11 substance related disorders

11 substance related disorders

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learning objectives 11

·  11.1 What is alcohol abuse and dependence?

·  11.2 What is drug abuse and dependence?

·  11.3 Are there addictive disorders other than alcohol and drugs?

Remarkable Recoveries from Life-Threatening Substance Abuse Lyle Prouse was born in Wichita, Kansas, in 1938 of American Indian heritage. As a child he was very interested in aviation and won his first airplane ride by writing an essay for Beechcraft Aircraft Company. Prouse, who grew up in the Indian community in Wichita, had a serious, long-term substance abuse problem, as did his parents, both of whom died from alcohol abuse. Many of his friends and associates were heavy alcohol abusers. After he finished high school he joined the U.S. Marines, became a pilot, and served in the Vietnam War. He was awarded several medals for his service in Vietnam. He left the military and obtained a flying position at Northwest Airlines, where he attained the rank of captain and worked for 22 years, flying Boeing 727 passenger aircraft.

In 1990, Captain Prouse and his flight crew enjoyed a night of heavy drinking while on a layover in Fargo, North Dakota. Prouse consumed a number of rum-and-Diet-Cokes, and his crew drank several pitchers of beer and apparently were very loud and belligerent. Although his crew left the bar earlier, Prouse remained longer and continued drinking. During their drinking binge the flight crew angered a customer in the pub, who later called the FAA, warning them against the problem drinking of the crew. The next morning the Northwest crew continued their flight to Minneapolis and were arrested and given substance use tests. They showed high levels of alcohol in their bloodstreams and were charged with violating a federal law, which included prison time as a result of operating a public transportation carrier under the influence of drugs or alcohol. Captain Prouse and his crewmembers served 12 months of the 16-month sentence they received. All three pilots lost their jobs and their pilot’s licenses as a result of the substance use violations.

Captain Prouse felt a great deal of depression and shame at the problems that he created for himself and others following the loss of the aviation career that he loved. He also experienced a great deal of financial problems from his employment termination. On several occasions he contemplated committing suicide. Captain Prouse entered inpatient substance abuse treatment not long after the incident.

After completing his recovery in an inpatient substance abuse treatment center, Prouse began a long and difficult process of rehabilitation and effort to restore his life without using alcohol. He made many public speeches describing his substance abuse and later wrote a book detailing what he had gone through (Prouse,  2001 ). Throughout his recovery he was determined to regain his flying status. It was necessary for him to retrain and retake all of the FAA licensing examinations in order to have his qualifications restored because he was required to requalify for every one of his licenses and ratings.

Captain Prouse was assisted in his recovery by a number of people who were impressed by his public disclosure of wrong-doing and his high motivation to recover from his substance abuse. After he appealed to the court to allow him the opportunity to obtain recertification, the court waived the legal restrictions that had been placed upon him at the trial. A friend of his who owned a trainer aircraft allowed him to earn the necessary flying time needed to be relicensed as a pilot. The CEO of Northwest Airlines, John Dasburg, who himself had grown up in a family with alcoholic abuse problems, took personal interest in Prouse’s struggle and encouraged his return to duty. He returned to flying with Northwest Airlines. Captain Prouse’s efforts and success at rehabilitation were indeed impressive. In 2001 he was granted a presidential pardon by President Clinton.

Interestingly, another one of the pilots on the Northwest “drunk pilots” flight, flight engineer Joe Balzer, who also spent 12 months in federal prison, also rehabilitated himself. He became involved with Alcoholics Anonymous and, over time, requalified for the aviation certification, eventually returning to the cockpit as a pilot for American Airlines (see his autobiographical account in Balzer,  2009 ).

The extensive problem of substance abuse and substance dependence in our society has drawn both public and scientific attention. Although our present knowledge is far from complete, investigating these problems as maladaptive patterns of adjustment to life’s demands, with no social stigma involved, has led to clear progress in understanding and treatment. Such an approach, of course, does not mean that an individual bears no personal responsibility in the development of a problem. On the contrary, individual lifestyles and personality features are thought by many to play important roles in the development of substance-related disorders and are central themes in some types of treatment.

Substance-related disorders  can be seen all around us: in extremely high rates of alcohol abuse and dependence, and in tragic exposés of cocaine abuse among star athletes and entertainers.  Addictive behavior —behavior based on the pathological need for a substance—may involve the abuse of substances such as nicotine, alcohol, Ecstasy, or cocaine. Addictive behavior is one of the most prevalent and difficult-to-treat mental health problems facing our society today.

