The preceding chapters of this book describe alcoholism; how it starts, how it develops, and how some people are captured by it. But while most people that drink do not become alcoholics, some do, and for them this attracts great shame. Shame causes us to lie about our drinking, hide our drinking and drink secretly, but shame is also responsible for our deep need to understand why we drink like we do. The reason for this is that shame is only attributed to actions that are freely chosen. If the actions are caused rather than chosen then no shame is warranted, and this is why we so desperately seek for reasons behind our behaviour.
Research shows that much of the likelihood that addiction will form is inherited. The simplest and most compelling evidence for this comes from studies of children born to alcoholic parents but raised in non-alcoholic families. Children born to alcoholic parents but adopted into non-alcoholic families are far more likely to become alcoholics than the average across the whole population. The increased likelihood of addiction isn’t just a little, it is huge; it is as much as ten times the average. Another study demonstrates that adoption itself is not the cause of this as the adopted children of non-alcoholic parents only suffer alcoholism at the normal rate. So it is not the distress of adoption that makes alcoholism more likely among children of alcoholics, nor is it being raised in a heavy-drinking environment (which is not present once they have been adopted), it is the inherited genes.
We inherit genes from our parents but we are not identical clones. Our parents’ height for example does not exactly determine our own, nor does them having a particular talent mean we will have it too. The same applies to vulnerability to addiction; just because one or more of our parents is alcoholic does not mean that we will be too. Just because our parents have the particular mental characteristics that favour addiction does not mean that will have them, and actually those particular characteristics aren’t even uncommon. The principal characteristics that favour addiction are; strongly preferring the benefit of something over its detrimental consequences, and strongly preferring a result now over a result later. But these are not unusual characteristics at all, in fact everybody has them to some extent and it is only how strongly they are expressed among individuals that varies. In potential addicts both of these characteristics are strongly expressed. This occurs completely routinely in the general population and it can occur regardless of whether or not we have alcoholic parents.
Having parents that are alcoholics does not mean that we are pre-destined to follow that course, we are not. Alcoholism itself is not directly inheritable, it is only the characteristics that favour susceptibility that may be. Equally, the coincidence of these same characteristics can occur perfectly randomly. But having alcoholic parents does make it more likely than average that their children will both have the characteristics that favour addiction and also that they will be raised in an environment where heavy drinking is the normal behaviour: the susceptibility is likely to exist and this susceptibility is very likely to be engaged. A family history of addiction is found in 50% – 60% of all alcoholics.
There is still a great deal to be discovered about the specific genetic components of addiction but among current research there is significant focus on a condition called alexithymia: a reduced ability to identify, define, and explain our own emotions. It has been shown to be a vulnerability factor for addiction, and also that it precedes addiction rather than being a consequence of it. Symptoms of alexithymia include; poor emotional regulation, interpersonal problems, reduced social networks, and anxiety and depressive disorders, all of which seem very familiar to alcoholics. It is often an inherited condition and is particularly prevalent among those with a family history of alcoholism. Alexithymia is present in 6% – 10% of the general population, but in as many as 78% of alcoholics, and this is far too large a variance to be coincidental.
It is beyond doubt that vulnerability to addiction is to a significant extent inheritable. It is also known that the fundamental characteristics favouring addiction are not rare, they are perfectly commonplace. What is less clear is the extent to which our individual personality traits encourage susceptibility.
Individual traits have been comprehensively studied in efforts to identify the “addictive personality”, but the results of this research are indicative rather than conclusive. Personality traits are somewhat elective rather than rigid in that we can choose whether or not to deviate from them. Nevertheless there are personality traits that are significantly more commonly grouped among alcoholics than the general population. Some of these characteristics are clearly the result of addiction; compulsive behaviour, a very poor self-image and guilt are obvious consequences of alcohol-tolerance rather than causes. However there are other personality traits that favour addiction that are more pronounced among alcoholics than the remaining population. Impulsiveness and lack of patience indicate people who seek to be happy now rather than holding out for better things later on. These are consistent with the underlying characteristics of strongly favouring benefits over disadvantages and strongly preferring something now over later. But the significance of other personality traits more commonly found in alcoholics than in the general population is less clear. Alcoholics are more likely than normal to cope with stress poorly, have low frustration tolerance and be excessively sensitive to criticism. They are also prone to feelings of isolation, a high level of anxiety in interpersonal relationships, and emotional immaturity. All of these are traits that favour addiction because they are all relieved by drinking and can therefore build into self-reinforcing loops, but the extent to which they contribute to addiction is uncertain.
Just as there are personal characteristics that encourage addiction there are others that dis-favour spontaneous recovery, and the inability to correct problematic drinking is just as significant a part of addiction as are strengthening cravings. Among personality traits that are more significantly grouped among alcoholics are; ambivalence towards authority, independence, and being highly self-reliant. While these characteristics don’t contribute to addiction they do obstruct our ability to spontaneously recover from it. They make us less likely to value the opinion of others (doctors, therapists, counsellors etc.) and more likely to rely on our own opinions and resources. This in turn makes us less likely to accept advice or seek help and more likely to persist trying to solve the problem alone, and the longer we do this then the more committed our addiction becomes.
