Classifying Alcoholism: The 4 Stages and 3 Severity Levels

Alcohol misuse is a widespread public health challenge in the United States, with 25% of American adults reporting at least one heavy day of alcohol consumption (four or more drinks for women and five or more drinks for men) within the past year.1 Alcohol problems can be classified into four stages of alcoholism and three severity levels under the alcohol use disorder DSM-5 criteria.2,3

The Stages of Alcoholism

In 1960, Elvin Morton Jellinek, an alcohol use researcher and statistician, published The Disease Concept of Addiction. He proposed a new view of alcoholism, seeing it as a chronic, relapsing condition that requires medical treatment. He noticed a pattern of progression for the disease and developed the four stages of alcoholism.2

Pre-Alcoholic Stage

In the pre-alcoholic stage, the problems of alcohol consumption have not yet become apparent. This stage can be challenging to recognize because alcohol use has yet to become compulsive or problematic. You may just be experimenting with alcohol and then gradually start to consume more as a means of coping with stress or difficult emotions. As you continue to consume alcohol, you may develop tolerance to alcohol, meaning you’ll need to drink more to feel the same desired effects, such as relaxation or improved mood.2

Early Alcoholic Stage

The early stage (also called the prodromal phase) is considered a transitional stage as alcohol misuse patterns start to emerge. You may find yourself consuming alcohol more frequently and in higher amounts, using social situations as an excuse to drink, or consuming more alcohol to cope with hangover symptoms that occur when alcohol leaves your system.2

Additionally, episodes of binge drinking often characterize this stage. Some people may even experience blackouts, where they have no recollection of events that occurred while they were under the influence.2

Middle Alcoholic Stage

Jellinek considered the middle alcoholic stage to be the most crucial. At this stage, you may be using alcohol regularly, perhaps even starting your day with an alcoholic drink or consuming alcohol on the job. Your friends and family may begin to notice that your drinking has become problematic. You may also start to recognize the consequences of your alcohol use, although many people in this stage remain in denial.

Alcohol may be impairing your relationships, ability to work or attend school, and overall functioning in daily life. You may experience cravings and irritability when you are not under the influence. You may also start to notice more adverse health effects. Your hangovers may get worse, and you may begin to experience more severe alcohol withdrawal symptoms. You may even experience symptoms such as stomach bloating, shaking, sweating, and memory problems.2

Late Alcoholic Stage

The late alcoholic stage (also called the end stage) is considered the final stage of alcoholism. This occurs when you have no control over your drinking. At this point, you are completely dependent on alcohol. You need alcohol to feel normal, and you experience intense cravings and significant alcohol withdrawal symptoms, which could potentially be life-threatening.2

People in the late alcoholic stage may attempt to quit drinking several times and remain unsuccessful. While some people can live as “functioning alcoholics” and continue to work and participate in daily lives, others cannot maintain functioning. Potential consequences include job loss, financial difficulties, health issues, and family problems. However, no matter how well someone functions in this stage, they are still at risk of medical issues, such as liver disease caused by chronic alcohol use.

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Alcohol Use Disorder DSM-5 Criteria

While many people use the term, alcoholism is actually not a formal medical or mental health diagnosis. The clinical term is alcohol use disorder (AUD), which is defined as any drinking that causes distress or harm. It occurs you are unable to stop or reduce drinking despite negative personal, social, occupational, and health consequences. AUD is considered a medical condition encompassing the entire spectrum of alcohol misuse, with symptoms ranging from mild to severe.3,4

When being evaluated for alcohol use disorder (AUD), a healthcare professional will ask you the following questions from the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5) to assess your symptoms:3,4

In the past year, have you:

  • Drank more alcohol or spent more time drinking than you intended?
  • Wanted a drink so badly that it was all you could think about?
  • Spent a significant amount of time drinking or struggling with hangover symptoms?
  • Thought about cutting back or quitting drinking but been unable to do so?
  • Recognized that your drinking was interfering with your work or family life?
  • Continued to drink despite problems it was causing with your friends and family?
  • Given up on activities that you enjoy or are important to you because of your drinking?
  • Repeatedly been involved in situations that increase your risk of harm while under the influence (examples include unprotected sex, driving or swimming while drinking, and walking in dangerous areas)?
  • Continued to drink alcohol even when it makes you feel depressed, anxious, or makes other health problems worse
  • Or after having memory blackouts, where you can’t remember events that occur while you are drinking?
  • Developed a tolerance to alcohol and need to drink more to achieve the same effect?
  • Experienced withdrawal symptoms (irritability, insomnia, nausea, sweating, seizures, etc.) when alcohol wears off?

