alcoholism

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Definition

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.

Description

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 dysfunction.

Alcoholism causes or contributes to a variety of severe social problems including homelessness, murder, suicide, injury, and violent crime. Alcohol is a contributing factor in at least 50% of all deaths from motor vehicle accidents. In fact, about 100, 000 deaths occur each year due to the effects of alcohol, of which 50% are due to injuries of some sort. According to a recent special report prepared for the U.S. Congress by the National Institute on Alcohol Abuse and Alcoholism, the impact of alcohol on society, including violence, traffic accidents, lost work productivity, and premature death, costs our nation an estimated $185 billion annually. In addition, it is estimated that approximately one in four children (19 million children or 29 percent of children up to 17 years of age) is exposed at some time to familial alcohol abuse, alcohol dependence, or both. Furthermore, it has been estimated that approximately 18 percent of adults experience an episode of alcohol abuse or dependence a some time during their lives.

— Bill Asenjo, MS, CRC

Dictionary: al·co·hol·ism   (ăl'kə-hô-lĭz'əm, -hŏ-)

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A disorder characterized by the excessive consumption of and dependence on alcoholic beverages, leading to physical and psychological harm and impaired social and vocational functioning. Also called alcohol abuse, alcohol dependence.

The continuous or excessive use of alcohol (ethanol) with associated pathologic results. Alcoholism is characterized by constant or periodic intoxication, although the pattern of consumption varies markedly. Individuals admitted for the first time to an alcoholism treatment center typically have been consuming approximately 3–4 oz (80–100 g) of pure alcohol per day, corresponding to about seven to nine drinks or bottles of beer or glasses of wine. Studies have shown that problem drinking in these populations starts at about 2 oz/day (60 g/day), that is, four to five drinks per day, and that these are consumed in rapid succession, leading to intoxication on three or more days per week. Individuals who consume these levels of alcohol have also a greater than average risk of developing alcoholic liver cirrhosis. However, the levels should not be taken as absolute, since they can vary greatly in different individuals, according to body weight and other factors.

The symptoms and consequences associated with severe alcohol consumption also vary greatly; that is, in some individuals only a few may be present. These may consist of the development of physical dependence manifested as a state of physical discomfort or hyperexcitability (tremors or shakes) that are reduced by continued consumption; the development of tolerance to the effects of alcohol, which leads individuals to increase their consumption; accidents while intoxicated; blackouts, characterized by loss of memory of events while intoxicated; work problems, including dismissal; loss of friends and family association; marital problems, including divorce; financial losses, including bankruptcy or continual unemployment. Medical problems can include gastric ulcers, pancreatitis, liver disease, and brain atrophy. The last is often associated with cognitive deficiencies, as shown by the inability to comprehend relatively simple instructions or to memorize a series of numbers. See also Cognition.

Almost without exception, individuals seeking an early treatment for their alcohol problems have very good probabilities of recovery. The lesser the number of presenting problems described above, the better the chances of favorable outcome, and so an early identification of problem drinking by family, friends, employers, or physicians becomes very important. The types of intervention vary greatly, progressing from self-monitoring techniques to intensive outpatient and inpatient programs to Alcoholics Anonymous groups.

The exact mechanisms of the pharmacological actions of alcohol are not known. Alcohol can act as a stimulant at lower doses and as a depressant at higher doses. Even at very low doses alcohol can impair the sensitivity to odors and taste. Also, low doses are known to alter motor coordination and time and space perception, important aspects of car driving. Some effects are already seen at levels of 0.05%. Pain sensitivity is diminished with moderate doses. In some individuals, alcohol is known to diminish feelings of self-criticism and to inhibit fear and anxiety, effects which are probably related to an alcohol-induced sociability. These effects act, no doubt, as psychological reinforcers for the use of alcoholic beverages.

It is generally accepted that alcohol affects the nerve cell by preventing the production and propagation of electric impulses along a network consisting of axons and synapses. A major finding in the mid-1980s was that some of the neurologic effects of alcohol can be quickly reversed by new experimental drugs. Studies have shown that alcohol enhances the actions of an inhibitory brain neurotransmitter referred to as gamma-aminobutyric acid (GABA). Benzodiazepines, such as diazepam, are anxiety-reducing and sedative drugs which also enhance the effects of GABA. These effects can be reduced by experimental antagonist molecules, which interact in the brain in the same regions where GABA is found. See also Synaptic transmission.

The liver is responsible for about 80% of the metabolism of alcohol. In the liver, alcohol is first oxidized to acetaldehyde and then to acetate, which is metabolized in many tissues, including the brain, heart, and muscles. A 150-lb (68-kg) person metabolizes approximately 0.4 oz (10 g) of pure alcohol per hour (about 1 oz of a distilled beverage per hour) or, if alcohol is continuously present in the bloodstream, about 8–10 oz (190–240 g) of pure alcohol per day, equivalent to 1300–1600 calories per day. Since alcoholic beverages contain negligible levels of essential nutrients, these calories are called “empty calories.” Many alcoholics show malnutrition due to the fact that an important part of their caloric intake is alcohol. Alcohol also impairs the absorption and the metabolism of some essential nutrients. In the presence of alcohol, about 80% of oxygen consumed by the liver is devoted to the metabolism of alcohol; as a consequence, other substances such as fats, normally oxidized by the liver, are not metabolized, leading to fat accumulation in the liver. See also Liver; Malnutrition.

Alcoholic liver disease is characterized by two conditions: failure of the liver to detoxify noxious substances and to produce essential products; and increased resistance to blood flow through the liver. Alcoholic liver disease and liver cirrhosis rank among the 10 leading causes of mortality in the United States and Canada. See also Cirrhosis.

There is abundant evidence that tendency to alcoholism can be of familial origin, due to environmental, cultural, and genetic factors. A Swedish study demonstrated that identical twins are twice as likely to have a common alcoholic problem as fraternal twins. In an American-Danish study, it was shown that children of alcoholic parents are more likely to develop alcoholism (18%) than children of nonalcoholic parents (4%) when both groups of children were adopted by nonrelatives within 6 weeks of birth. See also Behavior genetics; Behavioral toxicology.

Pharmacotherapy for alcohol rehabilitation has been gaining wider acceptance. Specific pharmacotherapies which have received the most research attention utilize naltrexone and disulfiram. Other promising pharmacological interventions are acamprosate and buspirone. Naltrexone is an opiate receptor antagonist which blocks the effects of endogenous opioids in the brain. Research from animal studies suggests that alcohol activates endogenous opioid systems and, thereby, may contribute to the pleasurable effects produced by alcohol consumption. Consequently, naltrexone might reduce the reinforcing effects of alcohol consumed by people and decrease their incentive to drink. Disulfiram is a drug which causes an inhibition of the enzyme aldehyde dehydrogenase, leading to an increase in acetaldehyde blood levels. This rise will produce nausea, vomiting, tachycardia, difficulty in breathing, and changes in blood pressure leading to hypotension. Acamprosate may function to reduce alcohol-induced euphoria related to the effects of excitatory neurotransmitters such as N-methyl-D-aspartate and have some blocking effects on opiate receptors. Buspirone, a nonbenzodiazepine antianxiety agent, may decrease anxiety symptoms associated with a protracted alcohol withdrawal syndrome, thus reducing alcohol relapse potential. Both of these medications require further investigation to determine their effectiveness as a pharmacotherapeutic agent in the treatment of alcoholism.

The term ‘alcoholism’ was first used by a Swedish professor of medicine, Magnus Huss (1807-90), to mean poisoning by alcohol. Huss distinguished between two types of alcoholism. Acute alcoholism was a result of the temporary effects of alcohol taken within a short period of time — drunkenness and intoxication; chronic alcoholism was a pathological condition caused by the habitual use of alcoholic beverages in poisonous amounts over a long period of time. Using case studies to illustrate the condition of chronic alcoholism, Huss provided the first systematic description of the physical damage caused by excessive drinking. This first use of the term ‘alcoholism’ in 1852 emerged from a combination of specific historical circumstances within which changes in perceptions of excessive alcohol consumption were taking place.

Prior to the nineteenth century, symptoms and problems related to ‘habitual drunkenness’, or excessive alcohol use, were known and recorded, but habitual drunkards were seen as morally weak or criminal, rather than suffering from an illness or a disease. Public concern revolved around drunkards' moral attitudes and social behaviours, which were regarded as licentious, sinful, or criminal, punishable by a period in the stocks, whipping, or fines — or by the eternal damnation preached in fiery sermons. On the whole, however, the dominant social response

to drunkenness was tolerance and social disapproval; heavy drinking was not, in itself, regarded as a problem. The emergence of a new understanding of habitual drunkenness (or inebriety) as a disease was led by medical and psychiatric practitioners at the beginning of the nineteenth century, most notably by Benjamin Rush (1745-1813) in America and Thomas Trotter (1760-1832) in Scotland. According to some historians, it was Rush who provided the first clearly developed modern conception of alcohol addiction. This included the idea of gradual and progressive addiction; bouts of drunkenness characterized by an inability to refrain from alcohol; the description of the condition as a ‘disease’; and total abstinence as the cure. For the first time, ‘treatment’ became a possible option in responding to the harm associated with habitual drunkenness. Throughout the nineteenth century efforts were made to provide more scientific descriptions of the disease and its cure, leading, in 1901, to the use of the term ‘alcohol addiction’ to describe the inability to give up harmful drinking.

Twentieth century developments

During the first half of the twentieth century interest in alcoholism and the alcoholic waned. Prohibition in America and changing social conditions and consumption patterns in Britain drew attention towards control of the substance and away from the disease and its treatment. But with the repeal of prohibition in America, any attempt to address problems associated with drinking had to be concerned with the behaviour of individuals rather than with the consumption patterns of the nation or the nature of the substance itself. In post-prohibition America and, later, in post war Britain, the freedom of the majority to drink as they pleased was paramount. The nineteenth century temperance approach, which had inveighed against the dangers of alcohol itself, was now rejected as moralistic and unscientific and the focus of attention was, once again, on the disease of alcoholism.

The ‘new’ disease approach to alcoholism started in America and was led by three linked groups, often referred to as the ‘alcoholism movement’: a research group established at the Yale Centre for Alcohol Studies; Alcoholics Anonymous (AA) (a self-help group which was set up in 1935), and the National Committee for Education on Alcoholism (later the National Council on Alcoholism), which became the leading voluntary organization offering alcoholism treatment. The ‘alcoholism movement’ quickly spread to Britain and subsequently throughout the world.

In essence there was little difference between descriptions of the disease in Rush's work and later use of the term. The main objectives in labelling it as the ‘new’ approach to alcoholism were practical and political rather than based on any ‘scientific’ discovery. On the practical side was the desire to gain a better deal for people suffering from alcoholism. Promoting the disease concept was part of a strategy to combat the stigma and prejudice that hindered alcoholics and their families from seeking help and that was a barrier to securing the interest and involvement of the helping professions. On the political side, the concept served as a device to unite diverse interests, including the alcohol industry, because the focus was on a few unfortunate individuals rather than on the drinking habits of the majority.

The strategy was successful. The disease theory was accepted by the American Medical Association in 1956 and by a number of influential doctors and voluntary groups in Britain over the course of the 1950s and 60s. In the early 1950s, the World Health Organization formally declared its support and provided a definition of ‘alcoholism’ which noted that alcoholics were excessive drinkers, dependent on alcohol to the extent that they suffered noticeable mental disturbance or interference with bodily or mental health, interpersonal relations, and economic functioning. They were people who required treatment.

As in the previous century, there was continuing interest in refining the disease concept and in producing classifications or ‘typologies of drinkers’. The most famous typology was derived from the research of E. M. Jellinek, a member of the Yale Centre for Alcohol Studies and a consultant to the WHO during the 1950s. Influenced strongly by AA philosophy, Jellinek distinguished between five different types of alcoholism. Only two types (Gamma and Delta) were diseases because, in his view, they were addictions in the pharmacological sense that physical dependence on alcohol was present and too sudden cessation of alcohol use would result in withdrawal symptoms. The defining characteristics of Gamma and Delta alcoholism were: acquired increased tissue tolerance; adaptive cell metabolism; withdrawal and craving; and loss of control (Gamma alcoholism) or an inability to abstain (Delta alcoholism). Typically, Gamma alcoholics drank mainly in bouts and were often drunk; Delta alcoholics drank regularly to achieve a blood alcohol level at which they felt comfortable, usually without getting drunk. According to Jellinek, ‘alcoholics’ were those who suffered from Gamma or Delta forms of alcoholism. Other forms of alcoholism were considered to be symptomatic, the dependence on alcohol being psychological without the presence of physiological addiction; individuals in those groups were not, therefore, alcoholics.

