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Alcoholism.
I

INTRODUCTION

Alcoholism or Alcohol Dependence, chronic disease marked by a craving for alcohol. People who suffer from this illness are known as alcoholics. They cannot control their
drinking even when it becomes the underlying cause of serious harm, including medical disorders, marital difficulties, job loss, or automobile crashes. Medical science
has yet to identify the exact cause of alcoholism, but research suggests that genetic, psychological, and social factors influence its development. Alcoholism cannot be
cured yet, but various treatment options can help an alcoholic avoid drinking and regain a healthy life.
People tend to equate any kind of excessive drinking with alcoholism. But doctors and scientists recognize that disorders related to alcohol use lie along a continuum of
severity. They prefer to use the term alcohol dependence instead of alcoholism to designate the most severe of the alcohol-use disorders. The terms alcohol abuse and
problem drinking designate less severe disorders resulting from immoderate drinking.
Alcohol dependence develops differently in each individual. But certain symptoms characterize the illness, according to the National Institute on Alcohol Abuse and
Alcoholism (NIAAA), a United States government agency that is part of the National Institutes of Health. Alcoholics develop a craving, or a strong urge, to drink despite
awareness that drinking is creating problems in their lives. They suffer from impaired control, an inability to stop drinking once they have begun. Alcoholics also become
physically dependent on alcohol. When they stop drinking after a period of heavy alcohol use, they suffer unpleasant physical ailments, known as withdrawal symptoms,
that include nausea, sweating, shakiness, and anxiety (see Drug Dependence). Alcoholics develop a greater tolerance for alcohol--that is, they need to drink increasing
amounts of alcohol to reach intoxication. The World Health Organization (WHO) notes that other behaviors common in people who are alcohol dependent include seeking
out opportunities to drink alcoholic beverages--often to the exclusion of other activities--and rapidly returning to established drinking patterns following periods of
abstinence.

II

PREVALENCE

Alcohol dependence affects a broad cross section of society around the world. Statistics show that alcohol dependence touches successful business executives, skilled
mechanics, laborers, homemakers, and church members of all denominations. Scientists have not identified a typical alcoholic personality, and they cannot predict with
absolute certainty which drinkers will progress to alcohol dependence.
Alcohol use varies depending on an individual's social, cultural, or religious background. Some individuals do not drink at all--about one-third of adults in the United
States who are 18 and older, for example, abstain from alcohol. Others drink as part of social custom. Still others drink frequently and in substantial amounts. Those
suffering from alcohol dependence drink to appease an uncontrolled craving for alcohol or to avoid experiencing the unpleasant symptoms of withdrawal.
WHO estimates that about 76 million people worldwide suffer from alcohol-related disorders. The prevalence of the illness varies in different countries. In the United
States about 15 percent of the population experiences problems related to their use of alcohol. Of these, alcohol dependence affects about 12.5 million men and
women, or almost 4 percent of the population. Men are three times more likely than women to become alcoholics, while people aged 65 and older have the lowest rates
of alcohol dependence.
In the United States, people who start to drink at an early age are at particular risk for developing alcohol dependence. Estimates indicate that 40 percent of people
who begin to drink before age 15 will become alcohol dependent at some point in their lives. These individuals are four times more likely to become alcohol dependent
than those who delay drinking until age 21.
In Canada, an estimated 4 percent of the people aged 15 and older are alcohol dependent, and the number of male alcoholics is double that of females. The highest
rate of this illness occurs in Canadians between the ages of 20 and 24. In Canadian surveys about one in five current and former drinkers admit that their drinking
harmed them at some point in their lives, affecting their jobs or financial position.
Alcohol dependence has reached critical proportions in Russia, where it is estimated that almost a third of all deaths are related, directly or indirectly, to alcohol abuse.
Periodic efforts by the government to control drinking by closing distilleries, breweries, and bars have backfired. Instead of solving the problem, such tactics only
created a widespread black market for liquor--as well as a country of people who hide their drinking problems.
In Asian nations such as Japan, alcohol abuse has become a social concern. In these countries, drinking almost is required when conducting business. Bars are an
extension of offices, places where key decisions are made. A person who declines an invitation to a drink after work risks being passed over for promotion within the
company. Alcohol is readily available in Japan--vending machines along the streets of Tokyo dispense cans of beer and sake.

