Gender and Developmental Presentations
There are substantial differences in the prevalence of alcoholism among different gender, age and racial/cultural groups. Unfortu-nately, the high prevalence among young adult and middle-aged males often leads to inadequate consideration of the possibility that women and the elderly may drink excessively.
Women are more likely to abstain from alcohol, and if they do drink, they are more likely to consume less alcohol than men. Nevertheless, in comparison to men, problem drinking among women is more likely to be associated with negative mood states, particularly depression, anxiety and somatic symptoms. Alco-holic women identify negative emotions and interpersonal con-flicts as antecedents of a relapse to drinking more frequently than men and substance-dependent women more frequently report de-pressive and anxiety symptoms as motivators for treatment. This is consistent with epidemiological and clinical studies which show that women who are diagnosed with alcohol or drug de-pendence experience higher rates of mood and anxiety disorders than their male counterparts. Furthermore, it is more common among women that mood and anxiety disorders precede the onset of substance use and dependence. Alcoholic women have a Nega-tive profile of situations surrounding their alcohol use, charac-terized by solitary drinking and greater severity of alcohol de- pendence, whereas alcoholic men tend to have a Positive profile, characterized by social drinking and drinking in the context of positive emotions. Studies comparing male and female alcohol-ics have found that women are significantly older than men when a variety of alcohol-related milestones occur, including regular drunkenness, loss of control over drinking, first drinking prob-lems, drinking to relieve withdrawal symptoms, first attempt to stop drinking and realization that alcohol use is a problem. These studies have also found that women exhibit more rapid progres-sion than men between the time of first regular intoxication and first treatment (Randall et al., 1999).
Despite drinking for fewer years at lower levels, women have an increased sensitivity to toxic effects of alcohol on body organs. Alcoholic women are more likely to develop liver damage and, in general, alcoholic liver diseases tend to progress faster among women than men. The five-year mortality rate among alcoholic women is almost twice the mortality rate of alcoholic men. Alcoholic women diagnosed with alcoholic liver disease die almost a decade younger than alcoholic men. Alcoholic women appear to be more susceptible to alcohol-induced brain damage, evidenced by greater widening of the cerebral sulci and fissures in CT scans of the brain, as well as poorer performance in cognitive testing. The concept of “telescoping” has been used to describe the course of symptom progression observed among women who, despite beginning heavy drinking later than men, experience al-cohol-related problems and seek treatment sooner than men.
Since alcohol is distributed in the aqueous phase, greater body fat composition among women reduces the volume of distri-bution. This, combined with smaller average body mass, translates into higher BALs for women in response to a specified level of al-cohol consumption. In addition, less first-pass metabolism due to less gastric oxidation of ethanol may also contribute to the higher blood levels obtained by women following an equivalent dose of ethanol. Compared with men, women with alcohol problems are also at greater risk of comorbid drug abuse/dependence. Perhaps as a consequence of these differences, women alcoholics who seek treatment do so earlier in the course of the disorder than do men.
Since heavy drinking among women is most prevalent during the child bearing years, it has important public health im-plications for prenatal alcohol exposure and possible fetal alcohol effects. A variety of adverse outcomes have been related to heavy drinking in pregnant women, although the minimum amount of alcohol and the pattern of consumption necessary to produce such effects are not known. Heavy drinking in pregnant women may produce malnutrition in both the mother and the fetus, as well as spontaneous abortion, preterm delivery and intrauterine growth retardation. Alcohol-related birth defects (ARBDs) are estimated to occur in as many as 1 in 100 live births The most se-vere manifestation of ARBDs is fetal alcohol syndrome (FAS), a constellation of morphological and developmental defects result-ing from high-dose prenatal alcohol exposure. FAS is estimated to occur in 1 in 1000 to 1 in 300 live births. Prenatal or postnatal growth retardation, CNS involvement and characteristic facial dysmorphology are necessary for a diagnosis of FAS.
Since ARBDs can be avoided, the evaluation of pregnant patients should routinely include questions about alcohol and other substance use. Routine screening with an instrument such as the AUDIT, or the T-ACE (Chang, 2001), supplemented by questions concerning drug use, may also be useful with preg-nant women. Those pregnant women who are identified as heavy drinkers or drug users should be designated as “high risk” and provided with specialized, comprehensive perinatal care, includ-
ing rehabilitation and appropriate attention to related psychoso-cial disabilities.
There are a number of features that distinguish adolescents with alcohol abuse/dependence from adult alcoholics. As might be ex-pected, adolescents have comparatively short histories of heavy drinking. A corollary to this is the rarity of physiological depend-ence on alcohol and alcohol-related medical complications among adolescents. Nonetheless, abuse of alcohol and drugs contributes in important ways to morbidity and mortality in adolescents, the leading causes of which are motor vehicle accidents, homicide and suicide. The values and behavior of the adolescent’s peer group are important elements in the evaluation of alcohol use and abuse in the adolescent. The evaluation of adolescents with an al-cohol disorder must also take into account other prominent devel-opmental issues that characterize adolescence, including the con-flict inherent in asserting one’s independence from the family.
A number of instruments have been developed for the as-sessment of substance use symptoms and disorders in adolescents (Kaminer, 1994). As is generally true in dealing with adolescents, given their economic and emotional dependence, whenever pos-sible a thorough family evaluation is important for understanding the adolescent’s substance use and related problems.
Although heavy drinking is less prevalent in the elderly, it is none-theless an important source of morbidity in this group. Elderly al-coholics suffer from more chronic medical problems and poorer psychosocial functioning than elderly nonalcoholics. The increased use of prescription medications in the elderly increases the potential for adverse pharmacokinetic interactions with alcohol. In addition, decreased cognitive functioning associated with heavy alcohol use can increase medication errors and noncompliance in this group.
The manifestations of alcoholism in the elderly are often more subtle and nonspecific than those observed in younger indi-viduals. Because self-reported alcohol consumption may be partic-ularly unreliable in the elderly, other sources of information such as family and neighbors should be used to identify heavy drinkers. The following areas should be systematically evaluated in the eld-erly when heavy drinking has been identified: untreated medical illness, prescription drug abuse, psychiatric comorbidity, cognitive impairment, functional assessment and need for social services.
Similar to the approach used with younger adults, alco-holism in the elderly has been classified by age of onset. It has been estimated that about two-thirds of elderly alcoholics began heavy drinking prior to age 60, while the remaining one-third began heavy drinking after the age of 60. Late-onset alcoholism appears to be more common among women and people of higher socioeconomic status and is less frequently associated with a family history of alcoholism. As might be expected, older alco-holics with early-onset alcoholism also have more alcohol-related medical and psychosocial problems and are more likely to require alcoholism treatment.