Family and social effects Traditional stereotypes of people with alcohol problems include scruffy, derelict, amoral, weak-willed individuals without friends or family Carr, ; Catalbiano et al.
However, while people in lower socioeconomic groups are at increased risk of alcohol-use disorders, large proportions of individuals with such problems are highly functioning professionals Catalbiano et al. In addition, as discussed in Section 4, there is increasing evidence for. Despite this information, a recent review revealed persistent stigma associated with alcohol dependence.
Compared with other mental illnesses that are not linked to substance abuse, individuals with alcohol dependence were more likely to trigger negative emotions and social rejection, and were also less likely to be perceived as having a mental illness. The level of danger attributed was equivalent to that associated with schizophrenia. The authors concluded that alcohol dependence was particularly stigmatised, that individuals were more likely to be blamed for their condition Schomerus et al. Given the current context, with understanding of the biopsychosocial determinants of alcohol-use disorders, the question remains, why do stigma and negative stereotyping persist?
One possible explanation may lie in the fact that alcohol-use disorders often involve behaviour which puts others at risk. In a large scale Australian survey completed by more than 26, respondents, recent drinkers were asked whether they had done certain potentially harmful activities during the past year while drunk. Overall, one in five recent drinkers reported engaging in at least one potentially harmful activity while intoxicated AIHW, In addition, there may be specific negative impacts on those caring for an individual with an alcohol-use disorder.
Another potential reason for the continued negative feeling towards patients with alcoholuse disorders may be alcohol-induced impairment of social cognition. Further, consistent with other addiction-related disorders, alcohol-use disorders are frequently characterised by deceit, guilt and shame reviewed in Shaffer et al. Coupled with emotional abnormalities, indifference, shallowness and apathy Table 3 , this can clearly have a negative impact on interpersonal communication, and ultimately result in damage to crucial support relationships. Alcohol-use disorders, prevention and treatment At a societal level, there is evidence that alcohol price increases and reductions in alcohol availability and advertising, as well as legally enforced drink-driving penalties may be beneficial in the prevention of alcohol-use disorders Rehm et al.
Prevention and treatment approaches at the individual level, and the importance of the relationship between individuals with alcohol-use disorders and healthcare professionals are discussed below. It is clear that such perspectives are out-dated and counterproductive. Comprehensive care necessitates support and management at intervention, in detoxification and withdrawal, during acute alcohol-related health threats, and throughout on-going follow-up care. This process should include education, individual and possibly group therapy, and special care to address comorbid psychopathologies Carr, Medications such as acamprosate and naltrexone, which help to reduce dependence, may be included.
However, these should not be employed in isolation. Central to the success of current treatment approaches is the patients readiness and willingness to change, and their resulting level of engagement and compliance Catalbiano et al. Conversely, those who are less willing to change are less motivated and report lower treatment demand Ekendahl, It is important to note that, due to the physiological effects of alcohol, especially the frontal lobe impairment e.
Even indications of readiness to change may not be indicative of future treatment involvement Yonas et al. Indeed, waiting for the addict to be ready for treatment can be dangerous Clay, , p1. Many treatments for alcohol-use disorders focus on abstinence. However, there has been a great debate in the literature as to whether individuals with alcohol-use disorders, following a period of abstinence can learn to modify their behaviour and engage in controlled drinking Catalbiano et al.
This approach has been argued to be most appropriate for young people, with fewer alcohol-related problems McMurran, , but may not be appropriate for individuals with longer-term chronic alcohol issues Catalbiano et al. Nevertheless, it must be recognised that abstinence may not be a realistic goal for all individuals and that relapse is frequent Graham et al. This may be particularly important to acknowledge in situations where individuals have alcoholrelated chronic illness, where medications may have reduced efficacy, or even become harmful, with high or fluctuating levels of alcohol in the bloodstream.
In such cases, open. To address some of these negative attitudes, it has been argued that understanding pharmacological as well as cognitive-behavioural treatments should facilitate practitioner optimism in treatment of people with alcohol-abuse issues, specifically, an understanding of the biological reality of addiction allows physicians to understand addicts as having a brain disease Clay et al. Historically, we have attributed addictive illness, including alcoholism, to wilful misconduct, character flaws, weak will, moral turpitude, or just bad people.
