Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20

Psychiatric problems of alcoholics Leighton Y. Huey To cite this article: Leighton Y. Huey (1978) Psychiatric problems of alcoholics, Postgraduate Medicine, 64:6, 123-128, DOI: 10.1080/00325481.1978.11715004 To link to this article: https://doi.org/10.1080/00325481.1978.11715004

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Fifth of seven symposium articles in this issue

Psychiatric problems of alcoholics Consider What are the major psychiatric dysfunctions associated with or resultingfrom alcoholism? How does the relationship between a.flective disorder and alcoholism differ in men and women." How do the rates of allempted and completed suicides among alcoholics compare with rates among nonalcoholics?

Leighton Y. Huey, MD

In this overview of the psychiatric disorders and problems associated with alcoholism and alcohol abuse, true psychiatric illness which may account for excessive alcohol use is differentiated from the psychiatric sequelae of chronic alcoholism. This distinction is emphasized because of its important practical implications for treatment. A discussion of the psychiatric problems of alcoholics is, from the start, beset with a number of problems. Diagnostic confusion, which has so characterized psychiatry, extends to alcoholism as well. For example, certain patterns of drinking behavior (eg, periodic binge drinking) which would warrant a diagnosis of alcoholism under one system of classification might, in some instances, be a manifestation of underlying primary psychiatric disorder (eg, affective disorder). Questions as to whether alcoholism is secondary to an underlying psychiatric disorder or whether the psychiatric state is secondary to the alcoholism itself have contributed to the general lack of clarity in this important area. Nonetheless, in recent years a number of approaches and reports have helped resolve some of the ambiguity. The following discussion divides the psychiatric problems of alcoholism into two distinct but related and sometimes overlapping categories: (I) psychiatric disorders most closely associated with alcoholism and alcohol abuse and (2) psychiatric problems and syndromes resulting from alcoholism and alcohol abuse. Psychiatric disorders associated with alcoholism and alcohol abuse Affective disorders- These are some of the psychiatric disorders most often associated with alcoholism and alcohol abuse. They consist primarily of episodes of depressive illness alone or periods in which there is some combination or sequence of depression and mania in the absence of other preexisting psychiatric illness or of drug or alcohol continued

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A careful history will help distinguish true depressiv•e illness from a depressive st11te produced by alcoholism.

abuse. As is discussed later, it is essential to differentiate true depressive ilhess (primary) from a depressive state produced by chronic, excessive alcohol intake alone (secondary). A careful history which elucidates the symptoms or signs of psychiatric illness present prior to the development of excessive drinking will help determine whether the primary illness is one other than alcoholism. Several reports and lines of evidence suggest a relationship between affective disorder and alcoholism. Historically, the two were conceptually linked in the illness known as dipsomania, where pathologic drinking was thought to be symptomatic of manic-depressive illness. This subject has been reviewed by Freed. 1 Subsequent studies 2•3 suggfst that alcohol is used excessively by 8% to 32% of manicLeighton Y. Huey Or Huey is assistant professor of psychiatry at the University of California School of Medicine, San Diego, and acting chief of psychiatry at the Veterans Administratior Hospital. San Diego. In addition, he is clinical director of a mental health clinical research center funded by the National Institute of Mental Health. His major research interest is psychopharmacology.

Lou lmhof. OLR Photo/UCSD

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depressives. Mayfield and Coleman4 found that out of a sample of 59 manic-depressive men, 20% could be classified as alcoholics and another 22% as heavy drinkers. The incidence of depression in primary alcoholism is thought to be high. Cadoret and Winokur5 showed that at the time of admission to a hospital 41% of 173 persons with primary alcoholism had a depressive syndrome. An earlier study6 suggested that 6.8% of an alcoholic population had manicdepressive illness. The relationship between affective disorder and alcoholism may differ depending on sex. Winokur and Clayton7 found that women alcoholics are more likely than men alcoholics to have associated depression, suicidal ideation, and delusions. Furthermore, women more commonly have a history of primary depression antedating the onset of alcoholism, while in men depression tends to follow the appearance of alcoholism, usually by more than a decade. 8 Primary depression does occur in men, but not to the same extent as in women. In a study by Schuckit and associates9 of70 female alcoholics, 27% were noted to have histories compatible with affective disorder, and this subgroup appeared to be homogeneous and different from the subgroup with primary alcoholism. In depressed patients, drinking patterns may differ according to sex. One reports suggests that in men with secondary depression, drinking tends to be periodic and is more likely to be of the "bender" type than in women. On the other hand, drinking women with either primary or secondary depression appear to have longer periods of abstinence than do women with primary alcoholism. Further reinforcement of the relationship between alcoholism and affective disorder comes from family history studies which have been used in part to elucidate possible genetic contributions to the development of alcoholism. AmarkiO in an early investigation of male alcoholics reported that depressive syndromes were more often found in the relatives of alcoholics than in the general

