Diagnosis of alcohol use disorder from a psychological point of view

La diagnosi del disturbo da uso di alcol dal punto di vista psicologico

GIOVANNA CORIALE1, DANIELA FIORENTINO1, RAFFAELLA PORRARI1, GEMMA BATTAGLIESE1,
IDA CAPRIGLIONE1, FEDERICA CEREATTI1, SILVIA IANNUZZI1, BENILDE MAURI1,
DOMENICA GALLI1, MARCO FIORE2, MARIA LUISA ATTILIA1, MAURO CECCANTI1,
INTERDISCIPLINARY STUDY GROUP CRARL - SITAC - SIPaD - SITD - SIPDip
*E-mail: gcoriale@tin.it

1Centro di Riferimento Alcologico della Regione Lazio (CRARL), Sapienza University of Rome, Italy
2Institute of Cell Biology and Neurobiology (IBCN-CNR), Rome, Italy


SUMMARY. Alcohol use disorder (AUD) is one of the most common psychiatric disease in the general population, characterized by having a pattern of excessive drinking despite the negative effects of alcohol on the individual’s work, medical, legal, educational, and/or social life. Currently, the bio-psycho-social model describes properly AUD as a multidimensional phenomenon including biological, psychological, and socio-cultural variables affecting the nature, maintenance, and expression of the disorder. The AUD diagnostic process is crucial since the treatment success depends heavily on the accuracy and the adequacy of the diagnosis. The diagnosis is based on a comprehensive assessment of the patient’s characteristics and uses interviews and psychometric instruments for collecting information. This paper will provide insights into the most important psychological dimensions of AUD and on the best psychometric instruments for proposing AUD diagnosis.

KEY WORDS: alcohol use disorder, AUD, psychological alcohol dimensions, diagnosis, clinical interview, screening, assessment.


RIASSUNTO. Il disturbo da uso di alcol (DUA) è uno dei disturbi psichiatrici più comuni nella popolazione generale. Il DUA è caratterizzato da un pattern di bere eccessivo, che si mantiene nonostante gli effetti negativi che l’alcol ha sul funzionamento lavorativo, sulla salute, sulle problematiche legali, sull’educazione e sulla vita sociale. Attualmente, il modello bio-psico-sociale è quello che spiega meglio il DUA. Infatti, molte ricerche hanno fornito evidenze su come il DUA sia una patologia multidimensionale. Variabili biologiche, psicologiche e socio-culturali entrano in gioco nell’eziologia, nella natura, nel mantenimento e nel cambiamento nel tempo del disturbo. La fase diagnostica è un momento importante del processo di cura, perché il successo del trattamento dipende in larga misura dall’esattezza e dall’adeguatezza della diagnosi. La diagnosi clinica si basa su una valutazione globale del funzionamento del paziente e utilizza il colloquio e gli strumenti psicometrici come mezzo di raccolta di informazioni. Questo articolo fornirà una panoramica delle dimensioni psicologiche più importanti da valutare e sui migliori strumenti psicometrici da usare per una diagnosi adeguata.

PAROLE CHIAVE: disturbo da uso di alcol, DUA, dimensioni psicologiche collegate all’alcol, diagnosi, colloquio clinico, screening, valutazione.

INTRODUCTION
The American Medical Association defines the alcohol use disorder (AUD) a chronic and relapsing disease1. The bio-psycho-social approach to alcoholism is now generally considered the most appropriate to explain AUD. AUD complexity is characterized by a multifactorial pathogenesis with various clinical manifestations (mental and behavioral disorders, internal medicine diseases, neurological or psychiatric problems)2. The model includes the presence of a team of professionals (physicians, psychologists and psychiatrists) that integrate their work to develop diagnosis and treatment schedules. The AUD diagnostic process is crucial since the treatment success depends heavily on the accuracy and the adequacy of the diagnosis3. The diagnosis involves specific models, methods, and techniques aimed at developing hypotheses about the psychological feature of the person asking for help. The psychological diagnosis shows: 1) functional and dysfunctional aspects of the AUD person, and 2) these aspects are evaluable and quantifiable; 3) the AUD person is influenced strongly by the location (hospital, prison, home, specialized services for the treatment of AUD) where the diagnosis is made. The diagnosis is based on a comprehensive assessment of the patient’s symptoms and uses interviews and psychometric instruments as a tool for the collection of information. In clinical practice, the various services dealing with alcohol dependence differ greatly from each other in the type of the proposed assessment. This variability depends on the service nature, purpose and characteristics, on the available resources (spaces and operators), but also on the poor AUD knowledge available on what are the most functional tools to make a diagnosis 4-6. The knowledge of the AUD clinical characteristics are extremely important in order to determine what psychometric instruments to use in the AUD diagnosis.
EVALUATION OF THE AUD CLINICAL CHARACTERISTICS
The choice of the clinical features in the AUD diagnostic evaluation is a very delicate and complex process. In particular, some aspects that should be finely investigated for fostering treatment schedules are:
1. The motivation for change in people who have problems related to alcohol and/or other substances has a very important role. Scientific evidences have found that the level of motivation for change improves the treatment outcome7,8 facilitating the quit drinking.
2. The desire to drink (craving) is frequently connected to relapse and to the lack of adherence to treatment9. The desire to drink seems related specifically to the amount of alcohol drunk: the stronger the desire, the higher will be the alcohol consumption10,11. It has been shown that the combination between appropriate pharmacological interventions and psychological treatments may greatly reduce the drinking desire and the lack of adherence to treatment12-14.
3. AUD is frequently associated with other psychiatric disorders as the bipolar disorders and the cluster B personality disorders15. Such psychiatric problems if not properly identified and treated might greatly impair the AUD treatment16,17.
4. It has been widely documented the presence of cognitive difficulties related to alcohol abuse18-22. Main impairments regard the executive functioning (58%), the acquisition of new information (32%) with a minor frequency of general cognitive deterioration (4%)23. At neuro-anatomical and physiological levels, alcohol abuse seems particularly linked to impairments of the frontal lobe and the hippocampus, basically reversible with increasing abstinence24,25. Longitudinal studies, through the use of f-MRI, show an increase in the volume of gray matter26 and hippocampal structures27. It has been shown an improvement in the cerebral general structure21,28 following a period of abstinence of at least one month, in particular, the frontal and temporal structures29. Data on cognition suggest the importance of monitoring memory and learning functioning to adapt the psychological treatment of the clinical characteristics of the AUD person30.
5. AUD has also a negative impact on the quality of life of patient friends and family31. Although AUD is a chronic and relapsing disease, treatment should target to improve the patient quality of life. The World Health Organization (WHO) defines health not only as the absence of disease but also as a state of physical, mental and social well-being32. The construct of “quality of life” is a good indicator to assess and quantify the improvement due to abstinence from alcohol and therefore a measure of treatment efficacy33,34.