The most commonly used problem substances are those that affect mental functioning in the central nervous system (CNS)— psychoactive substances : alcohol, nicotine, barbiturates, tranquilizers, amphetamines, heroin, Ecstasy, and marijuana. Some of these substances, such as alcohol and nicotine, can be purchased legally by adults; others, such as barbiturates or pain medications like OxyContin (or marijuana in some states), can be used legally under medical supervision; still others, such as heroin, Ecstasy, and methamphetamine, are illegal.

The material described in this chapter was designed to provide both a historic and contemporary view of important research and theoretical strategies in understanding addictive disorders thus we will, in places, refer to the substance abuse versus substance dependence distinction. The following distinctions are important to understanding and diagnosing substance-related disorders:

·  •  Substance abuse  generally involves an excessive use of a substance resulting in (1) potentially hazardous behavior such as driving while intoxicated or (2) continued use despite a persistent social, psychological, occupational, or health problem.

·  •  Substance dependence  includes more severe forms of substance-use disorders and usually involves a marked physiological need for increasing amounts of a substance to achieve the desired effects. Dependence in these disorders means that an individual will show a tolerance for a drug and/or experience withdrawal symptoms when the drug is unavailable.

·  •  Tolerance —the need for increased amounts of a substance to achieve the desired effects—results from biochemical changes in the body that affect the rate of metabolism and elimination of the substance from the body.

·  •  Withdrawal  refers to physical symptoms such as sweating, tremors, and tension that accompany abstinence from the drug.

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The picture shows an 1891 Stale Beer Dive on Mulberry Street Bend, New York, with several drunk people from the neighborhood and includes beers being served by a young girl (Campbell et al.,  1892 ).

Alcohol Related Disorders

The terms  alcoholic  and  alcoholism  have been subject to some controversy and have been used differently by various groups in the past. The World Health Organization no longer recommends the term alcoholism but prefers the term alcohol dependence syndrome—“a state, psychic and usually also physical, resulting from taking alcohol, characterized by behavioral and other responses that always include a compulsion to take alcohol on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence; tolerance may or may not be present” (1992, p. 4). However, because the terms alcoholic and alcoholism are still widely used in practice, in scientific journals, and in government agencies and publications, we will sometimes use them in this book.

People of many ancient cultures, including the Egyptians, Greeks, Romans, and Israelites, made extensive and often excessive use of alcohol. Beer was first made in Egypt around 3000 B.C. The oldest surviving wine-making formulas were recorded by Marcus Cato in Italy almost a century and a half before the birth of Christ. About A.D. 800, the process of distillation was developed by an Arabian alchemist, thus making possible an increase in both the range and the potency of alcoholic beverages. Problems with excessive use of alcohol were observed almost as early as its use began. Cambyses, King of Persia in the sixth century B.C., has the dubious distinction of being one of the early alcohol abusers on record.

The Prevalence, Comorbidity, and Demo Graphics of Alcohol Abuse and Dependence

Alcohol abuse and alcohol dependence are major problems in the United States and are among the most destructive of the psychiatric disorders because of the impact excessive alcohol use can have upon users’ lives and those of their families and friends. It is estimated that 50 percent of adults who are 18 or older are current regular drinkers and only 21 percent are lifetime abstainers (Pleis et al.,  2009 ). In 2008, 23.3 percent of Americans aged 12 or older reported binge drinking, and 6.7 percent were found to be heavy drinkers (Substance Abuse and Mental Health Services Administration,  2010 ). An estimated 12.4 percent of persons 12 or older drove under the influence of alcohol at least once over the past year. An estimated 22.2 million persons (8.9 percent of the population aged 12 or older) were classified with substance dependence or abuse in the past year based on DSM diagnostic criteria. In this sample, 3.1 million people were classified with dependence on or abuse of both alcohol and illicit drugs, 3.9 million were dependent on or abused illicit drugs but not alcohol, and 15.2 million were dependent on or abused alcohol but not illicit drugs (Substance Abuse and Mental Health Services Administration,  2009 ).

DSM-5 criteria for: Alcohol Use Disorder

·  A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

·  1. Alcohol is often taken in larger amounts or over a longer period than was intended.

·  2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

·  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

·  4. Craving, or a strong desire or urge to use alcohol.

