eMedicine Specialties > Psychiatry > Addiction

Alcoholism

Author: Warren Thompson, MD, FACP, Associate Professor, Department of Internal Medicine, Mayo Medical School
Coauthor(s): R Gregory Lande, DO, FACN, Clinical Consultant, Army Substance Abuse Program, Department of Psychiatry, Walter Reed Army Medical Center; Raj K Kalapatapu, MD, Fellow in Geriatric Psychiatry, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: Aug 19, 2008

Introduction

Background

Alcoholism is common, serious, and expensive. Physicians encounter alcohol-related cirrhosis, cardiomyopathy, pancreatitis, and gastrointestinal bleeding, as well as intoxication and alcohol addiction, on a daily basis. Alcoholism is also associated with many cancers. Wernicke encephalopathy and Korsakoff psychosis are also important causes of chronic disability as well as dementia. Fetal alcohol syndrome is a leading cause of mental retardation. In addition, accidents (especially automobile), depression, dementia, suicide, and homicide are important consequences of alcoholism.

Alcohol-related diseases are discussed in separate articles. The focus of this article is screening, diagnosis, treatment, and new research findings on the natural history and heritability of alcoholism.

Pathophysiology

Alcohol affects virtually every organ system in the body and, in high doses, can cause coma and death. It affects several neurotransmitter systems in the brain, including opiates, GABA, glutamate, serotonin, and dopamine. Increased opiate levels help explain the euphoric effect of alcohol, while its effects on GABA cause anxiolytic and sedative effects.

Alcohol inhibits the receptor for glutamate. Long-term ingestion results in the synthesis of more glutamate receptors. When alcohol is withdrawn, the central nervous system experiences increased excitability. Persons who abuse alcohol over the long term are more prone to alcohol withdrawal syndrome than persons who have been drinking for only short periods. Brain excitability caused by long-term alcohol ingestion can lead to cell death and cerebellar degeneration, Wernicke-Korsakoff syndrome, tremors, alcoholic hallucinosis, delirium tremens, and withdrawal seizures. Opiate receptors are increased in the brains of recently abstinent alcoholic patients, and the number of receptors correlates with cravings for alcohol.

Frequency

United States

These statistics are based on the US National Longitudinal Alcohol Epidemiologic Study. Alcoholism is prevalent in 20% of adult hospital inpatients. One in 6 patients in community-based primary care practices had problem drinking. The following apply to the US adult population:

  • Current drinkers - 44%
  • Former drinkers - 22%
  • Lifetime abstainers - 34%
  • Abuse and dependency in the past year - 7.5-9.5%
  • Lifetime prevalence - 13.5-23.5%

Alcoholism is slightly more common in lower income and less educated groups. Vaillant studied the natural history of alcoholism and the differences between college-educated and inner-city alcoholic persons. He followed 2 cohorts (over 400 patients) of alcoholic patients over many years.1

According to Vaillant's research, inner-city men began problem drinking approximately 10 years earlier than college graduates (age 25-30 y vs age 40-45 y). Inner-city men were more likely to be abstinent from alcohol consumption than college graduates (30% vs 10%) but more likely to die from drinking (30% vs 15%). A large percentage of college graduates alternated between controlled drinking and alcohol abuse for many years. Returning to controlled drinking from alcohol abuse is uncommon, no more than 10%; however, this figure is likely to be high because it was obtained from self-reported data. Mortality in both groups was related strongly to smoking. Abstinence for less than 5-6 years did not predict continued abstinence (41% of men abstinent for 2 y relapsed).

International

The World Health Organization examined mental disorders in primary care offices and found that alcohol dependence or harmful use was present in 6% of patients. In Britain, 1 in 3 patients in community-based primary care practices had at-risk drinking behavior. Alcoholism is more common in France than it is in Italy, despite virtually identical per capita alcohol consumption.

Mortality/Morbidity

Alcohol use is the third leading cause of preventable death in the United States (after smoking and obesity). Annually, 85,000 deaths are attributable to alcohol at a cost of $185 billion.2,3 Almost half of these deaths are attributable to alcohol-related injury.

