Alcoholism & Alcohol Dependence

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Defining Alcoholism

What Is Alcoholism?

KEY TAKEAWAY

The term alcoholism refers to the consumption of alcohol to the extent that the individual is unable to manage their own drinking habits or patterns, resulting in side-effects that are detrimental to the quality of life of the alcoholic, or those around them.

An alcoholic is someone who continues to compulsively abuse alcohol in this way, despite the negative consequences in their life.

Someone with an alcohol problem will usually exhibit:

  • A physical compulsion to drink, beyond the underlying emotional addiction to alcohol
  • A mental obsession around access to alcohol, and securing access to the next drink
  • An automatic emotional response to use alcohol as a means to cope with life's stressors
  • Behaviour patterns to ensure ongoing access to alcohol. In more extreme cases, this may be at the cost of relationships, jobs, or other key life factors
  • Denial of the extent of their problem, and outright refusal to get help for alcohol addiction

Alcohol Use Disorder

Since "alcoholic" is perceived by many as an unhelpful term, alcoholism is often referred to as "alcohol use disorder" instead.

The extent to which someone is suffering from Alcohol Use Disorder, is defined by DSM-5 criteria, as the number of symptoms they experience from a list; where:

  • Mild Alcohol Use Disorder = 2-3 symptoms present
  • Moderate Alcohol Use Disorder = 4-5 symptoms present
  • Severe Alcohol Use Disorder = 6 or more symptoms present

Under these guidelines, an alcoholic is someone who fulfils any 2 or more criteria outlined in DSM-5 within the same 12 month period:

DSM-5 Criteria For Alcohol Use Disorder

1) Consuming more alcohol over time, or for longer than you intended.

2) Having a desire to stop drinking, but being unable to achieve this in practice.

3) Excessive time spent on obtaining, using, or recovering from alcohol use.

4) Experiencing cravings and strong urges to consume alcohol.

5) Being unable to fulfil obligations at home, school, or work, as a result of alcohol use.

6) Continuing to use alcohol, even when it causes relationship or social problems.

7) Neglecting important activities at work, socially, or recreationally, because of substance use.

8) Increasing exposure of self to risk, or danger, as a result of repeated and ongoing alcohol use.

9) Continuing to consume alcohol, even when you know you have a physical or psychological problem that could have been caused or made worse by alcohol.

10) Requiring more alcohol to get the same euphoric effect (developing tolerance).

11) Development of withdrawal symptoms, which can be relieved by drinking more alcohol.

What Is Binge Drinking?

Binge drinking refers to a pattern of excessive but temporary drinking for short periods, usually repeated over time. Binge drinkers may exhibit signs of long term alcohol addiction, but rationalise their drinking as a result of celebrations or other external events.

Binge drinking is considered a significant precursor to, and risk factor for, alcohol use disorder.

Binge drinking is defined as:

  • Males - 5 or more drinks per one day during the past month
  • Females -  4 or more drinks per one day during the past month

What Is Heavy Drinking?

Heavy drinking is usually defined as:

  • Males - 15 or more drinks per week
  • Females -  8 or more drinks per week

SAMHSA define heavy drinking as binge drinking for 5 or more days in the last month. [1]

Warning Signs Of Alcoholism

Based on our experience of working with thousands of clients since 2005, if you answer yes to 2 or more of the following questions, you may have an alcohol problem.

This is based on qualitative, subjective experience of our client group, as opposed to quantitative research data.

  • Can you consume alcohol on occasion without later craving the same feelings you achieved from the initial experience?
  • Are you thinking about consuming alcohol during regular day to day activities such as work, family time, or relationship life?
  • Do your everyday thoughts include obsessing about alcohol, or when your next drink will be?
  • Does consuming alcohol, or thoughts of alcohol, impede upon your other daily life activities?
  • Has your pattern of alcohol use progressed beyond occasional or become more frequent?
  • Does your alcohol use habitually co-incide with, or after specific situations in life such as work, relationship issues, children, finances, etc?
  • Does your ability to cope with certain events or situations in life depend upon alcohol use?
  • Do you show signs of irritability before or during drinking?
  • Are there difficulties at home or work as a result of your drinking?
  • Do you worry about having access to alcohol?
  • Is the amount of alcohol you consume slowly increasing over time, without any external event prompting this?
  • Do you promise to yourself or others to quit or reduce drinking habits, then later renege on those promises?
  • Do you prioritise drinking over other day to day activities, your personal appearance, hygiene, health, and emotional life?
  • Do you set out to drink a little, but end up drinking a lot?

