Drugs and Alcohol Today

Social and psychological aspects of alcohol misuse and dependence

Hannah Jethwa
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 Social and psychological
aspects of alcohol misuse
and dependence
Hannah Jethwa
Graduate medical student at Warwick Medical School
Downloaded by Texas State University San Marcos At 05:24 18 July 2016 (PT)

H.Jethwa@warwick.ac.uk

Abstract
Problem drinking includes a spectrum of drinking habits ranging from excessive alcohol intake to alcohol
dependence. Numerous risk factors are thought to increase the susceptibility to such drinking patterns – genetic,
environmental and constitutional. Although alcohol misusers are frequently stereotyped, from interviewing
numerous patients it is evident that there is no ‘typical alcoholic’. Alcohol consumption screening is widely
used; however, it is important for healthcare professionals to understand the social and psychological aspects of
problem drinking before advising abstinence. With this understanding, it is clear that governmental legislation
with regards to alcohol is more likely to cut down the number of social binge drinkers than the number
dependent on alcohol. The onus of reducing the number of individuals developing diseases as a result of chronic
alcohol misuse, therefore, lies with the healthcare profession; early screening of alcohol consumption and early
psychological intervention for susceptible individuals is key in this prevention.

Key words
Alcohol misuse, alcohol dependence, addictive behaviour, excessive appetite

Introduction
Although many people are aware of the negative
physical consequences of drinking to excess, a
small percentage of people display harmful drinking
patterns regardless. It is easy for those in the health
care profession to point fingers at patients admitted
with conditions that are supposedly ‘self-inflicted’.
Although some would argue that the decision to
start and maintain drinking alcohol at high levels
is solely due to choice, with a greater understanding
of the life histories of individuals who are, or once
were, dependent on alcohol, it becomes evident
that substance misuse may not have been a choice
at all. This then begs the question of whether
the onus is on the government to make it more
difficult for individuals to buy and consume harmful
amounts of alcohol, or on society to make it less
acceptable to drink heavily, or whether we can
ask the health care professionals to deal with the
psychological issues of those who turn to alcohol
misuse as a means of escaping from reality.
Method
Ten individuals with a history of alcohol
dependence were interviewed about their life
histories and drinking patterns. Interviews
were conducted with both inpatients and

