Alcohol sickness

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Classification according to ICD-10
F10 Mental and behavioral disorders due to alcohol
F10.0 acute alcohol intoxication (acute alcohol intoxication)
F10.1 harmful use of alcohol
F10.2 Addiction syndrome
F10.3 Alcohol withdrawal syndrome
F10.4 Alcohol withdrawal syndrome with delirium
F10.5 psychotic disorder
F10.6 amnesiac syndrome
F10.7 Residual and delayed psychotic disorder
F10.8 other mental and behavioral disorders
ICD-10 online (WHO version 2019)
William Hogarth : Gin Lane (1751)

The alcohol disease (including alcohol addiction , Äthylismus , Dipsomania , Potomanie , alcoholism , alcohol addiction , alcoholism or alcohol use disorder is called), the dependence of psychoactive substance ethanol (ethyl alcohol).

Symptoms

The procurement and consumption of alcohol increasingly determine life. Typical are a progressive loss of control over drinking behavior up to compulsive consumption, neglect of previous interests in favor of drinking, denial of addictive behavior, withdrawal symptoms with reduced consumption, tolerance to alcohol (“drinking stiffness”) and changes in personality.

The ICD-10 diagnostic system differentiates between addiction syndrome (F10.2) and harmful use of alcohol / alcohol abuse ( F10.1 ). The latter describes - as a weaker variant of the abuse behavior - alcohol consumption with demonstrably harmful effects (physically or psychologically), without any dependence being present. In the DSM-5, alcohol use disorder is divided into different degrees of severity, with alcohol use disorder of mild severity corresponding to ICD-10 diagnosis F10.1.

The number of people who suffer from alcoholism and the resulting social and economic damage are in absolute numbers in Europe and the USA - in addition to the damage to health from tobacco consumption - many times higher than with other drugs . 7.4% of health disorders and premature deaths in Europe are attributed to alcohol. This puts the disease in third place as a cause of premature death after tobacco consumption and high blood pressure . It is also the leading cause of death among young men in the EU .

Alcohol addiction as a disease

Princely directive of
April 21, 1911

The Swedish doctor Magnus Huss was the first to define the term alcoholism, which he coined as a disease, in 1849 . He distinguished between "acute alcoholism or poisoning" and "chronic alcoholism " . However, this realization did not take hold for a long time. In 1878, Abraham Baer , a prison doctor in Berlin , described alcoholism as the sum of the consequential damage. Elvin Morton Jellinek , who worked part-time for the WHO , established himself in 1951 with his view, inspired by his work with Alcoholics Anonymous , that alcoholism was a disease.

Diagnosis according to ICD – 10

Addiction syndrome

This section needs revision: this narrow definition applies to research only, see discussion page .
Please help to improve it , and then remove this flag.

The ICD-10 defines six criteria, of which three or more must be present at the same time for at least one month (or for a shorter duration: repeated within a year ) in order to be able to make a diagnosis of an addiction syndrome (F10.2):

  • Strong or compulsive desire to consume alcohol (technical term: craving )
  • Reduced ability to control the amount, the beginning or the end of consumption (i.e. more alcohol is regularly consumed or over a longer period of time than planned or there is a persistent desire and attempts to reduce or control alcohol consumption without this being sustainably successful )
  • Physical withdrawal symptoms when stopping or reducing consumption
  • Evidence of tolerance (increasing amounts of alcohol are required to produce the desired effect )
  • Narrowing one's mind on alcohol (i.e. neglecting other interests in favor of alcohol consumption )
  • Persistent substance use despite the health and social consequences for the user, although the person concerned is aware of or could be aware of the type and extent of the damage (e.g. liver diseases such as cirrhosis of the liver , deterioration in cognitive functions, loss of a driver's license or job, Separation of life partner, withdrawal of acquaintances and friends, etc.)

In contrast to previous ICD versions, the "classic" symptoms of physical dependence, i.e. H. Tolerance and withdrawal symptoms no longer necessarily exist if other symptoms apply sufficiently.

Harmful use of alcohol

The harmful use of alcohol (or alcohol abuse , F10.1) is distinguished from dependency syndrome. This diagnosis is given if there is no dependency syndrome so far , but the person affected (or his social environment) has suffered physical or psychological damage from his alcohol consumption (e.g. accident). This also includes negative consequences in interpersonal relationships as a result of limited judgment or problematic behavior of the person concerned. For the diagnosis, the harmful utility model must have existed for at least a month or have occurred several times over a year. In medical jargon - because of the chemical formula of ethanol (C 2 H 5 OH) - it is sometimes also referred to as C 2 -Abusus .

In 2016, the harmful use of alcohol led to approximately 3 million deaths worldwide, according to the WHO, representing 5.3 percent of all deaths.

Acute alcohol intoxication (acute alcohol intoxication)

An acute alcohol intoxication (F10.0) is detected when acute impairment of consciousness , the cognition , the perception , the emotions or behavior are present that can be clearly attributed to the effects of alcohol. At least one of the following behavioral problems must be observed for the diagnosis:

In addition, at least one of the following characteristics must be present:

Severe alcohol intoxication can also be associated with hypotension (low blood pressure), hypothermia (hypothermia), and a weakened gag reflex .

If complications arise from acute poisoning (e.g. injuries, aspiration of vomit, delirium , perception disorders , coma ), one speaks of a complicated intoxication . The type of complication is coded in the ICD-10 in fifth position (F10.0x).

One speaks of pathological intoxication ( pathological alcohol intoxication , F10.07) if the alcohol intoxication already occurs with a drinking quantity that does not cause intoxication in most people (less than 0.5 per mil) and is accompanied by verbal aggressiveness or physical violence, which for is atypical of those. There must be no organic brain damage or any other mental disorder (in this case, a different diagnosis should be given).

Other diagnostic categories related to alcohol

  • Alcohol withdrawal syndrome without (F10.3) or with (F10.4) delirium
  • Psychotic disorder , alcohol psychosis (F10.5x):
    • Alcoholic jealousy (F10.51)
    • Alcoholic hallucinosis (F10.52) with delusions of the patient in which he, for example, hearing voices that call him names. Alcohol-related psychoses can occur in acute intoxication, alcohol withdrawal, as well as in chronic alcoholics. A 2015 Dutch review of alcohol-induced psychotic disorders found a lifetime prevalence of 0.4% in the general population and a prevalence of 4% of alcohol-induced psychosis in patients with alcohol dependence . Alcohol psychosis can last a few weeks to months. Patients with alcohol-related psychosis have a 5% to 30% risk of developing chronic schizophrenia-like syndrome. Once diagnosed with alcohol-related psychosis, there is a 68% chance of re-entry and a 37% comorbidity (concomitant illness ) with other mental disorders. In addition to alcohol psychosis, patients have a much higher chance of developing anxiety disorders or depression or of dying of suicide .
  • amnesiac syndrome (F10.6; also: Korsakoff syndrome ): disorders in the area of short and long-term memory . There is no disturbance of the immediate memory (e.g. immediate memorization of numbers), delirium or general intellectual decline ( dementia ).
  • Residual and delayed psychotic disorder (F10.7): These include alcohol-related disorders such as B. the chronic organic brain syndrome in alcoholism, dementia and other milder forms of persistent impairment of cognitive abilities, persistent personality and behavioral changes, but also delayed psychotic disorders or reverberation states ( flashbacks ).

Diagnosis according to DSM-5

Alcohol Use Disorder (Alcohol Use Disorder)

The DSM-5 provides for twelve criteria, of which at least two must be present over a course of twelve months for an alcohol use disorder in addition to clinically significant conditions:

  1. Alcohol is consumed in larger quantities or for longer than intended.
  2. persistent desire or unsuccessful attempts to reduce or control alcohol consumption
  3. spending a lot of time procuring alcohol, consuming it or recovering from its effects
  4. Craving or a strong desire to consume alcohol
  5. Repetitive drinking that leads to failure to meet important obligations at work, school, or at home
  6. continued alcohol use despite persistent or repeated social or interpersonal problems caused or exacerbated by the effects of alcohol
  7. Important social, professional or leisure activities are given up or restricted due to alcohol consumption.
  8. Repeated consumption of alcohol in situations in which the consumption leads to a physical hazard
  9. Continued use of alcohol despite knowledge of persistent or recurring physical or psychological problem likely to be caused or made worse by alcohol
  10. Tolerance development, defined by one of the following criteria:
    • Demand for a marked increase in dose in order to induce a state of intoxication or a desired effect
    • significantly reduced effect with continued consumption of the same amount of alcohol
  11. Withdrawal symptoms that show up by any of the following criteria:
    • characteristic withdrawal syndrome related to alcohol (see criteria A and B for alcohol withdrawal)
    • Alcohol (or a very similar substance, such as benzodiazepines ) is consumed to relieve or prevent withdrawal symptoms.

In addition, classifications can be made in:

  • Early emitted and persistently remitted : Once the diagnostic criteria have been met, the additive early emitted is set after a three-month abstinence and the additive is permanently remitted after a twelve-month abstinence . The 4th criterion is not included for both classifications.
    • If a person remits in a protected environment, i.e. in environments in which no access to alcohol is possible (closed inpatient stays, prison, etc.), then in a protected environment is also coded.
  • different degrees of severity ( easy , medium , difficult ):
    • Mild : 2–3 symptom criteria are met
    • Medium : 4–5 symptom criteria are met
    • Severe : 6 or more symptom criteria are met

For mild severity, this corresponds to ICD-10 code F10.10; for moderate or severe alcohol use disorder, the diagnosis corresponds to ICD-10 code F10.20.