Alcoholism Signs & Symptoms

Since alcohol addiction is a behaviour, the signs of alcoholism can be recognised as behaviours, alongside how these behaviours usually manifest physically, later.

Emotional & Behavioural

  • Consuming increasing amounts of alcohol, over time
  • Drinking alcohol alone, deliberately
  • Habitual rationalisation, excusing drinking behaviour
  • Emotional or angry outbursts when challenged on drinking behaviours or actions whilst under the influence of alcohol
  • Neglecting physical appearance, daily responsibilities such as paying bills, etc

Physical

The impact of alcoholism on the physical body is normally proportionate to the amount of alcohol consumed, and the pattern or frequency of usage.

Physical effects can include:

  • Loss of appetite and weight reduction
  • Fatty liver, progressing to cirrhosis, in later stages
  • Compromised brain function and neurotransmitter balance
  • Nervous system damage, especially peripheral nervous system
  • Heart disease
  • Pancreatitis
  • Increased risk of stroke, cancer, dementia, seizures

Short Term Effects Of Alcohol Abuse

Blood Alcohol Concentration

Although dependent on intake history, BAC counts of up to .12% usually result in increased sociability, elevated mood, and somewhat delayed motor response.

As alcohol intake increases, and BAC count rises, effects can vary from co-ordination and balance issues, to coma, and danger to life.

Long Term Effects Of Alcohol Abuse

Liver damage, starting with fatty liver deposits, progress in later stages of alcoholism to cirrhosis of the liver, hepatic portal vein blockage, and ascites.

Alongside long term alcohol abuse run increased risks of pancreatitis or pancreatic cancer, stroke, memory loss, diabetes, heart disease, hepatitis, anemai, gout, gastritis, ovarian or prostate cancer, and central or peripheral nervous system dysfunction.

Tests For Alcoholism

Gov.uk FAST Alcohol Screening Test

FAST (Fast Alcohol Screening Test) is a short questionnaire used by emergency departments in the UK. It consists of a sub-set of questions from the larger AUDIT (Alcohol Use DIsorder Identification Test) test.

A score of 3 or more on the first or all 4 questions indicates a positive result, requiring completion of the remaining AUDIT questions.

AUDIT Screening Test

The remaining six questions in the AUDIT screening test indicate risk or likelihood of alcohol dependence.

NIAAA 11 Point Checklist

In the United States, the National Institute on Alcohol Abuse and Alcoholism provide the following checklist for categorisation of alcohol use disorder as mild, moderate, or severe.

How many times in the past year have you:

  • Drank more or longer than you'd planned?
  • Wanted to stop drinking but couldn't?
  • Spent a lot of time drinking and/or being sick afterwards?
  • Craved drink?
  • Found drinking to interfere with home, family, friends, work, or school?
  • Continued to drink despite problems?
  • Foregone doing something you love in favor of drinking?
  • Found yourself in dangerous situations while or after drinking?
  • Had blackouts or other medical problems caused or worsened by drinking?
  • Increased alcohol intake because you've built up a “tolerance”?
  • Experienced withdrawal symptoms when you didn't drink?

CAGE

The CAGE questionnaire is a short, easily applicable test, most often used in primary care settings.

  • C - Have you ever felt you should cut down on your drinking?
  • A - Have people annoyed you by criticizing your drinking?
  • G - Have you ever felt bad or guilty about your drinking?
  • E - Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Two positive responses to any of the above questions indicates existence of an alcohol problem that should be further explored.

