DIAGNOSIS, CLINICAL ASPECTS, AND
By Joseph R. Volpicelli, M.D., Ph.D.
Alcohol drinking has decreased in recent
two- thirds of all adults drink alcohol and one-third of all high
seniors report that they drink alcohol. The average alcohol consumption
for Americans over the age of 14 is 3 gallons of pure alcohol per
per year. The lifetime prevalence of alcoholism is about thirteen
in the United States. There are significant sex differences: about five
times as many men as women are alcohol-dependent . About one in five of
the people who use alcohol for recreational purposes become
for some part of their lives. Later, we will discuss why certain people
may be at special risk to become dependent on alcohol.
Alcohol-related deaths account for about
of all deaths in the U.S.--this ranks alcohol-related death between the
3rd (cerebrovascular diseases) and 4th (injuries) major causes of death
(Stinson, 1992). It is impossible to calculate the high cost of human
but we can calculate the cost of alcohol dependence with medical
lost work productivity and legal costs. On this basis alone, it is
that alcohol dependence costs society about 116 billion dollars per
(National Council on Alcoholism, 1986). About 40 percent of all
admissions are alcohol-related. Alcohol-dependent people use health
at twice the rate of the general population. Alcohol dependence is the
leading cause of lost productivity resulting from missed work days, as
well as, home and industrial accidents. Legal costs from drunk driving
and the prosecution of rapes and homicides also contributes to the high
cost of alcohol dependence.
DEFINITION OF ALCOHOL DEPENDENCE
When does someone cross that boundary
alcohol use and dependence? Three main symptom clusters have been used
to help draw this distinction.
Loss of Control. Some people have defined
by focusing on the degree of control over alcohol. In the past,
experts called this psychological dependence. For example, a business
may plan to have 1 or 2 beers after work, but he ends up having 5 or 6.
Loss of control also becomes evident when a person makes repeated, but
unsuccessful, attempts to cut down or stop drug use. Finally, loss of
is marked by compulsive thoughts and actions. Much of the day is spent
either thinking about getting high again or recovering from a previous
Maladaptive Consequence. A second measure
dependence is the presence of negative psychological, social, and
consequences. As discussed above alcohol dependence is the leading
of missed days at work. Alcohol dependence is also associated with
medical problems which we will discuss in more detail below. People who
continue to use alcohol despite adverse effects on their health,
or social functioning show symptoms of alcohol dependence.
Biological Adaptation. Finally, some
experts define dependence solely with physiological adaptation to
In the past this has been referred to as physical dependence. Physical
dependence is shown by either tolerance or withdrawal. Tolerance is
as a decrease in the response to alcohol as use continues over time.
it takes a progressively larger amounts of alcohol to produce the same
effect. Chronic alcohol users may also experience withdrawal symptoms
as rapid heart rates or excessive sweating when they stop or decrease
drinking. People who show either physical tolerance or symptoms of
are said to be physically adapted to the drug.
CLINICAL COMPLICATIONS OF ALCOHOL
The behavioral effects of alcohol
on two factors: one's beliefs and expectations about alcohol and the
of alcohol consumed. These factors interact in complex ways to
For example, many people think that
alcohol can increase
sexual arousal. Contrary to these expectations, sexual arousal
as blood alcohol level increases. However, sexual arousal increases for
people who believe they have consumed alcohol, but have really been
a non-alcohol substitute.
The dose of alcohol also interacts with
effects. Alcohol is a CNS depressant. At low doses, however, it
depresses inhibitory centers. This means that alcohol may decrease
inhibitions at low doses, and paradoxically increase aggressive or
behaviors. For example, some people will have a drink or two before a
function to decrease their social inhibitions. Other people are more
to express their feelings including anger when intoxicated. About one
of all suicides and homicides occur during alcohol intoxication. Also,
thirty-five percent of all rapes are related to alcohol drinking,
At higher concentrations (BAC > 100 mg
depresses both the excitatory and inhibitory centers. That is it
everything, from rational thinking to motor coordination. Alcohol
is responsible for about 50 percent of fatal car accidents and accounts
for 25,000 traffic fatalities each year. At still higher concentrations
(BAC > 500 mg %), alcohol suppresses consciousness leading to
Finally, alcohol can suppress respiratory centers and, particularly
combined with other sedatives (e.g.Valium), can lead to death.
Chronic Alcohol Dependence
There are several medical and psychiatric
from alcohol dependence. Clinical effects of alcohol dependence are
Gastrointestinal. Alcohol dependence is
the most common
cause of cirrhosis of the liver, the eighth leading cause of death in
United States. Alcohol is also associated with other gastrointestinal
such as ulcers, gastritis, and pancreatic cancer.
Cardiovascular. Alcohol causes several
complications and is responsible for about 15% of all cases of
and most of the cases of cardiomyopathy.
