Essay Grade

The Case of Kaylin Ma
Kaylin is 22 years old and the oldest child of two working-class parents. Her father is a
heating and air conditioning technician, and her mother is an administrative assistant at
a local community college. Both parents immigrated from Korea as children. Kaylin has
one younger brother, aged 9, who has been diagnosed with attention deficit
hyperactivity disorder (ADHD). Kaylin appeared normally dressed and is 5’4” tall.
Kaylin’s childhood was otherwise unremarkable. She reported that she has always
worked hard at school and generally was an “A” student through high school. She ran
track and was involved in many activities, socializing with boyfriends and her wide
friendship circle. She reported no particular difficulties with her parents other than
fighting with them over her decision to leave the state for college. After delaying
admission for a year and working, Kaylin left her home in New Hampshire at 20 to
attend college in Florida. As a freshman, she lived off campus with three other
roommates. She has been waitressing in Tampa since freshman year at a
bar/restaurant to supplement financial aid for tuition. She had very good grades (B+ to
A) in her first 2 years of college.
Kaylin is now a junior. She complained of chronic anxiety and problems with
concentration and attention. She still works long hours, and she recently took a course
in bartending so she can serve drinks and “make more.” She had managed to maintain
a B+ grade point average while studying juvenile justice up until this year. Kaylin initially
began drinking with friends at the restaurant after closing during her second semester of
sophomore year. She now drinks regularly on weekends with her college and “bar”
friends. She reported that since her 21st birthday party she has at times been “out all
night partying and drinking.”
She missed enough classes this year that her grades have begun to suffer. She had to
drop at least one course (and will need to retake it next year) due to nonattendance.
“This is because I don’t get enough sleep,” Kaylin said, and she stated that she was
simply unable to wake up in time for that course.
Kaylin attended this session with the social work counselor on campus because she
hadn’t been interested much in food this past semester. Her roommates insisted that
she get some help, as she had gone from “slight” to “reed thin.” Kaylin stated that they
are worried that she has an eating disorder. Kaylin denied any eating disorder, but she
admitted that she often has no time for meals and at times has “no appetite.” She often
reported mild nausea. Current weight was reported at 104 pounds.
Upon further assessment, Kaylin reported that she spent much of the last 2 months of
weekends drinking at her workplace as well as at college parties. She used “hair of the
dog” practices—e.g., a morning Bloody Mary—to feel better this past month, as she
sometimes had mild hand tremors in the morning and was strongly nauseous. She
admitted to being “foggy.” During these weekend experiences, she claimed to have full
memory (she denies blackouts) but reported that the hangovers make her “sound
sensitive” with headaches. She said she “feels” normal by the end of the day most
Mondays, but she also stated that she has trouble sleeping several nights a week
without an evening beer. Her mood varies over the week, and she admitted to chronic
anxiety and some tendency to get into “arguments” with her roommates when sober.
She set some limits for herself, such as three cocktails per weekend evening, but she
has often “not bothered” to maintain those limits for “other reasons.” She admitted
occasional alcohol use in high school, but her status as a varsity athlete motivated her
to limit her use. At the time of the assessment she was not involved in sports, clubs, or
other steady exercise, and she stated that she “has no time” for that or for boyfriends.
Chapter 15
Diagnosing Substance Misuse and Other Addictions
Let me get something off my chest. We are sometimes warned against the term addiction,
because it doesn’t have a scientific definition. Although this is true, the same can be said for
so much of the mental health nomenclature that if we were to avoid all inexact terms, we’d
find ourselves essentially tongue-tied. Depression, paranoia, phobia, anxiety, mania,
schizophrenia—on the street and in the popular press—all have meanings rather different
from their strict scientific usage.
The word addiction comes down from Roman law, where it meant “surrender to a
master.” How appropriate to use such a term for the behaviors we associate today with
substance misuse and other compulsions! This compact word conveys a clear sense of loss
of control and harm to the individual and to society. Other than lack of scientific rigor, its
principal drawback is a connotation of reproach that we in the mental health field would
rather avoid. (Habit, a term applied to the use of addictive drugs for over 100 years, has never
been much favored by professionals, either.)