$RUGSAND!LCOHOL4ODAYs6OLUME)SSUEs$ECEMBER©0IER0ROFESSIONAL 29
 Social and psychological aspects of alcohol misuse and dependence
outpatients between June and August 2009, and
individuals were chosen to include a variety of
alcohol consumption levels and socioeconomic
backgrounds. All individuals are currently
abstinent; duration of abstinence ranges from one
month to three years.
Results
A table was compiled (see Table 1, p31),
comparing the key facts relating to individual
drinking habits and relevant medical conditions.
It shows that although some risk factors for
problem drinking are associated with familial
history of alcohol misuse, two (20%) individuals
did not show this trend; furthermore, six (60%)
individuals identified triggers that led them to
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drink in excess, whereas four (40%) just drank
because they enjoyed the taste and effects of
alcohol. Additionally, although five (50%)
patients did enjoy drinking, five (50%) others did
not and only drank because of the need to manage
their dependence, differentiating between those
who may be considered as ‘hazardous recreational
drinkers’ and ‘dependent drinkers’.
Alcohol misuse
Although the reasons behind one’s proclivity
to drink harmfully or become dependent on
alcohol are not fully understood, environmental,
constitutional and genetic influences are believed
to play a role.
Despite government recommendations for
levels of safe drinking (21 and 14 units for men
and women, respectively) an NHS survey shows
that, in 2006, 31% of men and 20% of women
reported drinking over this limit in an average
week (NHS Information Centre, 2009).
Drinking between 22–50 units per week for
men and 15–35 units per week for women is
defined as ‘hazardous’ drinking, with increased risk
of developing physical harm, and drinking over
these levels is considered as ‘harmful’ drinking
(otherwise known as alcohol misuse), which
is the pattern of drinking associated with the
development of physical damage (Morgan &
Ritson, 2009).
A newspaper article from 2009 suggests that,
every year, the cost to the NHS of dealing with
incidents and conditions involving alcohol is £3
billion (The Telegraph, 2009).
Furthermore, there were 57,142 NHS hospital
admissions with a primary diagnosis related
to alcohol in 2006, a 52% increase on 1996
(Drinkaware, 2009). In 2007, 5,743 men and
30 $RUGSAND!LCOHOL4ODAYs6OLUME)SSUEs$ECEMBER©0IER0ROFESSIONAL
2,983 women died of an alcohol-related cause
(Swaine, 2009); the majority of these deaths were
attributed to alcoholic liver disease (51%) and
alcohol dependence (44%).
Although many people suggest that the price of
alcohol should be increased to reduce the amount
that people drink, the government, whose revenue
from alcohol was £14 billion in 2006 (British
Beer and Pub Association, 2006), is reluctant to
make such changes. Some groups, however, have
suggested that an alternative would be for the
drinks industry to invest more in treatment for
alcohol-related problems.
Alcohol dependence
It is thought that approximately 25% of individuals
misusing alcohol will become dependent (Medline
Plus Medical Encyclopedia, 2009).
According to Morgan and Ritson (2009)
‘alcohol dependence syndrome’ is characterised by:
s ASTRONGDESIREORCOMPULSIONTODRINK
s DIFFICULTYINCONTROLLINGTHEONSETORTERMINATION
of drinking or the levels of alcohol use
s APHYSIOLOGICALWITHDRAWALSTATEONCESSATIONOF
alcohol or its use to avoid withdrawal symptoms
s INCREASING TOLERANCE TO ALCOHOL SO THAT
increased amounts are needed in order to
achieve similar effects to those originally
produced by smaller amounts
s PROGRESSIVENEGLECTOFOTHERINTERESTS
s PERSISTINGUSEOFALCOHOLDESPITECLEAREVIDENCE
and awareness of the nature and extent of the
harm it is causing.
All patients interviewed admitted to displaying
features of the dependence syndrome.
Alcohol dependence – a disease?
Although ICD-10 (World Health Organization,
1994) describes alcohol dependence as being a
disease, there is an ongoing debate as to whether
this title is appropriate.
The classic disease theory states that certain
individuals have an increased susceptibility
to becoming alcohol dependent. The disease
develops if these individuals take up drinking,
resulting in a change from social drinking to
private drinking, increased tolerance to alcohol,
and the experience of negative symptoms in
the absence of consumption. More decisively,
individuals affected by the disease inevitably
develop an uncontrollable drinking habit, as the
disease specifically results in a loss of control and
increased tolerance (Fingarett, 1992). In line
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Table 1: Key information from patient interviews

Initials Gender Age Onset Onset Length Number Relationship Dependence Currently Family Cirrhosis Other Trigger
age of age of of regular of units with drinking history alcohol-
drinking regular drinking daily alcohol* related
drinking (years) problems

GB M 65 14 51 12 15 Positive Y N Y Y Peripheral Loss of

neuropathy job

DP M 39 15 15 15 20 Negative Y N Y Y Cerebellar Depression

ataxia,
peripheral
neuropathy

JR F 62 15 41 19 30 Positive Y N Y N N Unknown

PL M 50 20 33 13 30 Negative Y N Y Y N Bereavement

SK F 63 17 50 13 20 Negative Y N N Y N Breakdown
of
relationship

MS F 36 13 31 5 50 Positive Y N Y Y Liver Unknown

failure

PA M 46 ? ? ? 90 Positive Y N N Y Depression Unknown

DM M 39 14 20 18 38 Negative Y N Y Y N Unknown

DC F 44 15 31 10 30 Negative Y N Y Y N Divorce

JM F 45 14 25 10 24 Positive Y N Y Y N Bereavement

* Relationship with alcohol has been categorised as either positive, in which patient enjoys drinking alcohol, or negative, in which patient dislikes drinking but
continues regardless.

