Risk Factors (Genetics & Inherited Conditions)
Certain characteristics or factors make persons more likely to develop alcoholism; they include family history of the disorder, negative environment, emotional stress, access to alcohol, young age at first use, age range of eighteen to twenty-nine, male gender, and low level of education. Persons of certain races or ethnic origins, the unmarried, and children of alcoholics are more likely to become dependent on alcohol. Mental disorders such as major depression, anxiety, bipolar disorder, and antisocial personality disorder are associated with the development of alcoholism and may also be hereditary. Antisocial personality disorder has been referred to as the most important risk factor for alcoholism.
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Etiology and Genetics (Genetics & Inherited Conditions)
Alcoholism is a relatively common chronic and relapsing disorder that results in significant health and social consequences. Alcohol has a relatively high addictive potential in the general population and is even higher in susceptible individuals. Several epidemiology studies have been conducted to attempt to categorize genes and characteristics related to alcohol dependence. However, much is still not known about this disease and the role of genetics in the development, course, and outcome of alcoholism.
Genes under investigation for their potential role in this disorder are typically grouped by involvement in the metabolism of alcohol, rewarding circuits, and response to alcohol dependence treatment. The enzymes responsible for hepatic alcohol metabolism are alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH); the corresponding candidate genes are ADH2*2, ADH3*1, and ALDH2*2. Protective genes (associated with reduced alcohol consumption) are ADHB*2 and are found in Asians and Israeli Jews, while ADH1C*2 appears to protect against complications related to alcoholism, such as cirrhosis and pancreatitis. Gamma-aminobutyric acid (GABA) receptors are the most important inhibitory receptors and are involved in the rewarding circuit; alcohol acts as an agonist or activator of the GABAA receptor. Scots, Germans, Native Americans, and Finns have variants of GABRA6...
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Symptoms (Genetics & Inherited Conditions)
Early behavioral symptoms of alcoholism include frequent intoxication, a pattern of heavy drinking, drinking alone or in secret, or drinking alcohol in high-risk situations (such as drinking and driving). Erratic or dramatic changes in behavior with alcohol consumption, “blacking out,” or not remembering events that occurred while drinking, may also be signs of the disorder. Symptoms of alcohol dependence may become worse over time. The physical symptoms of alcoholism are many and can include jaundice (yellowing of skin or eyes), hepatitis (enlarged liver), abdominal pain, nausea and vomiting, infections, malaise (not feeling well), weight loss, fluid retention, problems with memory, and anorexia (decreased eating). Laboratory analyses may reveal increased liver enzymes, low potassium levels, low hemoglobin and hematocrit (indicating anemia), and vitamin deficiencies.
Symptom expression of alcohol dependence may differ by culture and ethnicity, because people of different cultures may express physical and mental ailments differently. Ethnic and racial groups may respond differently to alcohol and medications used to treat alcohol dependence. Some groups may even enjoy greater protection against alcoholism as a result of their genetics. Certain ethnic groups may be more susceptible to alcoholism or related complications. For instance, vulnerability to cardiomyopathy and Wernicke-Korsakoff’s syndrome may be heritable and may...
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Screening and Diagnosis (Genetics & Inherited Conditions)
Various questionnaires are commonly used to screen a person for alcoholism. Questions typically ask about the amount of alcohol consumed, how often drinking occurs, how much time is spent thinking about drinking, if withdrawal occurs after stopping drinking, and effects of drinking on personal life and health. Most persons with alcoholism will deny having the disorder, and family and friends may be questioned to support the diagnosis. Alcohol dependence is rarely diagnosed in a routine office visit. Diagnosis typically follows after a major negative health or social event occurs, such as liver disease or a motor vehicle accident. After diagnosis, patients may be subgrouped into type-I or type-II alcoholism; type-II is highly heritable (88 percent) while type-I has a relatively low heritability (21 percent).
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Treatment and Therapy (Genetics & Inherited Conditions)
Three candidate genes for alcohol treatment response are OPRM1, HTT, and COMT. Currently, treatment for alcoholism includes the use of medications such as naltrexone (opioid antagonist), acamprosate (taurine analog), or disulfuram (alcohol deterrent). Whether persons will respond to a certain medication and how long they will abstain from alcohol use may vary based on genetic makeup. Psychoanalysis and behavior modification are important parts of alcohol dependence treatment. Alcoholics Anonymous has a twelve-step support program for persons with alcohol dependence.
Continued study of the genes associated with different patterns of alcohol problems, protective genetic effects in populations with exceptionally low rates of alcoholism, and genetically based interventions (such as matching pharmacotherapies to different populations of individuals to forestall the development of the problem) are assured. The study of genetics and alcoholism is also likely to encourage growth in the field of ethnopharmacology, the study of how different therapeutic drugs differentially affect members of specific ethnic groups.
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Prevention and Outcomes (Genetics & Inherited Conditions)
The best way to prevent alcoholism is to avoid the use of alcohol. Alcoholism is associated with an increased risk of hepatitis, liver cancer, abuse of other substances (such as marijuana, cocaine, sedatives, and stimulants), sexually transmitted diseases and other infections, malnutrition, psychiatric illness, and premature death. Persons with alcohol dependence are more likely to gamble, smoke cigarettes, or engage in other risky behaviors.
The presence of alcohol in modern life may have genetic roots. Historically, it helped those who could tolerate its taste and effects to survive and be selected for when others who could not do so perished as a result of consuming contaminated water. Alcohol has a complex relationship to human life, and alcoholism will be studied for some time.
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Further Reading (Genetics & Inherited Conditions)
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Rev. 4th ed. Washington, D.C.: Author, 2000. This American professional manual describes all major psychiatric disorders. There is a chapter devoted to substance use disorders.
Goldman, David, Gabor Oroszi, and Francesca Ducci. “The Genetics of Addictions.” Nature Reviews Genetics 6 (2005): 521-531. An article that argues that addictions are moderately to highly heritable.
Gorwood, Philip, Mathias Wohl, Yann L. Strat, and Frederic Rouillon. “Gene-Environment Interactions in Addictive Disorders: Epidemiological and Methodological Aspects.” Comptes rendus Biologies 330 (2007): 329-338. Describes how “the gene-environment interactions approach could explain some epidemiological and clinical factors associated with addictive behaviours.”
Plomin, Robert, and Gerald E. McClearn, eds. Nature, Nurture, and Psychology. Washington, D.C.: American Psychological Association, 1993. The topic of alcoholism is discussed, among other topics, with an emphasis on comparing the roles of genetics versus social processes and the environment.
Strat, Yann L., Nicolas Ramoz, Gunter Schumann, and Philip Gorwood. “Molecular Genetics of Alcohol Dependence and Related Endophenotypes.” Current Genomics 9 (2008): 444-451. The authors claim that “Predisposition to alcohol...
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Web Sites of Interest (Genetics & Inherited Conditions)
American Psychological Association (APA). http://www.apa.org. This site provides access to PsycNET and PsycARTICLES, which can be searched for published information on the genetics of alcoholism.
National Center for Biotechnology Information (NCBI) and Online Mendelian Inheritance in Man (OMIM). Alcohol Dependence. http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=103780. Provides detailed information about the genetics of alcoholism.
National Institute on Alcohol Abuse and Alcoholism, ETOH. http://etoh.niaaa.nih.gov. ETOH is the chemical abbreviation for ethyl alcohol. This site includes reports related to alcohol dependence, including epidemiology, etiology, prevention, policy, and treatment.
The Pharmagenomics Knowledge Database (PharmGKB). http://www.pharmgkb.org/index.jsp. PharmGKB’s mission is “to collect, encode, and disseminate knowledge about the impact of human genetic variations on drug response. We curate primary genotype and phenotype data, annotate gene variants and gene-drug-disease relationships via literature review, and summarize important PGx genes and drug pathways.” There is a link to access Collaborative Study on the Genetics of Alcoholism (COGA) data.
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Causes and Symptoms (Magill’s Medical Guide, Sixth Edition)
The basis for alcoholism is physical dependence on alcoholic beverages and consequent problems in behavior and health. Problems related to alcohol probably developed soon after prehistoric humans discovered that fruit or grain, mashed and suspended in water, fermented into beverages that produced euphoria in users. The first recorded production of fermented beverages was of beer and wine in ancient Babylon and Egypt, respectively.
