Are You Almost Alcoholic? Taking a New Look at an Old Problem

According to the literature, you're either an alcoholic or you're not an alcoholic. But might more awareness of the in-between help us?

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Whitney Houston's cause of death has been identified as accidental drowning, but in the weeks leading up to the report, rumors were swirling. She had a confirmed history of alcohol and drug abuse, and reports indicate that she had been drinking heavily in the days before her last. Headlines like this occur far too often and when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this 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?

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.

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.

Presented by

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.

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