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Screening for Alcohol Problems—An UpdateThe prevalence of alcohol use disorders is significantly higher among patients visiting a primary care practitioner than among the general population (1,2). For this reason, clinicians have the opportunity to play a key role in detecting alcohol problems and in initiating prevention or treatment efforts. A variety of relatively brief screening instruments are available for this purpose (3–5). These instruments do not provide a diagnosis, but help identify patients who might benefit from a more thorough assessment of their drinking behavior (6). Following screening, the presence of an alcohol use disorder can be confirmed using standard clinical diagnostic criteria. The success of this approach has been demonstrated. In one study, 80 percent of patients whose screening results were confirmed by a formal diagnosis of alcohol dependence accepted referrals to alcoholism treatment programs (7). Patients should be screened not only for alcohol use disorders, but also for drinking patterns or behaviors that may place them at increased risk for developing adverse health effects or alcoholism (i.e., risky drinking) (5). Risky drinkers who have not yet become alcohol dependent often can be treated successfully within the primary care setting (8). This Alcohol Alert presents information on selected screening instruments for use with primary care patients as well as other patient populations among whom alcohol use is either highly prevalent or hazardous. Types of InstrumentsTwo types of alcoholism-screening instruments are available. The first type includes self-report questionnaires and structured interviews; the second type includes clinical laboratory tests that can detect biochemical changes associated with excessive alcohol consumption. The value of a screening instrument for measuring alcohol problems or other conditions is related to its sensitivity and specificity. Sensitivity refers to a test’s accuracy in identifying people who have an alcohol problem (i.e., people with the condition test positive). Specificity refers to the test’s effectiveness in identifying people who do not have an alcohol problem (i.e., people without the disease test negative). No screening instrument is perfect. It is not possible to optimize both sensitivity and specificity in the same screening instrument. The likelihood of over identifying alcohol use disorders occurs with increased sensitivity and the possibility of missing people who have an alcohol problem grows with increased specificity. Despite these limitations, research supports the use of formal screening instruments to increase the recognition of alcohol problems (5,9). QuestionnairesScreening instruments vary in their ability to detect different patterns and levels of drinking and in the degree of their applicability to specific subpopulations and settings (2). This section compares features of some of the most widely used screening questionnaires. Detailed information is available at the NIAAA Web site ( http://www.niaaa.nih.gov ). The CAGE questionnaire (10) has been evaluated in several studies, showing sensitivities ranging from 43 to 94 percent for detecting alcohol abuse and alcoholism (5). CAGE is well suited to busy primary care settings because it poses four straightforward yes/no questions that the clinician can easily remember and requires less than a minute to complete. However, the test may fail to detect low but risky levels of drinking (5). In addition, CAGE often performs less well among women and minority populations (11,12). The performance of CAGE can be improved by incorporating questions about the quantity and frequency of drinking, as recommended by NIAAA in The Physicians’ Guide to Helping Patients With Alcohol Problems (13). A study found that the screening strategy suggested in the Physicians’ Guide effectively identified alcohol abuse and dependence in a general population sample (14). The same approach also demonstrated better sensitivity and similar specificity compared with CAGE alone among African American patients in an urban emergency room (15). The Alcohol Use Disorders Identification Test (AUDIT) (16) also incorporates questions about quantity and frequency of alcohol use. In contrast to CAGE, AUDIT compares favorably with other instruments in detecting risky drinking, but is less effective in identifying alcohol abuse and alcoholism (5,17). Originally developed for primary care settings, AUDIT has proven useful among medical and psychiatric inpatients, in emergency rooms (17), and in the workplace (17–19). AUDIT is relatively free of gender and cultural bias (11,17,20). In addition, it shows promise for screening adolescents and older people, populations in which standard screening instruments produce inconsistent results (12,17,21–23). The major disadvantage of AUDIT is its length and relative complexity; clinicians require training to score and interpret the test results (3). Screening pregnant women for alcohol use has become increasingly important in light of new research showing that even low levels of prenatal alcohol exposure can harm the fetus. Unfortunately, although approximately 20 percent of women consume some alcohol during pregnancy, maternal drinking can be difficult to detect (24). At least two questionnaires are available that are appropriate for pregnant women, both derived in part from CAGE. T–ACE (25) takes approximately 1 minute to complete and is more accurate than AUDIT for detecting current alcohol consumption and risky drinking, as well as a history of past alcoholism; however, it is less specific (24). The five-item TWEAK (26) performs similarly to T–ACE (24) and can be used to detect a range of drinking levels from moderate to high-risk consumption (27). Alcohol consumption plays a role in a large percentage of trauma incidents, including motor vehicle crashes. RAPS4 is a four-item questionnaire derived in part from TWEAK and AUDIT. In both primary care and emergency room settings, RAPS4 showed consistently high sensitivity for detecting alcoholism across gender and ethnic subgroups, although its utility for screening for risky drinking or alcohol abuse has yet to be proven (28,29). Computer-Assisted Screening. Computers have been widely and successfully used in screening and in assisting alcoholism intervention (17,30). Studies have found no significant difference in accuracy between computerized and paper-and-pencil versions of AUDIT among inpatient alcoholics (31). Similar results have been achieved with CAGE in the primary care setting (31). In addition, small laptop computers have been used in large-scale alcohol screening surveys. For example, in Audio Computer Assisted Self-Interviewing (ACASI), a recorded voice asks questions that can be answered by pressing a few keys. Advantages include ease of use for respondents with poor literacy or computer skills, as well as increased privacy, although the interviewer remains nearby to offer assistance if necessary (32). The Internet provides an increasingly accessible, low-cost medium for screening and brief intervention (30). A pilot web site incorporating AUDIT and other alcohol history questions attracted more than 10,000 people during an initial 172-day trial. Of 2,253 people who took the test, 89 percent had scores suggesting harmful drinking or alcoholism, although 94 percent of participants of the total sample had never been diagnosed (30). The procedure is completely automated and self-administered. Biological MarkersIn contrast to self-report questionnaires, clinical laboratory procedures provide objective evidence of problem drinking. They are generally less sensitive and specific than questionnaires, but are valuable for corroborating results of interviews and questionnaires (33). The accuracy of these markers is affected by various factors such as nonalcoholic liver damage, use of medications or drugs, and by metabolic disorders. Three widely used tests and one promising new marker are described here. Gamma-glutamyl transferase (GGT) is the most commonly used biochemical measure of drinking (33). Chronic drinking of 4 or more drinks per day for 4 to 8 weeks significantly raises levels of this blood protein, at least in alcoholics (33). Four to five weeks of abstinence are usually required for GGT levels to return to within normal range (33). The ability of this test to detect long-term heavy drinking in the recent past makes GGT useful for monitoring abstinence in recovering alcoholics. However, nonalcoholic liver disease also can increase GGT levels, increasing the likelihood of false-positive results. Carbohydrate-deficient transferrin (CDT) is another blood protein that increases in concentration with heavy alcohol consumption (34). CDT values become elevated substantially earlier (1 to 2 weeks) in response to prolonged excessive drinking than