ALCOHOL ALCOHOL ABUSE AND ABUSE AND

DEPENDENCEDEPENDENCE

ADDICTIVE BEHAVIOURBehavior based on pathological need for substance or activity.

Most commonly used problem substances are:PSYCHOACTIVE DRUGSAlcoholNicotineTranquilizersHeroinAmphetamines

DSM-IV-TRDSM-IV-TRCRITERIA FOR SUBSTANCE-CRITERIA FOR SUBSTANCE-

DEPENDENCEDEPENDENCEDISORDERSDISORDERS• Tolerance, as defined by either a need for

markedly increased amounts of the substance to achieve intoxication or the desired effect or diminished effect with continued use of the same amount of the substance.

• Withdrawal, as manifested by either the characteristic withdrawal syndrome for the substance or closely related substance is taken to relieve or avoid withdrawal symptoms.

• The substance is often taken in larger amounts or over a longer period than intended.

. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

• Important social, occupational, or recreational activities are given up or reduced because of substance use.

• The substance use is continued despite knowledge of having a persistent physical or psychological problem.

DSM-IV-TRDSM-IV-TRCRITERIA FOR SUBSTANCE-ABUSECRITERIA FOR SUBSTANCE-ABUSE

DISORDERSDISORDERS• Recurrent substance use resulting in a failure to fulfil

major role obligations at work, school, or home .

• Recurrent substance use in situations in which it is physically hazardous.

• Recurrent substance-related legal problems

• Continued substance use despite having persistent or recurrent social or interpersonal problems

CLINICAL PICTURE OF ALCOHOL

ABUSE & DEPENDENCE

ALCOHOL’S EFFECTS ON THE ALCOHOL’S EFFECTS ON THE BRAINBRAIN

• At lower levels:

It stimulates brain cells and activates brain’s “pleasure areas”.(Braun,1996;Van Ree,1996)

• At higher levels:

It depresses brain functioning, inhibiting one of the brain’s excitatory neurotransmitters which in turn slows down activity in parts of the brain. (Koob,Mason,et al.,2002).

• Perception of cold, pain and other discomforts are dulled.

• Speech and vision is impaired and thought processes are confused(NIAAA,2001).

• Unpleasant realities are screened out.

THAT IS WHY IT IS NOT CONSIDERED SAFE TO DRIVE

THE PHYSICAL EFFECTS OF THE PHYSICAL EFFECTS OF CHRONIC ALCOHOL USECHRONIC ALCOHOL USE

• Liver may suffer irreversible damage.

(Martin, Singleton,& Hiller-Sturmhofel,2003).

• 15-30% of heavy drinkers develop cirrhosis of the liver, a disorder that involves extensive stiffening of the blood vessels.

PSYCHOSOCIAL EFFECTS OF PSYCHOSOCIAL EFFECTS OF ALCOHOL ABUSE & DEPENDENCEALCOHOL ABUSE & DEPENDENCE

Chronic fatigue

Oversensitivity

Personality disorganization may be reflected in loss of employment and marital break-up

Depression

PSYCHOSES ASSOCIATED WITH PSYCHOSES ASSOCIATED WITH ALCOHOL ABUSEALCOHOL ABUSE

ALCOHOL AMNESTIC DISORDER

SYMPTOMS:

• Memory defect

• Falsification of events

• Persons may not recognize familiar objects

• Planning & emotional deficits

• Intellectual decline

CAUSE: Deficiency of vitamin B & other dietary inadequacies.

CASE STUDYCASE STUDYALCOHOL AMNESTIC DISORDERALCOHOL AMNESTIC DISORDER

Averill B. was brought into the detoxification unit of a local country hospital by the police after an accident at a crowded city park. He was arrested because of his assaultive behavior toward others. At admission to the hospital, Averill was disoriented(did not know where he was),incoherent, and confused. When asked his name, he paused for a moment, scratched his head, and said, ”George Washington.”When asked about what he was doing at the park he indicated that he was “marching in a parade in his honor.”