Science does not support these outdated stereotypes. In , the American Medical Association declared alcoholism an illness. Hampered by prejudice, misinformation, and an outdated sense of hopelessness at our supposed inability to effect meaningful intervention, the medical community has been slow to respond. Even today, most medical students and residents complete training without benefit of a rudimentary working knowledge of addictive illness; an illness they will see in their office almost daily for the rest of their careers.
Carr, , p Table 5. Quote from Carr, summarising issues in the medical community. Nurses are at the coal-face of healthcare, and also have the potential to make a substantial contribution to alcohol-use disorder prevention, screening and treatment George, While overall, recent studies find evidence for neutral or positive attitudes toward the care of patients with alcohol-use disorders, suggestions remain of negative, stereotyped attitudes towards these patients. For example, studies have demonstrated that nurses may be more likely to describe patients labelled as being alcoholics as more unsocial, boring, uncooperative and unpleasant Wallston et al.
In this study, none of the participants. In contrast, in a study in a small community hospital with a specialised inpatient drug and alcohol program, nurses reported positive attitudes to working with drinkers Allen, Studies yield expressions of interest from nursing staff in working more in this area, and requests for more training Anderson et al. This is clearly an important area for development, since education results in more positive attitudes to care Allen, ; Geirsson et al.
Emergency department staff may also play a particularly critical role. A study of Scottish Accident and Emergency Departments found that one in seven admissions were related to alcohol consumption. A primary barrier identified by staff was motivational deficiency on the part of the patients. Therefore, without further training and support infrastructure, time, evidence-based techniques for healthcare professionals, specific treatment of alcohol-use disorders may be inadequate or overlooked.
This can be conceptualised as a reactive treatment of symptoms as they arise, as opposed to addressing the cause. A further barrier to working with patients with alcohol-use disorders is that they may not seek treatment. Only one in four people with alcohol-use disorders will pursue treatment, and most will approach their General Practitioner Schuckit, However, the difficulties that the patient must contend with relating to stereotyping and stigma from the general community as well as healthcare professionals should not be underrated.
This stigma may represent a significant hurdle for treatment. Further, as discussed earlier, alcohol-related brain damage can harm individual ability to understand risk and to plan, commit and be motivated to. This issue of impaired agency and a reduced capacity to choose health has been largely overlooked in treatment and public policy Dorrian, ; Williamson, a, b. Conclusions Taken together, alcohol-use disorders can be seen as a self-perpetuating feedback loop, where all aspects of the disease serve to reduce the ability to engage and comply with treatment.
This is illustrated in Figure 2, which displays psychosocial risk factors for developing alcohol-use disorders at the centre. Negative outcomes associated with alcoholuse disorders are displayed around the perimeter of the circle. It is clear that holistic, biopsychosocial thinking is required to address problems with alcohol-use disorders. In particular, it must be acknowledged that the most seriously ill patients will have progressed further in this loop, and current treatment approaches and public policy which emphasise individual choice will likely be completely inadequate.
Final recommendations resulting from the review are displayed in Table 6. The importance of support from friends, family and the wider community for those with alcohol-use disorders cannot be overstated. This support is required at times when these relationships are put under particular strain.
Stigma and stereotypes of individuals with alcohol-use disorders must be addressed at a community level, and among healthcare professionals, as they are out-dated, unhelpful and present barriers for treatment Education for healthcare professionals in evidence-based identification, treatment and follow-up for individuals with alcohol-use disorders is absolutely required and desired by the professionals themselves This education must emphasise the importance of positive, supportive, nonjudgemental interactions and provide a clear understanding of alcohol addiction as a relapsing brain disease, with recognised biological and social risk factors Education will also facilitate increased routine screening for patients particularly those who may be identifiable as at-risk e.
References Adele, B. Grief, alcohol dependence and women. Drug Alcohol Depend, 24 1 , Agrawal, A. Evidence for an interaction between age at first drink and genetic influences on DSM-IV alcohol dependence symptoms. Alcohol Clin Exp Res, 33 12 , PHE National Health Priority Areas.