Depending on the answers to your question, you may be diagnosed with alcohol use disorder (AUD) in one of three severity levels:3

  • Mild: If you answer yes to two or three of the questions above, you qualify for a diagnosis of mild alcohol use disorder (AUD) under the DSM-5.
  • Moderate: If you answer yes to four or five of the above questions, you qualify for a diagnosis of moderate alcohol use disorder (AUD) under the DSM-5.
  • Severe: If you answer yes to six or more of the screening questions, you qualify for a diagnosis of severe alcohol use disorder (AUD) under the DSM-5.

How Are the Stages of Alcoholism and Alcohol Use Disorder DSM-5 Criteria Different?

While many people still refer to the stages of alcoholism and find them useful, they are considered to be an outdated way of describing alcohol use disorder. The DSM-5 criteria allow for a broader range of symptoms and a more nuanced understanding of individuals’ experiences.

For example, the stages of alcoholism assume that every person in each stage exhibits certain symptoms and that the nature of their illness progresses in a universal way. The current clinical understanding of alcohol use disorder recognizes that each person has an individual experience with alcohol and that not every person will have the same symptoms. The DSM-5 diagnoses AUD based on 11 criteria and classifies severity based on the number of criteria that a person meets.1,2,3,4

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Consequences of Alcohol Misuse

Alcohol misuse has negative consequences at every stage and severity. Even people considered to be early alcoholics or those diagnosed with mild alcohol use disorder are at risk of adverse health effects.

For example, the risk of cancer increases with any alcohol consumption, even less than one drink.7 Research has also found that even moderate drinking (defined as two drinks or less per day for men and one drink or less for women) is associated with shrinkage in parts of the brain responsible for learning and cognition.5 Alcohol use can also be detrimental to the liver. Every year nearly 30,000 people die of alcohol-related liver disease.1

Other long-term health risks of alcohol use disorder include:6,7

  • High blood pressure
  • Heart disease
  • Digestive issues
  • Stroke
  • Cancers of the liver, colon, rectum, mouth, throat, esophagus, voice box, or breast
  • Depression and anxiety
  • Learning and memory problems
  • Weakened immune system
  • Social problems such as relationship and family issues, job-related problems, unemployment, etc.
  • Sexually transmitted diseases from sexually risky behavior while drinking
  • Injury or death from automobile accidents or falls that occur while under the influence

Seeking Treatment for Alcohol Use Disorder

Regardless of where you may fall in the stages of alcoholism or alcohol use disorder DSM-5 criteria, if you feel concerned about your alcohol use or the use of a loved one, it is best to seek professional assessment to determine whether or not alcohol addiction treatment is needed. Only a qualified mental health professional can give you an official diagnosis of alcohol use disorder.

To learn more about alcohol use disorder assessment and treatment options, call 800-839-1686Who Answers? to speak with an addiction treatment specialist. We can also point you toward an appropriate rehab program near you or in a preferred location.

Resources

  1. Centers for Disease Control and Prevention. (January 2022). Fast Stats: Alcohol Use.
  2. Page, P.B.( 1997). E. M. Jellinek and the evolution of alcohol studies: a critical essay. Addiction, 92(12). 1619-1637.
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
  4. National Institute on Alcohol Abuse and Alcoholism. (April 2021). Understanding Alcohol Use Disorder.
  5. Merz, B. (July 2017). This is Your Brain on Alcohol. Harvard Medical Publishing.
  6. Centers for Disease Control and Prevention. (December 2021). Alcohol Use and Your Health.
  7. Centers for Disease Control and Prevention. (Deceember 2020). Dietary Guidelines for Alcohol.

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