Letter to the Editor

The family has increasingly been recognized as an important component in the development, maintenance, and treatment of alcoholism. Few empirical studies, however, have examined alcoholism within a family context. Questionnaire and interview data were collected from women whose husbands received inpatient treatment for alcoholism. Since wives now typically work outside the home, this article focuses on the 60 employed wives. Employment was examined as a source of stress as well as social support. The majority of working wives reported minimal negative impact of their husbands' drinking on all areas of their work functioning, with a small subset indicating impairment attributable to the drinking. These wives were very satisfied with their current positions and described work as a positive experience. However, unobtrusive measures that alcoholism in a family member intrudes into the workplace were apparent, including changing jobs, absenteeism, and discussing husbands' drinking at work. Further, these women scored closer to a sample of depressed women than a community sample on measures of physical and mental health, depressed mood, and smoking symptoms. Possible reasons for the discrepancy between subjective reports and objective indicators are discussed.     

Attitudes regarding alcoholism among a group of drinking drivers

Ninety-four drinking drivers were surveyed to assess their attitudes on nine factors related to alcoholism and the alcoholic. Each of the factors was assessed according to Marcus' criterion. Two factors were extracted which differed from those of the general population norm group. These drinking drivers were positive in their belief that periodic excessive drinkers can be alcoholics and negative in their attitude regarding alcoholism as an illness. It was noted that apart from these two factors, these drinking drivers were equally ambivalent in their attitudes toward alcoholism and the alcoholic when compared to the norm group.     

Emergence of a Day-Care Centre for Alcoholics in India–its referral system and public response

The stigma of alcoholism has a long history in India. When Mr Ranganathan died an alcoholic at the age of 33, everyone condemned his affluence and parental upbringing. No one seemed to have understood the illness called ‘Alcoholism’. At that time in 1979, there were no specialized institutions in India to treat alcoholics. Mr Ranganathan's family took the initiative in establishing a day-care centre for alcoholics in 1980 in the belief that alcoholism is a treatable disease. A dedicated team of psychiatrists, clinical psychologists, social workers and a recovered alcoholic work for the centre. The foundation offers a three-phase programme, namely, detoxification, an intensive out-patient programme for 21 days, after-care and Alcoholics Anonymous. 465 cases were registered from 1981 to February 1984. Only five patients were female. The foundation also offers various programmes to educate the public. The good public response and the positive results of treatment justify the emergence of this centre in India.     

Evaluation of the Effects of Training of Paraprofessionals in the Treatment of Alcoholism: A Pilot Study*

A program for the training of paraprofessionals in alcoholism is outlined, and the characteristics of persons attracted are described. The effects of the program on a pilot group of 13 are evaluated. The training program attracts persons familiar with alcoholism through personal experience or previous helping experience. It modifies the trainees' attitude toward alcoholism as an illness and some personality traits, but does not increase the information about alcoholism in this already moderately knowledgeable group. The most important effect is the change in trainees' therapeutic technique from directive to non-directive. Follow-up indicates that the program enables trainees to use more techniques in their treatment of alcoholics and to progress to higher level jobs.     

Maximizing scarce service resources in a rural mental health clinic: should alcoholics be treated in separate programs?

One hundred nineteen patients at rural community mental health centers were divided into three diagnostic groups and compared to determine if alcoholic and nonalcoholic patients differ significantly in terms of psychopathology. The three diagnostic groups were primary diagnosis of alcoholism (N = 34), primary diagnosis of emotional disturbance (N = 39), and "other" diagnoses (N = 46). These groups were compared with respect to demographic variables, alcohol drinking patterns, psychopathology, and attitude toward treatment. The alcoholic patient group tended to be single, male, and inpatients; while the nonalcoholic group tended to be married, female, and outpatients. These groups differed significantly with respect to alcohol consumption and drinking patterns and effects, but did not differ significantly with respect to their attitudes toward mental illness or their MMPI profiles. The results of the "other" diagnostic group generally fell between those of the alcoholic and nonalcoholic groups, suggesting that it was a heterogeneous group of subjects. The total subject population evidenced elevated MMPI profiles, indicating the presence of a high level of psychopathology, but there was no clear distinction between the alcoholics and the other groups in terms of type or degree of psychopathology. Implications for treatment are discussed.     