The active ingredient in fermented beverages is ethyl alcohol (alcohol), a colorless, mild-smelling liquid that boils at 79 degrees Celsius. Alcohol content in such beverages is indicated as “proof.” If divided by two, the proof number indicates the approximate percentage of alcohol present. For example, 20-proof wine contains about 10 percent alcohol. In contrast, 80-proof brandy and vodka, beverages known as hard liquors, contain about 40 percent alcohol, because such liquors have been “fortified” by adding pure alcohol prepared via distillation. Other beverages known as hard liquors include whiskey, scotch, and rye. They typically are discussed separately from beer and wine.
Abuse of alcoholic beverages first became epidemic during the Middle Ages, when development of widespread alcohol distillation produced hard liquors and made it easy to attain alcoholic euphoria and stupor. In 2008, almost 52 percent of individuals in the United States ages twelve and older reported being...
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Treatment and Therapy (Magill’s Medical Guide, Sixth Edition)
In the mid-1930’s, alcoholism, previously viewed as criminal and immoral behavior, was first conceived to be a disease. There is no known immediate, miracle cure for alcoholism. Treatments with demonstrated effectiveness for alcohol problems, however, do exist. Treatments involving a combined biological, psychological, and social approach, complete with follow-up, often appear most helpful. For most individuals, however, an important phase—or possibly even a permanent feature—of treatment involves total abstinence from alcoholic beverages, all medications that contain alcohol, and any other potential sources of alcohol in the diet.
The recognition of alcoholism as a medical problem has led to the establishment of alcohol rehabilitation centers, where psychiatric treatment, medication, and other therapies are used in widely different combinations. The supportive programs of the organization Alcoholics Anonymous are also viewed as effective deterrents to a return to alcohol problems. Another well-known medical treatment aimed at encouraging sobriety is the drug disulfiram, more popularly known as Antabuse. This drug is given when individuals who wish to avoid all use of alcoholic beverages require a deterrent to drinking in order to achieve this goal. It is important to note, however, that no drug should ever be given secretly to someone by well-meaning family or friends. This is especially important with Antabuse...
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Perspective and Prospects (Magill’s Medical Guide, Sixth Edition)
Modern efforts to deal with alcohol problems are often considered to have begun in the early twentieth century, with the activities of the American temperance movement and the Anti-Saloon League. These activities culminated in the period called Prohibition after Congress passed the 1919 Volstead Act, proposed by Minnesota congressman Andrew J. Volstead. The idea behind the act was that making intoxicating beverages impossible to obtain would force sobriety on Americans. Prohibition turned out to be self-defeating, however, and it increased the incidence of alcohol and related problems. Subsequently, the act was repealed in 1933, ending Prohibition.
The next, and much more useful, effort to combat alcoholism was the founding of AA. Because AA does not reach the majority of individuals with alcohol problems, other efforts have evolved as treatment methodologies. Among these have been psychiatric counseling, alcohol rehabilitation centers, family counseling, and alcohol management programs in the workplace. Treatment efforts have even taken to the Web. These endeavors, funded by the federal government and private industry, largely from 1970 forward, continue to improve treatment success by identifying problems earlier, encouraging prevention, and making treatment more effective for a broader range of people.
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For Further Information: (Magill’s Medical Guide, Sixth Edition)
Alcoholics Anonymous. http://www.aa.org. A group whose primary purpose is to help members stay sober and help other alcoholics to achieve sobriety.
Alcoholics Anonymous World Service. Alcoholics Anonymous. 4th rev. ed. New York: Author, 2001. Offers steps to recovery and personal stories of rehabilitation.
Beers, Mark H., et al., eds. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, N.J.: Merck Research Laboratories, 2006. This book contains a compendium of data on the etiology, diagnosis, and treatment of alcoholism. Contains good cross-references to the psychopathology related to the disease, drug rehabilitation, and Alcoholics Anonymous.
Collins, R. Lorraine, Kenneth E. Leonard, and John R. Searles, eds. Alcohol and the Family: Research and Clinical Perspectives. New York: Guilford Press, 1990. Reprinted in 2005, this book addresses genetics, family processes, and family-oriented treatment. Aspects of genetic testing and markers are covered, along with adolescent drinking, children of alcoholics, and alcoholism’s effect on a marriage.
Dwyer, Frank. Annotated AA Handbook: A Companion to the Big Book. Rev. ed. Ft. Lee, N.J.: Barricade Books, 2000. The entire text of the first edition of Alcoholics Anonymous is supplemented here with comprehensive explanatory notations and cross-references, as well as a history of the book and...
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Alcoholism (American Indians Ready Reference)
Article abstract: American Indians, whether living on or off reservations, have extremely high rates of alcoholism; many Indian problems with crime, health, and poverty are related to heavy drinking
The most severe health problem among contemporary American Indians is alcoholism. The reasons for the problem are complex, but central among them are poverty, a pervasive sense of despair (particularly among young reservation Indians), and the stresses involved in adjusting to non-Indian life. Both Indian and non-Indian sources, contemporary and historical, also point to drinking as one reaction to the profound disruption of Indian societies that began soon after Europeans landed in the Americas and which intensified through the years.
Early Contact Years
With the exception of parts of the Southwest, alcoholic beverages did not exist in North America before the Europeans came, though they were widely used by Central and South American natives. Early French and English explorers, trappers, and merchants often gave Indians liquor as a gift or exchanged it for food or furs. By the early 1600’s, for example, French Canadian traders were encouraging the use of alcohol among the Huron, even though the Catholic church deplored such practices and the French government outlawed the sale or use of liquor in trade. As early as 1603, French priests in Canada reported that many natives were drinking alcohol heavily during...
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Alcoholism (Encyclopedia of Genetic Disorders)
Alcoholism is a chronic physical, psychological, and behavioral disorder characterized by excessive use of alcoholic beverages; emotional and physical dependence on them; increased tolerance over time of the effects of alcohol; and withdrawal symptoms if the person stops drinking.
Alcoholism is a complex behavioral as well as medical disorder. It often involves the criminal justice system as well as medicine and other helping professions. Its emergence in an individual's life is affected by a number of variables ranging from age, weight, sex, and ethnic background to his or her family history, peer group, occupation, religious preference, and many other categories. Moreover, persons diagnosed with alcoholism may demonstrate considerable variety in their drinking patterns, age at onset of the disorder, and the speed of its progression.
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), distinguishes between Alcohol Dependence and Alcohol Abuse largely on the basis of a compulsive element in Alcohol Dependence that is not present in Alcohol Abuse. Some psychiatrists differentiate between so-called primary alcoholism, in which the patient has no other major psychiatric...
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Alcoholism (Encyclopedia of Medicine)
The essential feature of alcohol abuse is the maladaptive use of alcohol with recurrent and significant adverse consequences related to its repeated use. Alcoholism is the popular term for two disorders, alcohol abuse and alcohol dependence. The hallmarks of both these disorders involve repeated life problems that can be directly attributed to the use of alcohol. Both these disorders can have serious consequences, affecting an individual's health and personal life, as well as having an impact on society at large.
The effects of alcoholism are quite far-reaching. Alcohol affects every body system, causing a wide range of health problems. Some such problems include poor nutrition, memory disorders, difficulty with balance and walking, liver disease (including cirrhosis and hepatitis), high blood pressure, muscle weakness (including the heart), heart rhythm disturbances, anemia, clotting disorders, decreased immunity to infections, gastrointestinal inflammation and irritation, acute and chronic problems with the pancreas, low blood sugar, high blood fat content, interference with reproductive fertility, and weakened bones.
On a personal level, alcoholism results in marital and other relationship difficulties, depression, unemployment, child abuse, and general family...
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Alcoholism (Encyclopedia of Science)
Alcoholism is a serious, chronic (can be curbed or regulated but cannot be cured), potentially fatal condition in which a person has an uncontrollable urge to drink alcoholic beverages. Alcoholism can be seen in both the rich and the poor, the young and the old, and males and females. It is estimated that 75 percent of alcoholics are male and 25 percent are female.
Biological, psychological, social, and cultural factors all seem to play a role in the development of alcoholism. Children with a biological parent who is an alcoholic are more likely to become alcoholics than are children who do not have an alcoholic parent. Peer pressure, the social acceptability of drinking, and a desire to escape from emotional stress and anxiety can all set the stage for a person's descent into alcohol addiction.
How alcohol affects the body
Alcohol is a depressant that acts as a numbing agent on the central nervous system. Some adults can drink alcohol-containing beverages in moderate amounts without experiencing significant side effects. The ability to tolerate alcohol differs from person to person. Alcohol affects women more easily because women lack a stomach enzyme present in men that breaks down some of the alcohol before it reaches the intestines. Thus, if a man and a woman both drink a glass of wine, more alcohol will enter the woman's bloodstream than...
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Alcoholism (Encyclopedia of Children's Health)
Alcoholism, or alcohol dependence, is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as "A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress."
