Progressive, Chronic, and Acute Alcoholism – The Differences

Physicians use the criteria available in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) to diagnose a person who has Alcohol Use Disorder (AUD). AUD is the medical term for “alcoholic”. Older medical terms used by addiction specialists were “alcohol abuse disorder” and “alcohol dependence disorder”. Since alcohol dependence is one of the main features of AUD, addiction specialists have simplified the diagnosis into “AUD”. A person who has AUD can have a mild, moderate or severe case of AUD depending on how many symptoms s/he has.

For the non-medical “lay person” the term “alcoholic” means a person who has difficulty dealing with life without drinking. He or she has become overly dependent on alcohol as a drug, drinking even to a point of ruin. Often, alcoholics exhibit withdrawal symptoms when they try to quit drinking. And they do try to quit, but it appears that their will-power is not enough.

There is also social stigma when a person identifies himself of herself as an “alcoholic”, thus, there is a recent trend of doing away with the negative labels. The catch phrases we hear now are “sober living” and “sober warrior”. More established ways of dealing with alcoholism include joining a drug rehab programme and/or attending mutual support groups such as Alcoholics Anonymous or SMART Recovery.

The National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine defines alcoholism as a primary disease. Factors that contribute to its development involve a person’s genetics, psychological state, and environment. In an article published in JAMA (Journal of the American Medical Association), addiction is also characterised as “progressive” in nature.

In this article, we are going to explain clearly what “Progressive Alcoholism” means. Because “Chronic Alcoholism” and “Acute Alcoholism” are terms that are often mentioned but not clearly explained, we will highlight the difference between the two. In all, we hope to have a better comprehension of how alcoholism presents itself as a health issue.

Progressive Alcoholism

When physicians refer to the term, “progressive disease”, what is often meant is that it is a disorder that does not undo itself, but only gets worse. Hence, the AA saying, “once a pickle, never a cucumber.”

The notion that alcoholism is a progressive disease was first introduced by E. Morton Jellinek, in the 1950’s. Today, the Jellinek curve is still widely used in medical literature.

Alcoholism as a progressive disease is characterised as:

Difficulty drinking in moderation once drinking has commenced

Periods when deterioration is not obvious, but is in fact happening

Needing intervention or alcoholism will only get worse

Some people also use the term “functioning alcoholic to describe a person who can seemingly carry on with every day activities, but is in fact burdened with the difficulties of an alcohol addiction.

Functional alcoholics are usually:

  • Lone drinkers
  • Drinks at unusual times of the day
  • Relies on drinks to relax
  • Drinks while on the way to work or school, “to feel confident”
  • Needs to drink in order to focus
  • Gets drunk even without intending to be drunk
  • Can drink a huge amount without feeling inebriated
  • Is in firm denial about having a drinking problem

It is important to note that functioning alcoholics may seem to be able to handle the daily hurdles of life. Most can be responsible enough with family and work responsibilities. However, though they do not seem to harm others with their actions, they are troubled by their drinking behaviour. Often, they are not aware that they are harming themselves with their addictive behaviour.

Progressive alcoholism can also be understood under the framework of brain damage as a result of heavy alcohol consumption. The areas of the brain hardest hit are

  • Ventral striatum and prefrontal cortex – the reward system of the brain
  • Hippocampus – controls memory
  • Cerebellum – regulates movement
  • Reticular activating system – sets our person’s sleeping and waking patterns

Once these areas of the brain are damaged, it would take time to get them back to their original condition. As alcoholism progresses, the damage gets worse and does not repair itself or reverse itself unless there is effective intervention.

Chronic Alcoholism

A recent research effort by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) identified five alcoholic subtypes. These are:

  • Young adult alcoholic
  • Young antisocial alcoholic
  • Functional alcoholic
  • Intermediate familial alcoholic
  • Chronic severe alcoholic

It is within the context of NIAAA’s subtypes that the term “chronic alcoholic” can be understood.

The NIAAA developed this typology to help people understand that alcoholism can be expresses differently among individuals, but these differences can be predictable described if we know what type of alcoholic we are dealing with.

