AlcoholismPage 1 of 1
Alcoholism and Co-occurring Disorders
The term "comorbidity" refers to the presence of any two
or more illnesses in the same person. These illnesses can be medical or
psychiatric conditions, as well as drug use disorders, including alcoholism.
Comorbid illnesses may occur simultaneously or sequentially. The fact
that two illnesses are comorbid, however, does not necessarily imply that
one is the cause of the other, even if one occurs first.
An understanding of comorbidity is essential in developing
effective treatment and prevention efforts. For example, since alcoholism
causes liver disease, measures to decrease alcohol consumption will help
reduce the incidence of liver disease. With respect to treatment, persons
exhibiting comorbid alcohol-related and medical or psychiatric disorders
often fall through the cracks of the health care system because of administrative
distinctions among addiction, medical, and mental health-related services.
Patients are often forced to choose between clinical settings, often resulting
in neglect of one condition.
Alcoholism and other disorders might be related in a number
of ways. Alcoholism and a second disorder
can co-occur, either sequentially or simultaneously, by coincidence.
Alcoholism can cause various medical and psychiatric conditions or increase
their severity. Comorbid disorders might cause alcoholism or increase
its severity. Both alcoholism and the comorbid disorder may be caused,
separately, by some third condition. Alcohol use or alcohol withdrawal
can produce symptoms that mimic those of an independent psychiatric disorder.
Research on the nature of the relationship between comorbid
disorders generally relies on surveys of either the clinical population
(persons in treatment) or the general population. Most studies of comorbidity
are based on clinical samples. This may result in inflated estimates of
comorbidity, since persons with multiple ailments may be more likely to
seek treatment (Berkson's fallacy). This trend may be countered to
some extent by the reluctance of some alcoholism treatment centers to
admit persons exhibiting serious psychiatric problems. Thus, the prevalence
of comorbid psychiatric disorders among alcoholics in treatment does not
reflect the actual prevalence of such comorbidity in the community.
Additional methodological difficulties complicate both
clinical and general population investigations. For example, estimates
of comorbidity will also vary depending on how alcohol use disorders are
defined. Definitions of alcoholism have included formal definitions
of abuse and dependence appearing in psychi atric classification systems
such as the DSM-III-R; alcohol-related symptom ratings; serious
manifestations of physiological dependence (i.e., tolerance and withdrawal);
and various levels of heavy alcohol consumption. Since alcohol use,
alcohol withdrawal, and alcohol abuse and dependence may each relate to
comorbid conditions in an entirely different way, it is essential when
evaluating comorbidity to clarify which aspects of alcohol use are involved
. Similar considerations apply to the evaluation of comorbid disorders.
For example, when evaluating depression, it is important to distinguish
among sadness, grief, and major depressive disorder.
An important source of comorbidity data is the Epidemiologic
Catchment Area (ECA) program of the National Institute of Mental Health. The ECA surveyed more than 20,000 respondents residing in households,
group homes, and long-term institutions in five sites across the United
States to provide data about the prevalence and incidence of psychiatric
dis orders, as well as issues related to treatment. (Prevalence is the
number of existing cases; incidence is the number of new cases.
Conclusions about causal relationships between alcohol
use disorders and comorbid psychiatric disorders based on ECA data are
problematic, since sequencing criteria consisted of age at first symptom
of the alcohol use disorder, rather than age at onset of the syndrome
. Moreover, the ECA program defined alcohol use disorders as the occurrence
of enough symptoms to meet the associated diagnostic criteria over the
life course. The sporadic occurrence of isolated symptoms, perhaps years
apart, provides an insufficient basis for testing competing hypotheses
related to comorbidity.
Because the term "comorbidity" is often not applied to
medical conditions, a number of medical conditions that are often comorbid
with alcoholism are mentioned below. A discussion of comorbidity with
psychiatric disorders will follow.
Medical conditions. Alcohol has been shown to be directly
toxic to the liver. Approximately 90 to 100 percent of heavy drinkers
show evidence of fatty liver, an estimated 10 to 35 percent develop alcoholic
hepatitis, and 10 to 20 percent develop cirrhosis. Fatty liver is
reversible with abstinence, alcoholic hepatitis is usually reversible
upon abstinence, and while alcoholic cirrhosis is often progressive and
fatal, it can stabilize with abstinence. In addition to liver disease,
heavy alcohol consumption causes chronic pancreatitis and malabsorption
The prevalence of alcoholic cardiomyopathy (heart muscle
disease) is unknown. Alcohol-induced heart damage appears to increase
with lifetime dose of alcohol.
Alcohol can damage the brain in many ways. The most serious
effect is Korsakoff's syndrome, characterized in part by an inability
to remember recent events or to learn new information. The incidence of
alcohol-related brain damage is approximately 10 percent of adult dementias
in the United States. Milder attention and memory deficits may improve
gradually with abstinence.
Additional diseases strongly linked to alcohol consumption
include failure of reproductive function and cancers of the mouth,
larynx, and esophagus. Hospitalized alcoholics have also been found
to have an increased prevalence of dental problems, compared with nonalcoholic
psychiatric patients, including missing teeth and nonrestorable teeth
Psychiatric disorders. Despite the study's shortcomings,
data from the ECA provide a starting point for assessing the prevalence
of some comorbidities (on a lifetime basis). Based on ECA data, alcoholics
are 21.0 times more likely to also have a diagnosis of antisocial personality
disorder compared with nonalcoholics. Similar "odds ratios" for some other
psychiatric comorbidities are as follows: drug abuse, 3.9 times; mania,
6.2 times; and schizophrenia, 4.0 times. There is only a mild increase
in major depressive disorder among alcoholics (odds ratio 1.7), and essentially
no increase in anxiety disorders.
