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Help for a Chronic Severe Alcoholic Subtype

There have been numerous attempts by clinicians and researchers to identify different subtypes of alcohol use disorders (alcoholism). Depending on the method used, the variables used to determine the subtypes, and the goals of the researcher, there have been many different models of subtypes of alcohol abusers proposed. These models range from two-factor models to multiple-factor models.

One of the attempts to develop a typology of alcohol dependence was published in the journal Drug and Alcohol Dependence in 2007. The technique used a structural equation modeling technique known as latent class analysis that examines the relationships among variables, and attempts to develop relatively discrete categories based on the input data. This particular study used a nationally representative sample of individuals who had been diagnosed according to the DSM-IV criteria for alcohol dependence. The study considered:

  • The person’s family history of substance abuse, particularly alcohol abuse
  • The age when the person first started using alcohol
  • The age when individuals were diagnosed with alcohol dependence
  • The diagnostic profile from the DSM-IV diagnostic criteria that applied to the individual
  • The presence of any co-occurring mental health disorders, including other co-occurring substance abuse issues

The analysis generated several models, and the researchers determined that the model that produced five different clusters or subtypes was the best fit according to the statistical criteria that is commonly used to determine the best fitting models in these types of studies. One of these subtypes of alcohol dependence was the chronic severe alcoholic subtype.

Characteristics of Chronic Alcoholism

Based on the results of the research, there are several interesting characteristics associated with the chronic severe alcoholic subtype.

  • Individuals in this group had an early onset of drinking behaviors; the mean age of onset of drinking alcohol was 15.9 years old.
  • Despite having an early onset of drinking, they had a later onset of a diagnosis of alcohol dependence (mean age of 29 years).
  • Overall, this group had the lowest percentage of days where they were abstinent from alcohol.
  • This group displayed the highest rate of emergency room admissions due to drinking alcohol.
  • Compared to the other groups, this group had the highest probability of having a first- or second-degree relative also diagnosed with alcohol dependence.
  • Compared to the other four categories generated by the analysis, this group had the highest lifetime prevalence of bipolar disorder, major depressive disorder, dysthymia (a chronic and milder form of depression), generalized anxiety disorder, panic disorder, and social phobia.
  • This group had a high probability of co-occurring cannabis, cocaine, opiate, and/or tobacco use.
  • This group had the highest rates of attendance at inpatient programs, especially rehabilitation programs and detoxification programs. Individuals in the group also demonstrated significant motivation to seek out treatment in all areas, but poor success.

The group also had the highest probability for the endorsement of several of the symptoms from the DSM-IV diagnostic criteria, including:

  • Frequently drinking more alcohol than originally intended or drinking alcohol for longer periods than originally intended
  • Continued use of alcohol despite negative consequences
  • Having frequent unsuccessful efforts to cut down their use or stop use of alcohol
  • The highest probability of experiencing withdrawal symptoms.

Despite having significantly high ratings in several different areas associated with the diagnosis and presentation of an alcohol use disorder, this was the smallest group of the sample (9 percent of all participants). The data indicated that nearly three-quarters of these individuals had a family history of alcohol dependence. Most of the individuals were middle-aged individuals who had early onset of drinking behaviors.

Does This Research Offer Practical Information?

In short, yes, the research might offer some useful practical information that could be used to design treatment programs for individuals with alcohol use disorders. The more accurate and complicated answer to the question is that the clinical utility of this type of research has not had sufficient empirical evidence to confirm its reliability and validity. In other words, because this type of research can generate models that differ substantially depending on the sample of participants, and the criteria or variables used to determine the classes, it is questionable at best whether any single research study offers significant clinical utility.

There have been numerous critiques of the methods used in these types of studies that often emphasize their lack of clinical and predictive validity. Instead, when researchers begin to look at the results and commonalities between numerous studies of this type (e.g., comparing different categories from different studies that are similar in makeup) and use that information to determine treatment effectiveness, these studies have far more usefulness. It is interesting to note that a 2010 follow-up to the latent class analysis study was mostly descriptive in nature regarding how the participants in the study address their alcohol use disorder. There were no specific interventions or treatment protocols compared for their overall effectiveness for individuals in each category.

