A look at alcohol use disorder: What is it, and how is it treated?

What Is Alcohol Use Disorder? What Is Considered an Alcohol Use Disorder?

Alcohol use disorder (AUD) is the term that the American Psychiatric Association (APA) uses to describe a harmful drinking pattern, and is a diagnosis for when alcohol use meets clinical criteria for being distressing as defined in the Diagnostic and Statistical Manual of Disorders, Fifth Edition (DSM-5). 

AUD occurs specifically when one’s alcohol use is causing noticeable impairment and distress in someone’s life, impacting their daily functioning. Alcohol use becomes disordered, making the person feel out of control when they drink and including symptoms like having constant thoughts about drinking or having trouble stopping drinking once an individual has started. Many people don’t realize that seemingly small symptoms, such as these, are symptoms of AUD, and together can be enough to diagnose someone with AUD.

Is Alcoholism the Same as Alcohol Use Disorder?

Technically, “alcoholism” and “alcohol use disorder” often refer to the same condition. In the past, clinical language distinguished between “alcohol abuse” and “alcohol dependence,” but now those terms have merged into AUD. 

Colloquially, the term “alcoholism” is still often used to refer to AUD, and describes many of its symptoms along with other traits. However, “alcohol use disorder” is a less stigmatizing term and is more respectful of the person — AUD, and addiction in general, is a disease, and “alcoholism” often has the connotation to others of being a choice, just as calling someone an “alcoholic” conflates the person and the condition. People with AUD are not defined by their condition, and deserve the respect of separating the person from the disease.

Do All Excessive Drinkers Have Alcohol Use Disorder?

If you drink more than is recommended, but nothing else happens, you would still have the potential to meet criteria for AUD, since overconsumption will eventually become tolerance — and therefore, eventually, withdrawal.

However, this doesn’t always signify a bigger problem. If you exhibit multiple symptoms of AUD over time, it’s important to remember that they must occur within one year of each other. In terms of being in remission, early remission occurs when you have met criteria this year, but haven’t met them for at least three months, while sustained remission occurs after 12 months of not meeting criteria. 

However, if your alcohol consumption makes you concerned enough to consider that you might have AUD, it’s likely worth speaking with a mental health professional about your situation and addressing your usage or symptoms before they become true issues. Alcohol use does not have to meet criteria for AUD for it to be risky or harmful.

What Are the Symptoms of Alcohol Use Disorder in the DSM-5?

A DSM-5 diagnosis of AUD requires an individual to have at least two out of 11 possible symptoms, which can be combined in various ways, over the course of one year. To be diagnosed with the disorder, an individual demonstrates at least two of the following over a 12-month period:

Criteria grouping A: Impaired control over substance use

1. Consumes more alcohol or spends more time drinking than intended.
2. Wants to limit or halt alcohol use, but hasn’t succeeded.
3. Spends a significant amount of time obtaining alcohol, drinking alcohol, and recovering from alcohol consumption.
4. Craves alcohol.

Criteria grouping B: Social impairment

1. Has suffered consequences at home, school, or work due to recurring alcohol use.
2. Has suffered relationship problems due to recurring alcohol use.
3. Has given up or cut back on enjoyable activities due to recurring alcohol use.

Criteria grouping C: Risky use

1. Continues to use alcohol in situations when it’s physically dangerous (e.g., drives drunk, has unprotected sex).
2. Continues to use alcohol despite knowing it’s causing them physical or psychological harm. 

Criteria grouping D: Pharmacological

1. Has become increasingly tolerant of alcohol, meaning they are less sensitive to the effects of drinking and need to drink more to become intoxicated. 
2. Suffers withdrawal symptoms within a few hours or days after they stop drinking.

The DSM-5 also breaks down AUD by severity: 

• Mild AUD: Has 2-3 symptoms
• Moderate AUD: Has 4-5 symptoms
• Severe AUD: Has 6+ symptoms

People who show symptoms of AUD may tend to minimize or deny the severity of their symptoms, and the criteria can sometimes seem like not much is needed for someone to have AUD if they drink regularly. However, meeting the criteria is still hard to do without alcohol having a real impact on one’s life, even for somewhat regular drinkers.

Is Alcohol Use Disorder a Mental Illness?

AUD is both a medical condition and a mental health condition. The DSM-5 categorizes AUD as a substance use disorder. People use and misuse substances like drugs and alcohol all the time, but when they begin to have significant problems as a result and continue to use those substances despite the significant problems, their behavior pattern becomes a disorder. 

