Alcohol Use Disorder | Why Can't Some People Stop Drinking?

Alcohol Use Disorder (AUD) is a medical condition defined by an impaired ability to stop or control alcohol use despite adverse consequences in social, occupational, or health domains. It is not a sign of weakness or a moral failing; rather, it is a chronic brain disorder. The core feature of AUD is the loss of control over alcohol intake. This occurs because prolonged and excessive alcohol consumption fundamentally alters brain circuits responsible for reward, motivation, memory, and self-control. Specifically, alcohol hijacks the brain's reward system, leading to intense cravings and a compulsive need to drink. The term "disorder" is used to signify that this condition involves pathological patterns of behavior and cognition. It exists on a continuum, meaning its severity can range from mild to severe, depending on the number of symptoms present. Recognizing AUD as a spectrum helps in tailoring appropriate interventions, as the needs of someone with mild AUD are different from those of someone with a severe form of the disorder.

The severity of Alcohol Use Disorder is determined by the number of diagnostic criteria an individual meets within a 12-month period, based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The presence of 2 to 3 symptoms indicates a mild disorder. An individual with mild AUD might find themselves drinking more than intended on occasion or unsuccessfully trying to cut back. The presence of 4 to 5 symptoms is classified as a moderate disorder, where the consequences of drinking become more apparent, such as neglecting responsibilities at home or work. A severe disorder is diagnosed when 6 or more symptoms are present. In severe cases, a person's life may revolve around alcohol, demonstrating tolerance (needing more alcohol for the same effect) and experiencing withdrawal symptoms when not drinking.

A diagnosis of AUD is made by evaluating a set of 11 criteria outlined in the DSM-5. A qualified healthcare professional assesses these criteria based on the individual's experiences over the past year. Some of these criteria include: drinking more alcohol or for a longer period than originally intended; persistent desire or unsuccessful efforts to cut down or control alcohol use; spending a great deal of time in activities necessary to obtain, use, or recover from alcohol's effects; and a strong craving or urge to use alcohol. Other criteria involve recurrent use resulting in failure to fulfill major obligations, continued use despite social or interpersonal problems caused by alcohol, and giving up important activities because of alcohol use.

Yes, a formal diagnosis from a qualified medical or mental health professional is essential. While self-assessment tools can be helpful for initial screening, they cannot replace a comprehensive evaluation. A professional, such as a psychiatrist, psychologist, or primary care physician, can conduct a thorough assessment that includes a physical exam, a review of medical history, and a detailed discussion of drinking patterns and their consequences. This process is crucial to accurately diagnose AUD, determine its severity, and rule out any co-occurring medical or psychiatric conditions that might require different or additional treatment. A formal diagnosis is the foundation for creating a safe, effective, and personalized treatment plan.

Chronic alcohol exposure induces significant neuroadaptations in the brain. It disrupts the delicate balance of neurotransmitters, particularly GABA (gamma-aminobutyric acid), an inhibitory neurotransmitter, and glutamate, an excitatory one. Initially, alcohol enhances GABA's effects, causing relaxation, but the brain compensates over time by reducing GABA receptor sensitivity. Simultaneously, it increases glutamate activity, leading to a state of hyperexcitability during withdrawal. Furthermore, alcohol powerfully stimulates the mesolimbic dopamine system, the brain's "reward pathway." This creates a strong positive reinforcement for drinking. However, chronic use blunts this system, leading to a state where the individual no longer drinks for pleasure but to alleviate the negative feelings of its absence—a condition known as anhedonia. The prefrontal cortex, which governs judgment and decision-making, is also impaired, contributing to the loss of control that characterizes the disorder.