SUBSTANCE USE DISORDER
In DSM-5, the terminology has shifted once again. Whereas from DSM-III on we spoke
of substance dependence and substance abuseas two separate disorders, common sense has
at last prevailed, and their criteria have been combined into one grand collation
called substance use disorder. That term seems a little clumsy to me, however, so I’ll probably
continue to refer to people who have it as having substance dependence, for short. Substance
dependence has three principal features:
1. The person will usually be affected physiologically. This means that the drinking or
other substance use has been heavy and prolonged enough to cause tolerance, which is
the need for an increasing amount to satisfy craving, or withdrawal, in which symptoms
develop when the person abruptly decreases its intake. Sometimes there is both
tolerance and withdrawal.
2. Loss of control is the second constant feature of substance use disorder. It is shown by
using more than the person intends, repeated failure to control the use, preferring use
to important activities such as family life, and persistent use despite the knowledge that
it is either harmful to health or dangerous to the individual or others. I suppose I’d
include craving for the substance here—DSM-5 is the first manual that’s included it as
a symptom (and about time!).
3. Finally, several social issues that are the consequence of use affect patients who misuse
substances. These include a failure to fulfill important life roles, arguments and other
interpersonal disputes, and excessive time spent obtaining or using the substance.
I wouldn’t get too hung up over the exact number of criteria a person needs for
dependence. Two or three symptoms is the range required in DSM-5 for a rating
of mild substance use disorder, but it seems unlikely that many people with substance use
problems will have so few. The point is that those with few symptoms, left untreated, are
highly likely to develop more.
Samuel
How we assess substance dependence is based on two sorts of criteria—the loss of control,
and the consequences of use (including social, legal, financial, work, family, and
physical/medical). Even though our current diagnostic tools have been forged in
comparatively recent times, if we employ them carefully, they can help us mine the past to
unearth the perils of the present. As I’ve noted above, our assessment of substance
dependence is based on three sorts of symptom—physiological issues, loss of control, and
numerous social and personal consequences of use. See how many of them you can identify
in Samuel’s history.
Every student of English literature knows that, as a young man, Samuel Taylor Coleridge
wrote “The Rime of the Ancient Mariner.” Somewhat less well known is that his personal
history traces the route of an almost lifelong dependence on opium.
In the waning years of the 18th century, when Samuel’s use began, morphine, codeine,
and heroin had not been derived, and opium was usually swallowed in an alcohol tincture
called laudanum. Samuel used laudanum intermittently from his mid-20s, to enable sleep
and ease both worry and pain. At that time the concept of addiction was unknown, and
anyone with a few shillings could readily purchase narcotics without prescription from a
pharmacist. As an all-purpose remedy for homesickness, exhaustion, and the stress of
public performance, Samuel used up to a pint of laudanum per day—a whopping amount
by the standards of any era. He also consumed large amounts of alcohol.
Samuel’s first serious addiction to opium arose in his late 20s. Although he composed
his mystical poem “Kubla Khan” largely while under the influence of laudanum, on balance
the drug caused him to spend far more time daydreaming of literary glory than working
to attain it.
The physical symptoms that result from using opium are numerous and well
documented. For Samuel, one of the worst was constipation—“violent stomach pains and
humiliating flatulence”—that caused him agony. For relief, he would resort time and again
to enemas and other embarrassments that he regarded as punishment for his vice. With
his mood swinging from elation to despair, he would awaken screaming from terrifying
dreams. During a sea voyage, he hallucinated “yellow faces” in the curtain around his
bunk, and he had the illusion that the flapping sails were fish flopping about on deck.
In his notebooks, Samuel also noted symptoms that we recognize today as withdrawal:
joint pains, sweating brow, “windy sickness at the stomach,” diarrhea, fever, and despair.
