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Alcoholism

I. Epidemiology

A. Alcohol/drug problems are 2nd most common mental disorders, involving between 6% to 7% of adults. In adult males, they rank first at 8% to 10%. (NIMH, 1984.) 1 in 7 adults in USA are alcoholic or problem drinkers. Only 3% of alcoholics are on skid row

B. Comorbidity of Alcoholism and Other Mental Disorders (Kessler, 1994, '97):

14% of US population is highly comorbid for substance abuse and serious mental illness 37% of alcohol abusers & 53% of drug abusers have at least 1 other mental illness alcoholism, alcohol addiction, alcoholic).

78% of men & 86% of women with alc. dependence in the NCS had at least one other lifetime psychiatric disorder; in 63% this preceded the onset of alcoholism (NCS, '97). 25% to 50% of suicides involve alcohol (Frances ,'87); as do 20% of Emergency Room Visits Depressed alcoholics are at higher risk for suicide than non-alcoholic depressed patients. (Cornelius, JR, Am J Psychiatry 152:358-364, 1995)

More than 50% of younger alcoholics report regular, heavy polysubstance abuse.

C. 43% of US adults report exposure to alcoholism in their families.

D. Medical Problems: 3rd ranking cause of death in USA., after Cancer & Heart Disease; 100,000 alcohol related "premature" deaths per year; average 15 year reduction in life span.

II. Diagnosis

C. DSM-IV

1. Psychoactive Substance-Induced Organic Mental Disorders

303.00 Alcohol Intoxication

291.90 Alcohol Use Disorder Not Otherwise Specified (Pathological Intoxication)

291.80 Alcohol Withdrawal

291.00 Alcohol Delirium during withdrawal (Delirium Tremens)

291.30 Alcohol Psychotic Disorder with hallucinations (Alcohol Hallucinosis)

291,10 Alcohol Persisting Amnestic Disorder (Korsakoff Syndrome)

291.20 Alcohol Persisting Dementia

2. Substance Dependence (example: Alcohol Dependence 303,90)

a. Maladaptive use pattern leading to significant impairment or distress, as indicated by three or more of the following occurring at any time during same twelve month period:

1. Tolerance: need to markedly increase amount used to get effect; diminished effect with continued use

2. Withdrawal: characteristic withdrawal syndrome for the substance substance taken to relieve or avoid Withdrawal

3. Substance taken in larger amounts or over longer period than intended

4. Unsuccessful efforts to cut down or control use

5. Great deal of time spent taking or recovering from drug

6. Important activities given up or reduced

7. Continued use despite knowledge of problems caused

b. Qualifiers:

1. with or without physiological dependence (tolerance or withdrawal)

2. Remission: early or sustained; partial or full

3. Substance Abuse (example: Alcohol Abuse 305,00)

a. Maladaptive use pattern leading to significant impairment or distress, as indicated by one or more of the following occurring at any time during the same twelve month period:

1. recurrent use causing failure to fulfill major obligations: work, school or home

2. recurrent use in situations in which it is physically hazardous

3. recurrent substance-related legal problems

4. continued use despite problems caused or exacerbated by the effects of the substance

b. Has never met criteria for Substance Dependence for this class of substance

III. Practical Clinical Screening Tests

A. Michigan alcoholism screening test (mast) (see appendix i)

B. MMPI - MacAndrew Scale: A 48 item MMPI sub-scale (MacAndrew, 1981).

- C. CAGE (Ewing and Rouse)

V. Alcohol Related Syndromes

A. Simple drunkenness (Alcohol Intoxication 303.00) Blood Alcohol Concentration (BAC)

BAC over 150 mg.% in a person who does not appear very intoxicated, or over 300 mg.% in any awake person is evidence of physical addiction (tolerance) to alcohol. BAC may be 50% higher in women than in men consuming similar amounts of alcohol, because women have 1) smaller body size, 2) lower levels of gastric alcohol dehydrogenase, and 3) higher proportion of body fat.

B. Delirium tremens (Alcohol Delirium 291.00) (due to noradrenergic hyperactivity in the Locus Coeruleus, Gold & Miller, 1992)

E. Fetal alcohol syndrome (FAS)

1. Signs: infant shows signs of alcohol withdrawal early stage of liver disease mental retardation (44% had IQ. of 79 or below) retarded weight and height

2. Congenital heart disease and other defects: wide-set eyes, short palpebral fissure, short and broad-bridged nose hypoplastic philtrum, thinned upper lip and flattened mid-face

3. Incidence: Six-fold increase between 1979 and 1993, to 6.7 per 10,000 births (CDC, '95) 17% are stillborn or die shortly after birth 20% have birth defects; (32% show full "fetal alcohol syndrome")

4. Maternal alcohol use while breast feeding impairs child's motor development, but not mental development. (Little, NEJM 321:425-30, 1989)

5. Long-term effects of FAS: <6% able to function in school; most never hold a job. Average IQ in 61 subjects was 68 (Streissguth, "91). 72% have major psychiatric disorders (Famy '98)

F. Mild organic brain syndrome Moderate drinkers (2.1 oz/day): 85% show brain shrinkage on CAT Scan and 70% show cognitive loss and psychometric deficits. These are partially reversible with abstinence (Scientific American, April, 1985, pg. 76). Peak BAC levels determine amount of alcohol-induced brain damage, more than the total amount consumed. Volumetric MRIs show 11% gray matter loss & 25% increase in CSF volume in female alcoholics vs. female controls; almost double loss seen in male alcoholics (Hommer '99).

