cont. from

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.

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. 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 male alcoholic persons 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 type 2 alcoholic persons 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 is alcoholic. 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 alcoholic persons respond differently to an alcohol challenge. 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 nonalcoholic persons. 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 alcoholic persons, 26% were alcohol dependent by age 30 years, as opposed to 9% of the control group. Furthermore, 56% of the sons of alcoholic persons with lesser objective and subjective responses to alcohol became alcohol dependent, as opposed to 14% of the sons of alcoholic persons who did not demonstrate these decreased responses. This also held true for the sons of fathers who were not alcoholic, although the numbers were small.
  • Positive family history and lesser response to alcohol increased the likelihood of later development of alcohol dependence.

Other Problems to be Considered:

Other drug abuse (both prescription drugs and street drugs): Consider the possibility of other drug abuse, both prescription drugs and street drugs.

Comorbid disorders: Also consider comorbid psychiatric conditions such as anxiety and depression. Depression, anxiety, and antisocial personality all are more common in alcoholic persons than in the general population (20.5% vs 7.2%, 23.5% vs 11.1%, and 18.3% vs 3.6%, respectively).

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Reviewed: 04/2006