INTAKE INTERVIEW
Intake interviews are the most common type of interview in clinical psychology. The intake interview is important in clinical psychology because it is the first interaction that occurs between the client and the clinician. The clinician may explain to the client what to expect during the interview, including the time duration35. In AUD the purpose of the intake interview often includes establishing and diagnosing any problems the patient may have. Its purpose is establishing and diagnosing AUD and correlated problems of the patients to create and to personalize a treatment schedule35. The understanding of the reasons leading the AUD patient to seek for help is crucial during the interview36 (Figure 1) shows the clinical characteristics to evaluate during the interviews to determine a diagnosis of AUD including the severity of alcohol use, obsessive-compulsive nature of drinking, craving, poly-dependence, comorbidity with other psychopathological disorders as well as data about family situation, occupation and socio-relational adaptation (Table 1). The ability of the psychologist to carry out the intake interview is crucial to disclose subtle patients’ information for diagnosing AUD by using empathic statements such as paraphrases, feeling validation, and non-directive reflections of feelings aimed at creating a therapeutic alliance. The motivational interview should offer a model of how the intake interview should be conducted 8. Motivational style, in fact, provides clinical tools for preventing interruptions in the communication between patient and psychologist to easily build, even in people with low levels of motivation, a protected relational context where the patient may feel understood and welcomed37. The interactive style proved to be more capable of activating a problematic drinking change than the directive style38. Similar conclusions were reached by Rollnick et al.39 who considered the “confrontation” as an interactive counterproductive style.







PSYCHOMETRIC TOOLS FOR AUD DIAGNOSIS AND ASSESSMENT
Many psychometric tools for the diagnosis of AUD have been described and proposed, however, only a few have been actually validated in Italy40. The AUD diagnosis for the development of a treatment plan may be reached by collecting information on physical, psychological and social features of the patient40. Treatment monitoring is an important step of the care process, requiring indicators, traced from both interviews and psychometric tools, called also measure of “success” (outcome). Table 2 shows the psychometric instruments and questionnaires and dimensions investigated by each test and relative degrees of “recommendation and evidence”41 (Table 3). In particular, psychometric tools should be administered after at least 7 days of abstinence to minimize bias due to withdrawal side effects.
They include in particular the following tools.
Motivation to Change-Alcohol
Most of the motivation for change assessment tools refer to the concept of readiness to change as shown by Prochaska and DiClemente in their model of the stages of change42. The Motivation to Change-Alcohol questionnaire (MAC2-A), validated in Italy, was designed to evaluate the motivation to change in adult subjects with AUD who require or are referred for assessment and treatment43,44. MAC2-A  (Precontemplation, Contemplation, Determination, Action, Maintenance and Exit) also describing the motivation according to a three-factor model (Availability to change, Inner fracture and Self-efficacy). MAC2-A has been validated in Italy by a study analyzing 419 subjects recruited at 23 Italian sites. MAC2-A consists of 36 statements – 18 of these items measure stages of change, 12 items measure “discrepancy” and “self-efficacy” and 6 items evaluate “help-seeking”. Each item is rated to a 0-6 Likert scale from “not at all true” to “completely true”. At the end of the questionnaire there are six questions (Inner fracture, Self-efficacy, availability to change, stabilization, importance attributed to the change and the desire/temptation to alcohol). MAC2-A uses a 100-point visual analog scale (VAS) response format and each item is assessed on a 0-100 scale from “not at all” to “extremely”. All data are correlated with the self-declared abstinence days. MAC2-A also evaluates the help seeking, separately from the readiness to change, because the aspects of motivation for change and motivation to therapy might not always have similar development trends 45,46. The questionnaire allows to evaluate not only the motivation but also many other indices, for example, the “effective” perceived by the patient to make changes in order to plan treatment43,44 (Evidence B, Recommendation 1 of Table 3).
Severity of Alcohol Dependence Questionnaire
The Severity of Alcohol Dependence Questionnaire (SADQ)47 is a short, self-administered, questionnaire designed by the WHO to measure the severity of dependence on alcohol based on the premise formulated by Edwards and Gross48. It is composed of 20 items that measure the withdrawal symptoms both physical and psychological. The subject is asked to recall a month when he drank a lot, and starting from the memory of that, are posed some questions exploring: physical symptoms such as tremors, sweating, or stomach pain; moods; feelings of relief resulting from the consumption of alcohol; alcohol consumption; the rapid recovery of the addiction. Each item is scored on a 4-point scale ranging from 0 (never or almost never) to 3 (nearly always). The maximum possible score is 60. A score of over 30 indicates severe alcohol dependence. SADQ predicts the probability of reaching the goal of controlled drinking and severity of withdrawal symptoms 49-52 (Evidence A, Recommendation 1 of Table 3).









Addiction Severity Index
The Addiction Severity Index (ASI) is a semi-structured instrument used in face-to-face interview conducted by a counsellor for assessing the frequency of use of drugs and alcohol and the severity of the problems from its use. ASI may be used in the initial phase of the treatment and subsequently at follow-up53. ASI has been utilized extensively for treatment planning and outcome evaluation54. The original questionnaire was subjected to validation, updated and expanded until the publication of the fifth edition in 199055-57. In 1993 the European version was developed, called the European Addiction Severity Index (EuropASI). The ASI is also designed to address seven potential problem areas in substance-abusing patients: medical status, employment and support, drug use, alcohol use, legal status, family/social status, and psychiatric status. The questionnaire requires relatively long time of administration and could be difficult to use in those contexts in which the availability of time for the patient is limited or when the clinical setting is not appropriate or when the active participation required to the patient is insufficient. However, it remains highly recommended for the important information provided. In Italy the version of the questionnaire is edited by Consoli and Bennardo 58, however, the EuropASI is the mostly carried out59 (Evidence A, Recommendation 1 of Table 3).
Visual Analogue Scale
Visual Analogue Scale (VAS) collects information on self-reported craving intensity. It is a straight horizontal line of fixed length, usually 100 mm. The ends are defined as the extreme limits of the parameter to be measured orientated from the left (no symptoms) to the right (strong symptoms). The subject is required to indicate, for each specific substance (heroin, cocaine, alcohol, etc.): 1) the “desire” that she/he had during the previous week of investigation, putting a sign on a line for each substance of abuse; 2) the intensity of the desire to drink; 3) and if he/she has drunk. The VAS is very useful in the rapid assessment of craving for drug abuse 60,61 (Evidence A, Recommendation 1 of Table 3).
Obsessive Compulsive Drinking Scale
The Obsessive Compulsive Drinking Scale (OCDS) was developed to reflect obsessionality and compulsivity related to craving and drinking behaviour62,63. The questionnaire consists of 14 questions referred to the two weeks prior to the administration. OCDS consists of questions on the intensity of the desire, on obsessive and compulsive characteristics of drinking, on related thought, urges to drink, and on the ability to resist to drink and on the amount of alcohol drunk on relapses. The scale is sensitive and specific in capturing the obsessive-compulsive characteristics of thoughts connected to drinking, the desire and the ability to resist to these thoughts 64-68.
OCDS represents also an excellent monitoring tool, able to predict relapse and a treatment reliable indicator63,65,69,70. It has been translated into many languages including Italian71 (Evidence A, Recommendation 1 of Table 3).
