Paternal alcoholism predicts the occurrence but not the remission of alcoholic drinking: a 40-year follow-up.

OBJECTIVE: To test the effects of father's alcoholism on the development and remission from alcoholic drinking by age 40. METHOD: Subjects were selected from a Danish birth cohort that included 223 sons of alcoholic fathers (high risk; HR) and 106 matched controls (low risk; LR). Clinical examinations were performed at age 40 (n = 202) by a psychiatrist using structured interviews and DSM-III-R diagnostic criteria. RESULTS: HR subjects were significantly more likely than LR subjects to develop alcohol dependence (31% vs. 16%), but not alcohol abuse (17% vs. 15%). More subjects with alcohol abuse were in remission at age 40 than subjects with alcohol dependence. Risk did not predict remission from either alcohol abuse or alcohol dependence. CONCLUSION: Familial influences may play a stronger role in the development of alcoholism than in the remission or recovery from alcoholism.

Prediction of mortality at age 40 in Danish males at high and low risk for alcoholism.

OBJECTIVE: This prospective high-risk study examined the influence of father's alcoholism and other archival-generated measures on premature death. METHOD: Sons of alcoholic fathers (n = 223) and sons of non-alcoholic fathers (n = 106) have been studied from birth to age 40. Archival predictors of premature death included father's alcoholism, childhood developmental data, and diagnostic information obtained from the Psychiatric Register and alcoholism clinics. RESULTS: By age 40, 21 of the 329 subjects had died (6.4%), a rate that is more than two times greater than expected. Sons of alcoholic fathers were not more likely to die by age 40. Premature death was associated with physical immaturity at 1-year of age and psychiatric/alcoholism treatment. No significant interactions were found between risk and archival measures. CONCLUSION: Genetic vulnerability did not independently predict death at age 40. Death was associated with developmental immaturities and treatment for a psychiatric and/or substance abuse problem.

Analgesia in the intensive care unit. Pharmacologic and pharmacokinetic considerations.

Morphine is the preferred analgesic agent for the critically ill patient. Fentanyl is the preferred analgesic agent for critically ill patients with hemodynamic instability or for patients manifesting symptoms of histamine release with morphine or morphine allergy. Hydromorphone is an acceptable alternative to morphine for patients with significant adverse affects from morphine or severe renal dysfunction. Meperidine and intravenous codeine should be avoided if at all possible. APAP and NSAIDs may be useful in the management of acute pain secondary to their opioid-sparing effects. Use of nonopioid analgesics may reduce the dose of opioid required for adequate pain control and help to minimize opioid-induced side effects. NSAIDs should be used only when the benefit-to-risk ratio is favorable. APAP should be used as an adjunct but not as the sole analgesic agent in critically ill patients. Regardless of which agent or agents are used to optimize pain control, it is imperative that caregivers recognize that the optimal analgesic dose and regimen vary widely between patients. Based on the pharmacokinetics and pharmacodynamics of the agent(s) selected, enough time for an adequate trial should be allowed before switching to other agents. Employing these principles optimizes the use of medications in the management of the complex physiologic response to pain.

Comorbid psychiatric diagnosis and long-term drinking outcome.

This longitudinal study of alcoholics investigated which psychiatric comorbidities among alcoholics would predict very long-term drinking outcome. Previous research has yielded inconsistent findings. We hypothesized that antisocial personality characteristics alone among psychiatric comorbidities would show an association with poorer drinking outcome. The use of multiple measures of psychopathology, a relatively large sample size, and an absence of systematic treatment matching to particular patient groups were all aspects of the current study which allowed for a comprehensive examination of this issue. The study used single and multivariate correlational analyses. The setting was an inpatient Veterans Administration alcohol dependence treatment unit and follow-up clinic. Participants were 255 adult male veterans diagnosed with alcohol dependence. The predictors were the Symptom Checklist 90 (SCL), Minnesota Multiphasic Personality Inventory (MMPI), and Psychiatric Diagnostic Interview (PDI). The outcome measure was the Clinician Rating of Drinking Scale (CRDS). The study showed that antisocial personality characteristics alone were consistently associated with a worse long-term drinking outcome. However, despite the consistent presence of a statistical association between antisocial personality characteristics and a poorer long-term drinking outcome, the small size of the relationship is a very important issue which is discussed in detail.