·  5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

·  6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

·  7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

·  8. Recurrent alcohol use in situations in which it is physically hazardous.

·  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

·  10. Tolerance, as defined by either of the following:

·  a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

·  b. A markedly diminished effect with continued use of the same amount of alcohol.

·  11. Withdrawal, as manifested by either of the following:

·  a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499–500).

·  b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

The potentially detrimental effects of excessive alcohol use—for an individual, his or her loved ones, and society—are legion. Heavy drinking is associated with vulnerability to injury (Cherpitel  1997 ), marital discord (Hornish & Leonard,  2007 ), and becoming involved in intimate partner violence (Eckhardt,  2007 ). The life span of the average person with alcohol dependence is about 12 years shorter than that of the average person without this disorder. Alcohol significantly lowers performance on cognitive tasks such as problem solving—and the more complex the task, the more the impairment (Pickworth et al.,  1997 ). Organic impairment, including brain shrinkage, occurs in a high proportion of people with alcohol dependence (Gazdzinski et al.,  2005 ), especially among binge drinkers—people who abuse alcohol following periods of sobriety (Hunt,  1993 ).

One study reported that of the 1.3 million emergency room visits associated with drug misuse or abuse in 2007, 7 percent involved alcohol abuse in patients under age 21 (USDHHS, 2010). Cherpitel and colleagues ( 2006 ) explored the association of alcohol use and emergency room (ER) services among injured patients in several countries. Of 9,743 injured patients surveyed in 37 ERs in 14 countries, drinking within 6 hours before injury was associated with prior visits to the ER during the last 12 months. People who were heavy drinkers or were alcohol dependent were significantly more likely to report multiple prior emergency room visits.

Alcohol abuse is associated with over 40 percent of the deaths suffered in automobile accidents each year (Chou et al.,  2006 ) and with about 40 to 50 percent of all murders (Bennett & Lehman,  1996 ), 40 percent of all assaults, and over 50 percent of all rapes (Abbey et al.,  2001 ). About one of every three arrests in the United States is related to alcohol abuse, and over 43 percent of violent encounters with the police involve alcohol (McClelland & Teplin,  2001 ). In research on substance abuse and violent crime, Dawkins ( 1997 ) found that alcohol is more frequently associated with both violent and nonviolent crime than drugs such as marijuana and that people with violence- related injuries are more likely to have a positive Breathalyzer test (Cherpitel,  1997 ). Of the 1 million violent crimes that were suspected to be alcohol related in 2002, 30 percent of them were determined to involve alcohol use on the part of the offender. Two-thirds of cases in which victims suffered violence from an intimate (a current or former spouse) were alcohol related (U.S. Department of Justice,  2006 ).

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Alcohol is associated with over 40 percent of deaths and serious injuries suffered in automobile accidents in the United States each year (see Chou et al.,  2006 ).

Alcohol abuse and alcohol dependence in the United States cut across all age, educational, occupational, and socioeconomic boundaries. Alcohol abuse is found in priests, politicians, surgeons, law enforcement officers, and teenagers; the image of the alcohol-abusing person as an unkempt resident of skid row is clearly inaccurate. Alcohol abuse is considered a serious problem in industry, in the professions, and in the military as well. Recent research has shown that alcohol abuse has a strong presence in the workplace, with 15 percent of employees showing problem behaviors; many (1.68 percent, or 2.1 million people) actually drinking on the job; and 1.83 percent, or 2.3 million workers, drinking before they go to work (Frone,  2006 ). Some myths about alcoholism are noted in  Table 11.1  on p. 372.

In the past, most problem drinkers—people experiencing life problems as a result of alcohol abuse—were men; for example, men become problem drinkers at about five times the frequency of women (Helzer et al.,  1990 ). Recent epidemiological research has suggested that the traditional gap between men and women has narrowed when it comes to the development of substance abuse disorders (Greenfield et al.,  2010 ). There do not seem to be important differences in rates of alcohol abuse between black and white Americans, although Native Americans tend to have higher rates of alcohol abuse, and Asian Americans tend to have lower usage. It appears that problem drinking may develop during any life period from early childhood through old age. About 10 percent of men over age 65 are found to be heavy drinkers (Breslow et al.,  2003 ). Surveys of alcoholism rates across different cultural groups around the world have found varying rates of the disorder across diverse cultural samples (Caetano et al.,  1998 ; Hibell et al.,  2000 ).

