! Trigger warning - don't continue reading if it's too much !
When people say “alcoholic” a certain image comes to mind: a weak-minded person with no willpower. That they are abusive, aggressive, and should be kept away from “us” for our own safety. However, that isn’t an accurate description of people who suffer from Alcohol Use Disorder. Stereotypes about them may prevent them from getting professional help. So, actually what is Alcohol Use Disorder? How do people experience it? Learning together about this disorder helps us become more sympathetic to those affected by it, and dismantle the current persisting stigmas.
This article will cover:
- What is alcohol use disorder?
- Implications
- Classical (Pavlovian) conditioning
- Incentive-sensitization theory
What is Alcohol Use Disorder?
Alcohol use disorder is diagnosed when one’s patterns of alcohol use has significant negative impacts in everyday-life functioning and causes significant distress [2,7].
According to the DSM-5, the individual should have at least 2 of the following symptoms to be diagnosed [2]:
From these criteria, it is clear that alcohol use disorder is defined by behavioural and physical symptoms, which can include withdrawal, tolerance, and cravings [2].
Alcohol withdrawal is characterised by withdrawal symptoms that develop approximately 4-12 hours after the reduction of intake following prolonged, heavy alcohol ingestion[2]. Since withdrawal symptoms can be very unpleasant, individuals consume more alcohol despite adverse consequences, in order to avoid or to relieve withdrawal symptoms. This creates the problem of consuming more alcohol, even though individuals might be aware of the negative consequences of it.
Craving for alcohol is indicated by a strong desire to drink that makes it difficult to avert attention to anything else other than alcohol, which often results in the onset of drinking.
Implications
Individuals with Alcohol Use Disorder often turn to alcohol to relieve suicidal thoughts. However, this compulsive alcohol use in turn increases guilt and suicidal thoughts [5]. Suicidality is known to be caused by disinhibition, impulsiveness, and impaired judgement caused by excessive alcohol [8]. School and work performance are also at an increased risk from the after-effects of drinking or from actual intoxication[2]. The consequence of this may be getting fired from the job, which is considered a stressful event and induce individuals to further drink to relieve their negative feelings. These individuals therefore may continue to consume alcohol despite knowledge that alcohol use disorder poses significant physical (eg. blackouts, liver disease), social (work, school), or interpersonal problems (eg. violent arguments with spouse, child abuse) [2].
Another important and dangerous implication is that chronic alcohol use may induce other mental disorders, one of the most common being depression, and this indicates a less successful treatment outcome for both disorders, and a worse prognosis (expected development of the disorders) [3]. Successful treatments have already been developed that involve the individuals’ close others, so that they know how to cope with the problematic behaviours of their affected loved one, and learn how to reward good behaviours (such as not drinking for many hours) [3].
Classical (Pavlovian) conditioning
To understand the mechanisms of alcohol intake in Alcohol Use Disorder, psychologists have taken inspiration from the theory of Classical Conditioning.
In his original experiment, physiologist Ivan Pavlov noticed that his dogs started to drool after the sound of a bell [6]. He realised that this was the case after the bell was repeatedly followed by food. Hence, he theorised that after repeated pairings of the two, the bell (conditioned stimulus) became the dog’s cue to let them know that food (unconditioned stimulus) was coming soon [6]. Therefore, the result is that the dogs salivate right after the bell, as it becomes their predictor of food.
In alcohol consumption, there can be multiple conditionings. For example the bar and alcohol can be paired multiple times (one goes to a bar followed by their ordering alcohol) [10]. The result is that the context itself (being in a bar) gives rise to a strong desire for alcohol because there is a strong habit of ordering alcohol when in a bar setting [10]. This strong desire for alcohol therefore leads one to act upon their feelings and consume alcohol. Other examples can include friends, parties, social contexts. This is the reason why cues (situational contexts, or even state of mood) are important factors to be considered during treatment [3]. The implications on treatment may include not visiting the situational context [3].
Incentive - sensitisation theory
The National Institute on Drug Abuse (NIDA) defines addiction as “a chronic relapsing disorder, characterised by compulsive substance seeking, continued use despite harmful consequences, and long-lasting changes in the brain [7]. Now that we understand the concept of classical conditioning in alcohol use, the question naturally still remains; how do we explain chronic use of alcohol? Another interesting question is why do people in alcohol addiction still use alcohol, despite them admitting not liking alcohol after realizing the negative consequences?
