Beyond the Dumpster Fire: The Web of Alcohol Use Disorder

We explore Alcohol Use Disorder (AUD), covering diagnosis criteria, progression, causes, and effective treatment approaches according to the DSM.

• AUD falls under substance-related disorders in the DSM with 11 specific criteria
• Severity is classified as mild (2-3 criteria), moderate (4-5), or severe (6+ criteria)
• Criteria include drinking more than intended, inability to quit, cravings, and withdrawal symptoms
• People often drink to self-medicate stress, trauma, or negative emotions
• Effective treatment requires individualized approaches rather than one-size-fits-all solutions
• The trans-theoretical model (stages of change) recognizes recovery as a cyclical journey
• Motivational interviewing helps clients explore ambivalence and move toward healthier choices
• Family therapy helps relatives understand AUD and provide appropriate support
• Other effective approaches include contingency management, DBT, and relapse prevention
• Key assessment tools include AUDIT-C, CAGE, TWEAK, T-ACE, CRAFFT, and ASSIST
• Recovery should be viewed as a journey with potential relapses, not a one-time fix

Remember, it's in there!

If you need to study for your national licensing exam, try the free samplers at:  LicensureExams


This podcast is not associated with the NBCC, AMFTRB, ASW, ANCC, NASP, NAADAC, CCMC, NCPG,  CRCC, or any state or governmental agency responsible for licensure.

Transcript

Introduction to AUD and DSM Criteria

Speaker 1 0:07

Hi, there you lightworkers. I'm Dr Linton Hutchinson, and with me today is Eric Twatman.

Speaker 2 0:14

Hi you pillars of society. Today, the disorder of the day is AUD or alcohol use disorder, and we're going to include what you're going to look for in the DSM how it progresses, where it comes from and what the best treatments are Lucky for you.

Speaker 1 0:31

you inherited an allergy to alcohol.

Speaker 2 0:34

Yes, well, at least mom said she broke out whenever she took a sip, but I think I noticed a few sips happening regardless.

Speaker 1 0:43

Right, and every time that you take a sip, I know you break out in handcuffs.

Speaker 2 0:47

Well, yes, that's a good reason to quit. That last bender was. You know they had to write it up in the paper.

Speaker 1 0:54

Okay, so Ez, what do we need to know about AUD?

Speaker 2 0:58

Well, it's a substance-related disorder in the DSM which you know if you think about. It makes sense, and it's diagnosed when someone's relationship with alcohol starts resembling a toxic waste dump, draining their quality of life as they refuse to quit drinking.

Speaker 1 1:14

Hmm, so are there other disorders in the DSM that address alcohol use? Or is AUD the Taylor Swift of this category?

Speaker 2 1:24

Well, well, yeah, I listen to all its albums. Yes, there are differentials or other conditions to rule out, but we're going to be talking about AUD A because of its prevalence and because when it's comorbid with another disorder, it's usually obvious that that's part of the deal.

Speaker 1 1:49

Well, luckily Stacy isn't here she would ask you about specifiers. That's her favorite thing to talk about.

Speaker 2 1:58

Well, and it's well that you have her around, because there are three specifiers mild, moderate and severe. And you can tell because those specifiers there are 11 criteria in the DSM Mild is 2 to 3, moderate is 4 to 5, and severe is 6 or all the way up to 11.

Speaker 1 2:17

So give me an example of what those criteria might be.

Speaker 2 2:21

Well, drinking more or longer than intended, not being able to quit, even if you're trying, drinking larger amounts over a longer period than you intended to cravings that won to quit, even if you're trying, drinking larger amounts over a longer period than you intended to Cravings that won't quit. Symptoms when you do quit, basically when alcohol becomes your clungy BFF and won't take the hint.

Speaker 1 2:42

Or another one would be when you skip social events because you can't bring your own bottle right. Yes, exactly.

Speaker 2 2:49

Or you know that friend that comes to your house and immediately starts asking where the alcohol is right, yeah, so there's withdrawal symptoms that people have, like trembling or sweating, when they stop drinking.

Speaker 1 3:03

So what's that called?

Understanding Why People Drink

Speaker 2 3:05

That's called the DTs delirium tremens and yes, that's a definite sign that something's happening, and they all have to happen within a 12-month period. So you know, you had a craving back in 1975 and you haven't had it since. You're not a candidate.

Speaker 1 3:23

Uh-huh. So why do you think people drink anyway?

