INTRODUCTION

Project Overview

The following case study project involves the treatment of an individual, known here as George J. (This is not the individual's true name). George was initially presented to treatment for chronic alcoholism. The patient was brought into the treatment facility by his parents. His parents stated that despite numerous treatment attempts, George had been unable to maintain any significant length of abstinence from alcohol. Prior to entering treatment, George had been treated at a local hospital for injuries sustained when he drove his bicycle over an embankment while intoxicated. His parents stated that George had been in the ditch overnight, and that he was found the following morning by a passing pedestrian. George was treated at a local hospital for his immediate medical conditions. After George's stabilization, the hospital recommended that he be referred to a treatment center for his alcoholism. During the initial intake screening process, George stated that he was a forty-two year old medical doctor, who had been unable to practice medicine for the past three years due in part to his alcoholism. George stated that he had had four previous treatment episodes for his alcoholism. He had been hospitalized two times in 1993, once in 1994, and once in 1995. The patient stated that he had also been hospitalized in a psychiatric hospital in 1993 for a period of ten days, following a failed suicide attempt. At that time George had been given two DSM IV Axis I Diagnostic codes -- Axis-I 296.3x -Major Depression Recurrent, and 303.90 - Alcoholism. Upon admission into detox, George was receiving 25 mg. doses of Librium four times per day as a preventative step down for severe alcohol withdrawal. George was also taking one 100 mg. dose of Doxopin per day, for depression. George stated that he had only taken his Doxepin on an intermittent basis since he was first prescribed the medication in 1993.

An effective treatment approach was required in order to deal with George's specific needs. Because George had two separate Axis I Diagnosis', the theoretical approach selected for this case was the Integrative Dual Diagnosis Treatment Approach.

Chapter 2 of this project will examine a review of the literature related to the clinical problems of dealing with alcoholism, and alcoholism with co-existing mental illness. Chapter 2 will review the literature for various theoretical frameworks of alcoholism, its etiology, and treatment approaches. The theoretical approaches that will be reviewed in Chapter 2 are:

1.) Alcoholics Anonymous

2.) Psychoanalytic

3.) The Medical Model

4.) Family Interaction Concept

5.) The Behavioral Model

6.) Sociological Concept

7.) Transactional Analysis

8.) Models of Treatment for the Dually Disordered Population

9.) An Integrative Dual Diagnosis Approach

Chapter 2 will also include an overview of the dually diagnosed population, i.e. individuals with substance abuse coupled with mental health problems. Because the focus of this project concerns itself with the case study of an individual with alcoholism and depression, Chapter 2 will also include an overview of the current literature on depression, and depression as it relates to alcoholism.

REVIEW OF THE LITERATURE

Theories of Etiology

In trying to identify the causes of problem drinking, some researchers have stressed the role of genetic and biochemical factors; others have pointed to psychosocial factors, viewing problem drinking as a maladaptive pattern of adjustment to the stress of life; still others have emphasized sociocultural factors, such as the availability of alcohol and the social approval of excessive drinking. As with most other forms of maladaptive behavior, it appears that there may be several types of alcoholic dependence, each with somewhat different patterns of biological, psychosocial, and sociocultural causal factors. Recently, a committee of experts from the National Academy of Sciences (Institute of Medicine, 1990) concluded that identifying a single cause for all types of alcohol problems is unlikely.

Biological Factors

In an alcohol dependent person, cell metabolism has adapted itself to the presence of alcohol in the bloodstream and now demands it for stability. When the alcohol in the bloodstream falls below a certain level, withdrawal symptoms occur. These symptoms may be relatively mild -- including a craving for alcohol, tremors, perspiration, and weakness -- or more severe; with nausea, vomiting, fever, rapid heart beat, convulsions, and hallucinations. The shortcut to ending them is to take another drink. Once this point is reached, each drink serves to reinforce alcohol seeking behavior because it reduces the unpleasant symptoms. An unusual craving could result from a genetic vulnerability. The possibility of a genetic predisposition to developing alcohol abuse problems has been widely researched. Cotton, (1979) in a review of 39 studies of families of 6251 alcoholics and 4083 non-alcoholics who had been followed over 40 years, reported that almost one third of alcoholics had at least one parent with an alcohol problem. More recently, a study of children of alcoholics by Cloninger et al. (1986) reported strong evidence for the inheritance of alcoholism. They found that for males, having one alcoholic parent increased the rate of alcoholism from 11.4 percent to 29.5 percent, and having two alcoholic parents increased the rate to 41.2 percent. For females with no alcoholic parents, the rate was 5.0 percent; for those with one alcoholic parent the rate was 9.5 percent, and for those with two alcoholic parents it was 25.0 percent. However, it should be kept in mind that the majority of individuals in the study did not have alcoholic parents. Also, such studies do not rule out environmental influences such as modeling.