Neurological. Chronic alcohol dependence
severe damage to the peripheral and central nervous system. Peripheral
neuropathy is often responsible for the ataxia seen in chronic
Other neurological complictions caused by chronic alcohol abuse include
the following: Weinicke's disease (ocular disturbance, ataxia and
associated with thiamine dificiency, Korsakoff's psychosis, a permanent
inability to learn new information and finally, structural changes in
brain associated with severe cognitive impairment (dementia).
Immunologic. Alcohol drinking suppresses
function and cell-mediated immunity. This predisposes alcoholics to
infections including fatal cases of pneumonia and tuberculosis.
of cell-mediated immunity may be responsible for the higher incidence
several types of cancers seen in alcoholics.
Endocrine. Male alcoholics have increased
and decreased testosterone. This leads to impotence, testicular atrophy
Obstetric. An often overlooked
complication of alcohol
drinking is the adverse effects of alcohol during pregnancy that can
mental retardation, facial deformity, other neurological problems
Psychiatric. Chronic alcohol dependence
is often associated
with emotional problems. Many alcoholics have co-existing anxiety
(about 25%), depression (20%-40%), and occasionally hallucinations
hallucinosis). It is not clear if psychiatric disorders predispose to
dependence (self- medication hypothesis) or result from chronic abuse
alcohol. Alcohol-dependent patients are often suicidal, and about
of all suicides are committed by alcoholics, generally white males over
35 years old.
Just as alcohol intake depresses the
alcohol withdrawal produces overexcitation of the nervous system. Many
alcoholics begin to experience tremors called "the shakes" about 24
after their last drink. Without a drink, they begin to experience rapid
heart rates, sweating, decreased appetite, and difficulty sleeping. For
some individuals, symptoms of withdrawal can become quite severe. One
three days after their last drink, alcoholics can have a generalized
(rum fits). About three to five days after their last drink, these
can suffer from disorientation, high fevers, and visual hallucinations.
This syndrome is call delirium tremens (DTs). During the DTs people are
very susceptible to suggestion. For example, one patient became
that a pink elephant was dancing on an imaginary string between his
fingers. Individuals in DTs can also be paranoid. The DTs are a serious
medical emergency. Before aggressive modern medical treatment, fifteen
percent of patients with DTs died. Now with adequate medication and
support, fatalities from DT's are rare.
Following this initial withdrawal phase,
go through protracted alcohol withdrawal. This can last anywhere from
to four weeks. People in the protracted withdrawal phase remain anxious
and have difficulty eating and sleeping. In serious cases, alcohol
CAUSES OF ALCOHOL DEPENDENCE
All the psychological theories of drug
that alcohol satisfies some important need. Psychoanalytic theories
on unconscious needs while behavioral theories focus on the role of
reduction to account for alcohol abuse.
Psychoanalytic. One early psychoanalytic
that children who are fixated at the oral stage are more prone to abuse
alcohol later in life. Psychoanalysts theorize that oral fixation
when children are either frustrated in their oral dependent needs
mother) or too easily satisfied by oral stimulation (overprotective
When stressed as adults, oral-dependent people are more likely to turn
to alcohol to cope.
Adams (1978) suggests that it is not
who develop oral traits but rather children (particularly boys) with
mothers. Later in life such men will have a strong need to remain
on either their mother or another woman. When their needs become
they become angry. Unable to deal with anger assertively, these people
find that alcohol provides an effective way to reduce aggressive
It has the additional advantage of hurting those people around
Psychoanalytic theories make some
intuitive sense since
many alcoholics have immature social skills. They often turn to alcohol
to help cope with life stresses. Despite this intuitive appeal, there
little prospective data to support these theories. An alcohol dependent
person may exhibit dependent traits, however, these traits are just as
likely to result from chronic alcohol use as they are to lead to it.
if correlations exist between alcohol abuse and dependent
it is not clear which is the cause and which is the effect. In summary,
there is little evidence to support the oral fixation theory.
Tension Reduction. Another important
theory for alcohol
abuse is that alcohol drinking is reinforced because alcohol reduces
Conger (1951) proposed the Tension Reduction Hypothesis as a model for
alcohol drinking. The model assumes that alcohol can reduce tension and
people learn to drink alcohol to avoid or reduce unpleasant stress.
observations and studies appear to support this theory.
First, alcohol dependence and anxiety
coexist. Many anxious patients say that drinking alcohol helps them
anxiety. This is especially true of phobic patients who often use
to help face their fears. One patient could only travel over bridges
drinking five or more beers. Another patient needed to drink before
any social function. She would have one or two drinks while getting
and another two or three at the social function to help her feel more
One can easily see how using alcohol in this way can quickly lead to
sorts of problems we have outlined.
