Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

5. Alcohol 77withdrawal symptoms, broken relationships, and associated medical and psychiatricillnesses. Assessment of family functioning may reveal marital discord,spousal abuse, child abuse, financial problems, depression or anxiety syndromes,child neglect, child developmental problems, school dropout, and delinquency.At the community level, manifestations may include violence, accidents, propertydamage, economic costs of welfare or health services, and decreased workproductivity.A diagnosis does not have to be rushed. Interviews with collateral sourcesare often necessary. Some patients will fall into a “gray zone,” which means thatit is unclear whether an alcohol use disorder is present. In such circumstances,obtaining further information and following the patient over time should clarifythe diagnosis.ScreeningSeveral instruments and interviewing techniques enable the clinician to screenfor an alcohol use disorder. Interview techniques include the CAGE (Ewing,1984) and the TWEAK (Russell et al., 1991). CAGE is a mnemonic device:(Cut down: “Has anyone ever recommended that you cut back or stop drinking?”Annoyed: “Have you ever felt annoyed or angry if someone comments onyour drinking?” Guilt: “Have there been times when you’ve felt guilty about orregretted things that occurred because of drinking?” Eye-Opener: “Have youever used alcohol to help you get started in the morning, to steady yournerves?”). Positive answers to three of these four questions strongly suggestalcoholism. “TWEAK,” a similar mnemonic device is more useful than theCAGE in interviews with women. T assesses tolerance: “How many drinks canyou hold or how many drinks does it take to get high? (If it takes more than twodrinks to get “high” or six drinks to feel drunk, tolerance can be assumed to bepresent). W: “Have close friends or relatives worried about your drinking?” Eye-Opener: “Do you sometimes take a drink in the morning to wake up?” Amnesia:“Has a friend or family member ever told you things you said or did while youwere drinking that you could not remember?” K (cut): “Do you sometimes feelthe need to cut down on your drinking?” Positive answers to three or morepoints suggest alcoholism.Laboratory tests are useful for detecting heavy drinking. Serum gammaglutamyltransferase(GGT) has been established as a sensitive test of early liverdysfunction. GGT has a sensitivity of 50% and a specificity of 80% (Bean &Daniel, 1996), meaning that 50% of patients with drinking problems will bemissed by the GGT. However, 80% of people with an elevated GGT do havean alcohol problem (therefore, 20% of people with elevated GGTs are normaldrinkers).Another useful screening test is increased erythrocyte mean corpuscularvolume (MCV), which was elevated in 26% of the patients in a Mayo Clinic