One approach to understanding the precursors to alcoholism is to study the behavior of individuals who are at high risk for substance abuse but who are not yet affected by alcohol -- prealcoholic personalities. An alcohol-risk personality has been described by Finn (1990), as an individual (usually the child of an alcoholic) who has an inherited predisposition toward alcohol abuse and who is impulsive, prefers taking high risks, is emotionally unstable, has difficulty planning and organizing behavior, has problems in predicting the consequences of his or her actions, has many psychological problems, finds that alcohol is helpful in coping with stress, does not experience hangovers, and finds alcohol rewarding.

Finn et al. (1990) found that pre-alcoholic men show different physiological patterns than non-alcoholic men in several respects. Pre-alcoholic men are more sensitive to stress-response dampening (lessened experience to stress) with alcohol ingestion than nonalcoholic men. They also show different alpha wave patterns on EEG (Stewart, Finn, and Pihl, 1990). Pre-alcoholic men as defined by the personality characteristic, were found to show larger conditioned physiological responses to alcohol cues than were individuals who were considered low risk for alcoholism, according to Earlywine and Finn (1990). These results suggest that pre-alcoholic men may be more prone to develop tolerance for alcohol than low risk men. In support of possible genetic factors in alcoholism, some research has suggested that certain ethnic groups, particularly Asians and American Indians, have abnormal physiological reactions to alcohol. Fenna et al. (1971) and Wolff (1972) found that Asian and Inuit (A member of an Eskimo people) subjects showed a hypersensitive reaction, including flushing of the skin, a drop in blood pressure, and nausea, following the ingestion of alcohol. The relatively lower rates of alcoholism among Asian groups are tentatively considered to be related to a faster metabolism. However, Schaefer (1977, 1978) questioned these and other metabolism studies as a basis for interpreting cultural differences in alcoholism rates using more explicit criteria of metabolism between a group of Reddis Indians and a group of Northern European subjects. He concluded that further research into metabolism rate differences and sensitivity to alcohol needs to be integrated with studies focusing on relative stress in various cultures.

There has been evidence linking drug dependency or alcoholism with genetic factors, psychological factors, and sociocultural factors, but none of the research has demonstrated that any one of these factors is the major contributor to the etiology of chemical dependency (Lawson, Lawson and Rivers, 1996).

Psychosocial Factors

Not only do alcoholics become physiologically dependent on alcohol, but they develop powerful psychological dependence as well. Because excessive drinking is so destructive to an individual's total life adjustment, the question arises as to why psychological dependence is learned. A number of psychosocial factors have been advanced as possible answers.

Psychological Vulnerability -- Is there an "Alcoholic Personality?" -- A type of character organization that predisposes a given individual to turn to the use of alcohol rather than some other defensive pattern of coping with stress? In efforts to answer this question, investigators Integrative Dual Diagnosis Treatment Approach to an Individual have reported that potential alcoholics tend to be emotionally immature, to expect a great deal of the world, to require an inordinate amount of praise and appreciation, to react to failure with marked feelings of hurt and inferiority, to have low frustration tolerance, and to feel inadequate and unsure of their abilities to fulfill expected male or female roles. Morey, Skinner, Blashfield (1984) have shown that individuals at high risk for alcoholism development were significantly different in personality in terms of showing more impulsion and aggression, from those at low risk for abusing alcohol.

The two psychopathological conditions that have been most frequently linked to addictive disorders are depression (Lutz and Snow, 1985; Weissman et al., 1977; Woodruff et al., 1973) and antisocial personality (Cadonet et al., 1985; Seixas and Cadonet, 1974; Stabenau, 1984). By far, most of the research has related antisocial personality and addictive disorders, with about 75 to 80 percent of the studies showing an association between the two (Alterman, 1988; Grand et al., 1985). While such findings provide promising leads, it is difficult to assess the role of specific personality characteristics in the development of alcoholism. Certainly many people with similar personality characteristics do not become alcoholics, and others with dissimilar ones do. The only characteristic that appears common to the backgrounds of most problem drinking is personal maladjustment, yet most maladjusted people do not become alcoholics. An alcoholic's personality may be as much a result, as a cause of his or her dependence on alcohol. For example, the excessive use of alcohol may lead to depression, or a depressed person may turn to the excessive use of alcohol, or both.