Physical Health Tests

On a physical level, a Liver Function Test (LFT) can show deranged liver function attributes such as Bilirubin levels, or high blood levels of the enzyme Gamma Glutamyl Transferase which can indicate damaged bile duct function consistent with alcoholism.

Reasons People Drink

Indulging in the odd drink for a celebration is different to how someone in active addiction drinks alcohol.

So why do people abuse alcohol in an addictive way?

Physical Dependence

Like any drug, during the early stages, alcohol intake causes pleasant feelings such as relaxation, euphoria, increased sociability, etc.

In the longer term, the neurotransmitter mechanisms in the brain which are triggered by alcohol become 'habituated', meaning it requires greater and greater amounts of the substance to achieve the same cascading effects on other centres in the brain.

This leaves the individual chasing the original feelings of pleasure they first experienced, although these are never achievable in reality.

KEY TAKEAWAY

The brain and nervous system ultimately become used to the external substance of alcohol being present, and expect it to be present, for the processes of generating other neurotransmitters, and signalling other systems in the brain.

If alcohol is suddenly removed from the system, or not enough is present, this results in side-effects consistent with under-representation of certain neurotransmitters and modulators, meaning physical effects appear, such as trembling, headache, blood pressure changes, cardiac and breathing issues, etc.

When an alcohol addiction goes unchecked in this way for long enough, withdrawal from alcohol for even a minor time period, can lead to life threatening symptoms, very quickly.

At this point the individual is drinking not to attain pleasurable feelings, but to avoid much more serious withdrawal symptoms.

Co-occurring Mental Health Issues

Some will attempt to use alcohol to compensate for emotional issues, in the absence of other solutions, e.g. a diagnosis of non-complex anxiety or depression, or an issue with coping skiils or isolation/lack of connection with others.

In some cases, the individual has been diagnosed with a more complex psychological complaint such as bipolar disorder, a personality disorder, an eating disorder, or similar.

In these cases, it becomes very difficult to know which came first - the emotional issue, or the addiction.

Sometimes, the emotional issue has become compunded by alcohol, but, pre-dated alcohol use.

Other's experience is such that it seems as though alcohol use in some ways causes the emotional issue.

Individuals with a confirmed diagnosis of a complex mental health issue like this, can find themselves in a position where mental health workers refuse to progress treatment for (e.g.) anxiety or depression, until the underlying addiction is resolved.

However, the individual can feel that taking away the coping mechanism of alcohol, will increase anxiety or depression to an unmanageable degree.

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Causes Of Alcoholism

Environmental

Upbringing & Beliefs

In our own work, therapeutic breakthroughs with alcoholics often reveal that self-esteem issues developed early in life can lie beneath the repeated use of a coping mechanism like alcohol.

Exposure to alcohol use from a young age may increase likelihood of alcohol use later in life, and children can develop a conclusion about alcohol such that "the way to deal with stress in life, is to use alcohol."

Secondary beliefs children develop from observational learning can also corroborate the normalisation of alcohol intake. When young people witness the rationalisation of the negative side-effects of alcohol use, this can perpetuate false beliefs around alcohol, and allow the abuse of the substance to continue unchallenged.

Psychological Factors

Continued stress raises blood cortisol levels which can in turn increase likelihood of alcohol abuse, especially where alcohol has previously been used as a coping mechanism. [2]

A history of trauma can indicate a higher risk for alcoholism, or other addictions, as a means to cope with the unresolved emotional issues.

A history of depression or other more complex mental health issues, such as bipolar disorder, schizophrenia, or borderline personality disorder, may coincide with greater incidence of alcohol addiction, in our experience.

Social Group

  • Poor social connectedness - We've witnessed specific social patterns attached to alcohol abuse. Specifically, poor social connections, lack of accountability to others, and voluntary self-isolating behaviour can result in increase alcohol abuse.
  • Peers - Where peers demonstrate drinking as a coping mechanism, and enable the use of alcohol, pressure to drink can increase where it is perceived that not drinking may risk being ostracised from the group.
  • Enablers - Family and/or close friends can often act - unintentionally - as enablers in assisting the alcoholic to continue drinking.