III

PHYSICAL EFFECTS OF ALCOHOL

Ethyl alcohol, or ethanol, is present in varying amounts in beers and wines, and in distilled liquors such as whiskey, gin, and rum. When a person consumes alcohol, the
stomach and intestines rapidly absorb it. From there alcohol travels in the blood throughout the entire body, affecting nearly every tissue. Moderate and high doses of
alcohol depress the functions of the central nervous system, including the brain. The higher the alcohol level is in the blood, the greater the impairment.
As blood passes through the liver, enzymes break down alcohol into harmless byproducts, which are eliminated from the body six to eight hours later. But the rate at
which alcohol accumulates in the body may be faster than the rate at which the body eliminates it, resulting in rising alcohol levels in the blood. Consequently, alcohol
remains in the body, producing intoxicating effects hours after the last drink was swallowed.
Small amounts of alcohol may relieve tension or fatigue, increase appetite, or produce an anesthetic affect that numbs pain. Larger quantities inhibit or depress higher
thought processes, bolstering self-confidence and reducing inhibition, anxiety, and guilt. As a person becomes intoxicated, painful or embarrassing situations appear less
threatening and, as drinking progresses, speech may become loud and slurred. Impaired judgment may lead to incautious behavior, and physical reflexes and muscular
coordination may become noticeably affected. If drinking continues, complete loss of physical control follows, ending in stupor, and possibly death.

IV

SOCIAL EFFECTS OF ALCOHOLISM

Throughout most of history, society has viewed people who drink to excess as irresponsible, immoral, and of weak character. Punishment of drunkards was considered
necessary to protect the community. By the early 1900s, experts conceded that alcohol dependence may result from tissue changes caused by the action of alcohol.
These changes produce a continued need to drink, such that the individual seeks larger amounts of alcohol at more frequent intervals. However, society still regarded
taking or rejecting a drink as a matter of personal decision, thus all excessive drinking was considered a voluntary act. The individual, therefore, was held responsible
for his or her behavior.

Although a consensus is growing among health professionals that alcohol dependence is a disease, society's attitudes toward individuals with drinking problems remain
ambivalent and confused. Until the mid-20th century, the typical picture of the alcoholic was of someone without steady employment, unable to sustain family
relationships and most likely in desperate financial straits. But this stereotype was largely dispelled when highly respected people publicly admitted their alcohol
dependence and shared their successful recovery stories. Particularly critical in changing the way Americans view alcohol-use disorders were New York broker William
Griffith Wilson (more familiarly known as Bill W.) and Ohio physician Robert Holbrook Smith (Dr. Bob). In 1935 these two recovered alcoholics developed a program to
promote their successful philosophy for recovering from alcohol dependence. The program, which became known as Alcoholics Anonymous, has spread around the
world, helping millions of members to avoid alcohol use and rebuild their lives. In the late 1970s Betty Ford, the wife of former U.S. president Gerald Ford, disclosed her
struggle to recover from alcohol dependence. She helped raise the public's understanding about alcohol dependence through her open, honest revelations and her
creation of a groundbreaking treatment center for substance abusers in Rancho Mirage, California, now known as the Betty Ford Center.
Intoxication threatens not only the individual who drinks but also the surrounding community. Therefore, societies around the world have attempted to control excessive
use of alcohol. Temperance societies in the 19th and 20th centuries pushed for laws ranging from arrest and jail sentences for public drunkenness to prohibition of the
manufacture, distribution, and consumption of alcoholic beverages.
Today experts characterize alcohol-use disorders as a form of illness, and one so widespread that it constitutes a major public health problem. According to WHO,
alcohol dependence and other alcohol-use disorders undermine global health, accounting for 3.5 percent of the total cases of disease worldwide. This figure equals the
hazards posed by unsafe sex and surpasses two other formidable health foes, tobacco and illicit drugs. In the United States alone, the NIAAA estimates that alcoholism
causes losses of more than $185 billion a year in lost productivity, illness, and premature death.

