. can help classify mild, moderate, and severe AUD diagnoses. 

Last year, Dr. Zachary L. Mannes, a postdoc in the Department of Epidemiology at Columbia University Mailman School of Public Health and New York State Psychiatric Institute, and colleagues published a study in which they aimed to explore any potential relationships between the severity of AUD (no-AUD, mild, moderate, or severe, based on the DSM-5) and self-reported measures of other factors or “external validators”, such as levels of alcohol craving, functional impairment, and psychiatric conditions. To do this, they collected AUD diagnosis as well as measures of external validators in 588 participants. These validators included alcohol specific validators (i.e. Craving, Problematic Use, Harmful Use, Binge Drinking Frequency), psychiatric validators (i.e. Major Depressive Disorder/MDD and posttraumatic stress disorder/PTSD), and functioning validators (social impairments; physical and mental impairments).

Dr. Mannes and colleagues reported that in this cohort of subjects, participants with alcohol use validators had a significantly greater likelihood of a diagnosis with mild, moderate, and severe AUD than a no-AUD diagnosis. Psychiatric validators like MDD and PTSD had a significantly greater likelihood of a severe AUD diagnosis than no-AUD; this relationship was not seen for either mild or moderate AUD. Participants who had social, physical, and mental impairments had a greater likelihood of having severe AUD than no-AUD, but this was not seen for participants with mild or moderate AUD. When looking within participants with an AUD diagnosis (i.e. excluding a no-AUD diagnosis), participants with many alcohol-specific, psychiatric, and functional validators were more likely to have a severe AUD than either mild or moderate AUD.

Overall, the results of this study support the structure of the DSM-5 diagnosis for AUD, as those diagnoses with mild and moderate AUD had significant associations with alcohol use validators, while those with severe AUD had significant associations with alcohol use, psychiatric and functional validators. In other words, people with severe AUD had a higher likelihood of symptoms that affected other aspects of their lives including impairments in social functioning and presence of psychiatric conditions including MDD and BPD. This study emphasizes the importance of looking at levels of severity in AUD as the current DSM-5 does, as opposed to a binary yes/no diagnosis as older versions of the DSM had incorporated. This study also helps further the understanding of optimal ways to diagnose AUD and may help better understand potential treatment implications for various AUD severity. The study published by Dr. Mannes and colleagues supports and progresses the field of AUD research in order to better understand and characterize the symptoms, comorbidities, and diagnosis of AUD, so that medical professionals can better assist those who are struggling with the disorder. 

Edited by: Trang Nguyen, Maaike Schilperoort

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