There are many studies of the distribution of alcoholism in society and they vary widely in the proportion of the population identified as adversely affected by alcohol. This large variation depends entirely on the criteria by which alcohol impairment is measured, and for the sake of simplicity, and nothing more, it is presented as 5% in the following text.
There is no single factor that pre-determines that we will become alcoholic, in fact it is never the case that we are predestined in this way. There are however some portions of the population in which alcoholism is more prevalent than the norm and some individuals in which the likelihood it will occur is far higher. Alcoholism does not have an entirely random distribution. The great misconception in generalised addiction statistics is the assumption that the clustering around a particular factor is causal of addiction and this is often not the case at all. Youth for example is an oft-cited indicator: a very significant proportion of alcoholics started drinking in their early teens. From this many deduce that drinking young can cause addiction, but this isn’t a secure conclusion. A very large proportion of people will drink unwisely when they are younger and many will drink far too much and too often. But most will change this behaviour as they mature. There are many social drivers of excessive drinking among young people but significantly the two primary characteristics that drive addiction; recognising benefits more strongly than disadvantages and favouring now over later are both typical characteristics of adolescents. They usually recede at maturity and as they fade drinking becomes steadily more moderate and controlled. Studies of alcoholics show that many drank from a young age, and studies of people that didn’t drink at a young age show lower alcoholism rates; but the two are not as directly linked as may appear at first sight. Anybody can become addicted to alcohol if they drink a lot, and there are many reasons that someone might drink a lot, but most of these people will spontaneously recover if their circumstances change; 5% however will not. If you survey all alcoholics then you will find that most of them drank heavily in their youth, but if you survey all people that drank heavily in their youth (but were not from alcoholic parents) then only about 5% will be alcoholic: correlation is not the same as causation. Most people that drink to excess in their youth will develop drink-aversion triggers and as they mature and assume more responsible roles in society then these triggers strengthen and their drinking slows down. Most people, though they might drink heavily when younger, will spontaneously change to a normal drinking pattern as they mature. Drinking heavily in our youth does not cause alcoholism, but it is very likely that people that end up as alcoholics also drank as teenagers.
An increased statistical likelihood of alcoholism also occurs around people that spend a lot of their time in environments where heavy drinking is a regular part of normal social behaviour. People who are raised in surroundings where heavy drinking is routine and people whose social lives revolve around heavy drinking conform to the normal behaviour of those groups, so they drink heavily too. Just as most people that drink in their teens do not become alcoholic most of the people that drink heavily because that is the normal behaviour in their social groups will change their drinking patterns if their social groups change. But again, 5% will not.
A third significant group of people in which alcoholism is more prevalent is people that are for some reason persistently and severely distressed. Alcohol-tolerance in most alcoholics causes changes in neurotransmitter release that lower our mood, make us less socially engaged and increase our anxiety. In us these emotional changes are caused by our brain adapting to drinking over a significant period, but some people are in this state for other reasons. Childhood abuse or severe trauma can cause it as can unrelenting hardship or certain mental health issues. People who are persistently distressed like this may drink as a means to relieve their symptoms; aloneness, anxiety, and fear, shame etc and their drinking as a way to relieve these emotions quickly forms into powerful triggers. They build strong drinking triggers that fire whenever they are distressed (which is continuous for them) and this drinking to relieve the symptoms of distress forms itself into the same self-reinforcing feedback loop that occurs with alcohol-tolerance.
The prevalence of alcoholism is higher in the three groups identified here than in the whole of society; those drinking heavily while young, those in social groups where heavy drinking is normal, and those who are already persistently distressed. But these people do not necessarily all become alcoholics; very many will change their drinking behaviour perfectly spontaneously. Many young people will change their drinking behaviour as they mature, most people in heavy drinking social groups will drink normally if their social circle changes, and many of those living in persistent distress will change their drinking patterns if the source of their distress is addressed. In all these circumstances the majority of people are able to spontaneously change their drinking behaviour, but 5% will not.
This behaviour has been replicated in rats. Addiction begins and develops in the reward system and all animals that have a brain comprising two hemispheres have this reward system, so rats and mice have been the subjects of very many addiction experiments. Rats can become addicted by forcing them to drink heavily. If they are given no choice but to drink heavily (by only providing them water heavily laced with alcohol) then after a while their reward system directs them to seek and secure alcohol. If at this point you give them a choice of alcohol-laced water and sweetened water then the rats continue to drink the alcohol: they are addicted. But in this environment the rats are normally under significant duress; they are caged and entirely deprived of their normal environment. If they are placed in a comfortable and natural environment then they do not continue to drink the alcohol, they revert to plain water; that is most of them do. A similar result is seen in the soldiers returning from Vietnam. While enduring the distresses of war a huge number of these soldiers became heroin addicts, but on returning home most of them spontaneously recovered, but some did not. The ones that remain addicted, like the rats that didn’t revert to plain water, are the ones that lack the means to recover spontaneously… the 5%.