Alcohol dependence and related disabilities

Jellinek's classification has continued to have a significant influence over beliefs about alcoholism and about appropriate treatment approaches for alcoholics. But the ambiguities in the terms led to repeated efforts to clarify the concepts, resulting eventually in the substitution of ‘alcoholism’ with the term ‘alcohol-dependence syndrome’, approved by the World Health Assembly in 1976 and incorporated, three years later, into the International Classification of Diseases as a new medical diagnosis. One important feature of the syndrome is that it includes both psychological and physiological dependence. It has seven elements: subjective awareness of the compulsion to drink; narrowing of the drinking repertoire (drinking becomes predominantly a response to the need to avoid withdrawal so that daily intake becomes ‘scheduled’) ; primacy of drinking (drinking becomes more important than any other activity) ; altered tolerance to alcohol; repeated withdrawal symptoms; relief or avoidance of withdrawal symptoms by further drinking; reinstatement after abstinence (return to the drinking pattern established before abstinence, which can happen very quickly after starting to drink again).

At the same time as the alcohol dependence syndrome emerged as a new concept, a WHO group were formulating criteria for the identification and classification of alcohol-related disabilities. The report, published in 1977, described the range of mental, physical, and social disabilities related to alcohol use and emphasized that there were degrees of disabilities. It was not only the ‘alcoholic’ or alcohol-dependent person who was adversely affected by alcohol; damage might be incurred even if the individual was neither dependent nor an excessive drinker.

The emphasis on degrees of disability related to alcohol use rather than dependence is significant since it signalled changes in perceptions of the nature of the alcohol problem. The notion that ‘alcoholics’ suffering from a ‘disease’ were different from the remainder of the population was no longer generally accepted (although some groups still base their therapeutic approaches on disease theories). By the 1980s, many people preferred the term ‘problem drinking’, which covered a continuum of drinking harms, from relatively minor harm, such as behaving in socially embarrassing ways when drunk, missing work because of a hangover, or suffering a fall when drinking, to the severe harms associated with excessive and dependent drinking. Problem drinking was not a disease; it was a ‘learned behaviour’, and anyone who drank was at risk of becoming alcohol dependent. Concern now focused on the much greater number of people drinking above recommended levels, or in ways likely to incur harm to themselves, to other people, or to the wider community.

Today, the term ‘alcoholism’ and ‘alcoholic’ are regarded by many people as stigmatizing labels which are unhelpful in developing appropriate responses to alcohol-related harms. But their continuing use by some groups indicates the co-existence of alternative beliefs about the nature of harmful alcohol use and of different approaches to helping those who become ‘problem drinkers’ or ‘alcoholics’.

— Betsy Thom

Bibliography

• Heather, N. and Robertson, I. (1997). Problem drinking: the new approach, (3rd edn). Oxford University Press

See also addiction; disease; drug abuse.

Physiological addiction to alcohol, associated with persistent heavy consumption of alcoholic beverages. In addition to the addiction, there may be damage to the liver (cirrhosis), stomach (gastritis), and pancreas (pancreatitis), as well as behavioural changes and peripheral nerve damage.

The continued extreme dependence on excessive amounts of alcohol, accompanied by a cumulative pattern of deviant behaviors. The most frequent medical consequences of alcoholism are chronic gastritis, central nervous system depression, and cirrhosis of the liver, each of which can compromise the delivery of dental care.

Definition

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 15–54) had, at some time, met the criteria for alcohol dependence; and 7% had been alcohol-dependent in the past year. An earlier, similar study showed that about 5% of Americans qualified for a diagnosis of alcohol abuse at some point during their life. According to a 2002 report by the National Council on Alcoholism and Drug Dependence, 14 million Americans abuse alcohol, and 100,000 die annually of alcohol related preventable causes. Though it is difficult to develop accurate statistics worldwide, it is known that the incidence of what we call alcoholism has been steadily rising around the globe for several years.

Description

The effects of alcoholism are quite far-reaching. Alcoholism affects every body system, causing a wide range of drinking related health problems, including lower testosterone, shrinking gonads, erectile dysfunction, interference with reproductive fertility, weak bones, 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 of the entire gastrointestinal system, acute and chronic problems with the pancreas, low blood sugar, high blood fat content, and poor nutrition.

Its mental health implications include marital and other relationship difficulties, depression, unemployment, poor performance at school or work, spouse and 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 from motor vehicle accidents. In fact, 50% of the 100,000 deaths that occur each year due to the effects of alcohol are due to injuries of some sort. Alcohol costs the United States over $150 billion yearly in lost productivity and alcohol related medical expense.

Causes & Symptoms

A physical dependence on alcohol develops insidiously, over time. The body is a magnificent adaptor; therefore, with persistent use, many adaptations occur physically and psychologically, resulting in both a higher tolerance to and increased need for alcohol—craving it—The physical adaptation to alcohol involves changing levels and altered balances of neurotransmitters, chemicals in the brain which not only affect physical abilities like muscle coordination, but also mood. The abuse of alcohol is associated with a desire to feel better and to avoid feeling poorly. Initially a stimulant, it eventually acts as a central nervous system (CNS) depressant and is used in a majority of societies or cultures in the world as an accepted part of dealing with life events, except where religious opposition bans, discourages or prohibits its use, as in most Muslim communities. It is included in celebrations and, ironically, its use is perceived as an appropriate response to sadness and loss, such as at wakes.

There is, at this point, no single known factor that causes some people to be alcohol-dependent and others not. Recent genetic studies have demonstrated that close biological relatives of an alcoholic are four times more likely to become alcoholics themselves. Furthermore, this risk holds true even for children who were adopted away from their biological families at birth and raised in non-alcoholic homes, without knowledge of their biological family's difficulties with alcohol. Male gender,

being the child of an alcoholic parent or parents, extended family history and being of Irish (Celtic), Scandinavian, German, Polish, Russian or Native American ancestry, beginning drinking as a teenager, and being depressed or highly anxious all increase the risk of experiencing problems with alcohol. Further research may determine if genetic factors are accountable, in part, for differences in alcohol metabolism and increase the risk of an individual becoming an alcoholic. Other cause related factors in alcoholism include high levels of stress and turmoil or pain, having drinking friends, drinking partners, and "enablers"—people who facilitate a drinkers habits and denial mechanisms. Heavy advertising that makes drinking appear to be "sexy" or the basis of a good time also contributes. Consider, for example, the number of televised sporting events that are sponsored heavily by alcohol related enterprises.

One of the classic symptoms of alcoholism is denial of a problem with alcohol. An addicted person, under the influence of the addictive substance, is physically and psychologically motivated to perpetuate the addiction. Therefore, intervention often starts when loved ones, recognizing the signs and symptoms, bring attention to the problem and call for help. Occasionally, an intervention requires a whole family unit and outside assistance. Signs and symptoms of alcohol dependence and abuse may include the following:

• not remembering conversations or commitments
• losing interest in activities that were once pleasurable
• ritualized drinking, before, with, and after dinner and being upset if the pattern is interrupted
• becoming irritable as "happy hour" approaches, especially if alcohol is not available
• drinking alone or secretly
• hiding alcohol in unusual places
• ordering doubles, drinking quickly, and drinking to become drunk, intentionally
• focusing attention on the source of one's next drink
• unstable relationships, financial, legal, and employment difficulties

Physical symptoms of alcoholism can be broken into two major categories: symptoms of acute alcohol use and symptoms of long-term alcohol use.

Immediate (Acute) Effects of Alcohol Use

Though the initial reaction to alcohol may be stimulatory, ultimately alcohol exerts a depressive, uninhibiting effect on the brain. The blood-brain barrier does not prevent alcohol from entering the brain, so the brain alcohol level quickly becomes equivalent to the blood alcohol level. Alcohol's depressive effects result in impaired thinking, feeling and judgment, short term memory loss, muscle weakness difficulty walking, poor balance, slurring of speech, and generally poor coordination (accounting for the increased likelihood of injury and alcohol related injury statistics). At higher alcohol levels, a person's breathing and heart rate slows. Vomiting may occur, with a high risk of vomitus "aspiration" (inhaling vomit into the lungs), and may result in further complications includingpneumonia. Still higher alcohol levels may result in coma and death.

Effects of Long-Term (Chronic) Alcoholism

Alcohol is considered a lethal poison, requiring continuous detoxification by the liver. As drinking continues and overwhelms the liver's ability to detoxify, long term consequences to health occur, affecting virtually every organ system of the body.

NERVOUS SYSTEM. It is estimated that 30–40% of all men in their teens and twenties have experienced alcoholic blackout (loss of consciousness) as a result of drinking a large quantity of alcohol. In an alcoholic blackout, all memory of time and behavior surrounding the episode of drinking is lost. Alcohol causes sleep disturbances, thus affecting overall sleep quality. Numbness and tingling may occur in the arms and legs. Two conditions that may occur either together or separately are Wernicke's and Korsakoff's syndromes. Both are due to the depleted thiamin levels found in alcoholics. Wernicke's syndrome results in disordered eye movements, very poor balance, and difficulty walking, while Korsakoff's syndrome severely affects one's memory, preventing new learning from taking place.

GASTROINTESTINAL SYSTEM. Alcohol causes a loosening of the muscular ring (the cardiac sphincter) that prevents the stomach's contents from reentering the esophagus. As a result, acid from the stomach flows upward into the esophagus, burning those tissues and causing pain and bleeding, or gastro-esophageal reflux disease (GERD). Inflammation of the stomach can also result in bleeding (ulcers) and pain as well as a decreased desire to eat. A major cause of severe, uncontrollable bleeding (hemorrhage) in an alcoholic is the development in the esophagus of enlarged (dilated) blood vessels, which are called esophageal varices (varicose veins of the esophagus). These varices actually develop in response to the toxic effect of alcohol on the liver, and are extremely prone to bursting and hemorrhage.

A malnourished state arises from the loss of appetite for food—due to caloric substitution of alcohol and its effects on blood sugar levels—and interference with the absorption of nutrients throughout the intestinal tract. Inflammation of the pancreas (pancreatitis) is a serious and painful problem in alcoholics that disrupts carbohydrate and fat digestion, and increases the risk of insulin resistance, weight gain, hyperlipidemia, diabetes, and pancreatic cancer. Diarrhea is also a common symptom of chronic alcohol use, due to alcohol's effect on the pancreas.

LIVER. Because alcohol is broken down (metabolized) within the liver, that organ is severely affected by constant levels of alcohol. Alcohol interferes with the large number of important chemical processes that occur in the liver. As alcohol converts to blood sugar, which in turn converts to blood fat, the liver begins to enlarge, filling with fat, a condition called fatty liver. Cirrhosis, a potentially deadly complication, develops when fibrous tissue, while trying to support the extra burden placed on the liver by the accumulation of fat and liver cell weakness, interferes with the liver's normal structure and function. The liver may also become inflamed, a condition called hepatitis, producing jaundice, fatigue, and elevated liver enzymes indicative of liver cell death and destruction. Because of the liver's enormous role in digestion, metabolism and immunity, damage to the liver takes a serious toll throughout the body.

BLOOD. Alcohol can cause changes to any of the types of blood cells. Red blood cells become abnormally large. White blood cells (important for fighting infections) decrease in number, resulting in a weakened immune system. This places alcoholics at increased risk for infections and is thought to account in part for an alcoholic's increased risk of cancer (ten times greater than normal). Platelets and blood clotting factors are affected, causing an increased risk of bleeding and hemorrhage, especially when coupled with vascular weaknesses, varices, or aneurism.

