Alcohol and Related Disorders
Alcohol and Related Disorders
Alcoholism is defined as alcohol-seeking and - consumption behavior that is harmful. Long-term and uncontrollable harmful consumption can cause alcohol-related disorders that include antisocial personality disorder, mood disorders (bipolar and major depression ) and anxiety disorders.
Alcoholism is the popular term for the disorder recognized by the American Psychiatric Association (APA) as alcohol dependence. The hallmarks of this disorder are addiction to alcohol, inability to stop
drinking, and repeated interpersonal, school, or work-related problems that can be directly attributed to the use of alcohol. Alcoholism can have serious consequences, affecting an individual’s health and personal life, as well as affecting society at large.
Alcohol dependence is a complex disorder that includes the social and interpersonal issues mentioned above, and includes biological elements, as well. These elements are related to tolerance and withdrawal, cognitive (thinking) problems that include craving, and behavioral abnormalities including the impaired ability to stop drinking. Withdrawal is a term that refers to the symptoms that occur when a person dependent on a substance stops taking that substance for a period of time; withdrawal symptoms vary in type and severity depending on the substance, but alcohol withdrawal symptoms can include shaking, irritability, and nausea. Tolerance is a reduced response to the alcohol consumed and can be acute or chronic. Acute tolerance occurs during a single episode of drinking and is greater when blood alcohol concentration rises. Chronic tolerance occurs over the long term when there is greater resistance to the intoxicating effects of alcohol, and, as a result, the affected person has to drink more to achieve the desired effect.
The APA also recognizes another alcohol-use disorder called alcohol abuse. Alcohol abuse is similar to dependence in that the use of alcohol is impairing the affected person’s ability to achieve goals and fulfill responsibilities, and his or her interpersonal relationships are affected by the alcohol abuse. However, unlike a person with dependence, a person diagnosed with alcohol abuse does not experience tolerance or, when not drinking, withdrawal symptoms. People who abuse alcohol can become dependent on the substance over time.
Alcohol-related disorders are groups of disorders that can result in persons who are long-term users of alcohol. These disorders can affect the person’s metabolism, gastrointestinal tract, nervous system, bone marrow (the matter in bones that forms essential blood cells) and can cause endocrine (hormone) problems. Additionally, alcoholism can result in nutritional deficiencies. Some common alcohol-related medical disorders include vitamin deficiencies, alterations in sugar and fat levels in blood, hepatitis, fatty liver, cirrhosis, esophagitis (inflammation of the esophagus), gastritis (inflammation of the lining of the stomach), dementia, abnormal heart rates and rhythms, lowered platelets (cells important for forming a clot), leukopenia (decrease in the number of white blood cells that are important for body defenses and immunity), and testicular atrophy (shrinking of the testicles). Persons with anxiety, depression, or bipolar disorder may consume alcohol for temporary relief from their symptoms. Others, such as persons with antisocial personality disorder, may use alcohol in a way that may become part of a dual diagnosis of criminality and substance dependence.
The lifetime prevalence of alcohol abuse in the general population is thought to be between 13.7% and 23.5%. The disorder is more common in males than in females. Alcoholism and alcohol abuse affect 20% or more of adult hospitalized and ambulatory patients (those receiving care on an outpatient basis). Alcoholism can develop in people of all races and socioeconomic classes. Approximately two-thirds of Americans 18 years and older drink alcohol. The annual cost of alcohol abuse in the United States is $185 billion. Alcoholism ranks third in the United States as a preventable disease, and alcohol is related to approximately 20,000 deaths each year.
The cause of alcoholism is related to behavioral, biological, and genetic factors.
Behaviorally, alcohol consumption is related to internal or external feedback. Internal feedback is the internal state a person experiences during and after alcohol consumption. External feedback is made up of the cues that other people send the person when he or she drinks. Internal states pertaining to alcohol can include shame or hangover. Alcohol-related external cues can include reprimands, criticism, or encouragement. People may drink to the point of dependence because of peer pressure, acceptance in a peer group, or because drinking is related to specific moods (easy-going, relaxed, calm, sociable) that are related to the formation of intimate relationships.
