What is Normal Drinking Versus Problematic Drinking?
Drinking alcohol is an accepted and often encouraged part of American culture. Consider holidays where alcohol takes center stage. From New Year’s Eve parties to St. Patrick’s Day celebrations, to events like football games and house parties, drinking alcohol is considered an entrenched part of many of these gatherings.
Recognized as a part of our standard social fabric, drinking alcohol is often cited as the reason to get together– want to go out for a drink? It is even a presumed component of dining out. Consider when the waiter asks you immediately upon being seated – would you like something from the bar? It is no wonder that problem drinking can sneak up on someone.
Even Small Amounts of Alcohol Affect the Brain
Often, people don’t realize they are developing a habit or that their drinking is harming them until it is pointed out to them, or their health suffers, and even then, the first response is denial. No one wants to think they drink too much and it is common for someone to disagree that their alcohol intake is having a poor effect on their physical or mental health.
Yet the facts about the effects of alcohol can’t be denied! Drinking in excess shrinks our brains. It was found that the more someone drinks the more dramatic the effect on an individual’s cognitive abilities. Going from zero to one unit of alcohol was associated with 6 months of aging. Going from zero to four drinks was linked to more than ten years of aging.[1]
Even what may not be considered excessive drinking has an effect. The same study found that an individual who drinks two drinks a day ages their brain the equivalent of two years.
Currently, the CDC recommends that nonpregnant adults of legal drinking age who wish to drink in moderation should consume no more than 2 drinks in a day or less for men and one drink or less in a day for women.[2] Yet, as the 2022 University of Pennsylvania research revealed, even these CDC guidelines don’t mean that drinking is safe. Excessive alcohol use is the third-leading cause of preventable death in the US and the cause of over 140,000 annual deaths.[3]
Alcohol has been linked to numerous mental and physical health challenges. Various studies have revealed a direct correlation between drinking three or more alcoholic drinks per day and an increase in stomach and pancreatic cancers. Evidence also exists of the increased risk for other cancers as well, including, prostate cancer, liver cancer, and more. Beyond cancer, other health risks include:
Liver disease
High blood pressure
Stroke, heart, and gastrointestinal problems
Mental health issues
Poor sleep
Screening Tests are Easy Ways to Raise the Flag on Alcohol Dependency
Each year in April, a day is set aside known as National Alcohol Screening Day. The idea is to help raise awareness of the harmful effects of alcohol abuse and alcohol dependency. There are different ways to classify the extent of someone’s drinking but questionnaires either administered by an individual’s primary care physician, or through an online screening tool can help. While the results of a screening test do not equate to a diagnosis, they do help to provide input as to whether an individual has the potential for developing a substance use disorder involving alcohol.
Tests that someone can take at home include the CAGE questionnaire or the AUDIT (Alcohol Use Disorders Identification Test). The AUDIT is a simple and effective method to screen for unhealthy alcohol use. This test came from data from a World Health Organization study and is now the most commonly used instrument for alcohol screening. The CAGE assessment is comprised of four simple questions. Answering yes to two or more questions suggests substance dependency.
The acronym CAGE represents the keywords in each of the four questions used as a screening for alcohol dependency: Cut; Annoyed; Guilty; Eye.
The questions represented by the CAGE acronym are:
Have you ever felt you should “cut” down on your substance use?
Have people “annoyed” you by criticizing your substance use?
Have you felt bad or “guilty” about your substance use?
Have you ever used a substance first thing in the morning to steady your nerves or start the day (an “eye” opener)?
The most important thing in understanding whether alcohol is having a negative effect on you, or whether you may have an issue with alcohol dependence, is what you do about it. So, what is the next step if someone’s screening test gives them cause for concern? Seeking help can start with a visit to an individual’s primary care physician or a visit to a therapist or psychiatrist. If it is determined that alcohol may be impacting someone’s physical or mental health, motivational interviewing can be an important technique to identify these impacts and help support the positive lifestyle changes an individual is working toward in treatment.
Motivational interviewing helps individuals identify patterns in order to help them reach conclusions on their own about pursuing meaningful change. It is a technique that helps individuals gain a sense of motivation for change. Through discussion with their therapist or psychiatrist, motivational interviewing can help individuals see behaviors or patterns that they're not able to fully identify on their own.
