This chapter addresses diagnostic and assessment issues across the continuum of individuals suffering with alcohol problems, ranging from “misusers” to those who are severely dependent on alcohol. Although scientific study and clinical treatment historically focused on individuals who were severely dependent on alcohol, it is now widely recognized that such persons constitute a minority of the public suffering with alcohol problems. Epidemiological studies reveal that individuals with less serious alcohol problems outnumber those with severe alcoholism (Curry, Ludman, Grothaus, Gilmore, & Donovan, 2002; Institute of Medicine, 1990; World Health Organization, 2004). This recognition has led to increased research on and clinical attention to individuals with less severe alcohol problems, as well as the widespread acknowledgment that alcohol use problems lie along a continuum. To this end, changes in the alcohol use disorders diagnostic criteria from the fourth to the fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA], 2000a, 2013) reflect a move to a continuum-based (vs. taxonomy-based) conceptualization of alcohol use problems, and functionally extend the diagnosis to less severe cases.

In anticipation of publishing the DSM-5, the American Psychiatric Association convened a Substance-Related Work Group to update and improve the alcohol use disorder diagnostic criteria. The work group concluded that the overuse of the terms addiction and dependence has confused the diagnosis and treatment of people with alcohol use disorders and resulted in patients with normal tolerance and withdrawal being labeled as “addicts.” Moreover, they agreed that alcohol use problems are best conceptualized as a unitary construct, a conceptual shift from the biaxial distinction between alcohol abuse and dependence that appeared in DSM-IV. In addition, the work group eliminated the DSM-IV legal problems criterion from the DSM-5 criteria given substantial research documenting its limited clinical utility. They also added a new criterion to the DSM-5, alcohol craving, based on mounting empirical evidence in support of its diagnostic utility and centrality in regard to alcohol use disorder.

Several recent studies have supported the DSM-5 changes in regard to alcohol use disorders, particularly the adoption of a one factor model of disorder (e.g., Hagman & Cohn, 2011; Kuerbis, Hagman, & Sacco, 2013; Mewton, Slade, McBride, Grove, & Teesso, 2011). Interestingly, a recent study of the WHO’s ICD-10 alcohol dependence and harms criteria also supported a one-factor model. Thus, studies of both the American and international diagnostic systems’ criteria for alcohol use disorders support a single factor conceptualization. Moreover, it appears that the DSM-5 criteria are an improvement over the DSM-IV criteria for identifying those with low severity alcohol use disorders, particularly in college student (Hagman & Cohn, 2011) and older adult populations (Kuerbis, Hagman, & Sacco, 2013). That said, most studies have found only modest differences in alcohol use disorders prevalence rates when comparing the DSM-IV and DSM-5 (e.g., Dawson, Goldstein, & Grant, 2013; Edwards, Gillespie, Aggen, & Kendler, 2013), a finding that led Dawson et al. (2013) to conclude “[o]n the whole, the similarities in profiles of DSM-IV and DSM-5 AUD far outweighed the differences” (p. E312).

In DSM-5, alcohol use disorder is defined as a problematic pattern of use leading to significant impairment or distress as manifested by at least two behaviors such as: (a) using alcohol in larger amounts or for a longer time than intended; (b) a persistent desire or unsuccessful attempts to cut down or control use; (c) significant time being spent to obtain, use, or recover from alcohol use; (d) cravings or strong desires (urges) to use; (e) failure to fulfill obligations; (f) interpersonal problems occur because of persistent use; (g) the individual gives up important activities (work, social interaction) because of alcohol; (h) evidence of tolerance (defined as the need for increasing amounts of alcohol to achieve intoxication or a markedly diminished effect with continued use of the same amount); and (i) withdrawal (defined as physiological responses that occur after consistent and excessive use).

In DSM-5, a diagnosis of alcohol use is given a severity rating. Mild alcohol use disorder is assigned when two or three of the previously mentioned behaviors are present; moderate severity is defined as the presence of four or five symptoms; and six or more symptoms is labeled severe.

Current views about alcohol use problems are a grafting of concepts derived from research, clinical anecdotes, and common wisdom. Over the past century, public opinion has softened from viewing those who suffer with alcohol problems as moral reprobates to being victims of a disease. In the United States, the view that alcohol problems are a medical disorder became dominant in the mid-1900s with the rise of Alcoholics Anonymous (AA), the seminal work of E. M. Jellinek, and the proclamation by the American Medical Association that alcoholism is a disease. The embracing of the disease concept was intended to shift responsibility for dealing with alcohol problems from the criminal justice system to the health-care system.

