Alcohol & Alcoholism, Vol. 31, Suppl. 1, pp.

63-67, 19%

SUBTYPES OF ALCOHOLISM AND THEIR ROLE IN THERAPY

OTTO M. LESCH* and HENR1ETTE WALTER
Universitatskliruk fur Psychiatric Wahnnger Gurtcl 18-20, A-1090 Vienna, Austria

(Received 31 August 1995)

Abstract — In recent years, the term 'chronic alcoholism' has had a meaning that is more descriptive
than diagnostic. Several subtypes of alcoholism have been established and are now a necessary tool for
studying therapy outcome. Alcohol-dependent patients can be subtyped based on clearly assigned
dimensions (e.g. biological, sociological and psychological disturbances). Craving and the underlying
disturbance must be treated. The number of pharmacological agents that may reduce alcohol intake
has increased recently. We conducted a prospective long-term study based on four subtypes of alcohol-
dependent patients to assess the efficacy of acamprosate. Our findings demonstrate that these patient
subtypes are relevant to outcome in trials of pharmacological agents. We strongly recommend subtyping
alcohol-dependent subjects in future trials, because the usefulness of effective drugs could be overlooked
when they are tested in a heterogeneous population.

Fawcett et al., 1987; Naranjo et al., 1990; Pelc et

Downloaded from alcalc.oxfordjournals.org by guest on July 12, 2011

INTRODUCTION
In recent years, the term 'chronic alcoholism'
has had a meaning that is more descriptive than
diagnostic. However, diagnosis can be made on
the basis of subtypes of alcoholism if the following
criteria are taken into consideration: (1) dif-
ferentiation of patient type according to psy-
chopathology (Rounsaville et al., 1987); (2)
severity of illness, as assessed in accordance with
the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV); (3) course
of illness (different remission criteria, DSM-IV);
and (4) prognosis of illness (Lesch, 1985; Lesch et
al., 1994). Furthermore, a growing interest in
coexisting conditions, early detection of disease,
and alcohol 'craving' have added new dimensions
to the study of alcoholism.
During the past several years, a number of
research studies (Pickens and Johanson, 1992;
Ades et al., 1994) have focused on ways to help
alcohol-dependent patients reduce alcohol crav-
ing and improve quality of life. Certainly, studies
of several drugs (e.g. naltrexone, y-hydroxy-
butyric acid, serotonin reuptake inhibitors,
buspirone, acamprosate or calcium acetyl-
homotaurinate, tiapride, lithium, and disulfiram)
have led to better treatment outcomes for alcohol-
dependent patients (Fuller and Williford, 1980;
•Author to whom correspondence should be addressed.
al., 1990; O'Malley et al., 1992; Volpicelli et al.,
1992, 1995; Gallimberti et al., 1992; Malcolm et
al., 1992; Kranzler et at., 1994; Shawetal., 1994).
However, if a patient must have documented
chronic alcoholism to be included in clinical
studies, and if alcoholism is not differentiated into
subtypes, all investigational new drugs for the
treatment of alcoholism will be tested in extremely
heterogeneous patient populations. As a result,
effective therapies may not be identified.
RESEARCH STUDIES OF ALCOHOL
DEPENDENCE: SAMPLE SIZE AND
PATIENT TYPING
In a review of the statistical methods used in
studies of alcohol-dependent patients, Lehert
(1992) found that treatment outcomes are related
to sample size, i.e. the larger the sample size, the
less successful the treatment outcome.
Lesch (1985) and Lesch et al. (unpublished
data) have developed a classification system, or
typology (Types I to IV), for alcohol-dependent
patients. Their system categorizes alcohol-depen-
dent patients into specific types according to bio-
chemical, physiological, clinical, and behavioural
characteristics. Patients who have experienced
alcohol detoxification and withdrawal can also
be 'typed' according to this system. The presence
or absence of specific characteristics determines