conventional markers such as GGT (35). GGT and CDT are approximately equal in their ability to identify alcoholism. However, few conditions other than heavy drinking will elevate CDT levels, decreasing the probability of false positives (35). Disadvantages include lower sensitivity in women and adolescents, and the high cost of the laboratory analysis (33). Mean corpuscular volume (MCV), an index of red blood cell size, increases with excessive alcohol intake after 4 to 8 weeks (33). The sensitivity of MCV is too low to justify its use as a single indicator (35). However, it has higher specificity compared with other tests. MCV can detect evidence of earlier drinking after a long period of abstinence. For this reason, it is a poor indicator of recovery among alcoholics who have stopped drinking (35). Fatty acid ethyl esters (FAEEs) show promise as markers of maternal drinking. FAEEs are formed by the interaction of alcohol and natural fatty substances in the body. They have been detected in samples of meconium (i.e., the waste product of newborns). Some evidence suggests that analysis of FAEEs in meconium may indicate timing of prenatal alcohol exposure (34). Screening for Alcohol Problems—A Commentary by Raynard Kington, M.D., Ph.D., Acting NIAAA Director, and Richard K. Fuller, M.D., Director, Division of Clinical and Prevention ResearchNational Alcohol Screening Day (NASD) is a nationwide, one-day event that provides free and confidential screening for alcohol problems. During NASD, screening—along with public education and referral to treatment, when necessary—occurs in a variety of health care and community settings, including college campuses and military bases. This Alert describes a number of questionnaires and medical tests that can be used in primary care settings to screen individuals who have or who are at risk for developing alcohol problems. We hope that the information provided here will encourage practitioners to make the screening and referral that are the centerpieces of NASD an ongoing part of their practice throughout the year. Given the impact of heavy drinking on overall health and the prevalence of patients in the primary care system who have an alcohol use problem, screening and referral should be considered part of sound clinical practice, rather than simply added patient services. More information on screening is available at the National Institute on Alcohol Abuse and Alcoholism Web site at http://www.niaaa.nih.gov/publications/instable.htm. References (1) Fleming, M.F.; Manwell, L.B.; Barry, K.L.; and Johnson, K. At-risk drinking in an HMO primary care sample: Prevalence and health policy implications. American Journal of Public Health 88(1):90–93, 1998. (2) O'Connor, P.G., and Schottenfeld, R.S. Patients with alcohol problems. New England Journal of Medicine 338(9):592–602, 1998. (3) Allen, J.P., and Columbus, M. Assessing Alcohol Problems: A Guide For Clinicians and Researchers. National Institute on Alcohol Abuse and Alcoholism Treatment Handbook Series 4. NIH Pub. No. 95–3745. Bethesda, MD: the Institute, 1995. (4) Bradley, K.A.; Boyd-Wickizer, J.; Powell, S.H.; and Burman, M.L. Alcohol screening questionnaires in women: A critical review. Journal of the American Medical Association 280(2):166–171, 1998. (5) Fiellin, D.A.; Reid, M.C.; and O'Connor, P.G. Screening for alcohol problems in primary care: A systematic review. Archives of Internal Medicine 160(13):1977–1989, 2000. (6) Kitchens, J.M. Does this patient have an alcohol problem? Journal of the American Medical Association 272(22):1782–1787, 1994. (7) Israel, Y.; Hollander, O.; Sanchez-Craig, M.; et al. Screening for problem drinking and counseling by the primary care physician-nurse team. Alcoholism: Clinical and Experimental Research 20(8):1443–1450, 1996. (8) NIAAA. Alcohol Alert No. 43: Brief Intervention for Alcohol Problems. Rockville, MD: the Institute, 1999. (9) NIAAA. Alcohol Alert No. 8: Screening for Alcoholism. PH 285. Rockville, MD: the Institute, 1990. (10) Ewing, J.A. Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association 252(14):1905–1907, 1984. (11) Cherpitel, C.J. Screening for alcohol problems in the U.S. general population: A comparison of the CAGE and TWEAK by gender, ethnicity, and services utilization. Journal of Studies on Alcohol 60(5):705–711, 1999. (12) Steinbauer, J.R.; Cantor, S.B.; Holzer, C.E.; and Volk, R.J. Ethnic and sex bias in primary care screening tests for alcohol use disorders. Annals of Internal Medicine 129(5):353–362, 1998. (13) NIAAA. The Physicians' Guide to Helping Patients With Alcohol Problems. NIH Pub. No. 95–3769. Rockville, MD: the Institute, 1995. (14) Dawson, D.A. US low-risk drinking guidelines: An examination of four alternatives. Alcoholism: Clinical and Experimental Research 24(11):1820–1829, 2000. (15) Friedmann, P.D.; Saitz, R.; Gogineni, A.; Zhang, J.X.; and Stein, M.D. Validation of the screening strategy in the NIAAA “Physicians' Guide to Helping Patients With Alcohol Problems.” Journal of Studies on Alcohol 62(2):234–238, 2001. (16) Saunders, J.B.; Aasland, O.G.; Babor, T.F.; de la Fuente, J.R.; and Grant, M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption—II. Addiction 88(6):791–804, 1993. (17) Reinert, D.F., and Allen, J.P. The Alcohol Use Disorders Identification Test (AUDIT): A review of recent research. Alcoholism: Clinical and Experimental Research 26(2):272–279, 2002. (18) Hermansson, U.; Helander, A.; Huss, A.; Brandt, L.; and Rönnberg, S. The Alcohol Use Disorders Identification Test (AUDIT) and carbohydrate-deficient transferrin (CDT) in a routine workplace health examination. Alcoholism: Clinical and Experimental Research 24(2):180–187, 2000. (19) Hermansson, U.; Helander, A.; Brandt, L.; Huss, A.; and Rönnberg, S. The Alcohol Use Disorders Identification Test and carbohydrate-deficient transferrin in alcohol-related sickness absence. Alcoholism: Clinical and Experimental Research 26(1):28–35, 2002. (20) Volk, R.J.; Steinbauer, J.R.; Cantor, S.B.; and Holtzer, C.E. The Alcohol Use Disorders Identification Test (AUDIT) as a screen for at-risk drinking in primary care patients of different racial/ethnic backgrounds. Addiction 92(2):197–206, 1997. (21) Clay, S.W. Comparison of AUDIT and CAGE questionnaires in screening for alcohol use disorders in elderly primary care outpatients. Journal of the American Osteopathic Association 97(10):588–592, 1997. (22 ) Chung, T.; Colby, S.M.; Barnett, N.P.; et al. Screening adolescents for problem drinking: Performance of brief screens against DSM–IV alcohol diagnoses. Journal of Studies on Alcohol 61(4):579–587, 2000. (23) Chung, T.; Colby, S.M.; Barnett, N.P.; and Monti, P.M. Alcohol Use Disorders Identification Test: Factor structure in an adolescent emergency department sample. Alcoholism: Clinical and Experimental Research 26(2):223–231, 2002. (24) Chang, G. Alcohol-screening instruments for pregnant women. Alcohol Research & Health 25(3):204–209, 2001. (25) Sokol, R.J.; Martier, S.S.; and Ager, J.W. The T-ACE questions: Practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology 160(4):863–870, 1989. (26) Russell, M.; Martier, S.S.; Sokol, R.J.; et al. Screening for pregnancy risk-drinking: Tweaking the tests. Alcoholism: Clinical and Experimental Research 15(2):368, 1991. (27) Dawson, D.A.; Das, A.; Faden, V.B.; et al. Screening for high- and moderate-risk drinking during pregnancy: A comparison of several TWEAK-based screeners. Alcoholism: Clinical and Experimental Research 25(9):1342–1349, 2001. (28) Cherpitel, C.J. Brief screening instrument for problem drinking in the emergency room: The RAPS4. Journal of Studies on Alcohol 61(3):447–449, 2000. (29) Borges, G., and Cherpitel, C.J. Selection of screening items for alcohol abuse and alcohol dependence among Mexicans and Mexican Americans in the emergency department. Journal of Studies on Alcohol 62(3):277–285, 2001. (30) Cloud, R.N., and Peacock, P.L. Internet screening and interventions for problem drinking: Results from the www.carebetter.com pilot study. Alcoholism Treatment Quarterly 19(2):23–44, 2001. (31) Chan-Pensley, E. Alcohol-Use Disorders Identification Test: A comparison between paper and pencil and computerized versions. Alcohol and Alcoholism 34(6):882–885, 1999. (32) Lessler, J.T.; Caspar, R.A.; Penne, A.; and Barker, P.R. Developing Computer Assisted Interviewing (CAI) for the National Household Survey on Drug Abuse. Journal of Drug Issues 30(1):9–34, 2000. (33) Allen, J.P., and Litten, R.Z. The role of laboratory tests in alcoholism treatment. Journal of Substance Abuse Treatment 20(1):81–85, 2001. (34) Bearer, C.F. Markers to detect drinking during pregnancy. Alcohol Research & Health 25(3):210–218, 2001. (35) Helander, A. Biological markers of alcohol use and abuse in theory and practice. In: Agarwal, D.P., and Seitz, H.K., eds. Alcohol in Health and Disease. New York: Marcel Dekker, 2001. pp. 177–205.
