NIKOLAOS ATH. KARAKATSANIS

PSYCHIATRIST – PSYCHOTHERAPIST

DOCTOR OF UNIVERSITY OF ATHENS

Partner of A’ UNIVERSITY PCYCHIATRIC CLINIC

Defining alcoholism:

The exact definition of alcoholism is still under discussion. There is, usually, agreement when the addiction is severe and most of the elements of alcohol addiction syndrome are evident. However there is no clear defining line between someone’s being a drinker or becoming an alcoholic.

Alcohol dependence is not an absolute phenomenon without ratings, but like deafness or obesity, is met in various degrees.

The alcoholic increases the quantity of drinking from time to time. The fact that he drinks so often, has unpleasant psychological, social and physical consequences, such as family quarrels, accidents or problems at work. He also often drinks to relax and forget his worries.

Alcohol and mood:

Even though alcohol may promote pleasant feeling for a few hours, long-term use always leads to a gradual deterioration of mood. An individual who drinks a lot starts to feel more depressed and irritable.

Many alcoholics do not attribute these feelings to alcohol and if they do not reveal the fact that they drink, their doctor may complicate the problems by giving them tranquilizers, which add to alcohol’s actions and exacerbate depression.

Many social and professional problems, as well as marital problems are caused by the anti-sedative effect of alcohol.

There is a common view that alcohol acts as an aphrodisiac, but in reality many alcoholics suffer from impotence. Sudden memory loss, alcoholic hallucination, delirium tremens and seizures are very unpleasant effects of drinking large quantities. The alcoholic may find it impossible to remember what he did the previous night, even though he had his senses and was particularly vivid.

Delirium tremens is an extreme expression of alcohol withdrawal syndrome, which develops after a few days of abstention. Seizures are also an extreme form of abstinence syndrome, which can occur after 24 hours of no drinking. Depression and suicide are so common among alcoholics, as to those who suffer from a pure form of depression. In some cases, depression may be the cause which leads to drinking, but in some other cases it may be the result of heavy alcohol use and so the individual is relieved by not drinking at all.

Alcohol and body

There are enough indications, that consumption of 5, 10 or more beer bottles or the same amount of wine and spirits a day, increases the danger of cirrhosis of the liver. 80% of people who drink 10 or more beer bottles per day, are more likely to get sick from some liver disease. More than 20% of alcoholic have stomach ulcer. The alcoholic who is severely addicted is in danger of having a brain damage and decreased mental capacity, especially memory and learning abilities. This confusion is called Korsakov syndrome.

There are indications, that a pregnant woman, who drinks a lot, causes physical harm to her unborn child. The child may suffer from moderate or slight mental retardation, may have an abnormally small head, congenital heart disease or other congenital abnormalities. Alcohol may cause major mental and physical damage, when consumed in excessive quantities. Furthermore, it increases the risk of cancer and brain damage, as well as the risk of accidents, poisoning and acts of violence.

Social problems

Intoxication in public places is illegal and may be prosecuted, because a drunk person has no hesitations and is often annoying and aggressive. Alcohol is at the heart of many criminal acts of violence. The idea that alcohol releases a person from inhibitions also applies to aggressive sexual behavior.

Apart from the major expenses, that society pays, and the health cost of the drinker, people of the alcoholic’s direct environment have to deal sometimes with unbearable experiences.

A family problem

Most families with alcoholic members are going to suffer after the problem is eliminated, in the near future and many years later.

It has been found that alcoholics’ wives are generally more disturbed than the rest of the population. It is also widely believed that the alcoholics’ children are at great risk of becoming alcoholics themselves. It has been estimated that 25-50% of alcoholics had an alcoholic parent or close relative and that the children of alcoholics have twice as much possibilities of becoming alcoholics than children who do not have alcoholic parents. While up to now we thought that this family tendency is exclusively due to environmental conditions, there are indications that there is a hereditary factor.

Families with an alcoholic member (usually the father) are suffering violence, facing the dissolution of family cohesion, as well as long and lasting tension and difficulties in social transactions.

Alcohol and accidents

Alcohol intoxication can cause fearless and mischievous behavior that contributes to a party success, but it can have tragic consequences, resulting in car, industrial and domestic accidents.

GENERALLY

Alcoholism is a multifactorial disease which consists of two phases: During the first phase there is alcohol abuse, which is used as an anxiolytic by the drinker.

If use is not interrupted, the individual goes into the second phase of alcoholism, which is featured by addiction. When the individual is in the second phase, he shows withdrawal syndrome on interruption or reduction of alcohol and resistance to small doses. Alcohol abuse causes liver, brain and heart damages.

