This post builds on the details described in “The mechanics of alcoholism” and “The onset of addiction‘. It is better to have read those before continuing with this post.

Alcoholism is a chronic illness that is progressive, and if unchecked, fatal. “Chronic” is used here in the medical sense. Chronic does not mean that an illness is severe, it means it is forever. Chronic illnesses are those that are long lived; the sufferer usually has them for the rest of their life.

This is the case for alcoholism; it can be treated, but it can’t be cured. Alcoholism can’t be cured because of its origins in the mind. Once the mental connections have been made that make alcohol something to be sought out, and also something not to be avoided, then these are locked in place for life. This is a fundamental feature of the brain. Once we have learned something, then it can’t be unlearned. Relief from alcoholism therefore requires that, while we can’t remove these unwanted connections, we must stop using them in favour of others. This is incredibly difficult, both to achieve and to sustain. While we may over time develop alternate routes through our minds, the old pathways are still present, and can be re-traversed at any time. This is why relapse is so common.

Left completely unchecked alcoholics will drink themselves to death; the primal force that insists that they drink is incredibly powerful and insatiable. However, alcoholism is rarely completely unchecked; the sufferer may lack the means to acquire as much alcohol as they need, they get hospitalised and de-toxified, they are committed into treatment, or they die either accidentally or deliberately. With medical treatment becoming more available and more effective the most likely cause of death for an untreated alcoholic is either accident or suicide.

Alcohol itself does not make people suicidal; rather it contributes to a mounting burden of shame, guilt and worthlessness. As addiction deepens many alcoholics find that life is so unbearable that it is better to die than to continue living. This is an inevitable conclusion of the illness’s progression if it is left to run amok.
The body is affected by regular and large doses of alcohol in very many ways. The gastric system, liver and kidneys are all damaged through prolonged contact with alcohol. But these problems can mostly be remedied by medical intervention. It is the way the brain changes that is the most problematic.

The brain is not like other organs in the body. The other organs develop to maturity and then remain like that for the remainder of our lives. But the brain is constantly changing; learning and adapting in response to our changing situations.

The brain changes to maintain and improve its own performance. The first adaptation to prolonged exposure to alcohol is that tolerance increases. Alcohol is defined as a “depressant”. This does not mean it makes people depressed, it means that it slows down the speed of mental processing. Everyone experiences the effect of this if they become intoxicated: the speed of the brain slows down so that difficult and complex tasks can no longer be performed quickly enough for them to be conducted successfully. For example, walking upright is a learned skill. It requires the simultaneous coordination of all the large muscles in our body in response to information coming from our ears and eyes. It takes months to learn how to stand and walk, and only through repeated practice does it become sufficiently learned that we can do it fast enough to move without staggering. When we drink a lot of alcohol our brain function slows, and we can no longer coordinate all the muscle movements quickly enough to move smoothly or even stay upright.

The brain responds to this impediment to its function by releasing stimulants to temporarily speed up processing. If the brain is regularly exposed to high levels of alcohol then its ability to create the stimulant increases, in exactly the same way that regular exercise increases muscle size. As the brain produces more stimulant to counter the slowing effect of alcohol then a heavy drinker can consume far more alcohol before their mental function is seriously impaired. Prolonged heavy drinking leads to increased alcohol tolerance. But that increased stimulant production has additional effects which lock addiction in place even more firmly.

If the sufferer is drinking daily, and in significant amounts, then there is a constant presence of stimulant. This means that while not drinking the alcoholic experiences a racing mind, jumpiness and irritability. This racing mind will not slow enough to allow sleep; it will keep them awake at night, and the only way they know to offset this is to drink before going to bed.

The second physical change that occurs in the brain relates to the production of dopamine. Dopamine causes the wave of ease and contentment an alcoholic feels when they take their first drink. It is dopamine that causes this sensation, not alcohol. Dopamine is released into the brain in response to securing alcohol and then by the presence of alcohol. The elated sensation occurs before the alcohol is even absorbed into the bloodstream. For as long as the person keeps drinking the alcohol in their blood fools the brain into thinking that more dopamine and serotonin should be released. With regular and repeated heavy drinking the brain recognises it is releasing more dopamine than intended. It recognises there is too much dopamine and in response it reduces the number of cells actively producing it and detecting it.
The same reduction happens to serotonin production. While the alcoholic is drinking then their brain is fooled into releasing serotonin, and accordingly they become socially confident. But when the normal background level of serotonin reduces then they experience loneliness and social insecurity when not drinking.

