Ethanol deprivation & mood | 10.9.2018
by William Haning, MD | Oct 08, 2018
In the lead full-text article correlating symptoms of PTSD with risky or problem alcohol consumption (Posttraumatic Stress Disorder Symptom Association With Subsequent Risky and Problem Drinking Initiation), there is a direct association made between the finding of irritability and at-risk drinking. While the study is designed to examine PTSD in the context of alcohol use, it manages to reemphasize a finding that all addiction clinicians are familiar with, the prominence of irritability, mood reactivity and dysphoria, among those who engage in at-risk drinking. The timing for this finding came just as the U.S. Senate was compelled to examine the implications of a drinking history for a high level of executive function.
Alcohol use disorders are generally thought of in the context of intoxication. It is worth remembering that any penalties assigned to drinking are related to the actual blood level of alcohol. When we see patients in the emergency room, or whose elective surgical procedure is delayed, or who is being taken down by police for combat of behavior, or who has just lost her job as a result of insulting comments made during an office social event, the sentinel for all of these is the proportion of alcohol in the blood. But any set of criteria for alcohol use disorder includes far more than short-term behavior, that is, more than behavior while drunk. Most of us have agreed for almost 40 years (DSM3,1980) that it is not the volume of the alcohol consumed or even the frequency with which it is consumed that determines dependence upon alcohol, but rather the consequences of the drinking. Because the findings are less dramatic with acute abstinence, or even protracted abstinence, it does not mean that they are less severe or damaging. Many alcoholics – I use the self-designation intentionally – will report families or associates remarking to them, at some point in the first year of sobriety, “I sort of wish you were drinking again, you were at least more fun.” And if that doesn’t strike a resonant chord for those working with alcohol use disorder patients, it certainly will for those who treat nicotine dependence (i.e., tobacco use disorder DSM5). The DSM5 criteria aside, the literature of alcoholism acknowledges the chronically mood-dysregulating effects of alcohol use, extending even to those with long-term abstinence (e.g., Ziheri S & colleagues, Trait aggression and hostility in recovered alcoholics).
So back to the point: one reason learning theory does not work well in describing behaviors of alcohol use and abstinence is that some of the really bad stuff just happens when the alcohol intake stops. Yes, people die from alcohol poisoning. But with frightening frequency, before the advent of good withdrawal medication, they would die from its deprivation. In a learning-theory model, when somebody who has been intoxicated wakes up at 2:00 AM with a headache, agitation, hyperemesis, myalgias, and just Olympian misery… at that moment, it is not the alcohol that is causing distress, but the want of it. The temporal association with misery is with abstinence. And at some point, the withdrawing inebriate realizes that he or she felt much better, even elated and happy, when drinking five hours earlier. The lesson is obvious and compelling: if I want to feel better, I need to drink. This serves as an acute indicator for what will more protractedly happen in the weeks and months following the decision to abstain. Members of AA still call this a “dry drunk”, when one is fractious and even abusive. It is appropriate that such a mood is called “intemperate”: nasty, hypercritical, volatile, moody and insulting, all adjectives that describe the unhappy alcohol addict who is not drinking, in either the short or the longer term. And it is why the pattern of alcohol use that we call a disorder is a behavioral disorder, and not simply an intoxication.
– W. Haning, MD
It’s ironic, isn’t it, that things happen just as Dr. Haning describes, not only with alcohol but with ALL drugs of abuse. I think this is the spiritual/Satanic effect.
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