Genetic and environmental factors play an important role in alcoholism.

  1. Occasional alcohol abuse and acute intoxication

In acute use, alcohol levels above 50 mg/dl, cause euphoria, decreased reflexes, drowsiness, suppression of Central Nervous System (CNS), liver burden, and behavioral alteration. Alcohol levels in the blood after drinking depend on the individual’s weight, the kind of drinks and various other metabolic factors. A small glass of wine, which has 10-11% alcohol, can increase blood levels from 20 to over 50 mg/dl. Acute poisoning with intoxication is characterized by dizziness, ataxia, nausea and vomiting, as it occurs in levels above 150 mg/dl, while at levels over 350 mg/dl, respiratory depression, spasms, coma and death may threaten the drinker.

  1. Chronic alcoholism

During the systematic alcohol use, some individuals are more resistant than others, due to various genetic factors. There is a correlation of the differences observed in sensitivity with gene polymorphisms encoding tumor necrosis factor A and cytochrome P450 2E1. Women, obese and the elderly have less resistance to alcohol.

The beneficial effects of alcohol are important in small quantities. Specifically, based on studies, people who make prudent use of alcohol are less affected by cardiovascular disease and live longer. If you like alcohol and want to be absolutely safe, it is wise not to drink more than three times a week and over two glasses at a time, of relatively low alcohol content, such as beer or wine. The safety limits for women and the elderly are half of the above. According to studies, the dangers of wine are lower compared to other beverages. The toxic effect of alcohol, in the case of chronic alcoholism, is characterized by chronic systemic abuse and involves many organic systems. Functional overload, inflammation, parenchymal necrosis and cirrhosis of the liver are caused.

Alcohol is the second most widely used carcinogenic substance after tobacco and is associated with the development of gastrointestinal, head, breast and cervical cancers. Infertility, male impotence, loss of libido, gynecomastia, bleeding, jaundice, ascites, edema, alcoholic encephalopathy and alcoholic cardiomyopathy, are pathological problems caused by alcohol.

Withdrawal syndrome occurs in alcohol-dependent individuals ranging from mild to extremely severe. It starts within eight hours of consuming the last drink and is manifested by depression, stress, irritation, emotional instability and terror. In more severe cases, delirium tremens, convulsions or epileptic seizures occur. Generalized seizures may occur within 24-72 hours.

Delirium tremens manifests within 24-72 hours, but it can be observed up to 7-10 days later. It is an acute organic psychosis with confusion, tremor, hallucinations, nervousness, sweating, dehydration, electrolyte disorders, epilepsy and cardiovascular problems.


Special examinations during the medical pathological examination reveal whether the amount of alcohol consumed systematically by a particular person is dangerous for his or her body.

According to studies, about 10% of the population is problematic drinkers, with organic lesions or alcohol malfunctions, which is only revealed during the medical pathological examination (without the consequences of abuse being perceived by the subject).


Today there are medicines and supplements that mitigate the harmful effects of alcohol. These medicines should be given early, prior to the installation of organic damage and dependence syndrome.

The mobilization of willpower and personal activation is necessary in the attempt to stop alcohol or drastic reduction from the systemic drinker. Medicine is currently using special drugs of detoxification to help the alcoholic in this direction.

How does a person become an alcoholic? Are they born with disposition, or are they pushed by negative life experiences? Psychiatry has a lot to say about alcohol addiction. Many factors affect the decision to start drinking, the development of temporary problems with alcohol in teenage years and in the 20s and in the end, the ultimate development of alcohol addiction.

The beginning of alcohol consumption depends mainly on social, religious and psychological factors, although genetic features also seem to contribute. But the factors that influence someone’s decision to keep drinking until the stage of addiction are rather different.

A similar interaction between genetic and environmental influences contributes to many other medical and psychiatric disorders, and therefore, a review of these factors regarding alcoholism, provides a good insight into complex genetic disorders as a whole. Dominant or residual genes, although they are important, they only explain relatively rare situations. Most disorders have a level of genetic predisposition that usually involves a series of different genetically engineered features, each of which increases or reduces the risk of a disorder. It is possible that a series of genetic influences explains about 60% of the risk rate for alcoholism, while the environment is responsible for the remaining 40% of the difference.

Why do we drink?

