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