Alcohol intoxication

A. Recent alcohol use

B. Clinically significant behavioral or psychological changes (e.g., inappropriate aggressive or sexual behavior, affect lability, impaired judgment) that develop during or shortly after drinking alcohol.

C. Any of the following signs or symptoms that developed during or shortly after drinking alcohol:

  1. slurred speech
  2. Incoordination
  3. unsafe gait
  4. Eye movement disorder
  5. Disturbance in attention or memory
  6. Stupor or coma

D. The signs or symptoms are not due to any other medical disease factor or cannot be better explained by another mental disorder, including intoxication from another substance.

A corresponding ICD-10 coding is carried out depending on whether an alcohol use disorder is present:

  • without comorbid alcohol use disorder: F10.929
  • mild comorbid alcohol use disorder: F10.129
  • moderate or severe alcohol use disorder: F10.229

Course and picture of the disease

Alcohol sickness is not uniform. The notion of alcohol dependence as a uniform, chronically progressive (permanently progressive) addiction that ultimately leads to social decline (see also: misery alcoholism ) or death has proven to be wrong. For the sake of completeness, Jellinek's approach - which is to be regarded as outdated today - is nevertheless presented.

The ICD-10 classifies alcohol in the F10 category “Mental and behavioral disorders caused by alcohol”. In the diagnosis manual DSM-5 , alcohol dependence is classified in the chapter "Disorders related to alcohol".

The advisory literature largely dispenses with the term "alcoholism", which is mainly used in scientific literature. This is to emphasize the disease value of this disorder and to reduce inhibitions to seek the help of a doctor.

Alcohol sickness can begin with regular consumption of small amounts. Those affected do not always attract attention through frequent intoxication . Alcohol sickness is not always noticeable externally. If the person concerned continues to perform well, one speaks of a functioning alcoholic . The disease is often relatively inconspicuous and slow, usually over several years. Those affected are often not aware of the severity of their illness ; often they completely deny it.

Men have always been affected far more often than women. In its 2013 addiction report, the drug commissioner of the federal government assumes that around 9.5 million people in Germany exceed the quantities of alcohol that are classified as essentially harmless, of which around 1.3 million people are already alcohol dependent.

see also section → secondary diseases (in the article)

Course of disease

In 1951, the American physiologist Elvin Morton Jellinek presented a classification of the course of alcoholism that is still widespread today. He distinguished between four phases:

Pre-alcoholic or symptomatic phase
Jellinek saw as typical of his prodromal - or precursor phase that drinking in social contexts begins. Like most people, the potential alcoholic drinks in company, only that from drinking he will soon get satisfactory relief. However, he ascribes this more to the situation, to partying, gaming or society. He begins to look for such opportunities in which people drink "on the side".
Over time, tolerance to alcohol develops , which means that it needs more alcohol than before in order to achieve the desired state of euphoria . He drinks more often, also to make things easier for him. The psychological resilience diminishes, so that he soon drinks every day. He and his environment usually do not notice this.
Prodromal phase
Jellinek defines this as the phase of the first abnormalities.
For example, alcoholics in this phase have amnesia . He can behave completely normally and still sometimes remember little without being recognizably drunk. The alcohol is now no mere drink more, it is the alcoholic needed . He begins to realize that he drinks differently from other people and tries not to attract attention. That's why he secretly begins to drink. He thinks of alcohol more often than usual and drinks the first glasses hastily in order to get the effect as quickly as possible. Since he now feels guilty about his drinking, he tries to avoid the subject of alcohol in conversations.
The transition to chronic alcoholism is characterized by a usually inconspicuous increased need and craving for alcohol. Gradually, due to the physical habituation, an increasing amount of alcohol is necessary to achieve the same psychological effects as at the beginning of drinking. Drinking for relief at first only occasionally can then degenerate into permanent relief drinking.
Critical phase
The alcoholic can no longer control his drinking at all. He may be abstinent for a long time, but after the first small amount of alcohol he has an uncontrollable desire for more, until he is drunk or too sick to continue drinking.
He himself believes that he has only temporarily lost his willpower in these situations, but is already powerless against alcohol, i. H. alcohol dependent . He is usually not aware of this dependency or is suppressed. He looks for excuses for his drinking, especially for his failures, for which he finds reasons and causes everywhere except in his alcohol abuse.
These attempts to explain are important to him, because apart from alcohol he has no other solutions to his problems. In doing so, he defends himself against social stress. Because of his behavior, there are more and more conflicts with the family.
Whole families isolate themselves if they “cover up” the drinker (co-alcoholism, co-dependency ) or the relatives are ashamed of them. The alcoholic can thus fall into the role of a despot. He compensates for his shrinking self-esteem more and more by acting self-confidence and cocky demeanor.
The addict isolates himself more and more, but does not look for faults in himself, but in others. He increases his social isolation more and more, while at other times he often desperately begs for closeness, understanding and encouragement. Some people play down their drinking behavior with well-known sayings such as "Nobody can refuse a glass in honor". Or he completely loses interest in his surroundings, aligns his activities with drinking and thus develops solitary behavior with self-pity, in which he in turn "comforts" himself with alcohol. Social isolation and entanglement in lies and explanations become particularly noticeable features of chronic alcoholism.
Chronic phase
The alcohol now completely dominates the drinker. His personality changes. He drinks during the week, in broad daylight, in the morning. Noise can extend for days. In the chronic stage, social contact is usually only possible with people who also drink a lot. In the group, mutually encouraged, they develop even more conspicuous behavior until the last remnant of decency, legal awareness and self-respect disappears in a state of intoxication. Motor restlessness and anxiety can now herald a withdrawal syndrome, which can only be avoided by continuing to drink.
In this phase one can hardly speak of "satisfaction" in the intoxication. Rather avoids and the addict fights usually only fast or reinforced occurring withdrawal symptoms if necessary with the help of cheap products or even denatured alcohol such as methylated spirits .
In the end stage of the chronic phase, alcohol psychoses with typical hallucinations , fear and disorientation can occur, often combined with vague religious wishes. Epileptic seizures or life-threatening delirium tremens can occur. Quite a few alcoholics take their own lives .
In this final phase, the patient is most ready to accept help. Admission to a suitable, mostly psychiatric hospital for "detoxification" or better said for "physical withdrawal" is then life-saving and at the same time a possible "entry point" to the necessary withdrawal treatment.

Gundula Barsch describes the course of the disease differently from Jellinek:

  • Initial phase = initial phase = trying out and experimenting with curiosity as the main motive
  • Change in motivation to use
  • Relocation of the reference group
  • Practice in the sense of learning the rules of a consumption milieu
  • External labeling = attribution of characteristics of the person by outsiders
  • Self-management typical of the milieu = adopting a drug-related lifestyle with corresponding values, norms and behavioral styles
  • Subsumption of one's own identity under that of the dependent category = adoption in self-image and as an orientation for behavior

Manifestations of the disease

Magnus Huss defined “acute alcoholic disease” in 1849 : In addition to what is now referred to as alcohol poisoning , Huss also included delirium tremens , since it is an acute state of chronic poisoning. He subdivided the "chronic alcohol disease" according to whether the symptoms originate from the somatic (physical) or the psychological (emotional) "sphere" or from both.

Jellinek's 1951 concept, which is still widespread today, divides alcoholics into five types:

  • The alpha type (problem drinker, relief drinker) drinks to remove internal tension and conflicts (such as despair) ("grief drinkers"). The amount depends on the respective stressful situation. The main risk here is psychological dependence. Alpha drinkers are not alcoholic, but at risk.
  • The beta type (occasional drinker) drinks large quantities on social occasions, but remains socially and psychologically inconspicuous. Beta drinkers have a lifestyle close to alcohol. Frequent alcohol consumption has negative health consequences. You are neither physically nor psychologically dependent, but at risk.
  • The gamma type (binge drinker, alcoholic) has longer periods of abstinence , which alternate with periods of heavy intoxication. Loss of control is typical: he cannot stop drinking, even if he already feels that he has had enough. Although he feels safe because of his ability to abstain from longer periods of time, he is alcoholic.
  • The delta type (level drinker, mirror drinker, alcoholic) strives to keep their alcohol consumption as constant as possible throughout the day (including at night); hence the term mirror drinkers (constant / r blood alcohol concentration or mirrors ). These can be comparably low concentrations, but these usually increase as the disease progresses and the alcohol tolerance increases with it. The addict remains socially inconspicuous for a long time (“functioning alcoholic”) because he is seldom recognizably drunk. Nevertheless, there is strong physical dependence. He needs to drink alcohol constantly to avoid symptoms of withdrawal . Continuous drinking results in physical damage. Delta drinkers are not capable of abstinence and are alcoholics.
  • The epsilon type (dipsomania, quarter drinker, alcoholic) experiences periods of excessive alcohol consumption at irregular intervals with loss of control, which can last for days or weeks. In between he can stay abstinent for months. Epsilon drinkers are alcoholic.