63

1996 Medical Council on Alcoholism

64 O. M. LESCH and H. WALTER
Table 1. Type I alcohol dependence: patient characteristics
1. Occasional consumption of alcohol (i.e. 'social
drinking') develops into habitual drinking (from
'I like it' to 'I am used to it').
2. Alcohol craving gets more and more out of control.
One drink leads to additional consumption of
alcohol or to intoxication.
3. Alcohol is consumed to counteract symptoms of
alcohol withdrawal.
4. Patient often seeks treatment when symptoms of
alcohol withdrawal occur (e.g. delirium tremens,
seizures, tremor, perspiration, sleep disorders).
5. Family history is positive for alcoholism.
6. Childhood development and interpersonal relation-
ships are apparently normal.
7. Social effects of alcohol consumption are minimal,
patient commits no criminal acts.
8. Patient is viewed by others as being able to tolerate
alcohol and frequently receives outpatient treat-
ment for alcohol dependence before being admit-
ted to a hospital for detoxification.
If two of characteristics 1-4 are present and there are no
indications of Type IV alcohol dependence, the patient
should be diagnosed as having Type I dependence.
Although characteristics 5-8 are frequently present in
Type I alcohol dependence, their presence is not nec-
essary to confirm a diagnosis of Type I dependence.
the patient type. Type IV is the first category in
Lesch's system; it is followed by Types III, I, and
II.
While Lesch's group stresses the importance
of using subtypes to classify alcohol-dependent
patients, they still suggest that a stepwise
approach using DSM-IV and/or International Stat-
istical Classification of Diseases and Related Health
Problems, 10th revision (ICD-10) criteria is
important to establish the initial diagnosis. After
the diagnosis has been made, the cut-off points
then serve to define the typology. If one examines
the typology on an item-by-item basis, several
items can be found that match those in the DSM-
IV and ICD-10; however, those items that are
judged by Lesch et al. as important for the
typology — those indicating the interaction of the
effects of alcohol and a patient's vulnerability —
are not found in either the DSM-IV or ICD-10.
If DSM-IV criteria are used correctly in
assessing a diagnosis according to all five axes and
not only in axis 1 in which alcohol dependence is
defined, one notes that there are overlaps between
typology and a patient diagnosed on all axes. To
our knowledge, there are no trials underway and
Table 2. Type II alcohol dependence: patient charac-
teristics
1. Alcohol is consumed for its sedative effects (i.e.
to 'self-medicate' anxiety and other psychosocial
disorders).
2. Patient exhibits behavioural changes when under the
influence of alcohol (i.e. the inconspicuous and
passive patient becomes aggressive).
3. When environment is changed (e.g. relaxed atmos-
phere during holiday seasons), patient consumes
less than normal amounts of alcohol.
4. Patient becomes less active during leisure time.
5. Interpersonal relationships with spouses, family
members, and others are significantly impaired.
6. Patient exhibits self-destructive tendencies (e.g. sui-
cide attempts) when under the influence of alco-
hol.
7. Alcohol is frequently consumed in conjunction with
sedative drugs.
8. Patient exhibits no severe, somatic disorders related
to alcohol dependence and no severe alcohol with-
drawal symptoms.
If characteristics 1, 2 and 8 are present and if Types I, III
Downloaded from alcalc.oxfordjournals.org by guest on July 12, 2011
and IV are not present, the patient should be diagnosed
as having Type II dependence. Although characteristics
3-7 are frequently present in Type II alcohol dependence,
their presence is not necessary to confirm a diagnosis of
Type II dependence. In addition, if the patient enters
treatment in a late stage of the disease, alcohol-related
disabilities (e.g. organic brain syndrome) and psycho-
social disorders can confound the typology. In such cases,
the diagnosis may be mixed (e.g. Type II and Type III)
and thefinaldiagnosis should be delayed until the patient
has abstained from alcohol for 6 weeks or longer.
no data available with regard to this important
issue; however, this is an area that merits further
study.
According to Lesch's group, Type I patients
drink alcohol to counteract symptoms of alcohol
withdrawal (Table 1). Type II patients use alcohol
as a conflict-solving and anxiety-reducing agent
(Table 2). Type III patients ingest alcohol to 'self-
medicate' affective disorders and, in such cases,
alcohol is frequently used as an antidepressant
(Table 3). Both Type II and Type III patients
experience withdrawal symptoms in the late stages
of alcohol dependence. Type IV patients have a
history of cerebral impairment that precedes the
development of alcohol dependence (Table 4).
Since the reasons for alcohol intake are not
universal, different causes for craving and relapse
