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.
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,
|ALCOHOL CONCENTRATION AND EFFECT RELATIONSHIP|
|0.02–0.03||Mood elevation; slight muscle relaxation|
|0.05–0.06||Relaxation and warmth; increased reaction time; decreased fine muscle coordination|
|0.08–0.09||Impaired balance, speech, vision, hearing, and muscle coordination; euphoria|
|0.14–0.15||Gross impairment of physical and mental control|
|0.20–0.30||Severely intoxicated; very little control of mind or body|
|0.40–0.50||Unconscious; deep coma; death from respiratory depression|
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.
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:
- 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.
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 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.
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.
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.
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 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.
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- —A phenomenon whereby a drug user becomes physically accustomed to a particular quantity of alcohol (or dosage of a drug), and requires ever-increasing quantities in order to obtain the same effects.
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