Symptom Checklist-90
Symptom Checklist-90 (SCL-90) instrument evaluates a broad range of psycho-pathological problems and symptoms72. Applying factorial analysis Derogatis73 proposed nine subscales or dimensions labeled: somatisation, obsessive compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Patients are asked to rate the severity of their experiences with 90 symptoms over the past week on a 5-point scale ranging from 0 ‘not at all’ to 4 ‘extremely’. In the SCL-90 3 indexes are defined: GSI (General Symptomatic Index) is the ratio between the sum of all items and those analyzed; PST (Positive Symptom Total) is the number of items scored positively; PSDI (Positive Symptom Distress Index) is the sum of all the items, and the PST 74. Approximately 12-15 minutes are necessary for its compilation and it is relatively easy to compile. A high score in a given dimension indicates high expression of the corresponding distress. By using the SCL-90-R75, it was observed in a sample of alcoholics, symptoms 2-5 times more severe than in the general population76. In AUD people, SCL-90 is a valid and useful screening tool in measuring patient progress or treatment outcomes72,77-79. This scale may predict relapse80. In Italy, a first SCL-90 version was provided by Dell’Erba81 with a few changes, compared to the original version, in the questions and scoring. In 2011, it has been also published another validated version of the test edited by OS Giunti (Evidence A, Recommendation 1 of Table 3).
Minnesota Multiphasic Personality Inventory
Minnesota Multiphasic Personality Inventory (MMPI, now versions 2, MMPI-2) is one of the most widely used standardized psychometric tests of adult personality and psychopathology82. It is used both in the psychological and psychiatric field. The current MMPI-2 has 567 true/false questions, 8 validity scales, 10 clinical subscales, 16 supplemental scales, 15 content scales, PSY-5 (Personality Psychopathology Five) scales, 27 subscales related to the components of the content scales, and 28 subscales of Harris-Lingoes83. It usually takes between one and two hours to complete depending on reading level. The Italian version of the MMPI-2 was edited by Pancheri and Sirigatti and was issued by OS Giunti in 1995. The MMPI-2 is widely used in the AUD context to detect symptoms associated with neuroticism (hypochondriasis, depression and hysteria), anxiety84 and personality disorders (dependent disorder, antisocial and borderline)85. An important limit of the test is the expenditure of time necessary for its compilation and for the scoring (Evidence A, Recommendation 1 of Table 3).
Millon Clinical Multiaxial Inventory
Millon Clinical Multiaxial Inventory - Fourth Edition (MCMI-IV) is the most recent edition of the Millon Clinical Multiaxial Inventory86. It represents a new and valid adult psychological assessment tool used alternatively or in addition to psychopathological questionnaires of personality already in use87. The previous version of the Millon Clinical Multiaxial Inventory (MCMI-III) has more than 700 empirical studies, based on scientific researches and dozens of specialized texts dedicated. Only the Rorschach test and MMPI-2 have more researches published in the last five years88. The inventory is composed by: 15 Personality Pattern Scales, 10 Clinical Syndrome Scales, 5 Validity Scales: 3 Modifying Indices; 2 Random Response Indicators, 45 Grossman Personality Facet Scales (based on seth Grossman’s theories of personality and psychopathology). Moreover, MCMI-IV offers updated norms that are based on a clinical adult population, a new scale, DSM-5 and ICD-10-CM alignment, updated narrative content and a new and solid therapeutic focus. The brevity of the MCMI-IV allows clinicians to maintain an efficient and productive clinical practice 86. The MCMI-IV is also used on the population of alcoholics89-91. In Italy, we have validated only the MCMI-III (Evidence A, Recommendation 1 of Table 3).
Temperament and Character Inventory
Cloninger proposed a sociobiological model of addiction that integrates the genetic, neurobiological and psychological components 92. The model finds its practical application in the Temperament and Character Inventory-TCI93 based on four temperaments (Novelty Seeking [NS], Harm Avoidance [HA], Reward Dependence [RD], and Persistence [PS]) and three characters (Self-directedness [SD], Cooperativeness [CO], and Self-transcendence [ST]) each of which corresponds to a specific pattern of behaviour in response to various environmental stimuli. The temperamental traits are stable and genetically determined, little affected by the socio-cultural components of personality. Each of the first three dimensions reflect the activities of the three main brain systems, namely: the Central system of behavioural activation (dopamine), central system of behavioural inhibition (serotonin), central system of behavioural maintenance (noradrenaline). The temperament traits are, according to Cloninger, a powerful tool to distinguish the various personality disorders or to locate vulnerability to a wide spectrum of mental disorders 94. The character traits are to be placed in relation to educational and socio-environmental influences and are able to strongly predict the presence of personality disorders92 associated with AUD95,96. This test is validated in Italy by Fossati et al.97,98 (Evidence A, Recommendation 1 of Table 3).
Beck Depression Inventory
Beck Depression Inventory (BDI) is a 21-items, self-report rating inventory that measures characteristic attitudes and symptoms of depression frequently associated with AUD99. There is a four-point scale for each item ranging from 0 to 3. The sum of all the individual item scores indicates the severity of depression: higher total scores indicate more severe depressive symptoms. In 1996, the questions in the BDI were revised (BDI-II) to reflect changes made in the DSM-IV. Like the BDI, the BDI-II also contains 21 questions, with each answer being scored on a scale of 0 to 3100. The cutoffs used, however, are somewhat different: 0-13: minimal depression; 14-19: mild depression; 20-28: moderate depression; 29-63: severe depression. The BDI-II reflects two components of depression: the affective subscale that contains 8 items (pessimism, past failures, guilty feelings, punishment feelings, self-dislike, self-criticalness, suicidal thoughts or wishes), and worthlessness and the somatic subscale with other 13 items (sadness, loss of pleasure, crying, agitation, loss of interest, indecisiveness, loss of energy, change in sleep patterns, irritability, change in appetite, concentration difficulties, tiredness and/or fatigue, and loss of interest in sex) 100. The two subscales were moderately correlated at 0.57, suggesting that the physical and psychological aspects of depression are related rather than totally distinct101-103. The BDI takes approximately 10 minutes to complete, although clients require a fifth/sixth grade reading level to adequately understand the questions104. Although designed as a screening device rather than a diagnostic tool, the BDI is sometimes used by health care providers to reach a quick diagnosis105. The BDI is found useful in monitoring the severity of the changes in depression over time103. The instrument has been frequently used in treatment programs of psychoactive substances and/or alcohol dependence106. The BDI suffers from the same problems as other self-report inventories and the scores can be easily exaggerated or minimized by the person completing them107 (Evidence A, Recommendation 1 of Table 3).
State-Trait Anxiety Inventory
State-Trait Anxiety Inventory (STAI)108 is a self-report assessment device which includes separate measures of state and trait anxiety. According to the author, state anxiety reflects a transitory emotional state characterized by subjective, consciously perceived feelings of tension and apprehension, and by raised autonomic nervous system activity. It is floating over time and can vary in intensity. In contrast, trait anxiety denotes relatively stable individual differences in anxiety proneness and refers to a general tendency to respond with anxiety to perceived threats in the environment 109. Both the STAI Y-1 (State Anxiety) and STAI Y-2 Form (Trait Anxiety) comprise 20 items each and are scored on 4-point forced-choice Likert-type response scales rated from 1 (not at all) to 4 (very much so). Scores range from 20 to 80, with higher scores suggesting greater levels of anxiety110. In the Italian standardization of the test three samples were used (adult workers, students of high schools and military recruits). The test takes 15 minutes to be filled. The instrument has been frequently used in the treatment programs of the psychoactive substances and/or alcohol dependence111-114 (Evidence A, Recommendation 1 of Table 3).