The lowering of the regular dopamine level also has a profound effect on the heavy drinker; their overall daily sensation of pleasure is lowered, and they are unhappy when not drinking. The simplest relief from this discontent is to take a drink. They will get the immediate wave of ease and comfort when they take the first drink, but now they now need to drink more to feel good.

The effects of reduction in the regular dopamine and serotonin levels and the constant presence of stimulant combine. When the alcoholic is not drinking they are agitated, lonely and depressed. The only way to regularise the brain now is to have a drink.

When the addiction has reached this point of development then the sufferer has to drink simply to feel normal; they have to drink to achieve the same sense of personal comfort that they had before ever drinking at all. Once a heavy drinker has begun to drink to relieve this discomfort then the downward spiral is firmly locked into place. They drink to get relief from the misery of the lower dopamine levels, they drink to get rid of the racing mind and irritability, and they have to drink far more to gain any sense of pleasure from drinking. Drinking more further reduces the number of cells producing and detecting dopamine and serotonin thus making them lonelier and more miserable… so they drink.

Alcoholics drink in response to entirely automated processes that they are completely unaware of and every time they repeat the cycle the brain learns more deeply and the processes become faster and more dominant. Over an extended period of time the first and immediate response to feeling any distress is to have a drink. Others are added too; tired?→ drink, lonely?→drink, angry?→ drink, hungry?→ drink.

By this stage the alcoholic is drinking completely compulsively. Their normal state is that their minds are racing and they feel unhappy, isolated and irritable. They now need to drink what most people would consider an excessive amount just to feel normal. They can now no longer drink enough to become happy; they pass out first. But as soon as they wake the demand to drink again will be there.

As more and more of their time gets committed to drinking, and to being functionally impaired as a result of drinking, their place in the world starts sliding backwards. They start failing to meet the standards society expects, as well as their own, and they start failing at work and at home. Their standing in the world is in decline and the damage to their self-image is huge. They begin to sense that they are failures and despite their efforts they feel unrecognised and unvalued. Ultimately they start to feel completely worthless, and life itself: pointless.

They have vaguely linked drinking as a part of this demise in their social standing, but it is by now only one of very many issues troubling them; they are surrounded by problems… their life is nothing but problems, and they can see no escape from this misery. By this time they will have tried to control their drinking many times. There will have been numerous occasions where they intended to not drink, or only have a couple, but the silent demand to drink overwhelmed them.

It is difficult to describe this wordless compulsion to those who have not experienced it, but this is similar:

Imagine you are in a room. There is no-one else there except a baby, and the baby is crying. The crying nags terribly. You only have to pick the baby up to stop it crying, but you’re not allowed to. It carries on crying. The longer you leave it alone the more insistent the crying becomes. Even though it would be very easy to pick up the baby and make the screaming stop, you mustn’t. You can’t get away from the screaming, and it just goes on, and on and on; it never stops. Time passes very slowly, and the crying continues, and continues without pause. It is impossibly irritating. Eventually it becomes too much, and you yield. You pick up the baby.

That’s what it’s like when an alcoholic doesn’t drink for a while. The demand that you pick up the baby feels precisely like the demand that an alcoholic pick up a drink. It has no words, shape or form; it is just an urgent imperative demand. The longer they resist, the more urgent the demand becomes, until eventually they have to give in to it.

There is no sudden dividing line at which somebody either is or isn’t an alcoholic. Alcoholism is progressive and develops very slowly. It creeps on so slowly that the sufferer is completely unaware of the changes in them. Also, because it is a progressive illness not all alcoholics experience or exhibit the same severity of symptoms; some are sicker than others. But in general terms the longer they have been drinking heavily the more entrenched is their addiction. But they won’t really be aware of it. They will only be able to recognise a long tem trend of a gradual increase in the amount they drink.

These are some of the behaviours alcoholics display as their addiction strengthens.