In 1981 Cloninger defined only two types:

  • The type I alcoholism : the "milieu embossed" Alcoholism knows both male and female sufferers. In both cases, abuse can be severe or mild. The disease usually gets worse quickly. The lower the social status, the more difficult the course. The person concerned tries hard to keep harm away from himself and is relatively dependent on “reward”. Depression and anxiety disorders are common with him , which he tries to combat with alcohol. The genetic disposition is usually low.
  • The type II alcoholism
    This type has only affected males. The abuse is usually of moderate severity, but manifests itself early. While the mother is usually inconspicuous, the father often developed his alcohol problem before the age of 25 and is also prone to crime. Those affected often show anti-social behavior with a high willingness to take risks. They use alcohol to euphorize and also tend to abuse other stimulants . The genes are probably much more decisive here than the social factors.

In 1992, SY Hill added the Cloniger classification

  • Type III alcoholic , which, like type II alcoholic , is strongly genetic, but has no anti-social components.

Criticism of Jellinek's concepts

Like Johannes Lindenmeyer, George Eman Vaillant considers Jellinek's view of the course of the disease to be too straightforward, predetermined and unstoppable. They would be based on experience, not on scientific studies. Many would find their way back to moderate drinking behavior or even abstinence. However, they both consider the basic concept to be correct.

Alcohol Addiction Biology

Alcohol significantly affects the metabolism in the brain. It stimulates the GABA receptors in the brain and nervous system and inhibits the NMDA receptors , which allows alcohol to relax and relieve anxiety. However, since the GABA receptors develop tolerance with constant stimulation , larger and larger amounts are required in the case of prolonged alcohol abuse in order to achieve the desired effect.

These effects are also based on the increased production of dopamine and endorphins . But the strong withdrawal symptoms also favor an existing dependency.

When alcohol is withdrawn, it can be seen that the excitatory NMDA receptors were upregulated as a countermeasure against the inhibition by the alcohol and the inhibitory GABA receptors were downregulated. If the alcohol is now gone, the excitatory system is significantly more effective than the inhibitory system. This explains the various symptoms of physical withdrawal syndrome. As the nerve cells are no longer suppressed, overexcitation leads to feelings of fear, tremors, hallucinations and even seizures. That is why the patient drinks alcohol again at an early stage in order to get rid of the agonizing symptoms.

Causes of disease

Genetic factors

Twin and adoption studies suggest that close relatives of alcohol addicts are three to four times more at risk of alcohol dependence. Genetic factors explain only part of the risk, however, a large part can be traced back to environmental and interpersonal factors (e.g. cultural attitudes, availability, expectations regarding the effects of alcohol on mood and behavior, personal experiences with alcohol and stress) .

Research currently assumes that 40 to 60% of alcohol disease is genetically influenced. This mainly relates to innate differences in alcohol tolerance and the liver's degradation capacity . These include, for example, the enzyme alcohol dehydrogenase . In some people there is a variant with reduced activity, which leads to more severe symptoms of intoxication. This makes alcohol addiction less likely. People who can tolerate a comparatively high amount of alcohol, on the other hand, are particularly at risk of becoming dependent on alcohol in the long term.

There is also evidence of innate differences in the relationship between the pleasant main effect and the unpleasant aftereffect of alcohol (two-phase effect of alcohol) . The effects of alcohol on the sons of alcoholics only take effect at higher concentrations than on other people. In order for the person to become dependent on alcohol, however, they must first drink substantial amounts of alcohol over a long period of time, which is not hereditary.

A deficiency of the neurotransmitter dopamine , which is released to a greater extent when alcohol is consumed and which lifts the mood (reward system), can also be genetic . Other genetic factors are still being investigated.

It was investigated whether an inherited increased activity of the enzyme salsolinol synthase is involved in the development of alcohol addiction. In animal experiments, the production of salsolinol and thus the mood increased significantly after the administration of alcohol. Less salsolinol would therefore trigger fewer reward stimuli and thus mean less danger. However, this has now been refuted.

About 80% of inpatient alcoholics have first- or second-degree relatives who have alcohol problems. If first-degree relatives are affected, the risk of becoming ill is seven times higher. In addition, it was found in twin studies that heredity is apparently more in the foreground in women, while men are heavily dependent on environmental influences.

Scientists from the National Genome Research Network (NGFN) wrote in the journal "Molecular Psychiatry" that studies have shown that two mutations in the CRHR1 gene (corticotropin releasing hormone receptor 1) influence susceptibility to increased alcohol consumption. This gene is responsible for a protein that plays a role in processing stress and controlling emotions. The risk of developing the disease in children who grew up separately from their alcoholic parents is three to four times higher than that of children of non-alcoholic parents.

A change in the MAOA gene appears to be associated with alcoholism, substance abuse and antisocial behavior (see also: Warrior Genes ).

Social factors

Social causes

In many cultures, alcohol is a socially recognized drug that can be obtained easily and cheaply , and its consumption is almost expected in some situations. Examples are the bourgeois drinking culture (after-work beer, "toasting" with congratulations ), high society meetings (whiskey and cigars) or fraternization through common "drinking" (see drinking culture in Europe # Drinking customs ). The consumption of alcohol is accepted to a certain extent in all walks of life.

Men in particular are often expected to be able to drink a certain amount of fluency as evidence of manliness and resilience . Since heavy alcohol consumption increases alcohol tolerance, this social definition of status also promotes the spread of alcoholism.

It has been proven that stress in the world of work is one of the factors that increase the risk of addiction (see also: bonus crisis ).

Family causes

Statistically speaking, children of parents with addictions are more often dependent than other children. Growing up with an addict in the family is a considerable psychological burden. Physical, psychological and sexual violence ( sexual abuse ) combined with addiction in the family of origin are considerable risk factors. Daughters from addiction families are also much more likely to marry an alcoholic themselves again. On the other hand, it is beneficial if the parents overcome their alcohol addiction.

The first contact with alcohol usually takes place at family celebrations. Children from parental homes in which a lot of tobacco and / or alcohol is consumed start experimenting with it earlier and more intensively. It is noticeable that the influence of the mother's consumer behavior is greater than that of the father, which is apparently related to the fact that mothers are still more involved in bringing up children. However, if the children experience this very negatively, they can also develop a negative attitude towards alcohol.

Systemic approaches postulate that there are dysfunctional familial patterns in many addiction families. In general, rigid external borders and diffuse internal borders are assumed, which lead to the isolation of these families and, on the other hand, make it extremely difficult for young people to break away. Depending on the sex of the alcoholic, there is a pattern of conflict avoidance (men) or willingness to conflict (women) in these families.

Adolescents with alcoholic parents have a noticeably low activity of the amygdala ( emotional center in the brain), which significantly increases the risk of developing the disease themselves.

Psychological factors

In terms of learning theory , the rapidly occurring positive effects of alcohol (e.g. relaxation, feelings of happiness) act as direct amplifiers for addictive behavior ( operant conditioning ). In a neutral situation it is about positive reinforcement (something positive is added). In an uncomfortable (stressful) situation, alcohol acts as a negative reinforcer , i.e. That is, an uncomfortable state (e.g. fear, tension, anger) is eliminated. The latter especially plays a role if the person concerned has been in a negative situation for a long time. These mechanisms play an essential role in maintaining the problem.

Frequently, however, the first consumption does not result in a positive experience, sometimes even negative effects (e.g. bitter taste, dizziness, nausea). In the case of first-time consumption, social reinforcement by turning to the reference group (e.g. peer group ) and the observed positive effect on others play an important role ( model learning ). If alcohol is readily available, consumption is rated highly in the reference group (social pressure) , if the person concerned has a strong bond with this group and if he can be influenced by this group, the likelihood of consumption is high. A positive result expectation (see social cognitive learning theory ) with the social advantages of alcohol consumption (easier contact, belonging to a certain reference group, etc.) or the effects of the substance are also risk factors. General life skills such as B. Abilities to cope with stress , self-confidence and communication skills (see also social competence ), and in particular the ability to reject consumer offers despite social pressure. A critical attitude and a critical handling of legal psychoactive substances is also a protective factor.

The attribution theory posits a specific pattern of alcoholics in locus of control , but this refers only to alcohol consumption. It is assumed that alcoholics tend to attribute their alcohol consumption more externally . This means that the causes of drinking behavior are ascribed to external factors that cannot be controlled by them. These generalized expectations are acquired through social learning.

So far, no specific addict personality has been found. By various authors v. a. psychodynamic alignment, however, it is believed that alexithymia (difficulty naming, distinguishing, and expressing feelings) is over-random in addicts.

Various studies also show a close connection between sensation seeking and addictive behavior, assuming biological mechanisms. However, there is a possibility that sensation seeking is just a superficial symptom of an underlying ADHD .

Other protection and risk factors

Breastfeeding may reduce the risk of becoming alcoholic. This was the result of an evaluation of the “Copenhagen Perinatal Cohort” study. The long-term study includes the data of 6562 Copenhageners who are now 44 to 46 years old. The risk of becoming dependent on alcohol was almost 50 percent higher for subjects who were only briefly breastfed as children than for subjects who had been breastfed for a long time. A high testosterone concentration during embryonic development seems to be a risk factor for the later development of alcohol dependence.

