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Definitions and causal factors of alcoholism
Alcoholism consists of a repetitive intake of alcoholic beverages to an extent that the drinker is harmed. The harm may be physical or mental; it may also be social or economic. Implicit in the conception of alcoholism as a disease is the idea that the person experiencing repeated or long-lasting injury from his drinking would alter his behaviour if he could. His failure to do so shows that he cannot help himself, that he has “lost control over drinking.” This conception incorporates the idea of addiction or dependence.
Formal definitions of alcoholism vary according to the point of view of the definer. A simplistic, old-fashioned medical definition calls alcoholism a disease caused by chronic, excessive drinking. A purely pharmacological-physiological definition of alcoholism classifies it as a drug addiction recognizable by the need for increasing doses to produce desired effects and by the occurrence of a withdrawal syndrome when drinking is stopped. This definition is inadequate, since alcoholism does not resemble other addictions in the need for increased doses. Opium addicts become adapted to and require as much as hundreds of times the normal lethal dose, but the increased amounts to which alcoholics become adapted are well below the normal single lethal dose. Moreover, the withdrawal syndromes in alcoholism occur inconsistently, sometimes failing to appear in the same persons who experienced them previously and apparently never occurring in some persons who cannot be distinguished from confirmed alcoholics.
Behavioral rather than pharmacological-physiological signs are much more consistent and reliable in defining and diagnosing alcoholism. A sophisticated definition representing modern conceptions of comprehensive medicine classifies alcoholism as a disease of unknown cause, without recognizable anatomical signs, manifested by addiction to or dependence on alcohol. A more comprehensive definition incorporating the perspectives of both psychological and physical medicine recognizes that alcoholism may be either a symptom of another underlying, possibly psychological, disorder or a disease itself: alcoholism, in this view, is a chronic and usually progressive disease or a symptom of an underlying psychological or physical disorder, characterized by dependence on alcohol (manifested by loss of control over drinking) for relief from psychological or physical distress or for gratification from alcohol intoxication itself, and characterized also by a consumption of alcoholic beverages sufficiently great and consistent to cause physical or mental or social or economic disability. Here, the conception of disease undoubtedly rests on the evidence of disablement.
The various definitions that rely on the symptom of loss of control over drinking often consider the loss of control to consist of an inability to stop drinking once it is started, implying that the alcoholic can choose not to take the first drink. But the more comprehensive definition sees the alcoholic as starting a drinking episode because he cannot refrain. Nor does the loss of control over drinking hold true all the time. As with symptoms in many diseases, the loss of control is active in most alcoholics only inconsistently. This means that an alcoholic is not always under internal pressure to drink and can sometimes resist drinking, or, if he drinks, he can sometimes drink in a controlled way. The inconsistency of the loss of control is, however, consistent with a definition of alcoholism based on learning psychology: alcoholism, in this definition, is a learned (or conditioned) dependence on (or addiction to) alcohol that irresistibly activates resort to drinking whenever a critical internal or environmental stimulus (or cue) presents itself. This definition leaves room for the conception that alcoholism may start as a symptom of an underlying disorder, which induces the learning of the alcoholismic pattern, and that once the pattern is fixed or conditioned it may become a disease in its own right (that is, an addiction), capable of surviving even the disappearance of the original underlying cause. Some theorists who regard alcoholism as primarily a symptom do not necessarily subscribe to the idea that it is learned, although they recognize that it may progress to the state of a primary disease.
Alcoholism is a multifarious phenomenon requiring more than one definition. Epidemiologists need a definition that will enable them to identify alcoholics within a population not available for individual examination. Such a definition may rely on a quantity-and-frequency measurement of drinking and also on behavioral features, including injurious effects measurable by instrumental indexes, such as a formula resting on the relation of alcoholism to diseases of known frequency among alcoholics or a drinking-history questionnaire or a preoccupation-with-alcohol scale. Sociological-behavioral definitions emphasize deviance from a norm, especially drinking that exceeds customary dietary use or diverges from the social customs of the drinker’s community; such a definition may use as a criterion the way a drinker is regarded by those who know him; his arrests, hospitalizations, and clinical diagnoses; or his membership in a self-defining group, such as Alcoholics Anonymous. Legal definitions tend to rest on habitual intemperance that endangers others, injures the public welfare, or threatens the health, welfare, or competence of the person himself.
