The DSM-IV-TR classifies drug disorders into substance use disorders (substance dependence and abuse) and substance-induced disorders (substance intoxication, substance withdrawal, induced delirium, anxiety, depression, psychosis and mood disorders). Sometimes it is difficult assessing patient’s psychiatric complaints because heavy drinking is associated with alcoholism can co-exist with, contribute to or result from several different psychiatric syndromes. (Shivani, Goldsmith & Anthenelli, 2002) In order to improve diagnostic accuracy, distinguishes among alcohol-related psychiatric symptoms and signs, alcohol-induced psychiatric syndromes and independent psychiatric disorders that are commonly associated with alcoholism emerges to be essential. Patients’ gender, family history, and course of illness over time also should be taken into account. Alcohol-related psychiatric symptoms and signs
Heavy alcohol consumption directly affects brain function and brain chemical and hormonal systems known to be involved in many common mental disorders thus can manifest itself in a broad range of psychiatric symptoms and signs. (Koob, 2000) And this usually the first problem which brings the patients seek help. The symptoms vary depending on the amount of alcohol used, how long it is used and how recently it was used as well as patient’s vulnerability to experiencing psychiatric symptoms in the setting of consumption. For example, during intoxication, smaller amount alcohol may produce euphoria whereas larger amount may produce more dramatic changes in mood. Alcohol also impairs judgment and aggressive, antisocial behaviours that may mimic certain externalizing disorders such as ASPD. Alcohol-induced psychiatric syndromes
The essential feature of alcohol-induced psychiatric syndromes is the presence of prominent and persistent symptoms, which are judged- based on their onset and course as well as on the patient’s history, physical exam, and laboratory findings to be the result of the direct physiological effects of alcohol. Given the broad range of effects of heavy drinking may have on psychological functioning, these alcohol-induced disorders span several categories of mental disorders, including mood, anxiety, psychotic, sleep, sexual, delirious, amnestic and dementia disorders. Alcoholism with comorbid, independent psychiatric disorders Alcoholism is also associated with several psychiatric disorders that develop independently of the alcoholism and may precede alcohol use and abuse. One of the most common of these comorbid conditions is ASPD, and axis II personality disorder marked by a longstanding pattern of irresponsibility and violating the rights of others with alcohol. (Stinson et al., 2006)
The three major purposes for a comprehensive assessment are to determine a diagnosis, devise a treatment plan and to make appropriate referrals. The assessment should provide a clinical picture of the client’s personal level of functioning, history, presenting problems, family and social context in the client’s life. It is very important that the assessment process requires the gathering of comprehensive, accurate information, for a valid diagnosis and appropriate treatment. - It is vital that the counsellor needs to collect valid and reliable information. Both formal diagnosis, as listed in the Diagnostic and Statistical Manual of Mental Disorders (APA, 1994) and informal diagnosis, if the client has had therapy in the past can be made.
- Comprehensive assessment is essential in designing a treatment plan. The more information provided concerning the etiology, functioning level and prognosis of the problem, the better the treatment plan. - Comprehensive assessment also provides information in order to made appropriate referral. The counsellor may decide to provide treatment solely or in conjunction with some other drug treatment specialists. Generally there are three categories of assessment measures: subjective data and physiological data. -Subjective data
To collect information of demographics, family and living situations, employment, education, drinking history (including development of the drinking problem and current drinking) and the effects on the subject’s cognitive, psychosocial, behavioural and physiological functioning. (Aalto & Seppa, 2005)For example, some questionnaires focus on problems caused by alcohol consumption, the Alcohol Use Disorder Identification Test (AUDIT) (Saunders, Aasland, Babor, de le Fuente, & Grant, 1993) There are ones with diaries focussing on the quantification of alcohol consumption, such as quantity-frequency, time-period or time-line follow-back methods. (Webb et al., 1990) More recently, a low level of response (LR) to alcohol (the need for higher amounts to have an effect) is a genetically influenced characteristic that is both found in populations at high risk for future alcoholism and that predicts alcohol related life problems in future. This Self-Rating of the Effects of Alcohol (SRE) questionnaire asks for estimate of number of drinks required to produce each of four effects at different times in their lives. (Miller, Thomas, & Mallin, 2006) In addition, the survey included the Alcohol Use Disorders Identification Test-C (AUDIT-C), a three-question alcohol screening test adapted from the original AUDIT developed by the World Health Organization for use in primary health care. The AUDIT-C is a simple, reliable screening tool that focuses on the frequency of drinking, quantify consumed on the typical occasion and the frequency of heavy episode drinking. (Bush, Kivlahan, McDonnell, & al., 1998) Again, there is no such perfect measure that SRE was found to be biased and not able to identify high functioning middle-age women. (Schuckit, Smith, Danko, & Isacescu, 2003) The difficulty with these specific questionnaires is that people who drink alcohol in general tend to neglect or underestimate their alcohol consumption. (Koch et al., 2004) The accuracy of these measures is based on the patient's awareness of and willingness to acknowledge his or her pattern and level of alcohol use as well as negative effects of drinking. At least some individuals who drink excessively will fail to do this. (Allen & Litten, 2001) - Physiological data