Exercise testing to enhance wives' confidence in their husbands' cardiac capability soon after clinically uncomplicated acute myocardial infarction

The effects of wives' involvement in their husbands' performance of treadmill exercise testing 3 weeks after clinically uncomplicated acute myocardial infarction was compared in 10 wives who did not observe the test, 10 who observed the test, and 10 who observed and participated in the test themselves. In a counseling session after the treadmill test, couples were fully informed about the patient's capacity to perform various physical activities. Wives' final ratings of confidence (perceived efficacy) in their husbands' physical and cardiac capability were significantly (p < 0.05) higher in those who also performed the test than in the other 2 groups. Only wives who walked on the treadmill increased their ratings of their husbands' physical and cardiac efficacy to a level equivalent to those of their husbands. Spouses' and patients' perceptions of patients' cardiac capability after treadmill testing and counseling at 3 weeks were significantly correlated with peak treadmill heart rate and workload at 11 and 26 weeks. Efficacy ratings at 3 weeks were slightly better than peak 3-week treadmill heart rate and workload as predictors of treadmill performance at 11 and 26 weeks. Participation in treadmill testing early after acute myocardial infarction is an effective means for reassuring spouses about the capacity of their partners to resume their customary physical activities with safety.     

Cortical gray matter loss in treatment-naïve alcohol dependent individuals

Background: Most studies of the impact of alcohol dependence on the brain have examined individuals in treatment. Such samples represent a small proportion of alcoholics in the general population. Such samples may embody a bias (Berkson's fallacy) if the association between variables (for example, alcoholism and cortical gray matter loss) differs between the population of alcoholics in treatment and alcoholics in the general population. Our objective was to determine if treatment‐naïve alcoholics show structural brain changes versus controls and to compare our findings with reports evaluating alcoholic samples drawn from treatment populations. Methods: Structural MRI was used to assess whole brain and regional volumes of cortical gray matter and white matter in 24 young to middle‐aged treatment‐naïve alcohol‐dependent males versus 17 controls. Results: Cortical gray matter volumes in alcohol‐dependent individuals were negatively associated with age and lifetime duration of alcohol use (which were highly confounded). These subjects showed reduced whole brain (p < 0.05), prefrontal (p < 0.01), and parietal (p < 0.05) cortical gray matter compared with controls. White matter and temporal cortex, tissues that usually show volume reductions in samples drawn from treatment, did not differ between treatment‐naïve alcoholics and controls (all p > 0.40). Conclusions: Our findings are consistent with the hypothesis that structural brain changes in treatment‐naïve alcoholics are less severe than those reported in clinical samples of alcoholics, perhaps due to less concomitant psychopathology and a reduced severity of alcoholism in treatment‐naïve alcoholics. However, caution must be taken when comparing our findings with results from clinical samples, as we did not directly compare treatment‐naïve alcoholics with treated alcoholics and our treatment‐naïve sample tended to be younger than the (clinical) samples reported in the literature. Nevertheless, we suggest that most of the reports of the central nervous system consequences of alcoholism may not accurately describe the majority of alcoholic‐dependent individuals.     

Marital Stability among Wives of Alcoholics: An Evaluation of Three Explanations

Sixty women currently or formerly married to alcoholics were interviewed in order to assess the stressfulness of their marriage, stressfulness of their childhoods, and their closeness to divorce. In support of sociological predictions, the more stressful the marriage the closer the wife was to divorce. Contrary to psychoanalytic predictions, personality disturbance, indexed by stressfulness of childhood, did not correlate with closeness to divorce. Factor analytically derived subscales of marital and childhood stressors showed a significant psychosocial interaction; wives shy as children were more likely than their more outgoing counterparts to endure their husbands' verbal abuse of them and their children. In addition, influence by others to separate, positive attitudes toward divorce, fear of violence, and little or no good period early in marriage all correlated positively with closeness to divorce. Possible alternative explanations for the present results and needed future research are discussed.     