Consequences of alcohol addiction

Alcohol withdrawal syndrome

A withdrawal syndrome can occur when alcohol consumption is reduced or stopped abruptly. Severe to life-threatening withdrawal symptoms can occur. Withdrawal symptoms are nausea , nervousness , insomnia , the strong urge to drink alcohol ("drinking pressure"), irritability and depression . If the physical dependency is already advanced, there are, for example, profuse sweating, tremors (especially of the hands), flu-like symptoms and - in extremely bad cases - seizures with tongue bite and hallucinations up to the dreaded delirium tremens .

The incomplete delirium (so-called "predelir") shows hallucinations, sleep disorders and nervousness , especially towards evening . The patient is sweating and shivering, and grand- mal seizures may occur. The actual delirium tremens is noticeable through disorientation , over-excitability and psychotic phenomena such as illusory misjudgment as well as optical (seen) and tactile (felt) hallucinations. The autonomic nervous system derails, the patient gets a fever, high blood pressure, a pulse that is too fast (tachycardia) and sweats a lot ( hyperhidrosis ). Tremor ( tremor ) is mandatory. Seven percent of all delirium are life-threatening with severe circulatory disorders.

Change of character

The alcohol-toxic change in personality is one of the most serious consequences of alcohol consumption. It is a consequence of long and regular alcohol consumption. The change in personality is different for alcohol addicts. In addition to marked impairment of the performance of memory, concentration, drive and attention, a frequent occurrence of jealousy delusions is noticeable. Above all, the reaction patterns to everyday stresses and conflicts are affected, which makes the overall personality appear inharmonious and dedifferentiated. Depression can also occur as comorbidities (concomitant disease). As a result of long-term alcoholism, there are also psychotic disorders that were previously absent. In addition, interests are narrowed down to the addiction, while previous activities as well as personal hygiene and hygiene are neglected. The often increased aggressiveness and willingness to use violence are very problematic. Up to 35% of domestic violence cases are due to alcoholism. The tendency to deny or to trivialize the alcoholic illness is also part of the change in personality.

Consequences for the family

Gustav Imlauer: At your feet

The problems of an alcoholic are often borne or compensated for by their partner and the whole family. On the one hand, the latter gain personal or social recognition from their help, and on the other hand they are also devalued. In the long term, they can develop a burnout , the burnout syndrome . The feeling of helping the alcoholic can initially increase personal self-esteem . Later a feeling of helplessness dominates. This behavior is known as " helper syndrome ". In self-help groups, alcoholism is seen as a family disease. The reason: in the family or in a partnership, often everyone is involved in a manifestation of addiction and its social consequences. By denying the problems and thought patterns, but also by the behavior of the relatives themselves, the alcoholic's illness is stabilized and a professional attempt at recovery is made more difficult. Partners who are subject to such mechanisms are known as co-alcoholics .

A major problem is the alcohol dependence of the elderly. They often live alone and can hide their drinking habits. It can lead to physical and mental deterioration, including dementia.

Social consequences and costs

The follow-up costs of alcoholism are very high. According to the Federal Ministry of Health, the total economic costs in Germany for accidents under the influence of alcohol in the years 2010 to 2014 totaled 7.77 billion euros.

Numerous criminal offenses such as theft, burglary, robbery and fraud are committed under the influence of alcohol, the total damage in Germany from 2011 to 2015 being more than 103 million euros.

In addition, there are significant costs in the health system, including indirect costs, e.g. B. due to inability to work, early retirement (economic losses) or increased divorce rates.

Children and adolescents in families exposed to alcohol suffer particularly. Among other things, you have poorer chances at school and when starting your career. Many children develop mental or alcohol problems themselves, some of which are due to (epi-) genetics - some for life. I.a. the group of children has received little attention so far because of its poor perceptibility.

In particular, the fetal alcohol syndrome leads to cognitive impairment.

Secondary diseases

Those who are alcoholic have an average life expectancy of 20 years shorter. Long-term alcohol abuse often results in (sometimes chronic) secondary diseases:

Malignant tumors

In 2016, a meta-study showed that there is strong evidence that alcohol consumption is causally responsible for throat, esophagus, liver, colon, rectal, breast and larynx cancer and that alcohol consumption can be assumed to account for 5.8 in 2012 % of all cancer deaths worldwide was responsible.

liver

Due to the increased exposure to alcohol, the organ initially increases its ability to break down this poison. The liver enlarges until it becomes fatty liver . With prolonged exposure, alcohol hepatitis and cirrhosis of the liver often develop with the corresponding consequences. The liver can then no longer fulfill its tasks. As a result of cirrhosis of the liver, varicose veins can form in the esophagus . These are an additional risk as the person concerned can bleed to death. The lethality (mortality) of such a bleeding is over 30%. Another common complication is hepatic encephalopathy . It arises because the damaged liver can no longer completely metabolize the ammonia and other toxins that are produced by natural digestive processes in the intestinal tract. This is how ammonia gets into the bloodstream and penetrates the blood-brain barrier into the brain. There, the astrocytes swell , which can contribute to the formation of brain edema . In the final stages, hepatic encephalopathy can lead to hepatic coma .

pancreas

The pancreas is also sensitive to alcohol. It can become acute or chronic ( pancreatitis ). Acute pancreatitis can be directly fatal. Chronic pancreatitis can result in excretory insufficiency, in which the organ no longer produces enough digestive enzymes, and / or diabetes mellitus .

Musculature

Skeletal and cardiac muscles are damaged (alcoholic myopathy or cardiomyopathy I41.4) .

The alcoholic myopathy coded with the number G72.1 in the ICD10 occurs in up to 30 to 40% of all chronic alcoholics. The legs are usually more severely affected than the arms. The toxic (poisonous) effects of alcohol cause rhabdomyolysis , i.e. i.e., the muscle fibers break down. Acute alcoholic myopathy occurs in about one percent of patients. She shows u. a. from swelling, severe pain, and cramps in the affected muscles.

metabolism

Excessive alcohol consumption can trigger gout because carboxylic acids compete with uric acid in the kidney's excretion mechanism . In addition, beer supplies purines due to the yeast residues it contains . Hormonal disorders can cause a wide range of symptoms due to the liver's insufficient ability to break down hormones , especially in the water and electrolyte balance and in the sex hormones . This can lead to the characteristic "feminization" of the figure (chest, stomach).

Cardiovascular system

Alcohol abuse can contribute to high blood pressure , heart muscle diseases (including the alcoholic cardiomyopathy mentioned above) and anemia (hyperchromic, macrocytic anemia). Anemia is mainly caused by an alcohol-related deficiency in folic acid and vitamin B12.

The risk of coronary sclerosis (calcification of the coronary arteries) and stroke is possibly even rarer with moderate alcohol consumption than in the normal population, as alcohol increases HDL cholesterol and thus prevents deposits on the vessel walls. Certain ingredients, e.g. B. the polyphenols in wine have a protective effect. The anticoagulant effect of alcohol (inhibition of platelet aggregation ) could also play a role here. With higher alcohol consumption (> 30 g / day), however, the overall risk of coronary heart disease (CHD) increases.

Gastrointestinal tract

Chronic alcohol consumption, often in connection with malnutrition or tobacco consumption , damages the mucous membranes in the mouth, throat, esophagus and stomach. The most common are inflammations of the esophagus and the lining of the stomach (gastritis). Cancer of the nasopharynx and throat cancer are more common in alcoholics than in the rest of the population; Particularly high-proof drinks are conducive to esophageal cancer . The risk of cancers of the oral cavity and tongue cancers multiplies when smoking and drinking at the same time. In addition, in cirrhosis of the liver , the aforementioned varicose veins in the esophagus, through which many patients bleed to death. In addition, the ammonia produced in the intestinal tract often causes hepatic encephalopathy in the advanced stages of liver cirrhosis , as the damaged liver is no longer able to metabolize toxins regularly.

Nervous system

Chronic alcohol consumption destroys axons such as the myelin sheaths of the brain and the peripheral nervous system . This presumably happens on the one hand through direct damage to the axons due to the cell-toxic properties of alcohol, on the other hand through impairment of myelin formation as a result of a lack of neurotropic vitamins (vitamins of the B group , especially thiamine ). One-sided nutrition, a generally increased need for vitamins and absorption disorders caused by changes in the gastrointestinal system (gastrointestinal tract) are discussed as causes for this .

Memory gaps ("film cracks") occur even with individual noises . In the long term, chronic neuropsychological weaknesses arise in attention , concentration , memory , learning ability , spatial imagination , time perception and problem-solving strategies. In addition, social disorders such as alcoholic jealousy and sexual deviation often develop .

Wernicke-Korsakoff syndrome is a serious long-term consequence in the central nervous system . Typically - often in connection with withdrawal - Wernicke encephalopathy , a neurological disease due to a vitamin B1 deficiency with ophthalmoplegia ( eye muscle paralysis with double vision), ataxia (uncoordinated, often excessive movements, especially when walking) and impaired consciousness occurs . This is followed by memory disorders, which are referred to as amnesic syndrome, Korsakow syndrome or Korsakow psychosis . Characteristic are severe disorders of memory and, increasingly, of long-term memory (especially episodic memory ), with memory gaps often being filled in by confabulations . Anatomically one finds changes in the area of ​​the diencephalon and midbrain .

