Alcohol Dependence is a condition characterized by the harmful consequences of repeated alcohol use, a pattern of compulsive alcohol use, and (sometimes) physiological dependence on alcohol (i.e., tolerance and/or symptoms of withdrawal). This disorder is only diagnosed when these behaviors become persistent and very disabling or distressing.
School and job performance may suffer either from hangovers or from actual intoxication on the job or at school; child care or household responsibilities may be neglected; and alcohol-related absences may occur from school or work. The individual may use alcohol in physically hazardous circumstances (e.g., drunk driving or operating machinery while intoxicated). Legal difficulties may arise because of alcohol use (e.g., arrests for intoxicated behavior or for drunk driving). Individuals with this disorder may continue to abuse alcohol despite the knowledge that continued drinking poses significant social or interpersonal problems for them (e.g., violent arguments with spouse while intoxicated, child abuse).
Alcohol intoxication causes significant intellectual impairment (and stupid behavior). Once a pattern of compulsive use develops, individuals with this disorder may devote substantial periods of time to obtaining and consuming alcoholic beverages. These individuals continue to use alcohol despite evidence of adverse psychological or physical consequences (e.g., depression, blackouts, liver disease, or other complications). Individuals with this disorder are at increased risk for accidents, violence, and suicide. It is estimated that 1 in 5 intensive care unit admissions in some urban hospitals is related to alcohol and that 40% of people in the U.S.A. experience an alcohol-related accident at some time in their lives, with alcohol accounting for up to 55% of fatal driving events. More than one-half of all murderers and their victims are believed to have been intoxicated with alcohol at the time of the murder. Severe Alcohol Intoxication also contributes to disinhibition and feelings of sadness and irritability, which contribute to suicide attempts and completed suicides.
Only 5% of individuals with Alcohol Dependence ever experience severe complications of withdrawal (e.g., delirium, grand mal seizures). However, repeated intake of high doses of alcohol can affect nearly every organ system, especially the gastrointestinal tract, cardiovascular system, and the central and peripheral nervous system. Gastrointestinal effects include gastritis, stomach or duodenal ulcers, and, in about 15% of those who use alcohol heavily, liver cirrhosis and pancreatitis. There is also an increased rate of cancer of the esophagus, stomach, and other parts of the gastrointestinal tract.
One of the most common associated general medical conditions is low-grade hypertension. There is an elevated risk of heart disease. Peripheral neuropathy may be evidenced by muscular weakness, paresthesias, and decreased peripheral sensation. Most persistent central nervous system effects include cognitive deficits, severe memory impairment, and degenerative changes in the cerebellum (leading to poor balance and coordination). One devastating central nervous system effect is the relatively rare Alcohol-Induced Persisting Amnestic Disorder (Wernicke-Korsakoff syndrome) in which there is a dramatic impairment in short-term memory. Men may develop erectile dysfunction and decreased testosterone levels.
Repeated heavy drinking in women is associated with menstrual irregularities and, during pregnancy, with spontaneous abortion and fetal alcohol syndrome (leading to mentally retarded, hyperactive children). Alcohol Dependence can suppress immune mechanisms and predispose individuals to infections (e.g., pneumonia) and increase the risk for cancer.
Individuals with Alcohol Dependence are at increased risk for Major Depressive Disorder, other Substance-Related Disorders (e.g., drug addiction), Conduct Disorder in adolescents, Antisocial and Emotionally Unstable (Borderline) Personality Disorders, Schizophrenia, and Bipolar Disorder.
Alcohol use is highly prevalent in most Western countries. However, in most Asian cultures, the overall prevalence of Alcohol-Related Disorders is relatively low. In Muslim countries, the Islamic religion strictly prohibits alcohol (hence the rates of Alcohol-Related Disorders are very low). In the Western countries, this disorder occurs much more commonly in males (with a male-to-female ratio of 5:1). The lifetime risk of Alcohol Dependence is approximately 15% in the general population. In any year, 5% of the general population will actively be suffering from Alcohol Dependence.
Alcohol Dependence has a variable course that is frequently characterized by periods of remission and relapse. The first episode of Alcohol Intoxication is likely to occur in the mid-teens, with the age at onset of Alcohol Dependence peaking in the 20s to mid-30s. The large majority of those who develop Alcohol Dependency do so by their late 30s.
Alcohol Dependence often has a familial pattern, and it is estimated that 40%-60% of the variance of risk is explained by genetic influences. The risk for Alcohol Dependence is 3 to 4 times higher in close relatives of people with Alcohol Dependence. Most studies have found a significantly higher risk for Alcohol Dependence in the monozygotic twin than in the dizygotic twin of a person with Alcohol Dependence. Adoption studies have revealed a 3- to 4-fold increase in risk for Alcohol Dependence in the children of individuals with Alcohol Dependence when these children were adopted away at birth and raised by adoptive parents who did not have this disorder.
Follow-up studies of the typical person with an Alcohol Use Disorder show a higher than 65% 1-year abstinence rate following treatment. Even among less functional and homeless individuals with Alcohol Dependence who complete a treatment program, as many as 60% are abstinent at 3 months, and 45% at 1 year. Some individuals (perhaps 20% or more) with Alcohol Dependence achieve long-term sobriety even without treatment.
A cluster of physiological, behavioural, and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take alcohol. There may be evidence that return to alcohol use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals.
A definite diagnosis of dependence should usually be made only if three or more of the following have been experienced or exhibited at some time during the previous year:
- a strong desire or sense of compulsion to take alcohol;
- difficulties in controlling alcohol-taking behaviour in terms of its onset, termination, or levels of use;
- a physiological withdrawal state when alcohol use has ceased or been reduced, as evidenced by: the characteristic withdrawal syndrome for alcohol; or use of the alcohol with the intention of relieving or avoiding withdrawal symptoms;
- evidence of tolerance, such that increased doses of alcohol are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol-dependent individuals who may take daily doses sufficient to incapacitate or kill non-tolerant users);
- progressive neglect of alternative pleasures or interests because of alcohol use, increased amount of time necessary to obtain or take alcohol or to recover from its effects;
- persisting with alcohol use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm.
Narrowing of the personal repertoire of patterns of alcohol use has also been described as a characteristic feature (e.g. a tendency to drink alcoholic drinks in the same way on weekdays and weekends, regardless of social constraints that determine appropriate drinking behavior).
It is an essential characteristic of the dependence syndrome that either alcohol taking or a desire to take alcohol should be present; the subjective awareness of compulsion to use alcohol is most commonly seen during attempts to stop or control alcohol use.