However many times he promised himself that he would quit, in the end he always
returned to opium’s “hideous bondage” (in the words of one friend), which left him
brooding, lying, and neglecting his work and family. Guilt made him try to conceal the
amount he used. In later life he wrote self-pitying letters to friends, whom he accused of
misunderstanding him, and he suffered from depression that would suddenly well up and
overwhelm him. At one time, he entertained ideas of suicide.
In later years, Samuel’s usage was eventually controlled when a physician put him on
a prescription, but he sought an additional supply anyway. His druggist allowed him
this—but in amounts so tiny that he could live and once again even work effectively.
Analysis
With a little effort, we can compare the symptoms Samuel showed over 200 years ago to
today’s criteria for substance use disorder. In Table 9.3 (also available
at www.guilford.com/morrison6-forms), you’ll note the symptoms of intoxication Samuel
recorded. Next, we’ll use the definition of dependence provided at the beginning of the
chapter to verify that he was in fact dependent on opium. From the amount of laudanum he
consumed, we know that he tolerated quantities far greater than an individual
unaccustomed to its use could have handled, and of course he suffered severely from
withdrawal symptoms. His use began when he was a young man and persisted throughout
his life; along the way, we can find ample evidence of lack of control. From his own notes and
letters, we can see how he craved the drug; he used it despite the evidence of its physical
effects, allowed it to displace his work and social responsibilities, and continued using it
despite repeated efforts to curtail its use. Even at over two centuries’ remove, he fully meets
modern criteria for severe opioid use disorder.
The use of multiple substances is common, and today, after a suitable in-depth interview,
Samuel would probably be diagnosed as having both opioid and alcohol use disorders. But
should we also diagnose a mood disorder? The profound gloom he experienced from time to
time was severe enough that he had suicidal ideas; yet, because it seemed entirely
consequent to his use of opium, I wouldn’t call it an independent mental disorder (shaved by
Occam’s razor). Instead, Figure 11.1 points us to a step 3 diagnosis of substance-induced
depression.
Comment
One problem with assessment of substance misuse is the reliability of the informant, as with
Samuel, who worked hard to hide the true extent of his addiction. Here’s where the
diagnostic principle regarding collateral history is especially useful. I always want to trust
my patients, but whenever I know that one may be tempted to defer, shade, or otherwise
alter the truth, I look for help from informants who care about the patient. I’ll also lean on
objective measures such as laboratory tests—luxuries that were not available 200 years ago.
Substance misuse is often the story of comorbidity. Various studies have found that a third
to a half of those who use substances have another mental diagnosis, whereas nearly 30% of
patients with other mental disorders meet criteria at one time or another for a substance use
disorder. Samuel’s depression was related to his substance use, which is the usual case. In
fact, nearly every class of mental disorder you can think of is more common in persons with
substance dependence. Only infrequently, however, is the disorder one that they would have
suffered anyway, regardless of their experience with alcohol or drugs. But these secondary
disorders can closely mimic independent mental or emotional illnesses. In most cases, with
time and abstinence, the secondary symptoms will abate.
Chuck
In the throes of evaluating substance use, it can be very difficult to decide whether a person’s
symptoms are all pursuant to the substance or indicate another, independent disorder. If the
former, they should disappear once the misuse has been brought under control.
At 38, Chuck sought care because of depression. “Life isn’t very good, Doc,” was his chief
complaint. A tradesman who made good money when he worked, often Chuck didn’t. June
was the financial mainstay of their little household, but she was a bartender who too often
tasted her own wares. She had sent along a note in a sealed envelope that bore evidence
of clumsy steaming and resealing; she complained in it that with Chuck she had little or
no sex. He admitted that he had read a lot about alcohol and sexual problems; he’d tried
Viagra, but realized that drinking had clobbered his sex drive. “Something to do with
testosterone levels, Doc,” he informed me. “You can read about it on the ’net at . . . ” From
memory, he recited a URL full of dots and slashes.