HEART AND CIRCULATORY SYSTEM. Small amounts of alcohol cause a drop in blood pressure, but increased use begins to raise blood pressure dangerously. Increased blood pressure negatively affects the kidneys. While some studies demonstrate that one to two alcoholic drinks per night improves heart disease risk values, higher amounts and chronic intake produce high levels of circulating fats, which increases the risk of heart disease. Heavy drinking results in an enlarged heart, coronary arterial disease (CAD), peripheral vascular disease, weakening of the heart muscle, abnormal heart rhythms, a risk of blood clots forming within the chambers of the heart, and a greatly increased risk of stroke. Strokes result when a blood clot from the heart enters the circulatory system, goes to the brain, and blocks a blood vessel. Stroke may also result from a hemorrhage within the brain, as weakened vessel walls give way and platelet deficient blood pours through.

REPRODUCTIVE SYSTEM. Heavy drinking has a negative effect on fertility in both men and women, decreasing testicular and ovarian size, interfering with sperm and egg production and viability, disrupting menstrual cycles, and reducing libido. When pregnancy is achieved reduced quality of sperm and egg may significantly and permanently affect the quality of life, pre-, peri- and postnatally, of the child. A child born to an alcohol using woman has a great risk of being born with fetal alcohol syndrome, which causes distinctive cranial and facial defects, including a smaller head size, shortening of the eyelids, and a lowered IQ. Developmental disabilities, heart defects, and behavioral problems are also more likely.

Diagnosis

The DSM-IV breaks substance abuse into specific criteria that can be of aid in diagnosing a substance abuse problem. These criteria are paraphrased here to relate to alcoholism. At least one of the following must have manifested itself within a 12-month period to qualify for a diagnosis of alcohol abuse:

• Recurrent alcohol use that results in failure to fulfill major role obligations at work, school, or home. Specific examples are repeated absences from work or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; and neglect of children or household.
• Recurrent alcohol use in situations in which it is physically hazardous. Specific examples are driving an automobile and operating a machine while impaired by alcohol use.
• Recurrent alcohol-related legal problems, such as arrests for alcohol-related disorderly conduct.
• Continued alcohol use despite having persistent and recurring social or interpersonal problems caused or exacerbated by the effects of the alcohol. Examples include arguments with a spouse about the consequences of intoxication, and alcohol-related physical fights.

A diagnosis of alcohol dependence requires habitual, long-term tolerance for and heavy consumption of alcohol as well as the development of symptoms of withdrawal when the amount of alcohol in the system is substantially lowered or completely stopped. Once a pattern of compulsive alcohol use has developed, alcohol-dependent people may devote large portions of their time to the procurement and drinking of alcohol.

A significant number of illnesses categorized in DSM-IV as alcohol-induced disorders has come into being as a result of alcohol abuse and dependence, illustrating the negative impacts of alcoholism on physical and mental health. Among the psychiatric diagnoses that are included in alcohol-induced disorders are:

• dementia
• amnestic disorder
• psychotic disorder
• mood disorder
• anxiety disorder
• sexual dysfunction
• sleep disorder

As previously mentioned, due to the strong element of denial and a need, usually, for an intervention, diagnosis is often brought about because family members call an alcoholic's difficulties to the attention of a physician. A physician may become suspicious when a patient suffers repeated injuries or begins to experience medical problems that are related to the use of alcohol. In fact, some estimates suggest that about 20% of a physician's patients are alcoholics, a percentage which is higher than the general population and lower than the increased risk to health posed by alcoholism. In other words, alcohol related illness may prompt an alcoholic to see medical counsel, but their illness may not be recognized as alcohol related until the disease toll is quite advanced.

Questionnaires that try to determine what aspects of a person's life may be affected by use of alcohol can be an effective diagnostic aid. Determining the exact quantity of alcohol that a person drinks is much less important than determining how his or her drinking affects health, relationships, jobs, educational goals, and family life. In fact, because the metabolism of alcohol (how the body breaks down and processes alcohol) is so individual, the quantity of alcohol consumed is not part of the criteria list for diagnosing either alcohol dependence or alcohol abuse.

One very simple tool for beginning the diagnosis of alcoholism is called the CAGE questionnaire. It consists of four questions, with the first letter of each key word spelling out 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?

Other, longer lists of questions may help determine the severity and effects of a person's alcohol use. A thorough physical examination may reveal the physical signs suggestive of alcoholism, such as an enlarged liver, a visible network of enlarged veins just under the skin around the navel (called caput medusae) (or herniated umbilicus), fluid in the abdomen (ascites), yellowish tone to the skin (jaundice), decreased testicular size or gynecomastia (breast enlargement in men), osteoporosis, physical deterioration, loss of teeth, evidence of old injuries, and poor nutritional status. Diagnostic testing may include cardiovascular, CNS, GI, general chemistry and liver function tests (LFTs) and reveal poor stress test performance, arterial disease, congestive heart failure, palsy, loss of coordination, reflux disease or history of stomach ulcer, irritable bowel syndrome, an increased red blood cell size and anemia, abnormal white blood cells (cells responsible for fighting infection) counts or characteristics, abnormal platelets (particles responsible for clotting), and increased liver enzymes. Given the genetic risk factors for alcoholism, determinations of familiar alcoholism related illness and death may be additive.

Treatment

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 (because of, or leading to, the alcoholism), many of the treatments for alcoholism involve dealing with and relieving stress. These include massage, meditation, and hypnotherapy. A list from the Mayo Clinic also includes acupuncture (may reduce craving, anxiety, depression, tremor, fatigue, and the symptoms of withdrawal), biofeedback (monitoring of internal systems for stress reduction), behavioral therapy motivational enhancement therapy (problem acknowledgment), and aversion therapy (may involve simultaneous use of medications the cause nausea or vomiting with relapse.)

Nutritionally oriented practitioners may be consulted to address the malnutrition associated with long-term alcohol use. Careful and remedial attention toward a healthier diet and lifestyle, including use of nutritional supplements, such as vitamins A, B complex, and C; certain fatty acids; amino acids; zinc; magnesium; and selenium—supplements that support antioxidant, detoxifying, restorative and corrective deficiencies—may further enhance recovery and lessen the likelihood of relapse.

Herbal treatments include milk thistle (Silybum marianum), which is thought to protect the liver against damage. Other herbs are thought to be helpful for the patient suffering through withdrawal. Some of these include the antidepressive attributes of lavender (Lavandula officinalis), the calming and restorative nerve tonifying effects of skullcap (Scutellaria lateriflora), chamomile (Matricaria recutita), and valerian (Valeriana officinalis), the stimulating and GI helpful effects of peppermint (Mentha piperita), and the bladder aid, yarrow (Achillea millefolium).

Allopathic Treatment

Allopathic treatment of alcoholism has two parts. The first phase is the treatment of acute effects of alcoholism, called detoxification. The second phase involves learning how to live with the disease of alcoholism.

Withdrawal

Detoxification, or withdrawal, involves helping the person to rid his or her body of alcohol as well as the harmful physical effects of the alcohol. Because the person's body has become accustomed to alcohol, he or she needs care and monitoring during withdrawal. Withdrawal is an individual experience, 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 drinking (the adaptation factor). Withdrawal symptoms can range from mild to life threatening. Mild withdrawal symptoms include nausea, ache, diarrhea, difficulty sleeping, excessive sweating, anxiety, and trembling. This phase may last from three to seven days. More severe effects of withdrawal may include hallucinations (in which a patient sees, hears, or feels something that is not real), 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 or DTs) are those with other medical problems, such as malnutrition, liver disease, or Wernicke's syndrome. Delirium tremens usually begins about three to five days after the patient's last drink and may last a number of days. Withdrawal usually progresses from the more mild symptoms to the more severe ones.

Patients going through only mild withdrawal, monitored carefully to make sure that more severe symptoms do not develop, may not require medication, however, fluids are encouraged to facilitate detoxifying the person's system. Patients suffering more severe effects of withdrawal may need to be given sedative medications, benzodiazepines like Valium or Librium, to relieve discomfort and to avoid the potentially life threatening complications of high blood pressure, fast heart rate, and seizures. Because of the patient's nausea, fluids may need to be given intravenously (through a vein), along with some necessary sugars and salts (electrolyte pushes). It is crucial that thiamin be included in the fluids, because thiamin is usually quite low in alcoholic patients, and deficiency of thiamin is responsible for the Wernicke-Korsakoff syndrome. In-patient treatment is usually short-term (three to seven days), though longer rehabilitation programs lasting weeks or even months are sometimes needed. Any treatment is usually followed by longer-term outpatient treatment.

Recovery

After the physical problems associated with alcohol withdrawal have been treated, the more difficult task begins: helping the person to clearly recognize the nature and severity of his or her illness. This is done on both an in-patient and outpatient basis. Alcoholism is a disease of denial; as members of Alcoholics Anonymous put it, it is "the only disease that keeps telling you that you do not have a disease." Recall that often the alcoholic is made aware of his or her condition through what is called an intervention, a meeting with family and/or significant people who describe for the alcoholic the symptoms of alcoholism that they have witnessed and how these symptoms have affected them. This is important because alcoholics who are actively drinking are often not aware of what they do, nor do they remember later what they have done. (Interventions are sometimes done before the problem becomes serious enough to require detoxification from alcohol). Essential to recovery is the awareness of powerlessness over the disease, acceptance of having the disease, and abstinence from the substance that perpetuates the disease.

There is no cure for alcoholism. Sessions led by peers, such as Alcoholics Anonymous (AA) meetings, are often part of in-patient hospital treatment. AA meetings, where recovering alcoholics meet regularly and provide support for each other's recovery, are considered among the best methods of preventing a return to drinking (relapse). The AA program is a twelve-step program. Its 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, reflecting on the ways in which the use of alcohol has hurt others, and if possible, making amends to those people. The final step involves carrying the message of hope and recovery to other sick and suffering alcoholics. The Serenity Prayer becomes an ally: "God grant me the strength to accept the things I cannot change, the courage to change the things I can change, and the wisdom to know the difference."

The best programs incorporate the alcoholic's family or loved ones into the therapy, because loved ones have undoubtedly been severely affected by the drinking. Many therapists believe that families, in an effort to deal with the alcoholic's drinking problem, develop patterns of behavior that unwittingly support or "enable" the patient's drinking. This situation is referred to as co-dependency. The twelve-step programs of Al Anon and Adult Children of Alcoholics are often very successful in helping the families or loved ones of alcoholics.

There are also medications that may help an alcoholic avoid returning to drinking. These have been used with variable success. Disulfiram (Antabuse) is a drug which, when mixed with alcohol, causes a very unpleasant reaction that includes nausea and vomiting, diarrhea, and trembling. Naltrexone (a drug that blocks a narcotic high and may reduce the urge to drink) and acamprosate seem to be helpful in limiting the effects of a relapse. Naltrexone, found to produce liver damaging side effects, may be a difficultly exercised option. None of these medications has been found to be helpful unless the patient is also willing to work very hard to change his or her behavior.

Expected Results

As noted earlier, there is no cure for alcoholism. Recovery from alcoholism is a lifelong process. In fact, people who have suffered from alcoholism are encouraged to refer to themselves ever after as a recovering alcoholic, never a recovered alcoholic. Alcoholism can only be arrested—by abstaining from the drug, alcohol. The potential for relapse (returning to illness) is always there, and it 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 successfully stop drinking for at least a year, and many for a lifetime.

Prevention

Prevention is primarily related to education and early intervention. In a culture where alcohol is so ingrained, education about the dangers of this drug is vitally important, even as early as early childhood. Since alcohol is the easiest and cheapest drug to obtain and the one most commonly used by teens, the first instance of intoxication (drunkenness) with alcohol usually occurs during the teenage years. It is particularly important that teenagers who are at high risk for alcoholism be made aware of this danger. Those at high risk include those with a family history of alcoholism, an early or frequent use of alcohol, a tendency to drink to drunkenness, alcohol use that interferes with schoolwork, a poor family environment, or a history of domestic violence. Peers are often the best people to provide this education, and groups such as SADD (Students Against Drunk Driving, a Marlborough, Massachusetts-based organization), appear very effective. Courts and schools sometimes provide education through local substance abuse programs, as well. Setting a good example, developing and practicing communication skills with your children, and frank discussions about the consequences of drinking, are all encouraged to prevent alcoholism related problems. Developing alternative coping skills to life's problems is also essential, as is encouraging a more distant perspective on the pervasive advertising that deceptively promotes alcohol's health reducing glamour.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.

