Medicine

The New Concept of the Alcoholic.

By Chris Rangel MD ⋅ July 3, 2007 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

The clichéd idea of an alcoholic is usually a “wino” type (middle aged or older, male, usually homeless), a barfly (your official address is a bar), or an abusive husband or boyfriend in a “wife-beater” Tee-shirt (please see any “COPS” episode for examples). I think it’s safe to say that most Americans still believe that the only real alcoholics are these stereotypes, i.e. people who have really screwed up lives AND drink a lot. But this is probably a self defense mechanism because if you have a job and a home, you don’t beat your wife and kids, and you don’t spend every night at a bar then you are not an alcoholic no matter how much you drink. Right? Well, not necessarily.

A new study (a survey of 1,484 American adults) from the National Institute on Alcohol Abuse and Alcoholism found that those common stereotypes of alcoholics actually make up a minority of all people who have alcohol related problems. The study authors found 5 general subtypes of alcoholics and interestingly 53% qualify as alcoholics between ages 18 and 20!

1. Young Adult subtype: 31.5 percent of U.S. alcoholics. Young adult drinkers, with relatively low rates of co-occurring substance abuse and other mental disorders, a low rate of family alcoholism, and who rarely seek any kind of help for their drinking.

This is not surprising considering that the predominant social culture for young adults these days is “partying” i.e. drinking to excess on selected nights. Think Lindsay Lohan but instead of calling it what it is, these types of alcoholics are commonly referred to as “partiers”.

2. Young Antisocial subtype: 21 percent of U.S. alcoholics. Tend to be in their mid-twenties, had early onset of regular drinking, and alcohol problems. More than half come from families with alcoholism, and about half have a psychiatric diagnosis of Antisocial Personality Disorder. Many have major depression, bipolar disorder, and anxiety problems. More than 75 percent smoked cigarettes and marijuana, and many also had cocaine and opiate addictions. More than one-third of these alcoholics seek help for their drinking.

3. Functional subtype: 19.5 percent of U.S. alcoholics. Typically middle-aged, well educated, with stable jobs and families. About one-third have a multigenerational family history of alcoholism, about one-quarter had major depressive illness sometime in their lives, and nearly 50 percent were smokers.

This is a very important subtype since these people can easily delude themselves into thinking that they don’t have a substance abuse problem because they are able to hold on to a job, a career, and a relationship without too much difficulty . . until it’s too late. Many alcoholic physicians and other highly educated professionals fall into this subtype.

4. Intermediate Familial subtype: 19 percent of U.S. alcoholics. Middle-aged, with about 50 percent from families with multigenerational alcoholism. Almost half have had clinical depression, and 20 percent have had bipolar disorder. Most of these individuals smoked cigarettes, and nearly one in five had problems with cocaine and marijuana use. Only 25 percent ever sought treatment for their problem drinking.

5. Chronic Severe subtype: 9 percent of U.S. alcoholics. Comprised mostly of middle-aged individuals who had early onset of drinking and alcohol problems, with high rates of Antisocial Personality Disorder and criminality. Almost 80 percent come from families with multigenerational alcoholism. They have the highest rates of other psychiatric disorders including depression, bipolar disorder, and anxiety disorders as well as high rates of smoking, and marijuana, cocaine, and opiate dependence. Two-thirds of these alcoholics seek help for their drinking problems, making them the most prevalent type of alcoholic in treatment.

This last group appears to be made up of the classic stereotypical alcoholic who because of his/her severe polysubstance abuse and higher rates of psychiatric disorders makes them stand out much more than the other subtypes who have higher rates of functionality.

So how do you define an alcoholic? The lay definition appears to be that of a person who’s “drinks too much” and this causes problems in their life. This is generally true but too simplistic. It’s probably more clinically accurate to replace “alcoholic” with the concepts of “substance abuse” and “substance dependence” as most psychiatrists and other experts do (I use the term “alcoholic” in this post for simplicity to mean anyone with any chronic alcohol related problems).

The DSM IV defines “abuse” as a pattern of recurrent substance use resulting in one or more of the following in a 12 month period; failure to fulfill major obligations (i.e. with work or school), use in physically dangerous situations (DWI is the most common), resulting in major legal problems (arrest for DWI is one of the most common), and continued use despite serious social or interpersonal problems.

At some point abuse become dependence i.e. a pattern of abuse where the user is now physically dependent on the substance. This is manifested by 3 or more of the following in 12 months; tolerance, withdrawal symptoms with sudden abstinence from use, use of ever increasing amounts, desires or unsuccessful attempts to cut down on use, increasing time spent obtaining or using the substance, use of the substance takes priority over other activities, and continued use despite significant problems.

Most people with alcohol problems likely fall into the “abuse” category. They are the ones who show up at AA meetings/rehab because they have to (ordered there by the courts, their boss, their wife). Their problem is acceptance. They don’t see their use as a pattern of abuse and they still want to live their “partying” lifestyle. This is why young people like Lohan are continually in and out of rehab. The people with dependence are the ones who go to AA/rehab because they want to. They desperately want to quit and are no longer physically able to. For them, alcohol use is no longer pleasurable.

How much is too much? Actually while light and regular use (4-14 drinks per week) can have health benefits, the consensus among studies is that the regular consumption of 3-4 or more drinks/day for males (2-3 or more for women) significantly increases the likelihood of problems. But the gray line between a non-problem drinker and a problem drinker depends on the person and less is known about “binge” drinkers in this regard.

Simply getting intoxicated does not mean that you have a problem or could potentially have a problem. But there are a few clues that you might look for to see if you are at risk. First, be aware of any family history of alcoholism/substance abuse esp. among 1st degree relatives. This increases your risk of abuse but does not automatically mean that you will have problems.

Second, there is evidence that heavy drinkers get an almost immediate and early response of feelings of euphoria and excitement with the initial 1-2 drinks. Light drinkers don’t tend to get this response but feel “drunk” sooner than heavy drinkers with continued drinking. This might help explain why light drinkers know when they have “had enough” while heavy drinkers are encouraged to drink more from their initial reactions. If you get this type of reaction with the first few drinks then you may be regularly drinking more than you think and are at increased risk of problems.

Third, carefully observe the drinking habits of people you know to be light or non-problem drinkers. Either don’t drink or try and match them drink for drink. When they stop drinking, ask yourself if you can or could easily stop at the point where they stopped and do it almost every time.

These are important questions since up to 30% of Americans have and continue to abuse alcohol. They are at increased risk of alcohol related social and health problems and the possibility of dependence. Just because you don’t fit the stereotypical picture of a drunk doesn’t mean that you are not one or at risk of becoming one.

The preceding has been a public service message from Rangel.com, and remember, don’t smoke marijuana because pot is bad and harmful*

*(Citation needed).