Comparing to subjective data, physiological data can overcome the subjectivity, underestimation in particular thus provides more precise and objective information about the drinking issue. It includes general medical and psychiatric history and examination. This is conducted through screening of blood, breath or urine for alcohol used, further on laboratory tests for abnormalities that may be accompanied acute or chronic alcohol use such as gamma-glutamy-transferase (GGT) or mean corpuscular volume (MCV), a measure of the average size of red blood cells. These may also be used during treatment for potential relapse. GGT is the most commonly used biochemical measure of drinking. However, it is not clear how much drinking is actually needed to cause GGT levels to elevate. And MCV tends to miss more alcoholics than GGT as MCV may be elevated by a variety of conditions other than heavy drinking such as non-alcoholic liver disease, smoking, advanced age or use of anticonvulsants etc. Thus applying the usual cut-off points for these tests, GGT turns out to have a low specificity whereas MCV shows a low sensitivity. This may lead to a gross misunderstanding with the patient and unnecessary further testing. Carbohydrate deficient transferring (CDT) has been recently approved as a marker for identification of individuals with alcohol problems as well as an aid in recognizing if alcoholic patients in treatment have relapsed. CDT and GGT appear to validly detect somewhat different groups of people with alcohol problems. GGT may best pick up those with liver damage due to drinking, whereas CDT seems to be related to level of consumption with or without liver damage. It should be kept in mind that biomarkers do not identify women or adolescents with alcohol problems as they do for male or adults in general. (Similarly, self-report screening tests are also generally less able to detect alcohol problems) (Allen & Litten, 2001) Previous studies showed that over 80% of internists and family clinicians report that they usually or always ask new outpatients whether they drink alcohol. Less than 20% of primary care physicians routinely use validated self-report alcohol screening instruments (e.g. CAGE questions or AUDIT) Fewer than half ask about maximum alcohol consumption on one occasion. Alcohol biomarker laboratory tests are rarely used. Reasons given by clinicians for not following recommended alcohol screening guidelines range from lack of time, to insufficient knowledge and skills, to pessimistic attitudes about the ultimate benefits of screening. A current study conducted by Miller, et al., (2004), they found that approximately 60% of clinicians surveyed frequently screen patients for alcohol use with quantity/frequency and CAGE questions. This is comparable to the incidence of screening found in previous studies. (Miller, Ornstein, Nietert, & Anton, 2004)Miller, et al. (2006) further found that over 90% of patients were in favour of screening and guidance about alcohol use and very positive about the use of biological alcohol markers. These findings suggest that physicians and clinicians may be convinced that patients are open to alcohol screening and would not be offended by it. Heavy drinkers may have more of a tendency to be embarrassed by such questions but there is no evidence they would be object to screening. The majority of patients would also be willing to receive alcohol biomarker blood tests, if their physicians and clinicians deemed such tests necessary. (Miller, Ornstein, Nietert, & Anton, 2004)
A growing body of efficacy data from controlled clinical trials suggests that psychotherapies are superior to control conditions as a treatment for patients with SUD. Psychotherapies attempt to bring about changes in patients’ behaviour, thought processes, affect regulation and social functioning. They share common tasks of 1. Enhancing motivation to stop or reduce substance use
2. Teaching coping skills
3. Changing reinforcement contingencies
4. Fostering management of painful affects
5. Enhancing social supports and interpersonal functioning
- Managing intoxication and withdrawal
Symptoms of alcohol withdrawal typically begin within 4-12 hours after cessation or reduction of alcohol use, peak in intensity during the second day of abstinence and generally revolve within 4-5 days. Treatment aims in moderating the severity withdrawal includes effors to reduce the CNS irritability and restore physiological homeostasis. Once clinical stability is achieved other medications should be consumed. Patients should also be observed for the re-emergence of withdrawal symptoms. - Psychosocial treatments