may need different pharmacological treatments
(Malcolm etai, 1992).
 SUBTYPES OF ALCOHOLISM
Table 3. Type III alcohol dependence: patient charac-
teristics
1. Alcohol is consumed to 'self-medicate' psychiatric
disorders (e.g. mood and motivational disorders,
sleep disturbances).
2. Family history is positive for psychiatric illnesses
(e.g. major depression, suicide, or alcoholism).
3. Patient exhibits self-destructive tendencies (e.g. sui-
cide attempts) whether sober or intoxicated.
4. Patient experiences alcohol-free periods or periods
of minimal alcohol consumption; patient drinks
when psychiatric disorders are active.
5. Somatic symptoms of alcohol withdrawal (e.g. per-
spiration, tremor) are mild or moderate.
6. Patient exhibits aggressive behaviour whether sober
or intoxicated.
7. Interpersonal relationships with spouses, family
members and others are significantly impaired.
If characteristics 1 and 4 are present and there are no
indications of Type IV alcohol dependence, the patient
should be diagnosed as having Type III dependence.
Although characteristics 2, 3, 5 and 7 are frequently
present in Type III alcohol dependence, their presence
is not necessary to confirm a diagnosis of Type III depen-
dence.
Table 4. Type IV alcohol dependence: patient charac-
teristics
1. History of cerebral brain damage before the age of
14 years.
2. History of somatic and psychiatric disorders before
the age of 14 years
3. Evidence for psychiatric, somatic, and social abnor-
malities is not limited to periods of alcohol con-
sumption (e.g. endemic hepatitis).
4. History of enuresis nocturna before the age of 14
years without severe psychiatric comorbidity (e.g.
schizophrenia).
5. History of seizure disorders that are not related to
alcohol withdrawal.
6 Patient becomes severely intoxicated after con-
suming low doses of alcohol. Symptoms of alcohol
withdrawal are mild.
If one of characteristics 1-5 is present, the patient should
be diagnosed as having Type IV dependence. Although
characteristic 6 is frequently present in Type IV alcohol
dependence, its presence is not necessary to confirm a
diagnosis of Type IV dependence.
SPECIAL METHODS AND PATIENT
CHARACTERISTICS
When the data from a multicentre study of
alcohol-dependent patients that was performed in
Austria, Switzerland, and Germany were
compiled, it was noted that the frequencies of
65
patient types were significantly different
(P =£ 0.05) (Leitner et al., unpublished data). The
variations occurred because the patient selection
criteria were not the same for all study centres.
We suggest, therefore, that multicentre studies be
designed in a way that allows patient charac-
teristics to be differentiated by the study centre. If
such a procedure is followed, outcome variations
between study centres will be easier to explain.
For example, when the data from a multicentre
study on the use of acamprosate (calcium acetyl-
homotaurinate) versus placebo in the treatment
of alcohol dependence were compiled recently, it
was noted that none of the study centres reported
similar results (Lesch et al., 1994; Poldrugo et al.,
1994; O. M. Lesch et al., unpublished data). The
lack of homogeneity of patients enrolled in the
study may have contributed to the problem.
At the Anton Proksch Institute in Vienna,
Austria, 270 alcohol-dependent patients were
Downloaded from alcalc.oxfordjournals.org by guest on July 12, 2011
included in our trial, which is part of a multicentre
study that includes approximately 4000 patients
from across Europe. Of these 270 patients, 260
could be classified according to the typology of
Lesch. Ninety-four patients were Type I, 61 were
Type II, 58 were Type III, and 47 were Type IV.
In these patients, classification by type was made
before the results of treatment were known.
Classification was performed by a psychiatrist who
was trained in the use of this classification system
but was not involved in the rest of the study.
'Typing' was completed mostly before the start of
the trial, but the latest occurred within the first 2
weeks after the start of the trial.
Our results showed that acamprosate effectively
reduced alcohol intake among patients of Types I
and II. We examined data from the first 360 days
of the study and calculated the mean number of
days that patients of Types I and II remained
sober while they were treated with acamprosate
and placebo, respectively. Type I patients who
were treated with acamprosate remained sober for
a mean 138 days (range = 0-133 days), whereas
Type I patients who were treated with placebo
remained sober for a mean 87 days (range =
0-100 days, P =£ 0.01). Type II patients who were
treated with acamprosate had a mean 160 days of
sobriety (range = 0-143 days), whereas Type II
patients who were treated with placebo had a
mean 115 days of sobriety (range = 0-115 days,
P=s0.05). Type III patients who were treated
66 O. M. LESCH and H WALTER

