The Biology of Alcoholism: Volume 6: The Pathogenesis of Alcoholism Psychosocial Factors PDF
Preview The Biology of Alcoholism: Volume 6: The Pathogenesis of Alcoholism Psychosocial Factors
THE PATHOGENESIS OF ALCOHOLISM PSYCHOSOCIAL FACTORS THE BIOLOGY OF ALCOHOLISM Volume 1: Biochemistry Volume 2: Physiology and Behavior Volume 3: Clinical Pathology Volume 4: Social Aspects of Alcoholism Volume 5: Treatment and Rehabilitation of the Chronic Alcoholic Volume 6: The Pathogenesis of Alcoholism Psychosocial Factors Volume 7: The Pathogenesis of Alcoholism Biological Factors THE PATHOGENESIS OF ALCOHOLISM PSYCHOSOCIAL FACTORS Edited by Benjamin Kissin and Henri Begleiter Downstate Medical Center Brooklyn, New York PLENUM PRESS. NEW YORK AND LONDON Library of Congress Cataloging in Publication Data Main entry under title: The Pathogenesis of alcoholism (The Biology of alcoholism; v. 6) Bibliography: p. 1. Alcoholics - Psychology. 2. Alcoholism - Social aspects. I. Kissin, Benjamin, 1917- . II. Begleiter, Henri. III. Title. IV. Series. [DNLM: 1. Alcoholism-Periodicals. WI BI852JM] RC565.B52 1971 vol. 6 616.86/1071 82-19029 ISBN-13: 978-1-4684-4276-2 e-ISBN-13: 978-1-4684-4274-8 001: 10.1007/978-1-4684-4274-8 © 1983 Plenum Press, New York A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y. 10013 Softcover reprint of the hardcover 1s t edition 1983 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher Contributors Gordon E. Barnes, Departments of Psychiatl)' alld Psycholvgy, Universit), vf Manitoba, Winnepeg, Manitoba, Canada Jane Duby, Alcohol Research Coordinator, Veterans Administration Medical Center, La]o lla, California Ulrich Gohike, Resource Policy Center, Thayer School of Engineering, Dart mouth College, Hanover, New Hampshire Andrew M. Greeley, Department of Sociology, University of Arizona, Tucson, Arizona John E. Helzer, Washington University School of Medicine, Department of Psychiatry, St. Louis, Missouri Robert Landeen, Department of Psychiatry, Dartmouth Medical School, Han over, New Hampshire Arnold M. Ludwig, Department of Psychiatry, University of Kentucky College of Medicine, Lexington, Kentucky William C. McCready, Department of Sociology, School of Svcial Service Administration, University of Chicago, Chicago, Illinois Dennis Meadows, Resource Policy Center, Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire Peter Park, Department of Sociology, University of Massachusetts, Amherst, Massachusetts Anne Robertson, Department of Psycholog)', UniversitJ of Wisconsin-Mil waukee, Milwaukee, Wisconsin. v vi Contributors Robin Room, Alcohol Research Group, Institute of Epidemiology and Behav ioral Medicine, Medical Research Institute of San Francisco, Berkeley, California Marc A. Schuckit, Alcohol Treatment Program, Veterans Administration Med ical Center, and Department ofP sychiatry, School ofM edicine, University of California, La Jolla, California Jan Simpkins, Addiction Research Foundation, Toronto, Ontario, Canada Joel Solomon, Department of Psychiatry, State University of New York, Down state Medical Center, Brooklyn, New York Peter Steinglass, Center for Family Research and Department of Psychiatry and Behavioral Sciences, George Washington University School of Med icine, Washington, D.C. Richard Stivers, Department of Sociology, Anthropology, and Social Work, Illinois State University, Normal, Illinois Robert Straus, Department of Behavioral Science, College of Medicine, Uni versity of Kentucky, Lexington, Kentucky John R. Taylor, Washington University School of Medicine, Department of Psychiatry, St. Louis, Missouri Gary Thiesen, Department of Sociology, University of Iowa, Iowa City, Iowa Paul C. Whitehead, Department of Sociology, Universit.v of Western Ontario and Addiction Research Foundation, London, Ontario, Canada Preface Pathogenesis is defined in Blakiston's Medical Dictional), as "the course of development of disease, including the sequence of processes or events from inception to the characteristic lesion or disease." The central position of the word "pathogenesis" in the titles of Volumes 6 and 7 in itself connotes a bias on the part of the editors in favor of the disease concept of alcoholism, inasmuch as the end product of the pathogenetic process is presumed to be a disease. But the disease model as here conceptualized is vastly different from that of Jellinek, or of Alcoholics Anonymous, or of psychoanalysis. In those theories, alcoholism is seen as the inevitable consequence of some specific flaw in the heredity or the experience of the afflicted individual that inexorably leads to alcoholism. In these present volumes, the alcoholic syndrome is viewed rather as the outgrowth of the interaction of a variety of biological, psychological, and social influences which, depending on the predom inance of one or another, may lead to different types of alcoholism. This view, which has been labeled the bio-psycho-social perspective, encompasses a larger view of the dynamics of the development of alcoholism, incorporating data from each of the phenomenologic levels involved. An additional complication arises from the fact that the physiolog ical and psychosocial stigmata of alcoholics, which are probably most often the result of prolonged drinking, frequently have come to be considered as causes of the disease. This is an inaccurate interpretation vii viii Preface based on the pseudoscientific fallacy that multiple correlations must signify causality. On the contrary, there is increasing evidence that some of the pathological mechanisms that evolve during the development of alcoholism exercise an exacerbating feedback effect on the very pro cesses that first led to the initiation of heavy drinking patterns, contrib uting strongly to the accelerated development of those patterns. Thus, three different classes of mechanisms must be distinguished from among the many aberrational phenomena associated with alcoholism: (1) predisposing influences that lead to the initiation