Four percent of the global burden of disease is attributable to alcohol. This figure rises to 7% in North America, Europe, Japan, and Australia and to 12% in Eastern Europe and Central Asia. Worldwide, alcohol is responsible for a percentage of a number of conditions, as follows:

Below are the statistically significant relative risks from a study by the American Cancer Society for men and women who consume 4 or more drinks daily. A drink is defined as one 12-oz beer, one 4- to 5-oz glass of wine, or one mixed drink containing 1.5 oz of spirits (80 proof). The relative risk for the noted maladies with consumption of 4 or more drinks daily is as follows:

  • Cirrhosis - For men, 7.5; for women, 4.8
  • Injuries - For men, 1.3
  • Ear, nose, and throat cancer; esophagus cancer; liver cancer - For men, 2.8; for women, 3

Moderate alcohol consumption (1-2 drinks/d) reduces the risk of cardiovascular disease in men and women by approximately 30%.4,5,6 The effect of heavy alcohol consumption on the risk of cardiovascular disease varies in different studies. The person's drinking pattern appears to have an effect on cardiovascular disease. Drinking with meals may reduce the risk, while binge drinking increases risk (even in otherwise moderate drinkers).

Moderate alcohol consumption appears to increase the risk of breast cancer in women. Total mortality is reduced with moderate alcohol consumption but not with heavy alcohol consumption; the cardiovascular benefit is offset by cirrhosis, cancer, and injuries. The amount of alcohol associated with the lowest mortality appears to be 2 drinks per day in men and 1 drink or fewer per day in women. Moderate alcohol consumption reduces the risk of developing diabetes, but heavy alcohol consumption may increase the risk. The cardiovascular benefit becomes important in men older than 40 years and in women older than 50 years. The risk of hypertension is increased with 3 or more drinks daily.

No benefits are noted in people at low risk for coronary disease (men <40 y and women <50 y). Recent data suggest an increase in coronary calcification with moderate alcohol consumption in young adults.7 This effect was exacerbated by binge drinking.

Of men aged 18-25 years, 60% binge drink. (Binge drinking is defined as 5 alcoholic drinks for men [4 for women] in a row.) Binge drinking significantly increases the risk of injury and contracting sexually transmitted diseases. Women who binge drink at this age are at higher risk of becoming pregnant and potentially harming an unborn child. (Any amount of alcohol consumption during pregnancy is risky.)

More than three quarters of all foster children in the United States are children of alcohol- or drug-dependent parents. From 60-70% of reported domestic violence incidents involve alcohol. Half of all violent crime is alcohol or drug related.

Overall, morbidity and mortality are related strongly to smoking, and people who drink heavily are less likely to quit smoking. Additionally, persons who begin smoking early are more likely to develop problems with alcohol.

With regard to pregnancy, fetal alcohol syndrome is the leading known cause of mental retardation (1 in 1000 births). More than 2000 infants annually are born with this condition in the United States. Alcohol-related birth defects and neurodevelopmental problems are estimated to be 3 times higher. Even small amounts of alcohol consumption may be risky in pregnancy. A 2001 study by Sood et al reported that children aged 6-7 years whose mothers consumed alcohol even in small amounts had more behavioral problems.8 In a study from 2003, Baer et al showed that moderate alcohol consumption while pregnant resulted in a higher incidence of offspring problem drinking at age 21 years, even after controlling for family history and other environmental factors.9 All women who are pregnant or planning to become pregnant should avoid alcohol.

Race

The 2 largest studies, the US National Comorbidity Survey and the Epidemiologic Catchment Area Survey, both showed a lower prevalence of alcoholism in African Americans than in white Americans. The prevalence was equal or higher in Hispanic Americans compared with white Americans.

Studies of Native Americans and Asian Americans are smaller. These studies indicate the prevalence of alcoholism is higher in Native Americans and lower in Asian Americans when compared with white Americans.

Sex

Alcoholism is at least twice as prevalent in men as it is in women. In the National Comorbidity Survey, it was 2.5 times more prevalent in men than in women. The lifetime prevalence was 20% in men and 8% in women. For alcohol abuse or dependence in the past year, the rates were 10% for men and 4% for women.

Women do not metabolize alcohol as efficiently as men. Hazardous drinking (not alcoholism) is greater than 1 drink daily for women and greater than 2 drinks daily for men.

