For years, I spent most of my time doing clinical trials. This work relied on very accurately diagnosing the individuals who would participate in the studies of various psychiatric medications. I took this work very seriously, because the results of these studies would often determine whether a new drug would make it to market or not. My colleagues and I went to great lengths to make sure every patient met the full criteria of the disorder being studied. If the candidate for a study lacked even one of the required symptoms for a diagnosis then that person would not be included in the study. In hindsight, this approach was essential for research purposes, but I learned that such a black-and-white way of making a diagnosis did not work as well in clinical practice.
In my clinical practice I noticed that many of the patients who came to me fell short of the full diagnosis of various psychiatric disorders. At first, I took a “wait and see” approach before going further. That was like waiting for the patient to satisfy all of the criteria for a diagnosis, as I’d learned to do when conducting clinical trials. However, what I witnessed was that most of the time my patients’ symptoms worsened and medication treatment was eventually required. Often times, psychotherapy, cognitive behavioral therapy, or a group therapy that was started in the early stages of treatment stopped or at least slowed the progression towards the full-blown disorder. Nevertheless, I found it difficult to let go of my bias to holding back any treatment until I felt the full criteria for a psychiatric disorder were met.
My attitude changed after we began doing clinical trials on patients with “sub-threshold” symptoms of attention deficit/hyperactivity disorder (ADHD) and bipolar disorder. These studies found that the subjects who were one or two symptoms shy of a full diagnosis suffered an equal degree of impairment across various psychosocial realms. Moreover, treatments that worked for those with the full diagnosis of ADHD or bipolar disorder seemed to work equally as well for those who were close to the full criteria for the particular disorder but did not meet the standards for a formal diagnosis.
At this point, I realized that treatment should be guided more by a patient’s suffering, not some set number of symptoms, age of onset, or other benchmark. This is especially true in regards to alcohol abuse and dependence. Most diagnostic categories include a diagnosis for those patients who do not quite reach criteria for a psychiatric disorder. The term “not otherwise specified” is applied to such patients. Maybe the symptoms have not been present long enough or maybe not enough symptoms are present, but these patients certainly suffer, sometimes as much as those who meet the full criteria of a psychiatric diagnosis. In regards to alcohol, however, the bias of professionals has been that someone either is abusing alcohol or dependent on it—that alternative is that they have no problem with alcohol at all. The diagnosis of alcohol abuse “not otherwise specified” does not exist in print, but I certainly see it in patients.
Television and print ads warn us of the dangers of alcohol and substance abuse, but these same sources of information mount multimillion dollar campaigns to sell alcohol. This may seem like a conflicting message, but I, too, feel that alcohol is something to enjoy as long as it does not destroy a person or their loved ones. My mission, then, is to help people recognize their drinking problems before they have a clear diagnosis. A person who is “almost alcoholic” may not even meet the minimum criteria for abuse alcohol, but alcohol takes its toll in personal, social, or economic terms. I’m writing about these patients who slip below the diagnostic radar screen, but who find themselves losing friends, family, and jobs because of alcohol. This book starts with recognizing the impairments associated with inappropriate drinking then moves to the important part of fixing the problem. That’s the reason we chose the title, Almost Alcoholic, in recognition of the fact that you don’t have to be an alcoholic to have a problem with drinking.