Alcohol use disorder or AUD Is this just another name for alcoholism? For alcohol abuse? Exactly what is it? To understand alcohol use disorder, it is helpful to understand the terms that came before it.
Alcohol Use Disorder: Background
The major authority defining such matters is the Diagnostic and Statistic Manual of Mental Disorders (DSM). It’s published by the American Psychiatric Association. The first DSM was published in 1952. It categorized alcoholism as a personality disorder. But it did not define it or provide any criteria to diagnose it.
The second edition (DSM-II) followed in 1968. Like the first, it categorized alcoholism as a personality disorder and provided no diagnostic criteria. But it noted that withdrawal provided the best evidence of alcoholism.
In 1980, DSM-III brought major changes. Alcoholism was no longer a personality disorder. The term alcoholism itself was replaced by a new category of conditions. It called them substance use disorders.
Alcohol disorders were listed as either alcohol abuse or alcohol dependence. A diagnosis of dependence required evidence of either tolerance or withdrawal.
In 1987, DSM-III was revised and published as DSM-III-R. It modified the number of criteria required for diagnosing abuse and dependence. It was followed by DSM-IV in 1994. DSM-IV was replaced by the current edition, DSM-5, published in 2013.
Under DSM-IV, if any one of four listed behaviors applied, the person was diagnosed as an alcohol abuser. In the current edition, if any two of 11 listed behaviors applies, the person has an alcohol use disorder (mild). This greatly increases the chance of being diagnosed.
Under DSM-IV, if any three of seven listed behaviors applied, the diagnosis was alcohol dependence. In the current edition, if four of 11 behaviors apply, the diagnosis is moderate alcohol use disorder. If six or more apply, the diagnosis is severe alcohol use disorder.
New Alcohol Use Disorder Criteria
There has been a fundamental, science-based change in the current edition. It is the rejection of the “either-or'” theory. That theory has been promoted by Alcoholics Anonymous for 80 years and is widely accepted. But it is an ideology not supported by science. The former dichotomy has been replaced by a continuum or spectrum of alcohol misuse. It’s consistent with scientific evidence.
Alcohol Use Disorder: Implications
Although this is a major improvement conceptually, the National Council on Alcoholism and Drug Dependence expressed alarm. The new criteria established for alcohol use disorder will classify millions more Americans as having alcoholism.1 It warned that
“Some experts are concerned that people who binge drink in their late teens and early adulthood could be seen as mild alcoholics. According to Time.com, about 40 percent of college students engage in binge drinking frequently enough that they might qualify for the new diagnosis, but only 5 percent of graduates over 26 are current alcoholics. Dr. Allen Frances, who chaired the task force that wrote the earlier edition of the DSM, said, ‘The DSM-5 decision to lump beginning drinkers with end-stage alcoholics was driven by researchers who are not sensitive to how the label would play out in young people’s lives.'”2
Dr. Frances asserted that overly broad definitions of alcohol use disorder will create “false epidemics” and “medicalization of everyday behavior.”
Many experts agree. Australian researchers estimated that about 60 percent more people would be diagnosed as addicted to alcohol under the new criteria. Another prominent expert is Dr. Thomas Babor. He observed that “The chances of getting a diagnosis are going to be much greater, and this will artificially inflate the statistics considerably.'”3
This will divert scarce resources away from alcoholics to people with life problems that usually resolve themselves.
The same expansion of diagnoses exists throughout DSM-5. For example, a person who grieves the death of a loved one for over two weeks is now diagnosed as mentally ill. The person has “major depressive disorder.” Medicalizing normal grief will be a bonanza to psychiatrists and pharmaceutical companies.
Similarly, “Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.”4
Increased Medical Expenses
Such expansion, of course, will lead to hundreds of millions of dollars in additional medical expenses. And it’s for people who don’t need any medication or treatment.
That problem may not concern the two-thirds of the DSM’s members who wrote the new alcohol criteria. They disclosed having financial ties to the pharmaceutical industry or other conflicts of interest.5
Soon after the new criteria were published, researchers reported that “nearly one-third of adults in the United States have an AUD at some time in their lives, but only about 20 percent seek AUD treatment.'”6 The study also claimed that the number of people suffering the new condition had grown over the previous 11 years. So concerns about the inflation of problems are obviously well-founded.
Alcoholism became alcohol dependence in 1980, and then expanded to become alcohol use disorder in 2013. Diagnostic levels for AUD were lowered greatly. So a large number of ordinary people are now being categorized as suffering alcohol use disorder. And the federal government is already suggesting the need for more medical treatment for the “epidemic.”
To understand the new criteria, just follow the money.
I. Popular Resources on Alcoholism
Coping with an Alcoholic Parent. eVideo. Millis, MA: Aquarius, 2006.
Frederiksen, L. If You Loved Me, You’d Stop. What You Really Need to Know when Your Loved One Drinks too Much. Menlo Park, CA: KLJ, 2008.
Langwith, J. Alcoholism. Juvenile readership. Detroit: Gale, 2010.
Lessa, N. and Gilbert, S. Living with Alcoholism. NY: Facts On File, 2009.
Meyers, R. and Wolfe, B. Get Your Loved One Sober. Springer, 2013.
Porterfield, K. Coping with an Alcoholic Parent. NY: Rosen, 1985.
Sally B and David B. Our Children are Alcoholics. Coping with Children Who have Addictions. Dubuque, IA: Islewest, 1997.
II. Scholarly Readings on Alcohol Use Disorder
Bucholz, K., et al. Can we subtype alcoholism? Alco Clin Exper Res., 1996, 20, 1462’“1471.
Hasin, D. Classification of Alcohol Use Disorders. Alco Res Hlth., 2003, 27(1), 5-17.
Martin, C., et al. How should we revise diagnostic criteria for substance use disorders in the DSM-V? J Abnor Psy., 2008, 117(3), 561-575.
Mohan, D., et al. Unidimensionality of alcohol dependence syndrome. Drug Alco Depend., 1995, 37, 163-166.
Schuckit, M., and Smith, T. A comparison of correlates of DSM IV alcohol abuse or dependence among more than 400 sons of alcoholics and controls. Alco Clin Exper Res., 2001, 25, 1-8.
Spitzer, R.L., et al. Research diagnostic criteria. Arch Gen Psych., 1978, 35, 773-782.
Ustun, B., et al. WHO Study on the reliability and validity of the alcohol and drug use disorder instruments. Drug Alco Depend., 1997, 47, 161-169.
III. Other on AUD
Urbina, I. Addiction Diagnoses May Rise Under Guideline Changes. New York Times, May 11, 2012.