Alcohol use disorder

Alcohol use disorder (AUD) is a common working diagnosis in case vignettes, and alcohol (like sedatives) is a substance where withdrawal itself can be dangerous, so safety and medical coordination come before talk therapy.

Criteria at exam depth (paraphrased). AUD uses the general substance use framework: at least 2 of 11 criteria within 12 months (impaired control, social impairment, risky use, tolerance and withdrawal). Severity: mild 2–3, moderate 4–5, severe 6+. Remission: early (3 to under 12 months without criteria other than craving) and sustained (12 months or more); "in a controlled environment" applies when access is restricted.

Alcohol withdrawal (paraphrased). After stopping or cutting down heavy, prolonged use, 2 or more signs develop within several hours to a few days: autonomic hyperactivity (sweating, rapid pulse), hand tremor, insomnia, nausea or vomiting, transient hallucinations or illusions, psychomotor agitation, anxiety, and generalized seizures. Withdrawal delirium (delirium tremens) is a medical emergency. Restlessness and insomnia when cutting back can be early withdrawal and warrant medical evaluation, not just coping skills.

Hinge differentials.

• Nonproblematic drinking: no impaired control or consequences.
• Alcohol-induced depressive or anxiety disorder: mood/anxiety symptoms emerge with heavy use or withdrawal and improve with sustained abstinence; an independent disorder precedes drinking or persists in abstinence.
• Sedative-hypnotic use disorder: similar picture, different substance; combined use raises overdose risk.
• Alcohol-related neurocognitive disorder / Wernicke-Korsakoff: confusion, ataxia, eye-movement problems, or memory loss with confabulation require urgent medical referral.

On the NCMHCE. Screen with the AUDIT (10 items; AUDIT-C is the 3-item brief version) or CAGE, and gather collateral and medical data; elevated liver enzymes corroborate a pattern self-report may understate. Ask about the last drink, amount and prior withdrawal or seizures; refer for medically managed withdrawal when risk exists. Recognize scope-of-practice limits when physical dependence exceeds your training. Screen suicide risk (alcohol increases impulsivity and lethality), impaired driving, IPV and co-occurring depression, anxiety and PTSD (e.g., drinking to self-medicate after deployment). Prioritize the alcohol use when it drives the other problems, use motivational interviewing with clients who minimize, and add CBT/relapse prevention and mutual-help groups. Medications for AUD (naltrexone, acamprosate, disulfiram) are referral awareness for the prescriber.

Clinical Pearl: Alcohol withdrawal can cause seizures and delirium, so any withdrawal signs mean medical evaluation first. Severity uses the same 2–3 / 4–5 / 6+ ladder.