Over the years, I’ve treated a lot of smart patients, but Chuck is the only one who’d
actually passed the test and joined Mensa. However, he had never finished high school;
after some suspensions (two for theft and one for assault on a teacher), he’d been kicked
out, and he said the Mensa card made him feel that he “had substance.” After leaving
school, he kicked around quite a lot, and then washed out of the Army after setting a boot
camp record for going AWOL. Next he tried his hand at violent crime. Though he was
pretty good at planning, he wasn’t so good at execution. After he and a partner robbed a
7-Eleven that netted them $84 and several 6-packs, they were nabbed just around the
corner as they consumed the proceeds of their evening’s work. After his release from
prison, he wrote a few bad checks and ripped off several employers for some valuable
tools, but for none of this was he ever caught.
By this time Chuck was 27, and his drinking, which had started during his brief Army
career, had picked up speed. He was downing nearly a 12-pack of beer each evening, and
he carried that practice to a series of jobs, none of which lasted longer than a month or
two. Then he got married—twice, without bothering about a divorce in between. His first
wife’s complaints of nonsupport led to information about his other activities, which
landed him “back in the can” for another few months. But with his second marriage came
a dowry of sorts—a father-in-law who was a big official in the union for one of the
construction trades. After a brief apprenticeship, Chuck seemed set for life with a job that
paid well and carried enormous benefits. Currently, however, he was drinking more than
he was working—at anything; even June was complaining.
Chuck told me that the feelings of depression had come on gradually, worsening over
the past half year or so. Fueled by his drinking, he fought with June “whenever I was sober
enough,” and his appetite was almost nil. His weight had begun to drop, and his sleep had
long since gone south.
After an especially hard drinking bout that lasted many weeks, Chuck needed
hospitalization. During the admission process, he was unsteady on his feet and even had
trouble writing his name. “I’m fine, I’m just terrific,” he kept saying, but he slurred his
words in a way that said he wasn’t really. The next morning on rounds, I was sure of it.
After a sleepless night, Chuck’s problem with coordination had progressed to a coarse
tremor that made him grip his juice glass with both hands.
By the following day, he was in full-blown withdrawal—sweating, pacing (when he
wasn’t falling down), and vomiting. He also complained about tiny cats “the size of mice”
that wore bells and off and on danced on the sill of his window. He thought that he was in
a lockdown at the county jail. While still recovering, he talked about another time he’d
been like this, when he was jailed after assaulting an undercover federal narcotics officer
who was trying to track a suitcase full of powdered cocaine. “Do I have any regrets? Sure,
I’m real sorry I got caught. Or ‘really,’ as we say in Mensa. But I don’t feel guilty, if that’s
what you mean. Guilt is for suckers.”
Analysis
In addition to his drinking and problems with the law, Chuck had three mental problems
requiring analysis—depression, psychosis, and disorientation. Figures 11.1, 13.1,
and 14.1 direct us to consider a disorder induced by substances. That would square with
some of what we know about alcoholism: People who drink heavily often have depression,
and alcohol-dependent individuals in the throes of withdrawal will sometimes suffer from
delirium tremens, during which they become disoriented and have visual hallucinations. In
the vast majority, the depression disappears once the drinking stops without further
treatment. This was why, though I always give high priority to the diagnosis of depression, I
elected not to treat Chuck for depression right away.
What about Chuck’s criminal behavior, and what did it say about his personality
structure? Whereas I’d hesitate to offer an early diagnosis for most personality disorders,
antisocial personality disorder rests firmly on objective facts that can be obtained from those
who know the patient well. Chuck’s long history of difficulties with authority and the law
(dating to his early teen years), along with his callous lack of guilt, provided a strong basis
for this diagnosis.
All things considered, I’d list Chuck’s various diagnoses in the order they needed to be
treated:
Delirium due to alcohol withdrawal (delirium tremens)
Alcohol use disorder
Depression due to alcohol use
Antisocial personality disorder
Because Chuck was in the middle of his withdrawal symptoms, listing the delirium first
underscores the importance of focusing first on this potentially life-threatening condition.