Also can in chronic alcohol consumption as part of a pellagra , a dementia syndrome arise. The cause is a lack of nicotinic acid (vitamin B3) or tryptophan . Neuropathologically, there are mainly changes in the large neurons of the motor cortex . The basal ganglia , the cerebellum or the anterior horn (cf. cerebral ventricle ) can also be affected. As a result, depressive states, tiredness, reduced concentration, confusion, hallucinations or optic neuropathy can occur, as well as (mostly as a preliminary stage) loss of appetite, diarrhea , glossitis , anemia and reddened skin ( erythema ).

Hepatocerebral degeneration can also occur as a result of alcoholic liver disease . The basal ganglia and the cerebellum are usually affected. The impairments are not reversible.

It often occurs in the course of an alcohol-induced cirrhosis to hepatic encephalopathy . In addition to part of a dementia syndrome, abnormalities such as cerebellar ataxia , dysarthria , tremor and choreoathetosis (extending movements of hands or feet) can appear. The Hepatic encephalopathy is caused by the inability of damaged liver, ammonia regularly to metabolize and other resulting in intestinal harmful substances. In this way, ammonia and other toxins get into the bloodstream unhindered and penetrate the brain through the weakened blood-brain barrier . There it causes the astrocytes to swell , which can lead to the formation of brain edema . In the end stage, hepatic encephalopathy progresses to hepatic coma .

The delayed atrophy of the cerebellum is a common and irreversible degenerative damage to the cerebellum, which preferably occurs in men. Above all, this leads to increasing cerebellar gait ataxia , extremity ataxia (especially of the legs), dysarthria and polyneuropathy. Thiamine deficiency , an immediate toxic effect of alcohol and electrolyte changes are discussed as causes . Neuropathologically, there is often atrophy of the Purkinje cells in the anterior and upper cerebellar worm .

The central pontine myelinolysis is a rare disease that the Pons (part of the brain stem relates). Typical is the relatively rapid development of symptoms of paralysis ( paraparesis , tetraparesis , or pseudobulbar paralysis ) and a significant reduction in consciousness. Wernicke encephalopathy often accompanies this .

The Marchiafava-Bignami disease is also rare disease that occurs mostly in men with chronic alcohol abuse and malnutrition. The corpus callosum is affected . It can seizures , vigilance , spasticity , tremor, frontal disinhibition (z. B. Logorrhoe , aggressiveness ), apathy and apractic disturbances come.

Tobacco-alcohol amblyopia can result from alcohol abuse and malnutrition in combination with tobacco consumption. This results in damage to the optic nerve with loss of visual acuity .

Damage to the cerebral vessels also increases the risk of strokes and cerebral hemorrhage (subcortical sclerosis).

Damage to the spinal cord ( funicular myelosis ) is caused by a lack of vitamin B12 caused by alcoholism.

The polyneuropathy a common chronic neurological disorder in combination with an alcohol abuse. It affects the peripheral nervous system . Initially, the symptoms usually consist of sensory disturbances and abnormal sensations such as tingling, v. a. of the lower extremities (legs), later also with motor restrictions. A value of 60 g of pure alcohol per day is regarded as the limit value for the development of polyneuropathy.

Others

The assumption that a reddened bulbous nose ( rhinophyma ) is causally related to alcohol abuse is common, but erroneous. However, the consumption of alcohol adversely affects the development of rhinophyma due to the vasodilation.

Chronic alcoholism reduces the production of the protein folate transporter 1 in the kidney cells and thus the reuptake of the excreted vitamin folic acid . In addition, the damaged intestine only absorbs a fraction of the folic acid, which is often not sufficiently contained in food anyway. Both factors explain low folate plasma levels in these patients. (Consequence: further metabolic disorders and miscarriages).

An English study (2012) that questioned and examined around 4,000 pregnant women came to the conclusion that even small amounts of alcohol have a negative effect on the intelligence of children.

Diagnosis

Self-assessment

Medical diagnostics are often preceded by the knowledge of the alcoholic or at risk of alcohol that “something is wrong” with their own alcohol consumption. In this phase self-tests can be performed. a. on the Internet or from information material from the advice centers.

Clinical-psychological diagnostics

Four areas of clinical-psychological diagnostics can be distinguished in alcoholics:

1. Screening procedure

Screening procedures are particularly suitable for general practitioners. They can provide initial clues as to whether you have an alcohol problem. They are not sufficient to make a diagnosis; a more differentiated diagnosis is required. In addition, it can be assumed that those affected who do not want to admit their alcohol problem (due to a lack of insight into the disease or a tendency to hide) will not be “discovered”.

  • The AUDIT test (Alcohol Use Disorders Identification Test) was developed by Babor and colleagues in 1992 on behalf of the WHO . It is a pure screening method that uses ten questions to determine mainly personal drinking habits. The AUDIT-C is available as a short version for the family doctor's practice, which only contains the three consumption questions of the AUDIT.
  • The MALT (Munich Alcoholism Test) by Feuerlein and colleagues consists of two parts, a third-party assessment part (laboratory values, withdrawal symptoms, secondary diseases, etc.) and a self-assessment part. It is also suitable for taking anamnesis .
  • The CAGE interview consists of four questions. If there are at least two “yes” answers, this indicates alcohol dependence.
C = Cut down: "Have you tried (unsuccessfully) to limit your alcohol consumption?"
A = Annoyed: "Have other people criticized your drinking behavior and annoyed you with it?"
G = Guilty: "Have you ever felt guilty about your alcohol consumption?"
E = Eye Opener: "Have you ever had a drink right after getting up to 'get going' or to calm down?"

2. Diagnosis of the conditions of origin

  • A more detailed differential diagnosis is possible with the Trier Alcoholism Inventory (TAI). Seven dimensions are mapped here on the basis of 90 questions: "Severity", "Social drinking", "Addicted drinking", "Motives", "Damage" and, in the case of existing partnerships, "Partner problems because of drinking" and "Drinking because of partner problems".
  • The questionnaire on functional drinking (FFT) by Beltz-Weinmann and Metzler (1997) provides information on which social and intrapsychic functions alcohol has taken on, and provides indirect information on the expectations behind it.
  • The Toronto Alexithymia Scale is a suitable tool to distinguish alexithyma from non-alexithymic sufferers.
  • With the help of the Tridimensional Personality Questionnaire (TPQ) from Cloninger , u. a. the personality trait of sensation seeking , which is often present in addicts, is recorded. This roughly corresponds to Cloninger's dimension of novelty seeking .
  • The stress-coping questionnaire (SVF) by Janke and colleagues can be used to record how stressful the person is coping with.
  • In addition, the usual method of keeping a diary in behavioral therapy can be used to record triggers for alcohol consumption . The amount of alcohol consumed, the location or the trigger situation and the personal reaction (thoughts, feelings, behavior) are noted daily.

3. Diagnosis of organic brain diseases

The diagnosis of organic brain diseases and complications such as B. Korsakow's syndrome or hepatic encephalopathy requires (in addition to medical diagnostics) suitable neuropsychological test procedures (e.g. for recording attention and memory performance or executive functions ). The selection of suitable test procedures and their evaluation should be carried out by a diagnostically experienced psychologist or neuropsychologist . For early detection of hepatic encephalopathy , for example, the animal naming test, the number connection test or the handwriting sample provide initial clues.

4. Diagnosis of possible underlying or accompanying mental illnesses

It is not uncommon for an alcoholic illness to be accompanied by another mental illness, such as B. An anxiety disorder , depression, or personality disorder . The diagnosis should also be made using appropriate diagnostic procedures that are available for the particular disease.

Laboratory values

Since the liver is overwhelmed with breaking down alcohol, it is gradually damaged by metabolic products that are no longer completely broken down. This takes place in several stages: First, the fatty liver forms. Only the gamma-glutamyltransferase (γ-GT) is increased. In fatty liver hepatitis , aspartate aminotransferase (GOT / ASAT), aspartate aminotransferase, alanine aminotransferase (GPT / ALAT) (GOT / ASAT) and alkaline phosphatases (AP) also increase. In the event of further damage, liver tissue is progressively and irreversibly submerged or it is converted into non-functional connective tissue . Now all the substances that the liver produces are also reduced, such as albumin , direct bilirubin and coagulation factors synthesized in the liver :

You can prove alcohol consumption (e.g. to clarify the question of guilt after a car accident) by:

  • Direct blood draw or a breath alcohol test a few hours after drinking alcohol
  • increased EtG ↑ ( ethyl glucuronide ), a new, sensitive short-term marker used since 2003. It proves (even one-off low) alcohol consumption up to three days later. This can be used to prove the one-time consumption of half a bottle of beer, even if the person has never drunk alcohol before or after
  • increased CDT ; this is a long-term marker (detectable from the fifth to around the 21st day), with CDT you can detect or estimate the amount of alcohol consumed in the last three weeks
  • Accompanying alcohol analysis for the detection of longer periods of intoxication
  • increased MCV , macrocytic anemia is the result of a diet-related folic acid deficiency

Change model by Prochaska and DiClemente

In their transtheoretical model (TTM), Prochaska and DiClemente postulated five phases that alcoholics go through on the way out of addiction. It is assumed that the exit from the dependency often only succeeds after several attempts. It is a circular model, the cycle can be run through several times.