The reason why people drink too much is a problem as complicated as their character or the environment in which they move. Habits, traditions, mood and associated costs play an important role in alcohol abuse and sensitivity – genetic and not only – of alcoholics. Among other things, people suffering from depression find shelter in the intoxicating feeling of alcohol, which gives them peace, companionship and feelings of euphoria.

Many experts fear that by sticking to the strict limits of the illness, people who drink are only troubled when they become seriously addicted. Alcoholism is not only due to hereditary factors. However, scientists are trying to prove that genes may be responsible for alcoholism. What is being inherited, of course, in alcoholism is not the illness but a predisposition.

There are different types of alcoholics. To get addicted to alcohol, a combination of symptoms is needed. The most crucial is the craving to drink. There are people who drink because they have depression and alcohol makes them feel better as we mentioned above. The braves drink just to feel “elevated”. Some support the view that drinking makes them behave more normally, and that they can indeed react better when they are drunk. Finally others drink to feel different.

Psychological theories of addiction

Various theories consider the use of alcohol as an antidote to reduce tension and anxiety, increase subjective feelings of strength, and reduce psychological pain. Perhaps the greatest interest has been attributed to the observation that alcoholics often report that alcohol reduces their feelings of nervousness and helps them deal with the daily pressures of life and relax. Psychological theories are based, in part, on the observation among non-alcoholic people, that the use of low-dose alcohol in a tense social state or after a difficult day can be linked to an enhanced sense of well-being and an improved ease of social relations.

At high doses, however, especially when the alcohol level drops in the blood, muscle tension and psychological feelings of nervousness and agitation increase. As a result, the relaxing effects of alcohol may affect small or very moderate doses of occasional drinkers, or relieve addicted alcoholic drinkers from withdrawal symptoms, but they play a secondary role in the challenge, meaning the explanation of alcoholism. The theories that alcohol can potentially enhance the feelings of having a strong and sexually attractive image of self and reduce the effects of psychological pain are difficult to assess definitively.

Psychodynamic theories of addiction

Perhaps relative to obviation of inhibitions or reduction of stress caused by lower doses of alcohol, may be the hypothesis that some people use alcohol as a medicine to help them cope with their self-punishing tough Ego and reduce their unconscious (in the psychoanalytic sense) levels of internal conflict. Moreover, classical psychoanalytic theory assumes that at least some alcoholics may be stuck in the oral stage of psycho-sexual development and use alcohol to relieve their frustration by taking the substance by mouth. Assumptions about fixed phases of psychosexual development, although useful, have had little effect on the usual therapeutic approaches to alcohol detoxification and are not the point of current extensive clinical research.

Similarly, most studies have not been able to document an “addictive personality” present in most alcoholics and have not linked any tendency to the lack of control of consuming a wide range of substances and foods. Although pathological results in personality tests are often found during drunkenness, alcohol detoxification and early rehabilitation, many of these pathological features do not lie ahead of alcoholism, most of them disappear with abstinence!

Similarly, studies of children of alcoholics who themselves do not have any other coexisting disorder usually document the high risks of children mainly for alcoholism. As it will be described below, a partial exception to these comments appears with the extreme impulsivity levels seen in 15% to 20% of alcoholics with antisocial personality disorder, because they have high risks of crime, violence and multiple substance addictions.


Behavioral theories of addiction

Expectations for the rewarding effects of drinking, cognitive attitude towards responsibility for one’s behavior, and the consequent enhancement after alcohol-use, all contribute to the decision of people to drink again after their first experience with alcohol and continue drinking despite health problems. These issues are important in the attempts to modify alcohol consumption behaviors in the general population and contribute to some important aspects of detoxification.

Socio – cultural theories of addiction

Socio-cultural theories are often based on observations from social groups with high and low rates of alcoholism. Theorists assume that ethnic groups, such as Jews, who introduce children to moderate levels of alcohol consumption in a family atmosphere and avoid drunkenness, have low rates of alcoholism. Some other groups, such as Irish people or some American Indian breeds with high abstinence rates but a drinking tradition at the point of drunkenness, are considered to have high rates of alcoholism. These theories, however, often depend on stereotypes that tend to be wrong, and prominent exceptions to these rules exist. For example, some theories based on the observations of the Irish and the French have predicted mistakenly high rates of alcoholism among the Italians.

Still, environmental facts, possibly including cultural factors, account for at least 40% of the risk of alcoholism. Consequently, although these are difficult to study, it is likely that cultural attitudes towards alcohol consumption, drunkenness, and personal responsibility for the consequences are important contributing factors to the rates of alcoholism problems in a society. In the end, social and psychological theories are probably highly correlated because they describe the factors that contribute to the beginning of consumption, the development of temporary problems with alcohol and even alcoholism. The problem is how to gather some definitive evidence to support or refute these theories.