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Antisocial personalitycharacterized by problems with authority, impulsive behavior, difficulty with close relationships, and overall disruption of school and work-is often associated with alcoholism.

population. In addition, male first-degree relatives had a higher incidence of alcoholism than would be predicted from the general population. In a series of studies by Winokur and Pitts, 11 alcoholism was five times more prevalent in the fathers of 36 patients with affective disorder than in the fathers of controls. In another study, 12 siblings were also noted to have an increased degree of alcoholism as well as affective disorder. Schuckit and associates 9 compared the firstdegree family members of women with primary alcoholism with the first-degree family members of those with alcoholism and a primary affective disorder and found a lower incidence of affective disorder in the former. At the same time, Winokur and associates 13 reported an elevated incidence of affective disorder in the close female relatives of alcoholics, while close male relatives tended to have an elevated incidence of alcoholism. This study also noted that rates of alcoholism in close family members of alcoholics were higher than those in the general population, the risk in male relatives being 30% to 50%. The association between affective disorder and alcoholism is in part reflected in the relationship between suicide and alcoholism; depression may frequently accompany both alcoholism and suicidal behavior. It has been noted that alcoholics have higher rates of both suicides and suicide attempts than do nonalcoholics 14 and that suicidal behavior appears to be more common in the later stages of alcoholism than in earlier phases.l5 At the same time it has been estimated that about one third of all reported suicides are associated with chronic alcohol abuse,l6 although this figure may be valid only for white middle-aged men. 17 Alcoholic intoxication, defined in one study as blood levels greater than 0.05 mg/ 100 m!, was found in about 30% of suicide attempts. 18 Another reportl 9 of 197 suicides showed that 48% of the 69 men in the group had blood alcohol levels over 0.05 mg/ I00 ml, while the corresponding figure for women was 18%. The development of depression

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and/or suicidal ideation as a consequence of alcohol intake is discussed later. The phase during which a person with an affective disorder drinks may be related to the predominant affective state. For example, patients who have periods of both mania and depression appear to increase alcohol intake only during the manic phase. This has been postulated as an attempt at self-medication. The determination of whether a patient with a drinking problem has a primary affective disorder or primary alcoholism directly governs treatment and prognosis. Effective forms of treatment for both depression and mania exist and in many instances will ameliorate the drinking problem. Personality disorders-A second psychiatric illness often associated with alcoholism is antisocial personality, or sociopathy, which is generally characterized by a lifelong history of problems with authority, impulsive and sometimes aggressive behavior, difficulty in developing close, meaningful relationships, and overall disruption of conventional productive life functions such as school and work.2o Several studies have found alcoholism in about 40% of a felon population.2 1 At the same time a higher incidence of antisocial personality has been reported22 in an alcoholic group compared with a nonalcoholic group. Whereas women alcoholics tend to have a higher incidence of primary depression, in men the most commonly associated psychiatric diagnosis predating the onset of alcoholism is antisocial personality. 7 In a recent preliminary report by Fowler and associates23 on the psychiatric diagnosis of 63 male alcoholic subjects, 21 (33%) had a diagnosis of alcoholism alone and the remaining 42 (67%) had psychiatric diagnoses in addition to alcoholism. The most frequent diagnosis unrelated to substance abuse was antisocial personality.l3,23 Data are very limited on the eventual development of alcoholism in other types of premorbid personalities. One large study24 classified 92% of a sample of alcoholics as having a personality disorcontinued 125

The incidence of schi2.ophrenia in alcoholics is probably quite low, but the opposite conditionalcoholism in schizophrenicsis quite common and i!!li speculated to be a form of self-tre;Eitment.

der, particularly of the passive-aggressive type. The attempt to delineate a so-called addictive personality has not been particularly fruitful to this point. Neuroses-Few studies have addressed the relationship between neurotic disorders and alcoholism. It has been suggested that anxiety neurosis in men is often masked by alcoholism. 25 Others26 have reported a higher freque:1cy of psychoneurotic and psychosomatic symptoms in alcoholics than in nonalcoholics. Work in this particular area must be regarded as tentative until additional data are forthcoming. Schizophrenia-Several studies have reported a relatively high proportion of schizophrenia in alcoholics, with some reports suggesting that over 30% of alcoholics are also schizophrenic. 27 These figures must be interpreted with caution. Questionable validity of the diagnosis of schizophrenia made in these studies probably explains the inflated figures. For example, nany patients diagnosed as schizophrenic may actually have an affective disorder or may derr.onstrate the timelimited picture of alcoholic paranoia or hallucinosis. Thus, the rate of occurrence of schizophrenia in alcoholics is probably quite limited, as demonstrated by one study of 259 alcoholics in which only four schizophrenics were found. 8 Other authors have concluded that ther'~ is no greater risk of development of schizophrenia among alcoholics than among the general population. 10 The opposite condition, that of excessive alcohol use in schizophrenics, has been studied as well. There is speculation that schizophrenics use alcohol as a self-prescribed regulator of mood and psychosis in an attempt to treat thf:ir symptoms. Two studies28,29 of large samples of s,;hizophrenics have reported associated alcoholism or excessive alcohol intake in 22% and 35%, respectively. Work in this area has been extensively reviewed by Freed.Jo Concurrent drug use-A significant proportion of alcoholics use other drugs. In one study,3 1 15% of a sample of alcoholics used barbiturates con-