Many theories of the cause of alcoholism rest on the limited perspectives of specialists in particular disciplines or professions. Thus, alcoholism has been thought to be caused by defects of heredity, nutrition, disorders of endocrine function, latent homosexuality, economic misery or affluence, bad social influences, or sinful gluttony. More discerning definitions and descriptions take into account the complexity of alcoholism, acknowledging that its causes are not yet knowable with certainty. The most comprehensive conceptions recognize that alcoholism may have a genetic or constitutional underlying factor–not a fateful heredity but a predisposition that renders some people more vulnerable to alcoholism than others. Some think the genetic vulnerability is specific not to alcoholism but rather more generally to a neurosis or an affective disorder that may manifest itself as alcoholism; the alcoholism may possibly represent a “choice of symptom” and be for some individuals a useful “sickness.” Others think the genetic factor may impose not vulnerability but, on the contrary, immunity to alcoholism, meaning that some people are unable to adapt to drinking on a level sufficient to gain the peculiar rewards that dispose a person to the development of an alcoholismic life pattern.
The comprehensive etiological view suspects that factors in infancy or early childhood, such as lack of parental care and love, overindulgence, or inconsistency in rearing practices, may lay the foundation of a vulnerable personality. On such a foundation, a dependent personality type or one marked by dependence-independence conflict may emerge; in adolescence this may manifest itself in an insecure self-sex image and a need to overcompensate–for example, by defiant exhibitionistic deviance. Such a problem-ridden personality may find exceptionally effective assuagement and reward in alcohol and learn to rely on intoxication as a mechanism for coping with problems. If this learning process is not interrupted and especially if the social surroundings respond encouragingly or permissively or ambivalently to heavy drinking and intoxication, then the vulnerable personality will become conditioned to react to difficulties by resort to intoxication. If the process lasts long enough, the outcome will be addiction to alcohol or a confirmed alcohol dependence. This comprehensive conception takes into account not only the possible genetic, pharmacological, psychological, and social factors but also the sociocultural context. It recognizes that the society defines and labels the phenomenon of alcoholism, that the culture contributes to its development or inhibition, and that behaviour that in one culture matches an adequate rational definition of alcoholism may not constitute alcoholism in another. Thus, periodic intoxication causing sickness for several days and necessitating absence from work may define alcoholism in a modern industrial community, but, in a rural Andean society, periodic drunkenness at appointed communal fiestas, resulting in sickness and suspension of work for several days, is normal behaviour. An essential aspect of the difference is that the drunkenness at fiestas is not individually deviant behaviour.
Prevalence of alcoholism
Estimates of the prevalence of alcoholism vary greatly, depending on how it is defined as well as on the methods of estimation. In the United States in the late 20th century, according to one sophisticated estimate, there were approximately 5,400,000 alcoholics–about 4,500,000 men and 900,000 women. In percentage terms, 7.3 percent of men and 1.3 percent of women were alcoholics or 4.2 percent of adults aged 20 and over. There were large variations among regions and states, the rates being higher in urban and industrialized areas. There was no objective evidence that the rates of alcoholism had risen since World War II, although the absolute numbers had increased substantially with the growth of the adult population. A widespread impression that alcoholism was increasing among women apparently reflected the greater visibility of female alcoholics caused by changing public and professional attitudes; formerly, there had been more masking of alcoholism in women than in men.
A constant rate of alcoholism, without any increase in numbers except in proportion to the growth of population, requires an annual incidence of several hundred thousand new cases. The process of becoming an alcoholic usually takes several years. Since in many cases the process is not carried to completion, there must be a population of several million pre-alcoholics (for example, “heavy drinkers” or “heavy-escape” drinkers) from whom the several hundred thousand new cases of alcoholism emerge each year. On the basis of national surveys of U.S. drinking patterns of the last few decades, it is estimated that the size of the “pre-alcoholic” population is about 4,000,000; these, together with the 5,400,000 alcoholics, may be considered the total of problem drinkers. There are indications, however, that, among the pre-alcoholics the sex differential is rather smaller than among the alcoholics, probably about four men to one woman. This implies that among women pre-alcoholics a smaller proportion cross the line to become full-fledged alcoholics.