BIOLOGICAL FACTORS IN BIOLOGICAL FACTORS IN ALCOHOL ABUSEALCOHOL ABUSE

THE NEUROBIOLOGY OF ADDICTION

Drugs differ in their biochemical properties as well as how rapidly they enter the brain.

Alcohol is usually drunk which is the slowest route.

The mesocorticolimbic dopamine pathway(MCLP) is the centre of psychoactive drug activation in the brain.

This neuronal system is involved in functions like:

• Control of emotions

• Memory

• Gratification

Alcohol produces euphoria by stimulating this area in the brain.

Since alcohol activates this “pleasure pathway” that is why people feel the urge to drink again.

With continued use, neuroadaptation or tolerance and dependence to the substance develops.

GENETIC VULNERABILITYGENETIC VULNERABILITY

Genetics plays an important role in developing sensitivity to the addictive power of drugs like alcohol. (Mustanski,Viken,et al,2003;plomin & DeFries,2003).

Research has shown that some people such as the sons of alcoholics, have a high risk for developing problems with alcohol because of an inherent motivation to drink or sensitivity to the drug( Conrod, Pihl,& Vassileva,1998).

An alcohol-risk personality has been described as an individual who has an inherited predisposition toward alcohol abuse and who is impulsive, prefers taking high risks and is emotionally unstable.

However, genetics alone does not account for the full range of alcohol and drug problems.

There are:

PSYCHOSOCIAL FACTORS

SOCIOCULTURAL FACTORS

Psychosocial Causal Psychosocial Causal Factors in Alcohol Abuse Factors in Alcohol Abuse

and Dependenceand Dependence

Psychosocial refers one's psychological development in and interaction with a social environment.Alcoholics not only become physiologically dependent on alcohol but develop a powerful psychological dependence i.e. become socially dependent on that drug to help them enjoy social situations.

Number of psychosocial factors are present:●Failures in Parental Guidance●Psychological Vulnerability●Stress, Tension Reduction and Reinforcement●Expectations of Social Success ●Marital and Other Intimate Relationships

Failures in Parental Guidance:

♦ Stable family relations and parental guidance which influence children is lacking in families of alcoholics.

♦ Children whose parents are extensive alcohol users are more vulnerable to developing substance abuse related problems.

♦ Formative experiences have direct influence on whether a youngster will become involved in maladaptive behaviour such as alcohol abuse.

♦ Negative parental models have longer range negative consequences once children leave the family situation.

Chassin and his colleagues (1993) found mediating factors that can influence adolescents in initiating alcohol use. They found that parental behaviour or parenting skills are associated with substance use in adolescents. Alcoholic parents are less likely to keep track of what their children are doing and this lack of monitoring leads to adolescent’s affiliation with alcohol using peers.

Psychological Vulnerability

These are personality characteristics that may predispose a person to use alcohol rather than some other defensive method of coping with stress. Research has shown that many potential alcoholics tend to be emotionally immature, expect a a great deal of the world, require an inordinate amount of praise and appreciation, react to failure with marked feelings of hurt and inferiority, have low frustration tolerance and feel inadequate and unsure of their abilities to fulfill expected male or female roles. Persons at high risk for developing alcoholism are significantly more impulsive and aggressive than those at low risk for abusing alcohol (Morey, Skinner and Blashfield 1984) (find answer why)

Research has found link between alcohol abuse disorder and other disorders such as antisocial personality, depression and schizophrenia. About half persons with schizophrenia have either alcohol or drug abuse dependency as well.(Kosten 1997)

There holds a strong relationship between antisocial personality and alcohol dependence. Though it is not clear which disorder leads to which one. High rates of substance abuse are found among antisocial personalities. (Clark watson and Reynolds, 1995)

Inspite of these researches it is difficult to assess the role of specific personality characteristics in the development of this disorder. Since many people with similar characteristics do not become alcoholics and some others not with these characteristics become alcoholics.

Personal maladjustment is the common characteristic usually present in all alcoholics.

Two psychopathological conditions most frequently linked to addictive disorders are depression and antisocial personality.

Gender difference too.(add to this slide)

Stress, Tension Reduction and Reinforcement

A typical alcoholic is discontented with his/her life and is unable and unwilling to tolerate stress and tension.