That maladaptive pattern is manifested, according to the DSM-IV, by the following behaviors occurring any time within one 12-month period:
- tolerance for alcohol
- withdrawal from alcohol
- alcohol taken in larger amounts and over a longer period of time than was intended
- persistent desire or unsuccessful efforts to cut down or control alcohol use
- much time spent in activities necessary to obtaining alcohol
- various important activities, for example, in socializing or at work, are given up or reduced because of alcohol use
- alcohol use continued regardless of the pattern of physical or psychological problems that it causes or worsens
Alcohol abuse has the same definition but is manifested by one (or more) of the following behaviors occurring within the same 12-month period:
- repeated alcohol use leading to failure to fulfill major role obligations at work, school, or home...
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Alcoholism (Encyclopedia of Alternative Medicine)
Alcoholism is the layman's term for alcohol dependence and alcohol abuse. According to the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association and commonly called the DSM-IV, the essential feature of substance abuse (in this instance, alcohol abuse) is maladaptive use of the substance with recurrent and significant adverse consequences related to its repeated use. Dependence is a physical addiction with psychological, social and genetic components. Despite damage to health, finances, reputations, and relationships, the alcohol dependent person will continue to drink unless an intervention occurs. Abuse, distinguished from dependence by retaining some control over the use of alcohol, nevertheless carries many of the same consequences over time, and certainly increases risk of dependence.
Today, alcohol abuse and alcohol dependence are often associated with abuse of, or dependence on, other substances including nicotine, marijuana, cocaine, heroin, amphetamines, sedatives, and anxiolytics (antianxiety drugs). Alcoholism is more common in males than in females, with an estimated male-to-female ratio as high as five-to-one. A United States study conducted between 1990 and 1991, using DSM standards, found that 14% of the adult population (ages 154) had, at some time, met the criteria for alcohol...
(The entire section is 4597 words.)
Alcoholism (Encyclopedia of Nursing & Allied Health)
Alcoholism is the popular term for alcohol abuse and alcohol dependence. The hallmarks of both of these disorders involve repeated life problems that can be directly tied to a person's abuse of alcohol. Alcoholism has serious consequences, affecting an individual's health and personal life, as well as having a negative impact on society at large. Alcoholism is the use of alcohol in any harmful way.
The effects of alcoholism are quite far reaching. Alcohol affects every body system, causing a wide range of health problems. Such problems include poor nutrition, memory disorders, difficulty with balance and walking, liver disease (including cirrhosis and hepatitis), high blood pressure, weakness of muscles (including the heart), disturbances of heart rhythm, anemia, clotting disorders, weak immunity to infections, inflammation and irritation along the entire gastrointestinal system, acute and chronic problems with the pancreas, low blood sugar, high blood fat content, interference with reproductive fertility, and weak bones.
On a personal level, alcohol can be responsible for marital and other relationship difficulties, depression, unemployment, child abuse, and general family dysfunction.
Alcoholism causes or contributes to a variety of severe social problems: homelessness, murder, suicide, injury, and violent crime. Alcohol is a contributing factor in 50% of all deaths due to motor vehicle accidents. In fact, more than 100,000 deaths occur each year due to the effects of alcohol, of which 50% are due to injuries of some sort. In the United States, the annual economic cost of alcoholism and alcohol abuse is estimated at more than $160 billion.
Causes and symptoms
There are probably a number of factors that work together to cause a person to become an alcoholic. Genetic studies have demonstrated that close relatives of an alcoholic are more likely to become alcoholics themselves. This risk appears to hold true even for the child adopted away from his or her biological family at birth and raised in a non-alcoholic adoptive familyith no knowledge of the biological family's difficulties with alcohol. More research is being conducted to determine whether genetic factors can account for differences in alcohol metabolism, thereby increasing the risk of an individual becoming an alcoholicr whether the involvement of genetics is less direct, perhaps producing personality traits that render people susceptible to alcoholism. Many investigators believe that environmental factors, such as availability and acceptance of alcohol, peer pressure, or stressful lifestyle are at least as important as genetic factors. At the time of this writing in early 2001, researchers were seeking the location of specific genes that affect susceptibility to alcoholism.
The symptoms of alcoholism can be broken down into two major categories, symptoms of acute alcohol abuse and symptoms of long-term alcohol abuse.
Immediate (acute) effects of alcohol abuse
Alcohol exerts a depressive effect on the brain. The blood-brain barrier does not prevent alcohol from entering the brain, so the brain-alcohol level will quickly become equivalent to the blood-alcohol level. Alcohol's depressive effects result in difficulty walking, poor balance, slurred speech, and generally poor coordination(i.e., accounting, in part, for the increased likelihood of injury). At higher alcohol levels, a person's breathing and heart rates will be slowed, and vomiting may occur, with a high risk of the vomit being inspired (breathed) into the lungs; this can result pneumonia, or in choking and death (especially if the person is unconscious). Extremely high blood alcohol levels may result in coma and death.
Effects of long-term (chronic) alcoholism
Long-term abuse of alcohol affects virtually every organ system of the body:
- Nervous system. An estimated 30-40% of all men in their teens and twenties have experienced alcoholic blackouts, which occur when drinking a large quantity of alcohol. This can also result in loss of memory of the time surrounding the episode of drinking. Alcohol is well known to cause sleep disturbances, so that overall sleep quality is affected. Numbness and tingling may occur in the arms and legs. Two syndromes, which can occur together or separately, are known as Wernicke's and Korsakoff's syndromes. Both are due to the low thiamin levels found in the blood of alcoholics. Wernicke's syndrome results in disordered eye movements, very poor balance and difficulty walking; Korsakoff's syndrome severely affects memory, preventing new learning from taking place.
- Gastrointestinal system. Alcohol causes loosening of the muscular ring that prevents the stomach's contents from re-entering the esophagus. Therefore, the acid from the stomach can flow backwards into the esophagus, thereby burning those tissues and causing pain and bleeding. Inflammation of the stomach can also result in bleeding and pain, and decrease the appetite. A major cause of severe, uncontrollable bleeding (hemorrhage) in an alcoholic is the development of enlarged (dilated) blood vessels within the esophagus, called esophageal varices. These varices are actually developed in response to liver disease, and are extremely prone to bursting and hemorrhaging. Diarrhea is also a common affect of alcohol abuse due to alcohol's effect on the pancreas. Another condition, inflammation of the pancreas (pancreatitis) can be a serious and painful consequence of alcoholism. Throughout the intestinal tract, alcohol interferes with the absorption of nutrients, creating a malnourished state. Alcohol is broken down (metabolized) in the liver, which is profoundly affected by consistently high alcohol levels. Alcohol interferes with a number of important chemical processes that also occur in the liver. As a result, the liver begins to enlarge and fill with fat (i.e., fatty liver), fibrous scar tissue interferes with the liver's normal structure and function (cirrhosis), and the liver may become inflamed (hepatitis).
- Blood alcohol can cause changes to all types of blood cells. Red blood cells become abnormally large. The number of white blood cells (WBCs) (important for fighting infections) decreases, resulting in a weakened immune system. This places alcoholics at increased risk for infections; it is thought to account, in part, for the increased risk of cancer in alcoholics (i.e., ten times the normal risk). Platelets and blood clotting factors are negatively affected, causing an increased risk of hemorrhage.
- Heart. Small amounts of alcohol can cause a drop in blood pressure. With increased use, however, alcohol begins to move blood pressure into a dangerously high range. High levels of fats circulating in the bloodstream increase the risk of heart disease. Heavy drinking results in an increase in heart size, weakening of the heart muscle, abnormal heart rhythms, and risk of the formation of blood clots within the chambers of the heart. These factors greatly increase the risk of stroke, which can occur if a blood clot from the heart enters the circulatory system, goes to the brain, and blocks one of its blood vessels.
- Reproductive system. Heavy drinking has a negative effect on fertility in both men and women. It decreases testicle and ovary size, thereby interfering with both sperm and egg production. When an alcoholic woman becomes pregnant, she assumes the great risk of giving birth to a baby who has fetal alcohol syndrome. This causes distinctive facial defects, lowered IQ, and behavioral problems.
Two different types of trouble with alcohol are identified. The first is called alcohol dependence, and refers to a person who is physiologically dependent on the use of alcohol. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), an individual must have three of the following traits to be diagnosed with alcohol dependence:
- Tolerance, meaning that a person becomes accustomed to a particular dose of alcohol and must increase the dose in order to obtain the desired effect.
- Withdrawal, meaning that a person experiences unpleasant physical and psychological symptoms when he or she does not drink alcohol.
