Alcoholism: Nature or Nurture?

On a continual basis we are bombarded with statistics regarding alcoholism. We hear about the enormous costs to societies, families, and individuals. We know that alcoholism can effect anyone. It is not prejudiced to race, color, sex, religion, or socioeconomic level. What exactly is alcoholism? What causes it? How do we treat it? Although continually revising our theories, we do have ideas of what alcoholism is. What we do not know; however, is the exact etiology of alcoholism. Some researchers have taken a biogenic paradigm while others have taken a psychogenic paradigm. Current research seems to point to more of a biogenic paradigm with psychogenic factors intermingled. However, the nature versus nurture debate is still ongoing despite this new research. Treatment, on the other hand, is known, but is in continual refinement. No one treatment seems to be better than another is. Here I will give a broad view of what alcoholism is, what causes it, and current treatment methods.

In order to understand etiology and treatment of alcoholism, it is important to have a clear understanding of what the term alcoholism encompasses. Charles Levinthal states that (1999) "alcoholism is a condition in which the consumption of alcohol has produced major psychological, physical, social, or occupational problems" (p. 33). A major component of an alcoholic’s psychological problems is a preoccupation with alcohol itself. Goodwin (1988) asserts that "the alcoholic thinks about alcohol from morning till night, and at night, if not too drunk to dream, dreams about alcohol" (p.33). They will ponder such thoughts as when they should have their first drink, when the next, and so on. They will remind themselves that the liquor store is closed on Sunday. The alcoholic’s thinking seems obsessional. Where there is obsession, compulsion may follow. In this case it follows a compulsion of drinking. If a person feels sad, he may drink so he’ll feel better. When the alcohol wears off, he feels sad again, so he drinks again. This perpetuates into a rollercoaster effect that is probably chemical in nature (Goodwin, 1988). An alcoholic also experiences self-deception. The alcoholic feels he can stop drinking at any time, and he often tells himself and others this. Of all psychological problems that effect alcoholism, depression is the most prominent. "It has been estimated that between one third and one-half of all alcoholics experience depressive symptoms sometime in their lives" (Levinthal, 1999, p. 199). There is an old saying that what goes up must come down. This is the case with alcoholics. The euphoria of alcohol is followed the depression of alcohol. Except for manic-depressives, alcoholics commit suicide more than any other group (Goodwin, 1988). In addition to depression, other psychological disorders have been found in alcoholics. The two most commonly found include anxiety disorder and antisocial personality disorder. It is important to keep in mind that many alcoholics abuse other drugs. A person may be dependent upon alcohol because of availability, but the multiple use of drugs, not just the alcohol, dominates the picture (Goodwin, 1988).

Social problems can include hindrance of maintaining a job, social relationship, or a stable family life. It is often difficult for alcoholics to maintain socially when often they are out of control, lying at all levels, and in a constant state of denial (FitzGerald, 1988). Within the family, the roles that are expressed often include the dependent, enabler, hero, scapegoat, lost child and the mascot. "The victims of alcoholism are spouses, children, other relatives, bosses, coworkers, pedestrians, drivers, police, judges, physicians who get called late at night, taxpayers who often pick up the bill for treatment, and the innocent and not so innocent people who cross the alcoholic’s path" (Goodwin, 1988, p. 47). However, the most detrimental effects of alcoholism can be seen in the physical/medical complications that arise.

Alcoholics who abruptly stop their intake of alcohol can experience serious physical withdrawal symptoms. Alcohol withdrawal syndrome begins with insomnia, vivid dreaming, and a severe hangover, followed by tremors, sweating, mild agitation, anxiety, nausea, vomiting, and increased heart rate and blood pressure (Kinney and Leaton, 1995). Even more serious is delirium tremens. These symptoms include extreme disorientation and confusion, profuse sweating, fever, and disturbing nightmares. While experiencing delirium tremens, an alcoholic is at risk for heart failure, dehydration, or suicide. In addition to these withdrawal symptoms, serious medical complications can arise within an alcoholic. Fatty liver, alcoholic hepatitis, and alcoholic cirrhosis can occur with chronic consumption of alcohol. Fatty liver results from fatty deposits building up inside liver cells. If the alcoholic abstains, this condition can be reversed. Alcoholic hepatitis is an inflammation of the liver. It causes jaundice, abdominal pain and fever. This condition can be reversed as well through abstinence. Alcoholic cirrhosis, the most serious of the liver conditions, develops because the accumulation of scar tissue chokes off blood vessels in the liver and destroys liver cells by interfering with the cells’ utilization of oxygen (Levinthal, 1999). Abstinence helps this condition, but it is only reversible through liver transplantation. In addition to liver conditions, alcoholics can develop cancers of the esophagus, pharynx, and larynx.