Gender inequality and the risk of HIV among married couples in North India

This study investigated the distribution and determinants of HIV risks among married couples in North India. Gender inequality emerged as a potential driver of HIV risks in this region. Data collection took place in 2003 in a probability survey of 3385 couples living in India's most populous state – Uttar Pradesh – and Uttaranchal. Couples' analyses utilizing generalized estimating equations showed that compared with husbands, wives were less knowledgeable about HIV (OR = 0.31, 95% CI = 0.27–0.36), more likely to consider themselves at risk for infection (OR = 6.86, 95% CI = 4.65–10.13), and less likely to feel that a wife had the right to refuse sex with her husband (OR = 0.50, 95% CI = 0.44–0.58). The proportion of husbands reporting non-marital sex in the past year was 7.1% and transactional sex in the past year, 2.2%. Among their wives, 73.4% were unaware of their husbands' non-marital sexual behaviors and only 28.9% of husbands reported condom use during their last non-marital sexual encounter. Logistic regression analyses showed that husbands' alcohol use, husbands' mobility, and urban residence were positively associated with husbands' non-marital sexual behaviors adjusting for other covariates. The data demonstrate that HIV prevention programs among couples in North India should consider both sexual risks and gender inequalities which potentially fuel HIV spread in this region.     

An Analysis of the Clinical Relevance of Type 1 and Type 2 Alcoholics

Predictions inherent in the proposed Type I/Type 2 continuum of alcoholic subtypes were indirectly explored in 31 sons of primary alcoholic fathers. The fathers' alcoholism was rated on a 0–5 scale utilizing characteristics typical of the Type 2 extreme of the continuum. If a predisposition to Type 2 alcoholism is genetically transmitted, then we would have predicted that the sons of Type 2 alcoholics would be more likely than the sons of Type 1 men to show an earlier onset of drinking, as well as more alcohol and substance intake and associated problems. The results did not support any consistent trend in the correlation between the FHP fathers' alcoholic characteristics and the sons' problem picture. Potential explanations for this finding are discussed including the possibility that the Type 2 extreme might represent a separate diagnostic entity, the antisocial personality disorder, and not alcoholism itself.     

The Attitudes toward Alcoholism Instrument: A Measure of Attitudes toward Alcoholics and the Nature and Causes of Alcoholism *

This study describes the development of a 24-item instrument dealing with attitudes toward alcoholics and alcoholism. Data are presented for 135 graduate students on six conceptually derived scales referable to attitudes toward alcoholics: Psychological Etiology, Physical-Genetic Etiology, Social Rejection, Humanism, Moral Weakness, and the Medical Illness Model. The scales were found to be relatively independent of one another and only minimally related to social desirability, sex of respondents, education, and age. In addition, a factor analysis was done. Satisfactory test-retest reliabilities were established for the scales on a new sample of 30 Ss. Validation data are also reported revealing that 41 hospitalized alcoholics had more negative views of alcoholics and were more likely to regard alcoholism as an illness caused by a physical disturbance than were non-alcoholics. Moreover, for non-alcoholics there was a significant inverse relationship between the reported quantity of alcohol consumed and the tendency to characterize the alcoholic as morally weak.     

Alcoholism as a risk factor in methadone maintenance: A randomized controlled trial

A randomized controlled trial of 625 addicts on methadone maintenance identified 105 (17 percent) as active alcoholics, 47 (8 percent) as inactive alcoholics, and 473 (75 percent) as nonalcoholics. Subjects were followed for up to 29 months (mean 53.7 weeks) to assess the influence of alcoholism on the rehabilitative process. During the study, alcohol consumption significantly decreased (p < 0.001) in active alcoholics. Indexes of productive activity on entry or during follow-up revealed no significant differences between active alcoholics and other patients with the exception of alcohol-related hospitalizations (p < 0.001). Behavioral indexes consistently improved with treatment in all patients, being greatest among active alcoholics (p < 0.01). During the study, 28 (7 percent) of 399 nonalcoholics were recategorized as active alcoholics, and remission from alcoholism was noted in 28 (27 percent) of patients who were initially classified as alcoholic. These findings suggest that alcoholism does not significantly affect rehabilitation from narcotic use and therefore should not be cause for detoxification from methadone maintenance.     

Children of Alcoholics:

Children of alcoholics are now seen as a special population of persons who are at risk for a host of medical, psychological and social problems. Because of genetic predisposition, these children are at increased risk for the development of alcoholism. Alcohol's impact upon the developing fetus may result in fetal alcohol syndrome or fetal alcohol effects. The psychological and social impact of alcoholism on the family may result in personality problems of various kinds. Progress in this area of investigation will depend upon development of typology of alcoholic families, alcoholics, and drinking patterns since variation in all of these is likely to result in varying impact upon children. Treatment of children of alcoholics must avoid stereotypes, follow from careful individualized assessments of the family, and involve many modalities and varied strategies.     