- The tendency to drink more alcohol than one intends(i.e., once an alcoholic starts to drink, he or she finds it difficult to stop).
- Being unable to avoid drinking or stop drinking once started.
- Having large blocks of time taken up by alcohol abuse.
- Choosing to drink at the expense of other important tasks or activities.
- Drinking despite evidence of negative effects on one's health, relationships, education, or job.
Under DSM-IV, a diagnosis of alcohol abuse requires that one of the following four criteria is met within a 12-month period. Because of drinking, a person repeatedly:
- Fails to live up to his or her most important responsibilities.
- Physically endangers himself, herself, or others (e.g., by drinking when driving).
- Gets into trouble with the law.
- Experiences difficulties in relationships or jobs.
Diagnosis is often brought about when family members relate the alcoholic's difficulties to a physician. A physician may become suspicious when a patient suffers repeated injuries or begins to experience medical problems that seem related to alcohol abuse. Alcohol abuse is so widespread that some estimates suggest that about 20% of a physician's patients will be alcoholics.
Diagnosis is aided by the answers to questionnaires that try to determine what aspects of a person's life may be affected by his or her abuse of alcohol. Determining the exact quantity of alcohol that a person drinks is much less important than learning how drinking affects his or her relationships, jobs, educational goals, and family life. In fact, because the metabolism of alcohol (how the body
breaks down and processes alcohol) is so unique, the quantity of alcohol consumed is not a criterion for diagnosing either alcohol dependence or alcohol abuse.
One very simple tool for beginning to diagnose alcoholism is the CAGE questionnaire. It consists of four questions, with the first letters of each key word spelling the word CAGE:
- Have you ever tried to Cut down on your drinking?
- Have you ever been Annoyed by anyone's comments about your drinking?
- Have you ever felt Guilty about your drinking?
- Do you ever need an Eye-opener (a morning drink of alcohol) to start the day?
There are other, longer lists of questions that help to determine the severity and effects of a person's alcohol abuse. Given the evidence of genetic involvement in alcoholism, it is important to ascertain whether any relative of the person has ever suffered from alcoholism.
Physical examination may reveal signs suggestive of alcoholism: evidence of old injuries; a visible network of enlarged veins just under the skin around the navel (called caput medusae); fluid in the abdomen (ascites); yellowish tone to the skin; decreased testicular size; and poor nutritional status. Lab work may reveal an increase in the size of red blood cells; abnormalities in WBCs (responsible for fighting infection) and platelets (particles responsible for clotting); and an increase in certain liver enzymes.
Treatment of alcoholism has two parts. The first step in the treatment of alcoholism, called detoxification, involves helping the person stop drinking and ridding his or her body of the harmful (toxic) effects of alcohol. Because the person's body has become accustomed to alcohol, he or she will need to be supported through withdrawal. Withdrawal will be different for different patients, depending on the severity of the alcoholism (as measured by the quantity of alcohol ingested daily and the length of time the patient has been an alcoholic). Withdrawal symptoms can range from mild to life-threatening. Mild withdrawal symptoms include nausea, aches, diarrhea, difficulty sleeping, sweats, anxiety, and trembling. This phase is usually over in about three to five days. More severe effects of withdrawal can include hallucinations, seizures, an unbearable craving for more alcohol, confusion, fever, fast heart rate, high blood pressure, and delirium (a fluctuating level of consciousness). Patients at highest risk for the most severe symptoms of withdrawal (referred to as delirium tremens) are those with other medical problems, including malnutrition, liver disease, or Wernicke's syndrome. Delirium tremens usually begins approximately three to five days after the patient's last drink, progressing from the more mild symptoms to the more severe, and may last a number of days.
Patients going through only mild withdrawal are simply monitored carefully to ensure that more severe symptoms do not develop. However, no medications are necessary. Treatment of a patient suffering the more severe effects of withdrawal may require sedating medications to relieve the discomfort of withdrawal and to avoid the potentially life-threatening complications of high blood pressure, fast heart rate, and seizures. Benzodiazepines are helpful in those patients suffering from hallucinations. If the patient is nauseated, fluids may need to be given through a vein (intravenously), along with some necessary sugars and salts. It is crucial that thiamin be included in the fluids, because of it is usually quite low in alcoholic patients. Further, thiamin deficiency can lead to Wernicke-Korsakoff syndrome.
After cessation of drinking has been accomplished, the next steps involve helping the patient avoid ever taking another drink. This phase of treatment is referred to as rehabilitation. The best programs incorporate the family into the therapy; it has no doubt been severely affected by the patient's drinking. Some therapists believe that family members, in an effort to deal with their loved one's drinking problem, sometimes develop patterns of behavior that unintentionally support or "enable" the patient's drinking. This situation is referred to as "codependence," and must be addressed in order to successfully treat a person's alcoholism.
Sessions led by peers, where recovering alcoholics meet regularly and provide support for each other's recoveries, are considered to be among the best methods of preventing a return to drinking (relapse). Perhaps the most well-known group of this kind is called Alcoholics Anonymous, which uses a "12-step" model to help people avoid drinking. These steps involve recognizing the destructive power that alcohol has held over the alcoholic's life, looking to a higher power for help in overcoming the problem, and reflecting on the ways in which the abuse of alcohol has hurt others and, if possible, making amends to those people.
There are also medications that may help an alcoholic avoid returning to drinking. These have been used with varying degrees of success. Disulfiram (Antabuse) is a drug that, when mixed with alcohol, causes a very unpleasant reaction that includes nausea and vomiting, diarrhea, and trembling. Naltrexone (Revia) and acamprosate (calcium acetylhomotaurinate) seem to be helpful in limiting the effects of a relapse. None of these medications would be helpful unless the patient is also willing to work very hard to change his or her behavior.
Alternative treatments can be a helpful adjunct for the alcoholic patient once the medical danger of withdrawal has passed. Because many alcoholics have very stressful lives (whether because of or leading to the alcoholism is sometimes a matter of debate), many of the treatments for alcoholism involve dealing with and relieving stress. These include massage, meditation, and hypnotherapy. The malnutrition of long-term alcohol abuse is addressed by nutrition-oriented practitioners, with careful attention being given to a healthy diet and the use of nutritional supplements, such as vitamins A, B complex, and Cs well as certain fatty acids, amino acids, zinc, magnesium, and selenium. Herbal treatments include milk thistle (Silybum marianum), which is thought to protect the liver against damage. Other herbs believed to be helpful for the patient suffering through withdrawal include lavender (Lavandula officinalis), skullcap (Scutellaria lateriflora), chamomile (Matricaria recutita), peppermint (Mentha piperita), yarrow (Achillea millefolium), and valerian (Valeriana officinalis). Acupuncture is believed to both decrease withdrawal symptoms and to help improve a patient's chances for continued recovery from alcoholism.
Recovery from alcoholism is a lifelong process. In fact, the person who has suffered from alcoholism is encouraged to refer to himself or herself ever after as "a recovering alcoholic," never a recovered alcoholic. This is because most researchers in the field believe that one can never fully recover from alcohol because the vulnerability to alcoholism is still part of the individual's biological and psychological makeup. The potential for relapse (returning to illness) is always there, and must be acknowledged and respected. Statistics suggest that, among middle-class alcoholics in stable financial and family situations who have undergone treatment, 60% or more can be successful at an attempt to stop drinking for at least a year, and many for a lifetime.
Health care team roles
The International Nurses Society on Addictions (IntNSA) says that it is appropriate for nurses to assess patients for alcohol-related problems in any setting, and to initiate discussion of such problems with not only the patient, but also the family, significant others, and appropriate members of an interdisciplinary health team. Nurses have a responsibility to educate and counsel alcoholic patients, their families, and significant others. Nurses with special knowledge or experience in the subject can play an important role in educating both the community and fellow health-care professionals. General-care nurses might wish to seek help or advice from a clinical specialist in alcoholism. According to IntNSA, the nurse's role in treating alcoholism is not restricted to psychiatric and mental health nursing, as it involves every other clinical nursing specialty. It is important that nurses be aware of community resources so that they can make appropriate treatment referrals. IntNSA offers Certified Addiction Registered Nurse certification to nurses who pass rigorous testing.
Prevention must occur at a relatively young age, since the first experience with alcohol intoxication usually occurs during the teenage years. It is particularly important that teenagers who are at high risk for alcoholismhose with a family history of alcoholism, early or frequent abuse of alcohol, a tendency to drink to drunkenness, alcohol abuse that interferes with school work, a poor family environment, or a history of domestic violencere educated about alcohol and its longterm effects. How this is best achieved, without irritating the youngsters and losing their attention, is a matter of debate and study.
