Alcoholics’ drinking patterns can take various forms which are quite different from each other. In this chapter we shall be discussing what types of drinking pattern we can recognize and the usefulness of distinguishing between them.
Some writers on alcoholism, particularly influenced by Alcoholics Anonymous, have tended to concentrate exclusively upon one pattern of drinking (which we shall be describing under the heading of the compulsive alcoholic) and to ignore the many other distinct forms that are to be found. So many of their members drink in this pattern that to them it is the paradigm of alcoholism. Jellinek1 puts it: ‘Alcoholics Anonymous have naturally created the picture of alcoholism in their own image’. This narrow approach does a serious disservice. It must be firmly realized that there are many people who have to be classified as alcoholics and need treatment on that basis, but who are not of the compulsive variety. Otherwise errors will be made both in the provision and planning of treatment services, and by turning away people who are motivated for treatment and would be eminently responsive.
A close examination of his drinking pattern makes possible much more than the mere recognition that a man is an alcoholic. Getting a careful account of the mode of drinking is essential for correct diagnosis and on this depends the treatment regime which will be advised.
Some people drink themselves into alcoholism without perceiving that they are addicted. They may not have any conspicuous abnormality of personality. Sometimes, and this is far from being uncommon, a man will present with a physical illness or injury, the nature or circumstances of which prompt the doctor to question him about drinking. He may have broken his leg and appeared intoxicated at hospital; he may have a gastric ulcer or another condition to which alcohol is known to predispose; he may have one or more of the well recognized complications of alcoholism such as cirrhosis of the liver or peripheral neuritis. Questioning reveals three things: that he regularly consumes a great deal of alcohol, that he has never considered himself an alcoholic and that he has not before had any medical trouble from drinking. The physician or surgeon who views his task primarily as that of treating the physical disorder has grounds to diagnose the underlying alcoholism, but may be inclined to leave the interrogation there; the patient is then thought’of as someone who is the victim of alcohol without being affected by alcoholism. Alternatively he may be recognized as an alcoholic but the management of this aspect of his condition is not pursued. The notion that he is an alcoholic or that he is dependent on alcohol he would vigorously dismiss if it were put to him. But it is not. The physician’s disinclination to explore the diagnosis is strengthened if the patient does not show any craving for alcohol while he is being treated. Only if he asks for alcohol or shows withdrawal symptoms will the true nature of his dependence be apparent to all.
In our opinion, alcoholism developing by mischance, through long exposure but without predisposing factors in the personality, is extremely rare. Appropriate interviewing techniques will generally elicit from such patients first that if they do not have a drink their equanimity and poise is sufficiently disturbed to prevent them carrying on smoothly with life and, second, that there have been occasions when they have become fearful of the hold alcohol has gained on them, and tried to give it up. In spite of their protestations that on discharge they will effortlessly stop drinking, they seldom do so. Most of these people have insidiously become addicted to alcohol, but because they have acquired a high tolerance they have never appeared blatantly intoxicated. Consequently they may not come to medical notice until nutritional disorders develop, often hastened by dietary restrictions due to economic stringency. It is a great disservice to allow such people to leave hospital unacquainted with the reality of their situation. Occasionally one of them will manage to give up drinking by his own efforts but for the great majority special treatment is essential if they are not to continue to deteriorate. These people are addicted to alcohol. They cannot go for long without drinking once away from the sheltered environment that hospital provides. When they leave they revert to abnormal drinking. An accountant of 40 was admitted to hospital with a gastric ulcer. At that time he was drinking two bottles of whisky a day. This was noted as a cause for his ulcer, and he was advised to cut down. When he was told why, he cheerfully assented. However, when he left hospital he found himself unable to do so. Eight months later he had an attack of delirium tremens. Even after this he could not accept that he was an alcoholic. It was only after a subsequent suicide attempt that he consented to enter hospital for the treatment of alcoholism. Evidence of a lifelong personality abnormality was then revealed. As a child if he was called on to perform at school or at parties he would weep. As a young man he could speak in public only if he drank beforehand. Towards his mother, and subsequendy towards his wife, he was both excessively aggressive and abnormally dependent. In the therapeutic situation he at first attempted to evade exploration of his behaviour by adopting a manner of jaunty superficiality. When this was penetrated he became seriously involved in his own treatment.