Mortality in male alcoholics after ten to fourteen years.

OBJECTIVE: Alcoholics frequently die prematurely. The purpose of this study was to determine: (1) whether subjects in a sample of 360 male alcoholics, followed over a period of 10-14 years, died prematurely: (2) if so, from what causes; and (3) whether such deaths are predictable from characteristics present at initial assessment. METHOD: Subjects were male veterans (N = 360) with a diagnosis of alcoholism admitted to an inpatient substance abuse treatment program at the Kansas City Veterans Affairs (VA) Medical Center during 1980-1984 who consented to participate in intake evaluations and subsequent follow-ups at 1 year and 10-14 years later. Of the 357 (99.2%) men located at the 10-14 year follow-up, 96 (26.6%) were confirmed as deceased, 255 survivors agreed to be reassessed and 6 subjects refused reassessment. Information regarding cause of death was obtained from death certificates, VA records and other sources. RESULTS: At intake, the subsequently deceased men were older, had less education, lower psychosocial functioning, more medical problems and greater psychiatric severity. Their overall death rate was 2.5 times greater than that of a reference group of men. Men in the 35-44 year age group were 5.5 times as likely to die. A statistical model utilizing measures of alcohol dependence to predict mortality from intake to 10-14 year follow-up indicated that alcoholics who limited drinking were half as likely to die whereas those who engaged in morning drinking were 2.5 times more likely to die. CONCLUSIONS: Alcoholic men, especially those in the group aged 35 to 44 years, have a significantly higher risk of premature death than a reference group of men. Men who engaged in morning drinking and could not limit drinking appeared to be at higher risk of mortality 10 years later.

Breast-feeding and alcoholism: the Trotter hypothesis.

OBJECTIVE: The authors' goal was to determine whether early termination of breast-feeding contributes to later alcohol dependence, as proposed more than 200 years ago by the British physician Thomas Trotter. METHOD: In 1959-1961, a multiple-specialty group of physicians studied 9, 182 consecutive deliveries in a Danish hospital, obtaining data about prepartum and postpartum variables. The present study concentrates on perinatal variables obtained from 200 of the original babies who participated in a 30-year high-risk follow-up study of the antecedents of alcoholism. RESULTS: Of the 27 men who were diagnosed as alcohol dependent at age 30, 13 (48%) came from the group weaned from the breast before the age of 3 weeks; only 33 (19%) of the 173 non-alcohol-dependent subjects came from the early weaning group. When challenged by other perinatal variables in a multiple regression analysis, early weaning significantly contributed to the prediction of the severity of alcoholism at age 30. CONCLUSIONS: The data support the hypothesis that early weaning may be associated with a greater risk of alcohol dependence later in life.

The comparative validity of eleven alcoholism typologies.

OBJECTIVE: This study directly compared the clinical validity of 11 empirically defined alcoholism typologies to determine whether some typologies are clinically more valid than others. METHOD: A sample of 360 hospitalized alcoholic men were extensively evaluated at entry into the study and again 1 year later. Twenty-three measures of clinical validity were employed; 15 were postdictive and 8 were predictive. Postdictive retrospective measures obtained at entry into the study included family history, age of onset and lifetime course characteristics associated with alcoholism severity, general psychopathology and psychosocial functioning. Predictive outcome measures drawn from information obtained during the 1-year follow-up included: abstinence, alcoholism severity and clinician ratings of outcome. The measures were subjected to various statistical analyses, including factor analysis. RESULTS: We found that all of the alcoholism typologies met at least 7 of the 23 a priori measures of clinical validity. The correlations between these conceptually and methodologically disparate typologies were often striking. Exploratory factor analysis, which explained 35% of the variance, suggested three possible underlying dimensions to account for the overlap among typologies: (1) age and its correlates, including age-of-alcoholism onset; (2) "pure" alcoholism versus psychiatrically heterogeneous alcoholism that encompassed antisocial personality disorder; and (3) current severity of psychiatric distress, impairment and dysfunction. CONCLUSIONS: No single method of subtyping alcoholics clearly emerged as superior. All demonstrated some degree of predictive and postdictive clinical validity. Most methods of subtyping correlated positively with each other at moderate, but typically significant, levels.

