Alcoholism

Alcoholism is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the detriment of the drinker’s health, personal relationships, and social standing. It is medically considered a disease, specifically an addictive illness, and in psychiatry several other terms are used, specifically “alcohol abuse” and “alcohol dependence,” which have slightly different definitions. In 1979 an expert World Health Organization committee discouraged the use of “alcoholism” in medicine, preferring the category of “alcohol dependence syndrome“. In the 19th and early 20th centuries, alcohol dependence in general was called dipsomania, but that term now has a much more specific meaning. People suffering from alcoholism are often called “alcoholics“. Many other terms, some of them insulting or informal, have been used throughout history. The World Health Organization estimates that there are 140 million people with alcoholism worldwide.

The American Medical Association supports a dual classification of alcoholism to include both physical and mental components. The biological mechanisms that cause alcoholism are not well understood. Social environment, stress mental health, family history, age, ethnic group, and gender all influence the risk for the condition. Significant alcohol intake produces changes in the brain’s structure and chemistry, though some alterations occur with minimal use of alcohol over a short term period, such as tolerance and physical dependence. These changes maintain the person with alcoholism’s compulsive inability to stop drinking and result in alcohol withdrawal syndrome if the person stops. Alcohol misuse has the potential to damage almost every organ in the body, including the brain. The cumulative toxic effects of chronic alcohol abuse can cause both medical and psychiatric problems.

Identifying alcoholism is difficult for the individual afflicted because of the social stigma associated with the disease that causes people with alcoholism to avoid diagnosis and treatment for fear of shame or social consequences. The evaluation responses to a group of standardized questioning is a common method for diagnosing alcoholism. These can be used to identify harmful drinking patterns, including alcoholism. In general, problem drinking is considered alcoholism when the person continues to drink despite experiencing social or health problems caused by drinking.

Treatment of alcoholism takes several steps. Because of the medical problems that can be caused by withdrawal, alcohol detoxification is carefully controlled and may involve medications such as benzodiazepines such as diazepam (Valium).

People with alcoholism also sometimes have other addictions, including addictions to benzodiazepines, which may complicate this step.

After detoxification, other support such as group therapy or self-help groups are used to help the person remain sober.

Thombs (1999) states according to behavioral sciences alcoholism is described as a “maladaptive behavior”. He explains this must not be confused with “misbehavior”. Behavioral scientists explain that addicts have a behavior pattern that may lead to destructive consequences for themselves, their families and society. This does not label addicts as bad or irresponsible

Compared with men, women are more sensitive to alcohol’s harmful physical, cerebral, and mental effects

Signs and symptoms

Early signs

The risk of alcohol dependence begins at low levels of drinking and increases directly with both the volume of alcohol consumed and a pattern of drinking larger amounts on an occasion. Young adults are particularly at risk.

Long-term misuse

Alcoholism is characterized by an increased tolerance of and physical dependence on alcohol, affecting an individual’s ability to control alcohol consumption safely. These characteristics are believed to play a role in impeding an alcoholic’s ability to stop drinking.

Alcoholism can have adverse effects on mental health, causing psychiatric disorders and increasing the risk of suicide. The onset of depression is a common symptom.

The National Institute on Alcohol Abuse and Alcoholism defines binge drinking as the amount of alcohol leading to a blood alcohol content (BAC) of 0.08, which, for most adults, would be reached by consuming five drinks for men or four for women over a 2-hour period.

According to the National Institute on Alcohol Abuse and Alcoholism [NIAAA], men may be at risk for alcohol-related problems if their alcohol consumption exceeds 14 standard drinks per week or 4 drinks per day, and women may be at risk if they have more than 7 standard drinks per week or 3 drinks per day. (A standard drink is defined as one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits.

