FREE ESSAY ON ALCOHOLISM

ALCOHOLISM

alcoholism
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.
Physiological therapies 
Chemical fences 
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.
Aversion 
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.
Psychological therapies 
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.
Alcoholics Anonymous 
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.