Mini-Mental State Examination
At the clinical level, the early detection of a global cognitive malfunction is very important. AUD subjects in these conditions may not benefit from standard treatment and have, therefore, needs of specific treatment23,115. In this regard, it is recommended to use some tools that allow a rough but still important screening of cognitive disorders. The Mini-Mental State Examination (MMSE)116 allows quickly to identify a mental impairment or a cognitive impairment. It is commonly used in medicine to screen for dementia but also to estimate the severity and progression of cognitive impairments. MMSE takes between 5 and 10 minutes and examines functions including spatial and temporal orientation, memory, language, attention, and constructive ability. It has been used on many clinical populations including people with AUD115-117 (Evidence A, Recommendation 1 of Table 3). If the performance at the MMSE or one of its subtests are deficient, we recommend in AUD people a careful diagnosis using tests that assess memory, visual-spatial skills and visual-constructive, attention and executive functions23. Such careful diagnosis should serve to understand if the impaired performance on MMSE is due to impairments of specific functions most sensitive to the negative effect of alcohol or to a general cognitive impairment.
Wechsler Adult Intelligence Scale
The sub-test vocabulary scale of the Wechsler Adult Intelligence Scale (WAIS-R)118 is composed of 39 words that the subject must define orally. For each response is given a score of 2, 1 or 0 points, depending on the relevance of the definition. The performance of this sub-test results to be correlated to the IQ and often used as a measure of pre-disease intellectual functioning119 also in the population of alcoholics120,121. In the 2013, it has been published by OS Organization (OS Giunti) the Italian translation of Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) and the last version of vocabulary subtest is commonly used122 (Evidence A, Recommendation 1 of Table 3).
Global Assessment of Functioning and World Health Organization’s Disability Assessment Schedule
The Global Assessment of Functioning (GAF)123 is a numeric scale used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of an individual. The scale was entered in DSM-IV-TR and uses a scale from 100 (extremely high functioning) to 1 (severely impaired). The DSM-5 replaced the GAF with the WHODAS (World Health Organization’s Disability Assessment Schedule), an interview more detailed and objective than GAF scale124. The main advantage of the GAF would be its brevity. Moreover, the last one has been extensively used in the treatment programs of the psychoactive substances and/or alcohol dependence125 (Evidence A, Recommendation 1 of Table 3).
Short-Form Health Survey
The Short-Form Health Survey (SF-36) came out from the Medical Outcome Study (MOS) and is used to indicate the health status of particular populations, to plan treatment and to measure the impact of clinical and social interventions126,127. The SF-36 consists of eight scales that investigate vitality, physical functioning, bodily pain, general health perceptions, and physical role functioning, emotional role functioning, social role functioning and mental health. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. There is a validated version in Italy128. The test is easy to administer and its compilation may take from 5 to 15 minutes. A shorter version of the 12-question test (SF-12) has been published with equal reliability and validity of the longer version129. SF-36, compared to SF-12, has been found very useful as outcome measures and often used in the studies on AUD130-132 (Evidence A, Recommendation 1 of Table 3).
Outcome evaluation and follow-up
Outcome is defined as the effect on an individual’s health status attributable to an intervention. The primary aim of any health care service is to have a positive impact on the health and wellbeing of its clients. For this reason, the systematic measurement of treatment outcomes is an important part of the care process133. Outcome evaluation of alcoholics’ requires combined analyses of drinking associated behaviours during the treatment, adherence to therapeutic programs and secondary non-drinking outcomes134. Outcome measures are, however, indicators defining and quantifying the outcome efficacy. Crucial issues are the identification of the treatment outcome variables134. The abstinence is not necessarily always the only goal of a treatment programs, nevertheless it remains the more used indicator of treatment outcome135-141. Abstinence from alcohol could be an important measure of success, but only if it is associated with improvements in other aspects of the patient’s life (psychopathology, quality of life, social and cognitive functioning)138,142,143. In turn, the overall improvement is possible, only when: 1) the diagnostic phase is organized in order to build a comprehensive framework of the patient psycho-social features; 2) the treatment provides an adequate response to the patient’s discomforts. After treatment, it is necessary that treatment outcomes are monitored through follow-up meetings. More than half of patients in the treatment for substance use disorders relapse within the first year. However, patients undergoing detoxification remain highly at-risk for relapsing also after years from the intervention 144-147. Frequent follow-ups are essential to support patient during the recovery period. The term “follow-up” is used for defining interventions after the end of the primary treatment.
It is found that after intensive initial treatment episodes, a period of less intensive treatment is necessary in an effort to extend and reinforce the period of abstinence148,149. Is not clear which could be the optimal length and intensity of the continuing care but it has been hypothesized that a longer treatment is associated with greater positive effects on quit drinking150, while the intensity of the treatment is not significantly associated with a positive outcome151. Indeed, it is important that during the follow-up time, the clinical interviews should be associated with the administration of tests to control the clinical condition of the AUD patient. The phases which characterize the process of diagnosis and treatment (assessment, diagnosis, treatment plan, treatment and follow-up) are summarized in Table 4, with an indication of the psychometric tools used considering the administration intervals.



CONCLUSIONS
The diagnostic process has as its goal to gather important information for developing a reliable diagnosis but also for scheduling appropriate treatments. At the present time, no standardized approaches of AUD diagnosis are ordinarily available152-157. However, in order to facilitate the acquisition of a realistic and comprehensive picture of the patient’s clinical condition it is very important that a wide range of clinical dimensions is investigated (history of addictive disorder, readiness to change, physical condition, mental and psychiatric state, presence of trauma, suicidal thoughts, family history). Clinical interviews and psychometric instruments are used by professionals to primary collect information. This review has focused on diagnostic tools with Italian validation, a well-known scientific relevance and on simple administration. For this reason, we have included for each described tool, information about the scientific evidence and grade of recommendations (based on Table 3) 41. In conclusion, it may be quite useful to highlight the guideline recommendations proposed by the National Institute for Health and Clinical Excellence40. showing that in the care process, it should be given priority in potentiating the relationships, based on mutual trust, not only between the patient and the professional but also between the professional and the patient family. Furthermore, it should be stressed that in AUD the assessment should finely investigate the severity of the addiction and an eventual psychopathological comorbidity in order to promptly program an appropriate therapeutic intervention.

Conflict of interests: the authors have no conflict of interests to declare.

**Interdisciplinary Study Group - Centro Riferimento Alcologico Regione Lazio (CRARL), Società Italiana per Il Trattamento dell’Alcolismo e delle sue Complicanze (SITAC), Società Italiana Patologie da Dipendenza (SIPaD), Società Italiana delle Tossicodipendenze (SITD), Società Italiana di Psichiatria e delle Dipendenze (SIPDip): Giovanni Addolorato, Giovanni Alessandrini, Vincenzo Ailotta, Fabio Attilia, Giuseppe Barletta, Egidio Battaglia, Ida Capriglione, Valentina Carito, Onofrio Casciani, Pietro Casella, Fernando Cesarini, Mauro Cibin, Rosaria Ciccarelli, Paola Ciolli, Angela Di Prinzio, Roberto Fagetti, Emanuela Falconi, Michele Federico, Giampiero Ferraguti, Simona Gencarelli, Angelo Giuliani, Antonio Greco, Guido Intaschi, Luigi Janiri, Angela Lagrotta, Giuseppe La Torre, Giovanni Laviola, Roberta Ledda, Lorenzo Leggio, Claudio Leonardi, Anna Loffreda, Fabio Lugoboni, Simone Macrì, Rosanna Mancinelli, Massimo Marconi, Icro Maremmani, Marcello Maviglia, Marisa Patrizia Messina, Martino Mistretta, Franco Montesano, Esterina Pascale, Michele Parisi, Roberta Perciballi, Fabiola Pisciotta, Claudia Rotondo, Giampaolo Spinnato, Alessandro Valchera, Mario Vitali, Valeria Zavan.
