When we think about alcohol abuse or alcoholism, our thoughts often go to situations where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?
It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.
A second category that is used by mental health and other professionals to render a diagnosis — alcohol abuse — was added to the official Diagnostic and Statistical Manual (DSM) long after alcohol dependence. Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking. Examples of such consequences would be an arrest for driving under the influence or domestic violence, a severe illness such as diabetes, or the loss of a job due to poor performance.
Men and women (and only those men and women) who meet the criteria for alcohol abuse or dependence have been considered (by professionals and insurers) to be eligible for treatment. This categorical way of viewing alcoholism has prevailed until now. However, as it works toward the first revision of the DSM in more than 15 years, the American Psychiatric Association has been taking a new look at many diagnostic categories. Under consideration is a paradigm shift in the way we view mental illness, including substance use. At the core of this new paradigm is the idea that some conditions might be better thought of as existing on a spectrum rather than in terms of discrete categories such as alcohol abuse and dependence.
We are supportive of this paradigm shift, and we believe it is particularly relevant with respect to drinking. To be specific we have proposed that drinking be viewed in terms of the spectrum depicted below.
THE DRINKING SPECTRUM
We believe that, as opposed to thinking only those men and women whose drinking has progressed to the point where they need help, that many people in the mid-range may also be suffering as a result of drinking. That suffering may take the form of declining job performance and declining health so that the individual does not yet recognize it as being related to drinking.
Here are a few signs that an individual may have moved out of the normal social drinking part of the spectrum and into the almost alcoholic zone:
- You drink to relieve stress.
- You often drink alone.
- You look forward to drinking.
- Your drinking may be related to one or more health problems.
- You drink to relieve boredom or loneliness.
- You sometimes drive after drinking.
- You drink to maintain a “buzz.”
- Your performance at work is not what it used to be.
- You aren’t comfortable in social situations without drinking.
- You find that drinking helps you overcome your shyness.
The almost alcoholic zone is actually quite large. The people who occupy it are not alcoholics. Rather, they are men and women whose drinking habits range from barely qualifying as almost alcoholics to those whose drinking borders on abuse. One thing we do know about them is that the more their drinking correlates with the above statements the more likely they are to drift further into the almost alcoholic zone.
Research on treatment for drinking problems has advanced considerably in the past 15 years, thanks in part to funding for controlled clinical trials. That research has resulted in a number of strategies that individuals can use to either stop or reduce their drinking. These methods are detailed in Almost Alcoholic: Is My (or My Loved One’s) Drinking a Problem? Of significance is that these methods have proven effective not only for men and women who are alcohol dependent, but also for those with less severe drinking problems.
An expanded view of drinking behavior in terms of a spectrum as opposed to discrete categories might be viewed by some as opening the door to over-diagnosing the associated problems. We believe the opposite will prove to be the case: that this paradigm shift will allow people to recognize problems earlier and to seek solutions without having to be labeled as alcoholics.
JOSEPH NOWINSKI & ROBERT DOYLE
Joseph Nowinsky is a clinical psychologist and author of Saying Goodbye: How Families Can Find Renewal Through Loss. Robert Doyle is a clinical instructor in psychiatry at Harvard Medical School. They are co-authors of Almost Alcoholic. [h/t: The Atlantic]