With motivational interviewing, the idea is that instead of the typical hierarchical interaction where the therapist/doctor has all of the information and the knowledge in an attempt to teach the patient, it is more of a level playing field. With motivational interviewing, the client/patient is seen as the expert in his/her life. The expert (therapist, physician, etc.) works with him/her to reach a joint understanding of their behaviors and patterns based on life experiences to help move the individual forward and take action toward a healthier lifestyle.
Alcohol Addiction Should be Treated Individually
Alcohol addiction looks different for everyone which is why it is important for a provider to conduct an individualized evaluation of how alcohol is potentially impacting and playing out in someone's life. Since alcohol isn’t the only substance that may be responsible for its effects, a trained professional will evaluate the intake of all substances, including caffeine and nicotine for example.
Therapists and psychiatrists rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) to guide primary diagnosis for quantifying and classifying alcohol use – whether it is mild, moderate, or severe. Even if an individual is not meeting the criteria for problematic drinking, there still may be underlying impacts. It may be surprising to some that even low levels of alcohol intake can impact brain chemistry resulting in emotional and physical health effects.
While it may not always be problematic or unmanageable, there are signs such as anxiety, panic, irritability, sleep pattern changes, lack of deep restful sleep, depression, changes in memory, and difficulty with concentration and attention that may be related to alcohol abuse. Those impacts can lead someone to seek out help without realizing that these symptoms may be connected to drinking. A credible professional will spend time examining and differentiating the underlying cause of true major depression or other mental health challenges and to what extent if any, substances are involved.
The only definite way to determine the role of alcohol in someone’s behavioral health struggles is to remove the alcohol from the equation to evaluate any changes. However, for individuals that have been drinking heavily for a long time, those brain changes can take months, even up to a year, to stabilize and return to normal.
Is Alcohol Use Disorder a Mental Health Condition?
The short answer is yes. Alcohol provides a reinforcing pattern at the beginning that feels good or can eliminate anxiety or other negative feelings. However, over time, the brain changes and adapts to alcohol use. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), “Addiction is a chronic relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain. It is considered both a complex brain disorder and a mental illness. Addiction is the most severe form of a full spectrum of substance use disorders and is a medical illness caused by repeated use of a substance or substances.”
Some frightening implications of heavy drinking that may point to an abuse problem is when an individual blacks out or can’t remember certain portions of the day or evening while they were consuming alcohol. Alcohol impacts the memory centers of the brain and the cerebellum that dictate movement which is why field sobriety tests are used to evaluate disordered movements such as unsteady gait and poor hand-eye coordination.
When the brain becomes accustomed to alcohol use individuals may state that they have a “high tolerance” to alcohol which really indicates that more is needed to have the same effect. Tolerance happens because alcohol use changes the chemistry in your brain. Some individuals may lose the positive reinforcing effects of alcohol and begin to need it to alleviate any withdrawal symptoms to help them maintain a baseline. This complex interplay of neurochemistry and behavioral effects is the combination that keeps someone actively using alcohol. That’s why addressing it takes both a behavioral intervention and therapeutic intervention.
When considering the risk for alcohol use disorder there are many factors that layer into the propensity to develop the condition. Studies show there is a 50% genetic contribution.[4] The other half is personal influences like psychosocial and environmental stressors, such as the friends that someone spends time with and what they do when they get together. Underlying trauma, including unresolved childhood trauma, also plays a role.
What can someone do who is concerned about exposure to alcohol?
Choose social settings carefully. Don’t put yourself in a situation where alcohol is the focus.
Confide in members of a close support system. Be open with individuals to support you in your goals and be specific with them in identifying what they are and why sticking to your goals is important to you.
Create a level of accountability. That could mean having conversations on the front end of any potential social interactions with friends, letting them know you are not planning on drinking, and to not only support you with that but helping you remember that goal in the moment.
At Clarity, we meet patients where they are in their struggles. We take a holistic and comprehensive recovery approach starting with motivational interviewing and a physical examination. Next, getting the substance out of an individual’s system safely and effectively (also known as detoxing) helps the underlying neurochemical changes to settle in and stabilize. While it seems like a difficult journey, our partnership with patients is an individualistic approach that may incorporate the combination of medication management along with psychotherapy to help individuals break the grip of alcohol addiction.
[1] https://penntoday.upenn.edu/news/one-alcoholic-drink-day-linked-reduced-brain-size [2] Alcohol Questions and Answers | CDC [3] Deaths from Excessive Alcohol Use in the United States | CDC