From the results of this study the characteristics of the Chronic Alcoholic are:

  • Usually men who started drinking at 16 years of age
  • Were only diagnosed around 28-30 years old
  • Low motivation to abstain from alcohol
  • Tends to have a direct relative who is also addicted to alcohol
  • Will have an A&E visit due to alcohol-related medical emergencies

Can have mental health condition at the same time as having alcohol addiction. The usual co-occurring disorders are: depression, anxiety disorders, and social phobia.

Can also have other addictions to substances which include: cocaine, heroin, cigarettes and marijuana

Has tried intervention programs such as detox, rehab (in-patient and out-patient), and mutual support groups—but they do not successfully recover from addiction.

Medication has been used to treat chronic alcoholism to some degree of success. Since chronic alcoholics do not have a positive experience of rehab, some addiction specialists recommend brief psychosocial interventions instead along with the medications.

Acute Alcoholism

In medical practice, the term “acute” is almost always used in contrast to the word “chronic”. Simply said, an acute form of a disease is something that happens abruptly, has a short duration span, and must be dealt with quick corrective action. In contrast, a chronic disease is something that has lasted longer and needs maintenance medication or treatment.

If a person is suffering from acute alcoholism, s/he may be suffering from negative effects of drinking alcohol in the brief period that alcohol was consumed.

Acute alcoholism is also called “alcohol poisoning”. This brief period usually lasts a few hours and is considered a medical emergency. Acute alcoholism can also be used to describe a period of heavy binge drinking.

Events and situations that trigger an acute bout of alcoholism include:

  • Experience of trauma
  • Stress – prolonged or a sudden stressful event
  • Social situations where heavy drinking is encouraged

Because there is a tendency for upsetting events to trigger an act of heavy drinking, we can ask, “Why do some people turn to alcohol and some do not when stressed?”

Genetics and the surrounding environment are the two major factors that decide what type of coping mechanism a person employs during trying times. The person who suffered from an acute episode of alcoholism could have inherited genetic tendencies to render him/her prone to alcoholism. Likewise, the if the people surrounding the person act like drinking is part of everyday life—ingrained in their family rituals and so on—the drinking behaviour is encouraged.

It is already an established fact that children raised in homes where there is an alcoholic addicted adult tend to start drinking heavily themselves. In addition, the burden of having an alcoholic parent takes a toll on children who may not be mentally able to handle the demands of taking care of themselves and an incapacitated adult.

What progressive, chronic and acute alcoholism have in common

The negative physical, emotional and psychological effects of alcoholism cannot be ignored. Whether alcoholism is called a progressive disease or it is a chronic life-long condition or just a case of acute alcoholism, the problem is serious. Like any other disease that necessitates treatment, the sooner help is given, the better.

Successful treatment of alcoholism is not a far-fetched idea. People have recovered from alcoholism, and it is not all about self-discipline. Nor is it simply a matter of joining a group like AA. If alcoholism is treated like a disease that it is, it can be approached as a health issue instead of a moral issue. Although spiritual interventions are effective, they should not be the end-all-be-all of alcoholism treatment. According NIAAA, successful treatment encompasses

  • Behavioural Treatments – counselling and psychotherapy interventions such as 12 Step Programs and Cognitive Behavioural Therapy (CBT)
  • Medications
  • Joining mutual support groups

The NIAAA also advocates the use of other forms of treatment outside residential in-patient rehabs. These alternatives are:

  • Outpatient treatment, where the person visits treatment providers in a set schedule (physicians psychotherapists and out-patient clinics)
  • Inpatient overnight stays in a hospital for a short and specific period of time.

In the UK, the NHS recommends detox in a clinic if AUD is severe. But there is also an option for home detox with assistance from a healthcare provider if alcoholism or AUD is mild to moderate.

The specifics of AUD treatment depends on many factors including the person’s goals for treatment, family situation, and general state of health. The initial steps of obtaining treatment are usually the hardest to take, but seeking the right kind of help in the right places will pay off in the long run.

