Self-diagnosis and self-prescribing: Time for a rethink.

Alcoholism diagnosis and treatment is gripped by an all-pervading attitude, engendered by AA and 12-Step followers that one is an alcoholic by confession, not medical diagnosis.  AA advocates that before anyone can be helped with alcoholism, they must first admit that they are an alcoholic and then follow a therapy regime which revolves around counselling, group therapy and the acceptance of a “greater power” which will, it is hoped, lead the alcoholic away from his illness.

Statistics, such as they are, showing the success rate of this treatment fail to demonstrate a recovery rate which out-performs spontaneous recovery with no treatment of any sort, about 5% per annum.

The DSM-5 criteria for diagnosing Alcohol Use Disorder is not a lot better in setting out what alcoholism is or, indeed, providing guidance in how to treat it.  For instance, the first criteria is  “Had times when you ended up drinking more, or longer, than you intended?”  The rest follow in the same fashion, referring to what might be described as “negative outcomes” or situations one might find oneself in.  Only in the last of the criteria is there a mention of some physical symptoms which might point towards an underlying physiological condition which might be treated medically, such as “trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart or a seizure”.

The more of these negative outcomes and symptoms one has and the more serious they are, the more serious is the Alcohol Use Disorder.  The criteria, updated in 2013 by the American Psychiatric Association eliminates “legal problems” as a criteria.

It is surely odd that what should be seen as a medical or psychiatric illness should ever have been diagnosed by reference to the times one has been arrested and appeared in court, but this passes without comment in the world of alcohol treatment.

It’s certainly right to look at symptoms of an illness in any diagnosis but the symptoms of AUD don’t appear to give any guidance as to their specific origin or to their being spefically related to over-consumption of alcohol.    At best DSM-V is indicative that there is a problem but only because it refers to alcohol consumption.  It asks the question “Do you drink too much?” to diagnose a person as someone who “drinks too much”.

The theory behind the use of baclofen in alcoholism suggests a better approach to alcoholism diagnosis and treatment.  Ameisen set out a new construction of alcoholism as a neurologically driven anxiety-craving which results in an overwhelming and uncontrollable craving for alcoholism.   Of course, the negative consequences of this illness to the sufferer are the same as those set out in DSM-V, but Ameisen tracks the origin of this disorder to a chemical imbalance, a shortage of endogenous GHB in the brain of the sufferer which can be treated with baclofen.  This gives a very clear description of a neurological illness and points towards a cure, even if the precise mechanism of the illness needs further study.

DSM-V is, at best, a tool for describing the seriousness of the illness and that is very useful from a medico-legal perspective in determining when a person is suffering from an illness which might have legal consequences but it provides no insight into how to treat the illness or the manner in which it causes the alcoholic to behave in the way which he does, creating such a wide range of very dangerous and damaging symptoms and consequences.

It would be very odd if other illnesses were only defined in terms of the consequences to the sufferer.  Cancer involves the uncontrolled growth of cells which can be seen using various techniques.  It would be absurd to begin treating a cancer patient based on their own profession that they are a cancer sufferer or on the basis of symptoms which are at best, ambiguous and not to take a biopsy or perform a scan.  But such is the state of play in alcoholism treatment.

Surely the time has come to focus on the physiological effects of alcohol use and to re-examine our approach to diagnosis and treatment and to move away from a sociological view of alcoholism as a basket of negative outcomes and symptoms of unknown origin which collectively suggest that a patient who is drinking to much should reduce their drinking.











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