Alcoholism has multiple and sometimes conflicting
definitions. In common and historic usage, alcoholism is any
condition that results in the continued consumption of
alcoholic beverages, despite health
problems and negative social consequences. Modern medical
definitions 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 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. 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,
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 is higher than 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. Professor David Zaridze,
who led the international research team, calculated that alcohol
had killed three million Russians since 1987.
Classification
The definitions of alcoholism and related terminology vary
significantly between the medical community, treatment programs,
and the general public.
Medical definitions
The
National
Council on Alcoholism and Drug Dependence and The
American Society of
Addiction Medicine define 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." The
DSM-IV (the dominant diagnostic manual in psychiatry
and psychology) defines
alcohol abuse
as repeated use despite recurrent adverse consequences. It further
defines
alcohol dependence as
alcohol abuse combined with
tolerance,
withdrawal, and an uncontrollable drive to drink.
(See
DSM diagnosis below.) Within psychology and
psychiatry, alcoholism is the popular term for
alcohol
dependence. 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.
Because alcoholism is often used in a derogatory sense in politics
and religion, the meanings of the words surrounding it are often
used imprecisely.
Use refers to simple use of a substance.
An individual who drinks any alcoholic beverage is
using
alcohol.
Misuse,
problem
use,
abuse, 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.
Moderate Use is defined by
The Dietary
Guidelines for Americans as no more than two alcoholic
beverages per day for men and no more than one alcoholic beverage
per day for women.
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.
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.
Signs and symptoms
Effects of long term alcohol misuse
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.
Alcoholism can have adverse effects on mental health causing
psychiatric disorders to develop. Approximately 18 percent of
alcoholics commit suicide. Research has found that over fifty
percent of all suicides are associated with alcohol or drug
dependence. In adolescents the figure is higher with alcohol or
drug misuse playing a role in up to 70 percent of suicides.
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.
- 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.
- 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 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.
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.
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. Chronic alcohol misuse can cause panic disorder to
develop or worsen an underlying panic disorder via distortion of
the neurochemical system in the brain.
The co-occurrence of
major
depressive disorder and alcoholism is well documented. 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. 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".
- 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. 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
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. Sedative-hypnotic drugs
such as
barbiturates and
benzodiazepines which have a similar
mechanism of action to alcohol (which is also a sedative-hypnotic)
also have a similar risk of causing death during withdrawal.
Alcohol's primary effect is the increase in stimulation of the
GABAA 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,
anhedonia) 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.
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.
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
report 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.
- 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 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. Like the CAGE
questionnaire, it uses a simple set of questions - a high score
earning a deeper investigation.
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.
At least one genetic test exists for an
allele that is correlated to alcoholism and opiate
addiction. 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.
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.
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:
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:
However, none of these blood tests for biological markers are as
sensitive as screening questionaires.
Prevention
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.
Management
Treatments for alcoholism (antidipsotropic) 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.
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. 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.
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
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. 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".
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%.
- Naltrexone is a competitive antagonist for opioid
receptors, effectively blocking our ability to use endorphins and
opiates. Alcohol causes the body to release 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..." The COMBINE study was unable to
demonstrate efficacy for Acamprosate.
- 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. 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. 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.
Medications which may worsen outcome
- Benzodiazepines, whilst useful
in the management of acute alcohol withdrawal, if used long-term
cause a worse outcome in alcoholism. Alcoholics on chronic
benzodiazepines have a lower rate of achieving abstinence from
alcohol than those not taking benzodiazepines. This class of drugs
are commonly prescribed to alcoholics for insomnia or anxiety
management. Initiating prescriptions of prescription (or solid
sedative-hypnotics) in individuals in recovery has a high rate of
relapse with one author reporting more than a quarter of people
relapse after being prescribed sedative-hypnotics. Patients often
mistakenly think that they are sober despite continuing to take
benzodiazepines. Those who are long-term users of benzodiazepines
should not be withdrawn rapidly, taper regimes of 6–12 months have
been found to be the most successful, with reduced intensity of
withdrawal.
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.
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.
