Alcoholism and Psychiatric Disorders

Diagnostic Challenges

Ramesh Shivani, M.D., R. Jeffrey Goldsmith, M.D., and Robert M. Anthenelli, M.D.

Clinicians working with alcohol-abusing or alcohol-dependent patients sometimes face a difficult task assessing their patient’s psychiatric complaints because heavy drinking associated with alcoholism can coexist with, contribute to, or result from several different psychiatric syndromes. In order to improve diagnostic accuracy, clinicians can follow an algorithm that distinguishes among alcohol-related psychiatric symptoms and signs, alcohol-induced psychiatric syndromes, and independent psychiatric disorders that are commonly associated with alcoholism. The patient’s gender, family history, and course of illness over time also should be considered to attain an accurate diagnosis. Moreover, clinicians need to remain flexible with their working diagnoses and revise them as needed while monitoring abstinence from alcohol. KEY WORDS: AODD (alcohol and other drug dependence); diagnostic algorithm; diagnostic criteria; screening and diagnostic method for potential AODD; patient assessment; AODR (AOD related) mental disorder; behavioral and mental disorder; symptom; comorbidity; major depression; manic- depressive psychosis; personality disorder; anxiety; patient family history; medical history

he evaluation of psychiatric com­ culty maintaining abstinence, to attempt challenges encountered in the psychi­ plaints in patients with alcohol or commit suicide, and to utilize mental atric assessment of alcoholic clients. Tuse disorders (i.e., alcohol abuse health services (Helzer and Przybeck or dependence, which hereafter are col­ 1988; Kessler et al. 1997). Thus, a thor­ lectively called alcoholism) can some- ough evaluation of psychiatric complaints Diagnostic Difficulties times be challenging. Heavy drinking in alcoholic patients is important to in Assessing Psychiatric associated with alcoholism can coexist reduce illness severity in these individuals. Complaints in Alcoholic with, contribute to, or result from several This article presents an overview of Patients different psychiatric syndromes. As a the common diagnostic difficulties associ­ result, alcoholism can complicate or ated with the comorbidity of alcoholism mimic practically any psychiatric syn­ and other psychiatric disorders. It then A Case Example drome seen in the mental health setting, briefly reviews the relationship between A 50-year-old man presents to the emergency at times making it difficult to accurately alcoholism and several psychiatric dis­ room complaining: “I’m going to end it diagnose the nature of the psychiatric orders that commonly co-occur with all . . . life’s just not worth living.” The complaints (Anthenelli 1997; Modesto- alcoholism and which clinicians should clinician elicits an approximate 1-week Lowe and Kranzler 1999). When alco­ consider in their differential diagnosis. history of depressed mood, feelings of holism and psychiatric disorders co-occur, The article also provides some general guilt, and occasional suicidal ideas that patients are more likely to have diffi­ guidelines to help clinicians meet the