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Social and psychological aspects of alcohol misuse and dependence

31
 Social and psychological aspects of alcohol misuse and dependence
with this theory, the disease progresses in regular,
predictable stages, irrespective of one’s personality,
background, social status or race (Fingarett, 1992).
A review by McLellan et al (2000) compared the
diagnoses, heritability, aetiology, pathophysiology
and response to treatments of alcohol dependence
compared with Type 2 diabetes mellitus, systemic
hypertension and asthma, and concluded
that genetic heritability, personal choice and
environmental factors are comparably involved in
the aetiology and course of all of these disorders
(McLellan et al, 2000); the authors state that this
provides evidence that alcohol (and other drug)
dependency can be classified as a chronic disease.
Sceptics of this theory, however, state that
‘the disease concept strips the substance abuser of
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responsibility ... and [a disease] cannot be cured by
force of will; however, alcohol misuse can’ (Baldwin
Research Institute, 2006).
Patient DP believes the term ‘disease’ may be
appropriate as ‘alcohol distorts your thinking to the
extent where you no longer have control over what is
happening’.
Theory of an ‘excessive appetite’
Dr Adam Huxley, Clinical Psychologist with the
Royal Free Hospital Alcohol Liaison Team, mentions
Orford’s theory of an ‘excessive appetite’, in which
individuals partake excessively in activities that are
rewarding but that, with excessive consumption,
result in urges to engage in the behaviour that leads
to negative consequences. In line with this theory,
the activity is not necessarily specific, and therefore
withdrawing from one activity may encourage an
increase in the other.
This may explain the trend observed for
individuals who both drink and smoke. Individuals
increase the number of cigarettes they smoke
per day when they stop drinking (patient JR
demonstrates this trend).
Interestingly, however, there does not seem to
be any evidence of individuals who quit smoking
increasing the amount of alcohol consumed;
furthermore, individuals appear to crave a cigarette
while having a drink but do not crave alcohol while
smoking.
Patient DP has mentioned that he considers
himself to study ‘obsessively’ since becoming
abstinent. Patients DC and GB also demonstrate
signs of compulsivity, saying that when they take
on a task they have to ‘do it well’. They compare this
to when they would go out for a short drink and not
be able to stop until they had ‘had a good drink’ (GB)
or ‘till the pubs closed’ (DC).
32 $RUGSAND!LCOHOL4ODAYs6OLUME)SSUEs$ECEMBER©0IER0ROFESSIONAL
The idea of an ‘excessive appetite’ is widely
accepted, but sceptics say that despite the
significant similarities between various so-called
addictions, there is evidence showing important
variations (Fingarette, 1992). The model,
however, provides a framework to explain such
behaviours regardless of the behaviour of choice.
Alcohol and mental health
There is a close relationship between alcohol
and mental health; those with mental health
issues are at an increased risk of alcohol problems
and vice versa (Institute of Alcoholic Studies,
2007). Mental health problems are present in
approximately 30% of those who are dependent
on alcohol but in only 12% of the general
population (Morgan & Ritson, 2009).
Potentially, numerous types of relationship are
involved:
s MENTAL HEALTH PROBLEMS MAY BE THE CAUSE OF
alcohol dependence
s PROBLEMS WITH ALCOHOL MAY LEAD TO MENTAL
health problems
s A COMMON FACTOR MAY EXIST FOR BOTH ALCOHOL
and mental health problems.
The possible coexistence of the conditions makes
treatment outcomes more challenging to assess.
Those with a primary mental health problem
who misuse alcohol are often difficult to manage,
as effective treatment necessitates the provision
of integrated specialist services. For example,
individuals experiencing schizophrenia need
regular maintenance medication and follow-up
that is more difficult to achieve if alcohol is
misused concurrently. In comparison, individuals
whose misuse of alcohol results in mental health
problems often improve substantially after
cessation of alcohol in the absence of major
psychiatric intervention.
In certain individuals, abstinence may uncloak
aspects of depression, anxiety or difficulties with
social interactions, and such issues need to be dealt
with effectually, by means of either psychological
intervention or medication, to improve the