  1. Pre-contemplation phase : The alcoholic does not consider himself dependent in this phase. Treatment is carried out at most under external pressure, the success of the treatment is unlikely to be permanent (if it does not go into phase 2).
  2. Phase of reflection ( contemplation ) : The person concerned begins to think about his alcohol consumption, weighs the advantages of abstinence (e.g. better liver values, being accepted again) with the costs (e.g. insecurity in society, feelings of loneliness) . This phase is usually associated with great ambivalence, an inner turmoil.
  3. Decision phase (preparation) : A decision is made and behavioral goals for drinking behavior are set, e.g. B. complete abstinence, controlled drinking, or continuing as before. Concrete references to possible courses of action are helpful for those affected in this phase.
  4. Implementation phase (Action) : The decision is put into practice (e.g. detoxification, visiting a self-help group, looking for a “dry” environment). However, these first steps do not say much about the persistence of change.
  5. Maintenance phase : There are first confrontations with difficult "temptation situations" in which the previously made decision can possibly be called into question again. In this phase, the aim is to consolidate the path, to maintain the changes in a stable manner, so that a permanent exit (termination) from the dependency is achieved. Alternatively it comes to relapse (relapse) . The relapse is not seen as a failure, but as a learning opportunity. This presupposes that the person concerned deals with the relapse situation and continues to work actively on the implementation of his decision (abstinence).

treatment

detoxification

The detoxification (alcohol withdrawal) usually takes place in an inpatient setting in a special detoxification station for alcoholics. This has the advantage that a large part of the (possibly life-threatening) withdrawal symptoms can be treated with medication under medical supervision.

In milder cases, outpatient withdrawal treatment is becoming increasingly widespread.

In Germany it is common to use "distraneurine" (active ingredient clomethiazole , not approved in Austria) or a preparation of the benzodiazepine type (such as diazepam , clorazepate ) and often antihypertensive agents from the active ingredient group of imidazolines (such as clonidine ). Sedating tricyclic antidepressants and low- or medium-potency neuroleptics are usually administered as support. In delirium tremens, the patient is given a highly potent antipsychotic, such as haloperidol . As an alternative to clomethiazole or benzodiazepines, the so-called TT scheme is also common, in which the neuroleptic tiapride and the antiepileptic carbamazepine are given. To reduce the risk of seizures, it is recommended the use of antiepileptic drug , which act both clomethiazole itself already antiepileptic and the benzodiazepines. If the patient has survived the withdrawal, his body is detoxified from the alcohol . The addiction as such is therefore not yet sufficient control. This is why long-term therapy is often initiated in the clinic and contact is made with advice centers and self-help groups .

psychotherapy

Framework

The psychotherapeutic treatment can be carried out on an inpatient basis (usually long-term withdrawal therapy) and / or on an outpatient basis.

It is often advisable to consider inpatient treatment prior to outpatient psychotherapy. Inpatient therapy is particularly recommended if the psyche, body or social area are severely disturbed, the patient is not or cannot be adequately supported by his environment, there is no professional integration, the living situation is not secure or the alcoholic is outpatient or partially inpatient Treatment is prone to relapse. Corresponding therapies are usually carried out in special addiction clinics as long-term (10–16 weeks) or short-term therapy.

Outpatient psychotherapies ( psychoanalysis , psychotherapy based on depth psychology and behavioral therapy ) have been taken over by health insurers since 1996 . So far, the prerequisite for outpatient treatment has been medium-term abstinence of at least two to three months. On April 14, 2011, the Federal Joint Committee decided that alcoholics will no longer have to be abstinent in order to begin psychotherapy if abstinence can also be achieved for a short time (i.e. in a maximum of ten treatment hours) without detoxification treatment. At the end of the ten hours of treatment, this must be determined by a medical certificate (which may not be issued by the therapist himself) using "suitable means" (mainly laboratory parameters), otherwise the therapy must be ended. In the event of relapses, appropriate treatment measures must be taken immediately to achieve freedom from addictive substances or abstinence.

The first point of contact for outpatient or inpatient therapy are addiction counseling centers or psychosocial counseling centers. Even health authorities can help.

Motivating conversation

The motivational interviewing (motivational interviewing) is a client-centered, but directive technique for constructing an intrinsic motivation for abstinence. It is therefore particularly important in the phase in which the alcoholic himself has not yet developed any awareness of the problem or is ambivalent about abstinence (see also the section on the model of change according to Prochaska and DiClemente in this article).

Cognitive behavioral therapy

In the treatment of alcoholics, u. a. the following cognitive-behavioral strategies are used:

with alexithymia :

  • cognitive differentiation of feelings
  • Perception and verbalization exercises (experience / emotion-activating measures, finding ways of expression)

at Sensation Seeking :

  • Developing new leisure behavior
  • Look for a stimulus substitute for “drug high ”

Psychoanalysis and psychotherapy based on depth psychology

Psychodynamic psychotherapies assume that unconscious conflicts and deficits in the structural level are the causes of mental illness. The aim of therapy is to compensate for deficits and to make the person concerned aware of their conflicts. Psychoanalytic theories see different causes for addiction. Addiction is often seen as a defense against depression. But psycho-traumatic causes can also support addiction from the perspective of psychoanalysis.

Other psychotherapy methods

Psychoeducation is usually part of every psychotherapy and means informing the patient about his illness and its effects on his body, his psyche and that of those around him as well as the effects on society. The patient's understanding of alcohol sickness is an important prerequisite for combating it. An impending relapse can also be recognized early and better. The motivation increases not to want to harm oneself or others through alcoholism.

Couple and family therapy : The partnership relationship and any existing children have generally suffered severely from human alcoholism. Unreliability, unpredictability and possibly violence as well as codependency have shaken trust and burdened and shaken the family. The therapy not only helps the family to stabilize themselves again, but also helps the alcoholic to offer a safe and stable environment.

Support groups

Self-help groups such as Alcoholics Anonymous , Blue Cross , Guttempler or Kreuzbund have proven themselves for many years . This is where dry and non-dry alcoholics meet at regular intervals to talk about their common problem (and their personal problems). With the Kreuzbund e. V. the family is also included. Self-help groups have a very supportive effect on the success of the therapy. Sometimes they can even be considered as an alternative to traditional therapy, especially if the patient has enough support from family and friends.

Alcohol addiction is always about interaction with other people. These are therefore to be included in the treatment. Life partners, children and possibly colleagues also play an important role in changing your own behavior. There are also self-help groups for relatives and friends of alcoholics, both together with and separately from the self-help offers for alcoholics, such as Al-Anon .

The Alcoholics Anonymous Twelve-Step Program has also found its way into clinics. Its approach is a path to mental recovery through a behavioral, cognitive and spiritual path. In the case of severely dependent persons (as far as one can speak of it) without accompanying mental illnesses, this shows a superiority over cognitive behavioral therapy .

Research history

According to a restrospective analysis of six studies from the 1960s and 1970s, LSD has potential in the context of psychotherapeutic treatment of alcoholic illness. The LSD studies included are, however, to be located earlier than the modern techniques of psychotherapy and therefore cannot be compared with this in terms of their effectiveness.

Since the worldwide ban on the most common hallucinogens as a result of the War on Drugs of former US President Richard Nixon in the 1960s, such psychotherapies have hardly been possible.

Post-acute treatment (weaning therapy)

Post-acute treatments usually include measures to quit alcohol in order to maintain, improve or restore the functionality and productivity of the chronically alcoholic in everyday life and at work. The target group are people with harmful use of alcohol (F10.1) and alcohol dependence (F10.2). However, only 3% of all alcohol addicts come to such therapy. It consists of long-term weaning on the one hand and personality development and social training on the other. For this purpose, a thorough anamnesis of the addiction history and behavior, as well as other accompanying disorders, is first created. Inpatient therapies usually take place in group and occasionally one-on-one discussions. They are carried out by social pedagogues, psychiatrists, psychotherapists, occupational therapists, alternative practitioners and pastors.

The essential and necessary knowledge in therapy is that the state of "non-alcoholism" is an essential prerequisite for "dryness", that the actual dryness is achieved through personal and social development and that this is a lifelong process. In order to make this “life sentence” seem a little less inaccessible, self-help groups like Alcoholics Anonymous advocate resolving not to drink for twenty-four hours at a time.

Practicing psychological psychotherapists can also treat the alcoholic illness as part of a therapy for alcohol-related disorders ( evidence-based guidelines of the Association of Scientific Medical Societies ) .

The therapeutic community refers to the totality of the people involved in the therapy, i. H. Doctors, psychotherapists, nurses, social workers, etc. as well as the patients. They should create a social climate that enables problems to be dealt with.

In practice, daily discussions are held (often in the morning), and group therapy is also very important. The patients are given tasks in everyday clinical practice (setting tables, gardening and the like). Often times, patients also choose a spokesperson to raise their concerns. This promotes personal and external responsibility. The main methods are: therapeutic community, social skills training, self-help group and drug therapy.

Social involvement is essential (e.g. through work, family, circle of friends and acquaintances, self-help group).

The behavioral therapy assumes that behavior is learned. It therefore tries to influence behavior through the knowledge of learning theories . The Cognitive behavioral therapy here is a group of psychotherapy methods that also cognitive contains items. In behavior therapy, some methods are also used for addiction disorders such as alcoholism.

