The Biology of Alcoholism: Volume 6: The Pathogenesis of Alcoholism Psychosocial Factors

717 Pages·1983·17.73 MB·English

by  Robert Straus (auth.)

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.