Alcoholics Anonymous, the ubiquitous mutual help approach that emerged in the 1930s, viewed alcoholism as a biological aberration—an “allergy” to alcohol (i.e., with repeated exposure to alcohol, alcoholics would quickly become physically dependent on the substance, and once dependent they would continue to drink to avoid withdrawal symptoms). To explain relapse, AA stated that alcoholics had an “obsession” to drink like normal drinkers. In addition, alcoholism was thought to be a progressive disorder (i.e., if alcoholics continued to drink, their problem would inevitably worsen), and persons who were mildly dependent on alcohol were thought to be in the “early stages” of developing alcoholism. Consequently, even those with mild problems were viewed as needing the same treatment as those who were severely dependent.

E. M. Jellinek, a scientist, attempted to bridge the gap between lay views and the evidence in support of the disease concept. He and others felt that the medical profession should be responsible for treating alcohol abusers (Bacon, 1973). Although he alluded to genetic components, he did not speculate as to why some drinkers develop alcohol problems but others do not. Jellinek did postulate that alcoholics: (a) use alcohol to cope with emotional problems; (b) over time develop tolerance to alcohol, thereby leading to increased consumption to achieve desired effects; and (c) eventually develop “loss of control,” where even small amounts of alcohol would initiate physical dependence and trigger more drinking (Jellinek, 1960). Finally, Jellinek proposed that there were many types of alcohol problems, including gamma alcoholism, which he felt was the most common type in the United States and a progressive disorder.

Over the past half century, considerable research has refuted these traditional conceptualizations. Although some individuals may be genetically predisposed to develop alcohol problems, a large proportion of individuals with alcohol problems do not have this positive family history, and a large proportion of individuals with a positive family history for alcohol use disorders do not have alcohol problems (Dahl et al., 2005; Humphreys, 2009). Research shows that social and cultural factors play a large role in the development of alcohol problems (Hendershot, MacPherson, Myers, Carr, & Wall, 2005; Miles, Silberg, Pickens, & Eaves, 2005; Penninkilampi-Kerola, Kaprio, Moilanen, & Rose, 2005). Moreover, in most cases of alcohol problems, the natural history of the disorder is not progressive (Dawson, 1996; Institute of Medicine, 1990); rather, it includes periods of alcohol problems of varying severity separated by periods of either nondrinking or drinking limited quantities without problems (Cahalan, 1970; King & Tucker, 2000). Also, natural history studies have found that recovery from alcohol problems in the absence of treatment is more prevalent than once thought (Bischof, Rumpf, Hapke, Meyer, & John, 2003; Dawson et al., 2005; Klingemann et al., 2001; Klingemann, Sobell, & Sobell, 2009; Mohatt et al., 2007; Sobell, Cunningham, & Sobell, 1996; Sobell, Ellingstad, & Sobell, 2000).

With regard to loss of control, research has demonstrated that even in very severe cases, physical dependence is not initiated by a small amount of drinking (Marlatt, 1978; Pattison, Sobell, & Sobell, 1977); other factors, such as conditioned cues (Niaura et al., 1988) and positive consequences of drinking (Orford, 2001), are necessary to explain why some people continue drinking despite having repeatedly suffered adverse consequences (Humphreys, 2009). Finally, considerable research shows that mildly dependent alcohol abusers respond well to brief interventions, often by reducing their drinking to nonproblematic levels rather than ceasing their drinking (Bien, Miller, & Tonigan, 1993; Cunningham, Wild, Cordingley, van Mierlo, & Humphreys, 2010; Hester, Delaney, Campbell, & Handmaker, 2009; Sobell & Sobell, 1993; Sobell & Sobell, 1995).

Unless the reasons to stop drinking are extremely compelling, individuals with alcohol problems are very ambivalent about ending their alcohol use. Alcohol use is widespread in our society, and even those with severe alcohol dependence like the subjective experience of drinking. For individuals at the less severe end of the alcohol problem continuum, ambivalence can be very pronounced because the decision to stop or reduce drinking is based on probable risks rather than certain consequences. Failure to recognize this commonplace and logical ambivalence about stopping drinking can seriously compromise the success of the assessment and treatment process.

