Disorders due to use of alcohol

ICD-10F10	Mental and behavioral disorders due to use of alcohol
DSM-5-TRF10.20	Alcohol Use Disorder, Moderate or Severe

1. Definition and nosology

Disorders due to use of alcohol (ICD-11: 6C40; DSM-5-TR: F10.20 Alcohol Use Disorder, AUD) — a group of disorders characterized by impaired control over alcohol use, continued use despite physical or psychological harm. ICD-11 subtypes: harmful pattern of use (6C40.1), alcohol dependence (6C40.2), intoxication (6C40.3), withdrawal syndrome (6C40.4), alcohol-induced delirium, psychotic, mood, anxiety disorders.

2. History

1. Jellinek E.M. (1960) — ‘The Disease Concept of Alcoholism’ — alcoholism as a disease.
2. DSM-IV — ‘Abuse’ and ‘Dependence’ as separate categories.
3. DSM-5 (2013) — unified ‘Alcohol Use Disorder’ (mild, moderate, severe).
4. ICD-11 — episodic harmful use, harmful pattern of use and dependence separated.

3. Epidemiology

• Lifetime prevalence: 14–29% (NIAAA NESARC); annual 5–14%.
• Sex: 2–3 times higher in males, but increasing in females.
• Mortality: about 2.6 million deaths per year worldwide (WHO 2024, 2019 data).
• Comorbidity: MDD, anxiety, PTSD, BPD, other substance use, liver disease, cardiovascular.

4. Etiology and pathogenesis

• Heritability ~49% (95% CI 43–53) (Verhulst B. et al. Psychol Med 2015).
• Neurobiological — dopamine reward circuit, GABA, glutamate, opioid systems.
• Environment — peers, stress, alcohol availability, cultural norms.
• Genetic markers — ADH1B, ALDH2 (protective in Asian population).

5. Clinical features

5.1 Alcohol use disorder (DSM-5-TR criteria, ≥ 2 out of 11)

• More/prolonged use;
• Unsuccessful attempts to cut down;
• A great deal of time is spent obtaining, using, or recovering from substances
• Craving;
• Work/school disruption;
• Continues despite social-interpersonal problem.
• Refusal of important activities;
• Use in a dangerous situation;
• Continuation despite physical/psychological problem;
• Tolerance;
• Withdrawal syndrome.

5.2 Intoxication

• Disinhibition, dysarthria, ataxia, nystagmus, cognitive impairment.
• Severe intoxication — coma, respiratory depression, hypoglycemia, death.

5.3 Withdrawal

• Mild: tremor, sweating, tachycardia, anxiety, nausea (6–24 hours after last drink).
• Moderate: autonomic hyperactivity, hallucinations (alcoholic hallucinosis).
• Severe: delirium tremens (DT) — 48–96 hours; altered consciousness, hallucinations, autonomic crisis; mortality ~1–4% among hospitalized patients (Schuckit M.A. N Engl J Med 2014); substantially higher in historical untreated series; seizures.

5.4 Complications

• Wernicke–Korsakoff (B1 deficiency), alcoholic liver disease, cardiomyopathy, polyneuropathy, fetal alcohol syndrome (FAS).

6. Diagnosis

6.1 Unified diagnostic criteria

DSM-5-TR — ≥2 of 11 criteria (mild 2–3, moderate 4–5, severe ≥6); ICD-11 — pattern of use (single episode of harmful use, harmful pattern of use, dependence); hazardous use belongs to QE10, not to 6C4x. ICD-11 duration requirement: harmful pattern of use — at least 12 months if use is episodic, at least 1 month if continuous; dependence — at least 12 months, or at least 3 months if use is continuous (daily or almost daily).

6.2 Differences between sources

• WHO AUDIT (Saunders 1993) — 10-item screening.
• NICE CG115 — diagnosis and treatment of alcohol disorders.
• SAMHSA TIP — international protocols.

6.3 Diagnostic algorithm

• AUDIT, AUDIT-C screening at primary care level.

• Clinical interview — TLFB (Timeline Followback) use pattern.
• Laboratory: GGT, AST/ALT, MCV, CDT (carbohydrate-deficient transferrin), complete blood count.
• Comorbidity (MDD, anxiety, PTSD, somatic illnesses).
• Withdrawal risk (CIWA-Ar).

6.4 Differential diagnosis

7. Examination and assessment

1. AUDIT, CIWA-Ar (withdrawal severity).
2. GGT, MCV, CDT, transaminases.
3. Thiamine level.
4. ECG, echocardiography (cardiomyopathy).
5. Comorbidity screening.