likelihood of long-term abstinence (Morgan &
Ritson, 2009). Interestingly, some research suggests
that moderate drinking may benefit certain mental
health problems (Hanson, 2007).
According to the self-medication hypothesis
proposed by Khantzian (1997), individuals who
are dependent on substances experience raised
levels of emotional suffering compared to the
non-clinical population; these individuals fail
 Social and psychological aspects of alcohol misuse and dependence
to acquire adaptive ways to deal with stress.
Khantzian (1997) argues that such individuals
become addicted to illicit drugs as the result of their
attempts to adapt their heightened reactions to
stress and alleviate their feelings, while attempting
to block out negative emotions or use avoidance
as their sole coping strategies.
A study by Barnett et al (2007) reported
that 61% of patients presenting with a first
episode of psychosis admitted to substance use,
a percentage almost twice as high as that of the
general population. The two most frequently
used substances were cannabis and alcohol, with
41% meeting the criteria for alcohol abuse or
dependence at some point in their life (Barnett et
al, 2007).
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Conditions that may encourage use of alcohol
as a coping mechanism include depression, anxiety,
obsessive-compulsive disorders, manic-depressive
illness and schizophrenia. The condition most
distinctly associated with alcohol abuse is
antisocial personality disorder (ASPD); the risk
of individuals with ASPD abusing alcohol is 21
times greater than that of the general population
(Institute of Alcoholic Studies, 2007). (Patient
DP was diagnosed with ASPD in his early teens.)
The risk of alcohol abuse is also increased
in those who have experienced previous sexual
abuse (patient DP mentioned his father ‘almost
had a sexual hold’ on him as a child). Numerous
reasons for both the positive and negative effects
of alcohol on mental state have been proposed,
including the means by which it interacts with
factors such as mood and personality of the
individual, the individual’s expectations of the
effects of drinking, and the circumstances in which
it is consumed. Other factors include the amount
and pattern of drinking; alcohol dependence is
usually characterised by a vicious circle of short-
term psychological benefits from drinking, at the
expense of long-term impairment and escalating
depression and feelings of hopelessness (Institute
of Alcoholic Studies, 2007).
Alcohol consumption may be either the cause
or the consequence of depression. Numerous
studies supporting a causal role have proposed
bi-phasic effects of alcohol, first producing a ‘sense
of euphoria’ then feelings of depression as blood
alcohol levels decrease. Furthermore, research has
demonstrated that the biological changes induced
in the brain by drinking alcohol imitate numerous
alterations noted in depressive mood disorders,
and it is also evident from the life histories of
alcohol misusers interviewed (patients GB and
$RUGSAND!LCOHOL4ODAYs6OLUME)SSUEs$ECEMBER©0IER0ROFESSIONAL
PL) that various anxieties contribute to depressive
emotions (Morgan and Ritson, 2009).
Despite the increasing body of evidence
suggesting the link between alcohol abuse and
mental health issues, Dr Huxley states that: ‘alcohol
is the poor cousin of drugs, and mental health is the
poor cousin of physical health’; therefore such issues
are not often picked up on within our current
health care system.
Social class and alcohol misuse
Chris Miller, Lead Nurse with the Alcohol Liaison
Service at the Royal Free Hospital, London,
states that: ‘there is a general assumption that certain
groups of people are more likely to drink, such as
those who are homeless and those from lower social
groups’. However, there does not appear to be any
significant correlation between social class and
alcohol misuse or dependence.
Some people believe, however, that alcohol
misuse tends to be easier to hide in higher social
groups (patient DP mentioned his family ‘hid their
problems well’) and those who are employed are
thought to be less likely to seek treatment due to
the presumed consequences of losing their job.
One’s disposable income does appear to be a
key influential factor in the amount of alcohol
consumed; those who are employed have been
found to drink more readily and heavily than
those who are not (Robinson & Lader, 2007),
and this status appears to be more important in
men than women. Furthermore, both sexes in the
professional and managerial classes drink more
