Alcohol use disorder, alcohol intoxication disorder and alcohol withdrawal disorder are a complex set of substance abuse disorders having common but varied pathways of development leading to the onset of the disorder. The factors responsible for the emergence of the above mentioned set of disorders have been listed and explained below:
BIOLOGICAL ETIOLOGY
• Genetic factors:
From the family pedigree studies it has been found that first degree relatives (parents & siblings) of an alcoholic are under high risk in developing alcohol related disorders in comparison with a general population(Cotton, 1979; Merikangas, 1990). Several twin studies have concluded that monozygotic twins have greater concordance rates in developing alcohol related disorders on comparison with the dizygotic twins (Kendler et al., 1992; McGue, Pickens, & Svikis, 1992). The adoption studies based on children of alcoholic parent(s) adopted at birth on comparison with children of non alcoholic parents adopted at birth and placed in non-alcoholic homes have led to the conclusion that the offspring adopted into a non-alcoholic home but born of an alcoholic parent develops alcohol related disorders at a higher rate (cf. Goodwin et al., 1974; Cloninger, Bohman, & Sigvardsson, 1981; Cadoret, Cain, & Grove, 1980)
. The above mentioned studies therefore scientifically prove that the predisposition of alcohol related disorders have a strong genetic contribution although the specific genes causing higher susceptibility in developing the disorder has not been found yet (NIAAA, 2000).
• Cognitive Factors:
Several findings have pointed out differences in electrophysiological features between alcoholic and non-alcoholic adults measured by the electroencephalographic (EEG) and event-related potential (ERP) methods related to the central nervous system (Begleiter, Porjesz, Bihari, & Kissin, 1984). These differences comprise of the brainwave patterns found in the frontal region of the brain, which is responsible for most of the cognitive functions such as attention, planning, and foresight. Therefore, these studies conclude that individuals with lowered activity in the prefrontal context are highly vulnerable for developing alcohol related disorders (Hill, Shen, Lowers, & Locke, 2000; NIAAA, 2000). Moreover studies done on young adult males indicated that lowered activity in the frontal and temporal lobes provided insight on the age of onset, degree of dependence and intoxication (Deckel, Bauer, and Hesselbrock, 1995).
• Psychopathology and Temperament Factors:
Studies have concluded that children with problem conduct disorder, oppositional defiant disorder and attention deficit disorder are at a higher risk of developing alcoholism especially if they have alcoholic parents (Tarter, McBride, Buopane, & Schneider, 1977; DeObaldia et al., 1983). However, there is not enough scientific evidence to prove that the sole contribution of Attention Deficit Disorder or Conduct disorder is responsible for the individual to be more susceptible for developing the disorder (August & Stewart, 1983; Boyle et al., 1992). Apart from this, Tarter and Vanyukov’s temperament model suggests that individuals who deviate with regards to norms based on temperamental factors such as emotionality, sociability, activity level, persistence and soothability are more prone to develop alcohol related disorders (Ohannessian & Hesselbrock, 1995; Tarter, Kabene, Escallier, Laird, & Jacob, 1990).
PSYCHOLOGICAL MODELS OF ETIOLOGY
Several models based on psychological theories provide great insight on the development of alcohol related disorders in individuals. Psychoanalytic models suggest that alcoholism was caused by fixation or regression to the oral stage of development. Additionally, another model suggests that the usage of alcohol is used to decrease the effects of a harsh super ego and therefore reducing the anxiety and rage arising from the intra-psychic conflict (McDougall, 1989). The behavioral models suggest that alcohol use disorders are learnt and maintained through social learning, classical and operant conditioning respectively. Operant conditioning theory pertains to alcohol use disorder as alcohol provides reinforcing effects such as elevated mood, reduced anxiety, etc. (Schuckit & Hesselbrock, 1994). The classical conditioning paradigm to alcohol use suggests that there is a distinct delay in the occurrence of the negative effects of drinking such as social consequences, personal costs, hangover, etc. and therefore highlights the positive reinforcing effects which occurs instantaneously on the consumption of alcohol (Wikler, 1973; Siegel, 1983). Social Learning models comprising of cognitive models such as expectancies, self-efficacy and attributions suggest that alcoholism maybe used as an end product in situations where the individual may fail to cope (NIAAA, 2000).Additionally, alcohol related disorders may co-occur with other conditions such as depression, anxiety, personality disorders, etc.
