Alcohol Dependence and Abuse
QUESTIONS TO ASK BEFORE ALCOHOL OR SUBSTANCE ABUSE TREATMENT, CHILDREN OF ALCOHOLICS
The abuse of alcohol in any of its various forms, exhibited by repeated episodes of excessive drinking often to the point of physical illness during which increasing amounts of alcohol must be consumed to achieve the desired effects.
The American Psychiatric Association ranks alcohol dependence and abuse into three categories (what society normally thinks of as "alcoholics"): 1) individuals who consume alcohol regularly, usually daily, in large amounts 2) those who consume alcohol regularly and heavily, but, unlike the first group, have the control to confine their excessive drinking to times when there are fewer social consequences, such as the weekend and 3) drinkers defined by the APA who endure long periods of sobriety before going on a binge of alcohol consumption. A binge can last a night, a weekend, a week, or longer. People in the latter two categories often resist seeking help because the control they exercise over their intake usually allows them to maintain a normal daily schedule and function well at work or at school aside from binges.
Other psychologists categorize alcohol dependence and abuse into "species." There are several species currently recognized by some in the medical community, including alpha, a minor, controllable dependence; beta, a dependence that has brought on physical complaints; epsilon, a dependence that occurs in sprees or binges; gamma, a severe biological dependence; and delta, an advanced form of gamma where the drinker has great difficulty going 24 to 48 hours without getting drunk. It should be noted, however, that many psychologists dispute these particular subdivisions on the grounds that the original data behind their creation has been shown to be flawed.
Alcohol dependence and abuse in adolescents and persons under 30 years of age is often accompanied by abuse of other substances, including marijuana, cocaine, amphetamines, and nicotine, the primary drug in cigarettes. These conditions may also be accompanied by depression, but current thinking is unclear as to whether depression is a symptom or a cause of alcohol dependence and abuse. Heredity appears to play a major role in the contraction of this disorder, with recent discoveries of genes that influence vulnerability to alcoholism. Studies of adopted children who are genetically related to alcohol abusers but raised in families free of the condition suggest that environment plays a smaller role in alcoholism's onset than heredity. Recent studies suggest that between 10 to 12 percent of the adult population of the United States suffers from some form of alcohol abuse or dependence.
Alcohol dependence and abuse typically appear in males and females at different ages. Males are more likely to begin heavy drinking as teenagers, while females are more likely to begin drinking in their mid-to-late twenties. In males, the disease is likely to progress rapidly; debilitating symptoms in females can take years to develop. According to the U.S. Department of Health and Human Services, 14 percent of males aged 18 to 29 report symptoms of alcohol dependence, and 20 percent revealed that their drinking has brought about negative consequences in their lives. As age progresses, these figures drop steadily. In females aged 18 to 29, similar statistics demonstrated that 5 to 6 percent admit to symptoms of dependence and that this number stays essentially the same until age 49, at which point it plummets to one percent. Females reporting negative consequences of drinking, however, begins at 12 percent but drops to statistical insignificance after age 60.
QUESTIONS TO ASK BEFORE ALCOHOL OR SUBSTANCE ABUSE TREATMENT
The following key issues should be considered in determining which option is the most appropriate for given circumstances:
- How severe is the substance abuse problem and is there any evidence (e.g., suicide attempts) to suggest that there may be other problems (e.g., depression)?
- What are the credentials of the staff and what form(s) of therapy (e.g., family, group, medications) are to be used?
- How will the family be involved in the treatment and how long will it be from treatment entry to discharge? Is there a follow-up phase of treatment?
- How will the adolescent continue his/her education during the treatment?
- How much of the treatment will our insurance cover and how much will we need to pay "out of pocket?"
A key physiological component of alcohol dependence is what is referred to as neurological adaptation, or, more commonly, tolerance, whereby the brain adapts itself to the level of alcohol contained in the body and in the bloodstream. This process occurs over time as the drinker drinks more regularly while increasing intake in order to achieve the desired effect. In some cases, however, high levels of tolerance to alcohol is an inborn physical trait, independent of drinking history.