– Drinking before a drinking function
– Repeating unwanted drinking patterns
– Drinking at inappropriate times
– Morning shakes or tremors
– Lying about how much they drink, when and where
– Not wanting to talk about their drinking
– Wanting to continue drinking when it’s time to leave
– Missing work or family obligations
– Hiding alcohol
– Setting drinking limits and not being able to stick to them
– Behaving out of character when drinking
– Eating becomes less important than drinking
– Surrounding themselves with heavy drinkers
– Drinking early in the morning
– Engaging in risky sexual behaviour when drunk
– Being irritable, nervous or uncomfortable when not drinking
– Regular occurrence of memory loss or blackouts
– Attempted periods of abstinence
– Personal relationships become less important than drinking
– Thinking becomes scattered and impaired

Exhibiting some or all of these symptoms isn’t the measure of whether or not someone is an alcoholic. The key measure of this is whether or not they are able to stop drinking when they choose to; and only the sufferer will know this with absolute certainty. In fact they are the only person that needs to know that this is true, but they are often the last to think it.

While some progression into alcoholism is observable, much more is kept hidden. The sufferer recoils from the shame associated with the word “alcoholic!” and covers their tracks to conceal the true extent of their drinking. In the face of mounting distress and depression they carry on pretending that nothing is wrong, but deep inside they feel that everything is wrong. While there is a progression of indicators visible to the observer, there is another progression, things that the sufferer is aware of but conceals from public display.

– Sneaking drinks or minimizing how much they actually consume
– Increasing alcohol tolerance
– Getting anxious when people are talking about those who drink too much
– Drinking to relieve uncomfortable emotion and stress
– Uncomfortable in a situation where there is no alcohol
– Using alcohol as a reward
– Inability to control alcohol intake after starting to drink
– Needing the first drink of the day
– Waking thoughts are preoccupied with drinking
– Feelings of real guilt about drinking
– Developing unreasonable feelings of resentment towards other people and the world
– Thinking of getting away as way to stop drinking
– Routinely drinking alone (hiding their drinking from public sight)
– Guilt extends into constant remorse
– Obsessing about alcohol (i.e. the next time they can drink, how they are going to get alcohol, who they’re going to drink with)
– Lost moral compass –(start doing things they wouldn’t have considered previously)
– Angry when their drinking is discussed
– Increasing sense of denial that their heavy drinking is a problem
– Experiencing fear that is not attached to any apparent threat
– Not being able to imagine their life without alcohol in it
– Desperately alone, restless, irritable, confused, depressed and scared
– Extremely low self-esteem. Nothing they try to do improves things
– Sense of complete hopelessness and impending doom
– Suicidal thoughts and planning

At the same time as they are aware that their position is untenable their mental state is increasingly perilous. Deep down they know that something is wrong with their drinking, but they have other stresses too. Every aspect of their lives is unravelling, and in addition to that there is a mounting burden of guilt. They drink secretly; hiding from the sight of others. That’s the only way they can drink as much as they need without being shamed. They do things that offend their own consciences time after time, and the list of their inappropriate behaviours is beyond counting; things they would never normally do, but things they’ve done nonetheless. They are completely confused as to how they’ve reached this point and the massive burden of guilt and shame keeps increasing.

They now can’t stop thinking about their troubles unless they have a drink. Their brains are so conditioned to the presence of alcohol that there is a massive oversupply of stimulant to keep the brain functioning. When they are not drinking their mind is a roaring and tumbling torrent of unresolved issues, bad outcomes, and guilty secrets. They play and re-play scenes in their mind to try to find different resolutions but they will not come, so the issues spin and twist and churn relentlessly.

They feel impossibly alone and scared; scared that their secrets will be found out and scared that this is it… this is all their life has amounted to. The loneliness is crushing. Even though they are surrounded by people, at home and at work, no-one seems to recognise how hard their life has become. No-one understands, and no-one is coming to help; they are on their own.

Alcohol is the only thing that gives them relief. It is the only thing that makes life bearable.

They are impossibly trapped, and can see no way out. They can’t control or limit their drinking; they’ve tried this many times and failed completely. They’ve tried to stop for periods, but usually only managed a few days… it’s impossible. Their position is hopeless; they are without hope. A life without alcohol is utterly unimaginable.

They can’t stop drinking, but they can’t carry on either.