Over 37 percent of alcohol abusers suffer from at least one coexisting mental disorder (Lapham et al.,  2001 ). Not surprisingly, given that alcohol is a depressant, depression ranks high among the mental disorders often comorbid with alcoholism. There is a high comorbidity of substance abuse disorders and eating disorders (Harrop & Marlatt, 2009). It is also no surprise that many alcoholics commit suicide (McCloud et al.,  2004 ). In addition to the serious problems that excessive drinkers create for themselves, they also pose serious difficulties for others (Gortner et al.,  1997 ). Alcohol abuse also co-occurs with high frequency with personality disorder. Grant and colleagues ( 2004 ) report that among individuals with a current alcohol-use disorder, 28.6 percent have at least one personality disorder.

The diagnosis of substance use disorder in DSM-5 is based upon a pathological pattern of behaviors that are related to the use of a particular substance, for example, alcohol. The DSM Criteria for Alcohol Use Disorder are reproduced on page 370 as an illustration. Two additional diagnostic criteria for Alcohol Related Disorders can be found in the DSM-5 manual: Alcohol Intoxication (p. 497) and Alcohol Withdrawal (p. 499).

The Clinical Picture of Alcohol Related Disorders

A great deal of progress has been made in understanding the physiological effects of alcohol on the brain. The first is a tendency toward decreased sexual inhibition but, simultaneously, lowered sexual performance. An appreciable number of alcohol abusers also experience blackouts—lapses of memory. At first these occur at high blood alcohol levels, and a drinker may carry on a rational conversation or engage in other relatively complex activities but have no trace of recall the next day. For heavy drinkers, even moderate drinking can elicit memory lapses. Another phenomenon associated with alcoholic intoxication (intoxication is defined as a state of being affected by one or more psychoactive drugs) is the hangover, which many drinkers experience at one time or another. As yet, no one has come up with a satisfactory explanation of or remedy for the symptoms of headache, nausea, and fatigue that are characteristic of the hangover.

ALCOHOL’S EFFECTS ON THE BRAIN

Alcohol has complex and seemingly contradictory effects on the brain. At lower levels, alcohol stimulates certain brain cells and activates the brain’s “pleasure areas,” which release opium-like endogenous opioids that are stored in the body (Braun,  1996 ). At higher levels, alcohol depresses brain functioning, inhibiting one of the brain’s excitatory neurotransmitters, glutamate, which in turn slows down activity in parts of the brain (Koob et al.,  2002 ). Inhibition of glutamate in the brain impairs the organism’s ability to learn and affects the higher brain centers, impairing judgment and other rational processes and lowering self-control. As behavioral restraints decline, a drinker may indulge in the satisfaction of impulses ordinarily held in check. Some degree of motor uncoordination soon becomes apparent, and the drinker’s discrimination and perception of cold, pain, and other discomforts are dulled. Typically the drinker experiences a sense of warmth, expansiveness, and well-being. In such a mood, unpleasant realities are screened out and the drinker’s feelings of self-esteem and adequacy rise. Casual acquaintances become the best and most understanding of friends, and the drinker enters a generally pleasant world of unreality in which worries are temporarily left behind.

TABLE 11.1 Some Common Misconceptions About Alcohol and Alcohol Abuse

Fiction Fact
Alcohol is a stimulant. Alcohol is actually both a nervous system stimulant and a depressant.
You can always detect alcohol on the breath of a person who has been drinking. It is not always possible to detect the presence of alcohol. Some individuals successfully cover up their alcohol use for years.
One ounce of 86-proof liquor contains more alcohol than two 12-ounce cans of beer. Two 12-ounce cans of beer contain more than an ounce of alcohol.
Alcohol can help a person sleep more soundly. Alcohol may interfere with sound sleep.
Impaired judgment does not occur before there are obvious signs of intoxication. Impaired judgment can occur long before motor signs of intoxication are apparent.
An individual will get more intoxicated by mixing liquors than by taking comparable amounts of one kind—e.g., bourbon, Scotch, or vodka. It is the actual amount of alcohol in the bloodstream rather than the mix that determines intoxication.
Drinking several cups of coffee can counteract the effects of alcohol and enable a drinker to “sober up.” Drinking coffee does not affect the level of intoxication.
Exercise or a cold shower helps speed up the metabolism of alcohol. Exercise and cold showers are futile attempts to increase alcohol metabolism.
People with “strong wills” need not be concerned about becoming substance abusers. Alcohol is seductive and can lower the resistance of even the “strongest will.”
Alcohol cannot produce a true addiction in the same sense that heroin can. Alcohol has strong addictive properties.
One cannot become a substance abuser by drinking just beer. One can consume a considerable amount of alcohol by drinking beer. It is, of course, the amount of alcohol that determines whether one becomes a substance abuser.
Alcohol is far less dangerous than marijuana. There are considerably more individuals in treatment programs for alcohol problems than for marijuana abuse.
In a heavy drinker, damage to the liver shows up long before brain damage appears. Heavy alcohol use can be manifested in organic brain damage before liver damage is detected.
The physiological withdrawal reaction from heroin is considered more dangerous than is withdrawal from alcohol. The physiological symptoms accompanying withdrawal from heroin are no more frightening or traumatic to an individual than alcohol withdrawal. Actually, alcohol withdrawal is potentially more lethal than opiate withdrawal.
Everybody drinks. Actually, 28 percent of men and 50 percent of women in the United States are abstainers.

