Signs of an Intermediate Familial Alcoholic Subtype

Researchers studying addictive behaviors have attempted to determine how different manifestations of addictive behavior naturally occur, and classify different types of alcoholics based on their history, symptoms, and other variables. Numerous typologies of individuals with alcohol use disorders (the current diagnostic label for individuals who suffer from addiction to, or abuse of, alcohol) have been developed. Many of these attempts suffer from severe methodological limitations, such as the classification developed by E. M. Jelinek that is commonly referred to in Alcoholics Anonymous literature and meetings. More recently, the use of sophisticated statistical techniques has been applied to classify various types of addictive behaviors.

Why would researchers want to determine if there are different types of alcoholics? There are several reasons:

• The understanding of how different types of addictive behaviors develop can lead to methods that may be used to prevent addiction in some individuals.
• Understanding different types of addictive behaviors can lead to early identification.
• Understanding the different classes of individuals with alcohol use disorder may help to develop more effective treatment programs targeted at individuals in each class.

In 2007, researchers applied a structural equation modeling technique known as latent class analysis to information collected from 1,484 individuals diagnosed as being alcohol dependent who participated in the National Epidemiological Survey on Alcohol Related Conditions. Latent class analysis is a sophisticated statistical technique that attempts to identify clusters of symptoms or related variables that can be used to classify individuals into specific types. The data used in the study included:

• The person’s family history of substance abuse
• The estimated age at which the person started abusing alcohol
• If the person had any co-occurring mental health issues, including any other history of substance abuse
• Data from their diagnostic profile, according to the DSM-IV diagnostic criteria

The researchers determined that out of all the different classification models generated by the analysis, a model that identified five different types of alcohol use disorders (alcohol dependence) fit the best. One of these types was labeled the intermediate familial alcoholic subtype.

Characteristics of the Intermediate Familial Alcoholic Subtype

The major characteristics of the intermediate familial subtype according to the data analysis are outlined below.

• The category is predominately composed of males, as 66 percent of the participants in the sample who were categorized in this class were male.
• Many of the individuals in this class had first-degree and/or second-degree relatives who also had a diagnosis of alcohol dependence (alcohol use disorder).
• Many of these individuals began drinking alcohol in their teen years.
• Many of the individuals in this group also had a co-occurring substance use disorder. The primary substances abused by this group in addition to alcohol were tobacco products, cannabis products, and cocaine.
• Many of the individuals in this class also had other co-occurring mental health disorders. The major co-occurring disorders in this group were major depressive disorder, bipolar disorder, obsessive-compulsive disorder, and generalized anxiety disorder.
• Individuals in this group that sought treatment often used withdrawal management, social support groups, or private treatment consisting of medical interventions and counseling.

Of the 1,484 participants in the study, 19 percent were classified in the intermediate familial alcoholic subtype classification. Nearly half of this group had experienced significant depressive symptoms; about 25 percent were diagnosed with bipolar disorder; about 20 percent abused either cannabis or cocaine products; and about 25 percent sought treatment for their alcohol use disorder.

What Does the Data Reveal regarding Assessment and Intervention?

Although one of the motivations of researchers who attempt to determine different types of presentations of mental health conditions, such as substance use disorders, is to eventually design specific intervention and assessment techniques to make the identification and treatment process more efficient, this particular research has not significantly added to this process. There are several reasons for this.

• Research has previously identified that many of the above risk factors actually apply to all individuals who have been diagnosed with any substance use disorder. There is very little clinical utility regarding the differentiation of individuals in this group from others belonging to other groups based on the research.
• Specific treatment techniques for individuals that can apply to any of the classes identified by any research are not well defined.
• According to numerous sources, including the National Institute on Drug Abuse (NIDA), there is no one-size-fits-all treatment approach, and every individual regardless of their clinical profile, or any artificial class they may qualify for, requires a general treatment approach that needs to be adjusted to fit their specific needs.
• Research that attempts to classify individuals with substance use disorders by their response to specific treatment interventions has slightly more clinical utility and does not replicate the five classes that were identified in this particular study.

From an academic point of view, this type of research helps investigators and clinicians to develop specific types of hypotheses and theories that can fuel future research and add to the understanding of addictive behaviors. In addition, there may be some subtle hints from this type of research that can help individuals identify potential alcohol abuse in themselves or others.

 

• An individual with a family history of a substance use disorder diagnosis should understand that they are at an increased risk to develop a substance use disorder, such as an alcohol use disorder, themselves.
• If an individual with a family history of substance abuse begins to question their own use of alcohol or other drugs, they should seek the advice of a mental health professional who specializes in addictive behaviors to determine the extent of any problems they may have.
• Individuals who experience severe issues with depression, anxiety, stress, etc., and who use alcohol or drugs should also be assessed for potential substance use disorders.
• Individuals who are being treated for other substance use disorders should also be assessed for a potential alcohol use disorder. Alcohol use disorders represent the most common manifestations of substance use disorders in the United States, and they are frequently co-occurring with other substance use disorders.
• The majority of individuals in the latent class analysis study did not voluntarily seek treatment on their own regardless of which classification they belonged to; only one of the five classes had a significant rate of individuals who voluntarily sought treatment. This finding suggests that a good number of individuals with alcohol use disorders may need the input of others to motivate them to seek help.