Training primary health care workers about drugs: a national survey of UK trainers' perceptions towards training. Drug Alcohol Rev, 15 4 , Allen, K. Attitudes of registered nurses toward alcoholic patients in a general hospital population. Int J Addict, 28 9 , Anderson, P. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol.
Lancet, , Anderson, S. Accid Emerg Nurs, 9 2 , Baird, M. Alcohol Clin Exp Res, 13 6 , Benishek, L. Prevalence and frequency of problems of concerned family members with a substance-using loved one. Am J Drug Alcohol Abuse, 37 2 , Byrne, G. Alcohol consumption and psychological distress in recently widowed older men Aust NZ J Psychiat, 33, Carr, G. Alcoholism: a modern look at an ancient illness. Prim Care, 38 1 , Carrigan, M. Self-medication in social phobia: A review of the alcohol literature.
Addict Behav, 28 2 , Casswell, S. Reducing harm from alcohol: call to action. Catalbiano, M. Australia: John Wiley and Sons. Clay, S. A review of addiction.
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Postgrad Med, 2 , E Crothers, C. Deykin, E. Adolescent Depression, Alcohol and Drug Abuse. Am J Public Health 76, Dorrian, J. Alcoholism: disease or symptom? The challenges of managing advanced alcoholism and chronic illness. Med J Aust, 11 , Durand, M. General practice involvement in the management of alcohol misuse: dynamics and resistances. Drug Alcohol Depend, 35 3 , Ekendahl, M. Will and skill - an exploratory study of substance abusers' attitudes towards lifestyle change. Eur Addict Res, 13 3 , Erickson, J. Willingness for treatment as a predictor of retention and outcomes.
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Huerta, M. Education, alcohol use and abuse among young adults in Britain. Soc Sci Med, 71 1 , Indig, D. Attitudes and beliefs of emergency department staff regarding alcohol-related presentations. Int Emerg Nurs, 17 1 , Johnson, B. Medication treatment of different types of alcoholism.
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Alcohol, memory blackouts, and the brain. Alcohol Res Health, 27 2 , Geneva, Switzerland. Williamson, L. Alcohol dependence in public policy: towards its re inclusion. Clin Ethics 4, Public policy on alcohol in the United Kingdom: Towards a safety net for the alcohol-dependent. J Law Med, 17 3 , Yonas, M. J Trauma, 59 2 , Young-Wolff, K. Mood-related drinking motives mediate the familial association between major depression and alcohol dependence. Alcohol Clin Exp Res, 33 8 , Belgium Fund for Scientific Research F.
Introduction In a broad sense, response inhibition represents as a useful concept to investigate impulsivity, a term referring to behavior that is performed with little or inadequate forethought Evenden, Impulsivity has been studied for many decades as a trait variable of human personality that is stable within an individual and varies normatively across the healthy population Barratt, Following the development of neuropsychology and cognitive neuroscience, impulsivity is often replaced with disinhibition, a term referring to the idea that top-down control mechanisms ordinarily suppress automatic or reward-driven responses that are not appropriate to the current demands Aron, Such a definition gives weight to the idea that alcoholism and other addictive behaviors might be the consequence of increased impulsivity, that is to say, when top-down mechanisms necessary to suppress actions, emotions and thoughts related to alcohol use are disrupted e.
Numerous reasons may lead to use alcohol recreationally including peer influence, personality characteristics, alcohol availability, which together tell something about how much of alcohol will be consumed. But once dependent, alcoholics persist in alcohol-taking despite awareness that their alcohol use is directly harmful to their health, their finances and their interpersonal relationships American Psychiatric Association, Frequent unsuccessful attempts to quit drinking are a classic and this relapse phenomenon could also have something to do with deficient inhibitory control over a response that provides immediate positive consequences.
From the information-processing perspective, cognitive factors are seen as mediators involved in the development of alcoholism e. An emerging view considers impairment of response inhibition as contributing significantly to the development of alcoholism e. The concept of response inhibition refers to the ability to suppress responses i.
In everyday life, there are many examples of the importance of response inhibition, such as stopping yourself from crossing a street when a car comes around the corner without noticing you. This idea has been documented by poor performance on a variety of cognitive tasks assessing dominant response inhibition in abstinent alcoholics e. In addition, poor response inhibition has been demonstrated to be a predictor of problem drinking in adolescents at risk for alcoholism e. Inhibition plays a central role in theorizing about human cognition and is often regarded as a key component of executive control e.