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currently. Another study23 found associated drug dependence in 28% of an inpatient male alcoholic population, although 36% of this same population acknowledged experimentation with illicit drugs and 18% admitted to abuse of prescription drugs. Generally, the drug experimentation was most pronounced in younger subjects and in those having a diagnosis of antisocial personality.

Psychiatric problems resulting from alcoholism and alcohol abuse Depression and suicidal ideation- While a significant proportion of persons use alcohol in response to some underlying psychiatric illness such as affective disorder, a body of evidence shows that alcohol by itself is capable of inducing dysphoric moods and behavior and other psychologic changes in alcoholics and "normals" who do not have other psychiatric disorders. Intoxication per se may thus be a major factor in the development of feelings of depression or sadness and suicidal ideation. Mayfield and Montgomery32 have hypothesized about the types of suicide attempts alcoholics appear to make. One type has been described as "abreactive" and is characterized by sudden, unpredictable attempts which occur at the onset of drinking or at a time of rapidly increasing levels of intoxication. The second type has been described as resulting from a "depressive syndrome of chronic intoxication." Experimental intoxication studies have shown that continuous heavy drinking can produce increased anxiety and depression in both alcoholics and nonalcoholics.33-35 Suicide attempts based on alcohol-induced depression occur after two or more weeks of heavy drinking and are associated with increased depression, psychomotor retardation, and social withdrawal. The depression and suicidal ideation are therefore a consequence of excessive alcohol intake and, as such, can clear once the drinking has stopped and withdrawal from alcohol has been completed. (This usually

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Intoxication per se may be a major factor in the development of feelings of depression and suicidal ideation.

occurs over a two-week period.) Psychiatric diagnoses made at the time a person is intoxicated or in withdrawal may reflect an artifact or epiphenomenon of his or her state rather than a true psychiatric illness. This is a classic example of how chronic excessive use of alcohol can induce a state that mimics a variety of psychiatric disorders. Alcoholic hallucinosis-This disorder usually follows a prolonged episode of drinking and is characterized by auditory hallucinations, sometimes frightening, occurring in a clear sensorium in a person with a history of chronic alcohol abuse. The hallucinations in men often involve homosexuality, while in women they may focus on promiscuity. Unlike in delirium tremens, in this disorder visual hallucinations are infrequent. Mood disturbance is usually pronounced, with fear and apprehension being characteristic. Delusions of persecution and reference are frequently present. While Bleuler36 originally proposed that alcoholic hallucinations might represent an underlying

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schizophrenic disorder which has been released by alcohol, several studies refute this hypothesis and classify alcoholic hallucinosis as a possible variant of the withdrawal syndrome.37,38 Recovery from alcoholic hallucinosis generally occurs over several days, although there may be recurrences should the patient resume drinking excessively. Treatment consists of withholding alcohol and providing sufficient supervision so the patient cannot harm himself or herself or cause harm to others. In those patients with excessive fear and anxiety, a neuroleptic may be used, but such drugs should be given with caution, as they can precipitate severe hypotensive episodes as well as lower the seizure threshold. Correction of possible vitamin deficiencies should be considered routine practice. Alcoholic paranoia- The clinical manifestation of this state is characterized by jealousy resulting from delusions of infidelity, sometimes to an extreme degree, occurring in any alcoholic but especially in those who have had difficulty establishing mature heterosexual relationships and whose personality is characterized by stubbornness, suspiciousness, and difficulty in accepting discipline.39 This condition is regarded as rare; in fact, there is some question whether data are sufficient to justify alcoholic paranoia being considered a discrete psychiatric syndrome.40 Therapy for this state is basically the same as that for alcoholic hallucinosis. Conclusion Distinction between psychiatric disorders closely associated with alcoholism and psychiatric syndromes and sequelae which can occur as part of alcohol withdrawal or chronic alcohol abuse has major practical implications for treatment of the alcoholic patient. A person presenting with what at first appears to be alcoholism may actually have an underlying psychiatric condition the treatment of which might very well lead to resolution of the continued 127

