KEY TAKEAWAYS
DSM-V defines common symptoms of alcoholism as (e.g.) larger intake than intended, unsuccessful efforts to cut down drinking, and excessive time spent obtaining alcohol, drinking, or recovering from intake[1].
However, Alcoholics Anonymous disagrees on specifically what defines an alcoholic, and thus the symptoms they experience.
AA asserts an alcoholic remains an alcoholic, even when free from behaviours or physical symptoms described by DSM-V.
Header | DSM-V | AA/12 STEPS |
|---|---|---|
BEHAVIOURAL | - Consuming more alcohol than intended. | - Compulsive, uncontrolled drinking |
PHYSICAL | - Cravings | - Abnormal craving for alcohol |
The Diagnostic and Statistical Manual (DSM-5) lists 11 symptoms of alcoholism, now referred to as alcohol use disorder.
If a person has two or three of these symptoms, they will have mild alcohol use disorder; if they have four or five, they will have moderate alcohol use disorder; if they have six or more, they will have severe alcohol use disorder.
Medical professionals, addiction treatment centres, alcohol support groups and people with lived experience of alcohol abuse may or may not find the DSM-5 criteria for Alcohol Use Disorder valid or useful.
Differing philosophical and theoretical approaches to alcohol misuse may also disagree on whether it is helpful to refer to a heavy drinker with symptoms of an alcohol problem as an alcoholic.
The DSM-5 Symptom Criteria Defining Alcohol Use Disorder
A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12 month period:
1. Alcohol is often taken in larger amounts or over a longer period of time than intended [1]
Prolonged and uncontrolled heavy drinking or binge drinking (five or more drinks in a row) driven by a compulsion to drink rather than by the expectations or norms of social drinking [2].
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use [1]
Wanting or trying to reduce alcohol intake or to stop drinking, and being unable to do so [3].
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects [1]
Thinking constantly about drinking. Life being overtaken and interrupted by buying or brewing alcohol, by heavy drinking and by hangovers or other withdrawal symptoms [2,3] .
4. Craving, or a strong desire or urge to use alcohol [1]
Constantly thinking about or longing for alcohol. Wanting to drink: either due to the physical symptoms of alcohol addiction or to being reliant on drinking to manage stress [4].
5. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home [1]
Prioritising alcohol over everything [2].
Arriving at work or school drunk, drinking at work or school, being constantly absent from work or school [5].
Being unable to perform sexually [6].
Using money needed for the family to buy alcohol, even if it leaves children or loved ones hungry or destitute.
Family arguments and family breakdown. Being unable to care for children [7].
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol [1]
Drinking through loneliness, mental health problems, poverty, motor vehicle accidents, self-neglect, unsafe sex, homelessness, domestic violence [7].
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use [1]
Being unable to work or study due to excessive drinking. Losing interest or motivation in friends or hobbies [2, 5, 7].
8. Recurrent alcohol use in situations where it is physically dangerous [1]
Drinking outside after dark to hide alcohol consumption, drinking in isolated waste ground or back alleys. Driving to buy alcohol even when drunk [7].
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol [1]
Continuing to drink even when aware of the health problems alcohol is causing; for example: trouble sleeping, high blood pressure, mental health disorders, cancer, liver failure [4, 7].
10. Tolerance [1]
Needing more progressively more alcohol to gain its pleasurable effects or to manage stress. This is a key sign of alcohol addiction [8].
Experiencing symptoms of alcohol dependence which begin after only after stopping drinking. Needing alcohol to relieve withdrawal symptoms:
The Alcoholics Anonymous Definition Of An Alcoholic
The 12-step movement - of which Alcoholics Anonymous or AA [10] is a part - uses the term "alcoholic" rather than alcohol use disorder.
The AA philosophy poses two main challenges to the DSM-V list of symptoms:
Alcoholism As A Disease
The DSM-V diagnostic criteria for alcohol use disorder is written such that alcohol use disorder can be diagnosed on the basis of either physiological or behavioural symptoms, or on the basis of a combination of both [1].
The 12-step movement asserts that alcoholism is primarily a biochemical disease, and thus that alcoholism will always have physical as well as behavioural symptoms.
Consequently, AA insists that alcoholism can never be treated solely by behavioural interventions such as counselling or therapy alone.
Only full abstinence - or stopping drinking completely - will prevent the body from reacting against alcohol in ways which cause addictive behaviour.
Within the different approaches to treatment, there remains a debate and a divide between abstinence-based and harm-minimisation approaches. The DSM-V does not take a position on this.
However, many practitioners would agree with AA that addiction treatment or the recovery journey is more likely to succeed when a person with alcohol misuse problems aims to cease drinking altogether [12].
Alcoholism Is A Life-Long Condition
Within the DSM-V criteria, a diagnosis of alcohol use disorder is valid only for as long as the person is experiencing the symptoms leading to that diagnosis.
From a DSM-V perspective, then, alcohol use disorder may be cured [1].
Contained within the AA diagnosis of alcoholism is the assertion that the allergy to alcohol which has caused the alcoholic's drinking behaviour is permanent and irreversible:
As a result of its assertion that moderate drinking will never be possible, AA believes that abstinence should be lifelong. AA members are encouraged to remain mindful of this by self-identifying as alcoholics even after they have stopped drinking.
Should Those With Symptoms Of Problem Drinking Be Defined As Alcoholics?
The 12-step movement, and Alcoholics Anonymous or AA, maintain that the term "alcoholic" is important, and necessary, in overcoming the denial which surrounds addiction and substance use disorder [11].
Therefore within AA, the first of the 12 steps - or the start of the recovery journey - involves referring to self as "an alcoholic".
Research demonstrates that, for some, self-identifying as an alcoholic in this manner can prove highly effective in overcoming alcohol abuse [12].
However, many people find the term "alcoholic " shaming, pejorative, and disrespectful.
Because alcohol misuse and alcohol addiction remain so highly stigmatised, the label of "alcoholic" conveys many negative connotations which deter many from seeking treatment [13].
Therefore, some treatment centres and recovery programmes prefer the person-first terminology of "a person with alcohol use disorder".
Research evidence shows that alcohol recovery is most likely when individuals feel empowered and respected, and using the right language is an important part of that [14].
Using CAGE and AUDIT Tools To Assess Drinking
Medical professionals often use the CAGE [15] and AUDIT [16] questionnaires to assess potentially harmful drinking, alcohol dependence, or alcohol addiction.
The Cage Questionnaire
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had a drink first thing in the morning (Eye-opener) to stop the shakes or manage a hangover? [15]
Help For Alcohol Issues
Support groups such as AA [11] and SMART Recovery [18] are open to all, and work hard to welcome new members.
NHS alcohol and drug partnership services [19] provide addiction and mental health treatment, care, and support to people with a drinking problem.
These can be accessed through referral from GPs and social care, signposting from pharmacies, and outreach from other services.
NHS services are free to all UK residents, as well as to refugees and asylum seekers and to some overseas workers.
Many voluntary sector organisations also provide a range of addiction services. The NHS website provides a directory of services [20] available across the UK.
Abbeycare [21] is one of the UK's leading private providers of addiction treatment.
In addition to its own services, Abbeycare's website provides a comprehensive free guide to finding and accessing the right form of treatment [22].