Definition of Alcoholism

Alcoholism is a primary and chronic illness whose evolution and manifestations are affected by genetic, psychosocial and environmental factors. This disease is often progressive and fatal. It is featured, on a continuous or periodic basis, by: a reduced ability to control the use of the substance, an intense and continuous intellectual involvement with “alcohol” alcohol, the use of alcohol despite all the adverse consequences, as well as a distorted way of thinking and especially denial.

The term “primary” refers to the nature of alcoholism as a disease entity to be further separated from other pathophysiological conditions that may be associated with it. The term “primary” implies that alcoholism, as a form of addiction, is not the symptom of an underlying morbid condition.

A disease is a non-voluntary disability. It represents all the pathological phenomena exhibited by a group of individuals. These phenomena are associated with a specific set of features that make these individuals differ from other people, which put them at a disadvantageous position.

“Progressive” and “fatal” often means that the disease persists over time and that physical, emotional and social changes are often cumulative and may be further developed as alcohol consumption continues. Alcoholism leads to premature death from alcohol overdoses, from organic complications related to the brain, liver, heart and many other organs, while it can also lead to suicide, homicide, motor vehicle accidents and other traumatic events.

“Reduced ability to control” means inability to restrict the use of alcohol or to restrict, whenever he drinks, the duration of a drinking episode, the quantities of alcohol consumed and / or the consequences of the various drinking behaviors.

“Intense and continuous spiritual engagement with the alcohol use” means that the person focuses on “alcohol” alcohol, its psychotropic activity and its use. Therefore, the relative importance that the person attributes to the substance often makes him direct all his energy to the use and overlook important obligations in his life.

“Adverse consequences” means either problems that have to do with excessive alcohol consumption or decline in areas such as: a) physical health (eg alcohol deprivation syndromes, liver diseases, gastritis, anemia, neurological disorders); (B) mental function (eg cognitive decline, mood swings and behavior), c) interpersonal relationships (eg conjugal problems, child abuse, social exclusion); d) occupation (eg student or problems at work), as well as legal, economic and intellectual problems.

 

The word “denial” is used here not only in the purely psychoanalytic sense of a single defense mechanism that denies the importance of events, but in the broader sense that includes psychological mechanisms that aim to prevent from any realization that the use of alcohol is not the solution, but the cause of the problems faced by the individual. Denial becomes a vital part of the disease and a major obstacle to the recovery process.

ASAM DECLARATION OF PUBLIC POLICY

(American Medical Association for Dependencies)

Copyright: American Society of Addiction Medicine, Chevy Chase, Maryland

Approved by NCADD and ASAM 9/76

Revised 2/90

Alcoholic Sclerosis Syndrome

A patient who has been drinking for a long time and suddenly stops drinking or reduces the intake of alcohol.

· Within a few hours, up to days, from the moment it decreases the intake of alcohol, displays 2 or more of the following symptoms:

– Overactive autonomic nervous system (sweating or tachycardia)

– tremor of hands

– insomnia

– nausea or vomiting

– hallucinations or short-lived illusions (visual, tactile or acoustic)

– psychokinetic irritation

– anxiety

– major seizures

· These symptoms cause clinically significant dysthymia or dysfunction at work, social or personal level.

· These symptoms are not due to a general clinical condition, nor can they be explained more effectively by another mental disorder.

Determine whether, with regard to Perceptual Disorders, the patient has modified sensory perceptions: acoustic, visual, tactile or visual hallucinations or illusions with intact intuition.

Alcoholic Toxicosis

The patient has recently consumed alcohol.

During or shortly after receiving the substance, the patient experiences significant behavioral and psychological changes that are not adjustable. Typically, withdrawal of inhibition of sexual and aggressive motives, mood swings, crisis disturbance, and dysfunction at work and social levels can be observed.

Shortly after drinking alcohol:

– dysarthric speech

– kinetic ataxia

– lack of physical synergy

– unsteady gait

– nystagmus

– attention or memory disturbance

– lethargy or coma

These symptoms are not due to a general clinical condition, nor can they be explained more effectively by another mental disorder.

BIBLIOGRAPHY

. Global Status Report on Alcohol. Geneva: 2004. [Last accessed on 2010 September 20]. World Health Organization (WHO)http://www.who.int/substance_abuse/publications/globalstatusreportalcohol2004_alcconsumpt.pdf .

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