Blood-brain barrier membrane that separates the circulating blood from reaching the brain and the fluid that surrounds it and the spinal cord. It prevents many damaging substances from reaching the brain, but alcohol is able to cross the barrier.
Dependence state in which a person requires a steady amount of a particular drug in order to avoid experiencing symptoms of withdrawal.
Detoxificationhe phase of treatment during which a patient stops drinking and is monitored and cared for while he or she experiences withdrawal from alcohol.
Relapse return to a disease state, after recovery appeared to be occurring; in alcoholism, relapse refers to a patient beginning to drink alcohol again after a period of avoiding alcohol.
Tolerance phenomenon whereby a drug abuser becomes physically accustomed to a particular quantity of alcohol (or dosage of a drug), and requires ever-increasing quantities in order to obtain the same effects.
Withdrawalhose signs and symptoms experienced by a person who has become physically dependent on a drug, experienced upon decreasing the drug's dosage or discontinuing its use.
"Alcoholism and Alcohol Abuse." In Cecil Textbook of Medicine, edited by J. Claude Bennett and Fred Plum. Philadelphia: W.B. Saunders, 2000.
Schuckit, Marc A. "Alcohol and Alcoholism." In Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.
Ianelli, Joseph, "When Alcoholism Hits Home." American Journal of Nursing. (July 1997): 68+.
O'Brien, Charles P. and A. Thomas McLellan, "Addiction Medicine." Journal of the American Medical Association. (June 18, 1997): 1840+.
Al-Anon, Alanon Family Group, Inc. P.O. Box 862, Midtown Station, New York, NY 10018-0862. (800)356-9996. <<a href="http://www.recovery.org/aa">http://www.recovery.org/aa>.
International Nurses Society on Addictions. 1500 Sunday Drive, Suite 102, Raleigh, NC 27607. (919)783-5871. <<a href="http://www.nnsa.org">http://www.nnsa.org>.
National Clearinghouse for Alcohol and Drug Information. <<a href="http://www.health.org">http://www.health.org>.
David L. Helwig
Alcoholism (International Dictionary of Psychoanalysis)
Alcoholism is not a psychoanalytic concept. The most rigorous definition, following from the basic notion of dependence, is the one provided by Pierre Fouquet: "An alcoholic is any man or woman who has lost the ability to do without alcohol." The word "alcoholism" was introduced by the Swedish physician Magnus Huss (1849) and mentioned in France by M. Gabriel (1866) in his medical dissertation. It appears in Freud's writings prior to 1900 in association with hysteria and hypnosis, as a form of "subjection," a "morbid habit," falling somewhere "between the organic affections and the disorders of the imagination." Principal occurrences of the word appear in letters to Wilhelm Fliess (especially that of December 22, 1897), in the attached manuscript (Draft H., 1895), and especially in the key text "Sexuality in the Aetiology of the Neuroses" (1898a). "Habit," Freud writes, "is a mere form of words, without any explanatory value" and "success will only be an apparent one, so long as the physician contents himself with withdrawing the narcotic substance from his patients, without troubling about the source from which their imperative need for it springs" (p. 276).
It was initially believed (Sigmund Freud, Karl Abraham, Sándor Ferenczi) that alcohol does not create symptoms but only promotes them, removing inhibitions, and destroying sublimation. The theory of alcohol addiction (1905d) is summarized in terms of its predominance among men beginning with the onset of puberty; its relationship to sexuality, and latent homosexuality, already identified as narcissistic and specular by Viktor Tausk (1913) and Lou Andreas-Salomé (1912); oral fixation, and autoerotic behavior. Emphasis later focused on the nature of the defensive process, an immediately effective means, but one that is too accessible, which is why it is so dangerous (1930a ). The economic approach to affects was emphasized nextoncepts of alexithymia (McDougall, 1978), instinctual discharge by the body ("resomatization of affects"), and acting out ("dispersion," "destruction of affects," "acts-symptoms"), depending on the authorll at the expense of psychic elaboration.
Alcohol plays the role of a unique substitute object and a trap, creating a pseudo-reality; the hallucinations associated with delirium tremens cease with the administration of alcohol. The narcissistic problematic (withdrawal) in fact harbors an autoerotic component and gives rise to defenses, barriers, or narcissistic prostheses, such as an overinvestment in work, children, "friends," etc., and alcohol. The mechanism of splitting into non-alcoholic (common, neurotic) and alcoholic sectors of the ego has denial as its corollary, but it is a denial that does not involve the perception of an external reality (difference of the sexes, castration) but rather the internal perception of the body itself. There exist silent zones, "matrices of painful, deadly territories that threaten the unity of the ego" (Mijolla and Shentoub, 1973). These are the parts of the body that lie outside symbolization and outside language, as described by Jean Clavreul (1959). For Paul Schilder and Walter Bromberg (1933), alcoholism is accompanied by a regression from castration that leads to bodily fragmentation. The alcoholic short circuit leaves no room for the establishment of loss, the source of desire, but rather establishes an ensemble of needs and repetitive acts that are without meaning. An analogy can be made with pathological games. Shame or opprobrium are distinguished from guilt. The superego of an alcoholic is demanding but "soluble in alcohol" (Simmel, 1930). There is no strong image with which the subject identifies, but identification can occur with someone hated, which can lead to "self-hatred." The indulgent and demanding mother who creates insecurity is the object of reverse fantasies (idealization).
The symbolism of alcohol is that of vital fluids (blood, "the blood of the vine," sperm, milk) or destructive humors (urine, feces), of the breast and the penis, good and/or bad. This symbolism is present in all the myths associated with alcohol, from Dionysus to the Eucharist.
The situation in terms of a psychoanalytic classification is still the subject of controversy. It is a narcissistic disorder, closer to manic-depression and paranoia than to neurosis, psychosis, or perversion. Its issues fall within the framework of addiction.
Intolerance to alcohol can be interpreted as a reaction formation to the excitations that alcohol promotes, or to the frequently negative attitudes toward alcoholics, sometimes as extreme as hatred (Winnicott, D. W., 1947), or even to the most primitive issues of the alcoholic that are awakened in the therapist. From the standpoint of treatment, it is a matter of detoxification or social prohibition (1927c)Not all men abandon this toxic supplement with the same facility" (1905c), "the only effective remedy is the resolution that draws its strength from a powerful current of the libido"s opposed to involvement of the superego (1966b ). The effectiveness of temperance movements appear to be associated with libidinal investments "torn from alcohol" and given expression in exhibitionism, or homosexual and narcissistic masochism.
There is a double risk of using the term "alcoholism": the risk of turning it into a closed and homogenized entity, or of breaking apart the clinical concept, reductively assimilating it to various diagnostic classifications (neurosis, psychosis, perversionetishism, for examplearanoia, manic-depression, psychopathy, etc.). To compound the problem, concepts such as homosexuality, orality, "disappointment," and "libidinal viscosity," risk serving as facile or even completely inappropriate explanations.
Freud himself often superimposed the phenomenology of drunkenness and the psychopathology of alcohol addiction, and even considered the relation of the alcoholic to his poison as nonconflictual, "the purest harmony," and "an example of a happy marriage" (1912d, p. 188). Blind spots with respect to his own relationship to toxic substances (cocaine, tobacco) led him outside the field of psychoanalysis when he postulated a "toxological theory" in psycho-pathology, which he did not abandon until the Outline of Psychoanalysis (Descombey, 1994).
There are a number of concepts related to alcoholism: addiction, alcoholic intoxication, alcoholic delirium and jealousy, delirium tremens (Viktor Tausk's delirium of action or occupation), alcohol-associated epilepsy. And it can be asked, as Freud asked about psychosis, if the terms "denial" and "repression" have the same meaning with respect to alcoholism as they do for the psychopathology of the neuroses. The same question could also be asked about the familiar use of the concepts of desire and pleasure when it comes to a clinical practice that is situated "beyond the pleasure principle" or within the register of need.
Post-Freudian authors who have done substantive work on alcoholism include James Glover (1938) and the Kleinians Herbert Rosenfeld (1964) (paranoidschizoid and depressive positions), Sándor Radó (1933) (pharamacothymia, initial anxiety depression, pharmacogenic orgasm, addiction crisis), and Michael Balint (1977) (basic fault). There has also been renewed interest in the subject in the work of the French psychoanalysts Jean Clavreul (1959), Alain de Mijolla and Salem A. Shentoub (1973); the Lacanians François Perrier (1975), Charles Melman (1976), A. Rigaud (1976), M. Lasselin (1979), and F. Gondolo-Calais (1980); as well as Jacques Ascher (1978), Joyce McDougall (1989), M. Monjauze (1991), and Jean-Paul Descombey (1985-1994).