The word “addiction” has fallen out of favor in mental health circles, but substance use disorders often (but not always) include an element of physical dependency. So, a person with alcohol use disorder might experience unpleasant withdrawal symptoms when they’re not drinking. Their brain circuitry might come to rely on alcohol, which intensifies cravings and makes relapse more likely. 

In some cases, acute alcohol withdrawal can lead to death, though a person’s drinking can be disordered without acute withdrawal. For reference, a hangover is technically a sign of mild withdrawal.

What Causes Alcohol Use Disorder?

There are many ways to think about how and why someone develops alcohol use disorder. Alcohol use disorder is a heterogeneous disease, meaning it’s pretty different for everyone. There’s no single origin story for the affliction. Therefore, “cause” is usually considered in terms of risk factors. Research has shown that the following elements can contribute to the development of AUD:

• Genetics. According to the DSM-5, genes are responsible for approximately 40-60% of alcohol use disorder cases. If someone has a close relative with AUD, they’re far more likely to develop the condition. However, it’s not always clear whether this is due to genetic traits or due to the increased risk of chronic stress, adverse childhood events,  and exemplified behavior in households where AUD is present. However, small genetic variations can help determine how a person metabolizes alcohol and how sensitive they are to it. 
• Environment. Someone’s immediate surroundings can influence their alcohol intake. On a cultural level, availability and cultural acceptance of excessive drinking may increase the risk for AUD. On a social level, peers can influence drinking, while a lack of peer and family support can increase someone’s AUD risk. Finally, on an emotional level, alcohol use is a maladaptive strategy for stress reduction, but conversely, it is likely to increase symptoms of anxiety and depression. Socioeconomic status has also been linked to AUD outcomes, as well as the presence of certain mental health conditions like depression and trauma. 
• Childhood and early life experiences. As with many mental health disorders, early childhood trauma, abuse, or neglect can set up the brain for problems down the road. AUD is also associated with conduct disorder and larger behavioral problems in children. The younger someone begins drinking, the higher their risk of developing alcohol dependence, possibly due to alcohol’s influence on gene expression.
• Gender. Though men still tend to suffer from AUD in greater numbers than women, women are catching up at an alarming rate. Women’s alcohol use tends to progress faster than men’s, which is called telescoping. Girls and women also suffer higher rates of sexual abuse and victimization, and may begin heavy drinking as a way of coping with negative affect and stress.
• Personality. Though there is no such thing as an “addictive personality,” high impulsivity has been linked to an earlier onset of AUD and a more severe course of illness. 
• Age. If someone starts drinking in adolescence when alcohol has a greater impact on the still-developing brain, they may become more impulsive, and hence more susceptible to severe AUD.

Alcohol Use Disorder and Other Mental Health Conditions

Harmful drinking patterns are associated with a large number of other mental health conditions, especially depressive disorders and anxiety disorders. Alcohol can also directly trigger certain psychiatric disorders. These are called alcohol-induced disorders and they typically resolve when the individual stops drinking.  

Alcohol use disorder can be present at the same time as other psychiatric disorders. When this happens, we call them comorbid disorders. Common AUD comorbidities include the following:

• Substance use disorders
• Nicotine use disorders
• Anxiety disorders
• Major depressive disorder (MDD)
• Attention-deficit/hyperactivity disorder (ADHD)
• Personality disorders
• Post-traumatic stress disorder (PTSD)
• Schizophrenia and psychotic disorders
• Bipolar disorders
• Eating disorders 

What Are Three Disorders Associated With Alcoholism?

Alcoholism, better referred to as alcohol use disorder, can cause or be co-occurring with a number of other mental health conditions. Some common ones are:

• Depression
• Anxiety
• PTSD

It may not always be clear at first whether one’s struggle with AUD is causing depression or anxiety to develop, or whether AUD developed as a coping mechanism to deal with the effects of another condition. Oftentimes, AUD can develop as a result of having trauma, PTSD, or other disorders and no tools to effectively deal with them. Alcohol use can also make conditions like depression and anxiety worse, whether one has AUD or not, meaning that the coping mechanism of drinking temporarily relieves the symptoms while exacerbating the issue in the long run. 

This isn’t to say AUD is a choice — it often develops when other aspects of one’s life become unmanageable, and can easily become unmanageable itself without proper support and treatment.

What Does Alcohol Use Disorder Look Like? How Do You Spot Alcohol Use Disorder in a Family Member?