Speaker 2 3:26

Well, often stress, trauma, negative emotions, which in that case we think of it as self-medication, but basically covering up the problems in life. And of course there's a genetic component, but mainly the, you know, we think of it as the self-medication as a starting point.

Speaker 1 3:47

So, basically, people drink to cover up the dumpster fires that they have of their lives, instead of trying to put them out.

Speaker 2 3:54

Yes, because we know alcohol is flammable. It's really the worst thing to put out the dumpster fire with.

Speaker 1 3:59

Yeah, that's right. Well, sometimes I self-medicate with sushi and extra wasabi.

Speaker 2 4:05

Yes, as a matter of fact, I've seen you laying in the gutter asking passersby for more wasabi and it's a sad sight and we're going to do an intervention soon for you.

Speaker 1 4:16

Okay, well, you know it does give me some temporary relief and, as you know that, once you start doing it, it leads to the vicious cycle where sushi becomes your primary method for coping with any problems that people have.

Speaker 2 4:31

Well, yes, when you've got to have wasabi, it's not that bad a self-medication thing, whereas alcohol can certainly ruin your life, and what's important to know is whether it's stress or traumas or physiological. It is a complex web of issues that can start a person down the path and it's important to deal with, regardless of which thread is coming to make it the problem in the person's life, or whether or not you understand what's driving the engine Once it's out of control. The point is to stop it. So you want to help the client find the root causes and also deal with the problems Right.

Speaker 1 5:10

So you, as a therapist, try to help the client find the root causes and also deal with the problems Right. So you, as a therapist, try to help the client by not blaming them. And another thing you need to do is try to identify the causes.

Speaker 2 5:19

You're right. Once you start blaming, you're really just heaping on what they've felt from everybody else, and now you're part of the problem.

Speaker 1 5:27

So once they understand why they drink, then that's it right.

Speaker 2 5:34

But once they understand why they're drinking where it's coming from, that's, like you know, seeing where you started on the road. But no, the problem is that they need to find a better coping strategy, like you have with celery juice.

Speaker 1 5:51

Except my celery juice. When I do it, it's a healthy kind of a thing, so I'm really not addicted to it.

Speaker 2 5:57

I only drink one glass a day every day yeah, it sounds like the definition of an addiction. Every day you got to have that green monkey on your shoulder there. Well, the bottom line is, when you're treating AUD, you should operate under the assumption that your client or your celery juice addict can recover. But it takes a lot of work from multiple directions, and it's not just understand how you drink and stop. It's all of the threads that are going to help.

Speaker 1 6:28

Okay. So the one thing you've got to remember is you have to have an individualized treatment plan with the client, because one size fits all just doesn't work Exactly Right. So how do we help clients with AUD? I assume it's more than just saying, just say no, and handling them. A celery juice recipe.

Speaker 2 6:51

The recipe you mean grinding up a bunch of celery. That is a toughie. Yes, as a matter of fact, there are multiple ways of dealing with it and one of them is your favorite.

Speaker 1 7:04

Yes, stages of change. Model right the trans theoretical model yes, absolutely the. The words are like music to my ears okay, we I know we just did a podcast on that, but that's right, let's go ahead and talk about the stages of change, or I call it the PCP-AMT.

Speaker 2 7:24

Yes, you do. You love to call it that Right, or?

Speaker 1 7:27

what are they? Pre-contemplation, pre contemplation, contemplation, preparation.

Speaker 2 7:33

Preparation.

Speaker 1 7:34

Action.

Speaker 2 7:35

Maintenance. Maintenance and termination, yes. And in pre-contemplation you don't think you have a problem, I I don't know why people are talking about it. I can quit anytime I want. It's not a deal. And so it's like their friend that having 12 cats is totally manageable. And then you know, all it smells like is the inside of a litter box. Then comes a contemplation stage where the client starts weighing the pros and cons. But they're still weighing it because they don't realize that it's a deal in their life. Sort of me like when I'm at an all-you-can-eat buffet.

Speaker 1 8:10

Right, okay. So what about motivational interviewing?

Speaker 2 8:15

Well, that's where you take a more active role. Right, because in the stages of change, you're helping the client realize what stage they're in. Right, in the motivational interviewing, you're doing just what it says. You're helping to motivate them to make those changes. So you know, go ahead and put down that bottle right, Right.