Severity of alcohol dependence and its relationship to additional psychiatric symptoms in male alcoholic inpatients

Many alcoholics suffer from distress associated with psychiatric symptoms in addition to alcoholism. Although there may be many such symptoms reported by the alcoholic, there may not be enough in any one category to meet DSM III criteria for an additional psychiatric diagnosis, and consequently these symptoms may not be considered in treatment planning. In addition, the prevalence and severity of psychiatric symptoms may be dependent on the progression of alcoholism. The purpose of this study was to examine whether a relationship exists between patterns of psychiatric symptomatology and the level of severity of alcohol dependence in an inpatient male alcoholic sample, and to describe how this information can be utilized to differentiate large groups of alcoholics into clinical meaningful categories. The study sample was comprised of 100 male alcoholic inpatients from the Alcoholism Treatment Unit at a metropolitan Veterans Administration Hospital. Subjects were administered The Michigan Alcoholism Screening Test (MAST), the Severity of Alcohol Dependence Questionnaire (SADQ), and the Symptom Checklist-90-Revised (SCL-90-R). Correlational analysis of the data supported the hypothesis that a positive relationship exists between the severity of alcohol dependence and the prevalence of additional psychiatric symptom patterns. Partial correlational analysis indicated that the length of the alcoholic's illness and the number of inpatient treatments for alcoholism enhanced the relationship between the severity of alcoholism and most of the symptom scales. The utility of assessing concurrent psychiatric symptomatology as it relates to the severity of alcohol dependence is discussed in relation to treatment planning and prognostic assessment of the patient.     

Two contrasting alcoholism treatment programs: a comparison of outcomes.

Participants in two 60-day alcoholism treatment programs with contrasting treatment philosophies and rationale were followed-up 1 year after discharge from the hospital. Widely different results were obtained with distinctly different alcoholic veteran populations. Response to treatment was highly favorable for less symptomatic alcoholics when direct emphasis was place upon the alcoholism per se and complete abstinence. Less favorable responses were achieved with overt neurotic alcoholics when treatment was designed to resolve underlying personality disturbances. Self-reports of marked depression, anxiety, and prior treatment for alcoholism were three pretreatment variables found significantly related to unsuccessful drinking outcome. The implication of these findings is that treatment outcome is largely dependent upon both the characteristics of the population treated and the treatment approach.     

Psychiatric Comorbidity in Alcoholism: Importance of Ascertainment Source

Although psychiatric comorbidity is often observed among individuals in treatment facilities for alcoholism, the prevalence and pattern of psychiatric comorbidity among alcoholic cirrhotics has not been well characterized. The present study aimed first to compare the prevalence of psychiatric comorbidity in cirrhotic individuals with alcoholism ascertained from a gastroenterology service with alcoholics ascertained from a treatment facility for alcoholism. Consistent with the findings of other investigators, the data suggest that there is a great degree of variability regarding the severity of alcoholism in alcoholic cirrhotic individuals. Furthermore, cirrhotics with alcoholism exhibited a less severe clinical picture of alcoholism as measured by less alcohol dependence and lower prevalence of psychiatric comorbidity than individuals in treatment for alcoholism. The main conclusion of this study is that ascertainment source is an important determinant of psychiatric comorbidity observed in alcoholic samples.     

Age and Ethnicity among Hospitalized Alcoholics: A Nationwide Study

Little is known about the broad-scale demographic characteristics of low income or indigent alcoholics in public hospital systems. The purpose of the study was to examine issues relative to age, race/ethnicity, and marital status for a large group (n = 62,829) of alcoholic men receiving inpatient care in Department of Veterans Affairs (VA) medical centers nationally. Subjects were VA inpatients completing alcoholism treatment (n = 27,562), in brief alcohol detoxification or short intervention (n = 9,322), or hospitalized for primary diagnoses other than alcoholism but with a secondary diagnosis of alcohol dependence syndrome (n = 25,945). Minority alcoholics were significantly younger than Caucasian alcoholics. Hispanic and African-American men, as well as older alcoholics, were significantly less likely to complete treatment or attend detoxification and more likely to be hospitalized for other primary diagnoses. Native Americans, however, were most likely to complete alcoholism treatment. Results suggest that members of some minority groups and elderly alcoholics seek inpatient care for diagnoses other than alcoholism and that, as a result, such individuals may need targeted interventions to encourage them to seek alcohol-specific care.     