Diamond, Ivan. "Alcoholism and Alcohol Abuse." Cecil Textbook of Medicine, edited by J. Claude Bennett and Fred Plum. Philadelphia: W.B. Saunders, 1996.

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.

Periodicals

Aesoph, Lauri M. "Kick the Habit—Naturally: Quit Drinking or Smoking With Herbs, Acupuncture, and the Right Diet." Vegetarian Times (March 1996): 100+.

Bullock, M. L., P. D. Culliton, and R. T. Oleander. "Controlled Trial of Acupuncture for Severe Recidivist Alcoholism." Lancet (June 1989): 1435–1439.

Dorsman, Jerry. "Improving Alcoholism Treatment: an Overview." Behavioral Health Management (January-February 1996): 26+.

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+.

"Spotting a Drinking Problem." Consumer Reports on Health (September 1997): 106+.

Organizations

Al-Anon, Alanon Family Group, Inc. P.O. Box 862, Midtown Station, New York, NY 10018-0862. (800) 356-9996. http://www.recovery.org/aa.

National Alliance on Alcoholism and Drug Dependence, Inc. 12 West 21st St., New York, NY 10010. (212) 206-6770.

National Clearinghouse for Alcohol and Drug Information. .

Other

Alcohol Abuse and Alcoholism. MedicineNet, Inc. 1996-2004. [cited May 28, 2004]. .

Alcoholism. Mayo Foundation for Medical Education and Research. 1998-2004. Updated, July 3, 2002. [cited May 28, 2004]. .

FAQs on Alcohol Abuse and Alcoholism. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Updated, March 2003. [cited May 28, 2004]. .

[Article by: Katherine E. Nelson, N.D.]

Definition

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
• repeated alcohol use in situations in which it is physically hazardous
• repeated alcohol-related legal problems
• persistent alcohol use despite its causing social and interpersonal problems or exacerbating them

This definition and the criteria established by DSMIV apply to both adults and children. The American Academy of Pediatrics (AAP) states that the pattern of use and abuse of alcohol in children and adolescents is not observably different from what is manifested in young people using marijuana or cocaine.

Description

The AAP divides the progression into childhood alcoholism into three stages:

• Stage 1: Experimentation with alcohol. Normally there is no change noted in physical status or behavior, and the drinking usually occurs only on weekends during social occasions with peers, making it the least detectable of the three. Peer pressure to use alcohol "just for fun."
• Stage 2: Actively trying to obtain alcohol. Alcohol use happens during the week to provide relief when stress is felt or to "feel good" when depressed.
• Stage 3: Preoccupation with alcohol. The child or adolescent has nearly lost the capacity for controlling alcohol use. Setting limits results in withdrawal symptoms, including depression, moodiness, or irritability. Severe withdrawal can result in serious medical problems, including delirium tremens.

Demographics

Prevalence and Severity of the Problem

Based on findings mostly coming from the 1990s, the National Council on Alcohol and Drug Dependence (NCAAD) cites the following in its fact sheet Youth, Alcohol and Other Drugs:

• Approximately 10.4 million Americans ages 12 to 20 have at least one drink per month. One fifth of these (2.1 million) are heavy drinkers who have five or more drinks on a minimum of five different occasions. More than half of these (6.8 million) are considered binge drinkers who have five or more drinks on a single occasion.
• Eighty percent of all high school seniors have tried alcohol.
• Eight percent of eighth graders, 24 percent of tenth graders, and 32 percent of high school seniors have been intoxicated from alcohol in the past month.
• Children who begin smoking tobacco before the age of 13 are significantly more at risk for alcohol problems.
• Among high school seniors, alcohol use is more prevalent among Caucasian and Hispanic students than among African American students.
• Junior, middle, and senior high school students consume 35 percent of all wine coolers sold in the United States as well as 1.1 billion cans of beer.
• A Southern Illinois University study showed that students with overall grades of D or F drank on average three times as much alcohol as students with overall grades of A.
• A United States Department of Justice survey showed that nearly one third of children below the age of 18 incarcerated in juvenile institutions are under the influence of alcohol at the time of their arrest.
• More than half (56%) of children and teens in grades five through 12 report that alcohol advertising encourages them to drink.
• Thirty percent of children in grades four through six state that they have received pressure from peers to drink beer.
• Two thirds of teenagers who drink report that they are able to make their own alcohol purchases.
• The total cost of alcohol use by young people, including automobile crashes, violent crime, alcohol poisoning, burns, drowning, suicide attempts, and fetal alcohol syndrome is more than 58 billion dollars each year.
• Eighty percent of teenagers do not know that a 12-ounce can of beer has the same amount of alcohol as a shot of whiskey or a five-ounce glass of wine.

Causes and Symptoms

In their article "Early Identification and Intervention for Adolescent Alcohol Use," Mark Werner and Hoover Adjer Jr., both fellows at the American Academy of Pediatrics (AAP), state that attitudes regarding alcohol use are developed quite early in life, usually by the age of eight. Parental attitudes regarding alcohol and behaviors related to alcohol use have a major impact on how children and young adults view drinking alcohol. Not every child or teen who experiments with alcohol becomes an alcoholic, but NCADD studies have shown that children who drink before the age of 15 are four times more likely to become alcoholic than those who begin drinking after the age of 21. Some evidence supports a genetic component to this disease. Parents who are themselves alcoholic or problem drinkers are more likely to have children who develop alcohol dependence. Statistically, one in five children who have an alcoholic parent becomes an alcoholic, too.

Physical symptoms seen in adult alcoholics, such as gastritis, pancreatitis, hepatitis, or even cirrhosis, usually are absent in childhood alcoholics. Such physical damage normally takes longer to develop and is more typical of long-term adult alcoholics. More often in potential childhood alcoholics, behavioral symptoms provide the most significant clues.

These behavioral warning signs, according to the AAP, typically include the following:

• decline in school functioning, decreased attendance, poorer grades, and/or general deterioration in social functioning in school
• increased isolation outside school; rejection of usual long-term friendships in favor of new or different friends
• frequent arguments or less communication with family members; being more secretive
• marked changes in grooming and clothing styles
• noticeable increase in unexplained injuries and fights
• running away from home
• depressive symptoms such as weight loss, sleep problems, lethargy, feelings of hopelessness, mood swings, suicidal feelings, or suicide attempts
• evidence of the presence of risk-taking behaviors such as either driving while under the influence of alcohol or driving with others who are intoxicated, engaging in violent behaviors such as fights, or participating in unsafe sex

When to Call the Doctor

It is worth noting that these behavioral warning flags can appear in non-alcoholic children or teens and also are usually not observed before the second or third stage of childhood alcoholism. Parents observing some or all of these warning signs need professional help to both clarify diagnosis and plan treatment. Individual and family denial is considered a large portion of any alcohol problem. Parents need objectivity and open and honest communication with their children in order to deal effectively with childhood alcoholism and to know when to seek help.

Diagnosis

As noted, behavioral symptoms help to determine the diagnosis, but not usually until the second and third stage of the disease. There are assessments available that can provide both earlier identification and intervention for childhood alcoholism.

Diagnostic assessments for alcoholism, according to the APA, include:

• CAGE, a mnemonic that points to four key questions by highlighting key words: "Cut down," "Annoyed," "Guilty," and "Early" (see below)
• Alcohol Use Disorders Inventory Test (AUDIT)
• Personal Experience Screening Questionnaire (PESQ)
• Problem Oriented Screening Instrument for Teenagers (POSIT)

CAGE is an assessment guide containing the following four questions:

• C: Have you ever felt the need to cut down on your drinking?
• A: Do you get annoyed at criticism by others about your drinking?
• G: Have you ever felt guilty about your drinking or something you have done while drinking?
• E: Have you ever felt the need for a drink early in the morning?

Treatment

Once assessment has led to a diagnosed problem with alcohol, its severity determines the treatment needed. In "Early Identification and Intervention for Adolescent Alcohol Use," Werner and Adjer divide problem teen drinkers into three groups:

• The first category includes those teens who are using alcohol occasionally but still doing well emotionally and developmentally and who are not drinking and driving. The treatment objectives for this group are to encourage abstinence and re-enforce safety by fostering the continuation of not driving while drinking and not driving with others who are drinking.
• The second category includes those teens who are more at-risk because while they are maintaining stability in physical, developmental, and emotional status, they are also drinking and driving. Professionals dealing with members of this group may not be able to maintain confidentiality, and people in this group may benefit from an introduction to organizations such as Students Against Drunk Driving (SADD).
• The third category includes those showing serious signs of impairment, including inability to follow through on obligations at school or on a job, alcohol-related encounters with police or the justice system, and mental health problems such as anxiety, depression, or oppositional-defiant behavior. These children may experience frequent acute intoxication or withdrawal symptoms, medical complications, or an inability to stop or reduce their alcohol intake. Werner and Adjer suggest that professionals dealing with members of this group probably need to set aside confidentiality in order to involve parents in the treatment process. Treatment may include detoxification in an in-patient facility and/or rehabilitation in a youth-centered substance abuse program.

Treatment Options

The following key issues should be considered in determining which treatment option is appropriate:

• severity of the problem and evidence to suggest other mental health problems (e.g. depression, suicide attempts)
• staff credentials of those treating the child or teen, and what forms of therapy (e.g., family, group, medications) are to be used
• nature of family involvement
• how education is to be continued during treatment
• if an in-patient program is necessary, what length it should be
• what aftercare is to be provided following discharge
• what portion of treatment is to be covered by health insurance and what needs to be paid out of pocket

Alcoholics Anonymous

Since its inception in the 1930s, Alcoholics Anonymous (AA) has been an important non-medical means of treating alcoholism with millions of members worldwide, many of whom are teenagers. It is a spiritual but non-religious program that fosters abstinence from alcohol based upon a belief that the person suffering from alcoholism is "powerless" over their addiction. AA suggests that people can stay free of alcohol by using an attitude that focuses on "one day at a time" and that consciously seeks spiritual support from "a power greater than themselves." AA is generally a part of most in-patient treatment and rehabilitation programs.

Prognosis

Prevention provides the best possible prognosis for alcohol abuse and dependence. The National Council on Alcoholism and Drug Dependence estimates that parents who talk with their children regularly about the danger from drugs (including alcohol) have children who are 42 percent less likely to use these substances. Once alcoholism is present, abstinence is the only known completely successful treatment. Children suffering from alcohol dependence continue for the rest of their lives to be at risk for problems with alcohol if they again drink. The prognosis is excellent for young alcoholics who remain alcohol-free and who do not substitute other drugs for alcohol, sometimes called "chewing their booze" in AA.

Prevention

Alcohol use and abuse has been a feature of Western culture for centuries, a facet of American life since Europeans arrived in North America, literally arriving with the pilgrims on the Mayflower. It is typically part of U.S. celebrations and even some American-observed religious rites. Because alcohol overuse and abuse has been so much a part of Western experience, there is clearly a tremendous need–among children and adults—for better education about both alcohol consumption and alcoholism. The statistics indicate that parents, teachers, and healthcare professionals need to begin educating children as early as possible regarding the risks involved in alcohol use. Parents who provide the example of limiting their own alcohol and other drug use can help their children inestimably. It should never be inferred that difficult situations can be better coped with by having a drink or that getting drunk is either helpful or amusing. Moreover, parents and other adults need to set the example by not driving a car or operating machinery while they are drinking or under the influence of alcohol.