Alcoholism doesn’t stop affecting the individual with liver conditions and cancer. It also produces serious deficits in problem solving, organization of facts, and remembering of information. Collectively these symptoms are known as alcoholic dementia. This is associated with a structural loss of brain tissue. Because of enlargement of the ventricles within the brain, an overall decline in intelligence, verbal learning and retention, and short-term memory is seen (Levinthal, 1999). Even more severe, is the disease Wenicke-Korsakoff syndrome, which is a two-stage process. In the first stage, Wernicke’s disease, a deficiency in Vitamin B1 causes significant neurological problems such as confusion and disorientation, abnormal eye movements, and difficulties in movement and body coordination (Levinthal, 1999). This deficiency is most prominent in alcoholics who go long periods of time barely eating and receive most of their caloric intake from alcohol. The second stage, Korsakoff’s psychosis, is a severe form of chronic amnesia. Alcoholics experiencing this disease have a very difficult time remembering information recently presented to them. They also have problems remembering information in past events. Clearly Wernicke-Korsakoff syndrome has detrimental effects to an alcoholic.

Another serious medical complication arising from alcoholism is fetal alcohol syndrome. In this syndrome the mother passes the alcohol into the bloodstream and through the placenta to the unborn fetus. Children born with FAS have distinct features such as small wide-set eyes, drooping eyelids, thin upper lip, and a smaller head. They are also underweight and experience mental retardation. The greatest risk to FAS seems to be within the first trimester of pregnancy when brain growth and development is rapidly taking place. Alcohol can also effect many other areas of human anatomy such as the reproductive, respiratory, endocrine, musculoskeletal, and nervous systems.

With all of the problems that arise from alcoholism, why do people become alcoholics? What causes them to pick up another glass when they know they may become depressed or develop cirrhosis? What causes a pregnant woman to drink when she knows it can harm her unborn fetus? Is it in their genes, or is it in their environment? Perhaps it is a combination of the two. According to Milam, (1992) the psychogenic model is based on the universal belief that alcoholism is a symptom or consequence of an underlying character defect, a destructive response to psychological and social problems, a learned behavior. The biogenic model recognizes that alcoholism is a primary addictive response to alcohol in a biologically susceptible drinker, regardless of character and personality (Milam, 1992). We might say that environment increases one’s exposure to alcohol, but the actual processes that result in addiction are biochemical an involuntary (Judge, 1997). This still does not illustrate the etiology of alcoholism, however. To do this one must take a look at adoption and twin studies and consider a concept of two types of alcoholism.

Researchers have used two different strategies for determining the proportional contributions of genes and shared family environment to the development of alcoholism among family members (Health, 1995). The adoption study compares biological children of alcoholic parents with other children raised in the same non-alcoholic environment (Cadoret, 1996). It can allow an opportunity for researchers to identify specific genetic-environmental interactions that could be relevant for designing early interventions for behaviors that predispose a person to alcohol abuse and dependence. Twin studies compare the differences in identical twins that share 100 percent of their genes and fraternal twins that share 50 percent of their genes (Prescott and Kendler, 1995). It is evident that a closer match of alcohol behavior between identical twins than between fraternal twins indicates genetic influences, since their upbringings are assumed to be identical. It is important to keep in mind, as with any research design, that the results are generalizable only to the extent that the population being studied is representative of the entire population.

