Problem Drinking, Alcohol Misuse & Alcohol Dependence
Problems related to alcohol consumption ranging from hazardous drinking, harmful drinking, alcohol misuse, and the most severe form of alcohol dependence. These terms have different definitions although used interchangeably in a non-medical society. Hazardous drinking refers to excessive consumption of alcohol, whereas Harmful drinking refers to levels of hazardous drinking in which damage to health is very likely. Alcohol Misuse refers to drinking that causes mental, physical, or social harm to the individual. Alcohol Dependence is the most severe form of alcohol abuse and is medically diagnosed when the DSM-IV and ICD-10 criteria for alcohol dependence are met. All these terms come under the wide umbrella of the term Problem Drinking.
How much alcohol is too much?
Alcohol has different effects on different individuals. The threshold of alcohol tolerance varies from individual to individual. Regardless, there are a set of guidelines and standards that have been put forward to categorise excessive alcohol intake for medical reasons and the purpose of law enforcement.
In the UK, the government advises men to drink no more than 3-4 units of alcohol per day, and 2-3 units per day for women. 1 unit of alcohol is equal to 10ml of pure alcohol, which is around the amount an adult can process in an hour. It is also recommended that everyone has at least 2 or 3 days off of alcohol a week.
Who are at a Risk of Alcohol Misuse
Excessive alcohol consumption leading to mental, physical, and social harm also known as alcohol misuse is not merely a bad habit that goes out of control. Several factors predispose an individual to the likelihood of alcohol misuse.
• Genetic factors - predisposition to alcohol misuse has been observed in sons of fathers who misuse alcohol, and in monozygotic twins. A mutation in the gene Aldehyde Dehydrogenase (ALDH2) which metabolizes alcohol is associated with a lower risk of developing alcohol misuse.
• Learning factors - religions, cultures, and households that do not encourage alcohol consumption have individuals with alcohol problems.
• Personality factors - alcohol misuse is observed in many people with chronic anxiety, a sense of inferiority, self-indulgent tendencies, and anti-social traits.
• Psychiatric disorders - Those with depressive disorder, panic disorder, and social phobia are at risk of alcohol misuse.
• Alcohol consumption in society - the risk of developing alcohol problems is directly proportional to the amount of alcohol consumption and alcohol problems prevailing in the society.
Alcohol dependence is a chronic disease in which the consumer has an uncontrollable addiction to alcohol. The consumer develops tolerance (requiring greater and greater amounts of alcohol to achieve the same effect and develops withdrawal symptoms upon cessation of alcohol use. This gravely affects the physical, mental, and social health of the person leading to problems at home and in the workplace. The diagnosis for alcohol dependence is done by a medical professional following the ICD and DSM-IV criteria.
• Hypertension, stroke, cancers of the mouth, pharynx, liver, breast, and esophagus.
• Fetal alcoholic syndrome if consumed during pregnancy leading to mental retardation and fetal abnormalities.
• Psychological damage
• Idiosyncratic alcohol intoxication leading to aggression during intoxication, memory blackouts, short term amnesia, and insomnia.
• Personality deterioration, mood and anxiety disorders, suicidal behaviour, pathological jealousy, and alcoholic hallucinosis.
• Delirium tremens is a high mortality condition seen in chronic alcoholics who withdraw leading to a rapid chaining picture of disordered mental activity, clouding consciousness, disorientation, severe agitation which lasts for around 3-4 days.
• Social damage
• Family problems, divorce, abandoned children, battered wives, affected children.
• Difficulty in working, problems with coworkers.
• Risk of road accidents, crime.
• Brief intervention - this including education and awareness about alcohol misuse and its consequences.
• Motivational interviewing
• Support and advice
• Withdraw alcohol (controlled drinking)
• High-intensity psychological treatments
• Alcoholics anonymous
• Medication (disulfurum, acamprosate)
1. Harrison, P. Shorter Oxford textbook of psychiatry (6th ed., pp. 444-463)
Health Risks Of Problematic To Dependent Alcohol Consumption
Alcohol consumption is an important risk factor for many health-related problems and is a major contributor to the burden of disease globally.
Understanding the health risks associated with problem drinking, identifying a problem drinker, and early management can save millions, if not billions of dollars in taxpayer money and can most importantly save lives.
Alcohol-Related Health Risks
The alcohol-related health risks are divided into 3 categories;
• Physical health problems
• Psychological health problems
• Social health problems
A person suffering from alcohol-related health problems may or may not be alcohol dependent. Alcohol consumption, even slightly above average can lead to dire health consequences depending on other co-morbidities of the individual.
Physical Health Problems
Problem drinking leads to physical damage in several ways;
• Direct toxic effects in tissues such as the brain and the liver.