with acamprosate had a mean 135 days of sobriety
(range = 0-147 days). Type III patients who were
treated with placebo had no significant differences
in the mean number days sober [mean, 119 days
(range = 0-134 days); NS]. The same was true for
Type IV patients [acamprosate: mean, 108 days
(range = 0-112 days); placebo: mean. 104 days
(range = 0-119 days); NS] (Lesch et al., 1994;
O. M. Lesch et al., unpublished data). In the
progression of our research, the question of
reliability did not arise, since the items used for
the 'typing' (see Tables 1-4) allowed for 'yes'
or 'no' answers to the key questions. We were,
therefore, unable to calculate a Crombach Alpha.
The development of construct item clusters, which
allow for reliability studies, is in progress and
these were not used in this study.
These examples show that special methods need
to be applied in clinical investigations of alcohol- Naranjo, C. A , Kadlec, K and Sellers, E. M. (1990)
ism. Alcoholism is a chronic condition with many
causes, and alcohol-dependent patients experi-
Moore, N., Pechery, C. and Zarnitzsky, C. (1990)
Methodology of therapeutic drug trials in alcoholism.
Progress in Alcohol Research 2, 247-272.
Kranzler, H. R., Burleson, J. A., Del Boca, F. K., Babor,
T. F., Korner, P., Brown, J. and Bohn, M. J. (1994)
Buspirone treatment of anxious alcoholics: a placebo-
controlled trial. Archives of General Psychiatry 51, 720-
731.
Lehert, P. (1992) Statistical methodology in clinical
research on alcoholism: a literature review. Alcohol and
Alcoholism 27, Suppl. 1, 73.
Lesch, O. M. (1985) Chronischer Alkoholismus. Typen und
ihr Verlauf. Thieme/Copythek, Stuttgart.
Lesch, O. M., Walter, H., Fischer, P., Platz, W., Hanng,
C , Leitner, A. and Benda, N. (1994) New develop-
ments of reducing alcohol intake (abstract). Alcoholism.
Clinical and Experimental Research 18, 43A.
Malcolm, R., Anton, R. F., Randall, C. L., Johnston, A.,
Brady, K. and Thevos, A. (1992) A placebo-controlled
trial of buspirone in anxious inpatient alcoholics.
Alcoholism Clinical and Experimental Research 16,
1007-1013.
Evaluation of the effects of serotonin uptake inhibitors
in alcoholics: a review. Presented at Novel Phar-