To understand addiction further, the Incentive-Sensitization Theory explains how the brain’s mesolimbic pathway plays a role in the continued pursuit to attain substances even despite strong desire to do so [9].
People initially experiment with substances because of its pleasant consequences, but relatively fewer people develop a strong addiction to them [1]. There has been increasing recognition that drugs can change the brain chemistry of susceptible/predisposed individuals in complex ways, and that these drug-induced changes contribute to the transition to addiction[1].
According to the Incentive-Sensitization Theory of addiction, addicted individuals have an attentional bias towards substance-associated stimuli, also known as sensitization (to alcohol cues) [9]. This is caused by the increase in dopamine in the mesolimbic pathway after consuming alcohol repeatedly [1,9]. The underlying explanation is that the individual is hypersensitive to the motivational effects of the substances, which were experienced after they consumed alcohol[9]. One may spot alcohol cues quickly because they are associated with the motivational effects of de-stressing and being more easy-going during social events [9]. People are therefore more likely to consume alcohol due to the attractive motivational salience: this intensified “wanting” of the alcohol again activates the mesolimbic pathway, which is associated with motivation and desire for rewarding stimuli [1,9].
Interestingly, a strong “wanting” for the alcohol is not accompanied by an equally strong “liking”. This is because the brain's “liking” mechanisms are slightly separated from the “wanting” mechanism [1]. Since only “wanting” systems sensitise, “wanting” the alcohol increases regardless of whether the alcohol is still liked after repeated usage.
After sensitization of the brain mesolimbic pathway, excessive “wanting” of the alcohol can be triggered by alcohol-associated cues or even solely their mental representations, especially in situational contexts where alcohol have been taken before or when one is under the same mood or feeling that lead them to take the alcohol in the first place (eg. stress, grief) [9,10]. These trigger cues are very important to keep in mind during treatment, as it may impact treatment success [4]. For example, treatment for heroin-addicted US soldiers returning from Vietnam was found to be more successful than in addicts on the streets [3,4]. The success was present because their addiction was formed in a different environment [4]. When in the US, they are exposed to relatively very few of those environmental cues and were therefore more successful in decreasing craving and stopping the heroin use[4]. This mechanism is the same in alcohol addiction[4,9].
It is clear then, that cues and triggers are very important in this disorder, especially when it comes to treatment!
In conclusion…
Alcohol Use Disorder is a complex mental disorder that is characterised by its compulsive alcohol-seeking and use. The disorder has many negative implications in the user’s daily life, and can increase the risk of suicide. The development of treatment should follow from the available theories such as the incentive-sensitisation theory, with the focus on cues and triggers that lead to alcohol use.
Bibliography
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- American Psychiatric Association, & K. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5 (R)) (5th Revised edition). Van Haren Publishing.
- Dom, G., & Moggi, F. (2014). Co-occurring Addictive and Psychiatric Disorders: A Practice-Based Handbook from a European Perspective (2015de editie). Springer.
- Leshner, A. I. (2003). Addiction Is a Brain Disease, and It Matters. FOCUS, 1(2), 190–193. https://doi.org/10.1176/foc.1.2.190
- The Link Between Alcohol Use and Suicide. (2022, 24 februari). Alcohol Rehab Guide. Geraadpleegd op 2 mei 2022, van https://www.alcoholrehabguide.org/resources/dual-diagnosis/alcohol-and-suicide/
- Mcleod, S. (2021, 22 augustus). Classical Conditioning. Simply Psychology. Geraadpleegd op 2 mei 2022, van https://www.simplypsychology.org/classical-conditioning.html
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- Robinson, T. E., & Berridge, K. C. (2001). Incentive-sensitization and addiction. Addiction, 96(1), 103–114. https://doi.org/10.1046/j.1360-0443.2001.9611038.x
- Yon-Sheng Khoo, S. Y. S. K. (2019). From Pavlov’s Dog to Rats Using Drugs. Frontiers for Young Minds. Geraadpleegd op 2 mei 2022, van https://kids.frontiersin.org/articles/10.3389/frym.2019.00058