What AUD looks like in people depends on the severity and symptomatology of the disorder. The following real-world signs may indicate that you’re struggling with alcohol use:

• Declining to attend events or do activities where alcohol isn’t served
• Feeling anxious or agitated in the hours or days after one stops drinking
• Hiding the amount one drinks from friends, family, and/or their doctor
• Saying they’re trying to control their drinking, but with no real change
• Experiencing memory loss or blackouts when drinking
• Spending a great deal of time thinking about alcohol when one is sober
• Having numerous, sometimes contradictory excuses for drinking (e.g., “I needed to celebrate a good day at work,” or “I needed to drown out a bad day at work”)
• Drinking to overcome the discomfort of a hangover or withdrawal symptoms
• Knowing that drinking is making them more depressed and/or anxious, but they do it anyway
• Drinking more than planned
• Continuing to drink despite consequences
• Promising oneself that they won’t drink, or they’ll only have X amount of drinks, but then they somehow change their mind
• Every strategy for relaxing including alcohol
• Making frequent jokes about being an alcoholic
• Getting angry or defensive if someone confronts them about their drinking
• Neglecting their responsibilities and obligations
• Getting into legal trouble
• Their personality changes when they drink
• Losing interest in food 
• Losing interest in one’s personal hygiene or appearance
• Losing interest in favorite activities

These symptoms are often more obvious to those close to the symptomatic person, such as friends and family members. If you know a family member who shows many of these symptoms and you want to approach them about their drinking, it’s important to speak to them from a place of respect, compassion, and nonjudgment. 

How Do I Approach Someone With Alcohol Use Disorder About Their Drinking?

If you’re approaching a person close to you about their drinking, the first thing to do is to make sure that it’s a time when they’re sober and not hungover/in withdrawal. It can be helpful to write down what you want to say beforehand so you don’t misspeak. It’s also important to make what you say about your own experience, not about their actions.

Keep in mind that drinking may be their sole coping mechanism, so they might not take it well — they may not want to hear you. 

People who struggle with drinking may get defensive about their behavior very quickly if they feel they are being judged, so in order to have a constructive and real conversation, you’ll need to avoid blaming or shaming language. The use of “I” statements can help with this. Offer your support and encouragement, and be prepared to suggest they get help from a medical and/or mental health professional who specializes in substance use. They can help them manage their symptoms and recover. 

If there is any concern for violence or any element of physical or emotional danger, consider talking in public or with a mediator. It can also be helpful to talk with a mental health professional on your own about what you want and what your boundaries should be going into the conversation depending on the outcome.

However, at the end of the day, you can’t control the actions of others. They are responsible for their behavior, and you can only offer your support and resources for them to use to get help. As much as AUD can be harmful to the person struggling with it, it can also harm those close to them. If you are close to someone with AUD, consider reaching out to a mental health professional and talking about your situation. Al-Anon also has resources for families of current and recovering alcoholics, with workshops on codependency and other relevant issues. They can also be helpful for figuring out how to talk to a loved one about their alcohol use.

What Are the Types of Alcohol Use Disorders?

Alcohol use disorder can be “mild,” “moderate,” or “severe” according to DSM-5 criteria. As stated above, someone with mild AUD exhibits two to three symptoms, while someone with moderate AUD has three to five and those with severe AUD show six or more.

Informally, there are countless names for different types of drinkers. For example, a dry drunk is what the founder of Alcoholics Anonymous (AA) christened someone who was technically sober, but hadn’t addressed any of the underlying issues that motivated them to drink. Because there’s been no real change, people like this are vulnerable to relapse.

Are There Stages of Alcoholism?

Alcohol use disorder can have a varying course. For some people, AUD might begin and then worsen at a steady pace. Other people may quit drinking, then relapse multiple times. And others may go into remission forever once they stop drinking. 

AUD relapse and recovery can also have stages. For example, one medical doctor who specializes in addiction refers to the emotional, mental, and physical stages of relapse and describes the stages of recovery: abstinence, repair, and growth.

How Does Alcohol Affect the Body?

Alcohol can affect the body both directly, on a cellular level, and indirectly in terms of leading to accidents, violence, injuries, and risky behaviors. The Surgeon General’s Report on Alcohol, Drugs, and Health cites 88,000 deaths in the US every year due to alcohol misuse. 

What Are the Short-Term Effects of Alcohol Use?

The short-term effects of alcohol depend on how much a person drinks, what their tolerance is, what their expectations are (related to the placebo effect), and other complex variables. In small amounts, alcohol can cause someone to feel mildly euphoric, talkative, relaxed, or uninhibited. In greater amounts, alcohol can lead to anger, mood swings, sleep deprivation, decreased sleep quality, REM suppression, slurred speech, unconsciousness, and even death. 

What Are the Long-Term Effects of Alcohol Use?