The APA suggests the following as the most effective ways that parents can aid their children in resisting drinking:

• Provide children with self-confidence by building self-esteem and not engaging in constant criticism. Good self-esteem is the best defense against peer pressure to drink.
• Listen to children. Parents who listen attentively and provide support during difficult times give their children invaluable aid in coping with pressures.
• Get to know the children's friends.
• Provide supervision and discourage teens from attending parties where alcohol is served or parents are absent, and band together with other parents to arrange alcohol-free social events for children.
• Be available and encourage children and teens to call home for a ride rather than drive with someone who has been drinking; assure children there will be no recrimination, as SADD recommends.
• Teach therapeutic coping mechanisms by modeling how to handle stress, pain, or tension in healthy ways, by exercising, using yoga and meditation, and talking about feelings.
• Understand the tremendous importance of child and adolescent issues, including alcohol and other drug use and acceptance by peers; be ready and able to discuss these subjects with children.
• Encourage and participate in enjoyable, worthwhile activities with children; be reassuring that there is time enough for both work and fun.
• Be willing to learn about alcohol abuse; attend, along with their children, programs offered by schools, churches, and other groups providing information about the prevention of alcohol abuse.
• Maintain healthy lines of communication with children; remember the saying, "You are only as sick as the secrets you keep."

Nutritional Concerns

Most childhood alcoholics do not reach the serious state of malnutrition that chronic adult alcoholics can reach. However, severe cases of alcohol abuse and dependence may result in a child or teen not eating normally, resulting in weight loss and vitamin deficiencies (B-vitamins particularly). Resumption of normal eating habits and possible addition of vitamin supplements can help in regaining normal nutrition.

Parental Concerns

Parents of alcoholic children often encounter persistent and highly traumatic worries regarding serious physical, emotional, social, and legal problems for the affected child as well as the terrifying possibility of that child's death or serious injury. Clearly, these concerns can take a huge toll in a family. The denial mentioned earlier is often a complicating factor. The notion of "Not my son or daughter!" can actually hinder treatment and recovery for a child. Parents are also often embarrassed by their child's alcohol abuse and may believe that it is somehow their fault. It is not uncommon for parents to feel isolated and to feel as if they are the only ones with this problem. High school programs such as the earlier-described SADD can address some of the fear regarding drunk driving. Parental support groups such as Tough Love programs and twelve-step groups such as Al Anon can help parents to better understand the problem they facing and can help make them aware that they not alone and that they have options.

Al Anon is a twelve-step program (that is, a program based on the twelve steps employed by Alcoholics Anonymous) that provides support and spiritual recovery for the families and loved ones of alcoholics. This program was begun in the early 1940s by the wives of some of AA's earliest members and founders, including Lois Wilson, wife of AA founder Bill Wilson. Twelve-step programs have spun off over the years to meet the needs of specific populations, including adult children of alcoholics and teens who are alcoholics.

Because parents of alcoholic children often believe they are responsible for their child's drinking, the Three C's that Al Anon offers its participants may be particularly helpful. These Three C's state:

• "I didn't cause anyone else's alcoholism."
• "I can't control anyone else's alcoholism."
• "I can't cure anyone else's alcoholism."

Tough Love, a program begun by Phyllis and David York, co-authors of a book by the same title, is designed to help families and especially parents cope with a variety of problems, including alcoholism and drug abuse, that often affect children and ultimately the whole family. Tough Love's approach is different from that of Al Anon. The ten beliefs listed below form the basis for this program and show clearly the difference in philosophy:

• Parents are people too.
• Parents' material and emotional resources are limited.
• Parents and kids are not equal.
• Blaming keeps people helpless.
• Kids' behavior affects parents. Parents' behavior affects kids.
• Taking a stand precipitates a crisis.
• From a controlled crisis comes the possibility of positive change.
• Families need to give and get support in their own community in order to change.
• The essence of family life is cooperation, not togetherness.

Al Anon and Tough Love are offered in a variety of formats to the families of alcoholic children through treatment centers, churches, and other community services. It is clear that there are dramatic differences between these two philosophies. But perhaps the best way for parents to decide which approach makes sense to them is to take the advice Al Anon offers all newcomers: "Take what you like and leave the rest."

Resources

Books

Egendorf, Laura K. Teen Alcoholism. Farmington Hills, MI: Gale, 2001.

Greenleaf, Victoria C. G. Fighting the Good Fight: One Family's Struggle against Adolescent Alcoholism. Fort Bragg, CA: Cypress House, 2002.

Shannon, Joyce Brennflech. Alcohol Information for Teens: Health Tips about Alcohol and Alcoholics. Detroit, MI: Omnigraphics, 2004.

Organizations

Alcoholics Anonymous. (See white pages of local telephone book for area groups.) Web site: www.alcoholicsanonymous.org.

National Council on Alcoholism and Drug Dependence. 20 Exchange Place, Suite 2902, New York, NY 10005. Web site: www.ncadd.org.

National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute of Health, Willco Building, 6000 Executive Blvd., Bethesda, MD 20892–7003. Web site: www.niaaa.nih.gov.

Students Against Drunk Driving (SADD). Marlborough, MA. 01752. Web site: www.saddonline.com.

Web Sites

Al-Anon and Alateen. Available online at www.al-anon.alateen.org (accessed October 16, 2004).

Alcoholics Anonymous. Available online at www.alcoholicsanonymous.org (accessed October 16, 2004).

"Alcohol Use and Abuse: A Pediatric Concern." American Academy of Pediatrics, Committee on Substance Abuse. Available online at (accessed October 16, 2004).

Werner, Mark J., and Hoover Adjer. "Early Identification and Intervention for Adolescent Alcohol Use." American Academy of Pediatrics. Available online at www.aap.org/advocacy/chm98ado.htm (accessed October 16, 2004).

"Youth, Alcohol, and Other Drugs: An Overview." National Council on Alcoholism and Drug Dependence. Available online at www.ncadd.org/facts/youthalc.html (accessed October 16, 2004).

[Article by: Joan Schonbeck, R.N.]

For more information on alcoholism, visit Britannica.com.

The term "alcoholism" is a noun and concept suggesting both a destructively and chronically excessive beverage alcohol consumption and a medical-style conception of the source, character, explanation, and social and medical handling of the purported condition. The word's introduction is often attributed to Swedish physician Magnus Huss in 1849. The same two broad ideas have been conveyed in a changing parade of terminology since 1800—including, for example, "dipsomania," "inebriety," "habitual drunkenness," "alcohol addiction," "problem drinker," and others. Ordinary language has many words for the excessive drinker, too—including "drunkard," "boozehound," "sot," "lush," "wino," etc.—although these do not necessarily connote medico-scientific causation. Slang words or phrases for drunkenness are most numerous of all—for example, "blitzed," "bombed," "blasted," "three sheets to the wind," "wiped out," and a great many more—one scholar counted hundreds. Beginning in the late 1970s, "alcohol dependence," or the "alcohol dependence syndrome," became the preferred medico-psychiatric terms for the condition. However, the word "alcoholism" has persisted in popular thought and common usage.

An American preoccupation with alcohol-related excess dates back to the beginnings of the republic and beyond. Dr. Benjamin Rush—a physician, signer of the Declaration of Independence, and often regarded as father to both American psychiatry and the American temperance movement—authored a treatise in 1784 titled An Inquiry into the Effects of Ardent Spirits, in which the disease character of chronic drunkenness was asserted. Establishment of an inebriate's asylum was proposed as early as 1830 in Connecticut, and such an institution given form in a widely read paper by Dr. Samuel Woodward in 1838. The Washingtonian Movement, a lay self-and mutual-help movement, gained wide fame in the 1840s and occasioned the rise of special homes for inebriates. This short-lived movement in turn gave way to the development of larger asylums in the 1850s and 1860s—the first such state-run institution opened in Binghamton, New York in 1864. Dr. Leslie Keeley opened the first of his private treatment sanatoriums in 1880, and by 1901 was reported to have thirty-nine facilities nationwide. National Prohibition (1919–1933) did little, however, to advance alcoholism treatment in the nation.

A "modern alcoholism movement," ostensibly aimed at rescuing the alcoholic from the ignorance and maltreatment of the past, had its beginnings very soon after the repeal of Prohibition on 5 December 1933. The Fellowship of Alcoholics Anonymous (AA) often dates its origins to a chance meeting between its two founders, "Bill W." (William G. Wilson) and "Dr. Bob" (Robert H. Smith) in May 1935. Soon afterward, the American scientific community began a push to unravel the mystery of alcoholism and other alcohol-related problems. Although the two post-Prohibition enterprises—AA and modern science—were remarkably different from each other in character and approach, a loose coalition of the two was fashioned in the mid-1940s by Marty Mann and E. M. Jellinek.

Marty Mann was the daughter of a well-to-do socialite family that fell on hard times in the Great Depression, and was herself brought low by heavy drinking in the mid-1930s. Mann was hired by E. M. Jellinek of the Yale Center on Alcohol Studies, the chief center for new alcohol science at the time, to persuade the American public that alcoholism was a disease, that the alcoholic required and deserved treatment, and that such care was a public responsibility. Mann's organization—originally named the National Committee for Education on Alcoholism (NCEA); later (and in its heyday), the National Council on Alcoholism (NCA); and eventually, the National Council on Alcoholism and Drug Dependence (NCADD)—was launched in October 1944. Behind the scenes, Jellinek and the leadership of Yale's alcohol science enterprise were hoping that Mann's new campaign would provide grassroots support for the expansion of alcoholism treatment and the promotion of scientific research—in much the same way that the American Cancer Society had served that function for cancer researchers. Jellinek doubtless looked forward to the expansion of AA as an ever growing source of members interested in scientific inquiry into alcoholism.

Perhaps the crowning achievement of the modern alcoholism movement was the creation of the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA), signed into law by President Richard M. Nixon on New Year's Eve, 1970. Along with the success of the modern alcoholism movement, however, came more than a few challenges and changes. New research, sponsored by NIAAA, undermined some of the tenets of the movement's traditional beliefs about alcoholism—seeming to show, for example, that some alcoholics could safely return to controlled drinking. The availability of new and significantly increased government funding for alcoholism research and treatment tended both to professionalize the field and to bring in competing conceptual models and institutions. Moreover, popular attention began to shift its focus to other alcohol-related problems: a new emphasis on fetal alcohol syndrome in the mid-1970s; the rise around 1980 of the Mothers Against Drunk Driving (MADD) campaigns; and a growing concern with college and underage drinking in the 1990s. These issues tended to dilute societal attention paid to the alcoholic, though a thriving alcoholism research enterprise continued apace at NIAAA.

Alcoholism, once the province of a determined post-Prohibition and post-World War II (1939–1945) movement, has become parent to a wider preoccupation with addictions. Through it all, however, AA has continued to sustain its central place in the alcoholism topic arena—despite the growth of a diffuse and vocal chorus of critics and providers of would-be alternatives. Illicit drugs—and the so-called "War on Drugs"—and tobacco have eclipsed alcohol in popular attention, and also to an extent reshaped and recontextualized alcohol as "a drug," or one among several "substance abuse" or "chemical dependency" problems.

Bibliography

Baumohl, Jim, and Robin Room. "Inebriety, Doctors, and the State: Alcoholism Treatment Institutions Before 1940." In Recent Developments in Alcoholism. Edited by Marc Galanter. Vol. 5. New York: Plenum Publishing, 1987. Essential reading on pre-1940 alcoholism treatment and conceptualization.

Blocker, Jack S., Jr. American Temperance Movements: Cycles of Re-form. Boston: Twayne Publishers, 1989. This author sees the alcoholism movement period as the most recent chapter in an ongoing historical story of temperance cycles.

Brown, Sally, and David R. Brown. A Biography of Mrs. Marty Mann: The First Lady of Alcoholics Anonymous. Center City, Minn.: Hazelden Information and Educational Services, 2001. A praiseful account but nevertheless rich in biographical information.

Katcher, Brian S. "Benjamin Rush's educational campaign against hard drinking." American Journal of Public Health 83, no. 2 (1993): 273–281.

Kurtz, Ernest. Not-God: A History of Alcoholics Anonymous. Center City, Minn.: Hazelden Information & Educational Services, 1979. The classic history of AA's origins and earlier years.

Levine, Harry Gene. "The vocabulary of drunkenness." Journal of Studies on Alcohol. 42, no. 3 (1981): 1038–1051. More words for drunkenness than you ever imagined.

White, William L. Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, Ill.: Chestnut Health Systems/Lighthouse Institute, 1998. A valuable historical compendium.

Wiener, Carolyn L. The Politics of Alcoholism: Building an Arena Around a Social Problem. New Brunswick, N.J.: Transaction Books, 1981. How the U.S. National Institute on Alcohol Abuse and Alcoholism affected this country's alcohol problems social arena.