Antisocial personality disorder. The strongest correlate
of alcoholism documented in the ECA is antisocial personality disorder
(ASPD). Determining the chronological relationships between the two
disorders is complicated by the following factors: both disorders
typically begin early in life, thus requiring retrospective reporting
from adults; there is considerable overlap in the symptoms of the two
disorders; alcohol or other drug abuse is itself one of the diagnostic
criteria for ASPD; and intoxication leads to behavioral disinhibition,
thus lowering the threshold for antisocial behavior.
Comorbid ASPD has prognostic and treatment implications
for alcoholics. Patients with ASPD have an earlier age of onset of alcohol
and other drug abuse and a more rapid and serious course of illness.
Bulimia. Bulimia is an eating disorder in which patients,
usually female, binge on sugar- and fat-rich meals, and purge regularly,
as by self-induced vomiting. This disorder is characterized by craving,
preoccupation with binge eating, loss of control during binges, an emphasis
on short-term gratification, and ambivalence about treatment--symptoms
that resemble those of addictive disorders. Bulimics commonly
exhibit multiple drug use disorders and have high rates of alcoholism.
Between 33 and 83 percent of bulimics may have a first-degree relative
suffering from alcohol abuse or alcoholism.
Depression. Although it has been suggested that alcoholism
and depression are manifestations of the same underlying illness, the
results of family, twin, and adoption studies suggest that alcoholism
and mood disorder are probably distinct illnesses with different prognoses
and treatments. However, symptoms of depression are likely to develop
during the course of alcoholism, and some patients with mood disorders
may increase their drinking when undergoing a mood change, fulfilling
criteria for secondary alcoholism. When depressive symptoms are secondary
to alcoholism, they are likely to disappear within a few days or weeks
of abstinence, as withdrawal symptoms subside.
Anxiety. Studies (not using ECA data) indicate that approximately
10 to 30 percent of alcoholics have panic disorder, and about 20 percent
of persons with anxiety disorders abuse alcohol. Among alcoholics
entering treatment, about two-thirds have symptoms that resemble anxiety
disorders. The relation between major anxiety disorders and alcoholism
is unclear. Several studies indicate that anxious patients may use
alcohol or other drugs to self-medicate, despite the fact that such use
may ultimately exacerbate their clinical condition.
The strongest correlation between alcoholism and severe
anxiety symptoms occurs in the context of alcohol withdrawal. The
severe tremors, feelings of tension, restlessness, and insomnia associated
with withdrawal begin to subside after 4 or 5 days, although a vulnerability
to panic attacks and to generalized anxiety may continue for months. Because
these symptoms decrease with abstinence, they are unlikely to represent
an independent anxiety disorder. Interestingly, subjects suffering
from both alcoholism and panic disorder are unable to distinguish between
a number of symptoms common to both disorders.
Other drug abuse. Based on ECA data, alcoholics are
35 times more likely than nonalcoholics to also use cocaine. Similar odds
ratios for other types of drugs are: sedatives, 17.0 times; opioids, 13.0
times; hallucinogens, 12.0; stimulants, 11.0; and marijuana and related
drugs, 6.0. Surveys of both clinical and nonclinical populations indicate
that at least 90 percent of alcoholics are nicotine dependent.
Comorbidity affects the course of illness and the response
to treatment of both alcoholism and its comorbid illnesses, whether these
occur simultaneously or sequentially. Because alcohol-related comorbidity
is so common, research is needed to improve the recognition and appropriate
management of alcohol abuse and alcoholism occurring in the context of
Alcoholism and Co-occurring Disorders--A Commentary
NIAAA Director Enoch Gordis, M.D.
Treatment for co-occurring illnesses in persons with alcoholism
should be a standard part of every alcoholism treatment program. Unfortunately,
many patients with such illnesses fall through the cracks; for example,
alcoholic patients with psychiatric problems who may be rejected by both
alcoholism programs and mental health programs. This situation is unacceptable.
In many instances, leadership can help solve this problem. Program directors
who are concerned about providing the best care to their patients should
work within their ser vice areas to develop comprehensive treatment networks
for multiply affected patients. In some cases, this may mean facilitating
changes in city, county, or State laws to mandate care for such patients.
In other cases, it might mean working to resolve differences in treatment
philosophy that make it difficult for patients to be treated for comorbid
conditions; for example, the requirement of some alcoholism programs that
methadone-maintained individuals be drug free before acceptance for treatment.
Patients who are alcoholic and who also suffer from other illnesses deserve
the same kind of comprehensive care as a cancer patient with pneumonia,
or a diabetic patient with glaucoma.
Researchers interested in the causes of disease will differ
on whether studying the patient with co-occurring disease is a promising
research strategy. On the one hand, the presence of one illness has been
known to modify the course of another for better or worse. Clearly, it
would be valuable to understand why. On the other hand, because we barely
understand the fundamentals of alcoholism, studying it in the presence
of other diseases may introduce complications. For example, diabetes increases
an individual's risk for atherosclerosis, but researchers interested in
atherosclerosis might not choose to unravel the causes of this disease
by studying it primarily in diabetic patients.
Because of the increase in the frequency of polydrug abuse,
alcoholism treatment programs must be aware of and prepared to deal with
this problem in their patients. It should be noted, however, that the
most common pattern of abuse in the United States is still alcoholism
Indepth Information on Alcoholism
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