When training social skills , an attempt is made to increase the social and interpersonal skills of a person concerned. Several standardized methods are available for this. The increase in skills in this area is intended to enable those affected to better deal with relationships with others. The skills trained also include dealing with conflicts.

The self-management therapy is to encourage the parties concerned therein even better control its behavior to. It cannot take place in self-treatment (= “self-directed”) - which the terms “self-management” and “ time management ” (= managing one's own person or one's own actions) wrongly suggest.

With the help of the therapist, the patient goes through a defined psychotherapeutic process.

Drugs for alcohol cessation

In alcoholics, the transmission of many messenger substances in the brain is disturbed. For example, the number of glutamate binding sites increases. Therefore, attempts are made to intervene with various drugs to regulate and thus to alleviate the psychological withdrawal symptoms. On the other hand, drugs like disulfiram create an aversion to alcohol.

Acamprosate

Acamprosate ( Campral in D, A, CH) is used as an anti-craving substance. It dampens the over-excitability of the brain caused by excess glutamate and intervenes in the reward system (there is no feeling of reward from alcohol). Acamprosate was significantly more effective than placebo in various studies . However, not all patients respond to it.

Naltrexone

Naltrexone , also an anti-craving substance, is a drug originally used for opioid withdrawal. It was approved for relapse prevention in 2010. It is used successfully. Alcoholics treated with naltrexone remain about 30% more dry than the untreated control group.

Disulfiram

Disulfiram (Antabuse) , which has been in use for a long time, has a different approach . By inhibiting the enzyme aldehyde dehydrogenase , which is needed to break down alcohol, the level of acetaldehyde increases when alcohol is consumed . This causes symptoms of poisoning such as severe headaches and nausea. That should make drinking impossible. The poisoning can also be vitally dangerous.

Baclofen

The muscle relaxant baclofen was first used by the French doctor Olivier Ameisen to treat his own alcohol addiction. Since he was successful with it, he also used it on patients. It is particularly suitable for alcoholics with cirrhosis of the liver, as it is hardly metabolized by the liver.

Antidepressants

It is currently being investigated whether drugs that interfere with the metabolism of the messenger substance serotonin (e.g. serotonin reuptake inhibitors such as fluoxetine ) are suitable for the treatment of alcohol dependence.

Regardless of this, therapy with these makes sense if depression is a concomitant disease. It is irrelevant whether it existed before or was only triggered by alcoholism. A balanced mood is very important for future drought.

Other medical procedures

Researchers are currently hoping for success in combating addiction with the endogenous substance GDNF, which is injected directly into the brain to help stop the craving for alcohol. So far, tests on rats injected with the growth factor have been successful. It is hoped that this knowledge can also be transferred to humans, since alcohol addiction in rats is based on similar processes as in humans. Acupuncture and ear acupuncture are also used to treat addictions . However, there is no scientific proof of its effectiveness. A slight improvement in the success of the therapy was found, but so far this has been attributed to the client's bond with the therapist resulting from acupuncture.

Some researchers also consider the use of medication to be effective because it prevents the euphoria after drinking.

Relapse

Forms of relapse

A distinction can be made between different forms of relapse:

Narrow relapse definition
Here any use of the addictive substance after a phase of abstinence is seen as a relapse.
Dry relapse
The person concerned falls back into his old behavior (e.g. cockiness, volatility, rigid and quick judgments about others) without drinking.
Misstep ( lapse )
Short-term and minor alcohol consumption, which (with serious reflection and connection with abstinence) can remain a one-off incident.
Severe relapse ( relapse )
Relapse into old drinking patterns in terms of amount, drinking frequency and drinking duration.
Creeping relapse
At the beginning there is an attempt to drink in a controlled manner. After an apparent success, however, there is a slip into old drinking habits with increasing physical and psychological withdrawal symptoms.

Causes of relapse

Classic conditioning

According to the concept of classical conditioning , it is assumed that the relapse can be triggered by a conditioned withdrawal symptom . During the period of substance abuse, the physical (withdrawal-related) metabolic disorder (unconditioned stimulus) and the need for alcohol felt during this (unconditioned reaction) are linked to the stimuli that regularly occur in the respective situation (e.g. moods, environmental situations, people). Once this connection has been established (conditioned) , it is sufficient that the alcoholic is exposed to these corresponding stimuli (e.g. certain pub, conditioned stimulus ) so that the need for alcohol ( conditioned reaction , substance craving ) occurs. The physical basis (metabolic disorder) no longer has to be present. The conditioned withdrawal symptom became a discriminative cue (i.e. it was learned that in this situation alcohol consumption leads to the elimination of the negative sensations, see operant conditioning ). This explains why, even after long years of abstinence, relapse can occur in certain situations. However, this theory does not yet provide an explanation for why not every conditioned stimulus automatically leads to renewed consumption and why there is not a relapse with every misstep.

Marlatt and Gordon cognitive-behavioral relapse model

Marlatt and Gordon (1985) assume that relapse does not occur suddenly, but prepares itself over a long period of time. In their model they fall back on concepts of the social cognitive learning theory of Bandura . The model includes the following components that influence the likelihood of relapse:

  1. Confrontation with a risk situation ( high risk situation , e.g. negative feelings, social conflict or social seduction)
  2. Coping strategies (coping response) for dealing with the risk situation
  3. Assessment of one's own abilities to cope with the situation ( expectation of self-efficacy , self-efficacy )
  4. Expectations concerning the direct effect of the alcohol ( earnings expectations , outcome-Expectancies )
  5. Abstinence Violation Effect (abstinence violation syndrome) .

If the person concerned is exposed to a risk situation , he will either cope with it (coping) or not. Coping with them leads to an increased expectation of self-efficacy and an overall lower likelihood of relapse.

If the situation is not coped with, there is a decrease in the self-efficacy expectation to get the situation under control without alcohol. Positive expectations about substance use (e.g. "then I will feel better") are updated and substance use (lapse) occurs . This can lead to problematic psychological processing, the abstinence violation syndrome . The incident (lapse) leads to a contradiction ( cognitive dissonance ) between the self-image of the person concerned (“I want to be abstinent”) and the specific behavior (alcohol consumption). This conflict can only be resolved by changing behavior (abstinence) or self-image (“I'm just a drinker”). In the latter case, one sees oneself as the cause of drinking ( internal attribution : “I am a failure”), which leads to self-esteem, guilt and shame and ultimately an increased likelihood of a complete relapse . However, if the person succeeds in dealing with the misstep “constructively” (e.g. “this is not a catastrophe now, I can learn from it and do it differently next time”), the relapse may possibly occur. U. be caught and become an incident (prolapse) . I.e. there is a return to the path to abstinence. According to Marlatt and Gordon, cognitive factors play a crucial role in relapse prevention.

Another risk factor described is a permanently unbalanced lifestyle , in which the daily stresses are not balanced by stabilizing activities or relief options. This also includes returning to unfavorable habits, such as B. social withdrawal or more frequent TV viewing, which can lead to dissatisfaction and the desire for immediate needs satisfaction.

The model offers various starting points for the prevention of relapses in the context of cognitive-behavioral therapy (e.g. lifestyle changes, learning coping strategies or cognitive restructuring ).

abstinence

Specialized clinics, self-help groups and therapists recommend total abstinence from all alcoholic foods to dry alcoholics, i.e. those who abstain from alcohol, because, according to experience reports, even small amounts of alcohol can trigger the desire for more. In this way the old cycle of dependency can arise anew; sometimes a praline with alcohol is enough. This can happen even after decades of abstinence.

This also applies to " non-alcoholic beer " and other beverages such as wine or sparkling wine that are sold as non-alcoholic . These often contain up to 0.5 percent alcohol; However, this does not need to be declared according to current regulations. In addition, taste and smell as well as the external similarity can trigger a desire for alcohol. An alcohol content of up to 0.5 percent is found as a natural by-product, sometimes unmarked, in fruit juices due to their natural fermentation.

It is also important whether the alcohol is consumed consciously or unconsciously . If the alcoholic decides to eat something even though it contains alcohol, the relapse is more likely than with a pure "accident".

Controlled drinking

Another approach in the treatment of alcoholism is controlled drinking , propagated in the German-speaking area primarily by Joachim Körkel . With a “10-step program” the patient should, among other things, check the general conditions, keep a drinking diary and set his drinking goals.

This approach is widely criticized. The term “controlled drinking” is not clearly defined and is only maintained by two to five percent of addicts for years. Only people who are not yet dependent could achieve this goal with a higher probability. Controlled drinking can therefore not be recommended as a general treatment principle for alcohol addicts.

forecast

An essential prerequisite for the success of therapy is the motivation of the addict. The sooner the alcohol disorder is treated, the better the chance of success. Patients who have a strong desire to stop drinking usually have a far better chance of becoming and remaining abstinent than those who have not yet realized the extent of their alcohol problem. Especially in the first six months after detoxification, the likelihood of relapse is very high. Withdrawal therapy improves the chances considerably. Around 15 percent manage to remain abstinent in the long term, while up to 85 percent of all alcohol-dependent patients who have only been detoxified will relapse. Supportive treatment with medication (anti-craving substances) (see there ) after long-term therapy promises even better results.