See also: Addiction; Dependence; Dipsomania; Indications and contraindications for psychoanalysis for an adult.
Bromberg, William, and Schilder, Paul. (1933). Alcoholic hallucinationsastration and dismembering motives. International Journal of Psychoanalysis, 14, 206-224.
Clavreul, Jean. (1959). La parole de l'alcoolique. Psychanalyse, 5, 257-280.
Descombey, Jean-Paul. (1985). Alcoolique, mon frère, toi: l'alcoolisme entre médecine, psychiatrie et psychanalyse. Toulouse: Privat.
. (1994). Précis d'alcoologie clinique. Paris: Dunod.
Freud, Sigmund. (1898a). Sexuality in the aetiology of the neuroses. SE, 3: 259-285.
. (1905d). Three essays on the theory of sexuality. SE, 7: 123-243.
. (1912d). On the universal tendency to debasement in the sphere of love. SE, 11; 177-190.
Huss, Magnus. (1849). Alcoholismus chronicus eller kronisk alkoholsjukdom. Stockholm: n.p.
McDougall, Joyce. (1989). Theaters of the body: a psychoanalytic approach to psychosomatic illness. New York: Norton.
Mijolla, Alain de, and Shentoub, Salem A. (1973). Pour une psychanalyse de l'alcoolisme. Paris: Payot.
Director, L. (2002). Relational psychoanalysis in the treatment of chronic drug & alcohol abuse. Psychoanalytic Dialogues, 12, 551-580.
Alcoholism (Encyclopedia of Drugs, Alcohol, and Addictive Behavior)
This section contains articles on some aspects of chronic drinking: Abstinence versus Controlled Drinking and Origin of the Term. For further information on this subject, see Disease Concept of Alcoholism and Drug Abuse and the sections on Complications, on Treatment and on Withdrawal.
Abstinence versus Controlled Drinking
The position of ALCOHOLICS ANONYMOUS (AA) and the dominant view among therapists who treat alcoholism in the United States is that the goal of treatment for those who have been dependent on alcohol is total, complete, and permanent abstinence from alcohol.
Abstinence was at the base of Prohibition (legalized in 1919 with the Eighteenth Amendment) and is closely related to prohibitionismhe legal proscription of substances and their use.
Although temperance originally meant moderation, the nineteenth-century TEMPERANCE MOVEMENT 's emphasis on complete abstinence from alcohol and the mid-twentieth century's experience of the ALCOHOLICS ANONYMOUS movement have strongly influenced alcohol- and drug-abuse treatment goals in the United States. Moral and clinical issues, however, have been irrevocably mixed.
The disease model of alcoholism and drug addiction, which insists on abstinence, has incorporated new areas of compulsive behavioruch as overeating and sexual involvements. In these cases, redefinition of abstinence from total avoidance to "the avoidance of excess" (what we would otherwise term moderation) is required.
Abstinence can also be used as a treatment-outcome measure, as an indicator of its effectiveness. In this case, abstinence is defined as the number of drug-free days or weeks during the treatment regimennd measures of drug in urine are often used as objective indicators.
By extension, for all those treated for alcohol abuse, including those with no dependence symptoms, moderation of drinking (termed controlled drinking, or CD) as a goal of treatment is rejected (Peele, 1992). Instead, providers claim, holding out such a goal to an alcoholic is detrimental, fostering a continuation of denial and delaying the alcoholic's need to accept the reality that he or she can never drink in moderation. One painful example of this is the case of Audrey Kishline, author of Moderate Drinking: The New Option for Problem Drinkers, and founder of the group Moderation Management. In the summer of 2000, Kishline pleaded guilty to a vehicular homicide incident in which she killed a father and his twelve-year-old daughter when she drove the wrong way on a Washington State highway. Her blood alcohol level at the time of the accident was 0.26hree times the legal limit.
In Britain and other European and Common-wealth countries, controlled-drinking therapy is widely available (Rosenberg et al., 1992). The following six questions explore the value, prevalence, and clinical impact of controlled drinking versus abstinence outcomes in alcoholism treatment; they are intended to argue the case for controlled drinking as a reasonable and realistic goal.
1. What proportion of treated alcoholics abstain completely following treatment?
At one extreme, Vaillant (1983) found a 95 percent relapse rate among a group of alcoholics followed for eight years after treatment at a public hospital; and over a four-year follow-up period, the Rand Corporation found that only 7 percent of a treated alcoholic population abstained completely (Polich, Armor, & Braiker, 1981). At the other extreme, Wallace et al. (1988) reported a 57 percent continuous abstinence rate for private clinic patients who were stably married and had successfully completed detoxification and treatmentut results in this study covered only a six-month period.
In other studies of private treatment, Walsh et al. (1991) found that only 23 percent of alcohol-abusing workers reported abstaining throughout a two-year follow-up, although the figure was 37 percent for those assigned to a hospital program. According to Finney and Moos (1991), 37 percent of patients reported they were abstinent at all follow-up years 4 through 10 after treatment. Clearly, most research agrees that most alcoholism patients drink at some point following treatment.
2. What proportion of alcoholics eventually achieve abstinence following alcoholism treatment?
Many patients ultimately achieve abstinence only over time. Finney and Moos (1991) found that 49 percent of patients reported they were abstinent at four years and 54 percent at ten years after treatment. Vaillant (1983) found that 39 percent of his surviving patients were abstaining at eight years. In the Rand study, 28 percent of assessed patients were abstaining after four years. Helzer et al. (1985), however, reported that only 15 percent of all surviving alcoholics seen in hospitals were abstinent at 5 to 7 years. (Only a portion of these patients were specifically treated in an alcoholism unit. Abstinence rates were not reported separately for this group, but only 7 percent survived and were in remission at follow-up.)
3. What is the relationship of abstinence to controlled-drinking outcomes over time?
Edwards et al. (1983) reported that controlled drinking is more unstable than abstinence for alcoholics over time, but recent studies have found that controlled drinking increases over longer follow-up periods. Finney and Moos (1991) reported a 17 percent "social or moderate drinking" rate at six years and a 24 percent rate at ten years. In studies by McCabe (1986) and Nordström and Berglund (1987), CD outcomes exceeded abstinence during follow-up of patients fifteen and more years after treatment (see Table 1). Hyman (1976) earlier found a similar emergence of controlled drinking over fifteen years.
4. What are legitimate nonabstinent outcomes for alcoholism?
The range of nonabstinence outcomes between unabated alcoholism and total abstinence includes (1) "improved drinking" despite continuing alcohol abuse, (2) "largely controlled drinking" with occasional relapses, and (3) "completely controlled drinking." Yet some studies count both groups (1) and (2) as continuing alcoholics and those in group (3) who engage in only occasional drinking as abstinent. Vaillant (1983) labeled abstinence as drinking less than once a month and including a binge lasting less than a week each year.
The importance of definitional criteria is evident in a highly publicized study (Helzer el al., 1985) that identified only 1.6 percent of treated alcoholism patients as "moderate drinkers." Not included in this category were an additional 4.6 percent of patients who drank without problems but who drank in fewer than thirty of the previous thirty-six months. In addition, Helzer et al. identified a sizable group (12%) of former alcoholics who drank a threshold of seven drinks four times in a single month over the previous three years but who reported no adverse consequences or symptoms of alcohol dependence and for whom no such problems were uncovered from collateral records. Nonetheless, Helzer et al. rejected the value of CD outcomes in alcoholism treatment.
While the Helzer et al. study was welcomed by the American treatment industry, the Rand results (Polich, Armor, & Braiker, 1981) were publicly denounced by alcoholism treatment advocates. Yet the studies differed primarily in that Rand reported a higher abstinence rate, using a six-month window at assessment (compared with three years for Helzer et al.). The studies found remarkably similar nonabstinence outcomes, but Polich, Armor, and Braiker (1981) classified both occasional and continuous moderate drinkers (8%) and sometimes heavy drinkers (10%) who had no negative drinking consequences or dependence symptoms in a nonabstinent remission category. (Rand subjects had been highly alcoholic and at intake were consuming a median of seventeen drinks daily.)
The harm-reduction approach seeks to minimize the damage from continued drinking and recognizes a wide range of improved categories (Heather, 1992). Minimizing nonabstinent remission or improvement categories by labeling reduced but occasionally excessive drinking as "alcoholism" fails to address the morbidity associated with continued untrammeled drinking.