V

DEVELOPMENT OF ALCOHOL DEPENDENCE

Alcohol-use disorders develop in a predictable pattern. Health professionals use three stages to describe this progression. Each stage is defined by a set of symptoms
that are used in early diagnosis and treatment. Most individuals who drink alcohol never progress beyond stage one and are commonly known as social drinkers. In this
stage, individuals drink alcohol primarily as an accompaniment to social situations. Drinking at this stage is not the central focus of a person's activities.
A small percentage of social drinkers progress to stage two. In this early stage of a drinking problem, many people do not show any signs of illness. But often, more
severe problems develop with time and continued heavy drinking. Activities that focus on drinking may take up increasingly larger amounts of time in the person's life,
and as problem drinking progresses the alcoholic's intoxicated behavior may become disagreeable and antisocial. A person may resort to drinking to relieve the physical
discomfort of withdrawal symptoms. Most often, attempts to avoid the discomfort result in morning drinking to offset symptoms that develop after a bout of drinking
the night before.
As drinking continues, drinkers cannot acknowledge that drinking and intoxication have become goals in themselves. Drinking may become a technique for coping with
problems, many of which have been brought about by alcohol use. Drinkers may neglect responsibilities to their family, seriously damaging relationships with their
partners and children. Their productivity at work declines, often resulting in job loss. Despite numerous negative consequences experienced as a result of their drinking,
they remain in denial about their problem. They continue to claim to friends or family that they can stop drinking any time they want to. But in actuality they find it
increasingly difficult to control their alcohol use.
Stage three is the final stage of alcohol dependence. In addition to suffering from many of the problems experienced by individuals in stage two, an individual in stage
three can no longer control his or her drinking. This impaired control, in which the compulsion to drink is overwhelming, is the key identifier that health professionals use
to diagnose people who have progressed to alcohol dependence.

VI

CAUSES

Scientists do not know precisely what causes alcoholism, but most experts suspect that a combination of factors are involved, which may explain why some people who
drink become alcohol dependent while most do not.

A

Physiological Causes

Scientists have explored the chemical action of alcohol among both normal individuals and individuals who suffer from alcohol-use disorders, particularly alcohol
dependence. Some studies suggest that some people may have a physical trait that enables them to drink large quantities of alcohol before feeling its intoxicating
effects. These people have an enhanced tolerance for alcohol. Scientists are unsure if this trait causes excessive drinking or develops as the result of such drinking.
Studies show that alcoholism runs in families--alcoholics are six times more likely than nonalcoholics to have blood relatives who are alcohol dependent. Researchers
have long pondered whether these familial patterns result from genetics or from a common home environment, which often includes alcoholic parents. Studies of twins
attempt to identify if alcohol dependence develops as the result of genetic factors, shared environmental influences, or a combination of both. Laboratory studies
compare the genetic structure in people who are alcohol dependent with those who have no personal or family history of the disease.
Studies of twins in the 1980s showed that patterns of alcohol dependence differed among identical twins, who share identical genes, and fraternal twins, who are
genetically different. If one twin becomes alcohol dependent, an identical twin is more likely to develop alcohol dependence than a fraternal twin. While these studies
suggest that a genetic factor plays a role in alcohol dependence, the results are difficult to interpret. Many of these studies assumed that all twins share a similar home
environment. But more recent studies revealed that the home environments of identical twins are more alike than the environments of fraternal twins. That is, as
children, identical twins are more likely than fraternal twins to play and study together and to share friends. And as adults, identical twins are more likely than fraternal
twins to stay in close contact with each other, possibly resulting in the development of similar behaviors. Scientists are conducting further twin studies that take into
account differences in home environments.
Scientists now recognize that alcoholism is a polygenic disease--that is, many genes are involved in increasing an individual's risk for developing alcohol dependence. In
addition to family studies that establish a broad genetic influence on alcoholism, scientists perform laboratory studies to try to identify the specific genes involved in the
development of alcohol dependence. One method scientists use is to look for genetic markers related to alcoholism. A genetic marker is a gene that produces an
observable trait and has a known location on a chromosome, the rod-shaped structures that carry genes. Once scientists have identified genetic markers, they attempt
to determine if the markers are inherited in people with alcoholism. If the marker is inherited along with alcoholism, scientists know that the genes that cause alcoholism
are likely located close to the genetic marker on the chromosome.
In 1998 researchers moved closer to the goal of finding the genes for alcoholism when they identified locations on four chromosomes where these genes are likely to
be. Some experts speculate that these genes may not be specific for alcohol dependence, but rather may determine temperament or personality traits that increase a
person's vulnerability to alcohol-use disorders.

B

Environmental Causes

Scientists recognize that alcohol-use disorders likely results from a complex interaction of biological influences and environmental factors. Environmental factors that
may affect the development of the disease include personal behavioral skills, peer influences early in life, parental behavior, societal and cultural attitudes toward alcohol
use, life stress, and availability of alcoholic beverages. Once a person has established a drinking pattern, environmental factors combined with physical changes induced
by heavy drinking may reinforce the continued use of alcohol.