90 Alcohol Research & Health Diagnosis of Alcoholism and Psychiatric Disorders

have grown in intensity since the man’s As is usually the case (Anthenelli how long it was used, and how recently wife left him the previous day. The client 1997; Helzer and Przybeck 1988), the it was used, as well as on the patient’s denies difficulty sleeping, poor concentra­ patient in this example does not individual vulnerability to experiencing tion, or any changes in his appetite or volunteer his alcohol abuse history but psychiatric symptoms in the setting of weight prior to his wife’s departure. He comes to the hospital for help with his excessive alcohol consumption (Anthe­ appears unshaven and slightly unkempt, psychological distress. The acute stres­ nelli and Schuckit 1993; Anthenelli but states that he was able to go to work sor leading to the distress is his wife’s 1997). For example, during acute and function on the job until his wife leaving him; only further probing intoxication, smaller amounts of alco­ left. The scent of alcohol is present on the during the interview uncovers that the hol may produce euphoria, whereas man’s breath. When queried about this, reason for the wife’s action is the man’s larger amounts may be associated with he admits to having “a few drinks to ease excessive drinking and the effects it has more dramatic changes in mood, such the pain” earlier that morning, but does had on their relationship and family. as sadness, irritability, and nervousness. not expand on this theme. He seeks help Thus, a clinician who lacks adequate Alcohol’s disinhibiting properties may for his low mood and demoralization, training in this area or who carries too also impair judgment and unleash acknowledging later in the interview low a level of suspicion of alcohol’s aggressive, antisocial behaviors that that “I really don’t want to kill myself; influence on psychiatric complaints may mimic certain externalizing I just want my life back to the way it may not consider alcohol misuse as a disorders, such as antisocial personality used to be.” contributing or causative factor for the disorder (ASPD) (Moeller et al. 1998). patient’s psychological problems. (Externalizing disorders are discussed The above case is a composite of In general, it is helpful to consider in the section “ASPD and Other many clinical examples observed across psychiatric complaints observed in the Externalizing Disorders.”) Psychiatric mental health settings each day, illustrat­ context of heavy drinking as falling symptoms and signs also may vary ing the challenges clinicians face when into one of three categories—alcohol­ depending on when the patient last evaluating psychiatric complaints in related symptoms and signs, alcohol- used alcohol (i.e., whether he or she is alcoholic patients. The questions facing induced psychiatric syndromes, and experiencing acute intoxication, acute the clinician in this example include: independent psychiatric disorders that withdrawal, or protracted withdrawal) co-occur with alcoholism. These three and when the assessment of the • Is the patient clinically depressed in categories are discussed in the following psychiatric complaints occurs. For the sense that he has a major depres­ sections. instance, an alcohol-dependent patient sive episode requiring aggressive who appears morbidly depressed when pharmacological and psychosocial acutely intoxicated may appear anxious treatment? Alcohol-Related Psychiatric and panicky when acutely withdrawing Symptoms and Signs from the drug (Anthenelli and Schuckit • What role, if any, is alcohol playing Heavy alcohol use directly affects brain 1993; Anthenelli 1997). in the patient’s complaints? function and alters various brain In addition to the direct pharmaco­ chemical (i.e., neurotransmitter) and logical effects of alcohol on brain • How does one tease out whether hormonal systems known to be function, psychosocial stressors that drinking is the cause of the man’s involved in the development of many commonly occur in heavy-drinking mood problems or the result of them? common mental disorders (e.g., mood alcoholic patients (e.g., legal, financial, and anxiety disorders) (Koob 2000). or interpersonal problems) may indirectly • If the man’s condition is not a major Thus, it is not surprising that contribute to ongoing alcohol-related depression, what is it, what is its likely alcoholism can manifest itself in a symptoms, such as sadness, despair, course, and how can it be treated? broad range of psychiatric symptoms and anxiety (Anthenelli 1997; Anthe­ and signs. (The term “symptoms” nelli and Schuckit 1993). refers to the subjective complaints a RAMESH SHIVANI, M.D., is an addiction patient describes, such as sadness or Alcohol-Induced Psychiatric psychiatry fellow; R. JEFFREY GOLDSMITH, difficulty concentrating, whereas the M.D., is a clinical professor of psychiatry term “signs” refers to objective phe­ Syndromes at and director of the Addiction nomena the clinician directly observes, It is clinically useful to distinguish Fellowships Program; and ROBERT M. such as fidgeting or crying.) In fact, between assorted commonly occurring, ANTHENELLI, M.D., is an associate such psychiatric complaints often are alcohol-induced psychiatric symptoms professor of psychiatry and director of the the first problems for which an alco­ and signs on the one hand and frank Addiction Psychiatry Division and of the holic patient seeks help (Anthenelli and alcohol-induced psychiatric syndromes Substance Dependence Program; all three Schuckit 1993; Helzer and Przybeck on the other hand. A syndrome at the University of Cincinnati College 1988). The patient’s symptoms and generally is defined as a constellation of of Medicine, Cincinnati Veterans’ Affairs signs may vary in severity depending symptoms and signs that coalesce in a Medical Center, Cincinnati, Ohio. upon the amounts of alcohol used, predictable pattern in an individual

