Patients commonly use a psychiatric disorder to deny alcohol abuse.

Unless strong evidence indicates

that the psychiatric disorder clearly precedes the alcoholism or is present during a long period of sobriety,
the best plan is to proceed as if alcoholism is the primary diagnosis. Arrange a consultation with a
psychiatrist for difficult cases because some patients who are treated for psychiatric conditions stop
drinking and do very well.
The physician should, nonetheless, perform a brief mental status exam to help guide the referral
process. Basic elements that should be covered in the mental status exam include an assessment of
mood, perceptual problems such as hallucinations, and a safety screen. The use of a standardized
instrument helps ensure important questions are asked and the results transmitted with some degree of
objectivity. Several validated instruments exist, including The Patient Health Questionnaire from the
Primary Care Evaluation of Mental Disorders (PRIME-MD)[22] and the Cornell Psychiatric Screen.[23]
Genetic psychiatric disorders, such as schizophrenia and bipolar disorder, are associated with
alcoholism.[24] The presence of both a serious, persistent mental illness and alcoholism is called dual
diagnosis. The physician must address both. Family history commonly reveals members with bipolar
disorder, alcoholism, or both. Despite this and despite an intensive search for a gene for alcoholism,
study results remain inconclusive. Nevertheless, some evidence indicates that genetics plays a major
role in alcohol abuse.

Twin studies
Identical twins have a higher concordance for drinking behavior and possibly alcoholism than fraternal
twins.
In a well-conducted twin study of 542 families, a single underlying trait for conduct disorder, antisocial
personality, alcohol dependence, and drug dependence was found, which was highly heritable and was
observed in both sexes.[25] Additionally, the study found that maximal alcohol consumption of fathers was
predictive of their children having behavior and substance abuse problems (>24 drinks in 24 h yielded
especially high risk). Not all at-risk children developed substance use or behavior problems. The
environment seemed to determine which, if any, manifested. Deviant peers and poor parent-child
relationships predicted early use (age < 15 y) of alcohol, which predicted later alcohol abuse and
antisocial personality. This study applies to early-onset alcoholism and type 2 alcoholism. More work is
needed on later-onset alcoholism and type 1 alcoholism.

Adoption studies
Whether reared by biologic or adoptive parents, sons of males with alcoholic problems are 4 times more
likely to have problems with alcohol than sons of persons who are not.
Two Swedish studies have suggested the following 2 types of male alcoholism:

Type 1 characteristics include (1) onset in adulthood (early twenties), (2) drinking to relieve
anxiety, and (3) inherited but requires an environmental trigger.
Type 2 characteristics include (1) an association with criminal behavior (sociopathy), (2) onset in
teen years, and (3) drinking to get high.
Sons of persons with type 2 alcoholism are 7 times more likely to develop type 2 alcoholism
compared with the general population.
The theories suggested from these studies are controversial and require confirmation in
additional populations.

Data from adoption studies on daughters of persons with alcohol problems are less clear. Daughters
might be at increased risk if the biological mother has alcoholism. A recent twin study in women found
higher concordance in monozygotic twins than in dizygotic twins.

Experimental studies
Schuckit and Smith found that sons of persons with alcoholism respond differently to an alcohol
challenge.[26] They report decreased subjective ratings for feeling intoxicated, and they objectively have
less body sway when given the same amount of alcohol as sons of persons without alcoholism. The
study population consisted of white, male college students who drank alcohol but were not alcohol
dependent themselves. The fathers in this study could not have psychopathology other than alcoholism
(ie, no sociopathy, no bipolar illness).
Ten-year follow-up data have been published recently for the first half of this cohort. Of the sons of
persons with alcoholism, 26% were alcohol dependent by age 30 years, as opposed to 9% of the control
group. Furthermore, 56% of the sons of persons with alcoholism with lesser objective and subjective
responses to alcohol became alcohol dependent, as opposed to 14% of the sons of persons with
alcoholism who did not demonstrate these decreased responses. This also held true for the sons of
fathers who did not have alcoholism, although the numbers were small.
Positive family history and lesser response to alcohol increased the likelihood of later development of
alcohol dependence.

Psychological studies
Behavioral models explain alcohol abuse in terms of learning theory. Through operant conditioning, the
reinforcing elements of alcohol use become habitual.
Cognitive models explain alcohol abuse in terms of automatic thoughts, which precede the persons
more identifiable feelings about alcohol. For example, an automatic thought might be I deserve a drink
because Ive had a rough day."
Psychoanalytic models explain alcohol abuse in terms of ego defenses and intrapsychic conflicts. The
alcohol serves as a way to escape the uncomfortable internal conflict.

http://emedicine.medscape.com/article/285913-clinical#b5