Hair loss Treatment Center

PARTICIPANTS Carol Weiss, MD Cornell University Medical Center - New York Presbyterian Hospital Richard Nelson Rosenthal, MD Beth Israel Hospital, NY

Many alcoholics don't even know they have a problem. So what are the symptoms of alcoholism? And when should you start worrying that you might have a problem? Joining us to answer these questions is Dr. Carol Weiss. She's an Addiction Psychiatrist and Clinical Assistant Professor of Psychiatry and Public Health at Cornell University Medical College, New York Presbyterian Hospital. Welcome.

And Dr. Richard Rosenthal, he's Chief of the Division of Substance abuse at Beth Israel Hospital in New York. Welcome.

So Carol, what's the difference between somebody who's an alcoholic and someone who just likes a drink or two?

CAROL WEISS, MD: Well, let's use the term "problem drinker" instead of alcoholic. An alcoholic is someone who has a problem with their drinking. Either they worry that they may have a problem, or someone else is worried that they have a problem. Just that is the beginnings of wondering whether or not you have a problem with drinking. There are some specific criterion that we use to determine whether or not somebody's a problem drinker. Have they tried to cut down and have been unable to cut down? Do they get annoyed and irritable when they drink? Do they feel guilty about their drinking?

And the most sever symptom is do they have to have a drink when they wake up in the morning?

That's sometimes called the CAGE questions: Cutting down; Annoyed; Guilty; Eye-opener. That's the sort of easy definition of alcoholism.

DAVID MARKS, MD : But someone who likes to take a drink at dinner, a glass of wine, that's not a problem, is it?

CAROL WEISS, MD : It's not a problem, if it's not a problem. If it doesn't disturb their social functioning, if it doesn't disturb their occupational functioning, if it doesn't disturb their health, it's not a problem. But if they find themselves being preoccupied with when they're going get their next drink. If they find themselves getting into trouble either with their family or with their health or at work because of their drinking, then there's a problem.

DAVID MARKS, MD: Okay. Rick, Carol mentioned CAGE questions very briefly. Tell me about them.

RICHARD ROSENTHAL, MD : What they are is a sort of set of pocket tools that--that most clinicians should know if they don't know it. What you can use them for is a--is a sort of a rapid screening of a person to see if there's really a problem around drinking. So if the idea is Cutting Down, that's the first CAGE question.

What that really goes to is something that we addiction psychiatrists and other people in the addiction field have recognized is probably the most important factor around addiction. We used to think is was sort of the heroin model, okay. Where you still have to become physiologically dependent on the drug and then show withdrawal syndrome when you stopped it. We've evolved from that. That can be a syndrome of dependence, for example. But loss of control has really become the hallmark of addictive disease.

And so if you have tried to cut down, made unsuccessful attempts to cut down, that means that there's an issue about you drinking more than you had intended. Okay?

And so that becomes a very powerful and important symptom.

That's the "C."

The second one is Annoyance. Let me go a little bit further than what Carol said. It's a little bit more than not only annoyance when you drink, but annoyance that other people may have pointed out to you that they think that you drink too much. So it's annoyance at having that being brought up to in any kind of a way.

The third one is Guilt, which is saying, I think maybe I shouldn't be doing this. If you're beginning to have thoughts or feelings that there's some wrongness about your alcohol drinking behavior, whatever that might be. That's a positive sign.

And the last, as Carol said, Eye-opener use of alcohol. If you have to get up and have "hair of the dog" in order to, you know, get yourself ready for work, you have a problem. Because that's a fairly strong sign that someone's got a fairly strong dependence problem that they need to immediately upon arising, use alcohol to get up to sort of a normal state without going into withdrawal.

DAVID MARKS, MD : Carol, if people answer positively with some of these CAGE questions, why don't they seek help?

CAROL WEISS, MD : Well, another hallmark of alcoholism is denial. It's very hard to admit that you have a problem, or to even realize that you have the problem. Your life sort of starts to develop itself around your drinking problem. So if you start getting to work late on Mondays or leaving early on Fridays, you just start telling yourself that you need a little more rest and relaxation, for example. Instead of saying I was hung over on Monday morning from the drinking. Also it's very frightening to give up alcohol. It becomes a friend to people. It becomes a way to cope for people. It becomes a way to have fun. And people aren't so keen on giving that up so quickly.

DAVID MARKS, MD : You touched on physiological--physical withdrawal. I think in peoples' minds people think of DTs, delirium tremens. The shakes. That's obviously not that common; correct?

RICHARD ROSENTHAL, MD : That's correct. It happens to people who have been drinking a lot and becomes physiologically dependent. And then usually stopped cold essentially and developed within several days, usually. A profound withdrawal syndrome where people become delirious and lose their orientation in terms of place, person, and time and can have seizures. And there's a mortality rate, people can die from untreated DTs. But fortunately most people don't experience that. But people who have been doing heavy drinking for weeks, months very often, even if they cut down, may experience withdrawal symptoms. And they start to perspire, their heart races, they can't sleep, they feel uncomfortable, they get very anxious. What will most people do in that state is go back and drink more alcohol. So you end up in a vicious cycle that's very hard to break. So adding to what Carol was saying about what we call the positive reinforcing qualities, the stuff that sort of feels good, that gets you to do it more, that takes anxiety away, and it's a social lubricant, right? People drink at cocktail parties and feel better and become more at ease and relaxed. There are also the avoidance of the negative affects, right. That's part of that eye-opener use of alcohol. You wake up in a bad mood with the shakes, all you need to do is take a little nip, and it puts it under control. So it's a very, very hard loop to get out of.