Alcohol relapse often occurs following a
event such as loss of a job or death of a spouse (Marlatt and Gordon,
For example, one patient had a very severe relapse following the
with his girlfriend. Stress from the breakup may have increased the
desire to use alcohol to relieve this stress. Epidemiological studies
support the Tension Reduction Hypothesis, since alcohol drinking is
with cultural stress. States with high rates of divorce, births,
and other stressful life events also have high rates of alcohol abuse
Straus, and Colby, 1985).
While clinical and epidemiological
the Tension Reduction Hypothesis, experimental studies fail to show
increased tension leads to increased drinking. If people drink alcohol
to reduce tension, we would expect that alcohol drinking would increase
during tension-arousing situations. This prediction led to many
results. For example, in laboratory studies, subjects who are
with an electric shock or who receive feedback that they have done
on a test do not increase drinking.
How can we account for these conflicting
tension reducing properties of alcohol may be specific to certain
Alcohol may reduce tension only for social stress but not for other
of stresses. Also, alcohol may reduce tension only in particular doses
(low doses but not high doses) and under certain conditions (in
but not experimental situations). In addition, alcohol may reduce
only for some individuals who carry a gene for alcoholism. Finally,
may not reduce tension but may dampen the impact of a stressful
The results of several studies support this hypothesis. Experienced
drinkers who are threatened with electric shock or social evaluation
less subjective and physiological signs of anxiety when intoxicated
when sober (Levenson, et al., 1980).
Recent reviews suggest yet another view
of the relationship
between stress and alcohol drinking. According to this analysis people
do not drink alcohol to reduce tension. Rather, they drink once tension
has stopped and a sense of relief has set in. This is known as the
hour" effect. It accounts for the frequent observation that anxiety and
alcohol drinking often go together. However, it is the sudden removal
stress that sets the occasion for drinking, rather than the situation
stress . For example, Volpicelli et al. (1990) found that rats
their alcohol drinking following, but not during, uncontrollable
In another study, rats living in a fearful environment tended to drink
less alcohol than rats removed from the fearful environment and placed
in a safe, home cage (Volpicelli, et al., 1982). One study of college
showed similar results. After completing a difficult (stressful) test,
half the students were told they did poorly, scoring in the lower 15th
percentile of their peers. The other half were told they did well,
in the upper l5th percentile. The relieved subjects--who thought they
well on the test -- drank more alcohol than subjects who believed they
did poorly (Lisman, 1986).
Genetics. Researchers have discovered
dependence runs in families. A classic study by Goodwin (1974),
the adopted children of alcohol-dependent parents to the adopted
of non-alcohol-dependent parents. In the children of alcohol-dependent
biological parents, the risk of becoming alcohol dependent increased.
contrast, if the adoptive parents were alcohol-dependent, there was no
increased risk of alcoholism. In general, if one biological parent is
the likelihood of a child becoming dependent increases nearly three
If both parents are alcoholic, the likelihood of alcohol dependence
about five times. However, the likelihood of alcohol dependence does
increase in children whose nonbiological parent is dependent on
This work shows that genetic factors affect the risk of alcohol
more than the family environment.
In an attempt to determine what specific
factor(s) increase their risk of alcohol abuse, researchers have
a series of studies comparing the biological children of alcohol
parents to the biological children of non-alcoholic parents. Several
emerge between these two groups.
One source of biological vulnerability
high risk subjects have some instability in their nervous system that
be counteracted by drinking alcohol. For example, sons of alcohol
fathers are less able to hold their body still when asked to stand at
compared to sons of nonalcoholic fathers (Hegedus et al., 1984).
people without alcoholic fathers sway more when intoxicated. However,
sons of alcoholic fathers drink alcohol, there is less body sway
1985). Also, patients who have an inherited disorder in which their
shakes, familial essential tremor, are more likely to abuse alcohol.
they drink alcohol, the tremor vanishes.
Another biological mechanism that may put
risk for alcohol dependence is increased sensitivity to the pleasure
effects of alcohol. Alcohol dependent patients will often report that
noticed a wonderful calm high the very first time they drank alcohol.
dependent patients also show pain relief, analgesia, following a small
dose of alcohol. These studies suggest that alcoholics receive more
or obtain more pain relief compared to non-alcohol abusing people.
Similarly people who are not abusing
alcohol, but have
alcohol dependent parents, are more sensitive to the pleasure producing
effects from alcohol. They report more pleasure associated with their
drink (Negoshi and Wilson,1987). Also, high risk people show increased
alpha waves (a measure of relaxation) after a small dose of alcohol.
studies show that in subjects with alcoholic parents, small doses of
increase peripheral levels of beta-endorphin by 170 percent. In
subjects without alcoholic parents do not have this large increase in