Alcoholic hallucinosis usually follows a prolonged drinking bout and is characterized b:lf auditory hallucinations and pronounced mood disturbance.

alcoholic behavior (eg, primary affective disorder with secondary alcoholism). Similarly, an alcoholic who has been drinking excessively for some time and who manifests dep1ressive signs and symptoms may have a completely different clinical picture once alcohol intake has been stopped for a sufficient period (generally about two weeks) to allow accurate assessment of bnseline psychiatric status. Only through such an approach can rational treatment be provided. Address reprint requests to Leighton Y. Hut-y, MD. Veterans Administration Hospital, 3350 La Jolla Village Dr. 5an Diego. CA 92162. CME Credit Quiz begins on page 155.

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16. Tinklenburg JR: Alcohol and violence. In Boume P, Fox R (Editors): Alcoholism: Progress in Research and Treatment. New York, Academic Press, lnc, 1973, pp 195-210 17. Goodwin DW: Alcohol in suicide and homicide. J Stud Alcohol 34:144-156, 1973 18. Batchelor IR, Napier MB: The sequelae and short-term prognosis of attempted suicide: Results of one-year follow-up of 200 cases. J Neurol Neurosurg Psychiatry 17:261-266, 1954 19. James lP: Blood alcohol levels following successful suicide. J Stud Alcohol 27:23-29, 1966 20. Robins LN: Deviant Children Grown Up. Huntington. NY, Robert E Krieger Publishing Co, lnc, 1975 21. Guze SB, Goodwin DW, Crane JB: Criminality and psychiatric disorders. Arch Gen Psychiatry 20:583-591, 1969 22. Goodwin DW, Crane JB, Guze SB: Felons who drink: An 8-year follow-up. J Stud Alcohol32:136-147, 1971 23. Fowler RC, Liskow BL, Vasantkumar LT, et al: Psychiatric illness and alcoholism. Alcoholism: Clinical & Experimental Research 1:125-128, 1977 24. De Vito RA. Aaherty LA, Mozdziez GJ: Toward a psychodynamic theory of alcoholism. Dis Nerv Syst 31:43-49, 1970 25. Pitts FN Jr: The biochemistry of anxiety. Sci Am 220:69-75, 1969 26. Manson MP: A psychometric determination of alcohol addiction. Am J Psychiatry 106:199-205, 1949 27. Gorwitz K, Bahn A, Warthen FJ, et al: Some epidemiological data on alcoholism in Maryland: Based on admissions to psychiatric facilities. J Stud Alcohol31:423-443, 1970 28. Parker JB Jr. Meiller RM, Andrews GW: Major psychiatric disorders masquerading as alcoholism. South Med J 53:560-564, 1960 29. Johanson E: A study of schizophrenia in the male: A psychiatric and social study based on 138 cases with follow-up. Acta Psychiatr Neurol Scand 33(Suppll25):1-132, 1958 30. Freed EX: Alcoholism and schizophrenia: The search for perspectives. J Stud Alcohol 36:853-881, 1975 31. Devenyi P, Wilson M: Abuse of barbiturates in an alcoholic population. Can Med Assoc J 104:219-221, 1971 32. Mayfield DG, Montgomery D: Alcoholism, alcohol intoxication, and suicide attempts. Arch Gen Psychiatry 27:349-353, 1972 33. McNamee HB, Mello NK, Mendelson JH: Experimental analysis of drinking patterns of alcoholics: Concurrent psychiatric observations. Am J Psychiatry 124:1063-1069, 1968 34. Nathan PE, Titler NA, Lowenstein LM, et al: Behavioral analysis of chronic alcoholism. Interaction of alcohol and human contact. Arch Gen Psychiatry 22:419-430, 1970 35. Williams AF: Self-concepts of college problem drinkers. I. A comparison with alcoholics. J Stud Alcohol26:586-594, 1965 36. Bleuler E: Textbook of Psychiatry. New York, Macmillan Publishing Co, Inc, 1976, pp 342-345 37. Gross MM, Halpert E, Sabot L: Some comments on Bleuler's concept of acute alcoholic hallucinosis. J Stud Alcohol 24:54-60, 1963 38. Schuckit MA, Winokur G: Alcoholic hallucinosis and schizophrenia: A negative study. Br J Psychiatry 119:549-550, 1971 39. Kolb LC: Modern Clinical Psychiatry. Ed 9. Philadelphia, WB Saunders Co, 1977, pp 649-650 40. Diagnostic and Statistical Manual of Mental Disorders. Draft of the Third Edition. American Psychiatric Association. 1977

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Psychiatric problems of alcoholics.

Postgraduate Medicine ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20 Psychiatric problems of alc...
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