of heavy drinking, (2) cyclical feedback processes that develop as a consequence of drinking but also exacerbate the drinking pattern, and (3) physiological and psychosocial stigmata of alcoholism that probably do not contribute significantly to the perpetuation of drinking. Unfortunately, differentiating among these various findings con cerning which is cause, which is effect, and which is both cause and effect is not an easy task. Part of the difficulty arises from the high number of aberrational variations in physiological and psychosocial function that have been described for alcoholics. Mark Keller, longtime editor of the Quarterly Journal of Studies on Alcohol, once propounded Keller's Theorem, which held that any study comparing any group of alcoholics with a control group on any variable would find statistically significant differences. This thesis may possibly be an exaggeration but it accurately describes the nature of the problem. Given the wealth of aberrational variables in all three phenomen ological spheres-the biological, the psychological, and the social-and given the difficulty in differentiating among those effects that are causes and those that are consequences, it becomes all too easy to present one or more theories of the pathogenesis of alcoholism-whether biological, psychological, or social-and to find evidence to support them. What is clearly needed is a theoretical frame of reference in which all these processes, and particularly the interactions among them, may be con sidered and tested. In the absence of any real evidence that all the abbe rational effects can be explained by postulating pathological mech anisms in only one of the three levels of phenomenological function, it is incumbent on us to carefully consider all three. Furthermore, since each of these levels of function is presumed to present more or less similar behavioral operations which differ mainly in their phenomen ologic expression, it is important to consider them within either an equivalency or an interactional context. One view of the bio-psycho-social perspective (Kissin and Hanson, 1982) postulates that alcoholism is a progressive condition with domi nance of different influences at different stages of the syndrome. In ix this formulation, people differ in the degree of their susceptibility to the development of alcoholism. This special vulnerability may be in either the social, psychological, or biological makeup, or in some combination of these. Given some pattern of increased vulnerability, the individual at risk will begin to drink more heavily, influenced at the beginning mainly by social factors. Of these "heavy drinkers," a certain proportion who are psychologically predisposed will develop a "psycho logical dependence" on alcohol and become "problem drinkers." A subsample of problem drinkers, either because of excessive intake of alcohol or because of increased constitutional susceptibility, or both, will develop a "physical dependence" that exhibits all the cyclic feedback of addictive disorders; at this point, they may be designated as "alco holics." The sequence of events in the progression from heavy drinking to alcoholism is illustrated in Figure 1. In this formulation, problem drinkers may possibly revert to heavy drinking or even to social drinking. This may explain the success of some controlled drinking programs with such individuals. However, once significant physical dependence with all of the self-reinforcing cyclic mechanisms of full blown alcoholism have developed, clinical experience suggests that controlled drinking is no longer a viable treatment goal. The interactional paradigm, with its particular emphasis on the feedback-feedforward relationship of cause and effect, is best repre sented in a computer model of alcoholism utilizing social, psychological, ABSTINENCE FIGURE 1. Progression of alcoholism. x Preface and biological mechanisms and the interactions among them. Such a model is presented in Chapter 13 of this volume. Earlier chapters outline in detail the social and psychological factors that went into the formulation of the working equations for that computer model. The nature of the biological mechanisms of alcoholism will be described in the next volume. It would be pretentious to assume that all or even most of the processes involved in the pathogenesis of alcoholism can be described in this present work. Our knowledge of the operating influences that contribute to the initiation and perpetuation of heavy drinking is still too meager to allow any such major synthesis. Indeed, aside from an insufficiency of information, our information may suffer from other assumptions we have made, particularly that of the bio-psycho-social perspective. Nevertheless, some coherent frame of reference is necessary in which the complex interactions among the multiple variables may be considered and tested. It would certainly have been preferable in 1971 to have begun the series The Biology of Alcoholism with two volumes on pathogenesis, but unfortunately at that time there was still too little data to support such an effort. Most of the material in Volumes 6 and 7 is new or, at the very least, recent. It is a tribute to the rapid strides that are being made in the scientific investigation of alcoholism that a comprehensive, coherent work such as this has become possible. There is sometimes an under standable pessimism about our inability to deal effectively with the clinical problems of alcoholism. Certainly a better understanding of the mechanisms involved in the pathogenesis of alcoholism should help us to address in a more rational manner both the prevention and the management of this ubiquitous condition. Benjamin Kissin Henri Begleiter New York REFERENCES Kissin, B., and Hanson, M., 1982, The bio.psycho.social perspectives in alcoholism, ill "Alcoholism and Clinical Psychiatry" (J. Solomon, ed.), pp. 1-19, Plenum Press, New York.
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