All material
contained in the Alcohol Alert is in the public domain and may
be used or reproduced without permission from NIAAA. Citation of the
source is appreciated.
Copies of the Alcohol Alert are available free of charge from the National Institute on Alcohol Abuse and Alcoholism Publications Distribution Center P.O. Box 10686, Rockville, MD 20849–0686. |
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Alcohol Alert Diagnostic Criteria for Alcohol Abuse and Dependence Diagnosis is the process of identifying and labeling specific conditions such as alcohol abuse or dependence (1). Diagnostic criteria for alcohol abuse and dependence reflect the consensus of researchers as to precisely which patterns of behavior or physiological characteristics constitute symptoms of these conditions (1). Diagnostic criteria allow clinicians to plan treatment and monitor treatment progress; make communication possible between clinicians and researchers; enable public health planners to ensure the availability of treatment facilities; help health care insurers to decide whether treatment will be reimbursed; and allow patients access to medical insurance coverage (1-3). Diagnostic criteria for alcohol abuse and dependence have evolved over time. As new data become available, researchers revise the criteria to improve their reliability, validity, and precision (4,5). This Alcohol Alert traces the evolution of diagnostic criteria for alcohol abuse and dependence through the current standards of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (6). For comparison, the criteria found in the World Health Organization's International Classification of Diseases, Tenth Revision (ICD-10) also are reviewed briefly, although these are not often used in the United States (7). Evolution of Diagnostic Criteria Early Criteria At least 39 diagnostic systems had been identified before 1940 (2). In 1941 Jlinek first published what is considered a groundbreaking theory of subtypes of what was, until 1980, termed alcoholism (2,8). Jellinek associated these subtypes with different degrees of physical, psychological, social, and occupational impairment (2,9). Formulations of diagnostic criteria continued with the American Psychiatric Association's publication of the Diagnostic and Statistical Manual of Mental Disorders, First Edition (DSM-I), and Second Edition (DSM-II) (10,11). Alcoholism was categorized in both editions as a subset of personality disorders, homosexuality, and neuroses (2,12). In response to perceived deficiencies in DSM-I and DSM-II, the Feighner criteria were developed in the 1970's to establish a research base for the diagnostic criteria of alcoholism (5,13). These criteria were the first to be based on research rather than on subjective judgment and clinical experience alone (5). Though designed for use in clinical practice, they were primarily developed to stimulate continued research for the development of even more useful diagnostic criteria (5). Several years later, Edwards and Gross focused solely on alcohol dependence (8). They considered essential elements of dependence to be a narrowing of the drinking repertoire, drink-seeking behavior, tolerance, withdrawal, drinking to relieve or avoid withdrawal symptoms, subjective awareness of the compulsion to drink, and a return to drinking after a period of abstinence (8) The DSM Criteria Researchers and clinicians in the United States usually rely on the DSM diagnostic criteria. The evolution of diagnostic criteria for behavioral disorders involving alcohol reached a turning point in 1980 with the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (14). In DSM-III, for the first time, the term "alcoholism" was dropped in favor of two distinct categories labeled "alcohol abuse" and "alcohol dependence" (1,2,12,15). In a further break from the past, DSM-III included alcohol abus e and dependence in the category "substance use disorders" rather than as subsets of personality disorders (1,2,12). The DSM was revised again in 1987 (DSM-III-R) (16). In DSM-III-R, the category of dependence was expanded to include some criteria that in DSM-III were considered symptoms of abuse. For example, the DSM-III-R described dependence as including both physiological symptoms, such as tolerance and withdrawal, and behavioral symptoms, such as impaired control over drinking (17). In DSM-III-R, abuse became a residual category for diagnosing those who never met the criteria for dependence, but who drank