In addition, choice impulsivity, as reflected by rapid temporal discounting may represent a separate impulsivity component e. One possibility is that the repeated use of alcohol may cause a gradual attrition of behavioral self-control, plausibly mediated by structural changes in the prefrontal cortex e. An alternative explanation is that deficient inhibitory control may be present prior to alcohol initiation, thus acting as a predisposing factor.
This vulnerability pathway has been increasingly recognized by neuroscientific models. Indeed, adolescents brain is relatively immature on these systems responsible for reward processing, motivation and regulation of these responses e. The reasons of these individual differences in term of brain maturation are beyond the scope of this paper, but the developmental pathway of brain maturation and its failures are fascinating topics. For instance, by using a cocaine self-administration procedure, Belin and colleagues found that, in rodents, high impulsivity predicts the switch to compulsive cocaine-taking.
It is likely that vulnerability and attrition ways are not mutually exclusive; poor inhibitory control prior to the onset alcohol use may lead to increase the risk to become. It is also possible that deleterious effects of alcohol are more pronounced in these individuals with poor inhibitory control.
For instance, a substantial body of research emphasised that exaggerated levels of novelty-seeking, which is highly correlated with impulsivity and aggressivity e. In young alcoholics, high levels of disinhibited and appetitive personality traits, such as impulsivity, boredom susceptibility, thrill and adventure seeking, excitement-seeking Finn et al. High impulsivity sub-scale of novelty seeking, which reflects poor control of appetitive and aggressive impulses, difficulties delaying gratification, acting without thinking and increased activity and assessed at 3 years of age predict the development of alcohol abuse in early adulthood Kirisci et al.
Sensation seeking, as defined as a strong need for varied, novel, and stimulation experiences, and willingness to take risks for the sake of such experiences Zuckerman, , is another of the personality traits associated with high levels of alcohol and drug use Andrucci et al. Although useful, the questionnaire-based methodology introduces a number of caveats in the context of alcoholic population.
The most meaningful may be that impulsivity itself could directly interfere with the completion of the questionnaires themselves, such that an impulsive subject may give less consideration to responses than a non-impulsive subject, the former having possibly less insight capacities than the latter. In addition, self-report questionnaires are susceptible to be highly dependent to social desirability that may naturally differ between alcoholic inpatients and healthy participants. For all these reasons, direct measurement of inhibitory control processes using laboratory tasks has considerably developed over the past decade.
In this category of tasks, participants are required to respond to target stimuli and not to non-target ones. For instance, on a tasks consisting to click a button when presented whit a five-digit number he or she thought was identical to the preceding number, alcohol-. In line with this idea, patients also had faster response times to target, which were inversely correlated with error rates across all subjects, which seemed to point to a fast-guess mechanism of impulsive response. Interestingly, in comparison with patients with late onset of problem drinking and no problem-drinking parent, those alcoholics with earlier age of problem drinking and who reported a problem-drinking father type 2-like alcohol dependence according to Cloningers typology demonstrated faster response latencies and more responses to non-target stimuli in the prepotent motor-response task.
A deficit of inhibitory control has been identified consistently as a feature of dependence to alcohol. For instance, in a previous study Nol et al. The theoretical framework on which this study was based is the control to action model developed by Norman and Shallice in which two control to action mechanisms are distinguished. The first, contention scheduling, is involved in routine situations in which actions are triggered automatically.
The second, the Supervisory Attentional System, SAS is needed in situations where the routine selection of action is unsatisfactory, and they conceived it as carrying out a variety of processes allowing the genesis of plans and willed actions. The test consisted of two sections A and B of 15 sentences each read aloud by the experimenter, in which the last word was missing. On this task, non-amnesic alcoholics were as fast and accurate as their controls to produce the expected words but slower and less accurate when the expected word was to be suppressed.
As suggested by a PET study Collette et al. Other results of this study were consistent with the existence of an inhibition deficit. In the Trail-Making test, alcoholics were slower than controls on the section B but not on the section A. Similarly, they showed poor performance in the alternate fluency task. Finally, patients spent more time to complete the flexibility condition of the Stroop test.
