Psychological factors Personality

It is now widely accepted that alcoholics do not present a homogeneous premorbid personality profile. However, some distinctive trait clusters have been identified which seem to characterize different types of alcoholics.(35) One such group (type 1) tend to score low in novelty seeking and high in harm avoidance and reward dependence. Another group (type 2) is formed by the natural thrill seekers, who appear to ignore harmful consequences and punitive responses. This latter cluster, which prevails mostly in males with early-onset alcoholism, is also typical of antisocial personalities. Of all personality features, conduct disorder and antisocial behaviour are the strongest predictors of alcohol misuse.(36) However, more than half the alcoholic population do not have such a personality background, presenting rather with a non-specific mixture of the different personality types described in clusters A, B, and C of the DSM-IV classification. (37)

Psychodynamic processes

In keeping with a 'topographic' notion of psychic structure, early psychodynamic writings viewed alcoholism and other addictions as regressive behaviours caused by unconscious conflicts about libidinal pleasures, homosexuality, and aggression. More recent formulations emphasize ego and self-developmental problems, and consider psychoactive substance abuse as a response to psychological suffering; an attempt at re-establishing homeostasis. This is known as the self-medication hypothesis of addictions,(3B) according to which, persons with self-regulatory deficiencies in the areas of self-care, self-esteem, self-object relations, and affect tolerance, would drink to palliate their distress.

Learning

An important sector of the scientific community considers alcohol abuse as a behavioural pattern which has been learned through mechanisms of classical (i.e. Pavlovian) and operant conditioning. According to this interpretation, the perpetuation of heavy drinking results from its association with conditioned stimuli (cues), and from the action of positive (pleasant effects) or negative (stress reduction) behavioural reinforcement. (39) Additional components of this equation are the so-called alcohol 'expectancies'. Alcohol abusers tend to overemphasize the pleasant aspects of drinking and to exclude the negative ones; the learning theory of alcoholism assumes that such a cognitive set is also acquired through social exposure. (2B)

Psychiatric comorbidity

Community and clinical epidemiology findings point to the presence of other psychiatric disorders as one of the most significant psychological risk factors in alcoholism. The risk is particularly high in persons with schizophrenia, bipolar disorder, major depression, social phobia, panic disorder, post-traumatic stress, attention-deficit hyperactivity disorder, and antisocial and borderline personality disorders. (40)

A major confounder in the interpretation of these findings is the poor specificity of psychiatric symptoms in the alcoholic population. A large proportion of the disorders diagnosed are alcohol induced and tend to dissipate in conditions of abstinence. This evidence led some authors to conclude that most of the excess psychopathology observed in alcoholics is secondary to alcoholism rather than a pre-existing risk factor. (4!.) It has also been suggested that the coexistence of alcoholism with other psychiatric illnesses (e.g. affective disorders) does not necessarily mean that one is causing the other, but rather that they both result from a common genetic influence/42

Brain dysfunction

Altered neuropsychological function can be seen as an additional risk factor in alcoholism: minimal brain damage, attention deficit, learning disabilities, head injuries, fetal alcohol effects, or the actions of other drugs of abuse are examples of brain conditions likely to increase individual vulnerability. Moreover, a transketolase deficiency (possibly genetic), which affects carbohydrate metabolism in the brain, is believed to predispose towards the occurrence of alcoholic organic brain complications/43)

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