Prediction of drinking outcomes for male alcoholics after 10 to 14 years.

This study reports on the long-term outcomes of 360 men who were hospitalized for alcoholism during 1980 to 1984 and followed at 12 months and again 10 to 14 years later. At the 10/14-year follow-up, 96 (26.7%) men were confirmed as deceased; 255 (70.8%) men participated in the assessment/interview battery completed during baseline hospitalization. The battery consisted of psychosocial, alcohol-related, and psychiatric measures. Two distinct but highly correlated outcome measures were selected: a clinical rating scale and a factor score. Overall, predictors from baseline and 12-month follow-up included age at intake hospitalization, alcoholism severity, social stability, drinking days, and antisocial personality disorder. Approximately 37% of the assessed survivors were either totally abstinent or drinking nonabusively throughout the 10/14-year follow-up, whereas another 37% continued to drink abusively. Men who abstained or reduced alcohol intake reported better physical health at follow-up than those who continued to drink. Although our findings did not directly link alcoholism to death, they strongly indicate that chronic alcohol abuse may lead to premature death.

Pharmacological treatment for antisocial personality disorder alcoholics: a preliminary study.

A short time ago, we reported that a subgroup of hospitalized alcoholic men with comorbid antisocial personality disorder (ASP) seemed to benefit significantly from antidepressant medication at the end of a 6-month period in a double-blind, random assignment, placebo-controlled study. In a reanalysis of those data, we divided the ASP alcoholic group (n = 29) into those who did (n = 15) and who did not (n = 14) also satisfy DSM-III-R criteria for an additional current mood and/or anxiety disorder and then compared the 6-month outcomes of these two smaller subgroups. Despite the small ns, the results for most drinking outcome measures indicated: (1) that ASP alcoholics with a current mood/anxiety disorder improved significantly more with pharmacological treatment, relative to placebo; and (2) that ASP alcoholics with no current mood/anxiety disorder failed to respond differentially to pharmacological treatment over the 6-month period. These findings suggest a possibly useful and inexpensive approach to the long-term management of a very difficult-to-treat subgroup of men substance abusers.

Validity of the CAGE questionnaire in screening for alcohol dependence in a walk-in (triage) clinic.

OBJECTIVE: This study assessed the value of the CAGE questionnaire in detecting alcohol dependence in the walk-in (triage) clinic of an acute care Veterans Affairs hospital. METHOD: Male veterans (N = 1,667) attending the walk-in clinic were asked several questions relating to whether they were current drinkers, were seeking alcohol treatment, and whether they had been hospitalized for treatment of alcoholism. Those who were current drinkers, were not seeking alcohol treatment and had not been hospitalized for alcohol treatment were given the CAGE questionnaire followed by a diagnostic interview utilizing DSM III-R criteria to determine the presence or absence of a lifetime diagnosis of alcohol dependence. RESULTS: The diagnostic interview revealed a prevalence rate for alcoholism of 22% in this clinic population. The CAGE scale, when used with one or more yes responses indicating a positive response, achieved a sensitivity of 86% and specificity of 93% when using the diagnostic interview as the criterion standard. CONCLUSIONS: This study adds to the evidence that the CAGE questionnaire is an effective, efficient, easily used screening instrument for the detection of alcohol dependence in a clinical setting.

A double-blind, placebo-controlled study of nortriptyline and bromocriptine in male alcoholics subtyped by comorbid psychiatric disorders.

