Sometimes alcoholism occurs in a patient already suffering from a severe psychiatric disorder. This must then take first place in management. Alcoholism can be the symptom which brings to notice people suffering from depression or schizophrenia, from psychiatric illness due to brain disease or from mental subnormality.
The physician who treats numbers of alcoholics will always be vigilant to detect the patient whose drinking should properly be regarded only as a symptom of severe underlying psychiatric illness, the diagnosis of which calls for careful history-taking and psychiatric examination.
A 6o-year-old unmarried business woman was now retired. For forty years she had cared for her mother whom she described as a very determined person, the decision-maker in the family despite her constant laziness.
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In addition to being selfish, the mother distressed the family by always wanting to be at whist-drives, parties or the theatre. She had been widowed early and in her old age was deteriorated mentally; she had bowel trouble and soiled in the house. Six months previously her daughter, the patient, got down in the dumps, felt unable to relax and slept poorly; she did not know what to do about her mother and resentfully thought that the old lady just did not care about controlling her bowel movements. She began to drink heavily, soon taking half a bottle of brandy every day and a good deal of sherry. The drink did not relieve her depression but gave her the necessary energy to attack the added washing as well as the household chores. A month before she was first seen for her alcoholism the family doctor arranged for her mother to enter a home. The patient became still more depressed. She felt like a lost soul, increasingly sad and sleepless. She realized that she could not stop drinking. ?I think I'm an alcoholic. I don't think I'll be able to control my drinking even if I get better from this depression. Everybody says I shouldn't feel guilty about putting my mother away but I should have been able to cope until she was finished. It's duty rather than love. She had used alcohol to boost herself up, to help her get some sleep, to reduce her restlessness and to ease the distress of ‹“worrying too much about things I needn't worry about.
This patient's illness was a depressive reaction originally centred round her resentment towards her mother; her sense of failure and self-blame when her mother had to be sent away were other symptoms of the illness. The alcoholism was secondary to the psychiatric disorder. Drug treatment for her depression with psychotherapeutic measures were successful. She recovered quickly and proceeded to arrange a long cruise for herself. Drinking was no longer a problem to her.
Alcoholism may also be seen occasionally as an early manifestation of the psychoses caused by syphilis of the brain (general paresis), brain tumours or as part of the general picture of senile mental deterioration. In this group with structural brain lesions, the drinking tends to be both purposeless and poorly organized.