Vol. 26, No. 2, 2002 91 over a discrete period of time. Such Alcohol-induced psychiatric disor­ Psychiatric Disorders syndromes largely correspond to the ders may initially be indistinguishable Commonly Associated sets of diagnostic criteria used for from the independent psychiatric with Alcoholism classifying mental disorders throughout disorders they mimic. However, what the Diagnostic and Statistical Manual of differentiates these two groups of disor­ Mental Disor ders, Fourth Edition ders is that alcohol-induced disorders Independent Major Depression (DSM–IV) (American Psychiatric typically improve on their own within Association [APA] 1994) and its several weeks of abstinence without Mood disturbances (which frequently successor, the DSM–IV Text Revision requiring therapies beyond supportive are not severe enough to qualify as (DSM–IV–TR) (APA 2000). care (Anthenelli and Schuckit 1993; “disorders”) are arguably the most Publication of the DSM–IV marked Anthenelli 1997; Brown et al. 1991, common psychiatric complaint among the first time that clinicians could 1995). Thus, the course and prognosis treatment-seeking alcoholic patients, specifically diagnose several “alcohol- of alcohol-induced psychiatric disorders affecting upwards of 80 percent of induced disorders” rather than having are different from those of the indepen­ alcoholics at some point in their drink­ to lump alcohol-related conditions dent major psychiatric disorders, which ing careers (Brown and Schuckit 1988; under the more generic rubric of an are discussed in the next section. Anthenelli and Schuckit 1993). In “organic mental syndrome” (Anthenelli keeping with the three broad categories 1997). Given the broad range of effects described above into which such com­ heavy drinking may have on psycho- Alcoholism with Comorbid, plaints may fall, mood problems may logical function, these alcohol-induced Independent Psychiatric Disorders be characterized as one of the following: disorders span several categories of Alcoholism is also associated with sev­ mental disorders, including mood, eral psychiatric disorders that develop • An expected, time-limited conse­ anxiety, psychotic, sleep, sexual, delirious, independently of the alcoholism and quence of alcohol’s depressant amnestic, and dementia disorders. may precede alcohol use and abuse. effects on the brain According to the DSM–IV, the essen­ These independent disorders may tial feature of all these alcohol-induced make certain vulnerable patients more • A more organized constellation of disorders is the presence of prominent prone to developing alcohol-related symptoms and signs (i.e., a syndrome) and persistent symptoms, which are problems (Helzer and Przybeck 1988; reflecting an alcohol-induced mood judged—based on their onset and Kessler et al. 1997; Schuckit et al. disorder with depressive features course as well as on the patient’s 1997b). One of the most common of history, physical exam, and laboratory these comorbid conditions is ASPD, an • An independent major depressive findings—to be the result of the direct axis II personality disorder1 marked by disorder coexisting with or even pre- physiological effects of alcohol. To be a longstanding pattern of irresponsibil­ dating alcoholism. classified as alcohol-induced disorders, ity and violating the rights of others these conditions also must occur that generally predates the problems When one applies these more precise within 4 weeks of the last use of or with alcohol. Axis I disorders commonly definitional criteria and classifies only withdrawal from alcohol and should be associated with alcoholism include those patients as depressive who meet of clinical significance beyond what is bipolar disorder, certain anxiety disor­ the criteria for a syndrome of a major expected from typical alcohol with­ ders (e.g., social phobia, panic disorder, depressive episode, approximately 30 drawal or intoxication (APA 1994). and post-traumatic stress disorder to 40 percent of alcoholics experience a The diagnostic criteria of the [PTSD]), schizophrenia, and major comorbid depressive disorder (Anthenelli DSM–IV and DSM–IV–TR do not depression (Helzer and Przybeck 1988; and Schuckit 1993; Schuckit et al. 1997a). clearly distinguish between alcohol- Kessler et al. 1997). (Several of these Some controversy exists as to the related psychiatric symptoms and signs common comorbid disorders are precise cause-and-effect relationship and alcohol-induced psychiatric syn­ reviewed in detail in other articles of between depression and alcoholism, with dromes. Instead, these criteria sets state this journal issue.) It is important for some authors pointing out that depres­ more broadly that any alcohol-related clinicians to know which disorders are sive episodes frequently predate the onset psychiatric complaint that fits the most likely to coexist with alcoholism of alcoholism, especially in women definition given in the paragraph above so that they may specifically probe for (Kessler et al. 1997; Helzer and Przybeck and which “warrants independent clin­ these conditions when evaluating the 1988; Hesselbrock et al. 1985). Several ical attention” be labeled an alcohol- patient’s complaints. studies found that approximately 60 induced disorder (APA 1994, 2000). percent of alcoholics who experience In other words, alcohol-related psychi­ a major depressive episode, especially 1The DSM–IV classifies mental disorders along several levels, atric symptoms and signs can be or axes. In this classification, axis II disorders include per­ men, meet the criteria for an alcohol- labeled an alcohol-induced psychiatric sonality disorders, such as ASPD or obsessive-compulsive induced mood disorder with depressive disorder, as well as mental retardation; axis I disorders disorder in DSM–IV or DSM–IV–TR include all other mental disorders, such as anxiety, eating, features (Schuckit et al. 1997a; Davidson without qualifying as syndromes. mood, psychotic, sleep, and drug-related disorders. 1995). The remaining approximately