This double-blind, placebo-controlled, 6-month follow-up treatment study investigated the efficacy of bromocriptine and nortriptyline in attenuating drinking behavior and psychiatric symptoms in 216 male alcoholic patients subtyped by comorbid psychiatric disorder(s). Three well-defined subtypes were examined: alcoholism only, alcoholism + affective/anxiety disorder, and alcoholism + antisocial personality disorder. It was hypothesized that both medications would relieve negative affective symptoms associated with alcohol use and would be particularly effective for the affective/anxiety subgroup. Contrary to our predictions, the only significant effects found were with the antisocial personality disorder patients who were receiving nortriptyline. One interpretation of the results was that nortriptyline may have reduced impulsive drinking in the antisocial personality disorder subgroup by actions on serotonergic neurotransmission.

Co-morbidity of lifetime psychiatric disorder among male alcoholic patients.

The lifetime co-morbidity of major psychiatric disorders among male alcoholics was examined with the structured Psychiatric Diagnostic Interview (PDI), which was administered to 928 patients undergoing alcoholism treatment at six Veterans Administration Medical Centers. Thirty-eight percent were positive for alcoholism only; 62% fulfilled inclusive lifetime diagnostic criteria for at least one other additional psychiatric syndrome. Thirty percent satisfied criteria for one additional syndrome; 16% for two additional syndromes; 12% for three; and 4% for four or more disorders in addition to alcoholism. Depression and antisocial personality were the most frequently identified co-occurring syndromes (36% and 24%, respectively) followed by drug abuse and mania (17% each). The additional psychiatric syndromes in this sample were clearly not randomly distributed; instead, certain disorders tended to cluster together such as: drug abuse and antisocial personality; mania and depression; depression and anxiety disorder; and schizophrenia and affective disorder. Implications for classification and treatment are discussed.

Outcomes of co-morbid alcoholic men: a 1-year follow-up.

In this prospective, 1-year study, 360 males admitted to an inpatient alcoholism treatment program were administered a DSM-III compatible structured interview and subtyped by co-occurring psychiatric disorder. Forty percent satisfied diagnostic criteria for alcohol dependence while 27% met criteria for alcohol dependence and one additional psychiatric syndrome. The dually diagnosed patients were divided into: alcohol dependence plus drug abuse, alcohol dependence plus antisocial personality and alcohol dependence plus depression. These subtypes were compared on multiple dimensions at intake and at 1-year follow-up. At follow-up, all groups showed significant improvement in drinking and psychosocial functioning. The results suggest that subtyping alcoholics by co-morbid psychiatric disorders may be a good postdictor of clinical history, but a poor predictor of drinking outcome.

MMPI experimental scale correlates of the MAACL--R with male alcoholics.

Concurrent and discriminative validity of the MAACL--R scales were studied by means of correlations with selected MMPI experimental scales (AR, DR, HOS, Poor Morale, and ES) for a sample of 88 male VA alcoholics. Concurrent validity of Anxiety, Depression, Hostility and PASS, and discriminative validity of the Anxiety scale were confirmed.

Diagnostic subgroups of antisocial alcoholics: outcome at 1 year.

Of 233 alcoholics initially evaluated and subdivided into groups with an additional diagnosis of antisocial personality disorder (ASP) only (N = 38), ASP plus drug abuse (N = 30), ASP plus major depressive disorder (N = 18), and those with no additional diagnosis (N = 147), 205 were followed up 1 year later. The ASP plus drug group, although younger and having fewer years of alcoholism, did worse in the 1-year follow-up on many indicators of alcoholism severity compared with the other antisocial groups and the alcoholism only group. The ASP plus depressed group demonstrated marked improvement on measures of psychopathology and alcoholism severity over the course of 1 year such that they were comparable on these measures at 1-year follow-up to the other antisocial groups. These findings may indicate that the ASP/drug alcoholic has a poor long-term prognosis compared with the ASP only alcoholic, while the ASP/depressed patient has a disorder comparable in prognosis to the ASP only alcoholic.