C

Psychological Influences

Many experts believe that a loss of control over drinking is as much psychological as it is physiological. Studies show that alcohol-dependent individuals will drink
excessive amounts of a nonalcoholic beverage if they believe it contains alcohol. Moreover, when they are given an alcoholic beverage that they believe is alcohol-free,
their drinking behavior is similar to that of persons not dependent on alcohol.
Many drinkers develop a psychological condition known as denial, in which they are unable to acknowledge that alcohol use lies at the root of many of their problems.
Denial was long thought to be a personality trait shared by all persons who suffer from alcohol-use disorders. Recent research suggests that denial may be a
psychological response to negative feedback people receive about their drinking. Some studies indicate that when approached with objective information about their
drinking and its consequences in an empathetic and nonconfrontational manner, many persons with significant drinking problems do not demonstrate denial.

VII

HEALTH CONSEQUENCES

While some studies have found that moderate use of alcohol has beneficial health effects, including protection from coronary heart disease, heavy and prolonged intake
of alcohol can seriously disturb body chemistry. Heavy drinkers lose their appetite and tend to obtain calories from alcohol rather than from ordinary foods. Alcohol is
rich in calories and can provide substantial amounts of energy. However, if it constitutes the primary source of calories in place of food, the body will lack vitamins,
minerals, and other essential nutrients.
Prolonged use of large amounts of alcohol may cause serious liver damage. In the first stage of liver disease caused by alcohol, fat accumulates in the liver. This stage
of the disease is known as fatty liver. Most people do not notice symptoms of fatty liver, although in some people the liver becomes enlarged and tender. Some people
with fatty liver develop hepatitis, which inflames and kills liver cells. Hepatitis is marked by jaundice, which gives a yellowish tint to the eyes and skin. Others may
develop cirrhosis, an irreversible condition in which normal liver tissue is replaced by scar tissue. The scarring prevents blood from traveling freely through the liver,
building blood pressure in the veins that run from the intestine to the liver. Consequently, the liver can no longer process toxins efficiently, causing poisons to build up
in the blood. This buildup can be fatal.
Heavy drinking also damages heart muscle. Nearly half of all cases of cardiomyopathy are caused by alcohol abuse. In this heart disease, the heart muscles, particularly
the right and left ventricles, enlarge and become flabby, reducing the heart's blood-pumping efficiency. This inefficiency reduces the flow of blood through the kidneys,
which normally filter excess salts and water out of the blood. Eventually the blood volume rises, causing a potentially fatal backup of fluid in the lungs.
Alcoholics tend to have high blood levels of the hormone epinephrine and deficiencies of the mineral magnesium. This combination produces severe arrhythmias, or
heartbeat irregularities, a common cause of sudden death in heavy drinkers. Chronic drinkers typically develop hypertension, a leading cause of stroke.
In some cases, alcohol withdrawal may lead to delirium tremens (DTs), which produces increasing confusion, sleeplessness, depression, and terrifying hallucinations. As
this delirium progresses, the hands develop a persistent and uncontrollable shaking that may extend to the head and body.
Women who drink excessive amounts of alcohol while pregnant run a high risk of having a baby born with fetal alcohol syndrome (FAS), the leading known cause of
birth defects. FAS results in a combination of mental and physical defects, such as retardation, a small head, and poor muscle tone. Some babies exposed to alcohol
during fetal maturation develop fetal alcohol effect (FAE), which produce more subtle symptoms, including behavioral problems, difficulty paying attention, or the
inability to think abstractly.