In most U.S. states, when the alcohol content of the bloodstream reaches 0.08 percent, the individual is considered intoxicated, at least with respect to driving a vehicle. Muscular coordination, speech, and vision are impaired and thought processes are confused. Even before this level of intoxication is reached, however, judgment becomes impaired to such an extent that the person misjudges his or her condition. For example, drinkers tend to express confidence in their ability to drive safely long after such actions are in fact quite unsafe. When the blood alcohol level reaches approximately 0.5 percent (the level differs somewhat among individuals), the entire neural balance is upset and the individual passes out. Unconsciousness apparently acts as a safety device because concentrations above 0.55 percent are usually lethal.

In general, it is the amount of alcohol actually concentrated in the bodily fluids, not the amount consumed, that determines intoxication. The effects of alcohol vary for different drinkers, depending on their physical condition, the amount of food in their stomach, and the duration of their drinking. In addition, alcohol users may gradually build up a tolerance for the drug so that ever-increasing amounts may be needed to produce the desired effects. Women metabolize alcohol less effectively than men and thus become intoxicated on lesser amounts (Gordis et al.,  1995 ).

DEVELOPMENT OF ALCOHOL DEPENDENCE

Excessive drinking can be viewed as progressing insidiously from early- to middle-to late-stage alcohol-related disorder, although some abusers do not follow this pattern. Many investigators have maintained that alcohol is a dangerous systemic poison even in small amounts, but others believe that in moderate amounts it is not harmful to most people. For pregnant women, however, even moderate amounts are believed to be dangerous; in fact, no safe level has been established, as is discussed in Developments in Research box below. The photos on page 374 show the differences between the brain of a normal teenager and those born with fetal alcohol syndrome (FAS), a condition that is caused by excessive alcohol consumption during pregnancy and results in birth defects such as mental retardation.

THE PHYSICAL EFFECTS OF CHRONIC ALCOHOL USE

For individuals who drink to excess, the clinical picture is highly unfavorable (Turner et al.,  2006 ). Alcohol that is taken in must be assimilated by the body, except for about the 5 to 10 percent that is eliminated through breath, urine, and perspiration. The work of alcohol metabolism is done by the liver, but when large amounts of alcohol are ingested, the liver may be seriously overworked and eventually suffer irreversible damage (Lucey et al.,  2009 ). In fact, from 15 to 30 percent of heavy drinkers develop cirrhosis of the liver, a disorder that involves extensive stiffening of the blood vessels. About 40 to 90 percent of the 26,000 annual cirrhosis deaths every year are alcohol related (Parrish et al.,  1991 ). Some countries, for example Britain and Scotland, have shown an increase in cirrhosis-related deaths in the last two decades because of the increased use of alcohol in their populations (Leon & McCambridge,  2006 ).

developments in RESEARCH: Fetal Alcohol Syndrome: How Much Drinking Is Too Much?