92 Alcohol Research & Health Diagnosis of Alcoholism and Psychiatric Disorders

40 percent of alcoholic women and men careful history of the chronological order compared with nonalcoholics, alcohol- who suffer a depressive episode likely of both illnesses because approximately dependent men are 4–8 times more have an independent major depressive 60 percent of patients with both alco­ likely, and alcoholic women are 12–17 disorder—that is, they experienced a holism and bipolar disorder started times more likely, to have comorbid major depressive episode before the using AODs before the onset of affec­ ASPD (Helzer and Przybeck 1988; onset of alcoholism or continue to exhibit tive episodes (Strakowski et al. 2000). Kessler et al. 1997). Thus, approxi­ depressive symptoms and signs even mately 15 to 20 percent of alcoholic during lengthy periods of abstinence. men and 10 percent of alcoholic women In a study of 2,954 alcoholics, Schuckit Anxiety Disorders have comorbid ASPD, compared with and colleagues (1997a) found that Overall, anxiety disorders do not seem 4 percent of men and approximately patients with alcohol-induced depression to occur at much higher rates among 0.8 percent of women in the general appear to have different characteristics alcoholics than among the general pop­ population. Patients with ASPD are from patients with independent depres­ ulation (Schuckit and Hesselbrock likely to develop alcohol dependence at sive disorders. For example, compared 1994). For example, results from the an earlier age than their nonantisocial with patients with alcohol-induced Epidemiologic Catchment Area survey counterparts and are also more prone to depression, patients with independent indicated that among patients who met having other drug use disorders (Cadoret depression were more likely to be the lifetime diagnosis of alcohol abuse et al. 1984; Anthenelli et al. 1994). Caucasian, married, and female; less or dependence, 19.4 percent also car­ In addition to ASPD, other condi­ experienced with other illicit drugs; less ried a lifetime diagnosis of any anxiety tions marked by an externalization of often treated for alcoholism; more likely disorder. This corresponds to only about impulsive aggressive behaviors, such as to have a history of a prior suicide 1.5 times the rate for anxiety disorders attention deficit hyperactivity disorder attempt; and more likely to have a fam­ in the general population (Regier et al. (ADHD) (Sullivan and Rudnik-Levin ily history of a major mood disorder. 1990; Kranzler 1996). Specific anxiety 2001), are also associated with increased disorders, such as panic disorder, social risk of alcohol-related problems. (For phobia, and PTSD, however, appear to more information on the relationship Bipolar Disorder have an increased co-occurrence with between alcoholism and ADHD, see According to two major epidemiologi­ alcoholism (Schuckit et al. 1997b; the article by Smith and colleagues, pp. cal surveys conducted in the past 20 Kranzler 1996; Brady et al. 1995). 122–129.) years (Helzer and Przybeck 1988; As with alcohol-induced depression, Kessler et al. 1997), bipolar disorder it is important to differentiate alcohol- (i.e., mania or manic-depressive illness) induced anxiety from an independent A Basic Approach to is the second-most common axis I anxiety disorder. This can be achieved Diagnosing Patients disorder associated with alcohol depen- by examining the onset and course of with Alcoholism and dence.2 Among manic patients, 50–60 the anxiety disorder. Thus, symptoms Coexisting Psychiatric percent abuse or become dependent on and signs of alcohol-induced anxiety Complaints alcohol or other drugs (AODs) at some disorders typically last for days to several point in their illness (Brady and Sonne weeks, tend to occur secondary to alco­ Clinicians working in acute mental 1995). Diagnosing bipolar disorder in hol withdrawal, and typically resolve health settings often encounter patients alcoholic patients can be particularly relatively quickly with abstinence and who present with psychiatric complaints challenging. Several factors, such as the supportive treatments (Kranzler 1996; and heavy alcohol use. The following underreporting of symptoms (particu­ Brown et al. 1991). In contrast, inde­ sections discuss one approach to diag­ larly symptoms of mania), the complex pendent anxiety disorders are character­ nosing these challenging patients (also effects of alcohol on mood states, and ized by symptoms that predate the see the figure). common features shared by both illnesses onset of heavy drinking and which (e.g., excessive involvement in pleasur­ persist during extended sobriety. able activities with high potential for Inquiring About Alcohol Use When painful consequences) reduce diagnostic Evaluating Psychiatric Complaints accuracy. Bipolar patients are also likely ASPD and Other Externalizing As illustrated by the case example to abuse drugs other than alcohol (e.g., Disorders described earlier, patients seldom vol­ stimulant drugs such as cocaine or Among the axis II personality disor­ unteer information about their alcohol methamphetamine), further complicat­ ders, ASPD (and the related conduct use patterns and problems when they ing the diagnosis. As will be described disorder, which often occurs during present their psychiatric complaints in greater detail later, it can be helpful childhood in people who subsequently (Helzer and Przybeck 1988; Anthenelli for an accurate diagnosis to obtain a will develop ASPD) has long been rec­ and Schuckit 1993; Anthenelli 1997). ognized to be closely associated with Unless they are asked directly about

2The axis I disorders most commonly associated with alcoholism (Lewis et al. 1983). their alcohol use, the patients’ denial alcoholism are other drug use disorders. Epidemiologic analyses found that and minimization of their alcohol-