—Ron Roizen

Swedish researcher Magnus Huss first used the term "alcoholism" in 1849 to describe a variety of physical symptoms associated with drunkenness. By the 1860s, Russian medical experts built on Huss's theories, relying on models of alcoholism developed in French and German universities to conduct laboratory studies on the effects of alcohol on the body and mind. They adopted the term "alcoholism" (alkogolizm) as opposed to "drunkenness" (pyanstvo) to connote the phenomenon of disease, and determined that it mainly afflicted the lower classes.

In 1896, at the urging of the Swiss-born physician and temperance advocate E. F. Erisman, the Twelfth International Congress of Physicians in Moscow established a special division on alcoholism as a medical problem. Within a year the Kazan Temperance Society established the first hospital for alcoholics in Kazan. In 1897, physician and temperance advocate A. M. Korovin founded a private hospital for alcoholics in Moscow, and in 1898 the Trusteeships of Popular Temperance opened an outpatient clinic.

That same year, growing public concern over alcoholism led to the creation of the Special Commission on Alcoholism and the Means for Combating It. Headed by psychiatrist N. M. Nizhegorodtsev, the ninety-five members of the commission included physicians, psychiatrists, temperance advocates, academics, civil servants, a few clergy, and two government representatives. Classifying alcoholism as a mental illness, members of the commission blamed widespread alcoholism on the tsarist government, which relied heavily on liquor revenues and refused to improve the socioeconomic conditions of the lower classes.

Although they accepted the definition of alcoholism as a disease, professionals could not agree on exactly what it was, what caused it, or how to cure it. These were topics of heated debate, and they could not be seriously discussed without critical analysis of the government's social and economic policies. Hence, the range of opinions expressed in professional discourse over alcoholism reflected the fragmentation of middle-class ideologies near the end of the imperial period: the abstract civic values of liberalism and modernization as borrowed from the West; a powerful and persistent model of custodial statehood; and a pervasive culture of collectivism.

With the Bolshevik Revolution of 1917, definitions of alcoholism changed. Seeking Marxist interpretations for most social ills, Soviet health practitioners defined alcoholism as a petit bourgeois phenomenon, a holdover from the tsarist past. Working from the premise that illness could only be understood in its social context, they determined that alcoholism was a social disease influenced by factors such as illiteracy, poverty, and poor living conditions. In 1926 the director of the State Institute for Social Hygiene, A. V. Molkov, opened a department, headed by E. I. Deichman, for the sole purpose of studying alcoholism as a social disease. Within four years, however, the department was closed and the institute disbanded. By placing blame for alcoholism on social causes, Molkov, Deichman, and others were, in effect, criticizing the state's social policies - a dangerous position in the Stalinist 1930s.

In 1933 Josef Stalin announced that success was being achieved in the construction of socialism in the USSR; therefore, it was no longer plagued by petit bourgeois problems such as alcoholism. For the next fifty-two years, alcoholism did not officially exist in the Soviet Union. Consequently, all public discussion of alcoholism ended until 1985, when Mikhail S. Gorbachev launched a nationwide but ill-fated temperance campaign.

Bibliography

Herlihy, Patricia. (2002). The Alcoholic Empire: Vodka and Politics in Late Imperial Russia. Oxford: Oxford University Press.

Segal, Boris. (1987). Russian Drinking: Use and Abuse of Alcohol in Prerevolutionary Russia. New Brunswick, NJ: Publications Division, Rutgers Center of Alcohol Studies.

Segal, Boris. (1990). The Drunken Society: Alcohol Abuse and Alcoholism in the Soviet Union, a Comparative Study. New York: Hippocrene Books.

White, Stephan. (1996). Russia Goes Dry: Alcohol, State, and Society. Cambridge, UK: Cambridge University Press.

—KATE TRANSCHEL

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 [1929]). The economic approach to affects was emphasized next—concepts of alexithymia (McDougall, 1978), instinctual discharge by the body ("resomatization of affects"), and acting out ("dispersion," "destruction of affects," "acts-symptoms"), depending on the author—all 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"—as opposed to involvement of the superego (1966b [1932]). 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, perversion—fetishism, for example—paranoia, 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).

Bibliography

Bromberg, William, and Schilder, Paul. (1933). Alcoholic hallucinations—castration 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.

Further Reading

Director, L. (2002). Relational psychoanalysis in the treatment of chronic drug & alcohol abuse. Psychoanalytic Dialogues, 12, 551-580.

—JEAN-PAUL DESCOMBEY

A chronic disease associated with the excessive and habitual use of alcohol; the disease, if left unattended, worsens and can kill the sufferer. Alcoholism is marked by physical dependency and can cause disorders in many organs of the body, including the liver (see cirrhosis), stomach, intestines, and brain. It is also associated with abnormal heart rhythms, with certain cancers, and, because of loss of appetite, with poor nutrition. The cause of alcoholism is very complicated and most often involves a mixture of physical, psychological, and possibly genetic factors.

• Recovered Glenn - New, Whole, and Happier! Finding alcohol and addiction help and support.
• The Recovery Blog This blog helps all people overcome alcoholism.

Alcohol and Health
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Alcoholic liver disease
Alcoholic hepatitis
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Alcoholism
Classification and external resources
MeSH	D000437

Alcoholism is a term with multiple and sometimes conflicting definitions to refer to the consumption of alcoholic beverages. In common and historic usage, alcoholism refers to any condition that results in the continued consumption of alcoholic beverages, despite health problems and negative social consequences. Modern medical definitions^[1] describe alcoholism as a disease and addiction which results in a persistent use of alcohol despite negative consequences. In the 19th and early 20th centuries, alcoholism, also referred to as dipsomania^[2] described a preoccupation with, or compulsion toward the consumption of, alcohol and/or an impaired ability to recognize the negative effects of excessive alcohol consumption.

Although not all of these definitions specify current and on-going use of alcohol as a qualifier for alcoholism, some do, as well as remarking on the long-term effects of consistent, heavy alcohol use, including dependence and symptoms of withdrawal.

While the ingestion of alcohol is, by definition, necessary to develop alcoholism, the use of alcohol does not predict the development of alcoholism. It is estimated that 9% of the general population is predisposed to alcoholism based on genetic factors.^{[citation needed]} The quantity, frequency and regularity of alcohol consumption required to develop alcoholism varies greatly from person to person. In addition, although the biological mechanisms underpinning alcoholism are uncertain, some risk factors, including social environment, stress,^[3] emotional health, genetic predisposition, age, and gender have been identified. For example, those who consume alcohol at an early age, by age 16 or younger, are at a higher risk of alcohol dependence or abuse. Also, studies indicate that the proportion of men with alcohol dependence are higher than that of the proportion of women, 7% and 2.5% respectively, although women are more vulnerable to long-term consequences of alcoholism. Around 90% of adults in United States consume alcohol and more than 700,000 of them are treated daily for alcoholism.^[4] Professor David Zaridze, who led the international research team, calculated that alcohol had killed three million Russians since 1987.^[5]

"King Alcohol and his Prime Minister" circa 1820

Contents 1 Definitions and terminology 1.1 Medical definitions 1.2 Terminology 2 Etymology 3 Epidemiology 4 Identification and diagnosis 4.1 Screening 4.2 Genetic predisposition testing 4.3 DSM diagnosis 4.4 Urine and blood tests 5 Effects of long term alcohol misuse 5.1 Physical health effects 5.2 Mental health effects 5.3 Social effects 6 Alcohol withdrawal 7 Treatments 7.1 Effectiveness 7.2 Detoxification 7.3 Group therapy and psychotherapy 7.4 Rationing and moderation 7.5 Medications 7.6 Dual addictions 8 Women and alcoholism 8.1 Biological differences and physiological effects 8.2 Psychological and emotional effects 8.3 Societal barriers to treatment 8.4 Implications for treatment 9 Societal impact 9.1 Stereotypes 10 Alcohol related crime 11 In film and literature 12 Politics and public health 13 See also 14 References 15 Further reading

Definitions and terminology

The definitions of alcoholism and related terminology vary significantly between the medical community, treatment programs, and the general public.

Medical definitions

The Journal of the American Medical Association defines alcoholism as "a primary, chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking."^[6]

The DSM-IV (the standard for diagnosis in psychiatry and psychology) defines alcohol abuse as repeated use despite recurrent adverse consequences.^[7] It further defines alcohol dependence as alcohol abuse combined with tolerance, withdrawal, and an uncontrollable drive to drink.^[7] (See DSM diagnosis below.)

According to the APA Dictionary of Psychology, alcoholism is the popular term for alcohol dependence.^[7] Note that there is debate whether dependence in this use is physical (characterised by withdrawal), psychological (based on reinforcement), or both.

Terminology

Many terms are applied to a drinker's relationship with alcohol. Use, misuse, heavy use, abuse, addiction, and dependence are all common labels used to describe drinking habits, but the actual meaning of these words can vary greatly depending upon the context in which they are used. Even within the medical field, the definition can vary between areas of specialization. The term "dipsomania" is used in medical and psychiatric circles to identify a condition which is characterized by the uncontrollable craving for alcohol or other intoxicants, which manifests for unknown reasons, and can be confused with alcoholism.

Use refers to simple use of a substance. An individual who drinks any alcoholic beverage is using alcohol. Misuse, problem use, abuse,^[8] and heavy use do not have standard definitions, but suggest consumption of alcohol to the point where it causes physical, social, or moral harm to the drinker. The definitions of social and moral harm are highly subjective and therefore differ from individual to individual.

Within politics, abuse is often used to refer to the illegal use of any substance. Within the broad field of medicine, abuse sometimes refers to use of prescription medications in excess of the prescribed dosage, sometimes refers to use of a prescription drug without a prescription, and sometimes refers to use that results in long-term health problems. Within religion, abuse can refer to any use of a poorly regarded substance. The term is often avoided because it can cause confusion with audiences that do not necessarily share a single definition.

Remission is often used to refer to a state where an alcoholic is no longer showing symptoms of alcoholism. The American Psychiatric Association considers remission to be a condition where the physical and mental symptoms of alcoholism are no longer evident, regardless of whether or not the person is still drinking. They further subdivide those in remission into early or sustained, and partial or full.

Etymology

1904 advertisement describing alcoholism a disease.

The term "alcoholism" was first used in 1849 by the physician Magnus Huss to describe the systematic adverse effects of alcohol.^[9]

In the United States, use of the word "alcoholism" was largely popularized by the founding and growth of Alcoholics Anonymous in 1935^{[citation needed]}. AA's basic text, known as the "Big Book," describes alcoholism as an illness that involves a physical allergy^{[10]:p.xxviii} and a mental obsession.^{[10]:p.23[11]} Note that the definition of "allergy" used in this context is not the same as used in modern medicine.^[12]

A 1960 study by E. Morton Jellinek is considered the foundation of the modern disease theory of alcoholism.^[13] Jellinek's definition restricted the use of the word "alcoholism" to those showing a particular natural history. The modern medical definition of alcoholism has been revised numerous times since then. The American Medical Association currently uses the word alcoholism to refer to a particular chronic primary disease.^[14]

A minority opinion within the field, notably advocated by Herbert Fingarette and Stanton Peele, argue against the existence of alcoholism as a disease. Critics of the disease model tend to use the term "heavy drinking" when discussing the negative effects of alcohol consumption.

Epidemiology

Total recorded yearly alcohol per capita consumption (15+), in litres of pure alcohol^[15]

Substance use disorders are a major public health problem facing many countries. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol."^[16] In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001.^[17] The World Health Organization estimates that about 140 million people throughout the world suffer from alcohol dependence.^[18][19]

Within the medical and scientific communities, there is broad consensus regarding alcoholism as a disease state. For example, the American Medical Association considers alcohol a drug and states that "drug addiction is a chronic, relapsing brain disease characterized by compulsive drug seeking and use despite often devastating consequences. It results from a complex interplay of biological vulnerability, environmental exposure, and developmental factors (e.g., stage of brain maturity)."^[14]

Current evidence indicates that in both men and women, alcoholism is 50-60% genetically determined, leaving 40-50% for environmental influences.^[20]

A 2002 study by the National Institute on Alcohol Abuse and Alcoholism surveyed a group of 4,422 adult alcoholics and found that after one year some were no longer alcoholics, even though only 25.5% of the group received any treatment,^[21] with the breakdown as follows:

• 25% still dependent
• 27.3% in partial remission (some symptoms persist)
• 11.8% asymptomatic drinkers (consumption increases chances of relapse)
• 35.9% fully recovered — made up of 17.7% low-risk drinkers plus 18.2% abstainers.