regularly and are more likely to drink excessively
than those in routine and manual employment
(Robinson & Lader, 2007).
Although it is expected that individuals with
more income are more likely to consume alcohol
in great volumes due to affordability, patient
PA, who has been homeless for many years,
consumed a greater amount of alcohol daily
compared to other patients; his income comes
from government sickness benefits (self-admitted
unknown condition) and he spent the majority of
this money on cheap cider. Therefore, we cannot
assume that higher social classes are more likely to
become dependent, even though they may drink
more socially.
Gender and alcohol misuse
In a study by the Social Issues Research Centre,
the majority of participants believed that alcohol
misuse was primarily a male preoccupation.
However, reports of women being increasingly
33
 Social and psychological aspects of alcohol misuse and dependence
involved in this activity are common (Social Issues
Research Centre, 2004). When questioned on trends
in drinking behaviour, participants from the police
and alcohol workers cited the increase in female
detainees as one of the most significant changes in
recent years (Social Issues Research Centre, 2004),
although there is still a male predominance.
Despite the widespread increase in the number
of women drinking to excess, there still remains
some stigma against women with drink problems.
Chris Miller suggests that one reason for this could
be that ‘more men have a drinking problem, so people
are more used to seeing men with such problems’.
Patient SK mentioned that she received a greater
sentence for drink driving than a man caught
for the same offence. Dr Huxley emphasises the
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increased stigma against women with drinking
problems and says, ‘women often find it harder to go
to services, particularly if they are parents as there are
fears that their children may come to the attention of
social services’.
Discussion
It is evident that excessive alcohol consumption is
becoming an increasing burden to the UK health
care system. The government is currently aiming to
reduce the number of alcohol misusers by increasing
the price and decreasing the availability of alcohol.
These measures are only likely to affect individuals
who drink excessively in social situations. The
pattern of drinking that leads to alcohol-related
disorders, however, is alcohol dependence rather
than occasional binge drinking. Having spoken to
numerous patients who were previously dependent on
alcohol (and now have various related pathologies),
it is apparent that at the stage of dependence, micro-
economical intervention would have had little to
no effect on their drinking habits. Reducing the
risk of alcohol-induced harm, therefore, requires
intervention at an earlier stage.
Although less than half of alcohol misusers
go on to become dependent, individuals cannot
develop dependence without having engaged in
alcohol misuse for at least several years. With
this in mind, the requirement for early screening
and intervention becomes evident. In some cases,
informing an individual about the risks of excess
consumption alone is not sufficient to make them
stop drinking (patient MS was not affected by
receiving her diagnosis of cirrhosis). Several of
the patients interviewed mentioned emotional
and psychological triggers behind their misuse and
therefore counselling for these issues before alcohol
dependence resulted would, in theory, have been
34 $RUGSAND!LCOHOL4ODAYs6OLUME)SSUEs$ECEMBER©0IER0ROFESSIONAL
more beneficial. Furthermore, patients who are
already dependent on alcohol seem to use drinking
as a ‘crutch’, and therefore a replacement support
system needs to be put in place before the patient is
able to become abstinent.
Overall, it is important to understand that every
alcohol misuser has different reasons behind their
abuse and we cannot judge them as having made a
‘choice’ to drink, but rather we should understand
that their life circumstances may have led them
to no other resort. Bearing this in mind, we can
only hope that our services improve to help such
individuals and that, with time, the stigma attached
to individuals who suffer from alcohol misuse and
dependence is abrogated.
Acknowledgements
With special thanks to Dr Marsha Morgan
(Consultant Hepatologist), Mr Chris Miller (Lead
Nurse with Alcohol Liaison Service) and Dr Adam
Huxley (Clinical Psychologist) from The Royal
Free Hospital, London, for their time and advice.
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