Traditional conceptualizations assert that individuals with alcohol problems will present in denial; that is, they will fail to recognize that their drinking is a problem (Nowinski, Baker, & Carroll, 1992). In response, traditional interventions attempt to confront and break through the denial. The rationale is that this procedure is consistent with the first step of AA (i.e., recognizing that one is powerless over alcohol; Nowinski et al., 1992). However, being confronted and labeled as alcoholic often elicits resentment, retaliation, and resistance to intervention. Stated simply, a confrontational approach to assessment and treatment can cause otherwise receptive clients to deny that they have an alcohol problem. An alternative approach concentrates on the ambivalence and avoids the use of confrontation, labeling, or other tactics that provoke defensiveness and resistance. This alternative nonthreatening, nonconfrontational style of interviewing is called motivational interviewing (MI; Miller & Rollnick, 1991, 2002, 2013; Substance Abuse and Mental Health Services Administration, 1999), which has grown immensely in popularity over the past two decades. Several randomized controlled trials (RCTs) of brief interventions using MI principles have found clinical significant improvements among individuals with alcohol problems (Bien et al., 1993; Burke, Arkowitz, & Menchola, 2003; Copeland, Blow, & Barry, 2003; Heather, 1990; Rubak, Sandbæk, Lauritzen, & Christensen, 2004; Sobell & Sobell, 1993), which has led MI to becoming accepted as an empirically supported treatment approach for alcohol problems.

Diagnostic formulations play an integral role in decisions about treatment goals and intensities, and are a requirement of insurance and clinical recording. An accurate diagnosis defines the problem in a way that can be communicated and understood by clinicians and researchers. A diagnostic formulation coupled with an assessment provides an initial understanding of the problem as well as a foundation for initial treatment planning. The two major diagnostic classifications of mental disorders are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the Mental Disorder section of the International Classification of Diseases (ICD). The first DSM (DSM-I) was published in 1952 by the American Psychiatric Association and was a variant of the ICD-6. Over the past few decades, changes in the DSM alcohol use disorder classification criteria have reflected both the state of knowledge and contemporary attitudes. For example, while the DSM-III-R viewed alcohol dependence as a graded phenomenon ranging from mild (enough consequences to meet criteria but no major withdrawal symptoms) to severe (several negative consequences and withdrawal symptoms), the DSM-IV separated psychological from physiological dependence by making physical dependence a specifier rather than a central symptom. Presently, the DSM-5 eliminates the distinction between alcohol dependence and alcohol abuse, and instead views alcohol use disorders as varying only in terms of severity.

Several common clinical features of alcohol use disorders complicate their diagnosis and treatment. First, there is a high prevalence of co-occurring psychiatric disorders among individuals with alcohol problems (National Survey on Drug Use and Health [NSDUH], 2004, 2006, 2007; Nunes, Selzer, Levounis, & Davies, 2010). Psychiatric disorders with an exceptionally high co-occurrence with alcohol disorders include mood disorders such as depression, anxiety disorders, schizophrenia, and personality disorders such as antisocial personality disorder and borderline personality disorder. Given the frequent co-occurrence with psychiatric disorders, diagnostic formulation with alcohol disorders must assess three things: (1) the extent and nature of the alcohol problem; (2) the extent and nature of psychiatric disorders; and (3) and the extent and nature of interaction between alcohol problems and psychiatric problems (Boden & Moos, 2009; Mack, Harrington, & Frances, 2010). Ideally, individuals should be alcohol free for several weeks in order to accurately assess for co-occurring psychiatric diagnoses, because active alcohol use can mask or exacerbate psychiatric symptoms (Schuckit, 1995).

Several studies have shown that people with alcohol use problems with co-occurring psychiatric problems have poorer treatment outcomes than people with alcohol use problems without co-occurring psychiatric problems (Le Fauve et al., 2004; Nunes et al., 2010). Although an integrated treatment approach involving additional and specialized counseling is often suggested for clients who have co-occurring disorders (Steele & Rechberger, 2002), there is a lack of empirical data about whether ancillary counseling improves treatment outcomes among individuals with a dual diagnosis of alcohol and psychiatric disorders (Assanangkornchai & Srisurapanont, 2007; Baigent, 2005; Echeburúa, Bravo de Medina, & Aizpiri, 2007; Le Fauve et al., 2004; Trull, Jahng, Tomko, Wood, & Sher, 2010; Whicher & Abou-Saleh, 2009).