Severe relapses make renewed withdrawal with subsequent therapy inevitable. Many patients only achieve stable abstinence after several therapeutic measures.

prevention

In view of the widespread use of alcoholism and its consequences, the first companies developed alcohol prevention programs in the early 1970s . In many, but not yet there are all companies contact, often from among the workforce, as operating addiction workers and addiction officer with appropriate continuing education and training, together with the company doctor work. You can be a partner for confidential discussions, but also be present in disciplinary discussions with employees who have become suspicious and their superiors and advise on how to proceed. For example, the University of Münster has a detailed service agreement on how to proceed in the case of employees with suspicious addictions.

In many European countries there are coordinated awareness campaigns on the subject of alcohol. B. known: "Alcohol? Know your limit!"

World Health Organization experts also found that high alcohol prices reduce alcohol consumption by adolescents (see also: Alcohol abuse among adolescents ). Also binge drinking , i. H. Carousal and excessive binge drinking are thereby reduced. A complete ban ( prohibition ) demonstrably does not solve the problem: Prohibition in the United States has shown that smuggling and illicit distillery can and will undermine this, and that alcohol consumption in illegality is far more difficult to control. The Commission sees the advertising of alcoholic beverages as very problematic. The association with sponsorships and other positive depictions of alcohol also encourage consumption.

Spread and extent of the disease

Worldwide

Years of life lost ( DALYs = disability-adjusted life years ) per million by alcohol abuse according to data of the WHO 2012th
  • 234-806
  • 814 - 1,501
  • 1,551-2,585
  • 2,838 ( India )
  • 2,898- 3,935
  • 3,953-5,069
  • 5,168 ( PR China )
  • 5,173-5,802
  • 5,861-8,838
  • 9,122-25,165
    • Per capita consumption of pure alcohol in liters among people over the age of 15

    Alcohol is the drug that most frequently leads to the development of addiction that requires treatment. In the UK , the number of "dependent drinkers" in 2001 was estimated at over 2.8 million.

    About twelve percent of adults in the US have had problems with alcohol addiction for at least some time in their life. The World Health Organization estimates that around 140 million people around the world are addicted to alcohol. In the United States and Europe, 10 to 20% of men and 5 to 10 percent of women meet the criteria for alcoholism at some point in their life.

    In Russia, the high mortality rate in January is also attributed to alcohol consumption on New Year's Eve, Christmas (7 January) and the days off between New Year's and Christmas. To combat alcoholism, the Russian government issued a ban on the sale of alcoholic beverages between 11 p.m. and 8 a.m. The standard work on alcoholism in Russia is A Contemporary History of Alcohol in Russia by Alexandr Nemtsov.

    Medicine and other sciences agree that alcoholism is a disease. For example, the American Medical Association explicitly names alcohol a drug and judges that drug addiction is a chronic, recurrent disease of the brain, described by obsessively searching for and using the drug despite its often devastating consequences.

    Alcoholism is more common in men than women, but the proportion of women has increased in recent decades.

    European Union

    7.4% of health disorders and premature deaths in Europe are attributed to alcohol. This puts it in third place as the cause of premature death after tobacco consumption and high blood pressure. It is also the leading cause of death among young men in the EU . It is estimated that around 55 million people in the EU consume alcohol in a risky manner (ICD10: F10.1) and another 23 million are dependent . In the region, eleven liters of pure alcohol per capita are drunk twice as much as the global average. The increase in binge drinking ( binge drinking ) among young people between 1997 and 2007 is dramatic. It is also increasingly practiced among adults. According to a survey by the WHO in 2003, over 38% of male drinkers in Poland and 30% of male drinkers in Hungary described themselves as weekly binge drinkers, compared to 24% in Great Britain and only 8.5% in Spain . Alcohol and its sequelae cause around 195,000 deaths annually in this area.

    Germany

    The first (known) wave of high alcohol consumption in Germany was the so-called brandy plague in the 19th century. To this day, consumption has fluctuated and is often underestimated. After the absolute alcohol consumption per capita had decreased at the beginning of the 1990s, it has currently (as of 2014) stabilized at just under ten liters per capita and year. This puts Germany in the top group internationally. The German Central Office for Addiction Issues (DHS) gave the following figures for 2009 (in its 2011 yearbook ): 73,000 premature deaths from alcohol; Annual consumption of pure alcohol per capita (from babies to old men) 9.7 liters. The WHO, on the other hand, indicates an average alcohol consumption of 11.8 liters for 2010. In an international comparison, Germany ranks 23rd worldwide in terms of average alcohol consumption and 19th place in a European comparison.

    According to current estimates, there are between 1.3 and 2.5 million alcohol-dependent people in Germany, 30 percent of them women. Around 9.5 million people consume alcohol in a risky (health-endangering) manner, i.e. consume more than 24 g (men) or 12 g (women) of pure alcohol per day. Around 5.9 million German citizens consume more than 30 g (men) or 20 g (women) daily.

    Sources estimate the number of deaths from alcohol consumption differently. The Federal Statistical Office counted 16,000 deaths from alcohol consumption in 2000; death occurred in 9550 cases from cirrhosis of the liver . The German Red Cross reports 40,000 deaths, including 17,000 from liver cirrhosis. The drug and addiction report 2009 of the drug commissioner of the German federal government even speaks of at least 73,000 deaths as a result of excessive alcohol consumption in Germany (for comparison: drug deaths from illegal drugs = 1477 cases, deaths as a result of tobacco smoking = 110,000 cases).

    According to a study by the Berlin Charité , 58% of all women drink alcohol during pregnancy. 10,000 children are born alcohol-damaged, 4,000 of them with full fetal alcohol syndrome (FAS). It is estimated that around 250,000 children, adolescents and young adults under the age of 25 are at high risk of alcohol or are already dependent. According to a survey from 2008, 6.8% of young people between the ages of 12 and 17 consume alcohol that is risky even for adults.

    In 2002, the Robert Koch Institute estimated the annual economic damage at 20 billion euros; Michael Adams estimates the direct costs of alcohol addiction (treatment costs of the diseases caused) at ten billion euros, the follow-up costs (lost work, early retirement, daily sickness allowance) amount to 16.7 billion euros.

    Other estimates come to 15 to 40 billion euros. This is offset by around 2.2 billion euros in government income from alcohol taxes and around 2.5 billion euros in VAT. The alcohol industry in Germany has a turnover between 15 and 17 billion euros and employs around 85,000 people. The social extent of alcoholism in the elderly was previously underestimated. Due to the increased life expectancy and the demographic development, one cannot assume a self-limiting illness. Worldwide, the death rate from alcohol (including traffic accidents, cancer, etc.) is one in 25. In Europe, one in ten people dies prematurely as a result of alcohol consumption.

    Austria

    The Austrian Institute for Addiction Prevention states that around a quarter of the Austrian population is abstinent. 18% drink to an extent that is harmful to health, five percent of residents over 16 years of age are considered to be chronically alcoholic (a total of ten percent of the population become ill). The latter consume a third of the pure alcohol consumed in Austria. The Federal Ministry of Health, however, says that 7.5% of adult men and 2.5% of adult women are ill with alcoholism.

    In Austria, alcohol is mainly consumed in the form of beer (2016: 102 liters per capita and year) and wine (2016: 28 liters per capita and year).

    Switzerland

    In Switzerland , a study from 2003 showed that 80% of fifteen-year-olds drink alcohol regularly, although the sale of beer and wine is prohibited under the age of 16 and the sale of spirits is prohibited under the age of 18. The Federal Alcohol Administration therefore regularly sends out test buyers.

    The total alcohol consumption has been falling slightly for decades, in 2011 it was 8.5 liters per inhabitant. Alcohol prevention and therapy is largely financed from the so-called alcohol tenth , a portion of the alcohol tax. From 2006 to 2011, an average of 15.1 million Swiss francs (CHF) was invested in addiction prevention and 11.4 million francs in therapy.

    According to information from the Swiss Specialist Office for Alcohol in Lausanne (SFA), the number of alcoholics in Switzerland is around 600,000, which corresponds to 7.7% of the total population, with another 300,000 considered at risk. Medical treatments, therapies and alcohol-related accidents cost around 700 million Swiss francs every year. Half of the alcohol sold was consumed by an eighth of the population. Seventeen percent of the Swiss are abstinent (figures for 2007).

    Connection with the use of other substances

    In longitudinal studies was to investigate whether the probability of alcohol problems with the previous use of other substances is related. Conversely, it was also investigated whether alcohol consumption was related to a change in the likelihood of later use of other substances.

    A study of 27,461 people who had no alcohol problems before using cannabis showed a five-fold increase in the probability of developing alcohol problems in the period up to a second study after three years (increase of 500%) compared to those who did not use cannabis had consumed. In another sample of 2121 people who already had alcohol problems at the time of the first study, the probability that these persisted after three years was 74% higher for cannabis users than for non-users.

    A study of the drug use of approximately 14,500 12th grade students showed that alcohol consumption was associated with an increased likelihood of later use of nicotine, cannabis and other illicit substances.

    literature

    Web links

    Wiktionary: Alcoholism  - explanations of meanings, word origins, synonyms, translations
    Wiktionary: Drunkenness  - explanations of meanings, word origins, synonyms, translations
    Wikiquote: Alcoholism  Quotes
    Wikisource: Drunkenness  - Sources and full texts
    Commons : Alcoholism  - Collection of Pictures, Videos and Audio Files

    Individual evidence

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