Static Ataxia: A Predictor of Alcoholism?*

Non-alcoholic college-aged males with and without a family history of alcoholism were compared on a measure of static ataxia (body sway). In two separate studies, subjects with alcoholic biological relatives showed significantly greater body sway than those without such relatives. This effect was independent of alcohol influence and subjects' typical drinking pattern. To the extent that subjects with a family history of alcoholism are at risk to become alcoholic, these results suggest that the previously reported motor impairment of alcoholics may exist prior to chronic alcohol intake. This possibility should be considered cautiously, due to two methodological issues: (a) differences between the two studies in measurement procedures and (b) the use of subjects' self reports for family history classifications. Methodological improvements and future research directions were discussed.     

Reliability and validity of the quantitative inventory of alcohol disorders (QIAD) and the veracity of self-report by alcoholics

The purpose of this study was to investigate a recently developed instrument for alcoholism severity: The Quantitative Inventory of Alcohol Disorders (QIAD). The primary intention was to demonstrate the reliability and validity of the QIAD as a diagnostic tool within the field of alcoholism. A secondary intention was to examine the veracity of alcoholics self-report on the QIAD and other alcohol-related instruments. The subjects for the experimental group were 25 inpatient alcoholics and their spouses. The control group consisted of 21 nonalcoholics and their spouses. All subjects were administered the QIAD, Michigan Alcoholism Screening Test (MAST), and the Alcohol Severity Rating Scale (ASRS). The alcoholics and partners were given the same tests 5 to 8 days after initial testing. The primary therapists for the alcoholics were asked to rate alcoholism severity for each subject using the ASRS. Pearson product moment correlation coefficients were used for the test-retest reliability procedure. Alcoholics scores on the QIAD, MAST, and ASRS were compared with their spouses scores using a test-retest procedure. Nonalcoholics scores on these instruments were also compared with their spouses' scores. Construct and concurrent validity for the QIAD were tested through comparison of QIAD scores of the alcoholics with their corresponding scores on the MAST and ASRS. t-Tests were used to determine differences between alcoholics and nonalcoholics on all three scales. The results of this investigation supported the position that the QIAD is a reliable and valid instrument for measuring alcoholism severity. The QIAD correlated highly for both the alcoholics and their spouses. The test-retest procedure revealed a high level of correlation. A significant difference was found between the QIAD scores of the alcoholics and nonalcoholics. Construct validity was demonstrated by significant correlations between the alcoholics QIAD and MAST scores, both measuring the extent of alcoholism. The QIAD demonstrated concurrent validity by significantly correlating with alcoholics ASRS ratings. High correlations between alcoholic and spouse scores on the QIAD supported the hypothesis that inpatient alcoholics can produce valid responses to self-report questionnaires.     

Night Driving (Mesopic) Visual Acuity in Sober Male Alcoholics with and without Liver Disease

Night driving (mesopic) visual acuity and recovery after dazzle has been reported to be reduced in patients with liver disease. Mesopic visual acuity and dazzle recovery were evaluated in 32 patients with alcoholic cirrhosis, 29 alcoholics without liver disease, and 27 age-matched normal controls. All subjects were sober for at least 7 days prior to visual testing, a mean sobriety period of 22 and 39 weeks in alcoholics and cirrhotics, respectively. Serum vitamin A levels and/or dark adaptation were normal in all. Mean best decimal acuities were not significantly different among the groups: alcoholic cirrhotics, 0.32 ± 0.02; alcoholics, 0.32 ± 0.02; and normals, 0.33 ± 0.03 at 2 min. Although cirrhotics had significantly higher SGOT and lower albumin levels than alcoholics, mesopic acuity did not relate to liver blood tests. Decimal acuity following a dazzle stimulus was not significantly worse in cirrhotics and alcoholics compared to normals. Sober patients with alcoholic cirrhosis or a history of alcoholism have no evidence of a static mesopic visual defect and therefore may not have impaired night driving vision.