Alcohol use disorder (AUD) is the current diagnosis for what may also be called chronic alcoholism, alcohol addiction, alcohol abuse, dipsomania, and alcohol dependence. This comprehensive look at alcohol use disorder will provide an in-depth explanation of the disorder, its causes, diagnostic criteria, symptoms, and treatments.
What Is 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 when a person’s alcohol use leads to noticeable impairment and distress in their life, affecting daily functioning. Drinking becomes disordered, making the person feel out of control when they drink. This may include symptoms like frequent thoughts about drinking or having trouble stopping drinking once they start. Many people may not realize that even seemingly small symptoms like these can indicate AUD and together can meet the criteria for diagnosis. To be considered AUD, symptoms must occur within one year of each other.
Alcoholism vs. Alcohol Use Disorder
“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. “Alcoholism” often has the connotation 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.
Causes of Alcohol Use Disorder
Alcohol use disorder is a heterogeneous disease, meaning it can be 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.
DSM-5 Criteria for Alcohol Use Disorder
To meet the alcohol use disorder DSM-5 criteria, an individual must exhibit at least two out of 11 possible symptoms over the course of one year. This classification of alcohol use disorder can help a person self-diagnose or alert them that they should check in with their healthcare provider.
Criteria grouping A: Impaired control over substance use
- Consumes more alcohol or spends more time drinking than intended
- Wants to limit or halt alcohol use, but hasn’t succeeded
- Spends a significant amount of time obtaining alcohol, drinking alcohol, and recovering from alcohol consumption
- Craves alcohol
Criteria grouping B: Social impairment
- Has suffered consequences at home, school, or work due to recurring alcohol use
- Has suffered relationship problems due to recurring alcohol use
- Has given up or cut back on enjoyable activities due to recurring alcohol use
Criteria grouping C: Risky use
- Continues to use alcohol in situations when it’s physically dangerous (e.g., drives drunk, has unprotected sex)
- Continues to use alcohol despite knowing it’s causing them physical or psychological harm
Criteria grouping D: Pharmacological
- Has become increasingly tolerant of alcohol, meaning they are less sensitive to the effects of drinking and need to drink more to become intoxicated
- Suffers withdrawal symptoms within a few hours or days after they stop drinking
The DSM-5 also breaks down AUD by severity:
- Mild AUD: Exhibits 2-3 symptoms
- Moderate AUD: Exhibits 4-5 symptoms
- Severe AUD: Exhibits 6+ symptoms
Symptoms of Alcohol Use Disorder
People who show symptoms of AUD may minimize or deny the severity of their symptoms and may feel it is “too easy” to meet the DSM-5 criteria for alcohol use disorder. Consequently, they may not take it too seriously. It can be helpful, then, to also consider some real-world signs and symptoms of AUD and how alcohol can impact a person’s life. Here are some examples of what a person with AUD may experience:
- 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 doing it anyway
- Drinking more than planned
- Continuing to drink despite the consequences
- 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 their personal hygiene or appearance
- Losing interest in favorite activities
Treatments for Alcohol Use Disorder
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. Common treatment options are:
- Alcohol use disorder therapy
- Alcohol use disorder medications
- Employing future treatment directions
A person with AUD might also choose an inpatient program, partial hospitalization, or go to a treatment center with specialized care teams (outpatient). Having an outpatient provider along with support groups like AA can also be a beneficial treatment route.
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.
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, including 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, like 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
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What Makes Treatment Difficult for Alcohol Use Disorder?
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. You may choose complete abstinence (zero tolerance) or take a harm-reduction approach.
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 means 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 returning to the environment where you used to drink. 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.
Do All Excessive Drinkers Have Alcohol Use Disorder?
If you drink more than is recommended, but nothing else happens, you may still meet the criteria for AUD, since overconsumption will eventually become tolerance — and therefore, eventually, withdrawal. However, this doesn’t always signify a bigger problem.
You will meet the criteria for AUD if you exhibit two of the aforementioned 11 DSM-5 criteria of alcohol use disorder within 12 months. Regardless of whether or not you are exhibiting two or more symptoms, 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 the criteria for AUD for it to be risky or harmful.
Alcohol Use Disorder Screening and Diagnosis
Most people diagnose themselves with AUD as only 1 in 6 American adults are asked about their drinking behaviors in healthcare settings. The CAGE questionnaire is a popular screening for AUD. 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 give you brief counseling and set up a treatment plan.
Is Alcohol Use Disorder a Mental Illness?
AUD is both a medical condition and a mental health condition. 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
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 develops as a result of battling trauma, PTSD, or other disorders without the tools to effectively cope. Alcohol use can also make conditions like depression and anxiety worse, 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.
DSM-5 Criteria for Alcohol Use Disorder Remission and Recovery
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. Those who follow an AUD treatment plan and successfully stay sober may be considered in remission. Here are the DSM-5 criteria for alcohol use disorder remission:
- 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).
Final Thoughts
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.