This often manifests as a desire to help a loved-one avoid pain in the short term, e.e. attached to a specific event. In this way, the alcoholic can gain access to money or resources required to continue abusing alcohol, as a means to overcome a life difficulty in the short term.

However, in the long term, this action only results in the alcoholic concluding that:

  • They can access alcohol when needed, as a means to escape from life's events or responsibilities
  • They will be enabled by others, in doing so
  • That using alcohol in this way, as a coping mechanism, is not only acceptable, but endorsed.

Later, when the addiction has spiralled out of control, these beliefs will often lead to manipulative or other malicious behaviour, in order for the alcohol to continue to access alcohol.

 Thus, the cycle has been lengthened, and the long term addiction enabled, by the family members.

KEY takeaway

What family members and loved ones need to realise here, is that at this point in the addiction cycle, alcohol has become the *only* way the alcoholic knows how to cope.

It used to be *one* way to cope, but now, it's the *only* way out.

Once the shame of a series of such events begins to compound each other, it's easy to see how a mild addiction escalates quickly into a serious one....as the emotional pain of admitting dependence would mean accepting responsibility for negative behaviours during addiction, and their consequences.

And, for most alcoholics, this is too much to bear, especially if access to alcohol is still readily available.

Genetic

Hereditary or genetic factors may render some individuals pre-disposed to developing an addiction to alcohol or other substances, e.g. if the individual has a parent or other relative who had problems with alcohol.

Existing evidence indicates that alcoholism is 50-60% genetically determined. [3]

High Functioning Alcoholism

What Is A High Functioning Alcoholic?

A high functioning alcoholic can be thought of as someone who may have a job that pays well, family life and established social bonds, yet still uses alcohol in a way that has detrimental effects on their lives.

Sometimes such individuals have developed a specific emotional deficit that they use alcohol to compensate for, e.g. the workaholic who believes "I'm never good enough," and uses alcohol to numb the emotional pain of the belief, as well as the toll the excess work takes on his body and personal relationships.

High functioning alcoholics are caught in the same cycle as anyone else suffering from addiction, but their habits may be perceived as more socially acceptable to others, based on their apparent ability to function well in specific areas of their life.

Signs Of A High Functioning Alcoholic

Denial

A high functioning alcoholic may use the external signs of his/her success as a reason to deny problematic drinking behaviour.

Nevertheless, no matter how outwardly successful the individual is, heavy abuse of alcohol over time, will ultimately catch up with the person in the form of physical and emotional issues.

Statistics On Alcohol Addiction

The WHO (World Health Organisation) reports an estimated 3.3 million deaths each year globally as a result of alcohol misuse, with 380 million people worldwide suffering from alcoholism. [4]

Alcoholism is least common in Africa, affecting only 1% of the population; whereas, Eastern Europe is worst affected, with 139,000 deaths from alcoholism in 2013 (same source). [5]

10% of all dementia cases are secondary to alcoholism. [6]

Up to 25% of alcoholics suffer from severe psychiatric issues. [7]

Around 12% of American adults have an alcohol problem at some point during their life. [8]

Over 50% of all suicides are connected to alcohol or drug addiction issues. [9]

47% of liver disease deaths in 2015 were correlated with alcohol use. [10]

Alcohol Poisoning

Alcohol poisoning occurs where alcohol intake has reached levels such that vital organs such as the brain and heart, begin shutting down, dramatically increasing risk of death.

2,200 people per year, or 6 people per day, die due to alcohol poisoning. [11]

Is Alcoholism Preventable?

Problem drinking most often develops slowly, over time. And since moderate alcohol intake is generally not a sign of emotional or physical dependence in the short term, someone's bad relationship with alcohol can be difficult to perceive clearly, until it's much more developed.

Nevertheless, there are ways to minimise the risk of alcoholism appearing as an issue in your or others' lives.