5. How do untreated and treated alcoholics compare in their controlled-drinking and abstinent-remission ratios?
Alcoholic remission many years after treatment may depend less on treatment than on post-treatment experiences, and in some long-term studies, CD outcomes become more prominent the longer subjects are out of the treatment milieu, because patients unlearn the abstinence prescription that prevails there (Peele, 1987). By the same token, controlled drinking may be the more common outcome for untreated remission, since many alcohol abusers may reject treatment because they are unwilling to abstain.Goodwin, Crane, & Guze (1971) found that controlled-drinking remission was four times as frequent as abstinence after eight years for untreated alcoholic felons who had" unequivocal histories of alcoholism" (see Table 1). Results from the 1989 Canadian National Alcohol and Drug Survey confirmed that those who resolve a drinking problem without treatment are more likely to become controlled drinkers. Only 18 percent of five hundred recovered alcohol abusers in the survey achieved remission through treatment. About half (49 percent) of those in remission still drank. Of those in remission through treatment, 92 percent were abstinent. But 61 percent of those who achieved remission without treatment continued drinking (see Table 2).
6. For which alcohol abusers is controlled-drinking therapy or abstinence therapy superior?
Severity of alcoholism is the most generally accepted clinical indicator of the appropriateness of CD therapy (Rosenberg, 1993). Untreated alcohol abusers probably have less severe drinking problems than clinical populations of alcoholics, which may explain their higher levels of controlled drinking. But the less severe problem drinkers uncovered in nonclinical studies are more typical, outnumbering those who "show major symptoms of alcohol dependence" by about four to one (Skinner, 1990).
Despite the reported relationship between severity and CD outcomes, many diagnosed alcoholics do control their drinking, as Table 1 reveals. The Rand study quantified the relationship between severity of alcohol dependence and controlled-drinking outcomes, although, overall, the Rand population was a severely alcoholic one in which "virtually all subjects reported symptoms of alcohol dependence" (Polich, Armor, and Braiker, 1981).
Polich, Armor, and Braiker found that the most severely dependent alcoholics (eleven or more dependence symptoms on admission) were the least likely to achieve nonproblem drinking at four years. However, a quarter of this group who achieved remission did so through nonproblem drinking. Furthermore, younger (under 40), single alcoholics were far more likely to relapse if they were abstinent at eighteen months than if they were drinking without problems, even if they were highly alcohol-dependent (Table 3). Thus the Rand study found a strong link between severity and outcome, but a far from ironclad one.
Some studies have failed to confirm the link between controlled-drinking versus abstinence outcomes and alcoholic severity. In a clinical trial that included CD and abstinence training for a highly dependent alcoholic population, Rychtarik et al. (1987) reported 18 percent controlled drinkers and 20 percent abstinent (from fifty-nine initial patients) at 5 to 6 year follow-up. Outcome type was not related to severity of dependence. Nor was it for Nordström and Berglund (1987), perhaps because they excluded "subjects who were never alcohol dependent."
Nordström and Berglund, like Wallace et al. (1988), selected high-prognosis patients who were socially stable. The Wallace et al. patients had a high level of abstinence; patients in Nordström and Berglund had a high level of controlled drinking. Social stability at intake was negatively related in Rychtarik et al. to consumption as a result either of abstinence or of limited intake. Apparently, social stability predicts that alcoholics will succeed better whether they choose abstinence or reduced drinking. But other research indicates that the pool of those who achieve remission can be expanded by having broader treatment goals.
Rychtarik et al. found that treatment aimed at abstinence or controlled drinking was not related to patients' ultimate remission type. Booth, Dale, and Ansari (1984), on the other hand, found that patients did achieve their selected goal of abstinence or controlled drinking more often. Three British groups (Elal-Lawrence, Slade, & Dewey, 1986; Heather, Rollnick, & Winton, 1983; Orford & Keddie, 1986) have found that treated alcoholics' beliefs about whether they could control their drinking and their commitment to a CD or an abstinence-treatment goal were more important in determining CD versus abstinence outcomes than were subjects' levels of alcohol dependence. Miller et al. (in press) found that more dependent drinkers were less likely to achieve CD outcomes but that desired treatment goal and whether one labeled oneself an alcoholic or not independently predicted outcome type.
As of 2000, there is no conclusive evidence to show that one single method of treatment is consistently more successful than another (Project MATCH). One of the largest (U.S.) clinical experimentsponsored by the National Institute on Alcohol Abuse and Alcoholismhows that of the three major treatments studied (cognitive-behavioral therapy [CBT], twelve-step facilitation [TSF], and motivational enhancement therapy [MET]), none emerged the clear "winner."
A group of 952 outpatients (some still drinking) and 774 patients (previously receiving residential/day hospital treatment) participated in the study, that spanned over twelve weeks. The two groups were each divided into three separate groups, each group receiving one of the three treatments.
Particpants were polled immediately after treatment and again every three months for a year in an effort to document their subsequent progress. Patients of all three treatments exemplified good and sustained results. In all, only 10 percent of the participants dropped out of the study itself; two-thirds finished the treatment(s). The percentage of days abstinent (PDA) rose in all three groups by 60 percent (from 20 to 80 percent), and suffered only minimal decline in the next year.
Controlled drinking (CD) is one of a number of approaches with an important role to play in alcoholism treatment. CD, as well as abstinence, is an appropriate goal for the majority of problem drinkers who are not alcohol-dependent (though there is no proven scientific method to determine who can and who cannot stop drinking after one or two drinks). In addition, while controlled drinking becomes less likely the more severe the degree of alcoholism, other factorsuch as age, values, and beliefs about oneself, one's drinking, and the possibility of controlled drinkinglso play a role, sometimes the dominant role, in determining successful outcome type. Finally, reduced drinking is often the focus of a harm-reduction approach, where the likely alternative is not abstinence but continued alcoholism.
(SEE ALSO: Alcohol; Disease Concept of Alcoholism and Drug Abuse; ; Treatment)
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TREATMENT OF ALCOHOLISM-PART II. (2000) Harvard Mental Health Letter 16
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WALSH, D. C., ET AL. (1991). A randomized trial of treatment options for alcohol-abusing workers. New En-land Journal of Medicine, 325, 775-782.
REVISED BY KIMBERLY A. MCGRATH
Origin of the Term
The term alcoholism is of relatively recent date; knowledge of the adverse effects of heavy alcohol (ethanol) consumption is not. A proverb describes alcohol as "both mankind's oldest friend and oldest enemy." Alcohol occurs in nature, and humans have long known how to ferment plants to create it; both its moderate and excessive use have therefore occurred since prehistory. The Bible cautions: "Do not look at wine when it is red, when it sparkles in the cup and goes down smoothly. At the end it bites like a serpent and stings like an adder" (Proverbs 23:31-32). A drunken Noah (Genesis 9:20-28) is one of a long line of such literary descriptions. In the classical era of the Greeks and the Romans we have drunks in the Character Sketches of Theophrastus, in the Satyricon of Petronius Arbiter, and in the Epistles of Seneca. In the 1600s, we have Shakespeare's porter in Macbeth (Act II, Scene 3) and others.
Viewing the long-term adverse effects of alcohol as a disease is a concept that also predates the term alcoholism. Benjamin Rush (1745-1813) and Thomas Trotter (1760-1832), both physicians, wrote extensively in this vein, using words such as drunkenness; their elder contemporary Benjamin Franklin (1706-1790) produced a glossary of 228 synonyms in use in 1737 for "being under the influence of alcohol." It was not until 1849 that the Swedish physician and temperance advocate Magnus Huss (1807-1890) first used the word alcoholism in his book Alcoholismus Chronicus (The Chronic Alcohol-disease). Huss's term, used originally in a descriptive sense to denote the consequences of the prolonged consumption of large quantities of alcohol, has come to connote a disease, believed by some to result in such consumption.
Huss meant by the term chronic alcoholism "those pathologic symptoms which develop in such persons who over a long period of time continually use wine or other alcoholic beverages in large quantities" and stated that it "corresponds with chronic poisoning." His book is filled with detailed case histories illustrating the various symptoms that might occur. Sweden was at that time highest in the list of countries that consumed liquors, and Huss, as attending physician to the Serafim Clinic In Stockholm, had ample opportunity to observe cases. The London Daily News of December 8, 1869, carried a story on "the deaths of two persons from alcoholism," which according to the Oxford English Dictionary was the first popular use of the word in English. From that time on, its use in both the professional and the popular literature greatly expanded. This is partly because of the natural process that popularizes usage of certain words and partly because of deliberate activities on behalf of the term alcoholism.
