What does alcoholism mean?
The diagnosis of alcoholism, in the sense of alcohol dependence, has the same meaning that a diagnosis of substance dependence has in general. This meaning can be summarized as a stable loss of the ability to maintain control over the urge to consume alcohol according to one’s own intentions. In other words, an alcoholic is someone who is no longer able to manage alcohol according to an intentional pattern, but instead experiences its effects, with drinking that no longer serves a plan, a source of pleasure, or the pursuit of useful effects. This inability to control drinking, which leads a person to drink “beyond” their intentions and to be unable to avoid drinking without considerable effort despite intending to do so, does not tend to reverse spontaneously; that is, it is chronic.
What does the term “alcoholic” mean?
Different expressions are used to describe someone who drinks too much or who drinks heavily and regularly, but alcoholism as a form of substance dependence is a precise diagnosis and is not equivalent to being a “habitual heavy drinker.” The term alcoholic, for example, can also be used to describe a condition of habitual intoxication. A person with alcohol dependence may be an alcoholic for long periods of their life, but may also go through periods in which they stop drinking. The difference between drinking habitually, with or without signs of intoxication, abusing alcohol, and being alcohol-dependent (an alcoholic) is precisely the main issue to establish when assessing an alcohol-related problem.
Although in everyday language it is often used as a more colloquial version of alcoholic or alcohol-dependent person, strictly speaking the meaning is therefore not identical.
Does feeling unwell when reducing or abruptly stopping alcohol mean that someone is an alcoholic?
Having problems when alcohol consumption is abruptly stopped does not mean that someone is an alcoholic; it simply means that they have become physiologically adapted to alcohol and are therefore sensitive to withdrawal. Alcohol withdrawal can be severe, involving dangerous mental disturbances with loss of contact with reality (hallucinations, disorientation in time and space), malnutrition and dehydration, and epileptic seizures that may be life-threatening. This condition, alcohol withdrawal, is not itself synonymous with substance dependence, although it is often one of its associated features.
The so-called “physical dependence,” as physiological adaptation is sometimes called, suggests that the relationship with alcohol is maintained in order to correct or prevent withdrawal symptoms. In reality, when there is a significant relationship with alcohol, it is not physiological adaptation that motivates it, but an urge to continue the behavior. In alcoholics, it is the desire to drink that produces frequent exposure to alcohol, and it is this exposure that subsequently produces physiological adaptation—not the other way around.
Is alcoholism a disease that depends on many factors?
Substance dependence is a disorder that reproduces itself, by definition. Many factors can influence drinking in its initial stages, the transition to heavy drinking, the cessation of drinking or its continuation, and indifference to the consequences. Once the mechanism of alcohol dependence has developed, however, it tends to reproduce itself independently of these other factors.
The meaning of an alcoholism diagnosis also includes the prediction that, regardless of particular circumstances, a relapse will eventually occur even after initially successful attempts to stop drinking. This, of course, applies in the absence of specific treatment.
Is someone who continues to drink despite health problems an alcoholic?
Many people may be reluctant to stop drinking even when they are warned that alcohol is already causing health problems, or that more serious consequences will occur if drinking continues. This typically happens with liver problems.
It is generally assumed that a person who is able to control themselves in order to live as well as possible should have little difficulty reducing or stopping drinking, and should be sufficiently frightened by the prospect of cirrhosis or another form of disability. However, simply identifying health problems related to alcohol consumption is not, by itself, sufficient to diagnose alcoholism. Resistance to eliminating alcohol or substantially reducing consumption should instead be assessed as a person’s behavior in relation to the intentions they have developed regarding their health.
Some drinkers who do not appear frightened by negative effects on their health may not be alcohol-dependent, but may instead be people who abuse alcohol in the context of an associated mental disorder, such as depression.
Does drinking habitually or in certain quantities cause harm even if someone is not an alcoholic?
Alcohol produces toxic effects depending on the amount consumed and the duration of regular consumption. Not everyone is equally sensitive to alcohol. In particular, some people develop serious damage after relatively short periods of abuse, including pancreatitis, hepatitis, or gastritis.
In any case, even a person who drinks regularly in a controlled manner and is not alcohol-dependent will develop a range of alcohol-related problems over time.
If someone has problems with alcohol but does not drink regularly, does not drink in the morning, and does not drink to the point of intoxication, can they still be an alcoholic?
Only some people with alcohol dependence drink continuously and are always “drunk,” or otherwise recognizable as drinkers. Others drink only at certain times of day, for example in the evening, and continue to carry out their normal activities in the morning for a long time.