  • Maintain strong social connectedness, especially during life's stressors and challenges. This means, developing strong coping mechanisms and a network of people who can assist you both personally and professionally, when life's issues arise.
  • Interpret mistakes and problems as temporary, and without impact upon who you are, your identity, or other unuseful conclusions that would impact upon self-esteem etc
  • Guard against the development of underlying mental health risk factors such as depression or anxiety, by quickly speaking up ,and asking for help, if you need it.
  • If you have a family history of addiction, be aware of the increased risks associated with this, and be alert to the possibility of skewed perceptions around what is a normal amount of alcohol to consume.
  • Take responsibility for your drinking. Be honest with yourself and others as to how your drinking impacts your life.
  • Ask yourself if alcohol is really an appropriate response, or way to cope with, certain situations or difficulties in life.
  • If you think you may be developing an alcohol problem, get external, qualified, opinion on your drinking habits, as quickly as possible.

Treatment Options For Alcoholism

Most, but not all, treatment options for alcoholism include the concept of abstinence.

This means, ceasing alcohol intake permanently, and maintaining this abstinence, over time.

Intervention

Intervention usually means having a group of loved ones gather around the individual suffering from alcoholism, to explain the negative consequences their addiction is having, usually with a view to helping the individual reach a decision about getting external help.

Part of this approach often involves explaining the negative consequences of what may happen, if the individual does not seek help.

We released more specific guidelines on how to help someone in this situation, in our pdf guide "How To Help A Loved One In Denial", available here (PDF Download).

How To Help A Loved One In Denial:
Step-By-Step

Supervised Detox & Rehabilitation

Undertaking a controlled detox from alcohol in a supervised setting can assist with the most dangerous elements of withdrawing from alcohol, as a springboard to move forward into the therapy work, and aftercare support, required for long term recovery from alcohol addiction.

Alcoholics Anonymous & Other Mutual Aid Support Groups

Whilst Alcoholics Anonymous does not offer medically supervised treatment, their community-driven mutual aid support group has brought together individuals who wish to stop drinking, world-wide, since the 1950s.

AA and other mutual aid groups typically require only that members have an underlying intention to stop drinking, and do not get involved in any form of treatment, opinion, or funded endeavour in the world of recovery.

FAQ

What is the prognosis for an alcoholic?

Long term recovery from alcoholism is possible, but requires reversing all of the physical and emotional habits, developed over time, during the period of active addiction. How challenging this is, will depend on a person's history with alcohol, and their emotional reasons for using alcohol as a coping mechanism in the first place.

This also does not account for the time taken to reverse any physical manifestations of addiction, such as liver damage, damage to heart, circulation, pancreas, peripheral nervous system, etc.

Are the effects of alcoholism reversible?

This will depend on the extent of physical damage caused to liver and other vital organs. In some extreme cases hospitalisation and close monitoring are required to stabilise liver function and respiratory responses until the body has a chance to heal.

In other less extreme cases, a more standardised regimen of alcohol detox medication can help restore equilibrium to the physical body and organ function.

The psychological recovery from alcoholism will entail greater amounts of emotional work, over an extended period of time. This can be thought more as a lifestyle change, than a one-off exercise.

What medications are used to treat alcohol abuse?

Different types of medication may be used depending on qualified professional advice, and the intended outcome.

  • Medications from the diazepine family, such as Chlordiazepoxide or Diazepam, are used to compensate for the absence of alcohol in the system ,and the risks of seizure and other complication, during (e.g.) a supervised residential alcohol detox process.
  • Medications such as disulfiram, also known as 'antabuse,' may be used to discourage alcohol intake, where symptoms such as nausea or vomiting will be present when the individual consumes alcohol whilst under the effect of the medication.
  • An opiate antagonist medication called Naltrexone is sometimes used in a similar way as disulfiram, as a deterrant, which blocks the euphoric effects of alcohol, and in some cases casues an allergic reaction to alcohol, such as vomiting or diarrhea.

Is drinking every night ok?

Those in active alcohol addiction often ask the question in this way, in the hope that the response will rationalise their continued drinking. However, the question of "how much is too much" is a qualitative one, as well as a quantitative one. i.e. an individual will know if they meet the criteria discussed above, in such as way that the quality of the rest of their life, is being negatively impacted upon, by alcohol intake.