In 1981 C. Robert Cloninger and colleagues conducted a study of alcoholism in Swedish adoptees and their adopted and biological parents (Cloninger, Sigvardsson, and Bohman, 1996). This study resulted in the classification of alcoholism into two types. Type I being milieu-limited alcoholism, and type II being male-limited alcoholism. In their original study, type I alcoholism was found to affect both men and women, required the presence of both genetic and environmental predispostions, commenced later in life after years of heavy drinking, and could take on either a mild or severe form (Cloninger et al., 1996). Type II alcoholism was found to affect mainly sons of alcoholics, influenced weakly by environmental factors, often began during adolescence or early adulthood, characterized by moderate severity, and usually associated with criminal behavior. A replication study followed that supported Cloninger’s results as well as other studies, which have added to the alcoholism classification. Type I alcoholics, those who have a low risk for developing alcoholism, generally exhibit better outcomes. Type II alcoholics exhibit more severe dependence symptoms, alcohol-related consequences and psychopathologies (Del Boca and Hesselbrock, 1996).

Further study found that Type I and Type II alcoholics not only differ in the age at onset and type of alcohol-related problems, but also in certain neurobiological markers. The markers include enzyme monoamine oxidase (MAO), serotonin activities, and patterns of electrical brain waves. Type II alcoholics have lower activity levels of MAO, which metabolizes neurotransmitters within the brain. Type II alcoholics also have reduced levels of serotonin, which is metabolized by MAO. We know that certain neurotransmitters have certain effects upon our behavior. Specifically, low MAO activity has been related to impulsiveness, extroversion, and sensation-seeking behavior (Cloninger et al., 1996). Results from this study identified three heritable personality traits that could describe characteristics of both type I and type II alcoholism. These traits include harm avoidance, novelty seeking, and reward dependence. Low harm avoidance identifies a person as being confident, relaxed, optimistic, and uninhibited. High harm avoidance identifies a person as being cautious, apprehensive, pessimistic, and inhibited. High novelty seeking traits are impulsive, exploratory, and distractible. Opposite to this are people with low novelty-seeking traits, which are reflective, rigid, and attentive to detail. Lastly, high reward dependence occurs in people who are emotionally dependent and eager to help others. The opposite is true for people with low reward dependence. Type I alcoholism is associated with high harm avoidance, low novelty seeking, and high reward dependence. Type II alcoholism is associated with low harm avoidance, high novelty seeking, and low reward dependence.

These personality traits led to a hypothesis about the underlying motivation for alcohol consumption in the two subtypes (Cloninger, 1987). According to the theory, the later onset of alcoholism by type I alcoholics occurs because their high harm avoidance initially inhibits the initiation and frequency of drinking (Cloninger, 1987). With frequent exposure to socially encouraged drinking; however, the risk of alcoholism increases. This is because the drinker’s anxiety is relieved after alcohol consumption. The type II alcoholic is motivated by the desire to induce euphoria (Cloninger, 1987). Hence, he keeps drinking and drinking trying to induce a higher level of euphoria. Since these personality characteristics are inherited independently of each other, they are not mutually exclusive and can occur in the same person (Cloninger, 1996). It seems that alcoholism in each individual is reflected upon by that individual’s personality traits.

Where does this leave us in the nature versus nurture debate? How do these two typologies fit in? We know that a type I alcoholic has alcoholism that is caused by both genetics and the environment. We also know that a type II alcoholic has alcoholism that is caused by predominately genetics. This being the case, we can conclude that the most serious forms of alcoholism do indeed result from primarily genetics. However, environment still plays a significant role in type I alcoholism. It appears that neither nature nor nurture can be ruled out. It seems a complicated interplay of the two is involved. More research is needed before we will know for sure. One thing is certain. No matter the cause of alcoholism, treatment for it is of the greatest concern for all society.

Treatment for alcoholism depends on the individual. A treatment program that works for one individual may not work for another. It is clear that when considering which form treatment to use, we must keep the uniqueness of each individual in mind. Current forms of treatment include biological interventions, which involve the use of medications, and psychosocial interventions such as self-help programs like Al-Anon or Alcoholics Anonymous. According to Levinthal, (1999) no one treatment approach is overwhelmingly superior to others.