Because I believed that drinking had directly caused his depression, I felt that it should
diminish once he got clear of alcohol.
Comment
Close to half of those who misuse alcohol, street drugs, or prescription medications will have
one or more additional mental disorders. Some conditions are more or less independent, but
often (perhaps usually), the substance use disorder will bring on depression, psychosis, or
an anxiety disorder; as such, they are not truly comorbid, only co-occurring. (See the sidebar
“Independent Mental Disorder or Substance-Related?”.) We need to know which is which,
because our treatment for mental disorders that arise only during substance use will be
different than for those that arise independently. Outcome for the dependent disorders may
be better or worse than for the independent ones, depending on how effectively we deal with
the substance use itself.
DISORDERS ASSOCIATED WITH SUBSTANCE MISUSE
Whether or not they represent independent diagnoses, some other disorders are commonly
associated with substance use. Table 15.1 summarizes some of this discussion.
TABLE 15.1. Classes of Mental Disorders That Can Occur during Intoxication (I) or Withdrawal
(W)
Alcohol
Amphetamines
Caffeine
Marijuana
Cocaine
Hallucinogens
Inhalants
Opioids
Phencyclidine (PCP)
Sedatives
aBecause
Delirium
Dementiaa
Psychosis
Mood
Anxiety
I/W
I
Yes
I/W
I
I/W
I/W
I
I
I
I
I
I
I/W
I/W
I
I
I
I
I/W
I/W
I
I
I
I/W
I
I
I
I
I
I
I
I
I/W
Yes
Yes
I
W
dementia is associated with long-term, heavy substance use, it scores only a “yes.”
Independent Mental Disorder or Substance-Related?
In deciding whether a patient’s mental disorder is substance-related or independent, I
consider several issues:
1. I f the other mental disorder started first, I would lean heavily toward independence—
that is, an illness not caused by the substance use. Antisocial personality disorder,
bipolar disorders, and schizophrenia are the conditions most likely to begin prior to
substance use.
2. I f it isn’t clear which started first, I’d apply the diagnostic principle
concerning undiagnosed and use either that label or unspecified [name of
condition], then carefully follow to see what happens once the substance use has been
dealt with.
3. A substance-related mental disorder should diminish or disappear within a month. If
the symptoms persist (perhaps even increase) after detoxification, I’d probably
diagnose an independent mental disorder.
4. For an independent mental disorder, I like to see more symptoms rather than fewer, so
as to fully meet (or exceed) diagnostic criteria for the illness in question.
5. I search for atypical symptoms. For example, the sudden onset of hallucinations,
unusual for schizophrenia, suggests a psychosis cause that is related to other medical
disorders or substance use. Visual, tactile, or olfactory hallucinations similarly suggest
a nonschizophrenia psychosis.
• Antisocial personality disorder. This is one of the few co-occurring conditions that
is not caused by the substance misuse. Over three-fourths of patients with antisocial
personality disorder also misuse substances, and 10–20% of males and about 5% of females
with alcoholism have this personality disorder. Some studies find that an especially heavy
history of severe substance use carries a stronger likelihood of comorbidity, especially with
antisocial personality disorder.
• Neurocognitive disorders. Delirium is found during intoxication with all substance
groups except caffeine; alcohol and the sedatives also produce delirium upon withdrawal. A
form of dementia can result from heavy and prolonged use of inhalants, and the form of
dementia (it used to be called amnestic disorder) known as Korsakoff’s psychosis is classic
for heavy, prolonged alcohol use with chronic thiamine insufficiency. There’s more about
this on page 225.