Intoxication is common in alcoholism, but it is not constant. The effect of alcohol on the brain is not recognizable only as drunkenness, but also as an alteration of varying degrees that affects everyday attitudes, social choices, and the ability to manage tension, relationships, and risks in interactions with other people.
Some alcohol-dependent people tolerate alcohol so well that they rarely appear grossly intoxicated. Nevertheless, the stimulating effect they experience can influence their behavior just as clearly, making them impulsive, intolerant, argumentative, or alternatively superficial and absurdly optimistic.
Why can’t an alcoholic “break up” with alcohol?
An alcoholic may be able to stop drinking periodically. What they generally cannot do is reduce the amount of alcohol in such a way as to return to pleasurable, controlled drinking.
The reason that drives them to drink is no longer a genuine reason for pleasure, nor a useful purpose (for example, drinking to improve their mood or calm themselves). In the explanations alcoholics provide—which are typically justifications offered to others rather than spontaneous explanations—there may be a thousand reasons, usually corresponding to the reasons that originally motivated drinking.
An alcoholic may cite as reasons or “excuses” the simple circumstances of their life or recent events, but there is no logical relationship between these circumstances and pathological drinking. By drinking, the alcoholic becomes “absent,” aggressive, unproductive, or pointlessly euphoric, and none of these states contains anything desirable for managing external problems.
Even when it comes to pleasure itself, the idea remains, but alcohol consumption by an alcoholic is a kind of missed appointment: the expectation is of a necessary and unique pleasure, while the reality is an absent, elusive pleasure accompanied by increasing problems.
Essentially, the reason that drives an alcoholic to drink is a stable modification in a part of the brain that normally serves to obtain pleasure or reduce discomfort, but which undergoes persistent changes under the continued effects of alcohol, becoming excessively “activated” and abnormally oriented toward alcohol.
In this mechanism, the reasons that initially made alcohol appealing are lost, or remain only as background elements, and the wheel begins to turn by itself.
How does someone become an alcoholic?
Basically, by drinking. Prolonged exposure to the substance is the only factor common to all people who develop substance dependence.
Long periods of habitual drinking or heavier drinking can be motivated by countless factors. Through these periods, people generally move from controlled consumption that in some way corresponds to a particular purpose, toward an irreversible loss of control and therefore dependence.
Does treatment for alcoholism aim to change a person’s lifestyle?
No. An alcoholic does not have a “lifestyle,” in the sense of a freely chosen way of living, but rather what may appear to be an extreme form of a habit taken to its ultimate consequences. In reality, this is a condition entirely different from a vice or a taste for excess.
In the treatment of alcoholism, the objective is to restore control over behavior in relation to alcohol—that is, to make the person capable once again of carrying out their intentions regarding drinking.
Does treatment for alcoholism aim at a choice of sobriety?
A person with alcohol dependence who seeks treatment fundamentally chooses treatment because they are unable to control their behavior in accordance with intentions that may involve sobriety, but may also involve controlled drinking.
Sobriety is often the result of alcoholism treatment, but this is not primarily a matter of choice. Rather, it reflects the ability of treatment to make that choice achievable. Once they regain control, an alcoholic can, if they wish, choose not to drink.
It would make no sense to say that if an alcoholic truly chooses not to drink, they will then be able to stop. That would mean thinking of an alcoholic as someone who is capable of controlling themselves according to their intentions.
Is pleasurable and controlled drinking possible as a result of treatment?
The condition of a person with alcoholism who is undergoing treatment is controlled by the treatment. It is possible that an alcoholic, even without stopping drinking completely, may eventually drink only sporadically.
This does not correspond to a return to normal or controlled drinking. It is simply a residual manifestation of the disorder, which the person experiences negatively, as a relapse, even if it is brief.
The presence of residual symptoms is not a reason to stop treatment or criticize the person. It is simply one of the probable outcomes, especially during the initial phase.
In a treatment approach aimed at the gradual extinction of drinking while under treatment, an initial response may consist of reduced or irregular drinking. Again, this should not be confused with a restored ability to drink in limited and non-harmful amounts.
How important is willpower in alcoholism?
As in other forms of substance dependence, the concept of “willpower” is merely an expression without a corresponding biological function. What we call will is an expression of the functioning of certain brain centers which, in substance dependence, become “redirected” toward substance use.
Treatment aims to control this drive, bringing it back into alignment with the person’s intentions.
Many alcoholics confuse strong motivation, or a state of great enthusiasm or determination to remain sober, with a new and solid willpower that will protect them against relapse. This belief typically supports the rejection of effective treatment and prepares the ground for subsequent relapses.
