Thoughts on the Definition of Alcoholism
There is no specific, universal definition of alcoholism that can be used to identify alcoholics at an early stage. It may be helpful to envision alcoholism not as a static condition, but rather as a pattern in motion. To use a mathematical analogy, alcoholism is not a point, or a point on a line, or a shape, or the simple arithmetic of addition and subtraction. Alcoholism is more like a function in calculus, describing a process in motion. Using a different analogy, the pattern of alcoholism can be compared to cloth patterns of Scottish plaid, which of course we know come in endless variety. When comparing different plaids up close, one sees lines of different thickness and color intersecting at ninety degree angles. But from a distance one can recognize these variations as a common pattern we generically call a plaid.
Continuing with the plaid analogy, the variable elements of lines and colors which compose the plaid are like the human characteristics which compose alcoholism. The lines of a plaid may be thicker or thinner, and of any color imaginable. Similarly, the human characteristics of alcoholism are common yet variable.
Returning to the mathematical analogy of alcoholism as a calculus of a process in motion, we infer that in alcoholism the behavior gradually changes, and the consequences gradually worsen over time. Alcoholism is not a static condition. It is a pattern of alcohol consumption and destructive consequences that develop over time.
From these analogies, a functional definition of alcoholism can be imagined as a process or pattern rather than a specific static condition: Alcoholism is a somewhat variable pattern of behavior involving the consumption of alcohol which is progressively destructive over time.
Patterns and Characteristics
It is common knowledge that certain populations, e.g. the Irish and the American Indian, are more prone to alcoholism than others. It is also well known that alcoholism can be prevalent in certain families. As technologies gradually improve, scientific research will continue to elucidate the nature of the genetic factors at play. Perhaps this is true for some alcoholics and not for others. Perhaps these factors are stronger in some and weaker in others. Suffice it to say that genetic factors do play some role in alcoholism.
Many arbitrary indicators have been used to support a diagnosis of alcoholism. Drinking in the morning, drinking alone, drinking before work, drinking and driving, traffic violations, motor vehicle accidents, missed days at work, a binge pattern of drinking, excessive intoxication, blackouts, fights, injuries, and other such signs are often pointed out by people concerned about another’s alcohol drinking. Because of their widely variable nature, these same signs are easily dismissed by the true alcoholic as variations of normal. However, for the true alcoholic, these are the threads of different thickness and color that are being steadily woven into a human fabric of alcoholism and self destruction.
It is the destructive aspect of alcoholism that makes it a disease. Ethanol, the alcohol we drink, is a chemical that causes direct and permanent injury to many if not all parts of the human body. The physical consequences are perhaps the easiest to observe and measure. Alcoholic liver disease, alcoholic neuropathy, alcoholic cardiomyopathy, and brain manifestations such as delirium tremens and the Wernicke-Korsakoff Syndrome are all common knowledge to the general public, even if they do not know the exact medical terminology. None of these things happen overnight. The twenty-five year old alcoholic does not see this coming in his future. The physical destruction happens insidiously and progressively, and there is no escaping this direct damage to the body.
The progressive destruction also happens in other parts of an alcoholic’s life. There are lost relationships, damage to existing relationships and marriages, lost job opportunities, financial crises, and legal trouble to name a few. Again, these are not unique to alcoholism, so it is common for the true alcoholic to ascribe these things to bad luck, poor choices or persecution.
The emotional aspects of alcoholism are of paramount importance. For each individual alcoholic, emotional factors probably played a key role in the development of alcoholism in the first place. With time and continued alcohol drinking, the emotional makeup predictably worsens. It is common to see depressed alcoholics and angry alcoholics. In fact, a radical change in the basic personality of an alcoholic gradually evolves over time. At twenty-five years old, an alcoholic may be normally social, pleasant, logical, funny, the life of the party. It is difficult for that person to imagine life twenty or thirty years later as a rejected, unreasonable, depressed or angry/bitter alcoholic.
The spiritual destruction caused by alcoholism includes a steady decline in self esteem. This occurs as an alcoholic gradually breaks the external rules of society, deservedly earning a sense of guilt. At the same time and perhaps more importantly, the alcoholic is breaking his own internal set of rights and wrongs, building a powerful sense of shame. With the losses that are typical of alcoholism, feelings of self-pity and resentment are common consequences, as the alcoholic is often loathe to admit the basic diagnosis and to take personal responsibility, but instead tends to externalize the blame. All this serves to gradually alienate the alcoholic, taking away more and more of the normal human experience, the spirit.
What To Do
As a physician, I assume people want to be as healthy as possible for as long as possible. In my work I aim to prevent disease. When that is not possible, the goal is to identify disease at an early stage when treatment is most likely to be effective and beneficial. Since alcoholism is currently not a preventable disease, early detection is the ideal strategy. Actually, that is the easy part. Alcoholism is a disease that is all too obvious to observers of the suffering person. The difficult part is the acceptance of an early diagnosis by the suffering person himself. Alcoholism is created and perpetuated by a complex of forces, including but not limited to genetic, emotional and social. For many if not most alcoholics, alcoholism serves as a temporarily-effective coping mechanism. But over time, the losses and destruction created by alcohol drinking surpass any benefit it may have as a coping mechanism. By then, the alcoholic behaviors and personality are so ingrained that most sufferers never recover.
In my experience, alcoholics and other addicts generally have an opportunity in their young forties, at “midlife,” to more clearly see the big picture, reassess their lives, and make a change for the better. In my experience, this effective resolution unfortunately happens for only a small minority of alcoholics and other addicts. The vast majority miss their opportunity for recovery, and continue on their path to self destruction.
Wellness programs concentrate their efforts and resources on people with a high degree of willingness to change, and the least effort and resources on those with the lowest degree of willingness to change. That strategy has proven to be the most efficient use of our time, effort, energy and resources. In a wellness program, if any effort at all is paid to those with low degrees of willingness to change, it is to at least try to increase that degree of willingness to change. For the alcoholic, we do that by providing honest reality checks at every opportunity, and by providing consistent “tough love” in order to not consciously or subconsciously support the addictive behaviors. The concept that Alcoholism is a somewhat variable pattern of behavior involving the consumption of alcohol which is progressively destructive over time should be pointed out to every alcoholic person who is willing to listen. Acceptance of a definition opens the door to the possibility of effective recovery. To best preserve health and happiness, this acceptance should come at the earliest age possible.
Ferd Crotte, M.D.
February 14, 2012
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