The University of Pittsburgh School of Medicine

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ALCOHOL ABUSE AND DEPENDENCY

The most common substance-related disorder in the United States is alcohol abuse and dependency. Between 30%-45% of all adults in the U.S. have experienced at least one episode of alcohol-related problems such as blackout, driving a vehicle while intoxicated, or missing work or school because of excessive alcohol consumption. It has been estimated that the cost to society is more than $150 billion per year. It is the third largest health problem after heart disease and cancer. Approximately 200,000 deaths per year can be attributed to alcohol abuse. The most common causes of these deaths are suicide, cancer, heart disease, and liver diseases. Drunken drivers are responsible for over half of the fatalities in automobile accidents and, if only late evening accidents are considered, over 75% of the fatalities. Alcohol consumption is associated with approximately 50% of all homicides and 25% of all suicides. It is estimated that alcohol abuse shortens life expectancy by about 10 years.

WHAT IS ALCOHOL DEPENDENCY AND ABUSE

There are a number of criteria for alcohol dependency and abuse according to the Diagnostic and Statistical Manual (DSM IV). Such individuals may need daily intakes of large amounts of alcohol in order to function adequately. They may have a regular pattern of heavy drinking limited to weekends and may even have long periods of sobriety interspersed by binges of heavy drinking for weeks or months. These patterns are often associated with the following behaviors:
 

These individuals often show impairment in social or occupational functioning such as arguments or difficulties with family members and friends, violence, work loss or legal troubles.

AGE, SEX, RACE AND SOCIOECONOMIC CLASS
While problem drinking is found in every age group those that tend to consume the most alcohol are between 20 and 35. Approximately 25% of adolescents 12-17 describe themselves as users of alcohol. More men than women drink alcohol and the sex ratio of alcohol-related disorders is 2-1 or 3-1. Alcohol-related disorders are observed among all races and socioeconomic classes. It should be noted that the skid-row alcoholic constitutes less than 5% of alcohol-related disorders while the percentage is particularly high among persons in the higher socioeconomic classes and those who have attained advanced degrees.

WHAT FACTORS INCREASE RISK FOR DEVELOPING ALCOHOL-RELATED DISORDERS
Behavioral, psychosocial, and genetic factors seem to play important roles in the etiology of alcohol-related disorders. Childhood history of attention-deficit/hyperactivity disorder and/or conduct disorder appear to increase the child's risk. There are social settings such as colleges and military bases where heavy and frequent drinking is seen as normal and socially accepted behavior. Parental drinking habits can affect children's drinking habits but may not affect alcohol-related disorders as much as previously thought.

Recent data strongly suggest that genetic factors play an important role in some alcohol-related disorders. The heritability association is stronger in males than in females. Studies indicate that individuals with first-degree relatives affected with alcohol-related disorder tend to be three to four times more likely to have alcohol-related disorder than individuals without affected first-degree relatives. The disorder is likely to be more severe in the individual with a family history of alcohol-related disorder. Studies of monozygotic and dizygotic twins show a much higher concordance rate among monozygotic twins than dizygotic twins. In fact, the dizygotic twins are no more likely to be concordant for alcohol-related disorder than siblings who are not twins. Adoption studies have also shown that children whose biologic parents have alcohol-related disorder are at higher risk even when they are reared by adoptive parents without the disorder. Those children whose biologic parents are not alcohol dependent do not appear to be at higher risk when their adoptive parents have alcohol-related disorder.

OTHER DISORDERS ASSOCIATED WITH ALCOHOL-RELATED PROBLEMS
It is not unusual to find that persons diagnosed with alcohol-related disorder also have other substance-related disorders and other psychiatric diagnoses. Approximately 30%-40% of people with alcohol-related disorder have had a major depression that met diagnostic criteria at some time in their lives. These individuals are at great risk for suicide. Because alcohol is particularly effective in temporarily reducing anxiety, many people use it for this reason. It has been estimated that 25%-50% of all persons with alcohol-related disorders also meet diagnostic criteria for anxiety disorder.

WHY IS IT HARD TO ADMIT THAT ONE IS ALCOHOL DEPENDENT?
Many people who are alcohol dependent use a psychological defense mechanism called "denial". While the dependency appears obvious to others, it is denied by the alcohol dependent person. The individual minimizes the problem by saying that it is not so bad, or says that the problem simply does not exist. While it appears that the drinker is lying, it is very likely that the severity of the problem is hidden from him/her. This is a self-protective mechanism. There are a number of reasons that the individual may deny the problem. Not every episode of drinking results in intoxication or loss of control. The individual who suffers blackouts may not remember all of the events that happened during an episode of heavy drinking. Some individuals believe that it is impossible for someone who has regular employment, does well in school or doesn't suffer serious personal or health problems to be alcohol dependent. In medical school, students may deny an alcohol dependency problem because they appear to function adequately. If they do recognize the problem, they may be afraid to seek treatment or not know where to turn for help. Unfortunately, denial or avoidance only serve to put student's personal and professional lives at great risk.

HOW WILL YOU KNOW THAT YOU HAVE AN ALCOHOL DEPENDENCY PROBLEM?

WHAT ARE TREATMENT ALTERNATIVES?
While some groups and clinicians support the idea of controlled drinking, most well- controlled studies suggest that complete abstinence is essential for those with alcohol-dependency. Treatment appears to have more success when the individual has support from family, friends and employers (even if these people have coerced the individual into treatment). The best prognosis is when the individual voluntarily utilizes one or more of the following treatment modalities:

WHERE CAN MEDICAL STUDENTS TURN FOR HELP?
There a number of confidential resources that can provide needed help for students who become aware that they have an alcohol dependency problem.

Adapted from:

Kaplan HI, Sadock BJ, Grebb JA. Synopsis of Psychiatry: Behavioral Sciences Clinical Psychiatry. Williams & Wilkins, Baltimore, 1994.

Daley DC, Miller J. Taking Control: A Practical Guide to Dealing With Chemical Dependency. Learning Publications, Inc., Florida, 1993.

U.S. Department of Health and Human Services. Moving Forward With Your Life: Leaving Alcohol and other Drugs Behind. DHHS Publication No. (SMA) 93-2000, 1993.
 
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SHARP / Clinical Depression / Alcohol Abuse and Dependency /
Anorexia Nervosa and Bulimia Nervosa