Second, many individuals with alcohol disorders also have problems with the use of other substances. For people with alcohol problems who use other drugs including nicotine, it is important to gather a comprehensive profile of all types of psychoactive substance use and substance use problems. Over the course of an intervention, drug use patterns may change (e.g., decreased alcohol use, increased smoking; decreased alcohol use, increased cannabis use). Furthermore, alcohol abusers who use other drugs may experience pharmacological synergism (i.e., a multiplicative effect of similarly acting drugs taken concurrently) and/or cross-tolerance (i.e., lessened drug effect because of past heavy use of pharmacologically similar drugs), both of which must be considered when treating those with alcohol problems who use other drugs. The foregoing speaks to important differences between the treatment of individuals with alcohol use problems only and of individuals who have other substance use problems in addition to their alcohol use problems (Batki et al., 2009; González-Pinto et al., 2010; Pakula, Macdonald, & Stockwell, 2009; Shillington & Clapp, 2006).

Third, people with an alcohol use disorder who drink alcohol daily and in large quantities are likely to experience withdrawal symptoms when access to alcohol is restricted. These symptoms can range from minor withdrawal symptoms (e.g., psychomotor agitation) to, in the most severe cases, delirium tremens (DTs). A history of past withdrawal symptoms, coupled with reports of recent heavy ethanol consumption, can alert clinicians that withdrawal symptoms are likely to occur upon cessation of drinking; such symptoms can be successfully managed with medical interventions. Moreover, some research suggests that severity of alcohol dependence may interact with response to treatment goals; different treatment intensities may be the most appropriate treatment with different levels of dependence (e.g., mild vs. severe), consistent with client-treatment matching (Babor & Del Boca, 2003; McKay, 2009). Thus, important diagnostic goals when assessing individuals with alcohol problems are to determine the severity of the problem and whether withdrawal symptoms are likely to occur when drinking is reduced.

Next to caffeine, alcohol is the second most used psychoactive substance (Adams, Martinez, & Vickerie, 2009). The World Health Organization (WHO, 2004) estimates that approximately 2 billion people worldwide consume alcoholic beverages and 76.3 million people have diagnosable alcohol use disorders. The global burden related to alcohol consumption, both in terms of (a) morbidity and mortality and (b) economic and social costs, is considerable. Worldwide, it has been estimated that alcohol causes 1.8 million deaths (3.2% of total) and a loss of 58.3 million (4% of total) of Disability-Adjusted Life Years (DALY) (WHO, 2004). High-level, long-term, chronic drinking dramatically increases the risk for more than 60 diseases (English & Holman, 1995; Gutjahr, Gmel, & Rehm, 2001; Ridolfo & Stevenson, 2001; Single, Robson, Rehm, & Xi, 1999). Alcohol use problems play a causal role in 20% to 30% of esophageal cancer, liver cancer, cirrhosis of the liver, homicide, epileptic seizures, and motor vehicle accidents worldwide (WHO, 2004). Acute intoxication from drinking is associated with motor vehicle traffic accidents, homicide and unintentional or intentional injury, falls, and poisonings (WHO, 2004). Moreover, alcohol consumption is linked to many harmful consequences for the individual drinker, the drinker’s immediate environment, and society as a whole. Alcohol-related social consequences include traffic accidents, workplace-related problems, family and domestic problems, and interpersonal violence (Klingemann & Gmel, 2001).

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) surveyed a representative sample of 42,862 American adults in the National Longitudinal Alcohol Epidemiologic Survey (Grant, 1997). It was found that the lifetime prevalence of alcohol dependence was 13.3%, and the past-year prevalence was 4.4%. Men were more likely than women to use alcohol and to have alcohol use disorders. NIAAA conducted a second survey of a representative sample of 43,093 Americans in the National Epidemiologic Survey on Alcohol and Related Conditions (Stinson et al., 2005) and found the 12-month prevalence of alcohol use disorders to be only 7.35%, and of comorbid alcohol and substance use disorders to be 1.10%. In terms of the stability of diagnoses, Hasin, Grant, and Endicott (1990) found that of those individuals originally diagnosed as alcohol dependent, 46% were still classified as dependent 4 years later, 15% were classified as having alcohol abuse, and 39% could not be diagnosed with an alcohol problem. Similarly, in a national survey, Dawson (1996) found that among 4,585 adults who previously had met criteria for a DSM-IV diagnosis of alcohol dependence, 28% still met the criteria for alcohol abuse or dependence, 22% were abstinent, and 50% could not be diagnosed as having an alcohol problem. As compared to people who had not been in treatment, treated individuals were more likely to be abstinent (39% vs. 16%), whereas those who had not been treated were more likely to be drinking asymptomatically (58% vs. 28%). In another national survey, Dawson (2000) reported that frequency of intoxication had the strongest association with the probability of having a diagnosable alcohol use disorder, followed by the frequency of drinking five drinks per day. These findings underscore that alcohol problems are not necessarily progressive.