In considering treatment for alcoholism pharmacologically, we must remember that many drugs have side effects. What may seem as a quick cure, can have serious consequences. Two types of medications, antidipsotropic and psychotropic, are used in the treatment of alcoholism. Antidipsotropic medications deter the alcoholic from drinking by producing an unpleasant reaction if one ingests alcohol (Fuller, 1995). The most widely used antidipsotropic medication is Disulfiram. Disulfiram inhibits alcohol dehydrogenase, allowing acetaldehyde to build up in the bloodstream. Because of this, people who consume alcohol along with disulfiram experience nausea, vomiting, rapid heart rate and palpations, and flushing of the face (Levinthal, 1999). Disulfiram is most useful in alcoholics who have a high motivation to quit drinking. This form of aversion therapy has a drawback in that is does not reduce the craving for alcohol. Since alcohol has a hypothesized relationship to activity receptors of the same dopamine-releasing neurons in the brain that have also been implicated in heroin, we need a drug that will inhibit these receptors (Levinthal, 1999). Naltrexone does just this. However, naltrexone does not make the patient sick. The drinks do not taste as good, and the desire for alcohol is greatly reduced (Harvard Mental Health Letter [HMHL], 1998). It is recommended for patients who are totally abstinent, but can be used by functioning alcoholics who haven’t been able to abstain. Another drug, acamprosate, helps to prevent relapse in alcoholism. It doesn’t make users sick if they drink. It also has no anti-anxiety, sedative, muscle relaxant, or antidepressant properties and produces no withdrawal symptoms (Sass, Soyka, Mann, and Zieglgansberger, 1997).

Psychotropic medications are used to alleviate the symptoms of withdrawal during alcohol detoxification (Rone, Miller, and Frances, 1995). Benzodiazepines have been well established in the treatment of alcohol withdrawal symptoms (Rone et al., 1995). Although these drugs may seem like a quick fix, it is not the case. Many alcoholics are experiencing medical complications as a result of their chronic drinking. For some of these medical conditions, medications are often contraindicated. It seems logical that in addition to taking medications, many patients also use psychosocial interventions concurrently.

Of the many psychosocial interventions, a study sponsored by the National Institute on Alcohol Abuse and Alcoholism found three treatments that work about equally well for all alcoholic patients (HMHL 1997). Cognitive-behavioral therapy (CBT), twelve-step facilitation (TSF), and motivational enhancement therapy (MET) were included. Cognitive-behavioral therapy (CBT) is used to correct maladaptive thinking and teach alcoholics how to avoid or deal with situations that tempt one to drink (Bower, 1997). Twelve-step facilitation (TSF) is used to help prepare alcoholics for a commitment to Alcoholics Anonymous. In TST, a therapist familiarizes the client with the philosophy of Alcoholics Anonymous and encourages attendance at AA meetings (Bower, 1997). Motivational enhancement therapy (MET) is aimed at improving willingness and readiness to change drinking habits. It helps clients to identify and mobilize personal strengths and resources that can reduce alcohol consumption (Bower, 1997). Bower (1997) states that TSF and AA might work best with alcoholics searching for religious and spiritual meaning in their lives. CBT may better suit alcoholics who display serious psychiatric symptoms and thinking difficulties. MET could best serve heavy drinkers who express little hope or desire for improvement. Regardless of which of these therapies is chosen, each does work. In addition to TSF, CBT, and MET, other popular psychosocial treatments include behavioral self-control training (BSCT), Alcoholics Anonymous (AA), rational recovery (RR), marital and family therapy (MFT), coping and social skills training (CSST), anxiety and stress management, and community reinforcement approach (CRA).

Behavioral self-control training (BSCT) is used to pursue a goal of abstinence or moderate and nonproblematic drinking. It consists of managing consumption of alcohol, self-monitoring, goal setting, rewarding goal attainment, and learning alternate coping skills. BSCT can be therapist directed, self-directed, or conducted in a group format. The goal of moderation has been controversial; however, researchers have extensively studied its effectiveness (Hester, 1995). BSCT seems to yield success rates comparable to treatments with a goal of abstinence. According to Hester, (1995) BSCT is most effective with alcoholics who experience less severe alcohol problems and dependence. Like other forms of treatment, BSCT, may not work for everyone.