In contrast, however, the results of a long term (60 year) follow-up of two groups of alcoholic men by George Vaillant at Harvard Medical School indicated that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence."^[22] Vaillant also noted that "return-to-controlled drinking, as reported in short-term studies, is often a mirage."

Identification and diagnosis

Multiple tools are available to those wishing to conduct screening for alcoholism. Identification of alcoholism may be difficult because there is no detectable physiologic difference between a person who drinks frequently and a person with the condition. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker's life compared with the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic's life has been significantly and obviously damaged, there are always borderline cases that can be difficult to classify. Unless they have M.C. type symptoms, and in these cases are probably alcoholics, no diagnosis needed.

Addiction Medicine specialists have extensive training with respect to diagnosing and treating patients with alcoholism.

Screening

Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.

• The CAGE questionnaire, named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further. The questionnaire asks the following questions:

1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?^[23][24]

The CAGE questionnaire, among others, has been extensively validated for use in identifying alcoholism. It is not valid for diagnosis of other substance use disorders, although somewhat modified versions of the CAGE are frequently implemented for such a purpose.

• The Alcohol Dependence Data Questionnaire is a more sensitive diagnostic test than the CAGE test.^[25] It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.

• The Michigan Alcohol Screening Test (MAST) is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses,^[26] driving under the influence being the most common.

• The Alcohol Use Disorders Identification Test (AUDIT) is a screening questionnaire developed by the World Health Organization. This test is unique in that it has been validated in six countries and is used internationally.^[27] Like the CAGE questionnaire, it uses a simple set of questions - a high score earning a deeper investigation.

• The Paddington Alcohol Test (PAT) was designed to screen for alcohol related problems amongst those attending Accident and Emergency departments. It concords well with the AUDIT questionnaire but is administered in a fifth of the time.^[28]

Genetic predisposition testing

Psychiatric geneticists John I. Nurnberger, Jr., and Laura Jean Bierut suggest that alcoholism does not have a single cause—including genetic—but that genes do play an important role "by affecting processes in the body and brain that interact with one another and with an individual's life experiences to produce protection or susceptibility." They also report that fewer than a dozen alcoholism-related genes have been identified, but that more likely await discovery.^[29]

At least one genetic test exists for an allele that is correlated to alcoholism and opiate addiction.^[30] Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol.^[31] Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism, and some researchers argue that evidence for DRD2 is contradictory.^[29]

DSM diagnosis

The DSM-IV diagnosis of alcohol dependence represents one approach to the definition of alcoholism. In part this is to assist in the development of research protocols in which findings can be compared with one another. According to the DSM-IV, an alcohol dependence diagnosis is:

...maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: tolerance; withdrawal; taken in greater amounts or over longer time course than intended; desire or unsuccessful attempts to cut down or control use; great deal of time spent obtaining, using, or recovering from use; social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequelae.

Urine and blood tests

There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC). These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:

• Macrocytosis (enlarged MCV)¹
• Elevated GGT²
• Moderate elevation of AST and ALT and an AST: ALT ratio of 2:1.
• High carbohydrate deficient transferrin (CDT)

However, none of these blood tests for biological markers are as sensitive as screening questionaires.

Effects of long term alcohol misuse

Main article: Long-term effects of alcohol

The primary effect of alcoholism is to encourage the sufferer to drink at times and in amounts that are damaging to physical health. The secondary damage caused by an inability to control one's drinking manifests in many ways. Alcoholism also has significant social costs to both the alcoholic and their family and friends. Alcoholics have a very high suicide rate and studies show between 8% and 21% of alcoholics commit suicide. Alcoholism also has a significant adverse impact on mental health. The risk of suicide among alcoholics has been determined to be 5,080 times that of the general public.^[32]

Physical health effects

It is common for a person suffering from alcoholism to drink well after physical health effects start to manifest. The physical health effects associated with alcohol consumption may include cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, increased chance of cancer, nutritional deficiencies, sexual dysfunction, and death from many sources. Severe cognitive problems are not uncommon in alcoholics. Approximately 10% of all dementia cases are alcohol related making alcohol the 2nd leading cause of dementia.^[33]

Mental health effects

Long term misuse of alcohol can cause a wide range of mental health effects. Alcohol misuse is not only toxic to the body but also to brain function and thus psychological well being can be adversely affected by the long-term effects of alcohol misuse. Psychiatric disorders are common in alcoholics, especially anxiety and depression disorders, with as many as 25% of alcoholics presenting with severe psychiatric disturbances. Typically these psychiatric symptoms caused by alcohol misuse initially worsen during alcohol withdrawal but with abstinence these psychiatric symptoms typically gradually improve or disappear altogether.^[34] Psychosis, confusion and organic brain syndrome may be induced by chronic alcohol abuse which can lead to a misdiagnosis of major mental health disorders such as schizophrenia.^[35] Panic disorder can develop as a direct result of long term alcohol misuse. Panic disorder can also worsen or occur as part of the alcohol withdrawal syndrome.^[36] Chronic alcohol misuse can cause panic disorder to develop or worsen an underlying panic disorder via distortion of the neurochemical system in the brain.^[37]

The co-occurrence of major depressive disorder and alcoholism is well documented.^[38][39][40] Among those with comorbid occurrences, a distinction is commonly made between depressive episodes that are secondary to the pharmacological or toxic effects of heavy alcohol use and remit with abstinence, and depressive episodes that are primary and do not remit with abstinence. Additional use of other drugs may increase the risk of depression in alcoholics.^[41] Depressive episodes with an onset prior to heavy drinking or those that continue in the absence of heavy drinking are typically referred to as "independent" episodes, whereas those that appear to be etiologically related to heavy drinking are termed "substance-induced".^[42][43][44]

Social effects

The social problems arising from alcoholism can be massive and are caused in part due to the serious pathological changes induced in the brain from prolonged alcohol misuse and partly because of the intoxicating effects of alcohol.^[33] Being drunk or hung over during work hours can result in loss of employment, which can lead to financial problems including the loss of living quarters. Drinking at inappropriate times, and behavior caused by reduced judgment, can lead to legal consequences, such as criminal charges for drunk driving or public disorder, or civil penalties for tortious behavior. An alcoholic's behavior and mental impairment while drunk can profoundly impact surrounding family and friends, possibly leading to marital conflict and divorce, or contributing to domestic violence. This can contribute to lasting damage to the emotional development of the alcoholic's children, even after they reach adulthood. The alcoholic could suffer from loss of respect from others who may see the problem as self-inflicted and easily avoided.

Alcohol withdrawal

Main article: Alcohol withdrawal syndrome

Alcohol withdrawal differs significantly from most other drugs in that it can be directly fatal. For example it is extremely rare for heroin withdrawal to be fatal. When people die from heroin or cocaine withdrawal they typically have serious underlying health problems which are made worse by the strain of acute withdrawal. An alcoholic, however, who has no serious health issues, has a significant risk of dying from the direct effects of withdrawal if it is not properly managed. Drugs which have a similar mechanism of action to alcohol also have a similar risk of causing death during withdrawal, including barbiturates and benzodiazepines.

Alcohol's primary effect is the increase in stimulation of the GABA_A receptor, promoting central nervous system depression. With repeated heavy consumption of alcohol, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence. Thus when alcohol is stopped, especially abruptly, the person's nervous system suffers from uncontrolled synapse firing. This can result in symptoms that include anxiety, life threatening seizures, delirium tremens and hallucinations, shakes and possible heart failure.

Acute withdrawal symptoms tend to subside after one to three weeks. Less severe symptoms (e.g. insomnia and anxiety) may continue as part of a post withdrawal syndrome gradually improving with abstinence for a year or more. Withdrawal symptoms begin to subside as the body and central nervous system makes adaptations to reverse tolerance and restore GABA function towards normal. Other neurotransmitter systems are involved, especially glutamate and NMDA.

Treatments

Treatments for alcoholism are quite varied because there are multiple perspectives for the condition itself. Those who approach alcoholism as a medical condition or disease recommend differing treatments than, for instance, those who approach the condition as one of social choice.

Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.^[16]

Effectiveness

When considering the effectiveness of treatment options, one must consider the success rate based on those who enter a program, not just those who complete it. Since completion of a program is the qualification for success, success among those who complete a program is generally near 100%. It is also important to consider not just the rate of those reaching treatment goals but the rate of those relapsing. Results should also be compared to the roughly 5% rate at which people will quit on their own.^[45] A year after completing a rehab program, about a third of alcoholics are sober, an additional 40 percent are substantially improved but still drink heavily on occasion, and a quarter have completely relapsed.^[46]

Detoxification

Main article: Alcohol detoxification

Alcohol detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking coupled with the substitution of drugs that have similar effects to prevent alcohol withdrawal.

Detoxification treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment. These rehabilitations (or 'rehabs') may take place in an inpatient or outpatient setting.

Group therapy and psychotherapy

A regional service center for Alcoholics Anonymous.

After detoxification, various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills.

The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety. Many organizations have been formed to provide this service. Alcoholics Anonymous was the first group, and has more members than all other programs combined. Some of the others include LifeRing Secular Recovery, Rational Recovery, SMART Recovery, and Women For Sobriety.

Rationing and moderation

Rationing and moderation programs such as Moderation Management and DrinkWise do not mandate complete abstinence. While most alcoholics are unable to limit their drinking in this way, some return to moderate drinking. A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7% of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. However, this group showed fewer initial symptoms of dependency.^[47] A follow-up study, using the same NESARC subjects that were judged to be in remission in 2001-2002, examined the rates of return to problem drinking in 2004-2005. The major conclusion made by the authors of this NIAAA study was "Abstinence represents the most stable form of remission for most recovering alcoholics".^[48]

Medications

A variety of medications may be prescribed as part of treatment for alcoholism.

• Antabuse (disulfiram) prevents the elimination of acetaldehyde, a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hangover symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast-acting and long-lasting uncomfortable hangover. This discourages an alcoholic from drinking in significant amounts while they take the medicine. A recent 9-year study found that incorporation of supervised disulfiram and a related compound carbamide into a comprehensive treatment program resulted in an abstinence rate of over 50%.^[49]

• Naltrexone is a competitive antagonist for opioid receptors, effectively blocking our ability to use endorphins and opiates. Alcohol releases endorphins, hence when naltrexone is in the body drinkers no longer get any pleasure from consuming alcohol. Naltrexone is used in two very different forms of treatment. The first treatment uses naltrexone to decrease cravings for alcohol and encourage abstinence. The other treatment, called pharmacological extinction, combines naltrexone with normal drinking habits in order to reverse the endorphin conditioning that causes alcohol addiction. This results in a reduced desire to drink that persists after naltrexone use is discontinued, as long as the patient always takes naltrexone before drinking.
  Naltrexone comes in two forms. Oral naltrexone (originally but no longer available as the brand ReVia) is a pill that must be taken one hour before drinking to be effective. Vivitrol is a time-release formulation that is injected in the buttocks once a month.