REFERENCES
  1. American Medical Association (AMA). Drug dependencies as diseases: policy H-95.983 of the AMA house of delegates. Chicago: IL: American Medical Association, 2012.
  2. Wallace J. The new disease model of alcoholism. West J Med BMJ Group 1990; 152: 502-5.
  3. Meier PS, Barrowclough C, Donmall MC. The role of the therapeutic alliance in the treatment of substance misuse: a critical review of the literature. Addiction 2005; 100: 304-16.
  4. Heather N, Raistrick D, Godfrey C. A summary of the review of the effectiveness of treatment for alcohol problems. The National Treatment Agency for Substance Misuse. 2006. www.nta.nhs.uk. Accessed June 13, 2017.
  5. Coriale G, Ceccanti M, De Filippis S, Caravasso CF, De Persis S. Disturbo da gioco d’azzardo: Epidemiologia, diagnosi, modelli interpretativi e trattamento. Riv Psichiatr 2015; 50: 216-27.
  6. Coriale G, Fiorentino D, Di Lauro F, et al. Fetal Alcohol Spectrum Disorder (FASD): neurobehavioral profile, indications for diagnosis and treatment Fetal Alcohol Spectrum Disorder (FASD): profilo neuro-comportamentale, diagnosi differenziale e indicazioni per il trattamento. Riv Psichiatr 2013; 48: 359-69.
  7. Demmel R, Beck B, Richter D, Reker T. Readiness to change in a clinical sample of problem drinkers: relation to alcohol use, self-efficacy, and treatment outcome. Eur Addict Res 2004; 10: 133-8.
  8. Hester RK, Miller WR. Handbook of alcoholism treatment approaches: effective alternatives. Oxford: Pergamon Press, 1989.
  9. Flannery BA, Poole SA, Gallop RJ, Volpicelli JR. Alcohol craving predicts drinking during treatment: an analysis of three assessment instruments. J Stud Alcohol 2003; 64: 120-6.
 10. Hillemacher T, Bayerlein K, Wilhelm J, et al. Volume intake and craving in alcohol withdrawal. Alcohol Alcohol 2006; 41: 61-5.
 11. Yoon G, Kim SW, Thuras P, Grant JE, Westermeyer J. Alcohol craving in outpatients with alcohol dependence: rate and clinical correlates. J Stud Alcohol 2006; 67: 770-7.
 12. Swift R, Pettinati HM. Choosing pharmacotherapies for the COMBINE Study – process and procedures: an investigational approach to combination pharmacotherapy for the treatment of alcohol dependence. J Stud Alcohol Suppl 2005; (15): 141-7; discussion 140.
 13. Volpicelli JR. Alcohol abuse and alcoholism: an overview. J Clin Psychiatry 2001; 62 Suppl 2: 4-10.
 14. Weiss RD, Kueppenbender KD. Combining psychosocial treatment with pharmacotherapy for alcohol dependence. J Clin Psychopharmacol 2006; 26 Suppl 1: S37-42.
 15. Mellos E, Liappas I, Paparrigopoulos T. Comorbidity of personality disorders with alcohol abuse. In Vivo 2010; 24: 761-9.
 16. Coriale G, Bilotta E, Leone L, et al. Avoidance coping strategies, alexithymia and alcohol abuse: a mediation analysis. Addict Behav 2012; 37: 1224-9.
 17. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2007; 64: 830-42.
 18. Ceccanti M, Hamilton D, Coriale G, et al. Spatial learning in men undergoing alcohol detoxification. Physiol Behav 2015; 149: 324-30.
 19. Ceccanti M, Carito V, Vitali M, et al. Serum BDNF and NGF modulation by olive polyphenols in alcoholics during withdrawal. J Alcohol Drug Depend 2015; 3: 214-9.
 20. Ceccanti M, Coriale G, Hamilton DA, et al. Virtual Morris Task Responses in individuals in an abstinence phase from alcohol. Can J Physiol Pharmacol 2018; 96: 128-36.
 21. Bartsch AJ, Homola G, Biller A, et al. Manifestations of early brain recovery associated with abstinence from alcoholism. Brain 2007; 130 (Pt 1): 36-47.
 22. Pitel AL, Witkowski T, Vabret F, et al. Effect of episodic and working memory impairments on semantic and cognitive procedural learning at alcohol treatment entry. Alcohol Clin Exp Res 2007; 31: 238-48.
 23. Theotoka I. Cognitive impairment in alcoholism. Ann Gen Psychiatry 2006; 5 (Suppl 1): S56.
 24. Bartels C, Kunert H-J, Stavich S, Kroner-Herwig B, Ehrenreich H, Krampe H. Recovery of hippocampus-related functions in chronic alcoholics during monitored long-term abstinence. Alcohol Alcohol 2006; 42: 92-102.
 25. Wobrock T, Falkai P, Schneider-Axmann T, Frommann N, Wölwer W, Gaebel W. Effects of abstinence on brain morphology in alcoholism. Eur Arch Psychiatry Clin Neurosci 2009; 259: 143-50.
 26. Pfefferbaum A, Sullivan EV, Mathalon DH, Shear PK, Rosenbloom MJ, Lim KO. Longitudinal changes in magnetic resonance imaging brain volumes in abstinent and relapsed alcoholics. Alcohol Clin Exp Res 1995; 19: 1177-91.
 27. Gazdzinski S, Durazzo TC, Studholme C, Song E, Banys P, Meyerhoff DJ. Quantitative brain MRI in alcohol dependence: preliminary evidence for effects of concurrent chronic cigarette smoking on regional brain volumes. Alcohol Clin Exp Res 2005; 29: 1484-95.
 28. Gazdzinski S, Durazzo TC, Meyerhoff DJ. Temporal dynamics and determinants of whole brain tissue volume changes during recovery from alcohol dependence. Drug Alcohol Depend 2005; 78: 263-73.
 29. Cardenas VA, Studholme C, Gazdzinski S, Durazzo TC, Meyerhoff DJ. Deformation-based morphometry of brain changes in alcohol dependence and abstinence. Neuroimage 2007; 34: 879-87.
 30. Ceccanti M, Inghilleri M, Attilia ML, et al. Deep TMS on alcoholics: effects on cortisolemia and dopamine pathway modulation. A pilot study. Can J Physiol Pharmacol 2015; 93: 283-90.
 31. Saatcioglu O, Yapici A, Cakmak D. Quality of life, depression and anxiety in alcohol dependence. Drug Alcohol Rev 2008; 27: 83-90.
 32. World Health Organization. Regional Office for Europe. Health promotion: a discussion document on the concept and principles: summary report of the Working Group on Concept and Principles of Health Promotion, Copenhagen, 9-13 July 1984. Copenhagen: WHO Regional Office for Europe, 1984.
 33. Préau M, Protopopescu C, Spire B, et al. Health related quality of life among both current and former injection drug users who are HIV-infected. Drug Alcohol Depend 2007; 86: 175-82.
 34. Lahmek P, Berlin I, Michel L, Berghout C, Meunier N, Aubin H-J. Determinants of improvement in quality of life of alcohol-dependent patients during an inpatient withdrawal programme. Int J Med Sci 2009; 6: 160-7.