• Psychosis. You expect the hallucinogens to produce psychosis (sometimes delusional
disorder), and they do; occasionally they produce prolonged visual disturbances that don’t
rise to the level of psychosis. These are flashbacks, during which the person will falsely
perceive movement at the periphery of vision, or other visual distortions such as trails,
geometric shapes, colors that are too intense (“over-Photoshopped,” someone once put it),
or objects appearing smaller or bigger than normal. When psychosis occurs with
phencyclidine (PCP) use, it usually abates after a few hours; sometimes, however, patients
will retain symptoms of catatonia or paranoid psychoses for weeks. Here are two problems
that can complicate the diagnostic picture: (1) Some patients may not be aware that they’ve
been given PCP; and (2) even if they know what they have ingested, others have no insight
that their symptoms are caused by the drug. Over half of those who use amphetamine
(especially methamphetamine) develop delusions, and some also have hallucinations. Too
often, they become violent. Whereas about 3% of those with alcoholism experience
psychosis during heavy drinking or withdrawal, marijuana rarely produces psychosis; it
creates its mischief by worsening the symptoms of actual schizophrenia.
• Depression. Over 75% of individuals with alcoholism develop depression, the symptoms
of which can mimic other clinical depressions. However, for the vast majority (about 95% of
men, perhaps 75% of women) the depression improves rapidly after cessation of alcohol use.
Mood disorder, especially depression, is also associated with most other drugs of misuse,
including marijuana (dysthymia tends to predominate), opioids, and the hallucinogens.
Depression also develops during withdrawal from amphetamine or cocaine.
• Anxiety. About three-fourths of those with alcoholism have panic attacks during
withdrawal, and a form of social avoidance similar to agoraphobia is also common during
the first few weeks of sobriety. Panic attacks may also occur during withdrawal from
sedative/hypnotics and intoxication with amphetamines. Marijuana users, especially
novices, commonly experience panic attacks, and anxiety disorders are also associated with
hallucinogen use.
• Substance use. No, I’m not being facetious. Although some individuals who use alcohol
disdain other drugs, and vice versa, many patients are equal-opportunity users.
Furthermore, we must always take great care to consider all of the “big four” drug sources:
alcohol, street, prescription, and over-the-counter.
OTHER ADDICTIONS
We tend to speak loosely and sometimes humorously of many behavioral “addictions,”
among them eating chocolate, watching TV, and buying things on eBay. However, several
disorders that involve difficulty controlling impulses to engage in harmful behavior bear
striking similarities to substance misuse. Because few of them represent much of a diagnostic
challenge, I’ll discuss them here in less than excruciating detail.
Gambling Disorder
People who gamble to the point of harming themselves and others will have symptoms
resembling those of substance use disorder. For example, symptoms like those of
dependence can include the need to put increasing amounts of money into play (tolerance)
and discomfort when attempting to stop gambling (withdrawal). Other symptoms include
illegal acts performed to obtain money for gambling and the disruption of personal
relationships. Gambling is also one of the non-substance-related behaviors (another is
overeating) that are often effectively managed through Twelve-Step programs. These
similarities have caused the migration of gambling disorder into the newly renamed DSM-5
chapter “Substance-Related and Addictive Disorders.”
Pyromania, Trichotillomania, Kleptomania
For hundreds of years, the Greek word mania (“madness”) has been used to mean “to have a
passion.” For over 100 years, the term has been largely co-opted for the “up” phase of bipolar
I disorder, but the older usage survives in the names of three contemporary disorders with
the general qualities of addictions: pyromania (fire setting), trichotillomania (hair pulling),
and kleptomania (stealing), each of which serves as a “master” to which the individual feels
compelled to surrender. Often beginning in childhood or adolescence, these disorders entail
behaviors that can become chronic and last well into adulthood. Despite the aspect of
surrender, they are ego-syntonic. That is, they are carried out in accord with the person’s
conscious wishes—not in response to, for example, hallucinations.
Unlike gambling and substance misuse, these conditions are not defined by lists of
behaviors that cause the person to run afoul of society. Instead, each behavior begins with a
rising tension or excitement that finds release only as the match is struck, the hair strand is
tweaked, or the unneeded (and unpaid-for) item is swept into a coat pocket. The tension may
be described as “itching” of the scalp in hair pulling, restlessness, or a combination of
pleasure and fear (as in kleptomania).