A comparison of familial and nonfamilial male alcoholic patients without a coexisting psychiatric disorder.

Both family history of alcoholism and the presence of additional psychiatric disorder in male alcoholic patients are associated with an earlier onset of problem drinking, greater alcoholism severity and poorer clinical outcomes. To assess the relative contribution of family history alone, a sample of 212 male alcoholics not positive for any other psychiatric disorder was selected and divided into those with a family history of alcoholism (FH+) or no family history of alcoholism (FH-) among first degree relatives. Although FH+ alcoholics reported a younger age of onset of problem drinking and greater severity of some alcohol-related sequelae, the differences were not as extensive or pronounced as those found in a previous study of a sample of psychiatrically heterogeneous patients (Penick et al., 1987). A bi-dimensional typology of alcoholism incorporating both additional psychiatric diagnoses and a positive family history of alcoholism is suggested.

Examination of Cloninger's type I and type II alcoholism with a sample of men alcoholics in treatment.

Cloninger's clinical method of classifying alcoholics into two groups (Types I and II) was examined with data obtained from 360 VA hospitalized male alcoholic patients. For operational criteria, the Cloninger clinical method of subtyping alcoholics employs age-of-onset of problem drinking and symptom-clusters supposedly associated with each subtype. Marked overlap was found between the symptom-clusters used to define the two subtypes. Ninety-one percent of the entire sample satisfied criteria for both symptom-clusters. Dividing the sample by early-onset (Type II, less than or equal to 25 years) and late-onset (Type I, greater than 26 years) alcoholism did not substantially reduce the overlap between symptom-clusters; i.e., 96% of the early-onset and 83% of the late-onset subgroups were positive for both symptom-clusters. Only 21 men (6%) could be classified when both age-of-onset and the type-appropriate symptom-cluster were used to separate patients. In hospital settings, at least, these findings suggest that the two-group clinical alcoholism typology proposed by Cloninger basically reflects the age-of-onset of problem drinking.

Subtyping male alcoholics by family history of alcohol abuse and co-occurring psychiatric disorder: a bi-dimensional model.

Six studies of 568 alcoholics in treatment are summarized to illustrate the interactive effects of familial alcoholism, other forms of family psychopathology and the lifetime prevalence of additional psychiatric disorder on the onset and course of male alcoholism. A family history of alcoholism as well as additional co-occurring psychiatric syndromes were associated with (1) earlier onsets of problem drinking, (2) a more virulent course and (3) greater heterogeneity of psychopathology among first degree relatives. A bi-dimensional method of classifying male alcoholics is proposed which combines a family history of abusive drinking and the presence or absence of co-morbid psychiatric disorders. Implications for the clinical researcher and practitioner are briefly discussed.

The stability of coexisting psychiatric syndromes in alcoholic men after one year.

Alcoholic men (N = 241) were administered a criterion-referenced, structured, DSM-III compatible, diagnostic interview while hospitalized and again 1 year later as outpatients. This interview independently evaluates the lifetime prevalence of 15 major psychiatric disorders. In addition to alcoholism, the most frequently occurring coexisting disorders were depression, antisocial personality and drug abuse. After 1 year, the number of positive syndromes declined slightly (chi = 2.0 to 1.8). However, the absolute and relative number of additional psychiatric syndromes remained stable over 1 year for the entire sample. Across individuals, the overall rates of agreement for the 15 syndromes ranged from a high of 100% to a low of 85%. Similarly, the agreement for the current and lifetime diagnoses ranged from 86 to 99%. These data indicate that a substantial portion of male alcoholics experience symptoms that are common to other psychiatric disorders. They also suggest that the endorsement of multiple psychiatric symptoms is not due simply to the acute emotional and physical distress that often accompanies a recent hospitalization for alcoholism treatment. Instead, for many male alcoholics, the symptom patterns appear to reflect additional psychiatric disorders that are stable over time and a potential target of treatment.