Speaker 1 8:38

So basically you're helping them explore their ambivalence about change and nudging in towards the healthier choices.

Speaker 2 8:47

Yes, and it's the nudging that makes it the more active part. You're not just sitting on the sideline anymore, you're actually intervening to a bigger extent.

Speaker 1 8:57

Right, so you do that, and a lot of things are going to come up to the surface. So when it bubbles up, then what?

Speaker 2 9:06

Well, right, and now they're looking at the. Well, back to the trans-theoretical model, they're looking at the contemplation stage they're actually looking at do I really need to drink that fifth of Jack Daniels every day? Or do I need to do something about fifth?

Speaker 1 9:21

of Jack Daniels every day, or do I need to do something about it? I thought you liked rum and coke. Well, how about family therapy? That sounds important too, unless, of course, part of your family is part of the problem.

Speaker 2 9:30

Not, unless you assume the family is part of the problem and that they need help in figuring out what to do with their problematic sibling, son, father, whatever it is, because often the family is just as clueless as what to do as the client themselves. So family therapy is important to help ground them in A what to look for and, b how they can actually be of help, rather than what they've probably been doing, which is just heaping on the guilt.

Speaker 1 10:00

Right, judgment and blame. They have a tendency to do that.

Speaker 2 10:04

Well, right and you can see where it comes from and, by the same token, you can see why it's so unhelpful.

Family Therapy and Support Systems

Speaker 1 10:10

Yeah, one of the problems with the family therapy is the fact someone's doing really well and let's say they were in the maintenance phase. Then they relapse and the wife or the husband or the grandparents starts blaming them and shaming them.

Speaker 2 10:26

Yes, If only you had stayed off the bottle, then we wouldn't be in this problem, which that's part of the genius of the trans-theoretical model is noticing the cyclical nature, like we mentioned in the podcast, of the fact that you expect it. It's baked into the theory that there are going to be problems, there are going to be relapses, and that you just expect it and that you figure out what to do, not if it happens.

Speaker 1 10:52

but when it happens. So I guess you'd have to spend a lot of time educating the family about what they can expect in terms of someone dealing with their addiction.

Speaker 2 11:03

Well, yes, and as a matter of fact, that's such a big part of it that we haven't talked about it yet. But you know about the 12-step programs, like in Alcoholics Anonymous. There's another group called Al-Anon that's specifically for families of alcoholics. It deals with the you know, their own 12-step journey in how to deal with the alcoholic member of their family. So, yeah, it's that big a thing that it's not just some little niche where you talk about family therapy. It's like part of what you need to deal with.

Speaker 1 11:35

It's a good point. It's a good point. You know, there's another technique contingency management.

Speaker 2 11:41

Yes, I figured you'd love that one because you like the Premack principle, don't you? I do like the Premack and it sounds just like it. Yes, tell us what it involves.

Speaker 1 11:51

Basically, you're going to be getting some type of tangible rewards for whatever positive behaviors you have regarding not drinking.

Speaker 2 12:00

Right. So you didn't drink today, so here's a nickel. Good job.

Speaker 1 12:03

No, it's got to be more than that is.

Speaker 2 12:06

Oh, you didn't drink, so here's a 10 spot. There you go. Yes, so basically classic behaviorist therapy where you're giving a positive reward for positive behavior, exactly, and not really talking about the negative behaviors, but basically just the positive side of things. How about DBT? Oh, yes, dialectical behavioral therapy. That actually has proven to be effective in a lot of the research studies that many people have used DBT successfully and it's proved to be a viable thing.

Speaker 1 12:46

Yeah, I'll tell you when I think about this. To answer any questions on AUD, on a licensing exam, it looks like I have to have a whole range of knowledge base from DBT to CBT to family therapy, to trans-theoretical models.

Speaker 2 13:03

So there's a lot involved in this problem in our society, that people have realized that, as you said at the beginning, you need the individualized approach to the person, which means that some people won't respond to the behavioral side, some people won't respond to the motivational interviewing side, so you've got to have a pretty broad spectrum, which makes it complicated if you're trying to take a test and they're asking about it. You're absolutely right.

Speaker 1 13:37

Yeah Well, one of the things that you need to know is the vocabulary. If you don't know the vocabulary, you may miss some questions. So let's go ahead and do a quick lightning round.

Speaker 2 13:44

Lightning round. I love it, I'll start. Craving is when you can't stop thinking about drinking, like me with pizza, when I'm really hungry at night.