Alcoholics Anonymous (AA) was founded in 1935. The philosophy is expressed in the now famous twelve steps as well as in their twelve traditions. The twelve steps are intended to preserve the integrity of the AA program (McGrady and Delaney, 1995). Some of the twelve steps include admitting that one is powerless over alcohol and turning themselves to God. AA functions as a type of group therapy with each individual working toward a common goal (Levinthal, 1999). Their goal is to abstain from alcohol. Meetings are frequently listed in local newspapers and are completely anonymous. Meetings are either open or closed. Open meetings allow any interested person to attend. Closed meeting only allow AA members. Members are able to tell of their personal struggles with alcoholism and support other members who are also struggling. New members are paired up with a sponsor who has usually completed the Twelve Steps. The sponsor can be a support system for the new member. According the philosophy of AA and other organizations, alcoholism is an irreversible disease, that abstinence is the only answer, and that even the slightest consumption of alcohol will trigger a cascade of problems that the alcoholic in incapable of handling (Levinthal, 1999). Despite the great support given by AA there are few scientific studies on the overall effectiveness of it. According to Levinthal, (1999) this is because anonymity is guaranteed to all members. This makes it difficult to conduct follow-up studies. However, what is known is that AA can be particularly effective when combined with other treatments such as medications and counseling. Over the years, many other organizations have come into focus, which help alcoholics. Al-Anon helps the spouses and family of alcoholics, and Alateen is a specialized AA program designed for teenage alcoholics.

Rational Recovery (RR) is the opposite of AA. It emphasizes a nonspiritual philosophy and a greater sense of personal control in the abuser (Levinthal, 1999). It is grounded in the principles of rational emotive therapy (RET). RR has a few core constructs including self-esteem, rational approach to change, and voices, a way of discussing irrational thinking (McGrady and Delaney, 1995). RR groups are peer led, but have a professional therapist as an advisor. Members are encouraged to attend for 6 to 12 months. After which time they move on with their lives. It is not a lifelong program that requires regular attendance. Like AA, RR can be quite successful when combined with other modalities of treatment. In addition to AA and RR, other organizations including Overcomers Outreach (OO), Women for Sobriety (WFS), Secular Organizations for Sobriety – Save Our Selves (SOS), and many others have a common goal in mind. That goal is to help an individual recover from alcoholism.

Marital and family therapy (MFT) is different from AA and RR in that it considers the alcoholic and the family within which the alcoholic lives. O’Farrell (1995) states that it is widely know that abusive drinking leads to marital and family discord such as divorce and child/spouse abuse. MFT includes recognizing that a problem exists and deciding to do something about it, stopping abusive drinking, and long-term maintenance of change. Coping and social skills training (CSST) provides the alcoholic with coping skills for daily living. Anxiety and stress management attempt to enable individuals to gain control of their reactions to stress by altering their perceptions and lifestyles and by enabling them to sue active coping strategies (Stockwell, 1995). Community reinforcement approach (CRA) utilizes social, recreational, familial, and vocational reinforcers to aid alcoholics in the recovery process (Smith and Myers, 1995). CRA has an optional part of its program, which includes disulfiram treatment. The drinker takes disulfiram and is reinforced for doing so.

With a multitude of treatments that are available, it’s not always easy determining what is best for each individual. Goals, intensity, content, and maintenance must be kept in mind when making a decision regarding implementation of treatment. Some clients may respond better to one treatment or another. Furthermore, a client may respond better with a combination of treatment methods. It has not been shown that any one treatment is superior to another, so it’s possible that some experimenting may be necessary. Regardless of which treatment is implemented, the ultimate goal is to help the client recover from alcoholism.

Alcoholism is a leach that sucks the life from an individual, families, and society. It takes a productive member from our community and turns one into a world of depression and loneliness. It is a multidimensional condition that includes physical/medical problems, psychological problems, preoccupation with drinking, and vocational, social, and family problems. Current research supports a two-tier subtype of alcoholism. Type I alcoholism is caused primarily by an interplay between genetics and the environment. Type II alcoholism is caused primarily by genetics. It would seem that some people are born with a susceptibility to alcoholism, and others are shaped more by their environment. Treatments for alcoholism include a variety of techniques such as biological interventions and psychosocial interventions. Specifically, some of these include antidipsotropic and psychotropic medications, cognitive-behavioral therapy, twelve-step facilitation, motivational enhancement therapy, marital and family therapy, coping and social skill training, anxiety and stress management, community reinforcement approach, and other self-help groups. The decision as to which treatment method is chosen will depend on the needs of each individual. This is because alcoholism effects each individual differently.

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