Alcoholism: Learned Behaviour versus Genetic Inheritance

Over the years, addiction specialists and behavioural specialists have had different opinions about how alcoholism originated. Largely, the consensus is that the two factors contribute to epidemic that is touted as a lifestyle disease. In the medical field, alcoholism is seen as a primary progressive disease. In the field of psychology, it is treated as a mental illness.

In this article, we will review the two major ways in which alcoholism is explained. It is not about whether genetics matter more than learning or vice versa. Alcoholism is a complex phenomenon which does not merit the stigma that it receives.

Alcoholism As A Disease: Alcohol Use Disorder

Alcohol Use Disorder (AUD) is the formal medical term used to describe what everyday language refers to as “alcoholism”. A person who is affected by alcoholism is called an alcoholic, and this name incurs a lot of negative associations. Popular depictions of alcoholics show a person who is not able to deal with life, dishevelled, irresponsible and self-destructive.

We must understand that AUD is what experts describe as a heterogeneous disease”. A heterogeneous is simply a disease that expresses itself differently from individual to individual. Examples of heterogeneous diseases are cancer and asthma. It is understood that cancer and asthma are diseases that have different origins and many subtypes. Alcoholism, or AUD, seen through medical lenses is treated the same way: it has multiple causes and a variety of subtypes.

Alcoholism: Genetic Determinants

A scientist in the medical field who specialises in aetiology studies the origins of a disease such as AUD. As AUD is classified as an illness, research on the aetiology of AUD has produced interesting findings on what predisposes individuals towards alcoholism. These findings are:

  • Genes predispose a person to AUD. People (male or female) who have direct relatives with AUD are 50 to 60% more likely to develop AUD than people who do not have alcoholic relatives.
  • Sensitivity to alcohol is found to be inherited. In people who have relatives with AUD, it was discovered that they have a higher tolerance for alcohol, and they get more stimulated when they consume alcohol. It is theorised that they have inherited more sensitive reward pathways in the brain for alcohol use.
  • People prone to AUD could have hyper-activate brain pathways involved in the reward mechanism. Also, there is a risk that these individuals will have maladaptive associative learning related to alcohol consumption.
  • Genes that make people more likely to have AUD have been identified. Although there is no single gene that can be called, an “alcoholic gene”, the identified genes, interacting with several factors, contribute to AUD occurrence.
  • The genes that predispose people to AUD are genes involved in GABA production, opioid production, dopamine generating genes, as well as acetylcholine and serotonin transmission genes.
  • Current research efforts focus on the identification of phenotypes that make a person prone to AUD. Phenotype studies involve taking samples from participants and finding genetic patterns
  • Variations in hundreds of genes, intricately co-operating with various social factors influence the occurrence of AUD. It is not just one or several genes involved, but a multitude
  • In 2019, a genomic study where 275,000 people participated, 18 genetic variants associated to AUD were identified.
  • It is theorised that 51 genes from various chromosome regions contribute to AUD.

There are several implications of aetiological findings on AUD. First, inheriting AUD is largely dependent of inheriting the genes and the person’s exposure to alcohol usage in his or her environment. Second, after identifying the genes, the challenge is to know which disorders happen along with it (co-morbid disorders), and what these diseases contribute to the occurrence of AUD.

Third, the genes do not only predict AUD, they also predict how severe it will be in an individual. The specifics have yet to be understood. Fourth, genetic inheritance of AUD carries along with it alcohol-associated diseases such as cancer and cirrhosis. To what extent do the alcoholic-susceptibility genes influence the occurrence of these co-morbid disorders?

Fifth, what direction or route do these risks take a person who has an alcoholic relative? To what extent can we change this trajectory of risk? And how? Lastly, we are still to find out added insights about phenotype studies with regard to using environmental factors to thwart the susceptibility to AUD.

Knowing that there are genetic factors is only the first step. Scientists plan to identify the genes, study how they function, know the extent of their influence, and ultimately find ways to prevent AUD from happening. This is especially true for the most vulnerable cohorts: people who have a close relative with AUD. It is not far-fetched to think that one day, there may be a vaccine created to ward off AUD.