SOCIOCULTURAL MODELS OF ETIOLOGY
Although genetic factors may increase the risk of developing alcohol related disorders, the presence of certain environmental factors strengthens this susceptibility of acquiring the disorder. Several studies on family violence, partner abuse, sexual abuse indicate the overarching fact that individuals who were exposed to such violence were at a higher risk of later becoming dependent on alcohol and other substances. Additionally, three contemporary models such as the family disease model, the family systems model and the behavioural family approach have been formulated to explain the influence of alcoholic family members on each other’s alcohol intake (McCrady, Kahler, & Epstein, 1998).All of the above mentioned models suggest that family members get into a pattern of drinking and become codependent in perpetuating the alcohol problem. Moreover, ist also suggests that the use of alcohol brings in harmony to the family and therefore their activities are structured around the consumption of alcohol. Subsequently, frequent interaction between the alcoholic parent and the child may also increase the child’s susceptibility of developing a alcohol related disorder due to poor parenting styles. On the other hand, alcohol consumption and peer influence has constantly been studied and the results conclude that peer influence seems to be associated with initiation of alcohol use and rate of drinking (Kandel & Yamaguhi, 1999; Wills, Vaccaro, & McNamara, 1992; Averna & Hesselbrock, 2001). Therefore, the social environment determines the effect of the interaction of biological, psychological and personality factors and determines the degree of chance in developing alcohol related problems (NIAAA, 2000).
TREATMENT
PYSCHOLOGICAL TREATMENT:
Psychologists may assist the client through treatment by first assessing the type and degree of the alcohol disorder and establishing a therapeutic relationship. Using one or more forms of counseling and behavioural therapy, the client’s psychological issues precipitating their drinking problems may be addressed. Behavioural therapy mainly draws from the learning theories such as operant conditioning and social learning theories. This treatment method mainly focuses on equipping the individual with the skills needed to cut down drinking, to build a strong social support system, to identify and create protective factors inorder to help the individual prevent relapse. Behavioral treatment includes cognitive behavioral therapy, motivational enhancement therapy, marital and family counseling and brief interventions. Cognitive Behavioral Therapy includes identifying the cues that lead to heavy drinking and dealing with the stress caused by withdrawal symptoms. It mainly targets the dysfunctional cognitions in order to develop healthy coping skills. Studies have demonstrated the efficacy of CBT in treating 58% of out patients as opposed to the patients who did not receive CBT (Magill & Ray, 2009). Motivational Enhancement Therapy focuses on increasing the individual’s motivation to reduce his drinking behavior and this is done by weighing the pros and cons of seeking treatment, developing realistic goals and equipping the individual with the skill to achieve these goals which in turn will reinforce the individual’s confidence. The effect of motivation therapy was studied and it was found that it significantly reduced consumption of alcohol in adolescents (Spirito et al., 2011). Additionally, marital and family counseling involves psycho-educating family members to deal with the individual and support his treatment plan. Studies have shown that strong support from the family through family therapy has led to successful abstinence as opposed to individual counseling. Brief interventions adopt a short counseling session based on any psychotherapeutic approach and also uses CBT tools and medication for treatment.
MEDICATION:
Research supports the use of medication in combination with psychotherapy in the development of a comprehensive treatment for alcohol related disorders in primary care. Medications with clinical verification of efficacy to treat alcohol related disorders are Topiramate (an anti¬ seizure medication); Selective Serotonin Reuptake Inhibitors (used to treat depression); Ondansetron (a serotonin receptor antagonist approved for nau¬sea); Baclofen (a γ¬aminobutyric acid¬b receptor agonist used for muscle spasticity), and atypical neuroleptics such as Aripiprozole and Quetiapine.
. Furthermore, corti¬cotrophin ¬releasing factor antagonists are under the scrutiny of researchers inorder to address the relationship between stress and alcohol consumption (NIH, 2015). In addition, benzodiazepines are utilized in the detoxification process under supervision when the client has completely stopped the consumption of alcohol. Since the client may lose vitamins in the detox phase it is important to provide supplements. Furthermore, to reduce craving, medicines such as Acamprosate, Naltrexone and Baclofen are used. On cessation of alcohol, alcohol deterrants such as Disulfiram may be used under specialist guidance.
MUTUAL HELP GROUPS:
Although behavioural therapy and pharmacological medication has proven to be useful, mutual help groups organized by peers have always played an important role in the treatment plan for alcohol related disorders (Centre for Substance Abuse Treatment, 2009). Alcohol Anonymous (AA) offers the oldest and well-known mutual help treatment program. Most of these support groups follows a 12-step program in overcoming addiction. This 12 step process involves recognizing that one has a problem and in turn building self efficacy and compassion for others suffering with similar problems which results in an increased capacity to alter self defeating thinking. Although initially the client may show resistance, the therapist may help in choosing a mutual help group in which the client feels comfortable in. This may increase the client’s interest in attending the sessions organized by these support groups (NIAAA, 2011).