Research indicates that heavy drinking by expectant mothers can affect the health of unborn babies, particularly binge drinking and heavy drinking during the early days of pregnancy (Burd & Christensen,  2009 ; Calhoun & Warren,  2007 )—a condition known as fetal alcohol syndrome. Newborn infants whose mothers drank heavily during pregnancy have been found to have frequent physical and behavioral abnormalities (Alison,  1994 ), including aggressiveness and destructiveness (Gardner,  2000 ), and may experience symptoms of withdrawal (Thomas & Riley,  1998 ). For example, such infants have shown growth deficiencies, facial and limb irregularities, damage to the central nervous system, and impairment in cognitive functioning (Kodituwakku et al.,  2001 ). Neuroimaging research has shown that there is an overall reduction of brain size and prominent brain shape abnormalities, with narrowing in the parietal region along with reduced brain growth in portions of the frontal lobe (Spadoni et al.,  2007 ). Moreover, children with FAS often show significant working memory deficits and altered activations patterns in some brain regions (Astley et al.,  2009 ).

As noted in The Third Report on Alcohol and Health (HEW,  1978 ), alcohol abuse in pregnant women is the third-leading cause of birth defects—the first two being Down syndrome and spina bifida (the incomplete formation and fusion of the spinal canal). Although data on FAS are often difficult to obtain, the prevalence has been estimated at between 0.5 and 2 cases per 1,000 births (May & Gossage,  2001 ).

How much drinking endangers a newborn’s health? The HEW report warns against drinking more than 1 ounce of alcohol per day (one 12-ounce can of beer or one 5-ounce glass of wine, for example). The actual amount of alcohol that can safely be ingested during pregnancy is not known, but existing evidence for FAS is strongest when applied to binge drinkers or heavy alcohol users rather than to light or moderate users (Kolata,  1981 ). Nonetheless the surgeon general and many medical experts have concurred that pregnant women should abstain from using alcohol as the “safest course” until the safest amount of alcohol consumption can be determined (Raskin,  1993 ).

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The effects of FAS can be both dramatic and long-lasting. This young child who had been diagnosed with FAS shows some of the permanent physical abnormalities characteristic of the syndrome.

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MRIs of three teenagers: (left) normal control, 13-year-old female; (center) FAS, 13-year-old male with focal thinning of the corpus callosum; (right) FAS, 14-year-old male with complete agenesis (nondevelopment) of the corpus callosum.

Alcohol is also a high-calorie drug. A pint of whiskey—enough to make about eight to ten ordinary cocktails—provides about 1,200 calories, which is approximately half the ordinary caloric requirement for a day (Flier et al.,  1995 ). Thus consumption of alcohol reduces a drinker’s appetite for other food. Because alcohol has no nutritional value, the excessive drinker can suffer from malnutrition (Derr & Gutmann,  1994 ). Furthermore, heavy drinking impairs the body’s ability to utilize nutrients, so the nutritional deficiency cannot be made up by popping vitamins. Many alcohol abusers also experience increased gastrointestinal symptoms such as stomach pains (Fields et al.,  1994 ).

PSYCHOSOCIAL EFFECTS OF ALCOHOL ABUSE AND DEPENDENCE

In addition to various physical problems, a heavy drinker usually suffers from chronic fatigue, oversensitivity, and depression. Initially, alcohol may seem to provide a useful crutch for dealing with the stresses of life, especially during periods of acute stress, by helping screen out intolerable realities and enhance the drinker’s feelings of adequacy and worth. The excessive use of alcohol eventually becomes counterproductive, however, and can result in impaired reasoning, poor judgment, and gradual personality deterioration. Behavior typically becomes coarse and inappropriate, and the drinker assumes increasingly less responsibility, loses pride in personal appearance, neglects spouse and family, and becomes generally touchy, irritable, and unwilling to discuss the problem. image6 Watch the Video Chris: Alcoholism on MyPsychLab

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As judgment becomes impaired, an excessive drinker may be unable to hold a job and generally becomes unqualified to cope with new demands that arise (Frone,  2003 ). General personality disorganization and deterioration may be reflected in loss of employment and marital breakup. By this time, the drinker’s general health is likely to have deteriorated, and brain and liver damage may have occurred. For example, there is some evidence that an alcoholic’s brain is accumulating diffuse organic damage even when no extreme organic symptoms are present (Sullivan, Deshmukh, et al.,  2000 ), and even mild to moderate drinking can adversely affect memory and problem solving (Gordis,  2001 ). Other researchers have found extensive alcohol consumption to be associated with an increased amount of organic damage in later life (Lyvers,  2000 ); however, recent research using fMRI has shown that this damage is partially reversible if the person abstains from alcohol use (Wobrock et al.,  2009 ).

