'Loss of Control' in Alcoholics Arnold M.
Ludwig, MD; Fernando Bendfeldt, MD; Abraham Wikler, MD; Ralene
\s=b\ This study evaluates the ability of alcoholics to regulate their blood alcohol levels (BAL) within a designated range by relying primarily on interoceptive cues. Forty male alcoholics and 20 control subjects were exposed to an initial training session in which they received sufficient ethanol to maintain them within a designated BAL range over a 21/2-hour period. They were then exposed to two experimental sessions, one providing "overfeedback" and one "underfeedback." During each session, subjects had ten drinking decisions to make with respect to regulation of their BAL. The results indicated that alcoholics displayed greater "loss-of-control" than control subjects. This finding supported the hypothesis that alcoholics may possess a neurophysiologic feedback dysfunction that contributes to their relative inability to regulate ethanol intake.
(Arch Gen Psychiatry 35:370-373, 1978)
postulated the following:
Craving for alcohol... represents] the cognitive correlate of subclinical alcohol withdrawal syndrome.... Craving can be aroused either by interoceptive cues, eg, ingested alcohol stimu¬ lating cerebral neuronal receptors, or exteroceptive cues, environ¬ mental situations associated with prior heavy drinking or with the psychological and physical effects of prior withdrawal experi¬ ences. As such it is a necessary but not sufficient condition for relapse.... While craving may initiate drinking, relapse is facili¬ tated through the complementary phenomenon of loss of control, a behavioral state characterized by the relative inability to respond to either internal or external cues which regulate alcohol consump¬ tion. a
According to common clinical lore, the "loss of control" (LOC) drinking pattern represents the sine qua non of
alcoholism.--' The classical clinical concept of LOC main¬ tains that a single drink or two, administered either wittingly or unwittingly to an alcoholic, will trigger an inordinate desire or a chain reaction for increased consumption of alcohol, eventually leading the drinker to the end point of drunkenness or stupor, a process over which he presumably has little control. However, with the exception of one study,4 recent investigations have failed to document the existence of "uncontrolled" drinking in alcoholics after administration of a single drink or numerous drinks of alcohol.'" Our definition of LOC (see above) takes cognizance of the discrepancy between the classical clinical concept and most of the experimental findings in that we postulate that LOC consists of a relative inability to modulate alcohol consumption: it need not always eventuate in gross intoxication or stupor. By no means does it imply that alcoholics have absolutely no
volitional power to control the amount and frequency of drinking or that they turn into servomechanisms guided solely by the desire to attain oblivion through alcohol. In attempts to account for LOC, clinicians have advanced a variety of explanations, ranging from classical and opérant conditioning mechanisms'" to the activation of specific hypothalamic centers in the brain," alcoholinduced dissociation of control centers in the brain,12 and alterations in cellular metabolism that become conditioned by the first drink.1'' Be these postulated mechanisms as they may, we hypothesize that LOC may be largely related to a neurophysiological feedback dysfunction in alcoholics that produces a relative deficit in their ability to regulate alcohol intake by utilizing appropriate exteroceptive cues, such as counting the number of drinks and drinking only at
socially specified times, and, even more so, interoceptive cues, such as perceived intoxication or degree of speech and motor impairment. These types of cues, then, may be regarded as a source for information feedback relevant to limiting or regulating the drinking rate and quantity. To
the extent that persons attend to these sources of feed¬ back, they demonstrate controlled drinking; to the extent they do not or cannot, they demonstrate LOC. The present study represents an initial report of our findings in an attempt to test this hypothesis. METHOD The study was designed to evaluate the comparative ability of alcoholics and "social drinkers" to maintain their blood alcohol levels within a predetermined, designated range by relying
predominantly on interoceptive cues experienced during a prior training session. In two subsequent experimental sessions, in which false exteroceptive feedback was provided, subjects were required to make ten decisions, at 15-minute intervals, whether or not to accept a drink in order to keep their subsequent blood alcohol level (BAL) within the designated range. The decisions and BAL responses of subjects over the course of the two sessions constituted the major outcome measures.
Subjects The experimental sample consisted of 40 male alcoholics, previously detoxified at the Veterans Administration Hospital. Selection criteria pertained to adequate health status, no overt evidence of organic brain damage, history of alcohol withdrawal Table 1—Selected
Department of Psychiatry, University of Kentucky College of Medicine, Lexington, KY 40506 (Dr Ludwig).
Downloaded From: by a East Carolina University User on 04/03/2018
40) 45.9 (9.0) 71.7(8.7) 4.4 (4.7) 10.6(2.1)
Mean age, yr Mean weight, kg Mean No. of admissionsMean education
Accepted for publication Feb 18, 1977. From the Department of Psychiatry, University of Kentucky College
admissions for alcohol-related
tAII subjects having finished assigned scores of "13."
80.2(11.0) 0.0 (0.0) 12.9(0.3) 65.0
year of college
120 135 150 165 180 195 75 90 105 NUMBER OF MINUTES AFTER PRIMING DRINK Mean blood alcohol levels (BALs) for alcoholics and controls. Training means pertains to average BAL attained over train¬ ing sessions (T) for alcohol (Ale) and Control (Cont) groups separately. They represent designated range, within 10 mg/100 ml, to be achieved by subjects during overfeedback (OF) and underfeedback (UF) experimental sessions. 45
Table 2.—Mean Values for Alcohol Intake, for Effects of Age and Weight Mean BAL Alcoholics Controls