In somewhat of a different approach to transmission of alcoholism, Lawson, et al. (1983) proposed or identified four parental types which are associated with the development of alcoholism in the offspring. They stated that alcoholics have typically had one or both parents in one or more of the following categories:

1.) The Alcoholic Parent - The child learns alcoholic behavior as a way of dealing with problems, modeling the parents' behavior.

2.) Teetotaler Parents - This parent is too rigid and has unreasonable expectations for the child, from which he eventually rebels by drinking.

3.) The Over-Demanding Parent - The stress of an overly demanding parent may result in such a low self esteem that the child turns to alcohol to feel better about himself.

4.) The Over-Protective Parent - The children of these parents never develop the self confidence necessary to deal with life's problems and may resort to alcohol as a coping mechanism.

Sociocultural theory of alcoholism is based on an ethnic group's approval/disapproval of drinking alcohol. Pittman (1967) placed cultural attitudes toward drinking on a continuum as follows: (1) abstinent culture; (2) ambivalent culture; (3) permissive culture; and (4) over-permissive culture. These attitudes reflect customs, values and sanctions of different ethnic and social groups. Thus, frequent and heavy drinking is accepted and even almost expected in some cultures. Examples include American Indians, and the Irish (McGoldrick, et al., 1982). Thus these groups tend to have more problems with alcoholism. Integrative Dual Diagnosis Treatment Approach to an Individual with Alcoholism and Coexisting Endogenous Depression 11 In contrast the authors point to the Jewish people as an example of an ethnic group which frowns upon excessive use of alcohol. The Jewish tend to emphasize intellectual achievement and pursuits, and disapprove of anything that interferes with these pursuits. Even though the Jewish do use alcohol in some of their religious ceremonies or rituals, they do not characteristically have problems with alcohol abuse as a group. Lawson, et al. (1983) identified three factors that contribute to alcohol consumption problems within a given culture. These include: (1) the degree to which the culture produces inner tension in its members; (2) the culture's attitude toward drinking; and (3) the degree to which the culture provides substitutes for alcohol usage.

The learning theory model holds that all behavior is learned through modeling and/or social reinforcement. Children who see their parents using alcohol as a coping mechanism would theoretically be more likely to model this alcohol usage for the same purpose for themselves. Also, if alcohol is effectively used to reduce situational anxiety, this is reinforcing to that individual. Thus, what works once is repeated again and again, forming a pattern that may lead to abuse and alcoholism.

Rapid social change and social disintegration also seem to foster excessive drinking. For example, the U.S. Public Health Service's Alaska Native Medical Center reported excessive drinking to be a major problem among the Inuit in many places in rural Alaska (Time and Apulzz, 1974). This problem was attributed primarily to rapid change in traditional values and ways of life, in some cases approaching social disintegration. The effect of cultural attitudes toward drinking is well illustrated by Muslims and Mormans, whose religious values prohibit the use of alcohol, and by orthodox Jews, who have traditionally limited it's use largely to religious rituals. The incidence of alcoholism among these groups is minimal. In comparison, the incidence of alcoholism is high among Europeans who comprise less than 15 percent of the world's population yet consume about half the alcohol (Sulkunen, 1976). Interestingly, Europe and six countries that have been influenced by European Culture -- Argentina, Canada, Chile, Japan, the United States, and New Zealand -- make up less than 20 percent of the world's population, yet consume 80 percent of the alcohol (Barry, 1982). The French appear to have the highest rate of alcoholism in the world, approximately 15 percent of the population. France has both the highest per capita alcohol consumption and the highest death rate from Cirrhosis of the Liver (Noble, 1979). Thus it appears that religious sanctions and social customs can determine whether alcohol is one of the coping methods commonly used in a given group or society. There appears to be many reasons why people drink, as well as many conditions that predispose individuals to do so and reinforce drinking behavior, however, the combination of factors that result in a person's becoming an alcoholic are yet unknown.

Alcoholism Theories and Views on the Etiology

In the field of alcoholism theory and treatment, a number of conceptual frameworks have been advanced, all of which purport to explain the nature of alcoholism.