• Poor diet and the deficiency of proteins and vitamins leading to nutrient-related health conditions.
• Higher risk of injuries and accidents due to intoxication.
• The general neglect of hygiene increases the susceptibility to infections.
• Gastrointestinal Health Disorders
• Damage to the liver - fatty infiltration, alcoholic hepatitis, cirrhosis, hemochromatosis, hepatocellular carcinoma, and hepatoma. Alcohol dependent cirrhotic patients have a 10-time risk of dying than the average population.
• Peptic ulcer disease causing pain in the abdomen or even a perforation of the stomach in unrelated cases.
• Oesophageal varices leading to bleeding.
• Health Disorders of the Nervous System
• Peripheral neuropathy affecting the nerve conduction in the body.
• Cerebellar degeneration leading to an unsteady stance and gait.
• Optic atrophy and Central pontine myelinolysis leading to blindness and visual defects.
• Marchiafava-Bignami Syndrome is characterized by damage to the neurons leading to difficulty in moving joints, loss of balance, epilepsy, loss of consciousness, and dementia.
• Cardiovascular Health Disorders
• Increased risk of stroke
It is important to note that men who drink about 10 units of alcohol a week appear to be less likely than non-drinkers to develop cardiovascular complications.
• Oral cancers
• Pharyngeal carcinomas
• Oesophageal carcinomas
• Hepatocellular carcinoma
• Breast cancer
• Other Health Disorders
• Hypoglycemic episodes
• Pregnancy-Related Health Disorders
• Fetal Alcohol Syndrome (FAS) occurs in children born to mothers who consume excessive alcohol during pregnancy. FAS is characterized by facial abnormalities, small stature, low birth weight, low intelligence, overactivity, and learning disabilities.
Psychological Health Disorders
Psychological health disorders associated with alcohol fall into 4 categories;
● Intoxication phenomenon
● Withdrawal phenomenon
● Toxic or nutritional disorder
● Associated psychiatric disorders
• Intoxication Phenomenon
As the name suggests, the symptoms associated with alcohol intoxication come under the intoxication phenomenon.
• Although the symptoms of intoxication vary from person to person depending on their tolerance and other factors. Lability of mood and belligerence often lead to unpleasant social outcomes.
• Idiosyncratic alcohol intoxication refers to maladaptive changes in behaviour such as sudden and unusual aggression occurring shortly after consuming alcohol.
• Memory blackouts or short term amnesia are often reported after heavy drinking.
• Withdrawal Phenomenon
• Withdrawal symptoms occur upon discontinuation of alcohol consumption.
• The symptoms range from anxiety to the serious psychiatric syndrome known as delirium tremens. Delirium tremens is characterized by disordered mental activity, clouding of consciousness, disorientation, impairment of recent memory, perceptual disturbances, and vivid hallucinations. There is severe agitation with restlessness, shouting evidence of insomnia, and other autonomous disturbances.
• Sweating, fever, tachycardia, raises blood pressure, and dilated pupils also occur.
Delirium tremens is a medical emergency warranting immediate medical help.
• Toxic disorder
The toxic disorder includes Korsakoff's Psychosis, Wernicke's Encephalopathy, and also Alcoholic Dementia.
• Psychiatric disorder
• Personality Deterioration - loss of interpersonal skills, attention to their usual interests, and responsibilities occurs as the need to obtain alcohol increases.
• Mood and Anxiety Disorders - Recurrent mood disorders frequently coexist with alcohol misuse. Depression is often associated along with interpersonal and social problems occurring as a result of alcohol misuse.
• Suicidal Behavior
• Pathological Jealousy- Excessive drinking develops an idea or delusion that their partner is being unfaithful.
• Alcohol hallucination- characterized by auditory hallucinations usually voices uttering insults, threats.
Social Health Problems
The social issues stemming from problem drinking is nothing new to anyone who's been in contact with an alcoholic.
• Family Problems
Marital and family tension is inevitable with problem drinking. The divorce rate is high among heavy drinkers. Partners of alcoholics become anxious, depressed, socially isolated. Husbands of 'battered wives' are known to drink frequently. Children of heavy drinkers are at risk of developing emotional or behavioural disorders and having a low performance at schools
• Difficulty at Work and Road Traffic Accident
Problem drinkers often have declining working progress, lower-grade jobs, and frequent dismissals. The relationships they build with work-mates are often unhealthy.
Offences such as larceny, fraud, sexual offences, crimes of violence, including murder are known to occur under intoxication.
Harrison, P., Cowen, P., Burns, T., & Fazel, M. Shorter Oxford textbook of psychiatry.