Vol. 26, No. 2, 2002 93 related problems lead them to withhold complaints or of laboratory results that (GGT); and changes in the mean vol­ this important information, which might further implicate alcohol in the ume of the red blood cells (i.e., mean makes assessment and diagnosis diffi­ patient’s psychiatric problems (Allen et corpuscular volume), which also is an cult. In addition, heavy alcohol use can al. 2000). Pertinent laboratory results indicator of heavy drinking. impair memory, which may make the could include positive breath or blood Laboratory tests, such as breathalyzer patient’s information during history- alcohol tests; an elevation in biochemical analyses or determination of blood taking less reliable. Therefore, clinicians markers of heavy drinking, such as the alcohol concentrations, should also be should gather information from several liver enzyme gamma-glutamyltransferase performed to search for evidence of resources when assessing patients with possible alcohol-related problems, includ­ ing collateral informants, the patient’s medical history, laboratory tests, and a Patient’s complaint: thorough physical examination. “Help! I am sad; anxious; in trouble.” After obtaining a patient’s permission, his or her history should be obtained Consider a possible role of alcohol from both the patient and a collateral informant (e.g., a spouse, relative, or 1. Probe for alcohol problems close friend). The information these 2. Talk with relatives/friends 3. Review medical records YES collateral informant interviews yield 4. Look for evidence on can serve several purposes. First, by physical examination establishing how patterns of alcohol 5. Review laboratory tests use relate to psychiatric symptoms and their time course, a clinician obtains additional information that can be used Psychiatric symptoms or syndrome? in the longitudinal evaluation of the patient’s psychiatric and alcohol problems, as described later. Second, by defining Symptoms only Syndrome the role alcohol use plays in a patient’s psychiatric complaints, the clinician is starting to confront the patient’s denial, Abstinence, support, Distinguish between which is the patient’s defense mecha­ alcoholism treatment, alcohol-induced watch and wait syndromes and nism for avoiding conscious analysis of independent the association between drinking and comorbid disorders other symptoms. Third, by knowing that the clinician will be talking to a family member, the patient may be more likely to offer more accurate information. Alcohol-induced syndrome Independent Fourth, if the patient observes that the comorbid disorder clinician is interested enough in the (dual diagnosis) case to contact family members, this may help establish a more trustful ther­ apeutic relationship. Fifth, by involving Abstinence, support, aftercare, Treat both disorders family members early in the course of relapse prevention simultaneously treatment, the clinician begins to lay the groundwork toward establishing a sup- porting network that will become an important part of the patient’s recovery Remain flexible with working diagnosis and follow up program. Finally, the collateral informant can provide supplemental information about the family history of alcoholism Schematic representation of a diagnostic algorithm for evaluating psychiatric com­ and other psychiatric disorders that can plaints in patients for whom alcoholism may be a contributing factor. The algorithm improve diagnostic accuracy (Anthenelli helps the clinician decide if the compliants represent alcohol-induced symptoms, or 1997; Anthenelli and Schuckit 1993). an alcohol-induced syndrome that will resolve with abstinence, or an independent A review of the patient’s medical psychiatric disorder that requires treatment. records is another potentially rich source of information. This review should look SOURCE: Anthenelli 1997. for evidence of previous psychiatric

94 Alcohol Research & Health Diagnosis of Alcoholism and Psychiatric Disorders

recent alcohol use that might aid in intoxication, acute withdrawal, protracted One approach to distinguishing the assessment. These results also can withdrawal, or stable abstinence for at independent versus alcohol-induced provide indirect evidence of tolerance least 3 months) these complaints are diagnoses is to start by analyzing the to alcohol (one of the diagnostic criteria occurring. chronology of development of symptom of alcohol dependence) if the clinician Because heavy alcohol use can cause clusters (Schuckit and Monteiro 1988). documents relatively normal cognitive, psychological disturbances, patients Using this technique as well as the behavioral, and psychomotor perfor­ who present with co-occurring psychi­ DSM–IV guidelines, one can identify mance in the presence of blood alcohol atric and alcohol problems often do not alcohol-induced disorders as those con­ concentrations that would render most suffer from two independent disorders ditions in which several symptoms and people markedly impaired. Subsequent (i.e., do not require two independent signs occur simultaneously (i.e., cluster) laboratory testing may also need to diagnoses). Therefore, the clinician’s job and cause