Epidemiology
[[Image:Alcohol use disorders world map - DALY -
WHO2002.svg|thumb|
Disability-adjusted life year
for alcohol use disorders per 100,000 inhabitants in 2002.
]]
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."
In the United Kingdom
, the number of 'dependent drinkers' was calculated
as over 2.8 million in 2001. The
World Health Organization
estimates that about 140 million people throughout the world suffer
from alcohol dependence.
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)."
Current evidence indicates that in both men and women, alcoholism
is 50-60% genetically determined, leaving 40-50% for environmental
influences.
A 2002 study by the
National
Institute on Alcohol Abuse and Alcoholism surveyed a group of
4,422 adults meeting the criteria for
alcohol dependence and found that after
one year, some met the authors' criteria for low-risk drinking,
even though only 25.5% of the group received any treatment, 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." Vaillant also noted that
"return-to-controlled drinking, as reported in short-term studies,
is often a mirage."
History
Etymology
1904 advertisement describing
alcoholism as a disease.
term "alcoholism" was first used in 1849 by the Swedish physician
Magnus Huss to describe the systematic adverse effects of
alcohol.
In the
United
States
, use of the word "alcoholism" was largely
popularized by the founding and growth of Alcoholics Anonymous in 1935 .
AA's basic text, known as the "Big Book," describes alcoholism as
an illness that involves a physical allergy and a mental obsession.
Note that the definition of "allergy" used in this context is not
the same as used in modern medicine. . The doctor and addiction
specialist Dr. William D. Silkworth M.D. writes on behalf of AA
that Alcoholics suffer from a "(physical) craving beyond mental
control".
A 1960 study by
E. Morton Jellinek is considered the
foundation of the modern
disease theory of alcoholism.
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.
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.
Society and culture
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, an incurable
and damaging condition.
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. 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.
A study quantified the cost to the UK of
all forms of
alcohol misuse as £18.5–20 billion annually (2001 figures).
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.
Studies by social psychologists Stivers and Greeley attempt to
document the perceived prevalence of high alcohol consumption
amongst the Irish in America.
Alcohol-related crime
Of the adult US population, at least 75% are drinkers; therefore,
about 6% of the total group are alcoholics. The alcoholism rate is
about 8% in groups in which almost 100% are drinkers. "If we
include alcohol abusers, the best estimate is 10.5 of working
Americans." "Many reports state that about 73% of felonies are
alcohol-related. One survey shows that in about 67% of
child-beating cases, 41% of forcible rape cases, 80% of
wife-battering, 72% of stabbings, and 83% of homicides, either the
attacker or the victim or both had been drinking."
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 disjointed 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,
Barfly,
Days of Wine and Roses,
My Name Is Bill W.,
Withnail and I,
Arthur,
Leaving Las Vegas,
When a Man Loves a
Woman,
Shattered
Spirits and
The
Lost Weekend chronicle similar stories of
alcoholism.
Women and alcoholism
Alcoholism has a higher prevalence among men, though in recent
decades, the proportion of female alcoholics has increased. 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). 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.
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. Examples of long term
complications include brain, heart, and liver damage and an
increased risk for breast cancer (see
alcohol and 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.
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.
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. 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.
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.
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. The complexity of alcohol use
disorders, particularly with gender-related issues, indicates that
the need for practitioners' knowledge, insight and compassion is
enormous. 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.
See also
References
Further reading
- Berry, Ralph E.; Boland James P. The Economic Cost of
Alcohol Abuse The Free Press, New York, 1977 ISBN
0-02-903080-3
- Milam, Dr. James R. and Ketcham, Katherine Under The
Influence: A Guide to the Myths and Realities of Alcoholism.
Bantam, 1983, ISBN 0-553-27487-2
- Pence, Gregory, "Kant on Whether Alcoholism is a Disease," Ch.
2, The Elements of Bioethics, McGraw-Hill Books, 2007 ISBN
0-073-13277-2.
- Royce, James E. and Scratchley, David Alcoholism and Other
Drug Problems Free Press, March 1996 ISBN 0-684-82314-4 ISBN
978-0-684-82314-0
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