Diagnosis

‘‘To find a man’s true alcohol intake, you double what he says and halve what his wife says.’’ – Anonymous.

In accordance with the diagnostic criteria presented by the DSM – IV, the diagnosis of alcohol related disorders often requires a combinatorial assessment of behavioral and physiological symptoms exhibited. The DSM – IV segregates alcohol related disorders into ‘Alcohol Abuse’, referring to repeated consumption while ignoring adverse consequences; and ‘Alcohol Dependence’ which can be described as a physiological manifestation of alcohol abuse that presents itself as withdrawal symptoms, physiological tolerance and a compulsive tendency to consume alcohol.toc  media type="youtube" key="uWvkGwyHiKs" height="283" width="378" align="left"The establishment of a distinction between alcohol abuse and alcohol dependence is crucial for an effective treatment, since alcohol abuse can be treated using psychotherapy alone whereas alcohol dependence requires the use of stringent pharmacotherapeutical treatment methods; which precede psychotherapy. Due to this difference, individuals suspected with suffering from an alcohol related disorder are often subjected to both behavioral and clinical tests in order to accurately identify the nature and severity of their disorder. A variety of screening tests, genetic predisposition tests and liver function tests are able to do so, whereby an appropriate treatment is chosen. The most widely used screening tests used, that test primarily for alcohol abusive behavior and possible dependence, include the AUDIT test and the CAGE questionnaire. These screening tests are particularly useful in the identification of potentially hazardous patterns of drinking and provide assistance for the detection of maladaptive drinking behaviors; hence the tests can also be used to monitor individuals who may be classified as ‘alcohol abusive’ rather than ‘alcohol dependent’; and adopt preventive measures to normalize their drinking behavior

Introduced by the World Health Organization (WHO) in 1989, the Alcohol Use Disorders Identification Test is composed of 10 questions which assess the quantity and frequency of alcohol consumption in an individual; a score of 8 and greater indicates maladaptive drinking behavior. The test can be performed orally (In the form of an interview) or as a written self-questionnaire. The simplicity of this test make it a widely applicable diagnostic tool; it has been shown to successfully diagnose alcohol related disorders across individuals from various racial and ethnic groups as well as provide accurate risk assessment across different age and gender groups. A study by Torres //et al// on Spanish individuals identified as having an alcohol related disorder according to the DSM-IV diagnostic criteria, showed a 91.7% efficiency of the AUDIT screening tool (with a cut off of 7 points) in the detection of hazardous drinking.
 * AUDIT Screening Test

A relatively less sensitive screening tool compared to AUDIT, the CAGE questionnaire consists of four simple questions that hint towards a possibility of alcoholism if an individual scores greater than 2. The questions are as follows [5] : Have you ever: (a) felt the need to Cut down your drinking? (b) felt Annoyed by criticism of your drinking? (c) had Guilty feeling about your drinking? (d) had a morning Eye opener?  Due to its low sensitivity as a screening tool, the CAGE questionnaire is often used as a diagnostic aid rather than a diagnostic method. However, owing to its simplicity it is still widely used in clinical settings. 55% of physicians who admit to screening their patients for substance related disorders tend to use this diagnostic aid [5].
 * =CAGE questionnaire =

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt;">In addition to the AUDIT and CAGE screening tools, some other tests including the CRAFFT questionnaire, the Paddington Alcohol Test (PAT) and Michigan Alcohol Screening Test (MAST) have also been developed, which test for the likelihood of an alcohol related disorder in more specific situations. Such tests are able to identify maladaptive patterns of drinking behavior that can detect alcohol abuse but fail to provide concrete clinical evidence for ‘alcohol dependence’. Since ethanol has a short residence time in the body due to its fast metabolism and subsequent removal, it is often difficult to assess alcoholism by measurement of alcohol concentration in bodily fluids and can only give a precise estimate of blood alcohol content after recent alcohol consumption, proving useful as an assessment for intoxication rather than a marker for alcohol dependence. However, prolonged exposure to ethanol induces identifiable changes in physiology which can be detected and used as a diagnostic tool for ‘alcohol dependence’; but the use of such methods remains controversial. Some of the established ‘biomarkers’ for alcoholism include [6].
 * =<span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt;">Physiological Markers =

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt;"> An assessment of altered levels in the aforementioned biomarkers can be helpful in the diagnosis of alcohol dependence but cannot be considered as sole indicators of alcoholism since these markers tend to have low sensitivity and cannot confirm chronicity of alcohol consumption when used individually [6]. Several other biomarkers exist, such as AST to platelet ratio index (APRI), Acetaldehyde, Dehydrogenases (Alcohol dehydrogenase and Acetaldehyde Dehydrogenase), Hemoglobin associated acetaldehyde (HAA), lipid profile and Carbohydrate-deficient Transferin (CDT), amongst others which are affected as a result of acute exposure to ethanol and hence seldom used for the diagnosis of chronic alcoholism. [6]
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt;">__Gamma-glutyltransferase (GGT)__: A serum enzyme involved in the breakdown of extracellular glutathione which allows for the reuptake of its precursor components for subsequent intracellular synthesis [7] . Elevated levels indicate chronic exposure to alcohol.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt;">__Mean Corpuscular Volume (MCV) of Erythrocytes__: an indicator for macrocytosis, which can be caused by ethanol is indicative of the chronicity of alcohol consumption. Combined abnormal levels of GGT and MCV are reliable markers for alcoholism.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt;">__Serum transaminase__: Aspartate aminotransferase (AST) and Alanine aminotransferase (ALT); ratio of AST : ALT is useful for the prognosis of alcohol induced liver disease. It is less indicative, since AST and ALT levels can be altered due to other physiological conditions as well. [6]

=<span style="background-color: #ffffff; font-family: Arial,Helvetica,sans-serif; font-size: 10pt; vertical-align: super;">**References** =