despite alcohol-related physical, social, psychological, or occupational problems, or who drank in dangerous situations, such as in conjunction with driving (17). According to Babor, this conceptualization allowed the clinician to classify meaningful aspects of a patient's behavior even when that behavior was not clearly associated with dependence (18). The DSM was revised again in 1994 and was published as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (6). The section on substance-related disorders was revised in a coordinated effort involving a working group of researchers and clinicians as well as a multitude of advisers representing the fields of psychiatry, psychology, and the addictions (2). The latest edition of the DSM represents the culmination of their years of reviewing the literature; analyzing data sets, such as those collected during the Epidemiologic Catchment Area Study; conducting field trials of two potential versions of DSM-IV; communicating the results of these processes; and reaching consensus on the criteria to be included in the new edition (2,19). DSM-IV, like its predecessors, includes nonoverlapping criteria for dependence and abuse. However, in a departure from earlier editions, DSM-IV provides for the subtyping of dependence based on the presence or absence of tolerance and withdrawal (6). The criteria for abuse in DSM-IV were expanded to include drinking despite recurrent social, interpersonal, and legal problems as a result of alcohol use (2,4). In addition, DSM-IV highlights the fact that symptoms of certain disorders, such as anxiety or depression, may be related to an individual's use of alcohol or other drugs (2). The ICD Criteria While the American psychiatric community was formulating its editions of diagnostic criteria for mental disorders, the World Health Organization was developing diagnostic criteria for the purpose of compiling statistics on all causes of death and illness, including those related to alcohol abuse or dependence, worldwide (1,4,20). These criteria are published as the International Classification of Diseases (ICD). The first ICD classification of substance-related problems, published in 1967 in ICD-8 (21), classified what was then called alcoholism with personality disorders and neuroses, as had DSM-I and DSM-II. In ICD-8, alcoholism was a separate category that included episodic excessive drinking, habitual excessive drinking, and alcohol addiction that was characterized by the compulsion to drink and by withdrawal symptoms when drinking was stopped (1). Although ICD-9 (22,23) included separate criteria for alcohol abuse and dependence, this revision defined them similarly in terms of signs and symptoms (1). According to Babor, an important assumption in ICD-9 was that alcohol use in the absence of dependence "merits a separate category by virtue of its detrimental effects on health" (1, p. 87). The category of alcohol dependence was central to the current revision, ICD-10 (1,2,7). Alcohol dependence is defined in this classification in a way that is similar to the DSM. The diagnosis focuses on an interrelated cluster of psychological symptoms, such as craving; physiological signs, such as tolerance and withdrawal; and behavioral indicators , such as the use of alcohol to relieve withdrawal discomfort (1). However, in a departure from the DSM, rather than include the category "alcohol abuse," ICD-10 includes the concept of "harmful use." This category was created so that health problems related to alcohol and other drug use would not be underreported (1). Harmful use implies alcohol use that causes either physical or mental damage in the absence of dependence (1). Moving Toward Agreement Between Diagnostic Criteria The DSM diagnostic criteria for psychiatric disorders are the criteria primarily used in the United States. The ICD is an international diagnostic and classification system for all causes of death and disability, including psychiatric disorders (4). Earlier editions of these two major diagnostic criteria dealing with alcohol abuse and dependence were criticized for being too dissimilar (2). Therefore, the DSM-IV and the ICD-10 were revised in a coordinated effort among researchers worldwide to develop criteria that were as consistent with one another as possible (1,2). Although some differences between the two major diagnostic criteria still exist, they have been revised by consensus as to how alcohol abuse and dependence are best characterized for clinical