The period of national prohibition in the United States (1919-1933) was accompanied by a lack of attention to the consequences of alcohol consumption, for understandable reasons. Such consumption was illegalermanently, it was assumednd as a result, it was thought that there would be little in the way of consequences. Indeed, such consequences as cirrhosis of the liver did decline abruptly during this period. But as enthusiasm for prohibition waned, and especially after it was repealed, a need to promote treatment became increasingly evident. One group involved in this promotion used alcoholism as the key word in their efforts, and accordingly were called the alcoholism movement by sociologists who subsequently studied their work. In an early statement of this movement, Anderson (1942) predicted that "When the dissemination of these ideas is begun through the existing media of public information, press, radio, and platform, which will consider them as news, a new public attitude can be shaped." It was also felt that the term, together with the disease connotations attached to it, would encourage the involvement of physicians in its study and treatment. The medical profession was viewed as critical to the success of the effort to increase the nation's concern about the consequences of alcohol consumption. The formation of the NATIONAL COUNCIL ON ALCOHOLISM, the largest public interest group in this area, was a project of the same movement. Their successful efforts may be the reason that the term alcoholism developed and sustained a popularity in the United States beyond anything it achieved in Europe and even in Scandinavia, where it was first used.
As the term alcoholism became widely used, its meaning broadened. In a 1941 review of treatment, ten definitions of chronic alcoholism and sixteen definitions of alcohol addiction were collected from the international literature. Originally used by Huss to refer to a disease that consisted of the consequences of alcohol consumption, alcoholism came in time to represent a disease that caused high levels of alcohol consumption (Jellinek, 1960). A variant theory attempts to preserve the original meaning: High levels of alcohol consumption resulted in consequences of various kinds, particularly in terms of damage to the central nervous system, which damage in turn caused the high levels of consumption to continue (Vaillant, 1983). That is, the term alcoholism evolved overtime from a primarily descriptive term to a largely explanatory concept. An example of a definition of alcoholism with clear explanatory intent is one that R. C. Rinaldi and colleagues produced in 1988 through an elaborate consensus exercise (a Delphi process) among eighty American experts, who defined the term as "a chronic, progressive, and potentially fatal biogenetic and psychosocial disease characterized by tolerance and physical dependence manifested by a loss of control, as well as diverse personality changes and social consequences." As a counterpoint to this line of development, a growing and increasingly influential literature holds that problems developing in the context of alcohol consumption do not constitute a disease at all (Fingarette, 1988).
The greater interest taken in alcohol consumption and its consequences as a result of the popularization of the term alcoholism has been gratifying as well as useful. But the broadening of meaning of the term, with much attendant controversy among the advocates of various definitions, has become problematic. For example, in a review of alternative definitions, Babor & Kadden (1985) concluded: "Clearly, the past and present lack of consensus concerning the definition of alcoholism and the criteria for its diagnosis does not provide a solid conceptual basis to design screening procedures for early detection or casefinding." Because of its imprecise meaning, the term alcoholism has for some time now been dropped from the two major official systems of diagnosis of diseases, the INTERNATIONAL CLASSIFICATION OF DISEASES of the World Health Organization and the DIAGNOSTIC AND STATISTICAL MANUAL of Mental Disorders of the American Psychiatric Association. A recent comprehensive study of treatment deliberately avoided the use of the word alcoholism as too narrow in its focus, while suggesting that the word was not incompatible with the phrase that it chose to usei>alcohol problemso refer to any problem occurring in the context of alcohol consumption (Institute of Medicine, 1990, pp. 30-31).
These recent attempts to be precise in the use of words represent a return to the more straightforward, descriptive use of alcoholism by its originator, Huss. Two major realities contributing to this change of direction have been widely recognized since Huss first used the term in the 1840s. One is that the problems people experience are complex, including those that may arise in the context of alcohol use. Although alcohol may be a factor in some such problemsven an important factort is not often the full explanation for them. Multiple factors, including heredity, early environment, cultural factors, personality factors, situational factors, and others, contribute to the development of human problems and must be considered in their resolution. This formulation should not be taken to minimize the important role of alcohol in such problems or to say that the reduction or elimination of alcohol consumption may not be a critical factor in the resolution of problems in particular individuals. The other reality has to do with the extremely broad spectrum of problems that arise in the context of alcohol consumption. Although a substantial proportion of these problems arise from those who drink too much over a long period of time and who usually have multiple problems (those to whom the term alcoholism is usually applied), an even greater burden of problems arises from those who drink too much over short periods of time, and who have only a few problems. The simple reason is that there are more of the latter than of the former (Institute of Medicine, 1990, chapter 9). To reduce the burden upon society effectively, both kinds of populations must be dealt with. An exclusive concentration on alcoholism may cause this reality to be overlooked.
The term alcoholism retains, and probably will always retain, its place in general, nontechnical speech as an indicator of serious problems that are the consequences of prolonged heavy alcohol consumption. Its continued popularity has some advantages, for the public-health consequences of such alcohol consumption are horrendous. The presence of a convenient shorthand term for this fact in the public consciousnessi>alcoholismerves as a continuing reminder of this major unfinished item on the public-health agenda. Certainly, there is a legitimate place in Western society for the use of alcohol. But with equal certainty, too many individuals fail to use alcohol wisely or well.
The ravages that prolonged exposure to alcohol produces in the human body are manifold, as Huss well understood; they include neurological problems (damage to the central and peripheral nervous systems), cirrhosis (fibrosis and shrinking) of the liver, hypertension (high blood pressure), and many forms of cancer, particularly of the digestive tract, to name but a few. If to these are added the consequences of short-term but intense exposure to alcohol and the intoxication it produces, one can include a high proportion of all accidents, burns, all types of violence including suicide, and especially automobile crashes, as well as the common behavioral effects of intoxication with which we are all too familiar. Small wonder that almost 30 percent of all admissions to hospitals in the United States are of persons with severe alcohol problems; yet most of these problems go unrecognized, and the individuals go untreated. About 50 percent of American women have or have had a parent, blood relative, or spouse to whom they would apply the term alcoholism; the figure is closer to 40 percent for men. The difficulties that this creates are legionnd its remediation would be a remarkable step forward.
(SEE ALSO: Addiction: Concepts and Definitions; ; Treatment, History of)
ANDERSON, D. (1942). Alcohol and public opinion. (1942). Quarterly Journal of Studies on Alcohol, 3, 376. An early manifesto of the alcoholism movement.
BABOR, T. F., & KADDEN, R. (1985). Screening for alcohol problems: Conceptual issues and practical consideratiions. In N. C. Chong & H. M. Cho (Eds.), Early identification of alcohol abuse. Washington, DC: U.S. Government Printing Office.
BYNUM, W. F. (1968). Chronic alcoholism in the first half of the 19th century. Bulletin of the History of Medicine, 42, 160-185. An excellent review of medical thought about alcohol problems at the time of Magnus Huss.
FINGARETTE, H. (1988). Heavy drinking: The myth of alcoholism as a disease. Berkeley: University of California Press. A comprehensive summary of the evidence against the disease concept of alcoholism.
HUSS, M. (1852). Chronische Alkoholskrankheit oder Alcoholismus Chronicus (Alcoholismus chronicus or the chronic alcohol disease). Translated by G. van dem Busch into German from the Swedish, with revisions by the author. Stockholm and Leipzig: C. E. Fritze. Original published 1849.
INSTITUTE OF MEDICINE. (1990). Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press. A detailed contemporary review of all aspects of treatment.
INSTITUTE OF MEDICINE. (1987) Causes and consequences of alcohol problem: An agenda for research. Washington, DC: National Academy Press. A comprehensive look at some basic issues in the field that includes extensive chapters on the medical, social, and psychological consequences of alcohol consumption.
JELLINEK, E. M. (1960). The disease concept of alcoholism. Highland Park, NJ: Hillhouse Press. The classic book on the disease concept. If read carefully, it is more skeptical than credulous.
RINALDI, R. C., STEINDLER, E. M., WILFORD, B. B., & GOODWIN, D. (1988). Clarification and standardization of substance abuse terminology. Journal of the American Medical Association, 259, 555-557.
TURNER, T. B., BORKENSTEIN, R. F., JONES, R. K., & SANTORA, P.B. (EDS.) (1985). Alcohol and highway safety. Supplement no. 10 to the Journal of Studies on Alcohol. New Brunswick, NJ: Rutgers University Center of Alcohol Studies. Covers multiple aspects of this complex and highly important area.
VAILLANT, G. E. (1983). The natural history of alcoholism: Causes, patterns, and paths to recovery. Cambridge: Harvard University Press. An ingenious attempt to discover what happens to people with severe alcohol problems by tracing their histories over long periods of time.
FREDERICK B. GLASER