Biologically, repeated use of alcohol can impair the brain levels of a “pleasure” neurotransmitter called dopamine. Neurotransmitters are chemicals in the brain that pass impulses from one nerve cell to the next. When a person is dependent on alcohol, his or her brain areas that produce dopamine become depleted and the individual can no longer enjoy the pleasures of everyday life—his or her brain chemistry is rearranged to depend on alcohol for transient euphoria (state of happiness).
Genetic studies have suggested that the GABA-A receptor alpha2 subunit gene (GABRA2) and alcohol dehydrogenase (ADH) genes increase the risk for alcohol dependence. The GABRA genes are related to a receptor for gamma-amino butyric acid (GABA), a chemical in the central nervous system that is believed to mediate some of the physiological effects of alcohol. ADH is a chemical involved in the oxidation of alcohol in the body. These genes related to alcohol abuse can be passed from parents to their children.
Other genetic studies have demonstrated that close 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 a nonalcoholic adoptive family, with no knowledge of their biological family’s difficulties with alcohol.
Individuals who are alcohol-dependent compulsively drink ethanol (the chemical name for alcohol) to the level of intoxication. Intoxication occurs at blood alcohol levels of 50 to 150 mg/dl and is characterized by euphoria at first, and then if blood concentrations of alcohol continue to rise, a person can become explosively combative. Neurologically, acute intoxication causes impaired thinking, lack of coordination, slow or irregular eye movements, and impaired vision. As the person repeatedly drinks, the body develops a reduced response to ethanol called tolerance.
People with chronic tolerance may appear to be sober (not intoxicated) even after consumption of alcohol that could cause death in non-drinkers. People with alcohol dependence may also develop alcoholic blackouts after large amounts of ethanol consumption. These blackouts are typically characterized by amnesia (loss of memory) lasting several hours without impaired consciousness. In other words, people experiencing blackouts appear to be conscious, but will not remember their actions during the blackouts after the intoxication has worn off.
People with alcohol dependence also develop alcohol withdrawal (a state of non-drinking) syndrome. The nervous system adapts to chronic ethanol exposure by increasing the activity of nerve-cell mechanisms that counteract alcohol’s depressant effects. Therefore, when drinking is abruptly reduced, the affected person develops disordered perceptions, seizures, and tremor (often accompanied by irritability, nausea, and vomiting). Tremor of the hands known as “morning shakes,” usually occurs in the morning due to overnight abstinence. The most serious manifestation of alcohol withdrawal syndrome is delirium tremens, which occurs in approximately 5% of people dependent on alcohol. Delirium tremens consists of agitation, disorientation, insomnia, hallucinations, delusions, intense sweating, fever, and increased heart rate (tachycardia). This state is a medical emergency because it can be fatal, and affected persons must be immediately hospitalized and treated with medications that control vital physiological functions.
The APA publishes a manual for mental health professionals called the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM. This manual lists criteria that each disorder must meet for diagnosis. The criteria are symptoms that must be present so that the diagnosis can be made. Alcohol dependence can be diagnosed if three or more of the following symptoms are present within a 12-month period:
- drinking alcohol in larger amounts and over a longer period of time than was planned
- Continued desire or attempts to stop alcohol use
- preoccupation with, and great deal of time spent seeking alcohol
- drinking is the focal point of person’s life (using takes up most of the person’s time)
- continued use despite health problems related to drinking (such as liver damage)
In order for a person to be diagnosed with alcohol abuse, one of the following four criteria must be met within a 12-month period. Because of drinking, a person repeatedly:
- fails to live up to his or her most important responsibilities at home, school, or work
- physically endangers him- or herself, or others (for example, by drinking and driving)
- gets into trouble with the law
- experiences difficulties in relationships or jobs
The diagnosis of alcoholism can either be based on medical and/or psychological conditions. With a long-term history of abusive drinking, medical conditions can result, and these could lead the physician to suspect a patient’s alcoholism. These medical conditions may include organ complications such as: cirrhosis (liver), hepatitis (liver), pancreatitis (pancreas), peripheral neuropathy (nervous system), or cardiomyopathy (heart). Additionally, recurrent trauma, resulting in bone fractures, fatigue, depression, sexual dysfunction, fluctuating blood pressure, and sleep disorders may prompt the clinician to further assess for alcoholism.