The existence of over 5,000,000 alcoholics in the U.S., plus possibly 4,000,000 other problem drinkers, of whom perhaps between 5 and 10 percent become alcoholics each year, places alcoholism in the front rank of public-health problems. Its gravity is underlined by the higher rates of mortality (2.5 times normal) among alcoholics. Suicide rates are 2.5 times higher; accidental death rates are seven times higher; and there is an enormously higher rate of general morbidity among alcoholics. One study found that, among patients in general hospitals, those identifiable as alcoholics range from 13 to 29 percent. Alcoholism-related psychoses account for about 15 percent of the male and roughly 3 to 4 percent of the female admissions to public and private psychiatric hospitals in the U.S. Admissions of alcoholics without psychosis–usually to participate in alcoholism-treatment programs–accounted for another 40 percent of the men and 13 percent of the women admitted to public mental hospitals and for 15 percent of the men and 4 percent of the women admitted to private mental hospitals. These statistics do not include pre-alcoholics and problem drinkers, although, from the viewpoint of preventive public health, they are those most in need of study and help.
Variations in the definition of alcoholism make it difficult to compare U.S. rates with those of other countries. The most comparable statistics are those of Canada, where the rate of alcoholism is much lower than in the U.S., about 2.4 percent, and the ratio of incidence among the sexes is about five men to one woman, as in the U.S. A rate of 3.5 percent has been reported from Sweden and 1.1 percent from Finland, each with a ratio of five men to one woman, and 0.8 percent from Northern Ireland, with a ratio of three men to one woman; other rates include 5.4 percent in Chile and 0.41 percent in Italy, with no indications of sex ratios. In England and Wales different estimators have suggested rates varying from as low as 1.1 percent to as high as 8.8 and 11 percent; and in Switzerland the suggested rates have varied from 2.2 to 13 percent. The rate in France has been estimated at as high as 15 percent of the adult population, but more conservative estimates suggest 9.4 percent.
Although the rate in France is probably higher than in any of the other countries mentioned, the degree of validity that may be attached to these estimates is so uncertain that all comparisons must be considered as unreliable. There is a strong subjective element in statistics of alcoholism. From time to time, professional opinion becomes aroused, a cry of alarm is raised, and the assumption is made that alcoholism is increasing. High estimates are then likely to emerge, based on local and insufficiently refined data. Often, increased admissions to hospitals for alcoholic mental disorders and sometimes increased consumption of alcohol are cited in evidence. But these data invariably fail to take account of changes in availability or use of facilities, changes in admission or diagnostic policies, or changes in the source of beverages–for example, from unrecorded to recorded supplies. In the Soviet Union a change in the internal political situation with the death of Stalin resulted in a shift from official denial that any significant problem of alcoholism existed to an outcry that its prevalence was widespread and serious, though no statistics were provided.
Treatment of alcoholism
The various treatments of alcoholism may be classified as physiological, psychological, and social. Many physiological treatments are given as adjuncts to psychological methods, but sometimes they are applied in “pure” form, without conscious psychotherapeutic intent or even with an effort to avoid it.
One of the popular modern drug treatments of alcoholism, initiated in 1948 by Eric Jacobsen of Denmark, uses disulfiram (tetraethylthiuram disulfide). The usual technique is to administer half a gram in tablet form daily for a few days; then, under carefully controlled conditions and with medical supervision, the patient is given a small test drink of an alcoholic beverage. The presence of disulfiram in the drinker’s body causes a reaction of hot flushing, nausea, vomiting, a sudden sharp drop of blood pressure, pounding of the heart, and even a feeling of impending death. These symptoms result from an accumulation of the highly toxic first product of alcohol metabolism–acetaldehyde. Normally, as alcohol is converted to acetaldehyde, the latter is rapidly converted, in turn, to other harmless metabolites, but in the presence of disulfiram–itself harmless–the metabolism of acetaldehyde is blocked, with the resulting toxic symptoms. The patient is thus dramatically shown the danger of attempting to drink while under disulfiram medication. A smaller daily dose of disulfiram is then prescribed, and the dread of the consequences of drinking acts as a “chemical fence” to prevent the patient from drinking as long as he continues taking the drug. Most therapists use the period of enforced abstinence to apply psychological and rehabilitative measures that should enable the patient ultimately to refrain from drinking without the chemical crutch. Variations of the technique include group-reaction tests and the substitution of motion pictures or verbal descriptions for the reaction test.