VIII

TREATMENT

The best methods to treat alcohol dependency vary, depending upon an individual's medical and personal needs. Some heavy drinkers who recognize their problem
appear to recover on their own. Others recover through participation in the programs of Alcoholics Anonymous or other self-help groups. Some alcoholics require longterm individual or group therapy, which may include hospitalization. And still others do not seek treatment at all. These people do not seek treatment as the result of a
combination of factors, including ignorance of the symptoms of alcohol-use disorders, the social stigma that still surrounds these disorders--that is, the fear of being
labeled an alcoholic--and an unwillingness to accept lifetime abstinence from alcohol as a treatment goal.
Numerous studies indicate that simple, brief interventions can be effective in changing drinking behavior in those who are not severely alcohol dependent. In brief
interventions, a problem drinker meets with a health professional for one to four sessions, with each session lasting from a few minutes to an hour. During these
meetings, the health professional makes the person aware that his or her current drinking patterns or medical problems are related to alcohol abuse and could progress
to alcohol dependence. Using a warm, reflective, and understanding style of delivery, the health professional employs a variety of strategies to encourage the individual
to change his or her drinking behavior. The goal of brief interventions typically is to help people moderate their drinking rather than resort to complete abstinence. Brief
interventions also have been used to motivate alcoholics to enter specialized treatment programs and work toward complete abstinence from alcohol.
For some alcoholics, treatment begins with detoxification, which safely rids the patient's body of alcohol while treating any physical complications that develop from
severe withdrawal symptoms, such as delirium tremens. Detoxification normally requires less than a week, during which time patients usually stay in a specialized
residential treatment facility or a separate unit within a general or psychiatric hospital. These facilities also offer extended treatment programs to help alcoholics in their
recovery effort.
Recovery also may involve individual counseling and group therapy to help a person who is alcohol dependent adapt to a new way of life, one that is not driven by
alcohol. Throughout the United States and Canada, public outpatient and inpatient clinics offer a variety of treatments for alcoholics. The National Council on Alcoholism
and Drug Dependence (NCADD) has affiliates in many cities that help people who are alcohol dependent find appropriate treatment programs. Many public mental
hospitals and Veterans Administration hospitals, as well as private clinics and hospitals, treat alcohol dependence.
Physicians may prescribe medications to help prevent alcoholics from returning to drinking once they have stopped. The drug disulfiram (sold under the trade name
Antabuse), interferes with the way the body processes alcohol. Taken in pill form daily, this medication generally has no noticeable effects until a person drinks alcohol.
The alcohol and drug interact to produce an extremely unpleasant reaction, including nausea, dizziness, headache, heart palpitations, and other problems. Alcoholics
then associate illness with drinking and, in many cases, avoid alcohol use. Naltrexone (ReViva) is a narcotic approved for use in alcohol treatment in 1995. Although

scientists are not certain how this medication works in the brain, it reduces an alcoholic's craving for alcohol, most likely by blocking the positive effects the individual
gets from drinking alcohol. Naltrexone is most effective when it is used in combination with counseling programs. Acamprosate (trade name, Campral) is used to help
alcoholics maintain abstinence once they have ceased drinking. Scientists believe it works by restoring balance among the chemicals that enable brain cells to
communicate with one another. Alcohol dependence disrupts this balance.
Most treatment programs effectively help alcohol-dependent persons stop drinking for a period, but they are less successful in preventing a subsequent return to
drinking. Treatment programs typically contain a component that focuses on helping alcoholics understand the situations, feelings, and interpersonal interactions that
trigger drinking. These programs teach people how to cope with these factors without returning to drinking.
In addition to formal treatment programs, other widely available community resources include vocational rehabilitation, family guidance, and religious counseling. Many
countries, including Poland, Finland, and South Africa, and some U.S. states have compulsory treatment programs for alcoholics who have committed crimes. Mutualhelp organizations, such as Alcoholics Anonymous and Rational Recovery, provide a free and effective method to cope with recovery.

A

Alcoholics Anonymous

Until the mid-1930s, alcohol-dependent individuals who could not afford a private sanitarium or psychiatrist could find help only at state hospitals, in jails, or through
street ministries. The formation of Alcoholics Anonymous (A.A.) in 1935 marked the first nonmedical approach that made sustained recovery from alcohol dependence
possible for many individuals. Today nearly 2 million people worldwide claim membership in A.A.
The A.A. program promotes psychological principles that help people live a healthy, stress-free lifestyle. The organization functions through local groups that have no
constitutions, officers, or dues. Anyone who has a drinking problem may become a member, provided he or she is willing to abstain from alcohol and make an honest
attempt to live by the principles outlined by the organization.
In A.A. meetings the individual learns that he or she suffers from a disease. Any feelings of unworthiness the individual feels are dispelled by supportive group
interaction. A.A. offers a twelve-step program to recovery. The twelve-step program confronts the problem of denial by urging alcoholics to admit that their drinking has
made their lives unmanageable. The program also calls for alcoholics to atone for the harm caused by their alcoholism, to commit themselves to live ethically and spread
the A.A. message to others, and to rely on a higher power greater than their own will. Mutual help groups for family members of alcoholics include Alateen, which serves
teenagers, and Adult Children of Alcoholics. Al-Anon is a mutual help group open to friends and family of alcoholics (see Al-Anon Family Groups).