Problem drinking in women is much less common than it is in men, and the typical onset of problem drinking in females occurs later than in males. However, progression is more rapid, and females usually enter treatment earlier than males. Women more commonly combine alcohol with prescription drugs of abuse than do males. Women living with substance-abusing men are at high risk.

Alcohol problems are less likely to be recognized in women, and women with alcohol problems are less likely to be treated. This may be because women are less likely than men to have job, financial, or legal troubles as a result of drinking.

Age

The prevalence of alcoholism declines with increasing age. The prevalence in elderly populations is unclear but is probably approximately 3%. A study of the US Medicare population found that alcohol-related hospitalizations were as common as hospitalizations for myocardial infarction.

Among older patients with alcoholism, from one third to one half develop alcoholism after age 60 years. This group is harder to recognize. A recent population-based study found that problem drinking (>3 drinks/d) was observed in 9% of older men and in 2% of older women. Alcohol levels are higher in elderly patients for a given amount of alcohol consumed than in younger patients.

Clinical

History

Diagnosis

The diagnosis of an alcohol problem is best made by the history. Laboratory tests have a sensitivity of no better than 50%, and physical examination is helpful only after the consequences of alcoholism are apparent. Early diagnosis based on a careful history can prevent such consequences. Physicians should use terms such as "person with an alcohol problem" rather than "alcoholic," which is a commonly used but demeaning shorthand term.

Although the dangers of alcoholism are well known, data suggest that physicians frequently fail to make the diagnosis. Less than 50% of people who went to their doctor because of alcohol-related issues were asked about the problem. Multiple studies on medical inpatients and surgical patients in university and community hospitals, as well as outpatients in internal medicine and family medicine practices, show a low recognition rate and an even poorer treatment rate. The following are possible reasons that alcohol-related problems are missed during diagnosis.

  • Patient factors contribute to the failure to diagnose alcohol problems. Patients frequently deny they have a problem. They might not link alcohol with its consequences. Patients may be unaware that a positive family history increases their risk for the disease. They might fear being reported to their employers. Patients might be too ashamed to report their problem.
  • Physicians frequently share the responsibility for the failure to diagnose alcoholism. Many physicians have a negative attitude toward persons with alcohol problems. They view these patients as demanding and feel that they waste society's resources.
  • Recognized substance abuse patients tend to have an antisocial personality disorder (type 2 alcoholism, characterized by an association with criminal behavior [sociopathy], onset in teen years, and drinking to get high), while those whose diagnosis is missed tend to have depression or anxiety. During residency training, physicians see a fair number of persons with type 2 alcoholism; these patients are often not truthful and have a poorer prognosis. This contributes to the belief among many physicians that alcoholism is not treatable, despite good evidence to the contrary (see Treatment). Also, physicians might hesitate to label a patient as alcoholic because of negative consequences. Physicians who have a problem with alcohol themselves are less likely to discuss alcoholism and its consequences with patients.
  • Physicians might not know how to screen for and diagnose alcoholism. However, screening for alcoholism is important (see CAGE questionnaire and AUDIT).
  • "How much do you drink?" is probably the question asked most commonly by doctors. This question has less than 50% sensitivity for alcohol problems. Blood tests, such as liver function tests and mean corpuscular volume, are not particularly effective; even the best test, gamma glutamyl transferase, has a sensitivity of only approximately 50%. Recently, sialic acid and carbohydrate-deficient transferrin levels have been touted as possible tests, but the sensitivities of both appear to be too low to be useful.