Citrated calcium cyanamide is another drug used with similar effect, preferred by some therapists because the reaction with alcohol is milder, though its protective potency is briefer. In Japan some therapists have reported giving very small doses of the cyanamide compound, thereby allowing the patient to drink very moderately without suffering a severe reaction but provoking the reaction if the patient attempts to drink immoderately. Other substances that can produce disagreeable reactions with alcohol include animal charcoal, the mushroom Coprinus atramentarius, numerous antidiabetic drugs, and the ground pine Lycopodium selago; however, except for the latter, which has had some trial in Russia, they have attracted very little clinical interest.
The U.S. /bcom/eb/article/idxref/3/0,5716,466975,00.htmlpsychiatrist W.L. Voegtlin developed a method of creating a conditioned reflex of aversion to alcohol by repeatedly giving the patient a precisely timed injection of an emetic drug just before a drink of his favorite beverage, resulting in nausea and vomiting before the alcohol could be absorbed. The consequent association of vomiting with drinking, causing aversion to the taste, smell, and sometimes even sight of alcoholic beverages, does not last indefinitely but may be reinforced periodically. Similar techniques have been tried in several European countries. Other methods of conditioning applied by behaviour therapists and learning psychologists include associating drinking with mild to painful electrical shocks or with temporary interruption of breathing by injection of a paralyzing drug.
Nutrition, hormones, drugs
A genetotrophic theory of disease holds that alcoholism is caused by a genetically determined need for extraordinary amounts of one or more vitamins. Accordingly, alcoholics have been treated with massive doses of multivitamins. Another theory holds that alcoholism is caused by some defect of the endocrine system, the adrenal-hypophyseal axis being most commonly implicated, and, accordingly, alcoholics have been treated by injections of adrenal steroids and adrenocorticotropic hormones. Other physical and drug therapies that have been tried in alcoholics include intravenous injections of alcohol, apomorphine, injections of autoserum and alcoholized serum, brain surgery, carbon-dioxide inhalation, oxygen by injection, nicotinic acid, nicotinamide-adenine dinucleotide, lysergide (LSD, lysergic acid diethylamide), strychnine, antihistaminic agents, and many tranquillizing and energizing drugs. None of these treatments has been shown in controlled studies to be more effective than others. With some treatments, controlled studies are extremely difficult to carry out. In many cases, moreover, the treatments are accompanied by simultaneous measures having potentially psychotherapeutic and socially rehabilitative effects, especially membership in such groups as Alcoholics Anonymous (see below). It is possible that the treatment that works best is the one that is most suitable for the particular patient. But it is also possible that the most effective therapy is the one the therapist believes in, and this factor of subjectivity may account for the inferior results achieved in controlled experiments. In the use of psychoactive drugs such as LSD, the aim often is not directly to affect the alcoholism but to produce changes in the patient’s emotional state that will help him respond to other psychosocial measures.
Psychotherapy in alcoholism encompasses the entire range of modalities applied in treating the psychoneuroses and character disorders, including individual and group techniques. The aim varies from eliminating some underlying cause to effecting just enough shift in the patient’s emotional state so that he can function at least temporarily without drinking. Psychoanalysis is rarely tried, having shown little success in alcoholism; analytically oriented therapies are more usual, chiefly with supportive aims. The only psychological technique developed specifically for alcoholism consists of gaining the patient’s recognition and acceptance of his actual condition, which alcoholics often resist. Such acceptance may then be followed by a therapeutic-rehabilitative regimen. Group therapies are regarded as more effective than individual modalities with alcoholics. These range from instructional lectures and superficial discussions to deep analytic explorations, psychodrama, hypnosis, psychodynamic confrontation, and marathon sessions. Mechanical aids include didactic motion pictures, movies of the patients while intoxicated, and taped records of previous sessions. Some therapists have experimented, as yet without definitive results, with milieus that reward and reinforce socializing behaviour, hoping thereby to extinguish the desocializing drinking behaviour. Many institutional programs rely on “total push,” subjecting the patient to a bombardment of methods, including drugs, hypnosis, physiotherapies, group sessions, lectures, Alcoholics Anonymous meetings, and individual psychological and religious counseling, with the hope that each patient will be affected favourably by whatever is most suitable for him. Other institutional programs rely on mere removal from the stressful outside environment, with a period of enforced abstinence. The therapists themselves may be psychoanalysts, psychiatrists, clinical psychologists, pastoral counsellors, social workers, nurses, police or parole officers, or lay counsellors–the latter often former alcoholics with special training.