The progression into alcoholism requires both drinking heavily over a sustained period and the absence of the means to stop. People that do not drink regularly will never undergo the changes in their brain that come with alcohol-tolerance so they will never become alcoholic. But some, and only some of those that drink heavily will, and this is very significant. The incidence of alcoholism is higher in the three parts of the population described above (youth drinkers, those in heavy drinking environments and the persistently distressed) than in the whole population, but they all have the same things in common: drinking heavily and drinking regularly. It is this that causes the prevalence of addiction in these groups. Drinking persistently doesn’t cause alcoholism, what it does is it engages that vulnerability where it exists, and the progression to alcoholism continues from there. The same vulnerability may exist in the rest of the population, but if these people don’t engage in regular and heavy drinking then that vulnerability is never exposed.
The things that create vulnerability to alcoholism are all internal; i.e. they are all contained within ourselves. But there are some widely held beliefs that some external factors influence addiction. Specifically, advertising and widespread availability are often cited as contributing to alcoholism, but neither of these is the case. Alcoholics do not need advertising to encourage us to drink; we already generate the need to drink within ourselves. Once we have become alcohol-tolerant then the demand that we drink comes from the consequences of being sober and no other stimulus is needed. Alcohol advertising does not cause addiction. This point is more obvious in the case of other addictive drugs. People become addicted to drugs like cocaine, heroin, and methamphetamine yet these are not advertised at all and you can’t just nip to a local store to get them. Advertising may have an influence on normal drinkers, but alcoholics are already going to drink anyway. Also the wide and easy access to alcohol does not cause addiction. Wide availability may encourage drunkenness, but not addiction. Alcoholics will go to extreme lengths to secure alcohol when they need it and whether or not it is convenient to access has no bearing on this. Making alcohol harder to access may have an impact on drunkenness but it has no impact on addiction. We do not drink because it is easy to do; we drink because we are compelled to. Neither advertising nor wide availability are direct causes of alcoholism, but they do have a peripheral effect. Of themselves they don’t cause addiction but they may encourage the heavy and persistent drinking that engages the vulnerability where it exists.
We had no way of knowing when we first drank that we were susceptible to addiction; we only did the same as everyone around us. We had no idea that we were initiating a process that would ultimately bring us to our knees, and there were no warning signs that this was happening until it was too late. Whether we inherited the mental characteristics that favour addiction or we got them through random variability makes no difference to the outcome. Once we drink regularly this leads to drinking more heavily and this is driven by the two crucial mental characteristics; greatly preferring the benefits of something over its drawbacks, and greatly preferring something now over something later. These two characteristics are neither created nor altered by drinking. We don’t make them this way because we drink, we are born this way.
We do not cause our alcoholism by drinking. Our only part in this is that we activated the susceptibility.
The longing to understand why we became alcoholic is driven by the need to avoid shame. If we drink because something compels us to rather than from making poor choices then we can avoid the shame of it. Understanding our addiction better can lift the shame we impose on ourselves but we cannot expect to remove the judgement of others. Most alcoholics only start to understand the nature of our condition as we struggle to confront it. We only seek out this knowledge when there is a need to know it and normal drinkers never have such a need. Their answer to the question “why don’t they just drink less?” is complete and satisfactory from their untainted viewpoint and they don’t need to research it further. We should not expect relief from judgement from people that do not know better because they have no need to know better. We fight off the designation “alcoholic” while we think that the cause of our problem is being a weak or bad person, but when we understand that our condition is not caused by poor control but by a condition causing the absence of control then we can accept it more easily. Shame obstructs seeking help and when we understand why we are the way we are with respect to alcohol then a huge burden of shame is lifted, a pillar that upholds denial is removed, and the barrier to seeking help is lowered. Understanding the causes of our addiction may make it easier to bear but it doesn’t change what has to be done. This knowledge does not undo the changes to neurotransmitter activity in our brain, it does not remove the triggers that have formed, it does not create the alcohol-avoiding triggers that did not form, and it does not rectify our distorted memory. Regardless of how our addiction formed the course of action required to become well again is the same; first we have to stop drinking, and then we have to undo the damage caused. But getting to the position when we can even contemplate stopping drinking can be a disastrous path. While we remain convinced that drinking is good and while our mind generates plausible reasons to continue drinking then we cannot stop; and everything continues to get worse. But eventually as our decline continues there comes a time that our position is so desperate that we will try anything to escape the misery; denial collapses and eventually, somehow, from somewhere, we find the will to change.