How are the results of alcoholism treatment measured?
The first parameter is the rehabilitation of mental functioning and social adjustment. The second is control over drinking.
Measurement must be considered over medium and long periods of time. Many alcoholics are capable of stopping drinking periodically. Therefore, when treatment begins, it is necessary to observe the person for at least a period longer than their previous ability to maintain abstinence before treatment.
Both to say that a treatment is working and to say that it is not working, several months are generally required. Above all, it is necessary to assess how the duration, pattern, and frequency of relapses change over time in comparison with the period before treatment.
A treatment that is declared to have failed at the moment of the first relapse is poorly managed, just as a treatment that is declared successful after a few weeks or a few months without relapse is poorly managed.
Is it true that people drink because of depression or stress?
These are common reasons for increasing one’s drinking habit or moving from occasional drinking to regular and heavier drinking.
It must always be remembered that drinking, and even heavy drinking, are not synonymous with alcoholism. Once alcoholism has developed, it does not recognize particular reasons. The alcoholic drinks as an alcoholic and drinks because they are an alcoholic.
The common reason for beginning to drink is recreational, or to improve one’s social functioning on occasions involving entertainment or interaction with others. Some people use alcohol as a kind of medicine to correct anxiety, stress, or depression, but this has nothing to do with the reason why they remain alcohol-dependent.
Once someone has become an alcoholic, the reasons that originally encouraged them to drink are no longer necessary. They may remain, but they are no longer required.
From a therapeutic standpoint, therefore, improving anxiety and depression in an alcoholic should not be expected to prevent relapse.
Is detoxification an important step?
Many alcoholics begin treatment with detoxification. In some cases, this is urgent because intoxication is causing damage that may subsequently prove irreversible, either to the brain or to other organs.
Detoxification is useful for resolving certain toxic effects, such as withdrawal. Other toxic effects need to be “repaired,” such as vitamin deficiencies.
There is, however, a major limitation: detoxification does not affect alcoholism itself, that is, the alteration in the mechanisms of control that corresponds to alcoholism.
A detoxified alcoholic is no less alcoholic than they were the day before detoxification. They are simply less intoxicated.
Treatment for alcoholism does not necessarily require initial detoxification.
Is it necessary to achieve sobriety first in order to have any hope of success?
This is a false concept.
First of all, moral demonstrations make no sense, as though this were a question of willpower. Treatments for alcoholism aim to control relapses, not merely to make sobriety possible.
Starting from an initial period of abstinence, it is actually impossible to know whether the treatment is working well until the first relapses occur, so that they can be measured and compared with the course of the disorder before treatment.
In some cases—although these are a minority—the treatment is effective enough from the beginning to allow complete control. In the majority of cases, however, this result is achieved over time, beginning with relapses lasting days, progressing to individual drinking episodes, occurring less and less frequently, and eventually leading to abstinence maintained for very long periods.
Most treatments currently available for alcoholism actually assume that the person will drink while undergoing treatment, thereby triggering a mechanism that promotes non-repetition of the drinking episode. In some cases this is because relapses are no longer associated with reinforcement of the desire to drink; in others, because they produce an unpleasant effect.
Some treatments, such as naltrexone, may even be taken only on “drinking days,” so that an alcoholic who is highly aware of their condition could, rather than trying unsuccessfully to suppress the desire to drink, protect themselves against the drinking episode that is about to occur by taking the treatment beforehand, thereby reducing the likelihood that the episode will continue into the following days.
Alcoholics who have been successfully treated for long periods may become capable of following this type of treatment regimen.
Should an alcoholic make an effort not to drink?
This question often creates confusion.
No doctor can reasonably claim to treat an alcoholic simply by asking them not to drink, because that would presuppose both freedom of choice and the ability to control the behavior.
It makes no sense to ask a sick person not to have symptoms and then leave the course of the illness in their hands.
In the early stages, it is actually counterproductive to distort the situation through heroic abstinence that will eventually fail if approached in these terms.
A properly functioning treatment allows abstinence to be maintained without effort. To believe that the effort is psychologically important because it constitutes a test of oneself means not having a clear understanding of the definition of alcoholism.
A person who abuses alcohol may conduct such a test on themselves, even without specific treatment. An alcoholic, by definition, cannot.
If alcoholism is defined as an illness, it is a condition whose resolution is not the responsibility of the patient alone. The patient should instead make an effort to undergo treatment and to maintain contact with the clinicians treating them, both when things are going well and when they are going badly.