Screening

The CAGE ([need to] cut down [on drinking], annoyance, guilt [about drinking], [need for] eye-opener) questionnaire is the best-known and most-studied short screening test for alcohol problems. The CAGE questions should be given face-to-face (not as a paper and pencil test) and should be asked before questions on quantity and frequency (the sensitivity of the questions drops if quantity questions precede them).
  • The following 4 questions make up the CAGE questionnaire:
    • Have you ever felt the need to cut down on your drinking?
    • Have people annoyed you by criticizing your drinking?
    • Have you ever felt bad or guilty about your drinking?
    • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
  • Patients who answer affirmatively to 2 questions are 7 times more likely to be alcohol dependent than the general population. Those who answer negatively to all 4 questions are one-seventh as likely to have alcoholism as the general population.
  • The sensitivity of the CAGE questionnaire was thought to be 75%. More recent studies, however, show that the sensitivity is lower, particularly in populations with a lower prevalence, such as among female and elderly populations. The CAGE questionnaire also may fail to identify binge drinkers and cannot identify those who have not experienced the consequences of alcoholism. Nevertheless, the CAGE questionnaire is brief and easy to administer
  • The CAGE questions are not useful for diagnosing hazardous drinking. Women should consume no more than 3 standard alcohol drinks on any one occasion and no more than 7 drinks per week10 and men younger than 65 years should consume no more than 4 drinks on any one occasion and no more than 13 standards drinks per week. Men older than 65 years should follow recommendations for women. Other drinking considered hazardous is any use of alcohol by children, teens, by those with a personal or family history of alcohol dependence, women who are pregnant or breastfeeding, and use before or during situations requiring attention or skill (eg, driving)
  • By itself, the CAGE questionnaire is not an adequate screening for alcohol problems.
The AUDIT (alcohol use disorders identification test) is the best test for screening because it detects hazardous drinking and alcohol abuse. Furthermore, it has a greater sensitivity in populations with a lower prevalence of alcoholism. One study suggested that questions 1, 2, 4, 5, and 10 were nearly as effective as the entire questionnaire. If confirmed, AUDIT would be easier to administer.

Table 1.AUDIT Questions and Scoring System

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Table
Questions0 Points1 Point2 Points3 Points4 Points
1. How often do you have a drink containing alcohol?NeverMonthly or less2-4 times a month2-3 times a week4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?1 or 23 or 45 or 67-910 or more
3. How often do you have 6 or more drinks on 1 occasion?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
4. How often during the past year have you found that you were not able to stop drinking once you had started?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
5. How often during the past year have you failed to do what was normally expected of you because of drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
7. How often during the past year have you had a feeling of guilt or remorse after drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
9. Have you or has someone else been injured as a result of your drinking?No Yes, but not in the past year Yes, during the past year
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?No Yes, but not in the past year Yes, during the past
year
Questions0 Points1 Point2 Points3 Points4 Points
1. How often do you have a drink containing alcohol?NeverMonthly or less2-4 times a month2-3 times a week4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?1 or 23 or 45 or 67-910 or more
3. How often do you have 6 or more drinks on 1 occasion?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
4. How often during the past year have you found that you were not able to stop drinking once you had started?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
5. How often during the past year have you failed to do what was normally expected of you because of drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
7. How often during the past year have you had a feeling of guilt or remorse after drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost daily
9. Have you or has someone else been injured as a result of your drinking?No Yes, but not in the past year Yes, during the past year
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?No Yes, but not in the past year Yes, during the past
year

The AUDIT can be administered as a paper-and-pencil test, but the CAGE questionnaire should be administered face to face. The CAGE questionnaire is less reliable when given after asking questions on frequency. If the patient answers questions on the CAGE questionnaire or AUDIT affirmatively, following up with additional questions about circumstances and reasons is important. Additional useful questions are found below (see Additional questions).

The diagnosis of alcohol dependence relies more on the consequences of alcohol use and less on the amount of alcohol consumed. Thus, if one suspects alcohol problems from answers to screening questions, attempt to determine what consequences of alcohol abuse the patient has experienced.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria are required to make the diagnosis of alcohol dependence. The diagnosis requires 3 of the following criteria in the DSM-IV-TR.

  • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 or more of the following, occurring at any time in the same 12-month period:
    • Tolerance, as defined by either of the following:
      • A need for markedly increased amounts of the substance to achieve intoxication or desired effect
      • Markedly diminished effect with continued use of the same amount of the substance
    • Withdrawal, as manifested by either of the following:
      • The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
      • The same (or a 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 was 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 (eg, visiting multiple doctors or driving long distances), use the substance (eg, chain-smoking), 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 or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (eg, current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption). Specify if:
      • With physiological dependence - Evidence of tolerance or withdrawal (ie, either item 1 or 2 is present)
      • Without physiological dependence - No evidence of tolerance or withdrawal (ie, neither item 1 nor 2 is present)

The following reasons illustrate the importance of screening for alcohol and drug abuse.