B

Other Recovery Approaches

While Alcoholics Anonymous is widely recognized as an effective source of support, not everyone responds to the group's spiritual bent. Other recovery approaches
include national organizations such as Rational Recovery and Secular Organizations for Sobriety/Save Our Selves (SOS).
Rational Recovery was developed in 1986 for people who find the A.A. approach unappealing. Rational Recovery promotes lifelong abstinence from alcohol and teaches
people how to recognize what is called an addictive voice, the thoughts and feelings that promote alcohol use. By identifying the addictive voice and separating from it,
people seeking to avoid alcohol can learn to avoid the actions the addictive voice instigates.
Secular Organizations for Sobriety/Save Our Selves (SOS) uses peer-group support to promote abstinence. In these support sessions, recovery is separated from
spirituality--individuals are encouraged to rely on themselves and others in the group, not a spiritual power, to gain sobriety. LifeRing is another organization that uses
support groups and a secular philosophy to help people overcome their problems with alcohol.

IX

PREVENTION OF ALCOHOL DEPENDENCE

A concerted effort by many public health organizations may in time enable society to readily identify early signs of problem drinking and encourage people to accept
early intervention before the condition worsens. Many agencies seek to improve public understanding about this illness, including the NIAAA, the Substance Abuse and
Mental Health Services Administration, the National Clearinghouse on Alcohol and Drug Information, Health Canada, and the Canadian Center on Substance Abuse.
Advertising campaigns, newspaper articles, feature stories in magazines, and motion picture and television presentations that call attention to the problem help lessen
any social stigma still attached to the disease. Schools and colleges sponsor programs that help students to recognize the symptoms of alcohol dependence and to know
how to get help when drinking becomes a problem. As the public becomes more aware of the health and social consequences of the disease, the incidence of alcohol
dependence may decrease, and earlier and better treatments may lead to higher recovery rates.

Reviewed By:
Brenda G. Hewitt
Enoch Gordis
Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.