significant distress in the set­ include other diagnostic procedures, such is to combine the data obtained from ting of heavy alcohol use or withdrawal as brain imaging studies, to rule out the multiple resources cited in the pre­ (APA 1994). For example, a patient indirect alcohol-related medical causes vious section and to establish a working who exhibits psychiatric symptoms and of the psychiatric complaints. For example, diagnosis. It may be helpful to begin signs only during recurrent alcohol use alcoholics suffering from head trauma this process by differentiating between and after he or she has met the criteria might have hematomas (i.e., “blood alcohol-related symptoms and signs and for alcohol abuse or dependence is likely blisters”) in the brain or other traumatic alcohol-induced syndromes. Thus, the to have an alcohol-induced psychiatric brain injuries that could cause psychiatric preferred definition of the term “diag­ condition. In contrast, a patient who symptoms and signs (Anthenelli 1997). nosis” here refers to a constellation of exhibits symptoms and signs of a psychi­ Finally, all patients should undergo symptoms and signs, or a syndrome, with atric condition (e.g., bipolar disorder) a complete physical examination. During a generally predictable course and dura­ in the absence of problematic AOD use this examination, the clinician should tion of illness as outlined by DSM–IV. most likely has an independent disor­ pay attention to physical manifestations Although heavy, prolonged alcohol der that requires appropriate treatment. of heavy alcohol use, such as an enlarged, use can produce psychiatric symptoms Establishing a timeline of the patient’s tender liver. The combination of positive or, in some patients, more severe and comorbid conditions (Anthenelli and results on laboratory tests and physical protracted alcohol-induced psychiatric Schuckit 1993; Anthenelli 1997), examination points strongly to a diag­ syndromes, these alcohol-related condi­ using collateral information from out- nosis of alcohol abuse or dependence. tions are likely to improve markedly with side informants and the data obtained This information can be used later on, abstinence. This characteristic distin­ from the review of the medical records, when the physician presents his or her guishes them from the major indepen­ may be helpful in determining the diagnosis to the patient and begins to dent psychiatric disorders they mimic. chronological course of the disorders. confront the denial associated with the In this context the clinician should addiction (Anthenelli 1997). focus on the age at which the patient Distinguishing Between first met the criteria for alcohol abuse Alcohol-Induced Syndromes and or dependence rather than on the age Differentiating Alcohol-Related Independent Comorbid Disorders when the patient first imbibed or became Symptoms from Syndromic Even after determining that a patient’s intoxicated. This strategy provides more Mental Disorders constellation of symptoms and signs has specific information about the onset of If the clinician suspects a diagnosis of reached syndromic levels and warrants problematic drinking that typically alcoholism is appropriate, the next step a diagnosis of a mood, anxiety, or psy­ presages the onset of alcoholism (Schuckit is to evaluate the psychiatric complaints chotic disorder, the possibility remains et al. 1995). If the clinician cannot in this context. As mentioned earlier, that the patient has an independent determine exactly the time point when alcohol produces its mind-altering and comorbid disorder that may require the patient met the criteria for abuse reinforcing effects by causing changes treatment rather than an alcohol-induced or dependence, this information can in the same neurotransmitter and syndrome that resolves with abstinence. be approximated by determining when receptor3 systems that are associated Although some people experience more the patient developed alcohol-related with most major psychiatric disease persistent alcohol-induced conditions problems that interfered with his or her states. Partly as a result of these direct (and some controversy remains over life in a major way and affected the brain effects, heavy alcohol use causes how to treat those patients), only ability to function. Probing for such psychiatric symptoms and signs that clients with independent comorbid problems typically includes four areas— can mimic most major psychiatric dis­ disorders should be labeled as having legal, occupational, and medical problems orders. These changes occur both in a dual diagnosis. as well as social relationships. The age- the absence and presence of alcohol, at-onset of alcoholism then is estimated and during the initial assessment the 3Receptors are protein molecules located on the surface by establishing the first time that alco­ clinician should determine when in the of a cell that interact with extracellular signaling molecules, hol actually interfered in two or more such as neurotransmitters and hormones, and convey that patient’s drinking cycle (i.e., during signal to the cell’s interior to induce the appropriate response. of these major domains or the first time

