barcelona . spain - European Association for the Study of the Liver

BARCELONA . SPAIN
78 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 79
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012
A NEW CONCEPTUAL UMBRELLA: ALCOHOL USE DISORDERS
Even though it will not be launched until May 2013, the new DSM V is at an advanced status and just slight
changes may be expected from now until its release (O’Brien, 2011). The working draft that is available
proposes relevant changes concerning addiction to substances. Abuse and Dependence will now be
combined in a single entity of graded severity: the Alcohol Use Disorder (AUD). This integrated entity is
defined with 11 criteria, which in fact merge the criteria previously used to define dependence and abuse.,
and it is expected that the future ICD-11 will also converge to this definition (see Figure 3).
Figure 3
THE ART OF ASSESSING ALCOHOL DEPENDENT PATIENTS: WHAT TO ASSESS AND HOW TO DO IT
Drinking patterns should be assessed carefully in alcohol dependent patients both quantitatively and
qualitatively. Amounts drunk per week and amounts drunk per drinking occasion should be registered using
standard drink units (SDU). SDU vary from country to country. In most EU countries they range between
8-10 grams, while in north America their range is 13-14 grams of pure alcohol per SDU. In alcohol dependent
patients, the use of other drugs, including tobacco and benzodiazepines, should also be routinely assessed.
In very defensive patients direct inquiries on their alcohol consumption may lead to relevant underestimates
of their drinking. In those cases a ‘normal day assessment strategy’ is recommended, which consists of
asking for a detailed descriptions of the activities performed during a normal day, where questions on drinking
are imbedded. There are various validated tools that may be used for screening. The AUDIT (Alcohol Use
Disorders Identification Test; Babor et al, 2001) is the actual golden standard. It has been validated to many
languages and has different cut-off values for hazardous drinking and alcohol dependence.
The biomedical assessment of alcohol dependent patients is very important not only because medicalisation
increases adherence to treatment, but because those patients usually present with a diversity of medical
problems. Alcohol is related to no less than 60 illnesses. a focussed anamnesis is required, and special
attention must be devoted to casualties, since they are very frequent. A blood test including liver enzymes
is also required.
Most of the harm produced by alcohol is in the mental health area. Assessment of mental health status must
include the identification of alcohol-related psychological distress (ie: guilt feelings, insomnia, irritability,
anxiety, disruptive behaviour, etc) as well as the assessment of psychiatry co morbidity usually found in
alcoholics: depression, anxiety disorders, personality disorders, etc. Special attention must be placed on
suicidal thoughts and suicidal attempts, since there is strong evidence of the links between alcohol and
suicide.
A second major change is that the number of criteria needed to qualify for a ‘moderate’ AUD is 2-3, while
a ‘severe’ AUD will be diagnosed to patients fulfilling 4 or more criteria. A third major change is that the
presence of physiological dependence (tolerance, withdrawal) wil be identified separately.
This new scenario will raise the prevalence of AUD (compared to alcohol dependence) and will place
higher requirements on the clinicians in order to differentiate severe and moderate AUD, as well as the
identification of physiological dependence, based on the presence of tolerance and/or withdrawal signs.
The criteria that define AUD cover four different areas: biological processes, medical harm, behaviour and
social & relational aspects. All of them must be assessed carefully in alcoholic patients (Figure 4).
Figure 4
The assessment of the social consequences of alcohol can often be done without attributing them to
alcohol. Family problems (including domestic violence), instability at work, financial difficulties and legal
antecedents (driving while intoxicated offences, aggressions, etc) are not uncommon. It is usually helpful
to conduct the assessment in the presence of a close relative. Even though this strategy may preclude the
patient to give some relevant information, in general it will provide more objective data on the severity of
the problems experienced.
Since alcoholics are often quite defensive, assessment must be conducted in a very empathic and
nonjudgmental attitude. Alcoholics tend to explain in detail ‘why’ things happened, but usually give scarce
information on ‘what’ actually happened. Clinicians should stick to the facts and avoid the trap to discuss
the reasons why things happened.
SUMMARY
The AUD is now seen as a single entity with graded levels of severity, and with a qualitative (taxonic) change
at the severe end of the spectrum, where tolerance and withdrawal signs are present. The assessment of
alcohol use disorders must be done in an empathic non judgmental attitude, and must include a careful
examination of drinking patterns, and an evaluation of the bio-medical, behavioural and social consequences
of AUD.