Tension Reduction Causal ModelPeople often drink to relax, they find alcohol tension

reducing and are in danger of becoming alcoholics even without and especially stressful life situation.

Motivational model (Cox and Klinger 1988)Accordingly the final pathway to alcohol is

motivation i.e. the person decides consciously or unconsciously whether to consume alcohol or not. Alcohol is consumed mainly because it is reinforcing the individual. Alcohol consumed brings affective changes, has mood altering effects and indirect effects such as peer approval.

Expectation of social success

> Recent researchers have found out that cognitive expectation might play an important role in both initiating of drinking and maintenance of that drinking behaviour once person has started using alcohol.

> Reciprocal influence model- adolescents start drinking because they expect that alcohol will increase their popularity and acceptance by peers.

> This model is important as it helps professionals to deter or atleast delay the onset of drinking among young people by providing them alternative and more effective social tools to meet their expectancies.

Marital and Other Intimate Relationships

◄ Excessive drinking often begins during crisis periods in relationships, particularly crisis that leads to hurt and self devaluation.

◄ When one of the spouses is an alcoholic the other is aware of this fact and is likely to take decisions based on the expectation that their partner is drinking, these may make the drinking behaviour more likely.

◄ In some instances the husband or wife may also begin to drink excessively possibly through reinforcement of such behaviour.

◄ Deterioration in alcoholics’ interpersonal relationships could further increase stress and disorganisation. The break up of relationships could be highly stressful leading to an increase in substance abuse problems.

◄ Family relationship problems have also been found to be central to the development of alcoholism. Family variables considered to predispose individual to substance use problems are-presence of alcoholic father, existence of acute marital conflict, lax maternal supervision, inconsistent discipline, lack of attachment with parent(s).

Sociocultural Factors

● Effect of cultural attitudes towards drinking is well illustrated by Muslims and Mormons whose religious values prohibit the use of alcohol and by orthodox Jews who have traditionally limited its use to largely religious rituals. Incidence of alcoholism among these groups is minimal. In comparison incidence of alcoholism is higher in Europeans, and consequences can be seen in the form of accidents, crime, increased liver disease.

● France has highest per capita alcohol consumption and highest death rate from cirrhosis of the liver (Noble 1979).

● Religious sanctions and social customs determine whether alcohol is one of the coping methods commonly used in a group or society.

● The expectation that alcohol leads to aggression is related to cultural tradition and early exposure to violent or aggressive behaviour.

Treatment of AlcoholismTreatment of AlcoholismWhen confronted with their drinking problem alcoholics may react

with denial or become angry and withdraw from the person who confronted them (Miller and Rollnick, 1991)

A multidisciplinary approach seems to be most effective in treatment of alcoholism because problems are often complex require flexibility and individuation of treatment procedures, and alcoholics needs change as treatment progresses.

The process usually comprises of these steps:► Detoxification ► Physical rehabilitation► Control over alcohol abuse behaviour► Development of individual’s realisation that he/she can cope

with problems of living and lead rewarding life without alcohol.

Traditional programs aim at abstinence from alcohol. Some follow controlled drinking. However relapse is common and is seen as a part of the treatment.

Use of Medications in Treating AlcoholicsUse of Medications in Treating Alcoholics

Medication is used to reduce cravings to ease the detoxification process and to treat co-occurring mental health problems that are thought to underlie drinking behaviour. Medications to Block the desire to drink are:► Disulfiram (Antabuse)-causes violent vomiting when followed by

ingestion of alcohol to prevent immediate return to drinking. Study by Adelman and Weiss (1989) reports that use of Antabuse has clear advantages over programs that don’t suppress drinking when drug is taken regularly.

Since drug self administered alcoholic may discontinue it’s use when released from hospital. Their primary advantage is that they interrupt the initial alcoholic cycle for some period of time during which therapy must be undertaken.

► Naltrexone- helps in reducing the “craving” for alcohol by blocking pleasure producing effects of alcohol.

► Valium- lower side effects of acute withdrawal.