 35. Kramer GP, Bernstein DA, Phares V. Introduction to clinical psychology. Upper Saddle River, NJ: Pearson Prentice Hall, 2009, p. 657.
 36. Carli R, Paniccia RM. Analisi della domanda. Teoria e intervento in psicologia clinica. Bologna: Il Mulino, 2003, p. 300.
 37. Miller WR, Rollnick S. Il colloquio motivazionale - Terza edizione: Aiutare le persone a cambiare. Trento: Edizioni Centro Studi Erickson, 2014, p. 594.
 38. Miller WR, Benefield RG, Tonigan JS. Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. J Consult Clin Psychol 1993; 61: 455-61.
 39. Rollnick S, Heather N, Gold R, Hall W. Development of a short “readiness to change” questionnaire for use in brief, opportunistic interventions among excessive drinkers. Br J Addict 1992; 87: 743-54.
 40. NICE Clinical Guidelines National Collaborating Centre for Mental Health. Alcohol-Use Disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Leichster: British Psychological Society, 2011.
 41. Istituto Superiore di Sanità. Come produrre, diffondere e aggiornare raccomandazioni per la pratica clinica: Manuale Metodologico. ISS, 2002.
 42. Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychother Theory Res Pract 1982; 19: 276-88.
 43. Spiller V, Zavan V, Guelfi G. La motivazione al cambiamento in alcologia. Validazione del questionario MAC2-A. Bollettino per le Farmacodipendenze e l’Alcoolismo 2009; 3: 105-14.
 44. Spiller V, Zavan V, Guelfi GP. Assessing motivation for change in subjects with alcohol problems: the MAC2-A Questionnaire. Alcohol Alcohol 2006; 41: 616-23.
 45. Freyer J. Readiness for change and readiness for help-seeking: a composite assessment of client motivation. Alcohol Alcohol 2005; 40: 540-4.
 46. Freyer J, Tonigan JS, Keller S, John U, Rumpf H-J, Hapke U. Readiness to change versus readiness to seek help for alcohol problems: the development of the Treatment Readiness Tool (TReaT). J Stud Alcohol 2004; 65: 801-9.
 47. Stockwell T, Murphy D, Hodgson R. The severity of alcohol dependence questionnaire: its use, reliability and validity. Br J Addict 1983; 78: 145-55.
 48. Edwards G, Gross MM. Alcohol dependence: provisional description of a clinical syndrome. Br Med J 1976; 1: 1058-61.
 49. Heather N, Brodie J, Wale S, et al. A randomized controlled trial of Moderation-Oriented Cue Exposure. J Stud Alcohol 2000; 61: 561-70.
 50. McCusker CG, Brown K. The cue-responsivity phenomenon in dependent drinkers: “personality” vulnerability and anxiety as intervening variables. Br J Addict 1991; 86: 905-12.
 51. Booth PG. Maintained controlled drinking following severe alcohol dependence: a case study. Br J Addict 1990; 85: 315-22.
 52. Davidson R. Assessment of the alcohol dependence syndrome: a review of self-report screening questionnaires. Br J Clin Psychol 1987; 26 (Pt 4): 243-55.
 53. McLellan AT, Luborsky L, Woody GE, O’Brien CP. An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. J Nerv Ment Dis 1980; 168: 26-33.
 54. Moos RH, Finney JW, Federman EB, Suchinsky R. Specialty mental health care improves patients’ outcomes: findings from a nationwide program to monitor the quality of care for patients with substance use disorders. J Stud Alcohol 2000; 61: 704-13.
 55. Alterman AI, McDermott PA, Cook TG, et al. New scales to assess change in the Addiction Severity Index for the opioid, cocaine, and alcohol dependent. Psychol Addict Behav 1998; 12: 233-46.
 56. Flórez G, Saiz PA, García-Portilla P, et al. Predictors of posttreatment drinking outcomes in patients with alcohol dependence. Eur Addict Res 2015; 21: 19-30.
 57. Fureman B, Parikh G, Bragg A, Mclellan T. Addiction Severity Index, 5th Edition. A guide to training and supervising ASI interviews. Philadelphia, PA: The University of Pennsylvania & Veterans Administration Center for Studies on Addiction, 1990.
 58. Consoli A, Bennardo A. Diagnosi e valutazione nelle tossicodipendenze e nell’alcolismo. Addiction severity index. Torino: Centro Scientifico Editore, 1995, p. 196.
 59. Kokkevi A, Hartgers C. EuropASI: European Adaptation of a Multidimensional Assessment Instrument for Drug and Alcohol Dependence. Eur Addict Res 1995; 1: 208-10.
 60. Maxwell C. Sensitivity and accuracy of the visual analogue scale: a psycho-physical classroom experiment. Br J Clin Pharmacol 1978; 6: 15-24.
 61. Nicholson AN. Visual analogue scales and drug effects in man. Br J Clin Pharmacol 1978; 6: 3-4.
 62. Anton RF, Moak DH, Latham P. The Obsessive Compulsive Drinking Scale: a self-rated instrument for the quantification of thoughts about alcohol and drinking behavior. Alcohol Clin Exp Res 1995; 19: 92-9.
 63. Anton RF, Moak DH, Latham PK. The Obsessive Compulsive Drinking Scale: a new method of assessing outcome in alcoholism treatment studies. Arch Gen Psychiatry 1996; 53: 225-31.
 64. Bohn MJ, Barton BA, Barron KE. Psychometric properties and validity of the obsessive-compulsive drinking scale. Alcohol Clin Exp Res 1996; 20: 817-23.
 65. Chick J, Anton R, Checinski K, et al. A multicentre, randomized, double-blind, placebo-controlled trial of naltrexone in the treatment of alcohol dependence or abuse. Alcohol Alcohol 2000; 35: 587-93.
 66. Malcolm R, Herron JE, Anton RF, Roberts J, Moore J. Recurrent detoxification may elevate alcohol craving as measured by the Obsessive Compulsive Drinking scale. Alcohol 2000; 20: 181-5.
 67. Roberts JS, Anton RF, Latham PK, Moak DH. Factor structure and predictive validity of the Obsessive Compulsive Drinking Scale. Alcohol Clin Exp Res 1999; 23: 1484-91.
 68. Moak DH, Anton RF, Latham PK. Further validation of the Obsessive-Compulsive Drinking Scale (OCDS). Relationship to alcoholism severity. Am J Addict 1998; 7: 14-23.
 69. Kranzler HR, Mulgrew CL, Modesto-Lowe V, Burleson JA. Validity of the Obsessive Compulsive Drinking Scale (OCDS): does craving predict drinking behavior? Alcohol Clin Exp Res 1999; 23: 108-14.
 70. Nakovics H, Diehl A, Croissant B, Mann K. Modifications of the Obsessive Compulsive Drinking Scale (OCDS-G) for use in longitudinal studies. Addict Behav 2008; 33: 1276-81.
 71. Janiri L, Calvosa F, Dario T, et al. The Italian version of the Obsessive-Compulsive Drinking Scale: validation, comparison with the other versions, and difference between type 1- and type 2-like alcoholics. Drug Alcohol Depend 2004; 74: 187-95.
 72. Derogatis LR, Covi L, Lipman RS, Rickels K. Dimensions of outpatient neurotic pathology: comparison of a clinical vrsus an empirical assessment. J Consult Clin Psychol 1970; 34: 164-71.