• Acamprosate (also known as Campral) is thought to stabilize the chemical balance of the brain that would otherwise be disrupted by alcoholism. The Food and Drug Administration (FDA) approved this drug in 2004, saying "While its mechanism of action is not fully understood, Campral is thought to act on the brain pathways related to alcohol abuse... Campral proved superior to placebo in maintaining abstinence for a short period of time..."^[50] The COMBINE study was unable to demonstrate efficacy for Acamprosate.^[51]

• Topiramate (brand name Topamax), a derivative of the naturally occurring sugar monosaccharide D-fructose, has been found effective in helping alcoholics quit or cut back on the amount they drink. In one study heavy drinkers were six times more likely to remain abstinent for a month if they took the medication, even in small doses.^[52][53] In another study, those who received topiramate had fewer heavy drinking days, fewer drinks per day and more days of continuous abstinence than those who received the placebo.^[54] Evidence suggests that topiramate antagonizes excitatory glutamate receptors, inhibits dopamine release, and enhances inhibitory gamma-aminobutyric acid function. A 2008 review of the effectiness of topiramate concluded that the results of published trials are promising, however at this time, data are insufficient to support using topiramate in conjunction with brief weekly compliance counseling as a first-line agent for alcohol dependence. ^[55]

Dual addictions

The AMA definition of alcoholism refers to a disease entity involving the use of alcohol and any cross-tolerant sedative-hypnotic, including barbiturates and benzodiazepines. As discussed above, the DSM-IV definition of alcohol dependence refers to alcohol only, and DSM-IV uses sedative dependence to refer to the disease entity involving non-alcohol sedative agents. Alcoholics may also require treatment for other psychotropic drug addictions. The most common dual addiction in alcohol dependence is a benzodiazepine dependence with studies showing 10 - 20% of alcohol dependent individuals having problems of dependence and/or misuse problems of benzodiazepines. Note that using alcoholism's definition, there is no dual addiction if one uses both alcohol and any solid sedative. Dependence on other sedative hypnotics such as zolpidem and zopiclone as well as opiates also occurs as well as illegal drugs. Benzodiazepine withdrawal can like alcohol be medically severe and include the risk of psychosis and seizures if not managed properly.^[56] Benzodiazepine dependency requires careful reduction in dosage to avoid a serious benzodiazepine withdrawal syndrome and health consequences. Benzodiazepines have the problem of increasing cravings for alcohol in problem alcohol consumers. Benzodiazepines also increase the volume of alcohol consumed by problem drinkers.^[57]

Women and alcoholism

Alcoholism has a higher prevalence among men, though in recent decades, the proportion of female alcoholics has increased.^[58] It is important to articulate the different biological and social ways alcoholism manifests in women in order to understand barriers to treatment and effective recovery strategies.

Biological differences and physiological effects

Biologically, women have symptom profiles from their alcohol use that differ in important ways from men. They experience a telescoping of physiological effects from alcohol use. Equal dosages of alcohol consumed by men and women generally result in women having higher blood alcohol concentrations (BACs).^[59] This can be attributed to many reasons, the main being that women have less body water than men. A given amount of alcohol, therefore becomes more highly concentrated in a woman's body. Besides this fact, women also become more intoxicated, which is due to different hormone release.^[58]

Women develop long-term complications of alcohol dependence more rapidly than do alcoholic men. Additionally, women have a higher mortality rate from alcoholism than men.^[60] Examples of long term complications include brain, heart, and liver damage^[58] and an increased risk for breast cancer. Additionally, heavy drinking over time has been found to have a negative effect on reproductive functioning in women. This results in reproductive dysfunction such as anovulation, decreased ovarian mass, irregular menses, amenorrhea, luteal phase dysfunction, and early menopause.^[60]

Psychological and emotional effects

Psychiatric disorders are generally more prevalent among those with alcohol disorders. This is true for both men and women, however the disorders differ depending on gender. Women who have alcohol-use disorders have co-occurring psychiatric diagnosis such as major depression, anxiety, panic disorder, bulimia, post-traumatic stress disorder (PTSD), or borderline personality disorder. Men with alcohol-use disorders more often have co-occurring diagnosis of narcissistic and antisocial personality disorders, bipolar disorder, schizophrenia, impulse disorders and attention deficit/ hyperactivity disorder.^[59]

Women with alcoholism are also more likely to have a history of physical or sexual assault, abuse and domestic violence than those in the general population.^[59] This trauma can lead to higher instances of PTSD, depression, anxiety, and a greater dependence on alcohol.

Societal barriers to treatment

Attitudes and social stereotypes about women and alcohol can create barriers to the detection and treatment of female alcohol abusers. Such beliefs stigmatize women who drink by characterizing them as "both generally and sexually immoral" or the "fallen women." Fear of stigmatization may lead women to deny that they are suffering from a medical condition, to hide their drinking, and to drink alone. This pattern, in turn, leads family, physicians, and others to be less likely to suspect that a woman they know is an alcoholic.^[60]

In contrast, attitudes and social stereotypes about men and alcohol can lower barriers to the detection and treatment of male alcohol abusers. Such beliefs reward men who drink by characterizing them as "both generally and sexually moral" or the "risen men." Reduced fear of stigma may lead men to admit that they are suffering from a medical condition, to publicly display their drinking, and to drink in groups. This pattern, in turn, leads family, physicians, and others to be more likely to suspect that a man they know is an alcoholic.

Women also tend to have a greater fear that the negative implications from the stigma will reflect poorly on their families. This may also keep them from seeking help.^[59]

Therefore, men also tend to have less fear that the negative implications from the stigma will reflect poorly on their families. This may encourage them to seek help.

Implications for treatment

Research has indicated a lack of adequate training for practitioners both in problematic alcohol use in general, and in relation to women's issues.^[59] The complexity of alcohol use disorders, particularly with gender-related issues, indicates that the need for practitioners' knowledge, insight and compassion is enormous.^[59] Better education and awareness surrounding the gender implications of alcoholism will help care providers to adequately treat women who suffer from alcoholism. Early intervention will also increase the probability of recovery.

Societal impact

The various health problems associated with long-term alcohol consumption are generally perceived as detrimental to society, for example, money due to lost labor-hours, medical costs, and secondary treatment costs. Alcohol use is a major contributing factor for head injuries, motor vehicle accidents, violence, and assaults. Beyond money, there is also the pain and suffering of the individuals besides the alcoholic affected. For instance, alcohol consumption by a pregnant woman can lead to Fetal alcohol syndrome,^[61] an incurable and damaging condition.^[62]

Estimates of the economic costs of alcohol abuse, collected by the World Health Organization, vary from one to six per cent of a country's GDP.^[63] One Australian estimate pegged alcohol's social costs at 24 per cent of all drug abuse costs; a similar Canadian study concluded alcohol's share was 41 per cent.^[64]

A study quantified the cost to the UK of all forms of alcohol misuse as £18.5–20 billion annually (2001 figures).^[17][65]

Stereotypes

Depiction of a wino or town drunk

Stereotypes of alcoholics are often found in fiction and popular culture. The 'town drunk' is a stock character in Western popular culture.

Stereotypes of drunkenness may be based on racism or xenophobia, as in the depiction of the Irish as heavy drinkers.^[66][67] In Australia, Canada, and the United States, Aboriginal people have similarly been stereotyped as alcoholics.

On the other hand, studies by social psychologists Stivers and Greeley^[68] attempt to document the perceived prevalence of high alcohol consumption amongst the Irish in America.

Alcohol related crime

See also: drug-related crime

Of the adult population at least three- fourths are drinkers, so about 6 percentage of the total group. The alcoholism rate runs about 8 percent to 12.Many reports state that about 73 percent of felonies are alcohol-related. A survey shows that in about 67 percent of child-beating cases, 41 percent of forcible rape cases, 80 percent of wife-battering, 72 percent of stabbings, and 83 percent of homicides, either the attacker or the victim or both had been effected by drinking. If we include alcohol abusers the best estimate is 10.5 of the working Americans.^[69]

In film and literature

In modern times, the recovery movement has led to more realistic depictions of problems that stem from heavy alcohol use. Authors such as Charles R. Jackson and Charles Bukowski describe their own alcohol addiction in their writings. The disjoined narrative of Patrick Hamilton's Hangover Square reflects the alcoholism of its central character. A famous depiction of alcoholism, and the psychology of an alcoholic, is in Malcolm Lowry's widely acclaimed novel Under the Volcano, which details the final day of the British consul Geoffrey Firmin on the Day of the Dead in 1939 Mexico and his choice to continue his extreme alcohol consumption instead of returning to the wife he loves.

Films like Bad Santa, Days of Wine and Roses, My Name is Bill W., Withnail and I, Arthur, Leaving Las Vegas, Shattered Spirits and The Lost Weekend, chronicle similar stories of alcoholism.

Politics and public health

Because alcohol use disorders are perceived as impacting society as a whole, governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism. The World Health Organization, the European Union and other regional bodies are working on alcohol action plans and programs.

See also

• Alcohol consumption and health
• Alcoholism in family systems
• Alcohol dementia
• Alcohol-related traffic crashes
• Alcohol tolerance
• Alcohol withdrawal syndrome
• Binge drinking
• List of countries by alcohol consumption
• Drunkenness
• E. Morton Jellinek
• Ethanol Metabolism biochemical discussion of alcohol metabolism
• List of deaths through alcohol
• Substance abuse
• Self-medication
• Wernicke-Korsakoff syndrome
• Willingway Hospital
• Medical diagnostics to test for alcohol use
  • Blood alcohol content
  • Full blood count
  • Liver function tests

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Further reading

• Alasuutari, Pertti (1992). Desire and Craving: A Cultural Theory of Alcoholism. Albany, NY: State University of New York Press. ISBN 0791410978. OCLC 24107485. 

• Beauchamp, Dan E. (1980). Beyond Alcoholism: Alcohol and Public Health Policy. Philadelphia, PA: Temple University Press. ISBN 0877221898. OCLC 6355436. 

• Berry, Ralph E.; Boland James P. The Economic Cost of Alcohol Abuse The Free Press, New York, 1977 ISBN 0-02-903080-3

• Browman, K. E. and J. C. Crabbe (2001, 2002). "Alcoholism: Genetic Aspects". in Neil J. Smelser and Paul B. Baltes. International Encyclopedia of the Social & Behavioral Sciences. Amsterdam, The Netherlands; New York, NY: Elsevier. pp. 371–378. ISBN 0080430767. 

• Clark, Walter B. and Michael E. Hilton (1991). Alcohol in America: Drinking Practices and Problems. Albany, NY: State University of New York Press. ISBN 0791406954. OCLC 22494114. 

• Díaz, Héctor Luis and Thomas D. Watts (2005). Alcohol Abuse and Acculturation among Puerto Ricans in the United States: A Sociological Study. Lewiston, NY: Edwin Mellen Press. ISBN 0773461051. OCLC 60311906. 

• Fingarette, Herbert (1988). Heavy Drinking: The Myth of Alcoholism as a Disease. Berkeley, CA: University of California Press. ISBN 0520062906. OCLC 16870623. 

• Galanter, Marc (2005). Alcohol Problems in Adolescents and Young Adults: Epidemiology, Neurobiology, Prevention, Treatment. New York, NY: Kluwer Academic/Plenum. ISBN 0306486253. OCLC 133155628 56653179 57724687 71290784. 

• Goodwin, Donald W. (2000). Alcoholism, the Facts (3rd ed.). Oxford, UK; New York, NY: Oxford University Press. ISBN 019263061X. OCLC 41834977 42622081 57339357 57621778 70861649. 

• Gusfield, Joseph R. (1996). Contested Meanings: The Construction of Alcohol Problems. Madison, WI: University of Wisconsin Press. ISBN 0299149307. OCLC 33281934. 

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This entry is from Wikipedia, the leading user-contributed encyclopedia. It may not have been reviewed by professional editors (see full disclaimer)

Dansk (Danish)
n. - alkoholisme, alkoholmisbrug

Nederlands (Dutch)
alcoholisme

Français (French)
n. - alcoolisme

Deutsch (German)
n. - Alkoholismus

Ελληνική (Greek)
n. - (παθολ.) αλκοολισμός

Italiano (Italian)
alcolismo

Português (Portuguese)
n. - alcoolismo (m)

Русский (Russian)
алкоголизм

Español (Spanish)
n. - alcoholismo

Svenska (Swedish)
n. - alkoholism

中文（简体）(Chinese (Simplified))
酒精中毒, 酗酒

中文（繁體）(Chinese (Traditional))
n. - 酒精中毒, 酗酒

한국어 (Korean)
n. - 알코올 중독

日本語 (Japanese)
n. - 習慣性の飲酒, アルコール中毒

العربيه (Arabic)
‏(الاسم) ألكحوليه, إدمان ألمسكرات, ألتسمم بالكحول‏

עברית (Hebrew)
n. - ‮התמכרות לשתיית אלכוהול, אלכוהוליזם, כהלת‬

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