  • Alcoholism is common and serious.
  • Failure to screen leads to misdiagnosis. Approximately 50-90% of alcohol problems are missed in the office.
  • Effective and simple screening tests are available.
  • Effective treatments are available, especially if the diagnosis is made early.
  • Early identification can prevent physical and psychosocial problems.
Additional questions, as present below, may be helpful when screening for alcoholism.
  • Have you ever had a drinking problem?
  • When was your last drink? (Less than 24 h is a red flag.)
  • Do you use alcohol to relieve pain, anxiety, or insomnia?
  • Have you ever been arrested for drinking, such as driving under the influence?
  • Have you ever lost friends or girlfriends/boyfriends because of your drinking?
  • Have you ever been to an Alcoholics Anonymous (AA) meeting?
  • The following are additional questions specific to the geriatric population:
    • Did your drinking increase after someone close to you died?
    • Does alcohol make you sleepy so that you often fall asleep in your chair?
  • The following are additional questions specific to the adolescent population:
    • Do you drink alone?
    • Do you ever miss school to go drinking or because you have a hangover? 

Physical

  • The following are signs and symptoms of alcohol withdrawal:
    • Nausea and vomiting
    • Diaphoresis
    • Agitation and anxiety
    • Headache
    • Tremor
    • Seizures
    • Visual and auditory hallucinations: Many patients who are not disoriented, and who therefore do not have delirium tremens, have hallucinations.
  • The following are signs of delirium tremens (ie, alcohol withdrawal delirium):
    • Tachycardia and hypertension
    • Temperature elevation
    • Delirium
  • The following are signs of chronic alcoholism:
    • Gynecomastia
    • Spider angiomata
    • Dupuytren contractures (also may be congenital)
    • Testicular atrophy
    • Enlarged or shrunken liver
    • Enlarged spleen
  • Ataxia, ophthalmoplegia (usually lateral gaze palsy), and confusion indicate Wernicke encephalopathy.
  • Anterograde and retrograde amnesia, often with confabulation and preceded by Wernicke encephalopathy, indicates Korsakoff syndrome.
  • Asterixis and confusion suggest hepatic encephalopathy.

Causes

Patients commonly use a psychiatric disorder to deny alcohol abuse. Unless strong evidence indicates that the psychiatric disorder clearly precedes the alcoholism or is present during a long period of sobriety, the best plan is to proceed as if alcoholism is the primary diagnosis. Arrange a consultation with a psychiatrist for difficult cases because some patients who are treated for psychiatric conditions stop drinking and do very well.

The physician should, nonetheless, perform a brief mental status exam to help guide the referral process. Basic elements that should be covered in the mental status exam include an assessment of mood, perceptual problems such as hallucinations, and a safety screen. The use of a standardized instrument helps ensure important questions are asked and the results transmitted with some degree of objectivity. Several validated instruments exist, including The Patient Health Questionnaire from the Primary Care Evaluation of Mental Disorders (PRIME-MD)11 and the Cornell Psychiatric Screen12 .

Genetic psychiatric disorders, such as schizophrenia and bipolar disorder, are associated with alcoholism. The presence of both a serious, persistent mental illness and alcoholism is called dual diagnosis. The physician must address both. Family history commonly reveals members with bipolar disorder, alcoholism, or both. Despite this and despite an intensive search for a gene for alcoholism, study results remain inconclusive. Nevertheless, some evidence indicates that genetics plays a major role in alcohol abuse.

  • Twin studies
    • Identical twins have a higher concordance for drinking behavior and possibly alcoholism than fraternal twins.
    • In a well-conducted twin study of 542 families, a single underlying trait for conduct disorder, antisocial personality, alcohol dependence, and drug dependence was found, which was highly heritable and was observed in both sexes.13 Additionally, the study found that maximal alcohol consumption of fathers was predictive of their children having behavior and substance abuse problems (>24 drinks in 24 h yielded especially high risk). Not all at-risk children developed substance use or behavior problems. The environment seemed to determine which, if any, manifested. Deviant peers and poor parent-child relationships predicted early use (age <15 y) of alcohol, which predicted later alcohol abuse and antisocial personality. This study applies to early-onset alcoholism and type 2 alcoholism. More work is needed on later-onset alcoholism and type 1 alcoholism.
  • Adoption studies