PSYCHOSES ASSOCIATED WITH SEVERE ALCOHOL ABUSE

Excessive use of alcohol can result in severe mental health problems. Several acute psychotic reactions fit the diagnostic classification of substance-induced disorders. These reactions may develop in people who have been drinking excessively over long periods of time or who have a reduced tolerance for alcohol for other reasons—for example, because of brain lesions from excessive long-term use. Such acute reactions usually last only a short time and generally consist of confusion, excitement, and delirium. There is some evidence that delirium may be associated with lower levels of thiamine in alcoholics (Holzbeck,  1996 ). These disorders are often called “alcoholic psychoses” because they are marked by a temporary loss of contact with reality.

Among those who drink excessively for a long time, a reaction called  alcohol withdrawal delirium (formerly known as  delirium tremens ) may occur (Palmstierno,  2001 ). This reaction usually happens following a prolonged drinking spree when the person enters a state of withdrawal. Slight noises or suddenly moving objects may cause considerable excitement and agitation. The full-blown symptoms include (1) disorientation for time and place, in which, for example, a person may mistake the hospital for a church or jail, no longer recognize friends, or identify hospital attendants as old acquaintances; (2) vivid hallucinations, particularly of small, fast-moving animals like snakes, rats, and roaches; (3) acute fear, in which these animals may change in form, size, or color in terrifying ways; (4) extreme suggestibility, in which a person can be made to see almost any animal if its presence is merely suggested; (5) marked tremors of the hands, tongue, and lips; and (6) other symptoms including perspiration, fever, a rapid and weak heartbeat, a coated tongue, and foul breath.

The delirium typically lasts from 3 to 6 days and is generally followed by a deep sleep. When a person awakens, few symptoms—except for possibly slight remorse—remain, but frequently the individual is badly scared and may not resume drinking for several weeks or months. Usually, however, drinking is eventually resumed, followed by a return to the hospital with a new attack. The death rate from withdrawal delirium as a result of convulsions, heart failure, and other complications once approximated 10 percent (Tavel,  1962 ). With drugs such as chlordiazepoxide, however, the current death rate during withdrawal delirium and acute alcoholic withdrawal has been markedly reduced.

A second alcohol-related psychosis is persisting alcohol disorder or alcohol amnestic disorder (formerly known as Korsakoff’s syndrome). This condition was first described by the Russian psychiatrist Korsakoff in 1887 and is one of the most severe alcohol-related disorders (d’Ydewalle & Van Damme,  2007 ). The outstanding symptom is a memory defect (particularly with regard to recent events), which is sometimes accompanied by falsification of events (confabulation). Persons with this disorder may not recognize pictures, faces, rooms, and other objects that they have just seen, although they may feel that these people or objects are familiar. Such people increasingly tend to fill in their memory gaps with reminiscences and fanciful tales that lead to unconnected and distorted associations. These individuals may appear to be delirious, delusional, and disoriented for time and place, but ordinarily their confusion and disordered actions are closely related to their attempts to fill in memory gaps. The memory disturbance itself seems related to an inability to form new associations in a manner that renders them readily retrievable. Such a reaction usually occurs in long-time alcohol abusers after many years of excessive drinking. These patients have also been observed to show other cognitive impairments such as planning deficits (Brokate et al.,  2003 ), intellectual decline, emotional deficits (Snitz et al.,  2002 ), judgment deficits (Brand et al.,  2003 ), and cortical lesions (Estruch et al.,  1998 ).

The symptoms of alcohol amnestic disorder are now thought to be due to vitamin B (thiamine) deficiency and other dietary inadequacies. Although it had been believed that a diet rich in vitamins and minerals generally restores such a patient to more normal physical and mental health, some research evidence suggests otherwise. Lishman ( 1990 ) reports that alcohol amnestic disorder did not respond well to thiamine replacement. Some memory functioning appears to be restored with prolonged abstinence. However, some personality deterioration usually remains in the form of memory impairment, blunted intellectual capacity, and lowered moral and ethical standards.

Alcohol Amnestic Disorder Averill B. was brought into the detoxification unit of a local county hospital by the police after an incident at a crowded city park. He was arrested because of his assaultive behavior toward others (he was walking through the crowded groups of sunbathers muttering to himself, kicking at people). At admission to the hospital, Averill was disoriented (did not know where he was), incoherent, and confused. When asked his name, he paused a moment, scratched his head, and said, “George Washington.” When asked about what he was doing at the park, he indicated that he was “marching in a parade in his honor.”

Biological Causal Factors in the Abuse of and Dependence On Alcohol

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