From the standpoint of symptom-based prevalence, the ratio of problem drinkers to severely dependent drinkers is a function of the definitions used and the populations sampled. Regardless of the definitions, on a problem severity continuum the population of persons with identifiable problems but no severe signs of dependence is much larger than the population with severe dependence. Problem drinkers constitute 15% to 35% of individuals in the adult population, whereas severely dependent drinkers account for 3% to 7% (Hilton, 1991; Institute of Medicine, 1990). Moreover, the prevalence of alcohol abuse is approximately twice the prevalence of alcohol dependence (Harford, Grant, Yi, & Chen, 2005).

Drinking problems are not distributed equally across sociodemographic groups. Males continue to outnumber females (NIAAA, 2005), though the gender gap in alcohol use disorders has been narrowing since the Vietnam War (Grant, 1997). Besides gender differences in prevalence, problem drinking tends to occur later in life for women (NIAAA, 2005). Alcohol-related problems also appear to be inversely related to age, with the highest problem rates occurring for those 18 to 29 years of age (Fillmore, 1988; NIAAA, 2000; Robins & Regier, 1991; Substance Abuse and Mental Health Services Administration [SAMHSA], 2004). Marital status also is related to problem drinking, with single individuals experiencing more physiological symptoms of dependence and more psychosocial problems than those who are married (Hilton, 1991; SAMHSA, 2006). Specifically, alcohol abuse or dependence is more prevalent among adults who have never married (16.0%) than among adults who are divorced or separated (10.0%), married (4.6%), or widowed (1.3%) (SAMHSA, 2006).

Even though epidemiological studies provide information on ethnic and racial differences in relation to alcohol use and abuse, the methods used for categorizing respondents’ cultural/ethnic backgrounds have been rudimentary. Consequently, data on ethnic differences must be considered preliminary. That said, across ethnic/racial groups, national epidemiological studies consistently document ethnic variation in drinking, alcohol use disorders, alcohol use, and treatment engagement and retention (Chartier & Caetano, 2010). Compared with other ethnic groups, (a) Native Americans and Hispanics report higher rates of high-risk drinking; (b) Native Americans and Whites have a greater risk for alcohol use disorders; (c) Native Americans, Hispanics, and Blacks experience more severe drinking-related consequences; and (d) Hispanic problem drinkers are less likely to enter and stay in treatment. Moreover, among alcohol-dependent drinkers, Blacks and Hispanics are more likely to demonstrate recurrent or persistent alcohol dependence. Among Asian Americans, alcohol problem rates are generally lower than among other ethnic and cultural groups (Galvan & Caetano, 2003; Makimoto, 1998; NIAAA, 1993). However, some evidence suggests that Asian Americans of mixed ethnic heritage may be at elevated risk for alcohol use problems (Price, Risk, Wong, & Klingle, 2002). Both Asian cultural norms and physiological sensitivity to alcohol appear to influence the likelihood of alcohol use problems among Asian American groups (Clark & Hesselbrock, 1988).

A thorough and careful assessment is critical to the development of meaningful treatment plans, and an accurate diagnosis of alcohol use and other concurrent disorders is integral to the assessment process. Assessment serves several critical functions; it provides clinicians with (a) an in-depth picture of a person’s alcohol use, problem severity, and related consequences—this picture can be used to develop an individualized treatment plan tailored to the needs of each client; (b) an objective process by which to gauge treatment progress; and (c) empirical feedback about how a treatment plan already in place could be improved. The depth and intensity of an assessment will be related to problem severity, the complexity of the presenting case, and the specific interests of the clinician and/or researcher conducting the assessment. The instruments and methods described in this chapter can be used clinically to gather information that is relevant to the assessment and treatment planning process. The implications of assessment data for treatment issues, such as drinking goals and treatment intensity, show how the clinical interview can significantly affect treatment.