The trail B requires inhibiting current realization strategy 1, 2, 3 to switch between numbers and. Performance in the alternate fluency task requires, notably, that subjects inhibit one search strategy to switch to another. In the Stroop test, the flexibility condition requires the subject to switch between two rules alternatively, that is to inhibit the current rule.
On the stop signal task, Goudriaan and colleagues found increased stop signal reaction time in alcoholic patients, which indicates weaker inhibition efficiency. In contrast to the inhibition of prepotent response for which responses to be inhibited are strongly automatic, the suppression of no longer relevant mental contents cognitive inhibition is appropriately assessed by the directed-forgetting procedure.
In this procedure Andrs et al. In addition, participants are instructed to perform a distracter task, thus requiring simultaneous maintenance and processing of information. Therefore, low performance in directed-forgetting would reflect impaired ability to inhibit a mental content held in working memory. In alcoholism, this type of inhibition could be of great importance; difficulty suppressing repetitive thoughts about drinking and drinking expectations might represent the core of a craving episode for alcohol May et al.
In a recent article Nol et al. Results showed that despite similar performances between groups in the double-item interference condition of the task, alcoholic participants did not improved their performance in the directed-forgetting condition relatively to the double-item condition, whereas control participants did. In addition, we also highlighted that alcoholics were more sensitive to intrusion errors in the directed-forgetting condition.
Finally, we found that the inhibition score measured by the difference in recall performance between the single-trigram and directed-forgetting conditions was positively correlated with the duration of alcoholism. These findings are interesting because they complete previous works showing prepotent response inhibition e. Indeed, abstinent alcoholics exhibited poor performance on a variety of dominant response inhibition tasks e.
As shown by Friedman and Miyake in the first study attempting to empirically evaluate proposed taxonomy of inhibition-related functions, inhibition of dominant response and inhibition of proactive interference may be considered as distinct processes. Therefore, alcoholism would be associated with deficit on those two types of inhibition.
However, each of inhibition deficits could be involved in separate aspects of the development and the maintenance of alcoholism. For instance, in Obsessive Compulsive Disorder OCD , compulsions symptoms may be related with failures in behavioral inhibitory processes leading to repetitive stereotyped behaviours e.
In the same vein, we hypothesized that prepotent response inhibition could prevent. In turn, when alcohol-related representation break through into awareness being loaded into working memory and experienced as a craving episode for alcohol e. It is obvious that this model remains largely speculative and that further investigations are needed to investigate the relationship between clinical phenomena characterizing alcoholism and different types of cognitive inhibition.
In a recent research Nol et al. One proactive interference inhibition task was Brown-Peterson variant in which participants had to learn four lists of eight words each. The first three lists were taken from the same semantic category, thus generating proactive interference to-be-inhibited for better performance.
As an example of intentional prepotent response inhibition task, the antisaccade task adapter from Roberts et al. Our main finding was that, compared to non-alcoholics, patients had poor performance on cognitive tasks requiring the inhibition of prepotent response. In contrast, alcoholics performed normally on tasks exploring the resistance inhibition to proactive interference.
The second major finding was that we found a relationship between inhibition of dominant response and alcoholics greater tendency to act impulsively in particular when facing with their negative feelings. An intriguing and important question remaining to be clarified if the relationship between enhanced attention for alcohol cues cognitive bias and impaired prepotent response inhibition cognitive deficit. Studies having used the alcohol Stroop task did not report difference between light and heavy drinkers Sharma et al.
One reason for the absence of cognitive disinhibition in the alcohol Stroop task is that both problematic users of alcohol and healthy participants made very few errors, thus reflecting a ceiling effect. Another limitation of the Stroop task is the questionable nature of inhibitory; whereas the Stroop task has generally been considered as examining resistance to interference Nigg, , it might also be viewed as taxing mechanisms of inhibitory control, i. We hypothesized that alcoholic subjects exhibit impairments in tasks requiring inhibitory control, as well as shifting. The aim was to test the ability of alcoholics to discriminate between alcohol-related and neutral words.
Sometimes, the alcohol-related words were the targets for the go. Foa , Edna B. He is a coauthor of Social Organization of Medical Work , published by the University of Chicago Press, as well as the author of many other works.
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