« Although a consensus is growing among health professionals that alcohol dependence is a disease, society’s attitudes toward individuals with drinking problems remainambivalent and confused. Until the mid-20th century, the typical picture of the alcoholic was of someone without steady employment, unable to sustain familyrelationships and most likely in desperate financial straits. But this stereotype was largely dispelled when highly respected people publicly admitted their alcoholdependence and shared their successful recovery stories. Particularly critical in changing the way Americans view alcohol-use disorders were New York broker WilliamGriffith Wilson (more familiarly known as Bill W.) and Ohio physician Robert Holbrook Smith (Dr. Bob). In 1935 these two recovered alcoholics developed a program topromote their successful philosophy for recovering from alcohol dependence. The program, which became known as Alcoholics Anonymous, has spread around theworld, helping millions of members to avoid alcohol use and rebuild their lives. In the late 1970s Betty Ford, the wife of former U.S. president Gerald Ford, disclosed herstruggle to recover from alcohol dependence. She helped raise the public’s understanding about alcohol dependence through her open, honest revelations and hercreation of a groundbreaking treatment center for substance abusers in Rancho Mirage, California, now known as the Betty Ford Center. Intoxication threatens not only the individual who drinks but also the surrounding community. Therefore, societies around the world have attempted to control excessiveuse of alcohol. Temperance societies in the 19th and 20th centuries pushed for laws ranging from arrest and jail sentences for public drunkenness to prohibition of themanufacture, distribution, and consumption of alcoholic beverages. Today experts characterize alcohol-use disorders as a form of illness, and one so widespread that it constitutes a major public health problem. According to WHO,alcohol dependence and other alcohol-use disorders undermine global health, accounting for 3.5 percent of the total cases of disease worldwide. This figure equals thehazards posed by unsafe sex and surpasses two other formidable health foes, tobacco and illicit drugs. In the United States alone, the NIAAA estimates that alcoholismcauses losses of more than $185 billion a year in lost productivity, illness, and premature death. V DEVELOPMENT OF ALCOHOL DEPENDENCE Alcohol-use disorders develop in a predictable pattern. Health professionals use three stages to describe this progression. Each stage is defined by a set of symptomsthat are used in early diagnosis and treatment. Most individuals who drink alcohol never progress beyond stage one and are commonly known as social drinkers. In thisstage, individuals drink alcohol primarily as an accompaniment to social situations. Drinking at this stage is not the central focus of a person’s activities. A small percentage of social drinkers progress to stage two. In this early stage of a drinking problem, many people do not show any signs of illness. But often, moresevere problems develop with time and continued heavy drinking. Activities that focus on drinking may take up increasingly larger amounts of time in the person’s life,and as problem drinking progresses the alcoholic’s intoxicated behavior may become disagreeable and antisocial. A person may resort to drinking to relieve the physicaldiscomfort of withdrawal symptoms. Most often, attempts to avoid the discomfort result in morning drinking to offset symptoms that develop after a bout of drinkingthe night before. As drinking continues, drinkers cannot acknowledge that drinking and intoxication have become goals in themselves. Drinking may become a technique for coping withproblems, many of which have been brought about by alcohol use. Drinkers may neglect responsibilities to their family, seriously damaging relationships with theirpartners and children. Their productivity at work declines, often resulting in job loss. Despite numerous negative consequences experienced as a result of their drinking,they remain in denial about their problem. They continue to claim to friends or family that they can stop drinking any time they want to. But in actuality they find itincreasingly difficult to control their alcohol use. Stage three is the final stage of alcohol dependence. In addition to suffering from many of the problems experienced by individuals in stage two, an individual in stagethree can no longer control his or her drinking. This impaired control, in which the compulsion to drink is overwhelming, is the key identifier that health professionals useto diagnose people who have progressed to alcohol dependence. VI CAUSES Scientists do not know precisely what causes alcoholism, but most experts suspect that a combination of factors are involved, which may explain why some people whodrink become alcohol dependent while most do not. A Physiological Causes Scientists have explored the chemical action of alcohol among both normal individuals and individuals who suffer from alcohol-use disorders, particularly alcoholdependence. Some studies suggest that some people may have a physical trait that enables them to drink large quantities of alcohol before feeling its intoxicatingeffects. These people have an enhanced tolerance for alcohol. Scientists are unsure if this trait causes excessive drinking or develops as the result of such drinking. Studies show that alcoholism runs in families—alcoholics are six times more likely than nonalcoholics to have blood relatives who are alcohol dependent. Researchershave long pondered whether these familial patterns result from genetics or from a common home environment, which often includes alcoholic parents. Studies of twinsattempt to identify if alcohol dependence develops as the result of genetic factors, shared environmental influences, or a combination of both. Laboratory studiescompare the genetic structure in people who are alcohol dependent with those who have no personal or family history of the disease. Studies of twins in the 1980s showed that patterns of alcohol dependence differed among identical twins, who share identical genes, and fraternal twins, who aregenetically different. If one twin becomes alcohol dependent, an identical twin is more likely to develop alcohol dependence than a fraternal twin. While these studiessuggest that a genetic factor plays a role in alcohol dependence, the results are difficult to interpret. Many of these studies assumed that all twins share a similar homeenvironment. But more recent studies revealed that the home environments of identical twins are more alike than the environments of fraternal twins. That is, aschildren, identical twins are more likely than fraternal twins to play and study together and to share friends. And as adults, identical twins are more likely than fraternaltwins to stay in close contact with each other, possibly resulting in the development of similar behaviors. Scientists are conducting further twin studies that take intoaccount differences in home environments. Scientists now recognize that alcoholism is a polygenic disease—that is, many genes are involved in increasing an individual’s risk for developing alcohol dependence. Inaddition to family studies that establish a broad genetic influence on alcoholism, scientists perform laboratory studies to try to identify the specific genes involved in thedevelopment of alcohol dependence. One method scientists use is to look for genetic markers related to alcoholism. A genetic marker is a gene that produces anobservable trait and has a known location on a chromosome, the rod-shaped structures that carry genes. Once scientists have identified genetic markers, they attemptto determine if the markers are inherited in people with alcoholism. If the marker is inherited along with alcoholism, scientists know that the genes that cause alcoholismare likely located close to the genetic marker on the chromosome. In 1998 researchers moved closer to the goal of finding the genes for alcoholism when they identified locations on four chromosomes where these genes are likely tobe. Some experts speculate that these genes may not be specific for alcohol dependence, but rather may determine temperament or personality traits that increase aperson’s vulnerability to alcohol-use disorders. »

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