Vol. 26, No. 2, 2002 95 an individual received treatment for other patient characteristics, such as Remaining Flexible with alcoholism. Further questioning should gender or family history of psychiatric Diagnosis and Follow Up address whether the patient ever devel­ illnesses. For example, it is well established Once a working diagnosis has been oped tolerance to the effects of alcohol that women are more likely than men or suffered from signs and symptoms to suffer from independent depressive established, it is important for the clini­ of withdrawal when he or she stopped or anxiety disorders (Kessler et al. cian to remain flexible with his or her using the drug, both of which are diag­ 1997). assessment and to continue to monitor nostic criteria for alcohol dependence. Not surprisingly, alcoholic women are the patient over time. Like most initial After establishing the chronology of also more prone than alcoholic men to psychiatric assessments, the basic the alcohol problems, the patient’s psy­ having independent mood or anxiety approach described here is hardly fool- chiatric symptoms and signs are reviewed disorders (Kessler et al. 1997). Alcoholic proof. Therefore, it is important to mon­ across the lifespan. The patient’s recol­ women and men also seem to differ in itor a patient’s course and, if necessary, lection of when these problems appeared the temporal order of the onset of these revise the diagnosis, even if improvement can be improved by framing the inter- occurs with abstinence and supportive view around important landmarks in treatment alone during the first weeks time (e.g., the year the patient graduated, of sobriety. The importance of contin­ her or his military discharge date, and ued followup for several weeks also is so forth) and by the collateral informa­ A family history of supported by empirical data showing tion obtained. This method not only a major psychiatric that most major symptoms and signs ensures the most accurate chronological are resolved within the first 4 weeks of reconstruction of a patient’s problems, disorder other than abstinence. Therefore, unless there is but also, on a therapeutic basis, helps ample evidence to suspect the patient the patient recognize the relationship alcoholism in an has an independent psychiatric disorder, between his or her AOD abuse and individual may a 2- to 4-week observation period is psychological problems. Thus, this usually advised before considering the approach begins to confront some of increase the likelihood use of most psychotropic medications. the mechanisms that help the patient of that patient having deny these associations (Anthenelli and The Case Example Revisited Schuckit 1993; Anthenelli 1997). a dual diagnosis. While establishing this chronological Recognizing that this was an emergency history, it is important for the clinician situation and that alcoholics have an to probe for any periods of stable absti­ increased rate of suicide (Hirschfeld and nence that a patient may have had, conditions, with most mood and anxiety Russell 1997), the emergency room clinician noting how this period of sobriety disorders predating the onset of alco­ admitted the patient to the acute psychiatric affected the patient’s psychiatric prob­ holism in women (Kessler et al. 1997). ward for an evaluation. The clinician lems. Using a somewhat conservative Given these observations, it is especially also obtained the patient’s permission to approach, such a probe should focus important in female patients to perform speak with his wife. Despite the patient’s on periods of abstinence lasting at least a thorough psychiatric review that probes denial of alcoholism, this interview with 3 months because some mood, psy­ for major mood disorders (i.e., major a collateral informant corroborated the chovegetative (e.g., altered energy levels depression and bipolar disorder) and clinician’s suspicion that the man had and sleep disturbance), perceptual, and anxiety disorders (e.g., social phobia). long-standing problems with alcohol that behavioral symptoms and signs related Knowledge of the psychiatric illnesses dated back to his mid-20s. Laboratory to AOD use can persist for some time. that run in the patient’s family also tests showing an elevated GGT level sup- By using this timeline approach, the may enhance diagnostic accuracy. For ported the diagnosis. Moreover, a review clinician generally can arrive at a work­ example, men and women with alcohol of the patient’s medical records showed a ing diagnosis that helps to predict the dependence and independent major previous hospitalization for suicidal most likely course of the patient’s con­ depressive episodes have been found to ideation and depression 2 years earlier, dition and can begin putting together have an increased likelihood of having after the patient’s mother had died. a treatment plan. a family history of major mood disor­ The clinician then formulated a work­ ders (Schuckit et al. 1997a). Similar ing diagnosis of probable alcohol-induced findings have been obtained for alcohol- mood disorder with depressive features, Considering Other Patient dependent bipolar patients (Preisig et based on three pieces of information. First, Characteristics al. 2001). Thus, a family history of a the patient had stated that his depression When evaluating the likelihood of a major psychiatric disorder other than started about 1 week before admission, patient having an independent psychiatric alcoholism in an individual may after his wife and family members con- disorder versus an alcohol-induced condi­ increase the likelihood of that patient fronted him about his drinking. This tion, it also may be helpful to consider having a dual diagnosis. confrontation triggered a more intense