In addition, researchers looking to use the information gleaned from their studies to identify specific treatment protocols for individuals with alcohol use disorders could use treatment outcome data in addition to other variables, such as diagnostic information, history, etc., to better identify what types of people or variables respond better to specific types of treatment, such as medications, therapy, inpatient treatment, outpatient treatment, etc. Studies that develop different typologies based on how specific symptoms present in individuals also often generate different results that are specific to recommending targeted treatments to deal with these symptoms (e.g., cravings as in the research of Otto Michael Lesch). The current study did not utilize any of these approaches.

Nonetheless, there are several broad conclusions that can be made about the chronic severe alcoholic subtype that might generate some interesting future research and be used in the development of treatment protocols.

  • Individuals who appear to have significant similarities to individuals in the study classified as the chronic severe subtype are most likely going to need substantial and intensive treatment.
  • Individuals who are similar to the chronic severe subtype alcoholic might best respond to a combination of medically assisted treatments (medical procedures and medications) and therapy.
  • Those who appear to have significant similarities to the chronic severe subtype of alcohol dependence also appear to generally be interested in seeking out various forms of treatment. Their motivation to enter treatment appears to be high, but their adherence to treatment may be lacking.
  • Individuals prone to developing physical dependence on alcohol, and with significant psychiatric comorbidity, might benefit from treatments that concentrate on relapse prevention.
  • Those with a family history of alcohol abuse and psychiatric comorbidity may have a significant genetic contribution to an alcohol use disorder that results in them being more likely to develop physical dependence on alcohol than other groups.
  • Individuals who have presentations similar to the individuals classified in the chronic severe alcohol dependent group in the study should be considered as high probability candidates for initial inpatient withdrawal management programs (medical detoxification programs).

Treatment for Severe Alcoholism

According to the 2010 follow-up to the latent class analysis study, the chronic severe alcoholic subtype demonstrated the least amount of improvement in their alcohol use disorder symptomatology even though they were the group that sought treatment at the highest rates. Obviously, these individuals are not having their needs addressed appropriately in treatment. Based on information known about individuals in this group and their potential needs, as well as information from the book Theory of Addiction, certain treatment protocols may be most effective for this group.

  • These individuals require intensive inpatient treatment initially. They will need 24-hour supervision and strict rules to help them avoid the temptation to relapse. The initial goals of inpatient treatment should be to successfully negotiate the withdrawal process; a physician-assisted withdrawal management program would be appropriate.
  • Many of these individuals might fare well in long-term residential treatment following the completion of the withdrawal management program, where they receive significant supervision and become part of a structured environment that helps them to initiate positive change.
  • As mentioned above, relapse prevention techniques need to be stressed in these individuals. The major goals of the treatment program should not be to instill motivation as it is quite apparent that these individuals seek treatment readily, but to deliver treatment in a practical fashion. The use of medically assisted techniques, such as medications like Antabuse and ReVia to deal with cravings, may be appropriate.
  • Aggressive treatment of comorbid mental health conditions should be initiated from the beginning of treatment. This includes the use of therapy, medically assisted treatments, and other methods that are available.
  • These individuals will likely benefit from engaging in positive lifestyle changes as well as complementary and alternative therapies, such as meditation, yoga, tai chi, etc.
  • If the individual is not interested in complementary and alternative therapies, they should attend specialized counseling to identify specific areas of interest that can be focused on as alternatives to the use of alcohol. This will allow the individual to separate from their old identity as an alcohol abuser.
  • These individuals should become heavily involved in 12-Step groups. This allow these individuals to attend daily meetings, develop a strong relationship with a sponsor, and form strong relationships with other peers in recovery. Another advantage to 12-Step groups is that they stress abstinence.
  • These individuals should be prepared to continue participation in 12-Step groups for many years and to seek ongoing treatment for any comorbid mental health conditions.

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