Psychological diagnosis can be accomplished through a clinical interview and history (biopsychosocial assessment), and from a choice of many standardized alcohol use tests. The biopsychosocial assessment is an extensive interview conducted by the clinician. During the interview, the clinician will ask the patient about many areas of life, including childhood, education, and medical history. One very simple tool for beginning the diagnosis of alcoholism is called the CAGE questionnaire. It consists of four questions, with the first letters 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 exist to help determine the severity and effects of a person’s alcohol use. Given the recent research pointing to a genetic basis for alcoholism, the doctor will also attempt to ascertain whether anyone else in the person’s family has ever suffered from alcoholism.
Diagnosis is sometimes facilitated when family members call the attention of a physician to a loved one’s difficulties with alcohol.
Comprehensive treatment for alcohol dependence has two components: detoxification and rehabilitation.
The goal of detoxification is to rid the patient’s body of the toxic effects of alcohol. Because the person’s body has become accustomed to alcohol, the person will need to be supported as he or she goes through withdrawal. Withdrawal will be different for different patients, depending on the severity of the alcoholism, as measured by the quantity of alcohol ingested daily and the length of time the patient has been dependent on alcohol. Withdrawal symptoms can range from mild to life-threatening. Mild withdrawal symptoms include nausea, achiness, diarrhea, difficulty sleeping, sweatiness, anxiety, and trembling. This phase begins between five and eight hours after the last drink, and is over in about three to five days. More severe effects of withdrawal can include hallucinations (in which a patient sees, hears, or feels something that is not actually real), seizures, a strong craving for alcohol, confusion, fever, fast heart rate, high blood pressure, and delirium (a fluctuating level of consciousness). Severe withdrawal can involve delirium tremens, which involve fever, delirium, intense sweating, and tremors. Patients at highest risk for delirium tremens are those with other medical problems, including malnutrition, liver disease, or Wernicke’s encephalopathy. Delirium tremens usually begins about three to five days after the patient’s last drink, progressing from the more mild symptoms to the more severe, and may last a number of days.
Patients going through mild withdrawal are simply monitored carefully to make sure that more severe symptoms do not develop. No medications are necessary, however. Treatment of a patient with more severe effects of withdrawal may require the use of sedative medications to relieve the discomfort of withdrawal and to avoid the potentially life-threatening complications of high blood pressure, fast heart rate, and seizures. Benzodiazapines are medications that ease tension by slowing down the central nervous system and may be helpful in those patients experiencing hallucinations. Because of the patient’s nausea, fluids may need to be given through a vein (intravenously), along with some necessary sugars and salts. It is crucial that thiamine be included in the fluids, because thiamine is usually quite low in patients with alcohol dependence, and deficiency of thiamine is responsible for Wernick’s encephalopathy.
After cessation of drinking has been accomplished, the next steps involve helping the patient stay healthy and avoid relapsing. (Relapse occurs when a patient returns to old behaviors that he or she was trying to change.) This phase of treatment is referred to as rehabilitation. The best programs incorporate the family into the therapy, because the family has undoubtedly been severely affected by the patient’s drinking. Some therapists believe that family members, in an effort to deal with their loved one’s drinking problem, sometimes develop patterns of behavior that unintentionally support or “enable” the patient’s drinking. This situation is referred to as “co-dependence,” and must be addressed in order to treat a person’s alcoholism successfully.
Psychotherapy helps affected persons to anticipate, understand, recognize, and prevent relapse. Behavioral therapy approaches typically include community-centered support groups, meetings such as Alcoholics Anonymous (AA), cognitive-behavioral therapy (CBT), and Motivated Enhancement Therapy (MET). CBT focuses on teaching alcoholics recognition and coping skills for craving states and high-risk situations that precipitate or trigger relapsing behaviors. MET can motivate patients to use their personal resources to initiate changes in behavior. Many people recovering from substance dependence find peer-led support groups helpful in helping them avoid relapse.
Two medications, naltrexone (ReVia) and acamprosate (Campral), can help decrease craving states in alcoholics. A version of naltrexone, called vivitrol, can be injected by a healthcare professional once a month to help reduce an individual’s urge to drink. In combination with psychotherapy, these medications can help reduce relapse. Another medication called disulfiram (Antabuse) affects the metabolism of alcohol and causes unpleasant effects in patients who consume alcohol while taking the medication. Antabuse should only be taken by people who are committed to recovery and understand that they are to avoid all contact with alcohol or alcohol-containing products. People who have alcohol dependence along with other disorders, such as depression, can work with their physicians to determine if medication might be a feasible treatment option for them.