    • Whether reared by biologic or adoptive parents, sons of males with alcoholic problems are 4 times more likely to have problems with alcohol than sons of persons who are not.
    • Two Swedish studies have suggested the following 2 types of male alcoholism:
      • Type 1 characteristics include (1) onset in adulthood (early twenties), (2) drinking to relieve anxiety, and (3) inherited but requires an environmental trigger.
      • Type 2 characteristics include (1) an association with criminal behavior (sociopathy), (2) onset in teen years, and (3) drinking to get high.
      • Sons of persons with type 2 alcoholism are 7 times more likely to develop type 2 alcoholism compared with the general population.
      • The theories suggested from these studies are controversial and require confirmation in additional populations.
    • Data from adoption studies on daughters of persons with alcohol problems are less clear. Daughters might be at increased risk if the biological mother has alcoholism. A recent twin study in women found higher concordance in monozygotic twins than in dizygotic twins.
  • Experimental studies
    • Schuckit and Smith found that sons of persons with alcoholism respond differently to an alcohol challenge.14 They report decreased subjective ratings for feeling intoxicated, and they objectively have less body sway when given the same amount of alcohol as sons of persons without alcoholism. The study population consisted of white, male college students who drank alcohol but were not alcohol dependent themselves. The fathers in this study could not have psychopathology other than alcoholism (ie, no sociopathy, no bipolar illness).
    • Ten-year follow-up data have been published recently for the first half of this cohort. Of the sons of persons with alcoholism, 26% were alcohol dependent by age 30 years, as opposed to 9% of the control group. Furthermore, 56% of the sons of persons with alcoholism with lesser objective and subjective responses to alcohol became alcohol dependent, as opposed to 14% of the sons of persons with alcoholism who did not demonstrate these decreased responses. This also held true for the sons of fathers who did not have alcoholism, although the numbers were small.
    • Positive family history and lesser response to alcohol increased the likelihood of later development of alcohol dependence.
  • Psychological studies
    • Behavioral models explain alcohol abuse in terms of learning theory. Through operant conditioning, the reinforcing elements of alcohol use become habitual.
    • Cognitive models explain alcohol abuse in terms of “automatic thoughts,” which precede the person’s more identifiable feelings about alcohol. For example, an automatic thought might be “I deserve a drink because I’ve had a rough day."
    • Psychoanalytic models explain alcohol abuse in terms of ego defenses and intrapsychic conflicts. The alcohol serves as a way to escape the uncomfortable internal conflict.

More on Alcoholism

Overview: Alcoholism
Differential Diagnoses & Workup: Alcoholism
Treatment & Medication: Alcoholism
Follow-up: Alcoholism
References
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Further Reading

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Keywords

alcoholism, alcohol dependence, alcohol abuse, Alcoholics Anonymous, AA, chronic alcohol use, chronic alcohol abuse, substance abuse, ethanol abuse, binge drinking, bender

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Contributor Information and Disclosures

Author

Warren Thompson, MD, FACP, Associate Professor, Department of Internal Medicine, Mayo Medical School
Warren Thompson, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Heart Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

R Gregory Lande, DO, FACN, Clinical Consultant, Army Substance Abuse Program, Department of Psychiatry, Walter Reed Army Medical Center
R Gregory Lande, DO, FACN is a member of the following medical societies: American Osteopathic Academy of Addiction Medicine and American Osteopathic Association
Disclosure: Nothing to disclose.

Raj K Kalapatapu, MD, Fellow in Geriatric Psychiatry, Mount Sinai School of Medicine
Raj K Kalapatapu, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Denis F Darko, MD, Executive Director, Clinical Research and Development, Neuroscience Global Licensing Medical Director, Clinical Neuroscience Therapy Area and CNS and Pain Control Research Area, AstraZeneca LP
Denis F Darko, MD is a member of the following medical societies: American College of Physicians and American Psychiatric Association
Disclosure: AstraZeneca Salary Management position

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other; Pfizer Honoraria Speaking and teaching

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

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