All three disorders entail secrecy—two because they are illegal, the third because it
causes the person to look funny and feel ashamed. However, once you’ve identified the
conduct, you’re almost home; setting fires and stealing don’t require much diagnostic finesse.
What they do require is your attention to fistfuls of exceptions. The problem is that these two
behaviors are far more common outside the context of mental disorder. In fact, people who
steal or set fires with other motives in mind may try to claim falsely that they suffer from the
mental disorder. That’s why we have to consider the rather long lists of circumstances in
which the diagnoses should not be made. For pyromania, the fire setting must not be due to
poor judgment (as in intellectual disability, substance intoxication, or dementia) or done for
profit, revenge, crime concealment, out of anger, or in response to psychosis. For
kleptomania, the items must not be stolen in response to anger, delusions, or command
hallucinations. In neither disorder can schizophrenia, mania, or a personality disorder better
explain the behavior. For trichotillomania, the restrictions are less severe, though the
criterion of clinical distress/impaired functioning would exclude ordinary cosmetic eyebrow
tweezing and depilation. (DSM-5 has moved trichotillomania to the “Obsessive–Compulsive
and Related Disorders” chapter and added a related disorder, excoriation [skin-picking]
disorder.)
For consistency with the foregoing chapters of Part III, I provide a decision tree for a
patient who has problems with addiction in Figure 15.1. However, you should have no
particular trouble making these diagnoses. The greater diagnostic challenges, as I have
described throughout this chapter, lie in determining the independent versus dependent
status of co-occurring disorders (in the case of substance misuse) and in determining
whether particular behaviors may be related to other disorders or motivations altogether
(in the case of some of the other addictions).
FIGURE 15.1. (Rather boring) decision tree for a patient who has problems with addiction.
ARTICLES
Vulnerability for Alcohol Use Disorder and Rate of
Alcohol Consumption
Joshua L. Gowin, Ph.D., Matthew E. Sloan, M.D., M.Sc., Bethany L. Stangl, Ph.D., Vatsalya Vatsalya, M.D., M.Sc.,
Vijay A. Ramchandani, Ph.D.
Objective: Although several risk factors have been identified
for alcohol use disorder, many individuals with these factors
do not go on to develop the disorder. Identifying early
phenotypic differences between vulnerable individuals and
healthy control subjects could help identify those at higher
risk. Binge drinking, defined as reaching a blood alcohol level
of 80 mg%, carries a risk of negative legal and health outcomes and may be an early marker of vulnerability. Using a
carefully controlled experimental paradigm, the authors
tested the hypothesis that risk factors for alcohol use disorder,
including family history of alcoholism, male sex, impulsivity,
and low level of response to alcohol, would predict rate of
binging during an individual alcohol consumption session.
Method: This cross-sectional study included 159 young social drinkers who completed a laboratory session in which
they self-administered alcohol intravenously. Cox proportional
Alcohol use disorder has a lifetime prevalence of nearly one in
three individuals in the United States (1). An important goal is to
identify at-risk individuals prior to the development of this
disorder so that they can be targeted for early intervention. One
way to determine early phenotypic differences in those at risk
is to examine behavior at the level of an individual drinking
session. For example, the rate of drinking and total alcohol
exposure may differ between those at high and low risk. These
parameters, however, are difficult to quantify in the field because of the lack of instruments that can continuously and
accurately monitor blood alcohol concentration. Furthermore,
asking individuals to report details about their rate of consumption does not account for variability in absorption and
metabolism (2) and would likely be inaccurate because intoxication impairs recall (3). Despite these measurement
difficulties, there is evidence that the rapid consumption of
large quantities of alcohol leading to a blood alcohol concentration of 80 mg%, defined as binge drinking (4), affects
psychological and physical well-being. Binge drinking is
associated with greater risk of negative health consequences
hazards models were used to determine whether