Alternative treatments can be a helpful adjunct for the alcoholic patient, once the medical danger of withdrawal has passed. Because many alcoholics have very stressful lives (whether because of or leading to the alcoholism is sometimes a matter of debate), many of the treatments for alcoholism involve managing and relieving stress. These include massage, meditation, and hypnotherapy. The malnutrition of long-term alcohol use is addressed by nutrition-oriented practitioners and dietitians with careful attention to a healthy diet and the use of nutritional supplements such as vitamins A, B complex, and C, as well as certain fatty acids, amino acids, zinc, magnesium, and selenium. Acupuncture is believed to decrease both withdrawal symptoms and to help improve a patient’s chances for continued recovery from alcoholism.
Antisocial personality disorder—Disorder characterized by behavior pattern of disregard for others’ rights. People with this disorder often deceive and manipulate, or their behavior might include aggression to people or animals or property destruction, for example. This disorder has also been called sociopathy or psychopathy.
Blackout —A period of loss of consciousness or memory.
Delirium tremens —Serious alcohol withdrawal symptoms that must be treated in a hospital and that may include shaking, delirium, and hallucinations.
Detoxification —A process in which the body is allowed to free itself of a drug while the symptoms of withdrawal are treated. It is the primary step in any treatment program for drug or alcohol abuse.
Euphoria —A feeling or state of well-being or elation.
Intoxication —Condition of being drunk.
Relapse —A person experiences a relapse when he or she re-engages in a behavior that is harmful and that he or she was trying to change or eliminate. Relapse is a common occurrence after treatment for many disorders, including addictions and eating disorders.
Thiamine —A B-vitamin that is essential to normal metabolism and nerve function, and whose absorption is affected by alcoholism.
Tolerance —Progressive decrease in the effectiveness of a drug with long-term use.
Wernicke’s encephalopathy —Group of symptoms that appears in people who are dependent on alcohol. The syndrome is due to a thiamine deficiency, and severely affects one’s memory, preventing new learning from taking place.
Withdrawal —Symptoms experienced by a person who has become physically dependent on a drug, experienced when the drug use is discontinued.
Most persons who use alcohol start to drink during adolescence or early adulthood. Approximately 50% of male drinkers have alcohol-related problems such as fighting, blackouts, or legal problems during their early drinking years, usually late teens or early twenties. People who cannot control their drinking behaviors will tend to accumulate drinking-related problems and become dependent on alcohol. Although many alcoholics can maintain sobriety with psychotherapeutic interventions alone, research indicates that medications such as disulfiram, in combination with psychotherapy, can be very effective for achieving sobriety.
Good prevention includes education and a knowledge of family (genetic) propensity. If alcohol dependence is present in a close family member, then relatives should know and be discouraged to drink beverages that contain alcohol. Education of older children and young teenagers concerning the negative effects and consequences of drinking alcohol may help to decrease or recognize problems before start or worsen.
Brozner, Elaine. New Research on Alcohol Abuse And Alcoholism. New York: Nova Science Publishers, 2006.
Dodes, Lance M. The Heart of Addiction: A New Approach to Understanding and Managing Alcoholism and Other Addictive Behaviors. New York: Harper, 2002.
Johnson, Bankole A., Pedro Ruiz, and Marc Galanter, eds. Handbook of Clinical Alcoholism Treatment. Baltimore, MD: Lippincott Williams & Wilkins 2003.
Alcoholics Anonymous. P.O. Box 459, New York, NY 10163. Telephone: (212) 870-3400. <http://www.alcoholics-anonymous.org/>
Substance Abuse and Mental Health Services Administration (SAMHSA). 1 Choke Cherry Road, Rockville, MD, 20857. Telephone: (800) 729-6686. <http://ncadi.samhsa.gov/>
Laith Farid Gulli, MD
Michael Mooney, M.A.,CAC,CCS
Tanya Bivins, B.S.N.,RN
Bill Asenjo, MS,CRC
Stephanie N. Watson