Downloaded from alcalc.oxfordjournals.org by guest on July 12, 2011

macological Interventions for Alcoholism, a satellite
ence biological, sociological and psychological symposium of the Fifth Conference of the International
disturbances. Clearly, studies that focus on early Society for Biomedical Research on Alcoholism;
detection and treatment of alcohol dependence Toronto, Ontario, Canada; June 17-22, 1990.
should be designed with a large variety of patient O'Malley, S. S., Jaffe, A. J., Chang, G., Schottenfeld, R.
S., Meyer, R. E. and Rounsaville, B. (1992) Naltrexone
types in mind (Waisberg, 1990; Hillemand et al., and coping skills therapy for alcohol dependence: a
1990; A d e s e / a / . , 1994). controlled study. Archives of General Psychiatry 49,
881-887.
Acknowledgements — This research was supported by grant Pelc, I., Lebon, O., Verbanck, P., Lehert, P. and Opsomer,
number P 09689-MED from the Fonds zur Fordcrung der L. (1990) Calcium-acetylhomotaurinate for maintaining
Wisscnschafthchen Forschung. Vienna. Austria to O.M.L abstinence in weaned alcoholic patients. Presented at
Novel Pharmacological Interventions for Alcoholism,
a satellite symposium of the Fifth Conference of the
REFERENCES International Society for Biomedical Research on
Alcoholism; Toronto, Ontario, Canada; June 17-22,
Ades, J., Barrias, J. A., Besson, J., Borg, S., Chick, 1990.
J., Lesch, O. M., Moore, N., Pelc, I., Poldrugo, F., Pickens, R. W. and Johanson, C. E. (1992) Craving: con-
Rodriguez-Martos, A. and Walburg, J. A. (1994) sensus of status and agenda for future research. Drug
Guidelines on evaluation of treatment of alcohol depen- and Alcohol Dependence 30, 127-131.
dence. Alcoholism: Journal on Alcoholism and Related Poldrugo, F., Chabac, S. and Lehert, P. (1994) Acam-
Addictions 30, Suppl., 39-41. prosate in the long-term treatment of alcoholism: is its
Fawcett, J., Clark, D. C , Aagesen, C. A., Pisani, V D.. use recommended within the psycho-social approach?
Tilkin, J. M., Sellers, D., McGuire, M. and Gibbons, (Abstract) Alcoholism: Clinical and Experimental
R. D. (1987) A double-blind, placebo-controlled trial Research 18, 43A.
of lithium carbonate therapy for alcoholism. Archives Rounsaville, B. J., Dolinsky, Z. S., Babor, T. F. and
of General Psychiatry 44, 248-256. Meyer, R. E. (1987) Psychopathology as a predictor of
Fuller, R. K. and Williford, W. O. (1980) Life-table analysis treatment outcome in alcoholics. Archives of General
of abstinence in a study evaluating the efficacy of Psychiatry 44, 505-513.
disulrlram. Alcoholism: Clinical and Experimental Shaw, G. K., Waller, S., Majumdar, S. K., Alberts, J. L.,
Research 4, 298-301. Latham, C. J. and Dunn, G. (1994) Tiapride in the
Gallimberti, L., Ferri, M., Ferrara, S. D., Fadda, F. and prevention of relapse in recently detoxified alcoholics.
Gessa, G. (1992) Gamma-hydroxybutyric acid in the British Journal of Psychiatry 165, 515-523.
treatment of alcohol dependence: a double-blind study. Volpicelli, J. R., Alterman, A. I., Hayashida. M. and
Alcoholism: Clinical and Experimental Research 16, O'Brien, C. P. (1992) Naltrexone in the treatment of
673-676. alcohol dependence. Archives of General Psychiatry 49,
Hillemand, B., Lhuintre, J. P , Boismare, F., Steru, L., 876-880.
 SUBTYPES OF ALCOHOLISM 67

Volpicelli, J. R., Watson, N. T.. King. A. C . Sherman. Waisberg, J. L. (1990) Patient characteristics and outcome
C. E. and O'Brien, C. P. (1995) Effect of naltrexone of inpatient treatment for alcoholism. Aduances in
on alcohol 'high' in alcoholics. American Journal of Alcohol and Substance Abuse 8, 9-32.
Psychiatry 152, 613-615.

Downloaded from alcalc.oxfordjournals.org by guest on July 12, 2011

Downloaded from alcalc.oxfordjournals.org by guest on July 12, 2011