purposes (18). Clinicians, international health agencies, and researchers are now better able to categorize people with alcohol dependence, abuse, and harmful use to plan treatment, collect statistical data, and communicate research results (18). Diagnostic Criteria--A Commentary by The research community has long found standardized diagnostic criteria useful. Such criteria provide agreement as to the constellation of symptoms that indicate the alcohol dependence syndrome and allow researchers all over the world to communicate clearly as to what kinds of disorders are being studied. Standardized diagnostic criteria are equally important and useful to clinicians. In the alcohol field, there have been many different ways by which clinical staff might arrive at a diagnosis--sometimes differing among staff within the same program. Although the use of standard diagnostic criteria may seem somewhat burdensome, it provides many benefits: more efficient assessment and placement, more consistency in diagnoses between and within programs, enhanced ability to measure the effectiveness of a program, and provision of services to people who most need them. As we move more and more into a managed health care arena, third-party payors are requiring more standardized reporting of illnesses; they want to know what conditions they are paying for and that these conditions are the same from program to program. The standardized diagnostic criteria presented in this Alert are based on the newest research, have been developed based on field trials and extensive reviews of the literature, and are continually revised to reflect new findings. Although clinical judgment will always play a role in diagnosing any illness, alcohol treatment programs that use standardized diagnostic criteria will be in the best position to select appropriate treatment and to justify their selection to third-party payors. References (1) Babor, T.F. Substance-related problems in the
context of international classificatory systems. In: Lader, M.; Edwards,
G.; & Drummond, D.C., eds. The Nature of Alcohol and Drug Related
Problems. New York: Oxford University Press, 1992. (2) Schuckit,
M.A. DSM-IV: Was it worth all the fuss? Alcohol and Alcoholism.
(Supp. 2):459-469, 1994. (3) Vaillant, G.E. The Natural History
of Alcoholism Revisited. Cambridge: Harvard University Press, 1995.
(4) Rounsaville, B.J.; Bryant, K.; Babor, T.; Kranzler, H.; &
Kadden, R. Cross system agreement for substance use disorders: DSM-III-R,
DSM-IV and ICD-10. Addic tion 88(3):337-348, 1993. (5) Feighner,
J.P.; Robins, E.; Guze, S.B.; Woodruff, R.A., Jr.; Winokur, G.; &
Munoz, R. Diagnostic criteria for use in psychiatric research. Archives
of General Psychiatry 26(1):57-63, 1972. (6) American Psychiatric
Association. Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition. Washington, D.C.: the Association, 1994. (7) World
Health Organization. The ICD-10 Classification of Mental and
Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines,
Tenth Revision. Geneva: World Health Organization, 1992. (8)
Edwards, G., & Gross, M.M. Alcohol dependence: Provisional
description of a clinical syndrome. British Medical Journal 1:1058-1061,
1976. (9) Jellinek, E.M. The Disease Concept of Alcoholism.
New Brunswick: Hillhouse Press, 1960. (10) American Psychiatric
Association. Diagnostic and Statistical Manual of Mental Disorders,
First Edition. Washington, D.C.: the Association, 1952. (11)
American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, Second Edition. Washington, D.C.: the
Association, 1968. (12) Nathan, P.E. Substance use disorders in the
DSM-IV. Journal of Abnormal Psychology 100(3):356-361, 1991. (13)
Keller, M., & Doria, J. On defining alcoholism. Alcohol Health
& Research World 15(4):253-259, 1991. (14) American Psychiatric
Association. Diagnostic and Statistical Manual of Mental Disorders,
Third Edition. Washington, D.C.: The Association, 1980. (15)
Cottler, L.B.; Schuckit, M.A.; Helzer, J.E.; Crowley, T.; Woody, G.;
Nathan, P.; & Hughes, J. The DSM-IV field trial for substance use
disorders: Major results. Drug and Alcohol Dependence 38:59-69,
1995. (16) American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders, Third Edition, Revised.
Washington, D.C.: the Association, 1987. All material contained in the Alcohol Alert is in the public domain and may be used or reproduced without permission from NIAAA. Citation of the source is appreciated.
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