8. Treatment

8.1 General principles (NICE CG115 · SAMHSA TIP 49 · APA 2018)

• Detoxification:
  1. Mild (CIWA-Ar <10) — outpatient;
  2. Moderate-severe — inpatient (hospitalization);
  3. Benzodiazepine (lorazepam, diazepam) — gold standard for withdrawal treatment;
  4. Thiamine 100–300 mg IV/IM × 3–5 days (Wernicke prophylaxis — BEFORE glucose).
  5. Hydration, electrolyte correction.
• Pharmacotherapy for relapse prevention:
  • Naltrexone (oral 50 mg or IM Vivitrol 380 mg monthly) — first-line; reduces cravings.
  • Acamprosate (666 mg × 3 times/day) — first-line agent; maintenance of abstinence.
  • Disulfiram — second-line; in a motivated patient; aversive reaction.
  • Topiramate, gabapentin — off-label.
• Psychosocial: Motivational Interviewing (MI), CBT, 12-Step facilitation (AA, NA), contingency management.
• SAMHSA — co-occurring substance use disorder and psychiatric comorbidity (dual diagnosis).
• Long-term relapse prophylaxis.

8.2 Treatment methods

• Motivational Interviewing (MI) — Miller W.R., Rollnick S — Enhancing readiness for behavior change; targets “ambivalence”.
• CBT for substance use — Trigger recognition, cravings management, coping skills, relapse prevention.
• Naltrexone, Acamprosate, Disulfiram — Pharmacotherapy against relapse.
• 12-Step Facilitation (AA, NA) — Project MATCH RCT — comparative effectiveness of CBT and MI.
• AUDIT, CIWA-Ar — Screening and withdrawal severity.

8.3 Differences between sources

1. NICE CG115 (2011).
2. APA Practice Guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder (2018).
3. SAMHSA TIP 49 (2009).

9. Prognosis

• With a multimodal approach, 40–50% achieve long-term remission.
• Comorbid MDD, BPD, other substance use disorder — poor prognosis.

10. Myths and misconceptions

Myth 1: “Alcoholism is a weakness of character”

Evidence: Jellinek 1960; WHO — alcohol use disorder is a medical condition; heritability approximately 50%.

Myth 2: “Detoxification alone is treatment”

Evidence: Detoxification is the initial step; relapse-prevention treatment is required; detox alone leads to 90%+ relapse.

Myth 3: “Naltrexone makes alcohol ‘unacceptable’”

Evidence: Naltrexone reduces craving and diminishes alcohol’s ‘reward’ effect; differs from disulfiram.

Myth 4: “The patient must hit ‘rock bottom’ before treatment begins”

Evidence: Early intervention is more effective; the “rock bottom” concept is not evidence-based.

Myth 5: “Alcohol is the safest substance and requires no treatment”

Evidence: WHO — alcohol causes 2.6 million deaths annually (WHO 2024, 2019 data); DT mortality is ~1–4% among hospitalized patients (Schuckit M.A. N Engl J Med 2014); substantially higher in historical untreated series.

Myth 6: “‘A little alcohol is safe’ in pregnant women”

Evidence: CDC, AAP — any amount of alcohol during pregnancy creates a risk of FAS; there is no ‘safe’ dose.

11. Sources

• WHO. ICD-11. 6C40 Disorders due to use of alcohol. 2024.
• APA. DSM-5-TR. 2022.
• NICE CG115. Alcohol-use disorders: diagnosis, assessment and management. 2011.
• APA. Practice Guideline for the Pharmacological Treatment of Patients with AUD. 2018.
• SAMHSA. TIP 49: Incorporating Alcohol Pharmacotherapies Into Medical Practice. 2009.
• Anton R.F. et al. COMBINE trial. JAMA 2006;295(17):2003–2017.
• Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity. J Stud Alcohol 1997;58(1):7–29.
• Verhulst B., Neale M.C., Kendler K.S. The heritability of alcohol use disorders: a meta-analysis of twin and adoption studies. Psychol Med 2015;45(5):1061–1072.
• Schuckit M.A. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med 2014;371(22):2109–2113.
• Saunders J.B., Aasland O.G., Babor T.F. et al. Development of the Alcohol Use Disorders Identification Test (AUDIT). Addiction 1993;88(6):791–804.
• Miller W.R., Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York: Guilford Press, 2013.