Alcohol is associated with hundreds of long-term health problems, including the following:

• Cardiovascular diseases and complications
• Low-grade hypertension
• Mental and behavioral disorders
• Liver cirrhosis and liver disease
• Pancreatitis
• Impaired immune response
• Sexual dysfunction
• Fertility issues
• Gastritis
• Stomach or duodenal ulcers
• Some cancers (e.g., esophagus, stomach, and breast)
• Peripheral neuropathy
• Cognitive impairment and dementia
• Neuroadaptive changes 

Alcohol use in pregnant women can also lead to fetal alcohol syndrome (FAS) and various pre-term birth complications.

Neurobiology of Alcohol

Alcohol primarily works on the brain by impeding the activity of the central nervous system. Alcohol boosts the effects of gamma-aminobutyric acid, or GABA, an inhibitory neurotransmitter. 

Alcohol also affects other neurotransmitters like serotonin, endocannabinoids, opioid peptides, and dopamine, which are all part of the brain’s reward pathways. This means that people keep drinking because of this positive reinforcement, but also because not drinking can cause them to feel bad (negative reinforcement) due to hyperactivity and dysfunction in the nervous system. This is what’s known as the addiction cycle. 

How Does Alcohol Use Disorder Affect Relationships?

Frequently, alcohol problems don’t just affect the drinker, but everyone close to them: kids, friends, family members, coworkers, etc. Alcohol abuse can lead to dysfunction within a couple or a family, but relationship dysfunction can also increase someone’s alcohol use. The reciprocal nature of these issues is why people in recovery from AUD often benefit from family therapy and/or marriage counseling. 

Parental alcoholism can also have a damaging effect on children’s mental health, leading to low self-esteem, externalizing disorders, and/or trust issues. 

What Happens When You Quit Alcohol?

If your body is dependent on alcohol and you stop drinking, you will likely experience short-term physical and mental discomfort due to withdrawal. Alcohol withdrawal can include a number of extremely unpleasant symptoms like: 

• Depression
• Anxiety
• Sweating
• Tremors
• Insomnia
• Nausea
• Gastrointestinal (GI) issues
• Cravings

These symptoms usually fade or at least become more manageable after 72 hours. This process is often called an alcohol detox, and for severe drinkers, it can be fatal. Because none of this feels good, and the only cures are time (several hours to a few days), medication, or more alcohol, many people choose to resume drinking. And to make matters worse, the more times you withdraw from alcohol and then relapse, the worse your withdrawal symptoms can be.

Within weeks, months, and years of not drinking, your body and mind will slowly recover from the drug. You’ll feel healthier and more energized after you get over these hurdles. But physical detox is only the first step in overcoming AUD. You also have to figure out the emotional side of the equation as well. With the right tools, such as help and support from a mental health professional, it’s very possible to undo alcohol’s damage to your nervous system — and to your life.  

Alcohol Use Disorder Screening and Diagnosis

Most people diagnose themselves with AUD. Research indicates that only 1 in 6 American adults are asked about their drinking behaviors in healthcare settings. The CAGE questionnaire is a popular screening for AUD. It asks people the following:

1. Have you ever felt you should 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 (Eye-opener)?

Other assessments include the Alcohol Use Disorders Identification Test (AUDIT), the Alcohol Dependence Data Questionnaire, the Michigan Alcoholism Screening Test (MAST), or one of the MAST derivatives. Lab tests and imaging are not required for an AUD diagnosis. 

If you receive the diagnosis in a clinical setting, your provider may provide brief counseling and prescribe a medication like naltrexone, then recommend therapy, harm reduction approaches, or a mutual support group. 

Is There a Good Solution for Reversing Alcohol Use Disorder?

Treatment for and recovery from AUD depends on the amount of support you need, the barriers to treatment, how long you’ve been using, and your own patterns and experiences. Common treatment options are:

• Inpatient programs
• Partial hospitalization
• Intensive inpatient/outpatient programs
• Treatment centers with specialized care teams (outpatient)
• Having an outpatient provider along with support groups like AA
• Medication management

It’s also important to receive treatment for any comorbid conditions, such as depression, anxiety, trauma, etc. Without treating issues that are causing or exacerbating AUD, it will be much more difficult to maintain sobriety and stay in remission.

What Makes Treatment Difficult for Alcohol Use Disorder?

You may choose complete abstinence (zero tolerance) or take a harm-reduction approach. Well-being can look different to different people, and since it can be very hard to escape alcohol, people may need to try a variety of tactics to stay sober. But you have to be ready to change. 

Because alcohol has hijacked your brain’s reward systems for so long, you’ll need to learn how to be happy without alcohol. Sometimes this can mean learning to be comfortable with being uncomfortable. You may have to “redefine fun.” This period of personal growth can be something to look forward to, rather than dread. After all, we tend to overestimate the pleasures of drinking, and underestimate its penalties. 