96 Alcohol Research & Health Diagnosis of Alcoholism and Psychiatric Disorders

drinking binge that ended only hours signs cluster, last for weeks, and mimic ANTHENELLI, R.M.; SMITH, T.L.; IRWIN, M.R.; AND SCHUCKIT, M.A. A comparative study of crite­ before his arrival in the emergency room. frank psychiatric disorders (i.e., are ria for subgrouping alcoholics: The primary/secondary The patient complained of irritable mood alcohol-induced syndromes). These diagnostic scheme versus variations of the type and increased feelings of guilt during the alcohol-related conditions usually dis­ 1/type 2 criteria. American Journal of Psychiatry past week, and he admitted he had been appear after several days or weeks of 151(10):1468–1474, 1994. drinking heavily during that period. abstinence. Prematurely labeling these BRADY, K.T., AND SONNE, S.C. The relationship However, he denied other symptoms and conditions as major depression, panic between substance abuse and bipolar disorder. signs of a major depressive episode during disorder, schizophrenia, or ASPD can Journal of Clinical Psychiatry 56:19–24, 1995. that period. lead to misdiagnosis and inattention BRADY, K.T.; SONNE, S.C.; AND ROBERTS, J.M. Second, the medical records indicated to a patient’s principal problem—the Sertraline treatment of co-morbid post-traumatic that the patient’s previous bout of depres- stress disorder and alcohol dependence. Journal of alcohol abuse or dependence. With Clinical Psychiatry 56:502–505, 1995. sion and suicidal ideation had improved knowledge of the different courses and with abstinence and supportive and prognoses of alcohol-induced psychiatric BROWN, S.A., AND SCHUCKIT, M.A. Changes in group psychotherapy during his prior depression among abstinent alcoholics. Journal of disorders, an understanding of the comor­ hospitalization. At that time, the patient Studies on Alcohol 49(5):412–417, 1988. had been transferred to the hospital’s bid independent disorders one needs to rule out, an organized approach to BROWN, S.A.; IRWIN, M.; AND SCHUCKIT, M.A. alcoholism treatment unit after 2 weeks, Changes in anxiety among abstinent male alco­ where he had learned some of the princi- diagnosis, ample collateral information, holics. Journal of Studies on Alcohol 52:55–61, 1991. and practice, however, the clinician can ples that had led to his longest abstinence BROWN, S.A.; INABA, R.K.; GILLIN, J.C.; ET AL. of 18 months. improve diagnostic accuracy in this Alcoholism and affective disorder: Clinical course Third, both the patient and his wife challenging patient population. of depressive symptoms. American Journal of said that during this period of prolonged Psychiatry 152:45–52, 1995. abstinence the patient showed gradual CADORET, R.J.; TROUGHTON, E.; AND WIDMER, R. continued improvement in his mood. He Note Clinical differences between antisocial and primary had worked an active 12-step program of alcoholics. Comprehensive Psychiatry 25:1–8, 1984. sobriety and had returned to his job as an Parts of this paper were previously pre- DAVIDSON, K.M. Diagnosis of depression in alco­ office manager. sented in: Anthenelli, R.M. A basic hol dependence: Changes in prevalence with drink­ During the first week of the current clinical approach to diagnosis in patients ing status. British Journal of Psychiatry 166:199– hospitalization, the patient’s suicidal with comorbid psychiatric and substance 204, 1995. ideation disappeared entirely and his use disorders. In: Miller, N.S., ed. HELZER, J.E., AND PRZYBECK, T.R. The co-occurrence mood gradually improved. He was trans- Principles and Practice of Addictions in of alcoholism with other psychiatric disorders in the ferred to the open unit and participated general population and its impact on treatment. Psychiatry. Philadelphia: W.B. 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Lifetime co-occurence of DSM–III–R alcohol sured by the clinician’s explanation that Alcoholism: Clinical and Experimental Research 24: abuse and dependence with other psychiatric disor­ the sleep disturbance was likely a remnant 492–496, 2000. ders in the National Comorbidity Survey. Archives of his heavy drinking that should continue American Psychiatric Association (APA). Diagnostic of General Psychiatry 54:313–321, 1997. to improve with prolonged abstinence. and Statistical Manual of Mental Disorders, Fourth KOOB, G.F. Neurobiology of addiction. Toward Nevertheless, the clinician scheduled Edition. Washington, DC: APA, 1994. followup appointments with the patient the development of new therapies. Annals of the American Psychiatric Association, (APA). Diagnostic New York Academy of Sciences 909:170–185, 2000. to continue monitoring his mood and and Statistical Manual of Mental Disorders, Fourth sleep patterns. KRANZLER, H.R. Evaluation and treatment of anxi­ Edition, Text Revision. 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Vol. 26, No. 2, 2002 97 MOELLER, F.G.; DOUGHERTY, D.M.; LANE, S.D.; SCHUCKIT, M.A., AND HESSELBROCK, V. Alcohol SCHUCKIT, M.A.; TIPP, J.E.; BUCHOLZ, K.K.; ET ET AL. Antisocial personality disorder and alcohol- dependence and anxiety disorders: What is the rela­ AL. The life-time rates of three major mood disor­ tionship? American Journal of Psychiatry 151:1723– induced aggression. Alcoholism: Clinical and ders and four major anxiety disorders in alcoholics 1734, 1994. Experimental Research 22:1898–1902, 1998. and controls. Addiction 92:1289–1304, 1997b. SCHUCKIT, M.A., AND MONTEIRO, M.G. Alcoholism, PREISIG, M.; FENTON, B.T.; STEVENS, D.E.; AND anxiety and depression. British Journal of Addiction STRAKOWSKI, S.M.; DELBELLO, M.P.; FLECK, D.E.; MERIKANGAS, K.R. Familial relationship between 83:1373–1380, 1988. AND ARNDT, S. The impact of substance abuse on mood disorders and alcoholism. Comprehensive SCHUCKIT, M.A.; ANTHENELLI, R.M.; BUCHOLZ, the course of bipolar disorder. Biological Psychiatry Psychiatry 42:87–95, 2001. K.K.; ET AL. The time course of development of 48:477–485, 2000. alcohol-related problems in men and women. REGIER, D.A.; FARMER, M.E.; RAE, D.S.; ET AL. Journal of Studies on Alcohol 56:218–225, 1995. SULLIVAN, M.A., AND RUDNIK-LEVIN, F. Attention Comorbidity of mental disorders with alcohol and deficit/hyperactivity disorder and substance abuse. SCHUCKIT, M.A.; TIPP, J.E.; BERGMAN, M.; ET AL. other drug abuse: Results from the Epidemiologic Diagnostic and therapeutic considerations. Annals Comparison of induced and independent major Catchment Area (ECA) study. JAMA : Journal of the depressive disorders in 2,945 alcoholics. American of the New York Academy of Sciences 931:251–270, American Medical Association 264:2511–2518, 1990. Journal of Psychiatry 154:948–957, 1997a. 2001.

Now Available!

Alcohol Consumption and Problems in the General Population: Findings From the 1992 National Longitudinal Alcohol Epidemiologic Survey

This compiliation of findings brings together in a single volume more than 40 articles based on the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES). This nationally representative household survey was designed and spon­ sored by the National Institute on Alcohol Abuse and Alcoholism; fieldwork was conducted by the U.S. Bureau of the Census. Interviews were held with 42,862 adults (18 years of age and older) living in the contiguous United States and the District of Columbia. Findings based on the NLAES interviews have been published in a wide range of peer-reviewed journals over the last eight years. These articles are presented in their entirety in this com­ pilation, grouped into 11 key topics:

Alcohol Consumption Patterns Drug Dependence and Abuse Alcohol Dependence and Abuse Other Alcohol-Related Medical Consequences of Problems Alcohol Consumption Treatment and Alcohol Family History of Alcohol Dependence Problems Guidelines for Public Health Alcohol and Depression Measurement and Methods Alcohol and Smoking

Supplies are limited. To order your free copy, contact the National Institute on Alcohol Abuse and Alcoholism Publications Distribution Center, P.O. Box 10686, Rockville, MD 20849–0686. You may fax your order to 703/312–5230 or order through NIAAA’s World Wide Web site (www.niaaa.nih.gov).

98 Alcohol Research & Health