Some widely used psychosocial treatments are: motivational enhancement therapy (MET), contingency management (CT), cognitive-behavioural (CBT), behavioural therapies (BT), 12-step facilitation (TSF), psychodynamic therapy/interpersonal therapy (IPT), marital and family therapies and group therapies. The central challenge of clinicians deal with SUD patients is the compulsive substance use, least initially results in euphoria or relief of dysphoria, with the aversive and painful effects of substance use occurring some time after the rewarding effects. Whereas most of other psychiatric disorders, the primary symptom is aversive or painful. Aiming to resolve this, motivation is essential to give up the rewards of alcohol use (MET), tolerate the discomfort of reduce or absence of alcohol use, take on the energy to avoid relapse where episodes of craving can occur through lifetime. Coping skills are very important to manage and avoid situations where possible relapse could be risky. Alternative source must be provided to replace alcohol use in the patient’s daily life. dysphoric affects, such as anger, sadness or anxiety must be managed in ways that do not involve continued alcohol use. Social interpersonal relationships that are supportive need to be developed or repaired. As the key component in BT, contingency management interventions to treat people dependent on psychoactive substances are based on a robust theoretical and empirical science literature that regards drug use and addiction as a form of operant conditioning in which behavior is controlled or shaped by its consequences. In order to earn the rewards (reinforcers), patients need to provide biological sample indicates recent drug use (negative). Researchers found that CM’s effectiveness is supported in various studies when used during treatment for clients dependent on alcohol. However after clients are no longer subject to contingencies, the magnitude of the treatment effect begins to decline, although it appears to decay relatively slowly over time. (Prendergast, Podus, Finney, Greenwell, & Roll, 2006) CBT is useful in relapse prevention and social skills training. Some studies found that CM is an afficcious treatment for reducing alcohol use and is superior during treatment to a CBT approach. CM is useful in engating substance abusers, retaining them in treatment and helping them achieve abstinence from use. CBT also reduces drug use from baseline lelvels and produces comparable outcomes on all measure at follow-up. (Rawson et al., 2006) However no particular type of psychotherapies has been found to be consistently superior when compared to other psychotherapies for treating SUD. There is also evidence to support the efficacy of integrated treatment for patients with co-occurring substance use and psychiatric disorder. (Anonymous, 2006) Recommending that patients in self-help groups, e.g. Alcoholics Anonymous (AA), is often helpful. (Anonymous, 2006) Based on the discussion above, it is remained that some more research is needed for clearer answers for better diagnosis, assessment and treatment for SUD in the future.
Aalto, M., & Seppa, K. (2005). Use of laboratory markers and the AUDIT questionnaire by primary care physicians to detect alcohol abuse by patients. Alcohol & Alcoholism, 40(6), 520-523. Allen, J. P., & Litten, R. Z. (2001). The role of laboratory tests in alcoholism treatment. Journal of Substance Abuse Treatment, 20(1), 81-85. Anonymous. (2006). PART A: Treatment Recommendations for Patients With Substance Use Disorders. The American Journal of Psychiatry, 163(8), 5-83. Bush, K., Kivlahan, D. R., McDonnell, M. R., & al., e. (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. . Archives of Internal Medicine, 158, 1789-1795. Grant, B. F., Dawson, D. A., Stinson, F. S., Chou, P., Dufour, M. C., & Pickering, R. P. (2006). The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence. Alcohol Research and Health, 29(2), 79-91. Koch, H., Meerkerk, G.-J., Zaat, O. M. J., Ham, M. F., Scholten, R. J. P. M., & Assendelft, W. J. J. (2004). Accuracy of carbohydrate-deficient transferrin in the detection of excessive alcohol consumption: a systematic review. Alcohol & Alcoholism, 39(2), 75-85. Koob, G. F. (2000). Neurobiology of addiction. Toward the development of new therapies. Annals of the New York Academy of Sciences, 909, 170-185. Miller, P. M., Ornstein, S. M., Nietert, P. J., & Anton, R. F. (2004). Self-report and biomarker alcohol screening by primary care physicians: the need to translate research into guidelines and practice. Alcohol & Alcoholism, 39(4), 325-328. Miller, P. M., Thomas, S. E., & Mallin, R. (2006). Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol & Alcoholism, 41(3), 306-310. Prendergast, M., Podus, D., Finney, J., Greenwell, L., & Roll, J. (2006). Contingency management for treatment of substance use disorders: a meta-analysis. Addiction, 101(11), 1546-1537. Rawson, R. A., McCann, M. J., Flammino, F., Shoptaw, S., Miotto, K., Reiber, C., et al. (2006). A comparison of contingency management and cognitive-behavioral approaches for stimulant-dependent individuals. Addiction, 101(11), 267-274. Saunders, J., Aasland, O., Babor, T., de le Fuente, J., & Grant, M. (1993). Alcohol use disorder identificantion test (AUDIT) in WHO collaborative project on early detection of persons with harmful alcohol consumption. Addiction, 88(2), 1-2. Schuckit, M. A., Smith, T. L., Danko, G. P., & Isacescu, V. (2003). Level of response to alcohol measured on the self-rating of the effects of alcohol questionnaires in a group of 40-year-old women. American Journal of Drug and Alcohol Abuse, 29(1), 191-201. Stinson, F. S., Grant, B. F., Dawson, D. A., Ruan, W. J., Huang, B., & Saha, T. (2006). Comorbidity between DSM-IV alcohol and specific drug use disorders in the United States. Alcohol Research and Health, 29(2), 94-106.