Another difficulty is having to return to the environment where you used to use. The familiar patterns, people, and issues you’ll once again be immersed in can make it extremely difficult not to relapse. This is why it’s helpful to find new friends and connections who are sober and removed from previous circles.

Another situation that makes treatment and remission difficult to maintain is having to reconnect with and repair family relationships that were damaged due to drinking. Repairing those relationships and owning up to past behavior is incredibly difficult, and that hardship can push people to once again reach for their reliable coping mechanism of alcohol to help them deal with the negative feelings and issues that come up.

In the end, many people just need to get enough time sober under their belt to know that sobriety makes them feel better than drinking.

Alcohol Use Disorder Treatment

As we’ve previously emphasized, alcohol use disorder is different for everyone. This means that interventions should be customized for each drinker. But – and this is crucial – every drinker should have hope that they can find a path to recovery. Though AUD is a chronic health condition that can last for years or a lifetime, the majority of people with AUD recover over time, whether on their own, with medication, or with plenty of psychosocial support. There are countless options for effective interventions. 

Alcohol Use Disorder Therapy

Many mental health professionals are specially trained to help people with alcohol use disorder. They might be certified addiction counselors (CACs), licensed clinical social workers (LCSWs), psychologists, licensed professional counselors (LPCs), psychiatrists, or another kind of experienced therapist. Here are some of the most effective psychosocial interventions for alcohol use disorder:

• Brief interventions, especially ones that include motivational interviewing, such as motivational enhancement therapy (MET)
• Operant conditioning approaches (e.g., contingency management and the community reinforcement approach)
• Cognitive behavioral therapy (CBT) and cognitive therapy to address negative thinking patterns and beliefs about drinking
• Acceptance- and mindfulness-based approaches
• 12-step facilitation (e.g., Alcoholics Anonymous)
• Other mutual support groups and self-help groups like SMART (Self-Management and Recovery Training)
• Coping skills and life skills training
• Lifestyle changes that incorporate self-care and mind-body relaxation
• Marriage counseling and/or family therapy

Alcohol Use Disorder Medications

The Food and Drug Administration (FDA) has approved three drugs for the treatment of alcohol use disorder. These medications are underutilized in the AUD population, only being prescribed to about 10% of people who seek help. 

• Naltrexone (Vivitrol, Revia), which can be taken orally or as a long-acting injectable. It prevents someone from feeling pleasure when they drink.
• Acamprosate, which can help alleviate withdrawal symptoms.
• Disulfiram (Antabuse), which causes someone to feel sick if they drink. 

Off-label medications that might hold promise for the treatment of AUD include topiramate, ondansetron, gabapentin, and varenicline. 

Future Treatment Directions

Evidence-based alcohol use disorder treatment options are expanding as researchers learn more about the condition. For example, evidence-based AUD interventions of tomorrow may include the following:

• Computerized, web-based, and mobile interventions (e.g., wearable devices and remote patient monitoring)
• Self-help interventions that use machine learning
• Deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS)
• Neurofeedback

An AUD Action Plan

How do you go from a self-diagnosis of alcohol use disorder to a full recovery? Start by feeling some compassion for yourself. This means accepting, without judgment, that you have struggled to master a potent drug. Self-compassion is the direct opposite of shame and depression, both of which tend to be part and parcel of alcohol abuse. So the first step is often to be kinder to yourself and more mindful of your hardships and your common humanity. Therapy can frequently help with this process. 

At the same time, you explore what protects you from drinking. What are your positive motivators? Alcohol use disorder tends to make people seek “highly salient alcohol rewards” over more meaningful things like strong relationships and long-term health. Recovery should include not just an absence of alcohol, but the presence of deeper, more abstract rewards. Think of recovery as a restoration of what makes you feel happy and whole.

And finally, DSM-5 criteria can specify whether someone is:

• In early remission: It’s been 3-12 months since the person has met AUD criteria. During this time they haven’t experienced any symptoms, though there’s an exception for craving (#4). 
• In partial remission: It’s been over 12 months since the person has met AUD criteria. During this time they haven’t experienced any symptoms, though there’s an exception for craving (#4).
• In a controlled environment: The person doesn’t have access to alcohol (e.g., they’re incarcerated or in a rehab facility).

It may take some time to find yourself again, but this courageous adventure can begin with sobriety. If you struggle with drinking or are being impacted by someone with AUD, consider seeking help from a mental health professional. They can give you a safe space to process what you’re going through and give you actionable tools to help you manage what you’re feeling. You’re not alone — there is help available.