Psychological Treatment Approaches

Detoxification is followed by psychological treatment including family counselling and use of community resources relating to other aspects of person’s social readjustment.

Focus of psychosocial measures in alcoholism treatment includes:

► Group therapy

► Environmental Intervention

► Behaviour Therapy

► Controlled Drinking

► Alcoholics Anonymous

Group Therapy

Involves confrontation. Alcoholics are forced to face their

problems with a knowing audience of “peers.”

Family treatment is another type where family members are invited to join group therapy methods. All members have a responsibility for cooperating in the treatment.

Environmental Intervention

Environmental support is an important factor to an alcoholic’s recovery. Alcoholics have strained relations with peers/family/friends and those around them are not as understanding and supportive. Treatment would not be helpful in a hostile environment, so it is important to have environmental support, close relations with friends and family. Relapse often associated to lack of this.

Behaviour Therapy

► Aversive Conditioning- presentation of some noxious stimuli with alcohol consumption to suppress drinking behaviour. Intramuscular injection of emetine hydrochloride, which produces nausea is given after giving patient alcohol so sight, smell and taste of beverage becomes associated with vomiting.

► Cognitive behavioural approaches target behaviours that contribute to the use of alcohol such as depression.

► Couples Therapy► Skills Training Procedure by Alan Marlatt and his colleagues

(1988)- it combines cognitive behavioural strategies of intervention with social learning theory and modeling of behaviour. Aimed at younger problem drinkers who are at a risk of developing severe problems. It involves imparting knowledge, developing coping skills, modifying cognitions and expectancies, acquiring stress management skills.

► Self-control training techniques- goal is to get alcoholics to reduce alcohol intake without necessarily abstaining altogether, but difficult for individuals who are extremely dependent on it.

Controlled Drinking

Research has been done by Miller and his colleagues (1986)-People can learn to drink moderately instead of giving it up altogether

Controlled drinking is more successful in persons with less severe alcohol problems. Also depends on willingness of professional whether to apply controlled drinking or abstinence.

Though idea is rejected by many people. Debate continues whether it is better than abstinence.

Alcoholics AnonymousPractical approach started by Dr. Bob and Bill W. in 1935 in Ohio.It operates as a self help counseling program in which both person

to person and group relations are emphasised. Accepts teenagers and adults, has no dues no fees does not keep records or case histories, not affiliated with any religious or political group, spiritual development is the key aspect of this approach.

Only first names are used to maintain anonymity. Discussions used to talk about problems and testimonials of those who have recovered.

Continued participation helps prevention of relapse.

► Outcome of treatment varies. Alcoholics with some personality disorder or affective disorders tended to have poorer outcomes as compared to those only being treated for alcoholism.

Treatment is most effective when :o Individual realises that he or she needs help.o When adequate treatment facilities are available. o When individual attends treatment regularly.o Has a positive relation with the therapist.o Regular check up sessions in the beginning of the

treatment are present.

Relapse Prevention

► Major problems in the treatent of alcoholism or any other addictive disorder is maintaining abstinence or self control.

► Relapse may occur. Though alcohol treatment programs show success rates in “curing” the problem in follow ups they show lesser rates of abstinence.

► It is important to maintain effective behaviour to prevent relapse. When individual learns to control he/she feels a sense of achievement and confidence leading to a greater ability to maintain control.

Binge Drinking in CollegeScott K. an 18 year old college freshman from a prestigious

university in Boston went to an off campus party. During and evening that was filled with heavy drinking, he lapsed into unconsciousness and his heart stopped. Although he was rushed to the hospital where medics attempted to revive him, it was too late. He died without regaining consciousness. His blood-alcohol level was 0.41 at that time which was 4 times the legal limit for driving in the state. This occurred just a few weeks after another college student had died and 12 of his classmates were hospitalised for alcohol poisoning after an evening of heavy drinking.

Binge drinking is very common in universities and is an internationa; problem. They pose a serious risk for substance abuse disorder.

Wechsler and his colleagues (1994) reported a strong positive relationship between the frequency of binge drinking and alcohol related health and life problems.

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