There is considerable debate as to the exact nature of alcoholism (the biological disease) and alcohol dependence and abuse (the psychological disorders). The disease model, which has been embraced by physicians and Alcoholics Anonymous for more than 50 years, is undergoing reexamination, particularly for its view that total abstinence is the only method for recovery. Many psychologists now believe that some victims of alcohol dependence and abuse can safely return to controlled drinking without plunging back into self-destructive binges. Experiments have been conducted that indicate the consumption of a few drinks after a lengthy period of abstinence can lessen the resolve to remain totally abstinent, but that a devastating return to abusive drinking is not the inevitable result. In fact, some psychologists contend that the binge drinking that occurs after initially "falling off the wagon" is less a result of the return of alcohol to the body than to the feelings of uselessness and self-pity that typically accompany such a failure to keep a promise to oneself.
CHILDREN OF ALCOHOLICS
A number of researchers have studied children of alcoholics (COAs) and their counterparts, children of non-alcoholic parents (nonCOAs). These points summarize their findings:
COAs and non-COAs are most likely to differ in cognitive performance: scores on tests of abstract and conceptual reasoning and verbal skills were lower among children of alcoholic fathers than among children of non-alcoholic fathers in one study (Ervin, Little, Streissguth, and Beck).
A research team (Johnson and Rolf) found that both COAs and mothers of COAs were found to underestimate the child's abilities.
School records indicate that COAs are more likely to repeat grades, fail to graduate from high school, and require referral to the school psychologist than their non-COA classmates. (Miller and Jang; Knop and Teasdale)
Researchers (West and Prinz) found that COAs exhibit behavior problems such as lying, stealing, fighting, truancy, and are often diagnosed as having conduct disorders.
Although it may be premature to suggest that a paradigm shift has occurred in the psychological community regarding alcohol dependence and abuse, many researchers do in fact believe that the disease model, requiring total, lifelong abstinence, no longer adequately addresses the wide variety of disorders related to excessive, harmful intake of alcohol. It is important to note, however, that the human body has no physical requirement for alcohol and that persons with a history of uncontrollable drinking should be very careful in experimenting with alcohol after having achieved a hard-won abstinence. Other factors to keep in mind are problems alcohol can cause to the fetuses of pregnant women, a condition known as fetal alcohol syndrome (FAS). Some researchers believe that children born with FAS are prone to learning disabilities, behavior problems, and cognitive deficits, although others feel the evidence is insufficient to establish a reliable link between these problems and FAS. Alcohol also has a negative effect on human organs, especially the liver, and a lifetime of drinking can cause terminal illnesses of the liver, stomach, and brain. Finally, drunk driving is a tremendous problem in the United States, as are violent crimes committed by people who are under the influence of alcohol. Findings for alcohol expectancies among school-age children indicate increasingly positive alcohol expectancies across the grade levels. By fourth grade children tended to believe that use of alcohol led to positive outcomes, such as higher levels of acceptance and liking by peers and a good mood with positive feelings about oneself. Findings also indicate that 25% of fourth graders studied reported feeling at least some peer pressure to consume alcoholic beverages; this figure increased to 60% among seventh graders
Dr. John Ewing developed a four-question test, known as the "CAGE" test, that therapists and the medical community frequently use as a first step to evaluate alcohol dependence and/or abuse. The test takes its name from a key word in each question: 1) Have you ever felt you should Cut down on your drinking? 2) Have people Annoyed you by criticizing your drinking? 3) Have you ever felt bad or Guilty about your drinking? And 4) Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? One yes suggests a possible alcohol problem.
Treatment modalities vary. Professionals frequently employ a combination of modalities. Studies indicate cognitive behavioral therapies improve self-control and social skills. Behavioral and group therapy have also proven effective. Self-help programs include Alcoholics Anonymous, Smart Recovery, and Rational Recovery. In some cases medications designed to ease drug cravings or block the effects of alcohol are prescribed. To reduce cravings, even acupuncture is being tried. The managed care environment has contributed to a belief that treatment should occur in the least restrictive settings that provide safety and effectiveness. Treatment settings vary from hospitalization to partial hospital care to outpatient treatment to self-help groups.
Barlow, David H. and V. Mark Durand, eds. Abnormal Psychology. Pacific Grove, CA: Brooks/Cole, 1995.
Knapp, Caroline. "My Passion for Liquor." New Woman (August 1995): 80-83.
Noble, Ernest P. "Moderate Drinking Is Not for People in Recovery." Addiction Letter (September 1995): 1-2.
Sheed, Wilfrid. "Down in the Valley." Psychology Today (November 1995): 26-28.
Szpir, Michael. "Alcoholism, Personality, and Dopamine." American Scientist (September 1995): 425-26.