If the quality of your life is being negatively impacted by alcohol use, and/or, you meet the quantitative guidelines set out by recognised bodies, then it is likely you have an alcohol problem, and thus that drinking every night is not ok.

What is the average life expectancy of an alcoholic?

There are a number of individual variables involved in life expectancy which make it impossible to provide a definitive answer to this, e.g. gender, age, co-occurring issues, frequency and recency of intake, co-occurring substance misuse, history of trauma, genetics, family history of addiction or trauma, etc.

What are the signs that someone may be a problem drinker?

Making excuses about drinking behaviour, prioritising drinking over other elements of daily life, introducing opportunities to drink into everyday activities, anger upon being challenged about drinking behaviour, denial, escalating expenses around alcohol, increasing irresponsibility across numerous areas of life, e.g. finances, diet, appearance, lifestyle, etc, are all signs that an individual may have a problem with alcohol.

What is it like being an alcoholic?

An alcoholic's daily thought process may revolve around:

  • Experiencing the feeling of being triggered by a sensitive subject/topic/person/place, possibly related to their early use of alcohol, and believing that the only way to cope with that, is to use alcohol.
  • Fear around maintaining access to alcohol or when they will next be able to drink
  • Guilt around an argument, disagreement, or negative consequence attached to their attempts to secure alcohol the previous day/night.
  • Shame over the long term habit of addiction that is developing, and fear of others finding out.

Once the active addiction has been in place for some time, these elements are almost entirely automatic, and unconscious, in the course of day-to-day life.

What if the people around an alcoholic don't see it as alcoholism?

Sadly, this happens more often than we'd like to imagine. Every day, well-intentioned family members rationalise or normalise, the behaviour of their loved one in active alcohol addiction, usually in an effort to help the loved one avoid short term pain.

This could mean assisting the alcoholic, financially, practically, or in other ways, to continue drinking in the way they have become used to.

The unfortunate effect of this is usually "short term gain for long term pain", meaning that the alcoholic then develops a belief that their drinking is "ok", "normal" or somehow acceptable, allowing them to continue the habit.

Why does an alcoholic want to blame others for his/her addiction?

Alcoholics who have a physical dependence upon alcohol, fear the physical and emotional consequences of giving up. They are subconsciously aware of, the external fallout and negative consequences their actions have had on others, in efforts to maintain their ongoing access to alcohol.

Thus, admitting personal responsibility for one of these actions would mean they are responsible for all such events or actions, and the potential guilt of this, can be overwhelming.

It is therefore easier, for an alcoholic to assign an external locus of responsibility, for their actions, than admit responsibility for one event, which could lead to admission of guilt for all such events, and a tidal wave of emotions which they are not equipped to handle.

What are the potential physical effects on appearance, of alcohol addiction?

Those who have had active alcohol addiction issues for a long period usually manifest symptoms of:

  • Red nose and/or swollen face as a result of vasodilation of capillaries
  • Underweight, as a result of appetite reduction
  • Conversely, some will show distended abdomen as a result of liver issues, ascites, or excess glycogen storage, as is often the case with beer drinkers.
  • Dry skin, e.g. psoriasis
  • Yellowing of the eyes

What do alcoholics find enjoyable about drinking so much?

Depending on the stage of addiction they are in, many alcoholics are not drinking to obtain pleasure, but to avoid the pain of withdrawals, as well as the emotional pain of taking responsibility for the damage their actions have caused to others.

In this way, continued abuse of alcohol is an escape from pain for the alcoholic, rather than a guilty pleasure.

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About the author

Peter Szczepanski

Pete has been on the GPhC register for 29 years. He holds a Clinical Diploma in Advanced Clinical Practice and he is a Clinical Lead in Alcohol and Substance Misuse for Abbeycare Gloucester and works as the Clinical Lead in Alcohol and Substance Use in Worcestershire. To read more about Pete visit his LinkedIn profile.