The places of treatment are as varied as the modalities, ranging from general hospitals to mental hospitals to mental-health outpatient clinics to specialized inpatient sanitariums and specialized alcoholism clinics to jails and penitentiaries to medical and psychiatric private offices, with patients often moving, randomly or systematically, from one milieu to another.
Awareness of the social and environmental elements in alcoholism has led to the development of treatment for spouses and occasionally for whole families, either separately or jointly, in the recognition that “the patient” is not just the alcoholic but the family unit.
A new trend in the United States, partly stimulated by court decisions prohibiting the jailing of alcoholics for public intoxication, is the establishment of detoxication centres that provide first aid along with guidance toward more fundamental treatment. But even if adequate programs and facilities for treating alcoholism were available, it is unlikely that they would solve the problem, given the large number of new cases each year. Only preventive public-health programs can eliminate alcoholism and thus far no likely methods of prevention have been devised.
The patient-centred self-help fellowship of men and women called Alcoholics Anonymous enables its members to share their common experience and thus to help each other. AA was founded in 1935 by two alcoholics, Robert Holbrook Smith and William Griffith Wilson; the latter had been strongly influenced by the Oxford Group. The members strive to follow Twelve Steps, a nonsectarian spiritual program the central points of which are reliance on God or a higher power as each individual understands that concept and the value of help to other alcoholics. Now a worldwide community of hundreds of thousands, the fellowship is organized in local groups of indeterminate size, has no dues, and accepts contributions for its expenses only from those attending meetings–where members narrate the stories of their alcoholic careers and their recovery in AA. Affiliation of the society or its groups with churches, politics, organizations, or institutions is barred by the AA Twelve Traditions.
AA apparently meets deep-seated needs among its members by enabling them to associate with kindred sufferers who understand them, to accept the disease concept of alcoholism, to admit their powerlessness over alcohol and their need for help, to depend without shame or stigma on others, and to involve themselves in activities within the group and in helping other alcoholics. These goals seem to provide adequate substitutes for the alcohol-dependent way of life. AA is thought by many to be the single most successful method yet devised for coping with alcoholism. It has spawned some allied but independent organizations: Al-Anon, for spouses and other close relatives and friends of alcoholics, and Alateen, for their adolescent children. The aim of such related groups is to help the members learn how to help an alcoholic or, at any event, how to live with one. Professionals in the field tend to think of AA as an inexpensive form of group therapy and a useful ally but recognize, as do the more sophisticated members, that it is not a panacea nor is it suitable for all types of alcoholics. Most experienced therapists agree that any form of treatment is likely to show a higher rate of success if the patient can be persuaded simultaneously to join Alcoholics Anonymous.
AA groups around the world resemble each other and generally use the ideological literature (including translations) published by the central office in New York, although there are some variations in style and conduct. In some countries the AA groups are sponsored by or affiliated with national temperance societies or accept financial support from government health agencies. There are also clubs for former alcoholics, usually sponsored by a particular institution for its former patients. One Scandinavian group seeks to achieve a stable degree of moderate drinking, rather than total abstinence.
Results of treatment
The success of treatment in behavioral or personality disorders is always difficult to appraise, and this is the case in alcoholism. The effects of new treatments tend to be reported enthusiastically, but critical examination of the results tends to reduce or cast doubt on the rate of apparent success. Controlled studies, when carried out, usually undercut the claims. Follow-up studies of persons treated have usually been too brief to determine whether permanent results had been achieved, and in most cases the investigators failed to locate a substantial proportion of the former patients. Moreover, the measures of “success” are inconsistent. Some investigators regard only total abstinence as a successful outcome; others are satisfied if drinking bouts are curtailed and the patient’s life adjustment is improved. Perhaps between 25 and 50 percent of alcoholics who receive some form of treatment either become abstinent or achieve some abatement of the severity of their illness. Alcoholism treatment programs connected with businesses and industries, in which the alcoholic must participate if he wants to keep his job, have reported even higher success rates. Forms of frankly compulsory treatment, even if grudgingly endured by alcoholics, seem to have a high rate of effectiveness. Some investigators have suggested that the older the patient and the longer the duration of his alcoholism, the more frequent is the occurrence of “spontaneous” recovery.
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