Speaker 1 13:53

Okay. Tolerance means that you need more alcohol to feel high, like needing extra espresso shots at your age.

Speaker 2 14:02

Yes, exactly, detoxification, the process of allowing the body to eliminate alcohol.

Speaker 1 14:09

Relapse is returning to drinking after you haven't done it for some period of time.

Speaker 2 14:15

Yes, Harm reduction is a set of strategies that aim to reduce the negative consequences of drinking Tools that a person can use to ameliorate their problems until they quit drinking.

Speaker 1 14:29

for good Enabling. Enabling is behavior that unintentionally supports a client's substance use.

Speaker 2 14:38

So let's summarize what we covered. Obviously, it's a complex thing. Like we mentioned, a lot of moving parts biological, psychological, physiological, social and the SM has clear criteria and it should be an individualized technique that's going to be most effective for that person. And there are different techniques motivational interviewing, cbt, relapse prevention and your favorite trans-theoretical model.

Speaker 1 15:07

Right, which is also known as Stages of change?

Speaker 2 15:11

Exactly, which is also known as stages of change? Exactly, yes, and so therapists and family members need to understand it as a journey, not a one-time thing. Not that I went to detox and now I'm finished. And, as we mentioned, ttm, the trans-theoretical model, has it baked in that there are going to be relapses, that there are going to be problems, that you're going to need to recognize the fact and not feel guilt over that fact, that there were problems in resurfacing after having problems with alcohol.

Speaker 1 15:42

Thanks for joining us today.

Speaker 2 15:44

Yes, thank you so much. We hope the podcast has given some valuable information that you might see in your licensing exam and some practical insights to help support your client's recovery. And remember it's in there, it's in there.

Speaker 1 15:59

Did we miss anything? No, this is starting to remind me of a Marvel movie, where they have a trailer after the credits.

Speaker 2 16:08

Oh, yes, really. If only we had Captain America, you know, swing in here, that would be good. But I'm glad people stuck around, because what we didn't talk about were assessment instruments.

Assessment Tools for AUD

Speaker 1 16:18

Okay, this one's pretty easy. If an assessment instrument has the word alcohol in it, you know what it's for. So let me give you some of the not obvious assessments that might show up on your licensure exam. One is called Audit C. You wouldn't think that has anything to do with alcohol, but it's a shortened version of Audit, consisting of three questions related to the frequency of alcohol use, the typical amount consumed and occasions when you end up having heavy drinking. How about the cage?

Speaker 2 16:53

as the cage is another assessment instrument and once again, you see the cage. You'd never guess it was for alcohol until you see the question, and it's four yes or no questions. Have you ever felt you should cut down the C? Have people been annoyed by your or criticized your drinking the A? Have you ever felt guilty about your drinking the G and the eye opener have you ever had to have a drink first thing in the morning to steady your nerves after a bender last night? And that's the E, c-a-g-e.

Speaker 1 17:25

Okay, there's a couple more. One's called Tweak and T-Ace and T-ACE. Tweek and T-ACE are assessment instruments specifically designed to work with pregnant women. Oh.

Speaker 2 17:41

All right. So Tweek and T-ACE are both for that.

Speaker 1 17:45

Yeah, both of them are Okay, all right.

Speaker 2 17:47

And then the CRAFT C-R-A-F-F-T is used to identify risky substance use, including alcohol, among adolescents and basically for anyone under 21.

Speaker 1 18:00

Right, and another one, or the last one we're going to talk about is called ASIST. You would never think that had anything to do with alcohol, but the ASIST is for Alcohol, Smoking and Substance Involve and substance involvement screening tests is what it's called. It's a comprehensive assessment instrument developed by the World Health Organization. It screens all levels of problems of risky substance use. Well, that's it for this part of the universe, Ez. How about you?

Speaker 2 18:31

Well, that sounds good, and I'm glad we had a little tag at the end, because the assessments, I think, are things that would show part of the universe. Ez, how about you? Well, that sounds good, and I'm glad we had a little tag at the end, because the assessments, I think, are things that would show up on the test as well. So I'm good now and I'm feeling like we could use a little reward of sushi from Publix.

Speaker 1 18:45

Well, how about some celery juice?

Speaker 2 18:48

Okay, I'll go out to the sushi. You have the celery juice and just crank down Either way. To reiterate to our listeners remember it's in there, it's in there.