VI. Etiology

A. Psychoanalytic theory

1. Addiction is a symptom of Depression (Kraepelin, 1919)

2. An abnormal Sexual Fixation (Ratio, 1933, & Abraham, 1960)

3. Evidence of an Oral Regression that causes alcoholism (Knight, 1937 & Freud, 1953)

4. Alcoholism causes "oral" personality traits (Vaillant, 1980)

B. Sociology American society sanctions the use of alcohol to cope with frustrations and alienation. Individuals' patterns of use and abuse are determined by their group. (Jessor)

C. Genetic theories - Some alcoholism clearly runs in families.

1. Danish adoption study sons of alcoholics raised by non-alcoholic foster parents: increased alcoholism. Boys raised by alcoholic foster parents: no increased alcoholism, if biologic parents are not alcoholic. (Goodwin, 1974)

2. Brain wave studies - Event Related Potential (Begleiter, Science 255:1493-96, 1984) Evoked-brain (P300) waves studied in 6 to 13 year old sons of alc. fathers (vs. controls) showed a neurophysiological deficit identical to that seen in chronic abstinent alcoholics.

3. Abnormal hormonal response patterns

a. Enhanced thyrotropin response in sons of familial alcoholics. Daughters showed no abnormalities (Moss, Arch Gen Psychiatry 43:1137-42, 1986.)

b. Diminished endogenous opioid activity and hence enhanced cortisol response to stress in families with high incidence of alcohol dependence (Wand, G., 1998).

c. Schuckit has demonstrated that a low level of response to alcohol at age 20 predicts the likely development of alcoholism at age 30 (Schuckit, am j psychiatry vo1151, '94.)

4. Stockholm adoption study: 862 males and 913 females, adopted and raised by non-relatives; two types of alcoholism were identified (Cloninger & Bohman, 1981).

a. "Milieu-limited" or TYPE I effects both men and women there is congenital susceptibility (both parents can have mild, adult onset alcohol abuse) severity is determined by post-natal stress. 

Risk in sons is twice the normal incidence 

Risk in daughters with an alcoholic mother is three times the normal incidence

b "Male-limited" or type II is passed only from fathers to sons fathers are both severely alcoholic and criminal sons have nine times the normal incidence early onset of alcohol abuse (before age 25) post-natal environmental has no influence daughters of such fathers have no increased incidence

Comparable subtypes have been found by Babor, 1992. Prospective personality "trait" studies

(MMPI, etc) have failed to document a typical PRE-alcoholic personality. However, certain constellations of personality traits, and biologic findings, may be associated with specific Alcoholic sub-types (Cloninger, 1987; Buydens-Branchey, 1989)

5. Neuro-biologic susceptibility to alcoholism (Tarter 84' & 85')

a. Temperamental deviations; biological & psychological characteristics associated with a vulnerability to alcoholism have been identified in male pre-alcoholics. They manifest cognitive and behavioral deficits and electrophysiological abnormalities suggestive of dysfunction along the prefrontal-midbrain neuroaxis.

VIII. Psychiatric Management of Alcoholism

A. Getting the patient into treatment; understanding:

The stages of change

(Pre-contemplation, contemplation, preparation, action, maintenance)

(Prochaska, 1992, Miller & Rollnick, 1991)

1. Educate the patient about the consequences of his or her drinking--medical, social, economic; involve family; connect their problems to their drinking. (Contemplation)

2. Clarify the patient's goals/agenda. Ambivalence is a major impediment to quitting. Explore both sides of the ambivalence. Non-judgmental approach works best.

3. Don't argue over the quantity of alcohol consumed or the label of alcoholism, focus on the need to do something about (or get help for) a "problem."

4. Negotiate a treatment contract or referral with patient (preparation): "alcoholism" vs. a "drinking problem" sobriety vs. controlled drinking

B. Treatment Options (Action) 

The Importance of Patient Matching

1. Detoxification: inpatient vs.. Outpatient vs. 28 day rehab programs one study has shown 28 day programs to be more effective than A.A. alone for stable, employed alcoholics. (Walsh, 1991) Most studies show no difference between inpatient and outpatient programs, and no difference between 1 week and 4 week inpatient programs.

2. Alcoholics anonymous; Alanon; Alateen (See Appendix II) 

Primary resource for uncomplicated alcoholism; middle class; individuals comfortable in groups & with spiritual orientation (there are also some non-religious 12 step programs, such as rational recovery/smart recovery)

3. Alcohol clinic / dual diagnosis programs

Severe psychiatric illness (psychosis, depression) requiring medication plus alcoholism treatment; lower social class; persons hostile to A.A.

4. Group therapy: (Litt, 1992)

Process oriented groups are better for Type I alcoholics (Yalom model)

Coping skills groups are better for Type 11 alcoholics (relapse prevention model)

5. Family therapy: A critical element for successful treatment (Steinglass, 1987)

6. Individual psychotherapy early problem drinkers (not yet alcoholics) upper-middle and upper class (if A.A. is unacceptable) schizoid individuals after 1 year sobriety in A.A.

C. Problems in referral to A.A.

1. Patient doesn't fit in A.A. group; must "shop-around," try 5 or more different groups.

IX. Adult children of alcoholics "ACoAs" (Black, 1981)

A. A "grass roots" self-help organization utilizing the A.A./12 step program and family systems theory, designed to aid anyone raised in a dysfunctional family. Members are mainly single women, between 20 and 40.

B. ACoA literature suggests a high incidence of borderline psychopathology, particularly in women. Similarities exist between PTSD and 

X. Is Treatment Successful?

A. Treatment is highly cost-effective (Brown Univ. Digest Addiction Theory, D. Lewis, Vol 17, 4/98)

B. NIAAA: 

18-month follow-up on all Federal programs

70% recovery (apparent by 6 months); 50% needed only minimal intervention