Alcohol abuse: How do you assess a problem?

Comprehensive assessment of alcohol abuse will be the basis of an individualized plan of treatment.  Depending upon the severity of alcohol abuse or dependence, the possible existence of comorbid psychiatric and physical disorders, the presence or absence of social support and possible evidence of previous response to treatment, decisions can then be made concerning the most appropriate intensity, setting or modality for alcohol abuse treatment. 

Although reports of denial among individuals experiencing alcohol abuse or dependence are legendary, there is substantial evidence that an accurate history of alcohol abuse may be obtained given professional, adequate assessment procedures under the right conditions.  A complete alcohol abuse history should include specific questions concerning the average amount of consumption, maximum consumption per drinking episode, the frequency of heavy drinking occasions, alcohol related social problems, and legal issues, (including the arrest or near arrest for driving while intoxicated), as well as psychiatric symptoms, and alcohol-related medical problems. 

It is crucial that questions concerning alcohol abuse and consumption are presented in a nonjudgmental way to enhance the likelihood of accurate reporting.  The optimal approach to history taking with a potential alcohol abuse individual includes reassuring them that information provided will be kept confidential.  Interviews are usually enhanced by initially asking questions that the individual may find least offensive (e.g. a review of symptoms or psychiatric symptoms, without relating these to alcohol use) and beginning questions with how rather then why to reduce the sense of judgment to the individual being questioned. 

The systematic clinical assessment of alcohol abuse often begins with a routine screening to identify active cases, as well as individuals at risk.  Over the last 25 years, a number of self-report screening tests have been developed to identify problems of alcohol abuse and dependence.  The Michigan Alcoholism Screening Test (MAST) developed by Seltzer in 1971, is one of the most often used instruments.  It contains 25 items that are asked about alcohol drinking habits as well as social, occupational and interpersonal problems associated with problem drinking.  Perhaps the most widely used test for screening for alcohol abuse is the CAGE, which contains only four questions: (1) Have you ever felt you ought to cut down on your drinking? (2) Have people annoyed you by criticizing your drinking? (3) Have you ever felt bad or guilty about your drinking?  (4) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover, that is, an eye opener?  Reliability and validity studies conducted in various treatment environments including psychiatric inpatients, ambulatory medical patients, prenatal clinics etc. have found generally accepted levels of sensitivity in determining alcohol abuse and dependence with these screening devices. 

Another screening device used to identify alcohol abuse is the Alcohol Use Disorders Identification Test (AUDIT), which is a 10-item screening device which may be used as a first step in a comprehensive and sequential alcohol use history.  The AUDIT covers various domains including alcohol consumption, symptoms of alcohol dependence, and alcohol-related consequences. It has been found to be effective (sensitive and specific) in differentiating alcoholics from nonalcoholics and has been found to be superior to the MAST in identifying hazardous drinkers, that is, those heavy drinkers that have not yet experienced serious harm from their drinking.  The AUDIT total score increases with the severity of the alcohol abuse and dependence and other alcohol-related problems, and can be used as part of a comprehensive approach to early identification and patient placement in alcohol treatment programs.  Because the misuse of both prescribed and illegal drugs is common among alcohol abuse individuals, screening should also include other psychoactive substances including tobacco products.

From DSM-IV-TR Mental Disorders: Diagnosis, Etiology and Treatment by Michael B. First and Allan Tasman

Additional Information and webpage by Paul Susic  MA Licensed Psychologist   Ph.D. Candidate  (Health and Geriatric Psychologist)

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