Alcoholism: Learning how to be an alcoholic

Having a relative with AUD increases the chances of developing the disease not just because of genetics. Behaviourists would argue that environmental factors matter more than genetic factors. The first way learning theories explain alcoholism is a behaviour is through “modelling.”

Modelling is explained as copying a behaviour we see someone doing. Drinking alcohol and being addicted to it is copied by people who live in close proximity to an alcoholic. The more we see something done, the more we are likely to copy it, even if we are doing it in an unconscious way. Particularly, children copy parents’ behaviours, even when parents tell them not to. Modelling is one of the key concepts of Social Learning Theory in Psychology.

Another way behaviourists explain AUD is the fact that relatives of people who have AUD are likely to experience behavioural problems, as living with an alcoholic is stressful. Because alcohol consumption is seen as a way to cope, the relative eventually uses alcohol to relieve the stress.

Lastly, individuals who live with AUD sufferers have a lot of opportunity to use the substance, because it is “just there.” Alcohol becomes a fixture in their daily lives—it is readily available and normally consumed as part of a routine.

Alcoholic behaviour is shaped and conditioned

When discussing environmental factors influence behaviour, two central concepts discussed are “conditioning” and “shaping”.  For conditioning, we refer to classical conditioning and “operant conditioning”. Shaping happens progressively as a person is being conditioned.

Developed by psychologists who come from the school of behaviourism, classical conditioning is when a previous neutral stimuli (for example, alcohol) becomes paired with a response (for example, relaxation). Drinking alcohol becomes associated with relaxation. This association in gradually strengthened as the paired stimuli and response is repeated again and again.

For operant conditioning, we must mention rewards and punishments. Accordingly, if an experience is rewarding, we repeat it. If it has a punishment, we tend not to repeat it.

In terms of alcohol use, both types of conditioning are soundly based in neurobiology. Studies have shown that the more usage a reward pathway has, the harder it is for unlearning to happen. It can be said that learning something in the brain-level is very similar to learning something with our bodies. The more we use a group of muscles, the more likely we retain muscle memory and do what we learned unconsciously.

Scientists argue that is learning can happen, then un-learning is possible too.

In this video, the speaker introduces the concept of a shared space as a key element to unlearning. In alcohol addiction, going to rehab is an option people take in order to combat the disease.

In a rehab setting, there is a shared space where unlearning can happen. In this closed environment, the focus is changing alcohol addiction behaviours. Most rehab centres in the UK embrace the 12 Step Program and Cognitive Behavioural Techniques. Both are proven ways to unlearn damaging behaviour.

When people who have similar experiences spend time together in a neutral ground, collaboration happens. We can say that the process of unlearning is enriched by the impact of having a helpful community—such is the appeal of rehab.

Another tool employed by behaviourists to correct addictive behaviour is counter-conditioning. What is usually done is pairing a previously pleasurable experience with something that feels negative. An example of this would be using a drug to illicit nausea when alcohol is consumed, the goal being to make AUD persons associate nausea with alcohol consumption.

As for “shaping”, behaviour is shaped by gradually making a person perform the desired action by slowly. Shaping applied in animal behaviour training would be giving a pet a special treat every time it moves closer to the desired behaviour a person wants it to perform. Reinforcing the desired behaviour by repeating it, slowly inching towards the desired behaviour, shaping is considered a success when the end goal is achieved. Behaviourists have successfully used shaping with persons with disabilities as well as cocaine addicted individuals. With some adaptations, it has been integrated in Behavioural Change Techniques focused targeting excessive alcohol consumption.

In a glance

  • Some people inherit the genes that make them prone to drink heavily.
  • It is prudent to consider not using alcohol is a family member is affected by AUD, as the tendency to develop AUD is stronger with direct relatives of AUD affected individuals.
  • Having the phenotype for AUD does not guarantee that a person will develop AUD.
  • Environmental and social factors will largely determine if an AUD-prone person will be affected by AUD.
  • Alcoholism as a behavioural problem can be systematically tackled; behaviour can change through psychotherapeutic measures using behavioural techniques.