 73. Derogatis LR. Misuse of the symptom checklist 90. Arch Gen Psychiatry 1983; 40: 1152-3.
 74. DiClemente CC, Hughes SO. Stages of change profiles in outpatient alcoholism treatment. J Subst Abuse 1990; 2: 217-35.
 75. Derogatis LR, Savitz KL. The SCL-90-R and the Brief Symptom Inventory (BSI) in Primary Care. In: Maruish ME (ed). Handbook of psychological assessment in primary care settings. Mahwah, NJ: Lawrence Erlbaum Associates, 2000.
 76. Mercier C, Brochu S, Girard M, Gravel J, Ouellet R, Paré R. Profiles of alcoholics according to the SCL-90-R: a confirmative study. Int J Addict 1992; 27: 1267-82.
 77. Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale. Preliminary report. Psychopharmacol Bull 1973; 9: 13-28.
 78. Lucchini A. La diagnosi nei disturbi da uso di sostanze. Milano: Franco Angeli, 2001.
 79. Haver B. Screening for psychiatric comorbidity among female alcoholics: the use of a questionnaire (SCL-90) among women early in their treatment programme. Alcohol Alcohol 1997; 32: 725-30.
 80. Sander W, Jux M. Psychological distress in alcohol-dependent patients. Evaluating inpatient treatment with the symptom checklist (SCL-90-R). Eur Addict Res 2006; 12: 61-6.
 81. Dell’Erba G. La valutazione sintomatologica con il Psychopathological State Index: aspetti metrici e clinici. Psicol Eur 1999; 21: 5-22.
 82. Camara WJ, Nathan JS, Puente AE. Psychological test usage: implications in professional psychology. Prof Psychol Res Pr 2000; 31: 141-54.
 83. Butcher JN, Graham JR, Ben-Porath Y, Tellegen A, Dahlstrom WG, Kaemmer B. MMPI-2 - Minnesota Multiphasic Personality Inventory-2. Firenze: Giunti OS, 1995.
 84. Limson R, Goldman D, Roy A, et al. Personality and cerebrospinal fluid monoamine metabolites in alcoholics and controls. Arch Gen Psychiatry 1991; 48: 437-41.
 85. Poldrugo F, Forti B. Personality disorders and alcoholism treatment outcome. Drug Alcohol Depend 1988; 21: 171-6.
 86. Millon T, Grossman S, Millon C. Millon Clinical Multiaxial Inventory-IV (MCMI-IV). Bloomington, MN: NCS Pearson, 2015.
 87. Millon T, Millon C, Grossman S. MCMI-III: Millon Clinical Multiaxial Inventory-III Manual, 4th Edition. Bloomington, MN: NCS Pearson, 2009.
 88. Craig RJ. New Directions in Interpreting the Millon Clinical Multiaxial Inventory-III (MCMI-III). Hoboken, NJ: John Wiley & Sons, 2005.
 89. Bryer JB, Martines KA, Dignan MA. Millon Clinical Multiaxial Inventory Alcohol Abuse and Drug Abuse scales and the identification of substance-abuse patients. Psychol Assess A J Consult Clin Psychol 1990; 2: 438-41.
 90. Craig RJ, Weinberg D. Assessing alcoholics with the Millon Clinical Multiaxial Inventory: a review. Psychol Addict Behav 1992; 6: 200-8.
 91. de Groot MH, Franken IHA, van der Meer CW, Hendriks VM. Stability and change in dimensional ratings of personality disorders in drug abuse patients during treatment. J Subst Abuse Treat 2003; 24: 115-20.
 92. Cloninger CR. Feeling good: the science of well-being. Oxford: Oxford University Press, 2004.
 93. Cloninger CR, Svrakic DM. The Temperament and Character Inventory (TCI): a guide to its development and use. Center for Psychobiology of Personality, Washington University, 1994.
 94. Svrakic DM, Whitehead C, Przybeck TR, Cloninger CR. Differential diagnosis of personality disorders by the seven-factor model of temperament and character. Arch Gen Psychiatry 1993; 50: 991-9.
 95. Pacini M, Maremmani I, Vitali M, Santini P, Romeo M, Ceccanti M. Affective temperaments in alcoholic patients. Alcohol 2009; 43: 397-404.
 96. Jang YL, Choi J, Min Y, Shim H, Lee H. P.6.b.008 Temperaments and characters associated with the relapse in alcohol-dependent patients. Eur Neuropsychopharmacol 2014; 24: S667-8.
 97. Fossati A, Cloninger CR, Villa D, et al. Reliability and validity of the Italian version of the Temperament and Character Inventory-Revised in an outpatient sample. Compr Psychiatry 2007; 48: 380-7.
 98. Martinotti G, Mandelli L, Di Nicola M, et al. Psychometric characteristic of the Italian version of the Temperament and Character Inventory—revised, personality, psychopathology, and attachment styles. Compr Psychiatry; 49: 514-22.
 99. Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-71.
100. Beck AT, Steer RA, Brown G. Manual for the Beck Depression Inventory-II. San Antonio: Psychological Corporation, 1996.
101. Steer RA, Ball R, Ranieri WF, Beck AT. Dimensions of the Beck Depression Inventory-II in clinically depressed outpatients. J Clin Psychol 1999; 55: 117-28.
102. Storch EA, Roberti JW, Roth DA. Factor structure, concurrent validity, and internal consistency of the beck depression inventory?second edition in a sample of college students. Depress Anxiety 2004; 19: 187-9.
103. Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clin Psychol Rev 1988; 8: 77-100.
104. Groth-Marnat G, Schumaker JF. Hypnotizability, attitudes toward eating, and concern with body size in a female college population. Am J Clin Hypn 1990; 32: 194-200.
105. Hersen M, Turner SM, Beidel DC. Adult Psychopathology and Diagnosis, Fifth Edition. Hoboken, NJ: John Wiley & Sons, 2007.
106. Hasin DS, Trautman KD, Miele GM, Samet S, Smith M, Endicott J. Psychiatric Research Interview for Substance and Mental Disorders (PRISM): reliability for substance abusers. Am J Psychiatry 1996; 153: 1195-201.
107. Bowling A. Mode of questionnaire administration can have serious effects on data quality. J Public Health (Bangkok) 2005; 27: 281-91.
108. Spielberger CD. State-Trait Anxiety Inventory: a comprehensive bibliography. Palo Alto, CA: Consulting Psychologists Press, 1984.
109. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, 1983.
110. Grös DF, Antony MM, Simms LJ, McCabe RE. Psychometric properties of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA): comparison to the State-Trait Anxiety Inventory (STAI). Psychol Assess 2007; 19: 369-81.
111. Donham GW, Ludenia K. Cross-validation of the State-Trait Anxiety Inventory with an alcoholic population. J Clin Psychol 1984; 40: 629-31.
112. Driessen M, Meier S, Hill A, Wetterling T, Lange W, Junghanns K. The course of anxiety, depression and drinking behaviours after completed detoxification in alcoholics with and without comorbid anxiety and depressive disorders. Alcohol Alcohol 2001; 36: 249-55.
113. Brown SA, Irwin M, Schuckit MA. Changes in anxiety among abstinent male alcoholics. J Stud Alcohol 1991; 52: 55-61.
114. Demirbas H, Celik S, Ilhan IO, Doğan YB. An examination of suicide probability in alcoholic in-patients. Alcohol Alcohol; 38: 67-70.
115. Smith KL, Horton NJ, Saitz R, Samet JH. The use of the mini-mental state examination in recruitment for substance abuse research studies. Drug Alcohol Depend 2006; 82: 231-7.