Physical

Long-term alcohol abuse can cause a number of physical symptoms, including cirrhosis of the liver, pancreatitis,epilepsy, polyneuropathy, alcoholic dementia, heart disease, nutritional deficiencies, peptic ulcers and sexual dysfunction, and can eventually be fatal. Other physical effects include an increased risk of developing cardiovascular disease, malabsorption, alcoholic liver disease, and cancer. Damage to the central nervous system and peripheral nervous system can occur from sustained alcohol consumption. A wide range of immunologic defects can result and there may be a generalized skeletal fragility, in addition to a recognized tendency to accidental injury, resulting a propensity to bone fractures.

Women develop long-term complications of alcohol dependence more rapidly than do men. Additionally, women have a higher mortality rate from alcoholism than men.  Examples of long-term complications include brain, heart, and liver damage and an increased risk of breast cancer. Additionally, heavy drinking over time has been found to have a negative effect on reproductive functioning in women. This results in reproductive dysfunction such as an ovulation, decreased ovarian mass, problems or irregularity of the menstrual cycle, and early menopause.

Alcoholicketoacidosis can occur in individuals who chronically abuse alcohol and have a recent history of binge drinking.

Psychiatric

Long-term misuse of alcohol can cause a wide range of mental health problems. Severe cognitive problems are common; approximately 10 percent of all dementia cases are related to alcohol consumption, making it the second leading cause of dementia.

Excessive alcohol use causes damage to brain function, and psychological health can be increasingly affected over time. Social skills are significantly impaired in people suffering from alcoholism due to the neuro toxic effects of alcohol on the brain, especially the pre frontal cortex area of the brain. The social skills that are impaired by alcohol abuse include impairments in perceiving facial emotions, prosody perception problems and theory of mind deficits; the ability to understand humor is also impaired in alcohol abusers.

Psychiatric disorders are common in alcoholics, with as many as 25 percent suffering severe psychiatric disturbances. The most prevalent psychiatric symptoms are anxiety and depression disorders. Psychiatric symptoms usually initially worsen during alcohol withdrawal, but typically improve or disappear with continued abstinence. Psychosis, confusion, and organic brain syndrome may be caused by alcohol misuse, which can lead to a misdiagnosis such as schizophrenia. Panic disorder can develop or worsen as a direct result of long-term alcohol misuse.

The co-occurrence of major depressive disorder and alcoholism is well documented. Among those with co morbid occurrences, a distinction is commonly made between depressive episodes that remit with alcohol abstinence (“substance-induced”), and depressive episodes that are primary and do not remit with abstinence (“independent” episodes). Additional use of other drugs may increase the risk of depression.

Psychiatric disorders differ depending on gender. Women who have alcohol-use disorders often have a co-occurring psychiatric diagnosis such as major depression, anxiety, panic disorder,bulimia, post-traumatic stress disorder (PTSD), or borderline personality disorder. Men with alcohol-use disorders more often have a co-occurring diagnosis of narcissistic or antisocial personality disorder, bipolar disorder, schizophrenia, impulse disorders or attention deficit/hyperactivity disorder. Women with alcoholism are more likely to have a history of physical or sexual assault, abuse and domestic violence than those in the general population, which can lead to higher instances of psychiatric disorders and greater dependence on alcohol.

Social effects

The social problems arising from alcoholism are serious, caused by the pathological changes in the brain and the intoxicating effects of alcohol. Alcohol abuse is associated with an increased risk of committing criminal offences, including child abuse, domestic violence, rape, burglary and assault. Alcoholism is associated with loss of employment, which can lead to financial problems. Drinking at inappropriate times, and behavior caused by reduced judgment, can lead to legal consequences, such as criminal charges for drunk driving or public disorder, or civil penalties for tortuous behavior, and may lead to a criminal sentence.

An alcoholic’s behavior and mental impairment, while drunk, can profoundly affect those surrounding them and lead to isolation from family and friends. This isolation can lead to marital conflicts and divorce, or contribute to domestic violence. Alcoholism can also lead to child neglect, with subsequent lasting damage to the emotional development of the alcoholic’s children.