Signs of an Alcohol Use Disorder

Individuals who might satisfy many of the conditions that are associated with the intermediate familial alcoholic subtype will display some signs and symptoms that may be specific to this class or may be more generalized in nature. According to the research and formal diagnostic criteria for an alcohol use disorder, some of the signs and symptoms to look out for these individuals include the following:

 

• Observations by relatives that someone’s drinking behavior is very similar to a first-degree or second-degree relative in the family who has been diagnosed with an alcohol abuse issue
• The person experiencing significant issues in their relationships, at work, at school, or in other important areas of life as a result of their use of alcohol
• The person drinking frequently to deal with emotional issues, such as depression, stress, anxiety, etc.
• The person frequently drinking alcohol in situations where the use of alcohol is personally dangerous or dangerous to others, such as before operating a motor vehicle, while using machinery, while taking care of minor children, etc.
• An individual who began using alcohol at a relatively early age
• The person giving up activities or failing to meet major role obligations as a result of their use of alcohol
• The person losing control of their use of alcohol
• The person rationalizing their use of alcohol as being “normal” for them even though it appears to be abnormal
• The person experiencing symptoms of physical dependence (tolerance and/or withdrawal) as a result of alcohol use

The notion of a familial type of substance use disorder often infers a genetic connection. Nonetheless, this is not necessarily true because individuals often learn behaviors from others, particularly parents and other relatives, and there is no specific genetic test or genotype that can be used to diagnose a substance use disorder in anyone. Using any singular factor or variable associated with the familial subtype as a barometer to suggest that an individual has an alcohol use disorder is not a sound approach; however, when one is able to confirm several different variables in an individual, the notion of a genetic connection may be strengthened. In the current case, these variables would include an individual having several or all of the following:

• Being male
• Having a first-degree or second-degree relative who was diagnosed with an alcohol use disorder (or some other substance use disorder)
• Having a history of using alcohol since the individual was a teenager
• Excessive use of other drugs in addition to alcohol
• Having some other mental health condition, including depression, bipolar disorder, obsessive-compulsive tendencies, etc.
• Displaying significant tolerance to alcohol or displaying both tolerance and withdrawal syndromes associated with alcohol use

When someone meets the majority of these conditions, one may suspect that the individual has the qualifications that satisfy membership in the familial subtype. However, it should be stressed that this designation is a result of a number of research studies and not a diagnostic category. What this designation may reflect is the notion that the individual has less control over their use of alcohol than other individuals and has a number of other co-occurring conditions that contribute to their alcohol use.

Treatment for Alcohol Use Disorder

Because the familial subtype of alcohol dependence is classified by research studies and not a diagnostic category, formal treatment programs are not designed to treat individuals who may meet this classification. Instead, treatment programs should be targeted to fit the specific needs of the case. In general, the overall approach to treating individuals with an alcohol use disorder should be followed, and certain adjustments to the overall treatment approach should be made in order to address the individual’s specific needs. This might include:

 

• Enrollment in a physician-assisted withdrawal management program (medical detox) on an inpatient basis initially
• Continued participation in treatment following completion of the withdrawal management program
• Addressing other mental health disorders concurrently with medications and therapy
• Addressing other issues with substance abuse
• The use of substance use disorder therapy, which is the backbone of any recovery program
• Participation in social support groups, such as 12-Step groups, community center groups, etc.
• The addition of specific interventions that apply to the case, such as medical interventions for physical conditions, tutoring for school, occupational training, vocational rehab, occupational therapy, case management, family therapy, etc.

Because many individuals with alcohol use disorders do not voluntarily seek treatment, it is often up to friends, relatives, coworkers, employers, and other concerned individuals to discuss the need for treatment with the person and convince them that they need to get help. Some general principles one should consider when approaching a person who has a suspected substance use disorder include the following:

• There is strength in numbers. Try to get three or four relatives, friends, or coworkers who know the person well to sit down with them and discuss their concerns.
• Consider performing a substance use disorder intervention.
• Express concern and do not accuse or label the person.
• Consult with a therapist who treats addictive behaviors prior to approaching the individual.
• Investigate appropriate treatment providers that the individual can consult with prior to approaching the person. Give the person a list of treatment providers, or go with the person to contact them.
• Be concerned and firm, but try not to make the individual feel as if they are being attacked.
• Expect resistance.
• Explain how the individual’s alcohol abuse affects you personally.

Oftentimes, an initial intervention may not be successful. Repeated attempts to approach the person may have the best result, and each attempt lays further foundation for future attempts.

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