116. Magni E, Binetti G, Bianchetti A, Rozzini R, Trabucchi M. Mini-Mental State Examination: a normative study in Italian elderly population. Eur J Neurol 1996; 3: 198-202.
117. da Penha Zago-Gomes M, Nakamura-Palacios EM. Cognitive components of frontal lobe function in alcoholics classified according to Lesch’s typology. Alcohol Alcohol 2009; 44: 449-57.
118. Orsini A, Laicardi C. Wechsler Adult Intellingence Scale-Revised-WAIS-R, Contributo alla taratura italiana. Firenze: Giunti OS, 1997.
119. Almkvist O, Tallberg I-M. Cognitive decline from estimated premorbid status predicts neurodegeneration in Alzheimer’s disease. Neuropsychology 2009; 23: 117-24.
120. Crawford JR, Parker DM, Besson JA. Estimation of premorbid intelligence in organic conditions. Br J Psychiatry 1988; 153: 178-81.
121. Di Sclafani V, Ezekiel F, Meyerhoff DJ, et al. Brain atrophy and cognitive function in older abstinent alcoholic men. Alcohol Clin Exp Res 1995; 19: 1121-6.
122. Wechsler D. Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV). Londra: Pearson Education, 2008.
123. Endicott J, Spitzer RL, Fleiss JL, Cohen J. The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 1976; 33: 766-71.
124. Gold LH. DSM-5 and the assessment of functioning: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). J Am Acad Psychiatry Law 2014; 42: 173-81.
125. Marsden J, Eastwood B, Ali R, et al. Development of the Addiction Dimensions for Assessment and Personalised Treatment (ADAPT). Drug Alcohol Depend 2014; 139: 121-31.
126. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30: 473-83.
127. Burholt V, Nash P. Short Form 36 (SF-36) Health Survey Questionnaire: normative data for Wales. J Public Health (Bangkok) 2011; 33: 587-603.
128. Apolone G, Mosconi P, Ware J jr. Questionario sullo stato di salute SF-36. Manuale d’uso e guida all’interpretazione dei risultati. Milano: Guerini e Associati, 2000.
129. Calsyn DA, Saxon AJ, Bush KR, et al. The Addiction Severity Index medical and psychiatric composite scores measure similar domains as the SF-36 in substance-dependent veterans: concurrent and discriminant validity. Drug Alcohol Depend 2004; 76: 165-71.
130. Larson CO. Use of the SF-12 instrument for measuring the health of homeless persons. Health Serv Res 2002; 37: 733-50.
131. Oslin DW, Slaymaker VJ, Blow FC, Owen PL, Colleran C. Treatment outcomes for alcohol dependence among middle-aged and older adults. Addict Behav 2005; 30: 1431-6.
132. Sannibale C, Fucito L, O’Connor D, Curry K. Process evaluation of an out-patient detoxification service. Drug Alcohol Rev 2005; 24: 475-81.
133. Slade M. What outcomes to measure in routine mental health services, and how to assess them: a systematic review. Aust N Z J Psychiatry 2002; 36: 743-53.
134. Corrao G, Bagnardi V, Zambon A, et al. Outcome variables in the evaluation of alcoholics’ treatment: lessons from the Italian Assessment of Alcoholism Treatment (ASSALT) Project. Alcohol Alcohol 1999; 34: 873-81.
135. Babor TF, Longabaugh R, Zweben A, et al. Issues in the definition and measurement of drinking outcomes in alcoholism treatment research. J Stud Alcohol Suppl 1994; (12): 101-11.
136. Finney JW, Moyer A, Swearingen CE. Outcome variables and their assessment in alcohol treatment studies: 1968-1998. Alcohol Clin Exp Res 2003; 27: 1671-9.
137. Litten RZ, Allen JP. Measuring alcohol consumption: psychosocial and biochemical methods. Totowa, NJ: Humana Press, 1992.
138. Cisler RA, Kivlahan DR, Donovan D, Mattson ME. Assessing nondrinking outcomes in combined pharmacotherapy and psychotherapy clinical trials for the treatment of alcohol dependence. J Stud Alcohol Suppl 2005; (15): 110-8.
139. LoCastro JS, Youngblood M, Cisler RA, et al. Alcohol treatment effects on secondary nondrinking outcomes and quality of life: the COMBINE study. J Stud Alcohol Drugs 2009; 70: 186-96.
140. Zweben A, Cisler R. Composite outcome measures in alcoholism treatment research: problems and potentialities. Subst Use Misuse 1996; 31: 1783-805.
141. Plinius Maior Society. Guidelines on evaluation of treatment of alcohol dependence. Alcohol 1994; 30 (Suppl.): 86.
142. Carroll KM, Onken LS. Behavioral therapies for drug abuse. Am J Psychiatry 2005; 162: 1452-60.
143. Zweben A, Fucito LM, O’Malley SS. Effective strategies for maintaining research participation in clinical trials. Ther Innov Regul Sci 2009; 43: 459-67.
144. De Soto CB, O’Donnell WE, De Soto JL. Long-term recovery in alcoholics. Alcohol Clin Exp Res 1989; 13: 693-7.
145. Hunt WA, Barnett LW, Branch LG. Relapse rates in addiction programs. J Clin Psychol 1971; 27: 455-6.
146. Jin H, Rourke SB, Patterson TL, Taylor MJ, Grant I. Predictors of relapse in long-term abstinent alcoholics. J Stud Alcohol 1998; 59: 640-6.
147. Miller WR, Hester RK. Inpatient alcoholism treatment. Who benefits? Am Psychol 1986; 41: 794-805.
148. American Psychiatric Association. American Psychiatric Association practice guidelines for the treatment of psychiatric disorders. Compendium 2006. Arlington, VA: APA Press 2006.
149. Blodgett JC, Maisel NC, Fuh IL, Wilbourne PL, Finney JW. How effective is continuing care for substance use disorders? A meta-analytic review. J Subst Abuse Treat 2014; 46: 87-97.
150. McKay JR. Is there a case for extended interventions for alcohol and drug use disorders? Addiction 2005; 100: 1594-610.
151. Dutra L, Stathopoulou G, Basden SL, Leyro TM, Powers MB, Otto MW. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry 2008; 165: 179-87.
152. Roche AM, Pollard Y. Improved services for people with drug and alcohol problems and mental illness. Adelaide: National Centre for Education and Training on Addiction (NCETA), 2006.
153. Iannitelli A, Castra R, Antenucci M. Doppia diagnosi o comorbidità? Definizioni e osservazioni cliniche. Ann Ist Super Sanità 2002; 38: 233-9.
154. Luciano M, Sampogna G, Del Vecchio V, et al. Critical evaluation of current diagnostic classification systems in psychiatry: the case of DSM-5. Riv Psichiatr 2016; 51: 116-21.
155. Ciafrè S, Fiore M, Ceccanti M, et al. Role of Neuropeptide Tyrosine (NPY) in ethanol addiction. Biomed Reviews 2016; 27: 27-39.
156. Ciafrè S, Carito V, Tirassa P, et al. Ethanol consumption and innate neuroimmunity. Biomed Reviews 2018; 28: 49-61.
157. Carito V, Ceccanti M, Ferraguti G, et al. NGF and BDNF alterations by prenatal alcohol exposure. Curr Neuropharmacol 2017 Aug 24.