For this reason, children of alcoholic parents can develop a number of emotional problems. For example, they can become afraid of their parents, because of their unstable mood behaviors. In addition, they can develop considerable amount of shame over their inadequacy to liberate their parents from alcoholism. As a result of this failure, they develop wretched self-images, which can lead to depression.

Medications

In the United States there are four currently approved medications for alcoholism: disulfiram, two forms of naltrexone, and acamprosate. Several other drugs are also used and many are under investigation.

  • Acamprosate(Campral) may stabilize the brain chemistry that is altered due to alcohol dependence via antagonizing the actions of glutamate, a neurotransmitter which is hyperactive in the post-withdrawal   By reducing excessive NMDA activity which occurs at the onset of alcohol withdrawal, acamprosate can reduce or prevent alcohol withdrawal related neurotoxicity. A 2010 review of medical studies found that acamprosate reduces the incidence of relapse among st alcohol dependent persons.
  • Baclofen, aGABAB receptor agonist, is under study for the treatment of alcoholism. A systematic review concluded that there is insufficient evidence for the use of baclofen for withdrawal symptoms in alcoholism.
  • Benzodiazepines, while useful in the management of acute alcohol withdrawal, if used long-term can cause a worse outcome in alcoholism. Alcoholics on chronic benzodiazepines have a lower rate of achieving abstinence from alcohol than those not taking benzodiazepines. This class of drugs is commonly prescribed to alcoholics for insomnia or anxiety management.
  • Initiating prescriptions of benzodiazepines or sedative-hypnotics in individuals in recovery has a high rate of relapse with one author reporting more than a quarter of people relapsed after being prescribed sedative-hypnotics. Those who are long-term users of benzodiazepines should not be withdrawn rapidly, as severe anxiety and panic may develop, which are known risk factors for relapse into alcohol abuse. Taper regimes of 6–12 months have been found to be the most successful, with reduced intensity of withdrawal.
  • Calcium carbimide (Temposil) works in the same way as disulfiram; it has an advantage in that the occasional adverse effects of disulfiram, hepatotoxicity and drowsiness, do not occur with calcium carbimide.
  • Disulfiram (Antabuse) prevents the elimination of acetaldehyde, a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hangover symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast-acting and long-lasting uncomfortable hangover. This discourages an alcoholic from drinking in significant amounts while they take the medicine. A recent nine-year study found that incorporation of supervised disulfiram and the related compound carbimide into a comprehensive treatment program resulted in an abstinence rate of over 50 percent.
  • Naltrexoneis a competitive antagonist for opioid receptors, effectively blocking the effects of endorphins and opiates. Naltrexone is used to decrease cravings for alcohol and encourage abstinence. Alcohol causes the body to release endorphins, which in turn release dopamine and activate the reward pathways; hence when naltrexone is in the body there is a reduction in the pleasurable effects from consuming alcohol.
  • Naltrexone is also used in an alcoholism treatment method called theSinclair Method, which treats patients through a combination of Naltrexone and continued drinking.
  • Ondansetron, a 5HT3 antagonist, is effective in the treatment of alcoholism; the combination of ondansetron and naltrexone is superior than either treatment alone.

Dual addictions

Alcoholics may also require treatment for other psychotropic drug addictions. The most common dual addiction in alcohol dependence is benzodiazepine dependence, with studies showing 10–20 percent of alcohol-dependent individuals had problems of dependence and/or misuse problems of benzodiazepines. Benzodiazepines increase cravings for alcohol and the volume of alcohol consumed by problem drinkers.

Benzodiazepine dependency requires careful reduction in dosage to avoid benzodiazepine withdrawal syndrome and other health consequences.

Dependence on other sedative hypnotics such as zolpidem and zopiclone as well as opiates and illegal drugs is common in alcoholics.

Alcohol itself is a sedative-hypnotic and is cross-tolerant with other sedative-hypnotics such as barbiturates, benzodiazepines and nonbenzodiazepines.

 

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