DAVID MARKS, MD : Is there a certain limit on the number of drinks a person can have before they can consider themselves alcoholics?

CAROL WEISS, MD : Well, that's a good question, because many times people say, "Well, I'm not an alcoholic because I only drink on weekends, or I only have a half a bottle of wine." Alcoholism has nothing to do with quantity or amount, it really has to do with how it impairs your functioning, how it affects your life. If you only drink once a week, but that once a week you drink and get into an accident with your car, you are a problem drinker. So it really has more to do with the problems that the use of the alcohol brings about than the absolute amounts.

DAVID MARKS, MD : So somebody has three cocktails a night, but it doesn't affect their daily living, it's not necessarily a problem?

CAROL WEISS, MD : Well, that's an interesting question, also. You have to define what it means, not a problem. The person who has three drinks a night may not think it's a problem. Let's say it's a man. His wife and children may think it's a problem that after his three drinks he just nods out and goes to sleep and doesn't interact with the rest of the family. Or slurring his speech all evening and not able to interact with his wife. So you can't just ask the person whether or not it's a problem. That's why it's so key that you have to include in your assessment other people in the person's life. Because he's not going think it's a problem.

But if in fact it doesn't affect his blood pressure, his liver enzymes, his getting up in the morning, his being alert when he needs to go to work, it's conceivable that it's not a problem. But you really have to probe very carefully. And also, one other aspect of it is, yes, he may not be having a lot of difficulty getting up in the morning. But it may be that he could work a lot better the next day if he didn't have those three drinks that night. So that becomes a judgment call.

DAVID MARKS, MD : So there's some subtle symptoms? Are there any physical signs? People think about the red nose, is there anything to that?

RICHARD ROSENTHAL, MD : Oh, absolutely. I mean, not that if you have a red nose, you're an alcoholic, you may be Rudolph. Okay. But there are physical changes that occur with people who have really been doing very heavy drinking. What I think is even more important again is sort of what Carol was talking about was they may be cognitive changes and they may be subtle. One of the things we're beginning to understand is that as people age, for example, they tolerate alcohol less well.

I mean, you know, day-to-day you may not see any changes. But there may actually be affect on brain functioning in terms of memory, in terms of working memory, in terms of being able to do tasks, be able to switch between tasks. And there may be an accumulative affect over time. So that people actually, if they're drinking the same amount year in, year out over a long period of time, they may actually do less well in terms of their mental functioning. So I think that those are the kinds of signs that don't generally show up as often because they're more subtle, but may actually have more affect. Then there are obviously the other kinds of signs that you see. There's sort of the classical ones in--in medicine, but when you see people with those kinds, either the big swollen belly that you get from a diseased liver. That someone's who got a very severe case of the disease. And it's been going on a very long time.

DAVID MARKS, MD : Okay. Is there a difference in the way men and women manifest the signs of alcoholism?

CAROL WEISS, MD : Yeah. There are a lot of differences. First of all, there are people who say that women manifest with problems with alcohol use after a shorter period of alcohol use. That is a man might be able to drink for many years before developing a problem. But with a woman it happens sooner. Why that is has to do with the physiology of women, perhaps. Women have more body fat, their water concentration is different than with men, and that may affect how it's--it manifests. Women tend to have more shame and guilt associated with their drinking than men do. It's not very socially accepted--it's less socially acceptable for a woman to drink than for a man. It was the case that women were much more reluctant to pursue treatment as a result of that.

That has shifted fortunately over the years that more women now are going to AA and other forms of treatment. But for a long time they were reluctant to show their head. Then of course women because they have different organs have different problems.

They have fertility problems associated with the drinking of alcohol, for example.

DAVID MARKS, MD : Now, are doctors failing to pick this up on routine exams? You go in to see your internist?

RICHARD ROSENTHAL, MD : Absolutely. There's not question about it that-- if we want to just talk about diagnoses, in other words, people who actually have what physicians would call diagnosable disorder. Not just problem drinking, but more severs cases where there's bona fide problems. There's a large percentage of the population, maybe 8%, that are going to make a diagnostic category over their lifetime, or more. And what we know is that in general practice, although it is getting better, most physicians are not asking those kinds of simple questions about simple drinking behavior.

And that's a shame, because often doctors can have a good effect. Especially, if someone has not made the transition from a problem drinker into a person with an abuse or a dependence problem. And so early intervention by a caring professional can make a difference. There's actually literature on that where it shows recent interventions by primary care physicians can have an impact on drinking behavior. Unfortunately, it's not done with any kind of regularity.

DAVID MARKS, MD : Well, leave the doctor out of it, let's say someone out there knows a loved on or friend who they think or suspect is an alcoholic. What should they do?

CAROL WEISS, MD : First of all, they should talk to the person, but not in a judgmental or attacking kind of way. Because they're going to get up the defenses of the person and make them irritable, angry, and even deny more fiercely that they have a problem. But gently discuss with them your concerns about what you've observed and that you're not the only person who's observed. That's often very helpful to point out. And to suggest to the person ways that they might be able to get help, other people that you know have the same problem and help that they've gotten.

DAVID MARKS, MD : So they should take some action?

CAROL WEISS, MD : They should take some action. And you should direct them toward getting help.

DAVID MARKS, MD : Carol Weiss. Rick Rosenthal. Thank you, very much for joining us. Alcoholism is a very severe problem in this country. Diagnosis is the first and possibly the most important step, and we hope this web cast helped out. I'm Dr. David Marks, thank you for joining us.